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

Factual Information 34 Marine Accident Reportprocedures, and guidance.” The manual further states that crewmembers are responsiblefor taking all reasonable care for their own health and safety and for that of all others onboard the ship and that they must cooperate with the company, master, chief engineer, andall others who are responsible for health and safety aboard ship.SMS Manual 03, Section 5, “Safety Procedures,” contains subsections on permitto-worksystems (5.7) and welding and flame cutting operations (5.13).According to the SMS manual, a permit-to-work system covers “operations onboard ship where the routine actions of one man may inadvertently endanger another.”The system identifies foreseeable hazards posed by various tasks and operatingenvironments and lists precautions and sequential actions to take when performing suchtasks. The SMS manual states, “In all instances it is necessary, before the work is done, toidentify the hazards 31 and then to ensure that they are eliminated or effectively controlled.”The manual further advises that the first and most important step in eliminating oreffectively controlling hazards is a situational assessment by the ship’s officer who isexperienced in the work and thoroughly familiar with relevant hazards. The subsectionspecific to hot or cold work stipulates that permits that grant permission for such workmust be countersigned by the chief engineer, staff chief engineer, master, or staff captain.The subsection on welding and flame cutting operations states, “No welding orflame cutting work should be undertaken unless the requirements of the ‘Hot WorkPermit’ are fully satisfied.” The manual stipulates that welding operations should beproperly supervised and kept under regular observation and that a person with a suitableextinguisher should be stationed to keep watch on areas not visible to the welder.Manual 07, “Safety of Operations—Engineering Department,” states that the staffchief engineer or engineering officer team leader must ensure that all measures andprecautions that are necessary for the safety of those concerned are taken before any repairor maintenance work begins. Investigators reviewed the Ecstasy records of hot workpermits issued for various maintenance tasks outside the ship’s machine shop andworkshop. The log and copies of approved permits do not include an application or anapproval for a welding project in the ship’s main laundry on July 20, 1998. After the fireonboard the Ecstasy, Carnival Cruise Lines revised its SMS to include safeguards againstunauthorized welding. See “Other Information,” later in this report.Manual 08, “Safety of Operations—Hotel Services,” states that the laundrymanager is responsible for, among other tasks, ensuring the safe operation of all laundryequipment and the proper cleanliness of the laundry room, laundry equipment, and thelaundry crew galley. The manual lists 17 required safety procedures for the laundry area.The procedures specify the required operating temperatures for washers, dryers, and themangle, proper handling of chemicals, and measures for handling linens, clothes, anduniforms. The laundry safety procedures also include prohibiting smoking in the laundryroom and performing a fire risk assessment at regular intervals.31 At the time of the Ecstasy accident, Manual 03 did not include a section on job hazard analysis. Sincethe accident, Carnival Cruise Lines has developed and added a chapter “Safe Systems of Work - Job HazardAnalysis.”