Factual Informati<strong>on</strong> 34 Marine Accident Reportprocedures, and guidance.” The manual fur<strong>the</strong>r states that crewmembers are resp<strong>on</strong>siblefor taking all reas<strong>on</strong>able care for <strong>the</strong>ir own health and safety and for that of all o<strong>the</strong>rs <strong>on</strong>board <strong>the</strong> ship and that <strong>the</strong>y must cooperate with <strong>the</strong> company, master, chief engineer, andall o<strong>the</strong>rs who are resp<strong>on</strong>sible for health and safety aboard ship.SMS Manual 03, Secti<strong>on</strong> 5, “Safety Procedures,” c<strong>on</strong>tains subsecti<strong>on</strong>s <strong>on</strong> permitto-worksystems (5.7) and welding and flame cutting operati<strong>on</strong>s (5.13).According to <strong>the</strong> SMS manual, a permit-to-work system covers “operati<strong>on</strong>s <strong>on</strong>board ship where <strong>the</strong> routine acti<strong>on</strong>s of <strong>on</strong>e man may inadvertently endanger ano<strong>the</strong>r.”The system identifies foreseeable hazards posed by various tasks and operatingenvir<strong>on</strong>ments and lists precauti<strong>on</strong>s and sequential acti<strong>on</strong>s to take when performing suchtasks. The SMS manual states, “In all instances it is necessary, before <strong>the</strong> work is d<strong>on</strong>e, toidentify <strong>the</strong> hazards 31 and <strong>the</strong>n to ensure that <strong>the</strong>y are eliminated or effectively c<strong>on</strong>trolled.”The manual fur<strong>the</strong>r advises that <strong>the</strong> first and most important step in eliminating oreffectively c<strong>on</strong>trolling hazards is a situati<strong>on</strong>al assessment by <strong>the</strong> ship’s officer who isexperienced in <strong>the</strong> work and thoroughly familiar with relevant hazards. The subsecti<strong>on</strong>specific to hot or cold work stipulates that permits that grant permissi<strong>on</strong> for such workmust be countersigned by <strong>the</strong> chief engineer, staff chief engineer, master, or staff captain.The subsecti<strong>on</strong> <strong>on</strong> welding and flame cutting operati<strong>on</strong>s states, “No welding orflame cutting work should be undertaken unless <strong>the</strong> requirements of <strong>the</strong> ‘Hot WorkPermit’ are fully satisfied.” The manual stipulates that welding operati<strong>on</strong>s should beproperly supervised and kept under regular observati<strong>on</strong> and that a pers<strong>on</strong> with a suitableextinguisher should be stati<strong>on</strong>ed to keep watch <strong>on</strong> areas not visible to <strong>the</strong> welder.Manual 07, “Safety of Operati<strong>on</strong>s—Engineering Department,” states that <strong>the</strong> staffchief engineer or engineering officer team leader must ensure that all measures andprecauti<strong>on</strong>s that are necessary for <strong>the</strong> safety of those c<strong>on</strong>cerned are taken before any repairor maintenance work begins. Investigators reviewed <strong>the</strong> <strong>Ecstasy</strong> records of hot workpermits issued for various maintenance tasks outside <strong>the</strong> ship’s machine shop andworkshop. The log and copies of approved permits do not include an applicati<strong>on</strong> or anapproval for a welding project in <strong>the</strong> ship’s main laundry <strong>on</strong> July 20, 1998. After <strong>the</strong> fire<strong>on</strong>board <strong>the</strong> <strong>Ecstasy</strong>, Carnival Cruise Lines revised its SMS to include safeguards againstunauthorized welding. See “O<strong>the</strong>r Informati<strong>on</strong>,” later in this report.Manual 08, “Safety of Operati<strong>on</strong>s—Hotel Services,” states that <strong>the</strong> laundrymanager is resp<strong>on</strong>sible for, am<strong>on</strong>g o<strong>the</strong>r tasks, ensuring <strong>the</strong> safe operati<strong>on</strong> of all laundryequipment and <strong>the</strong> proper cleanliness of <strong>the</strong> laundry room, laundry equipment, and <strong>the</strong>laundry crew galley. The manual lists 17 required safety procedures for <strong>the</strong> laundry area.The procedures specify <strong>the</strong> required operating temperatures for washers, dryers, and <strong>the</strong>mangle, proper handling of chemicals, and measures for handling linens, clo<strong>the</strong>s, anduniforms. The laundry safety procedures also include prohibiting smoking in <strong>the</strong> laundryroom and performing a fire risk assessment at regular intervals.31 At <strong>the</strong> time of <strong>the</strong> <strong>Ecstasy</strong> accident, Manual 03 did not include a secti<strong>on</strong> <strong>on</strong> job hazard analysis. Since<strong>the</strong> accident, Carnival Cruise Lines has developed and added a chapter “Safe Systems of Work - Job HazardAnalysis.”
Factual Informati<strong>on</strong> 35 Marine Accident ReportAccording to Carnival Cruise Lines’ officials, at <strong>the</strong> time of <strong>the</strong> <strong>Ecstasy</strong> accident,all officers and crewmembers assigned to ships in <strong>the</strong> company’s fleet had received ageneral overview training of <strong>the</strong> SMS. Employees had been given specific training inthose areas of <strong>the</strong> SMS pertaining to <strong>the</strong>ir duties. The company had established a scheduleof weekly reviews of <strong>the</strong> SMS, which included departmental meetings during whichsupervisors reviewed provisi<strong>on</strong>s of <strong>the</strong> SMS with crewmembers.Additi<strong>on</strong>al Oversight PracticesAccording to Carnival Cruise Lines’ officials, to complement its SMS, <strong>the</strong>company retained some management oversight practices that it had in place before itdeveloped its SMS. Management representatives, typically a shoreside ship supervisor ora port engineer or port captain, visited each ship in <strong>the</strong> company’s fleet at least <strong>on</strong>cem<strong>on</strong>thly to ensure that shipboard pers<strong>on</strong>nel were following and practicing corporate safetymanagement policies. In additi<strong>on</strong>, Carnival Cruise Lines had a quality c<strong>on</strong>trol committee,headed by <strong>the</strong> company president, that visited each ship yearly to meet with <strong>the</strong> master,department heads, and <strong>the</strong> entire crew to answer any questi<strong>on</strong>s <strong>on</strong> corporate policy andvessel operati<strong>on</strong>s.Medical and PathologicalMedical FindingsMedical resp<strong>on</strong>ders examined at least 70 passengers and crewmembers todetermine whe<strong>the</strong>r <strong>the</strong>y were injured and required additi<strong>on</strong>al medical treatment. Sixpassengers were treated by medical pers<strong>on</strong>nel and local hospitals for pre-existingc<strong>on</strong>diti<strong>on</strong>s; three passengers were treated for smoke inhalati<strong>on</strong>. Fourteen crewmemberswere treated for minor injuries, including smoke inhalati<strong>on</strong>, chest pain, lower back pain,cervical strain, knee pain, and a knee c<strong>on</strong>tusi<strong>on</strong>.Toxicological TestingCarnival’s requirements. At <strong>the</strong> time of <strong>the</strong> <strong>Ecstasy</strong> accident, Carnival CruiseLines’ health and safety manual c<strong>on</strong>tained <strong>the</strong> following requirements pertaining to drugtesting (italics added for emphasis):1. All testing for drugs will be by <strong>the</strong> analysis of urine.2. Prospective Company seafarers may be required to undergo drug testing priorto an offer of employment being made.3. Company seafarers may be required to undergo periodic drug testing.4. Unannounced testing may be carried out at intervals, initiated by Company. Allunannounced drug testing, including urine sampling, will be carried out byshore pers<strong>on</strong>nel <strong>on</strong>ly.