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

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National Transportation Safety Board. 2001. <strong>Fire</strong> On Board the Liberian Passenger Ship Ecstasy, Miami,Florida, July 20, 1998. Marine Accident Report NTSB/MAR-01/01. Washington, DC.Abstract: On the afternoon of July 20, 1998, the Liberian passenger ship Ecstasy had departed the Port of Miami,Florida, en route to Key West, Florida, with 2,565 passengers and 916 crewmembers on board when a fire started inthe main laundry shortly after 1700. The fire migrated through the ventilation system to the aft mooring deck wheremooring lines ignited, creating intense heat and large amounts of smoke. As the Ecstasy was attempting to reach ananchorage north of the Miami sea buoy, the vessel lost propulsion power and steering and began to drift. The masterthen radioed the U.S. Coast Guard for assistance. A total of six tugboats responded to help fight the fire and to tow theEcstasy. The fire was brought under control by onboard firefighters and was officially declared extinguished about2109. Fourteen crewmembers and eight passengers suffered minor injuries. One passenger who required medicaltreatment as a result of a pre-existing condition was categorized as a serious injury victim because of the length of herhospital stay. Carnival Corporation, Inc., the owner of the Ecstasy, estimated that losses from the fire and associateddamages exceeded $17 million.The National Transportation Safety Board determines that the probable cause of fire aboard the Ecstasy was theunauthorized welding by crewmembers in the main laundry that ignited a large accumulation of lint in the ventilationsystem and the failure of Carnival Cruise Lines to maintain the laundry exhaust ducts in a fire-safe condition.Contributing to the extensive fire damage on the ship was the lack of an automatic fire suppression system on the aftmooring deck and the lack of an automatic means of mitigating the spread of smoke and fire through the ventilationducts.The major safety issues discussed in this report are as follows: adequacy of management safety oversight, adequacyof the fire protection systems, adequacy of passenger and crew safety, and adequacy of engineering system design.As result of its investigation of this accident, the Safety Board makes recommendations to the U.S. Coast Guard,American Classic Voyages, Carnival Corporation, Inc., Carnival Cruise Lines, Crystal Cruises, Disney Cruise Line,Norwegian Cruise Line, Orient Lines, P&O Princess Cruises International, Ltd., Radisson Seven Seas Cruises, RegalCruises, Renaissance Cruises, Inc., Royal Olympic Cruises, Royal Caribbean Cruises, Ltd., and Silversea Cruises,Ltd., ABB, Inc., and the International Association of Classification Societies.The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety BoardAct of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, studytransportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Boardmakes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, andstatistical reviews.Recent publications are available in their entirety on the Web at . Other information about available publications alsomay be obtained from the Web site or by contacting:National Transportation Safety BoardPublic Inquiries Section, RE-51490 L'Enfant Plaza, S.W.Washington, D.C. 20594(800) 877-6799 or (202) 314-6551Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. Topurchase this publication, order report number PB2001-916401 from:National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(800) 553-6847 or (703) 605-6000The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reportsrelated to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
iiiMarine Accident ReportContentsAcronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viExecutive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viiiFactual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Activities on the Bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6<strong>Fire</strong> and Rescue Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Master . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Staff Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Safety Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Chief Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Galley Fitters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Certification and Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18General Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Main Laundry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Aft Mooring Deck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Operating Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Low-location Lighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24<strong>Fire</strong> Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Ventilation Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Vessel Certification and Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31International Safety Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Carnival Cruise Lines’ Safety Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Additional Oversight Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Medical and Pathological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Medical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Operating Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Other Damaged Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
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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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Factual Information 44 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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