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May 2, 2001

NTSB releases Ecstasy fire findings
The National Transportation Safety Board yesterday issued a preliminary report on the July 1998 fire on the Carnival cruise ship Ecstasy

EXECUTIVE SUMMARY
On the afternoon of July 20, 1998, the Liberian passenger ship Ecstasy had departed the Port of Miami, Florida, en route to Key West, Florida, with 2,565 passengers and 916 crewmembers on board when a fire started in the main laundry shortly after 1700. The fire migrated through the ventilation system to the aft mooring deck where mooring lines ignited, creating intense heat and large amounts of smoke. As the Ecstasy was attempting to reach an anchorage north of the Miami sea buoy, the vessel lost propulsion power and steering and began to drift. The master then radioed the U.S. Coast Guard for assistance. A total of six tugboats responded to help fight the fire and to tow the Ecstasy. The fire was brought under control by onboard firefighters and was officially declared extinguished about 2109. Fourteen crewmembers and eight passengers suffered minor injuries. One passenger who required medical treatment as a result of a pre-existing condition was categorized as a serious injury victim because of the length of her hospital stay. Carnival Corporation, Inc., the owner of the Ecstasy, estimated that losses from the fire and associated damages exceeded $17 million.

The major safety issues discussed in this report are as follows:

* Adequacy of management safety oversight;
* Adequacy of the fire protection systems;
* Adequacy of passenger and crew safety; and
* Adequacy of engineering system design.


As result of its investigation of this accident, the Safety Board adopted safsety recommendations to the U.S. Coast Guard, Carnival Corporation, Inc., Carnival Cruise Lines, cruise ship operating companies, Asea Brown Boveri Marine Group, AG, and the International Association of Classification Societies.

CONCLUSIONS

1. Although the Ecstasy's mooring deck sustained the heaviest fire damage, it was not the point of origin for the fire.

2. The fire on board the Ecstasy started in the main laundry and was ignited by an arc from a welding machine.

3. The fitters' (welders') lack of full compliance with the "hot work" permit procedures in Carnival Cruise Lines' safety management system manual increased the risks of fire in the main laundry.

4. The lint that accumulated in the ventilation duct of the main laundry created a serious fire hazard on the Ecstasy.

5. The procedures and standards for inspecting and maintaining laundry ventilation systems adopted by the marine industry and government agencies following the Ecstasy fire will improve safety on cruise ships.

6. If an automatic fire suppression system had been installed on the mooring deck, the fire on the Ecstasy would have been located and extinguished much sooner, thereby minimizing the extent of fire damage on the vessel and aft mooring deck.

7. The vessel's automatic fire sprinkler system effectively limited the spread of fire from the mooring station to adjoining decks, thereby preventing a significantly worse fire that would have caused greater damage and perhaps additional injuries.

8. If the main laundry's fire dampers had been equipped with a passive means of closure, such as a fusible link, the heat from the fire would have caused the dampers to shut sooner, which, in turn, might have prevented the spread of fire beyond the laundry area.

9. The fire detection system performed properly by providing an early indicator of a fire.

10. Although most survey respondents indicated that the Ecstasy practice drill adequately prepared them for the actual fire emergency, the drill lacked information about actions to take if you see smoke or if your muster station is unavailable that might have assisted passengers who encountered conditions or situations contrary to those during the drill.

11. Although the noise from the news helicopters may have interfered somewhat with the communications with passengers on the outside deck, crewmembers were able to effectively communicate with the mustered people and manage the emergency.

12. The procedures used by the Ecstasy's shipboard personnel to account for passengers and crewmembers during the emergency were not accurate.

13. The lack of consistency between the information provided at the practice drill about the provision of lifejackets and the procedures that crewmembers followed in distributing lifejackets during the actual emergency created unnecessary confusion among some passengers on the Ecstasy.

14. The lack of a means to call for help from the crew cabins delayed the rescue of two crewmembers and contributed to the severity of their smoke inhalation injuries.

15. The emergency response by shipboard and shoreside firefighters to the fire was timely and appropriate, resulting in the fire being properly contained and extinguished.

16. The failure to separate the power circuitry in the design arrangement of the auxiliary voltage supply to the high-speed breakers of the propulsion systems resulted in inadequate isolation of essential system components, which, in turn, resulted in the shutdown of both propulsion systems when a single distribution panel was damaged.

17. To ensure the highest levels of safety and reliability, ship owners should require the use of qualitative failure analysis techniques in the design and construction of their vessels.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of fire aboard the Ecstasy was the unauthorized welding by crewmembers in the main laundry that ignited a large accumulation of lint in the ventilation system and the failure of Carnival Cruise Lines to maintain the laundry exhaust ducts in a fire-safe condition. Contributing to the extensive fire damage on the ship was the lack of an automatic fire suppression system on the aft mooring deck and the lack of an automatic means of mitigating the spread of smoke and fire through the ventilation ducts.

SAFETY RECOMMENDATIONS

As a result of its investigation of this accident, the National Transportation Safety Board makes the following recommendations:

New Recommendations

To the U.S. Coast Guard:

1. During control verification examinations, review a drill scenario in which one or more main vertical zones are inaccessible and evaluate the procedural effectiveness of the crew in crowd control, crisis management, lifejacket distribution, and passenger accountability.

To Carnival Corporation:


2. For the ships in your fleet, revise the safety management system to include processes for preventing unauthorized flame cutting, grinding, or other activities that might ignite a fire.

3. For the ships in your fleet, develop plans to account for passengers and crewmembers in common emergency scenarios, in particular, a situation involving the inaccessibility of one or more main vertical zones and/or muster stations.


To Carnival Cruise Lines:

4. For the ships in your fleet, engineer, design, and implement system modifications to mitigate the spread of fire and smoke from the laundry rooms through ventilation ducts to other areas of the vessel.

5. Examine the propulsion systems on the ships in your fleet and, if necessary to ensure redundancy, modify the arrangement of the auxiliary voltage circuitry to the high-speed breakers where a single source supplies both port and starboard propulsion systems.

6. Revise the safety information disseminated to passengers to include actions to take if they encounter smoke or fire and/or if their muster station is not available.

To American Classic Voyages, Carnival Corporation, Inc., Crystal Cruises, Disney Cruise Line, Norwegian Cruise Line, Orient Lines, P&O Princess Cruises International, Ltd., Radisson Seven Seas Cruises, Regal Cruises, Renaissance Cruises, Inc., Royal Olympic Cruises, Royal Caribbean Cruise Lines, and Silversea Cruises, Ltd.:

7. For existing vessels with mooring deck design arrangements similar to Carnival Cruise Lines' Fantasy Class ships, install fire detection and suppression systems on mooring decks that carry high fire loads and presently have no automatic fire protection.

8. For existing vessels with ventilation system arrangements similar to Carnival Cruise Lines' Fantasy Class ships, install an automatic method or system to mitigate the spread of smoke and fire from laundry spaces through the ventilation ducts to other vessel areas.

9. Install emergency call systems in passenger staterooms and crew cabins so that people trapped during a fire emergency will have a means of signaling their location.

10. In the construction of new passenger ships, use qualitative failure analysis techniques to identify system components whose failure might cause a complete loss of propulsive power and take action to mitigate identified problems.


To Asea Brown Boveri Marine Group, AG:

11. Advise your customers owning ships with the same propulsion system design arrangements as the Ecstasy of the potential for system failure from the loss of auxiliary voltage to the high-speed breakers and recommend design changes to the propulsion system that would minimize these effects.


To the International Association of Classification Societies:


12. Recommend that your members require systems designers, manufacturers, and/or shipyards to perform and submit qualitative failure analyses to ensure the fail-safe operation of propulsion systems on new passenger ships.


Previously Issued Recommendations Resulting from this Accident Investigation


M-98-125
Immediately inspect, within your fleet of ships, the laundry ventilation systems, including ducts, plenums, and exhaust terminuses, for any combustible material, such as lint, and clean the systems, as necessary, to reduce the risk of fire. (Urgent)

M-98-126
Institute a program to verify on a continuing basis that the laundry ventilation systems, including ducts and plenums, remain clean and clear of any combustible material that poses a fire hazard on your vessels.


Previously Issued Recommendations Classified in this Report

* M-00-6 (previously classified "Open-Acceptable Response") is classified "Open-Unacceptable Response" for American Classic Voyages, Costa Cruise Lines, Orient Lines, Regal Cruises, Royal Olympic Cruises, and Silver Sea Cruises in the section of this report entitled "Locally Sounding Alarms."
* M-00-7 (previously classified "Open-Acceptable Response") is classified "Open-Unacceptable Response" for American Classic Voyages, Costa Cruise Lines, Orient Lines, Regal Cruises, Royal Olympic Cruises, and Silver Sea Cruises in the section of this report entitled "Locally Sounding Alarms."



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