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

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Factual Information 54 Marine Accident Reportcompanies have revised their SMS to include procedures for maintaining the ventilationducts in a fire-safe condition.Qualitative Failure AnalysisRegulatory requirements. In 1988, the Coast Guard issued regulations(46 CFR 62, “Vital System Automation” 43 ) requiring the use of a qualitative failureanalysis of certain automated systems, including propulsion control systems. In proposingthe regulatory requirement that designers, manufacturers, and/or shipyards perform andsubmit system failure analysis, the Coast Guard stated that the use of advanced automationtechnologies such as electronics and microprocessors made it increasingly difficult, “attimes impossible, for the Coast Guard, ship owners/operators, and classification societiesto evaluate safety.” The Coast Guard further stated:The Coast Guard has chosen to propose safety performance standards that, to thegreatest extent practicable, state the desired operation or function withoutaddressing detailed design criteria…As an alternative to detail evaluation, theCoast Guard proposes (to require) a failure analysis of the design and a selfcertificationof design compliance to certain…standards. [This process]emphasizes the responsibility of the parties most familiar with any automationsystem, i.e., the designer and manufacturer, to evaluate and certify the safety ofthe system. It also provides an evaluation means that is suited to technologicalchanges. In most cases, the failure analysis will identify a preferred fail-safe state.Systems that would be required to be independent, that is, have arrangements thatprovide a level of safety and reliability equivalent to complete duplication,include:• Controls systems• Alarms and instrumentation (monitoring systems)The IMO subsequently adopted regulations requiring that a failure modes andeffects analysis (FMEA) 44 be performed for the machinery and control systems of highspeedvessels. 45 The IMO and classification societies presently do not require the use ofFMEA for passenger vessel propulsion system designs. 4643 Subpart 62.10 defines system as an arrangement of elements that interact to perform a specificfunction and vital system as that which is essential to the safety of the vessel, its passengers, and its crew.44 An FMEA is an inductive approach to identifying engineering design deficiencies by examining eachindividual component or process in a system to determine how its failure or deviation from intendedperformance might affect the entire system. By conducting a FMEA, engineers can modify the design of asystem before it is built to avoid catastrophic or significant system failures.45 The International Code of Safety for High Speed Craft, adopted in 1994, mandated the use of FMEAbecause these craft employed new technologies.46LR’s Propulsion and Steering Machinery Redundancy contains provisional rules that are in additionto the classification society’s Rules and Regulations for the Classification of Ships. LR’s provisional rules,which are optional for vessel owners, stipulate the use of FMEA in designing propulsion systems, electricalpower supplies, essential services, control systems, and steering arrangements. According to LR’sprovisional rules, the FMEA report must show that a single failure in the propulsion and related auxiliarysystems will not cause loss of all propulsion or steering capability.
55 Marine Accident ReportAnalysisGeneralThis analysis first identifies factors that can be readily eliminated as causal orcontributory to the fire and determines where and how the fire started and how it spread.The report then discusses the following major safety issues, which were identified duringthe investigation:• Adequacy of management safety oversight;• Adequacy of fire protection systems;• Adequacy of passenger and crew safety; and• Adequacy of engineering systems design.This report also discusses the effectiveness of the emergency response effort.ExclusionsThe weather was not a factor in this accident. The vessel’s navigation, propulsion,and steering systems had no bearing on the cause of the fire. No engineering difficultiesoccurred before the outbreak of the fire. From documents and statements, the SafetyBoard determined that all officers were properly licensed and certified by the Liberiangovernment and were qualified to serve in their positions. Postaccident drug and alcoholscreenings of 79 crewmembers were negative for 76 individuals. The first officer testedpositive for marijuana, indicating that he had used the drug sometime in the weeks beforethe fire occurred. However, based on witnesses’ descriptions of the first officer’s actionson the bridge during the emergency, no behavioral evidence indicated that he wasimpaired by drugs at the time of the fire. Because the personnel who tested positive fordrugs have been dismissed from service and because of the improvements that CarnivalCruise Lines has made to its drug-testing program since this accident, the use of drugs andpostaccident testing will not be discussed further in this report.Accident AnalysisThe Ecstasy experienced a major fire at the aft end of the ship that affected twoMVZs. A combination of fire, heat, and smoke damaged the main laundry room, the sternthruster room, an air conditioning room, an electrical equipment room, the aft mooringdeck, and the steering gear room. In addition, some passenger staterooms and crew cabinson deck Nos. 2, 4, 5, and 6 sustained heat and smoke damage. The cruise ship
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Contents iv Marine Accident ReportS
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viiiMarine Accident ReportExecutive
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Page 96 and 97: Appendix B 86 Marine Accident Repor
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Page 100 and 101: Appendix D 90 Marine Accident Repor
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Fire on Board the Liberian Passenger Ship Ecstasy, Miami, Florida ...

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