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

Factual Information 48 Marine Accident ReportCarnival Cruise Lines’ Postaccident ActionsOn August 10, 1998, Carnival Cruise Lines, as part of its SMS program, issued toits fleet Operations Safety Bulletin (OSB) No 04-98, which states, in part:DESCRIPTION: Lint and other fibrous material might collect in the ship’sexhaust system and can pose a serious fire hazard. Even with our filtering system,a certain amount can get past the present filters. This OSB is being provided toalert the vessels to this potential fire risk.ACTION REQUIRED: Immediately conduct an extensive examination of allducts that are part of the exhaust system which originates from or near thelaundry. You are to remove all panels that are necessary to enable personnel todetermine the amount of lint in the duct system. Any lint found is to be removedby all available means including but not limited to, vacuuming, sweeping, handcleaning, washing, etc. You are to take photos prior to cleaning as well as after thecleaning to establish the status before and after.As the SMS requires, all dryer filters are to be inspected, cleaned and logged. Thefilter cleaning schedule is to be posted with records for signatures as per previousinstructions. A thorough fire risk and cleanliness inspection of all areas of thelaundry and adjacent spaces are to be completed on a regular basis and logged.Ensure that any outstanding work order for laundry equipment repairs becompleted, especially any dryer thermostats.ATTENTION ENGINEERING: Effective immediately, locate a suitable space tolock up all portable welding machines to prevent unauthorized use. Continue touse the Hot Work Permit as required by the SMS.COMPLETION REPORT REQUIRED: When finished with your examination,forward a report of your findings, including photos to the attention of Director ofFleet Safety. The time for completion is 15 September 1998.Carnival Cruise Lines made procedural changes to facilitate the readyidentification of crewmembers whose primary emergency duties involved crowdmanagement. According to the ship’s safety officer, before the Ecstasy accident, he hadprocured bright green hats, imprinted with the word “crew,” to issue to employees whowere in charge at muster stations. He had not had the opportunity, however, to distributethe hats before the Ecstasy sailed on July 20. At the suggestion of Safety Boardinvestigators, Carnival Cruise Lines revised the information presented at its emergencydrills to include an announcement advising passengers that crewmembers wearing thegreen hats were proficient in English and were specifically assigned to assist passengersduring an emergency.Carnival Cruise Lines installed equipment and made system modifications toreduce the amount of lint buildup in the ventilation ducts. The company added lint screensto all exhaust louvers in the main laundry and installed turbo-filters on the laundry dryersto reduce the amount of lint entering the exhaust ducts. The company also modified theexhaust plenums and fire dampers on the Ecstasy as well as other Fantasy Class ships inits fleet.