Fire on Board the Liberian Passenger Ship Ecstasy, Miami, Florida ...

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Factual Information 2 Marine Accident ReportThe photograph above shows the Ecstasy after the fire. The ship area indicated by the dottedline is illustrated in the cutaway below.Main Vertical Zone<strong>Fire</strong> BarrierMain Vertical Zone<strong>Fire</strong> BarrierSmokestackDECK 12DECK 11AFTPOOLAIRCONDITIONERLIFTMACH.POOLMACH.AIRCOND.DECK 10DECK 9DECK 8AIR CONDITIONERAIR COND.AFT DINING ROOMCABINCONTROLROOMGALLEY DUCTSENGINECASINGGALLEYDECK 7DECK 6SUPPLYSUPPLYELEC.EQUIP.ROOMCABINAIR CONDITIONING FAN ROOM & PLENUMSPASS. STAIRS & LIFTSCARGOLIFTAIR CONDITIONERDECK 5DECK 4DECK 3SUPPLYMOORING DECKSTEERING GEAR ROOMSSUPPLYEXHAUST FANSTORESFANMARSHALINGAREADECK 2DECK 1DRY TANKFRESH WATERMAIN LAUNDRYLINENPROPULSIONMOTOR ROOMAFTENGINEROOMAPPARATUS ROOMFORWARDENGINE RM.DECK 0STERN THRUSTERSFigure 1. On the day of the accident, the fire alarm panel on the bridge indicated that the first alarmactivated in the main laundry on deck No. 2. The ventilation system for the laundry penetrated a mainvertical zone (MVZ) and exhausted onto the mooring deck. Other early fire alarms indicated thatdetectors activated in the stern thruster room, the air conditioning plenum between decks No. 4 and6, an electrical room above the mooring deck, and both steering gear rooms below the mooring deck.inclement weather arrived. After the muster drill was completed, the Ecstasy departed thePort of Miami with 2,565 passengers and 916 crewmembers on board.After the Ecstasy departed its berth, crewmembers brought in and stowed thesynthetic mooring lines on the aft mooring station, which was on deck No. 4. A bosun dida final inspection of the area and secured the two weather-tight doors leading from themooring station to the passenger stateroom area on deck No. 4. He then exited the areausing the center crew stairway. According to the bosun, the weather door to this crewstairway was always left open. The mooring station log indicates that the mooring deckwas “all clear” and secured at 1650, meaning no machinery was in operation and nopeople were in the area. The bosun stated that he noted nothing unusual on the deck whenhe left.
Factual Information 3 Marine Accident ReportOnce the master directed the maneuver of the ship from the pier to mid-channel,the pilot began directing the passage out of the Port of Miami. The pilot stated that theonset of the voyage was routine. He further stated that no equipment malfunctionsoccurred, and the members of the bridge team performed their duties in a competent andprofessional manner.The Accident 2About 1630, a mangle 3 in the Ecstasy’s main laundry (figure 2) malfunctioned.The laundry manager telephoned a repair request to the hotel engineer, who, in turn, pagedthe on-call galley fitter (first fitter). The first fitter said that he was in the fitters’ workshopon deck No. 3, preparing to go off duty at 1730, when he was paged and told to go to themain laundry. He said that the laundry manager told him that the mangle was not workingproperly, and that its roller needed to be adjusted.SternMangleMain Laundry Crew Mess Dry LinenReceptionElectricalWorkshopand StorePropellorMotorRoomForwardEngineRoomEngineControlRoomFigure 2. Layout of deck No. 2, aft of the smokestack. In the main laundry, the washers and dryerswere on the port side of the ship, and the mangle was on the starboard side.The first fitter said that when he arrived in the main laundry, the crew was stillworking and the dryers were running. He said that he tightened a bolt on the mangle’sbridge, which directs the linen from the first roller to the second roller. He then started themangle to determine whether the adjustment fixed the problem. When the mangle stillwould not work properly, he continued the process of tightening the bolt and starting themachine until the bolt broke at its weld to the mangle.2 The Safety Board interviewed the laundry manager and the two galley fitters to determine whatoccurred in the laundry room before the fire. This accident narrative is compiled using information obtainedfrom those interviews. Because the fitters have the same job title, this report refers to the fitter who firstarrived in the laundry as the “first fitter” and the fitter who joined him as the “second fitter.”3 The mangle is a machine for ironing fabrics, such as table clothes and bed linen.
Page 1: PB2001-916401NTSB/MAR-01/01NATIONAL
Page 4 and 5: National Transportation Safety Boar
Page 6 and 7: Contents iv Marine Accident ReportS
Page 8 and 9: viMarine Accident ReportAcronyms an
Page 10 and 11: viiiMarine Accident ReportExecutive
Page 14 and 15: Factual Information 4 Marine Accide
Page 20 and 21: Factual Information 10 Marine Accid
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Factual Information 53 Marine Accid
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55 Marine Accident ReportAnalysisGe
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Analysis 57 Marine Accident ReportT
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Analysis 59 Marine Accident Reportf
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Analysis 61 Marine Accident Reports
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Analysis 63 Marine Accident Reporti
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Analysis 65 Marine Accident ReportA
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Analysis 67 Marine Accident ReportF
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Analysis 71 Marine Accident ReportM
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Analysis 75 Marine Accident ReportI
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Conclusions 77 Marine Accident Repo
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Recommendations 79 Marine Accident
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Recommendations 81 Marine Accident
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84 Marine Accident ReportAppendix B
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Appendix B 86 Marine Accident Repor
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Appendix C 88 Marine Accident Repor
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Appendix D 90 Marine Accident Repor
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92 Marine Accident ReportAppendix F
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Fire on Board the Liberian Passenger Ship Ecstasy, Miami, Florida ...

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