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

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Factual Information 32 Marine Accident ReportCarnival Cruise Lines presently runs 16 passenger vessels on pleasure cruises thatlast 3 to 16 days and that include itineraries to the Bahamas, Caribbean, Panama, Mexico,Hawaii, and Alaska. At the time of the accident, the operating company regularly ran theEcstasy on 3- and 4-day round-trip cruises from the Port of Miami. The 4-day cruisesdeparted on Monday and had stopovers at Key West and Cozumel, Mexico. The 3-daycruises left on Friday and sailed to Nassau, Bahamas, where it docked for 1 day beforereturning.International Safety RequirementsAt the 1994 SOLAS Conference, the IMO General Assembly adopted a resolutionentitled “The International Management Code for the Safe Operation of Ships and forPollution Prevention,” known, in brief, as the ISM Code, to encourage the continuousimprovement of safety management skills in the maritime industry.The ISM Code became effective on July 1, 1998, for all passenger ships and for thefollowing vessel types of 500 gross tonnage and over: oil tankers, chemical tankers, gascarriers, bulk carriers, and high speed cargo ships. 28The ISM Code requires a company 29 to establish and maintain a documented SMSthat, among other things, meets the following safety management objectives:1. Provides for safe practices in ship operation and a safe working environment;2. Establishes safeguards against all identifiable risks; and3. Continuously improves safety management skills of personnel ashore andaboard vessels, including preparing for emergencies related both to safety andenvironmental protection.The ISM Code establishes six functional requirements for an SMS:• Policies for ensuring safety and protecting the environment;• Instructions and procedures for ensuring safe vessel operation andenvironmental protection in compliance with international and domestic laws;• Defined levels of authority and lines of communications between and amongshipboard and shoreside personnel; 30• Procedures for reporting accidents and nonconformities;• Procedures for preparing for and responding to emergency situations; and28The rules for all other cargo ships and MODUs of 500 gross tonnage and over enter into effect onJuly 1, 2002.29 The ISM Code defines company, in part, as “the owner of the ship or any other organization orperson…who has assumed responsibility for operation of the ship from the shipowner and who, on assumingsuch responsibility, has agreed to take over all the duties and responsibility imposed by the Code.”30 The ISM code stipulates that a company’s SMS clearly define and document the master’sresponsibilities and emphasize his authority in its SMS.
Factual Information 33 Marine Accident Report• Internal audits and management reviews.The procedures required by the ISM Code must be documented and compiled in aSafety Management Manual (SMM), which must be maintained on board a company’sships.The ISM Code requires that a company provide necessary resources and shorebasedsupport to achieve SMS objectives that includes appointing a designated person orpersons ashore having direct access to the highest level of management.The flag state government is responsible for enforcing the ISM Code and forissuing documentation attesting that companies are in compliance with it. A companycomplying with the ISM Code is issued a Document of Compliance, a copy of which mustbe kept on board the ship. Ships in compliance with the ISM Code are issued a SMSdocument.Carnival Cruise Lines’ Safety Management SystemLR certified that Carnival Cruise Lines’ SMS and its vessels, including theEcstasy, were compliant with the ISM Code in December 1997, or 6 months ahead of theIMO deadline.Investigators reviewed the SMM maintained by Carnival Cruise Lines on boardthe Ecstasy. The SMM defines the organization of the company’s SMS, states its policies,and lists the various operating manuals that cover key shipboard operations. Manual 00 ofthe company’s SMM, entitled “Master Safety Management System,” contains a policystatement, which says, in part:The main objectives of the SMS are to ensure the motivation of all CCL personnelthrough effective education and training, and to outline specific responsibilitiesfor safety and environmental protection throughout all CCL operations.The SMS emphasizes a pro-active attitude toward the elimination of operationalproblems, such that require forward planning and prevention procedures, on thepart of all Carnival Cruise Lines personnel, will eliminate the occurrence ofproblems detrimental to the standard of passenger service offered by CarnivalCruise Lines and ensure safety at sea, personnel safety, and avoidance of damageto the environment.The individual manuals, in turn, identify operations that are considered special orcritical, establish safe procedures for conducting those operations, and assign qualifiedindividuals to perform the tasks necessary for the operations. For example, Manual 03,“Health and Safety,” indicates that the goal of the company is to “eliminate work-relatedaccidents, injuries, incidents and hazardous occurrences.” Manual 03 states thatmanagement responsibilities include providing the information, instruction, training, andsupervision necessary for compliance with health and safety requirements. The manuallists the staff captain as the designated HSO for the vessel and states that, as such, he isresponsible for ensuring compliance with “all health and safety instructions, rules,
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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 12 and 13: Factual Information 2 Marine Accide
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Page 67 and 68: Analysis 57 Marine Accident ReportT
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Page 71 and 72: Analysis 61 Marine Accident Reports
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Page 75 and 76: Analysis 65 Marine Accident ReportA
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Page 85 and 86: Analysis 75 Marine Accident ReportI
Page 87 and 88: Conclusions 77 Marine Accident Repo
Page 89 and 90: Recommendations 79 Marine Accident
Page 91: 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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