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

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Factual Information 38 Marine Accident ReportTable 4. Damage by Deck AreaDeck Location Observed Conditions and Damage2 Laundry crew galley(pantry)3 Refrigerators and dryprovision stores4 Passenger cabinsand corridorsThe galley and its contents were heavily covered with soot. Areashowed no evidence of flame exposure.Vent in the overhead above a sink contained soot.Port side: The overhead ventilation duct showed signs of intense heat.Near this vent, the steel deck was buckled and its paint was charredand cracked. The stainless steel sheathing of the cool storage spacewas warped, discolored blue, and had pulled away from joints.Starboard side: No visible damage. Vent covers had soot deposits.<strong>Fire</strong> damage, which included scorched carpeting and furnishings, waslimited to passenger cabins and corridor area nearest the WTDs.* The strings that directed the linens through the mangle were coated with wax.Survival FactorsThis section contains the regulatory requirements, Carnival Cruise Lines’provisions and procedures related to shipboard emergency training and drills, passengerfeedback obtained from interviews and a survey that the Safety Board mailed to a sampleof passengers, 32 and a detailed description of the actions by the emergency responders tothe incident.Regulatory Requirements:The following are excerpts from the SOLAS Regulations:Regulation 18: 3.1, “Emergency Training and Drills”:Each member of the crew shall participate in at least one abandon drill and onefire drill every month. The drills of the crew shall take place within 24 hours ofthe ship leaving port if more than 25 percent of the crew have not participated inabandon ship and fire drills on board that particular ship in the previous month.The Administration may accept other arrangements that are at least equivalent forthose classes of ship for which this is impracticable.3.2 On a ship engaged on an international voyage which is not a shortinternational voyage, musters of passengers shall take place within 24 hours aftertheir embarkation. Passengers shall be instructed in the use of the life-jacket andthe actions to take in a emergency.Regulation 25, “Drills”:On passenger ships, an abandon ship drill and a fire drill shall take place weekly.32 See “Postaccident Survey,” which appears later in this report.
Factual Information 39 Marine Accident ReportRegulation 53, “Muster List and Emergency Instructions”:The muster list shall show the duties assigned to members of the crew in relationto passengers in case of emergency. These duties shall include: warning thepassengers; seeing that they are suitably clad and have donned their lifejacketscorrectly; assembling passengers at muster stations; keeping order in thepassageways and on the stairways and generally controlling the movements of thepassengers; ensuring that a supply of blankets is taken to the survival craft.Emergency Procedures and DrillsCrew training. The Ecstasy safety officer stated that all crewmembers on boardhad participated in a “vessel familiarization program,” as required by STCW. Investigatorsreviewed the program curriculum and a sampling of personnel training files. The coursesprovided by the safety officer included Safety Communication, Signs and Alarms; CrewMuster Stations, How to Locate and Don Lifejackets; Man Overboard Initial Action; <strong>Fire</strong>Emergency Initial Action; Medical Emergency Initial Action; Close and OpenWeathertight, Watertight, and <strong>Fire</strong> Screen Doors; and Vessel Familiarization Assessment.A station bill on board the Ecstasy specified the responsibilities and emergencystations for each crewmember in the event of an emergency. According to the safetyofficer, fire drills were held weekly and were conducted as if an actual emergency existed.Crewmembers were required to report to fire stations with firefighting equipment andsimulate a response to a fire.At the time of the accident, Carnival Cruise Lines had not developed a crowdmanagement plan, including crowd control training for crewmembers. According to theEcstasy’s safety officer, he and the staff captain provided instruction on proper crowdcontrol procedures to crewmembers who were assigned to direct passenger evacuation,muster station leaders, lifeboat commanders, and other supervisory personnel during theweekly emergency drills and other routine training. The safety officer stated that the CoastGuard tested the crewmembers’ knowledge of crowd management procedures duringannual and quarterly CVEs. He indicated that, during emergencies when routineprocedures did not apply, the master or other officers provided instructions specific to thesituation.Passenger drill. Before the Ecstasy departed Miami, passengers were required toparticipate in an abandon ship, or muster, drill. According to the cruise director, hefollowed a script during the drill, which contained the following instructions:• Crewmembers will guide passengers to their muster stations and instruct themhow to wear the lifejackets.• If passengers must abandon ship, lifeboats would be lowered to theembarkation deck to allow them to board the boats.• If passengers do not have enough lifejackets in their cabin for the number ofoccupants including children, a cabin steward will provide extra lifejackets.
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 12 and 13: Factual Information 2 Marine Accide
Page 20 and 21: Factual Information 10 Marine Accid
Page 65 and 66: 55 Marine Accident ReportAnalysisGe
Page 67 and 68: Analysis 57 Marine Accident ReportT
Page 69 and 70: Analysis 59 Marine Accident Reportf
Page 71 and 72: Analysis 61 Marine Accident Reports
Page 73 and 74: Analysis 63 Marine Accident Reporti
Page 75 and 76: Analysis 65 Marine Accident ReportA
Page 77 and 78: Analysis 67 Marine Accident ReportF
Page 81 and 82: Analysis 71 Marine Accident ReportM
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
Page 94 and 95: 84 Marine Accident ReportAppendix B
Page 96 and 97: 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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