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

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Analysis 58 Marine Accident Reportraised position, which left a gap between the rollers and the entry housing to the adjacentexhaust ducts. This gap allowed the fire to spread into the roller exhaust ducts, which wasevidenced by heat damage to the paint on the exhaust ducts. In addition, the roller exhaustducts contained several inches of burned debris.Postaccident examination of the mangle blowers revealed that they were cakedwith partially burned lint and wax. The impeller on the aft fan had disintegrated, leavingrust-colored metal flakes imbedded in the lint and wax. The absence of an operational fanin this duct allowed more lint to accumulate in it than in the forward duct, which resultedin the aft duct sustaining far greater heat damage.In addition to the damage in the mangle’s vertical exhaust ducts, investigatorsfound 2-3 inches of burned debris in the main ventilation duct above the machine. <strong>Fire</strong>damage was present throughout the mangle exhaust duct system of the Ecstasy, indicatingthe fire probably proceeded through this system into the air conditioning room where itspread through the plenum exhaust ducts onto the mooring deck. The fire then ignited lintthat had been exhausted to the mooring deck and that had become imbedded in themooring line. The burning lint, in turn, ignited the mooring lines, which fueled a large,intense fire that raged for more than 2 hours, damaging deck areas above, forward, andbelow the mooring deck. Hot gases and smoke transferred from the mooring deck to otherareas of the vessel through the air conditioning ventilation system before bridge personnelsecured the system. The ventilation supply intakes for the stern thruster room, which arenext to the laundry room’s exhaust plenum on the mooring deck, transferred smoke andheat from the fully developed fire through the vent ducts into the stern thruster room,causing extensive damage there. Hot gases and smoke traveling through the ventilationducts also caused extensive heat damage and sooting in the steering gear rooms, severalpassenger cabins on decks Nos. 4, 5, 6 and 7, and the laundry crew galley. The injection ofsmoke and fire gases from the mooring deck fire into the intake systems caused the almostsimultaneous activation of smoke detectors on four different decks.Based on the amount of burned lint debris on the Ecstasy, investigators examinedthe main laundries of other Fantasy vessels and found large lint accumulations in theirlaundry exhaust systems, particularly the mangle exhaust ducts next to and above themachine. On one such ship, the Fantasy, the chief engineer stated that he had initiated aprogram of cleaning the exhaust ducts and plenum about every 20 days after he hadexperienced a problem closing a damper and had found the ducts clogged with lint.Although crew personnel had cleaned the ducts 4-5 days before the Safety Board’sinspection, investigators found several inches of lint buildup in the dryer ducts and theplenum. They also found that the mangle duct contained about ½ of an inch of lint and wascoated with a waxy/oily substance. On the mooring deck, investigators found that lintexhausted through the ventilation system had settled on and become imbedded in themooring lines.Flammability tests of lint collected from the sister ships showed that the materialwas ignited easily by a spark and burned for several seconds, leaving little residualmaterial behind. Therefore, the large lint buildup in the exhaust vents and the ventilationsystem represented such a hazard that a fire might have occurred even if the fitters had
Analysis 59 Marine Accident Reportfollowed the required welding permit procedures and had arranged to have a vessel safetyofficer present. Upon observing the laundry area, a safety officer probably would haverequired the fitters to eliminate the obvious lint that was on the deck and, possibly, the linton the mangle. At the time of the accident, Carnival Cruise Lines’ SMS did not containprocedures for inspecting or maintaining the laundry exhaust vents. The safety officerprobably would not have examined the vents in the overhead and identified the greatestfire risk. Thus, when the fitters began to work, the sparks shooting upward from theirwelding might still have ignited a blaze that crewmembers could not put out with theavailable fire extinguishers. The Safety Board concludes that the lint that accumulated inthe ventilation duct of the main laundry created a serious fire hazard on the Ecstasy.As a result of the Ecstasy fire, on October 20, 1998, the Safety Board issued thefollowing safety recommendations to cruise vessel owners and operators embarkingpassengers from United States ports:M-98-125Immediately inspect, within your fleet of ships, the laundry ventilation systems,including ducts, plenums, and exhaust terminuses, for any combustible material,such as lint, and clean the systems, as necessary, to reduce the risk of fire.(Urgent)M-98-126Institute a program to verify on a continuing basis that the laundry ventilationsystems, including ducts and plenums, remain clean and clear of any combustiblematerial that poses a fire hazard on your vessels.Of the 22 recipients, all but Bergen Line Services responded that they had takenmeasures and had initiated on-going inspection programs to comply with therecommended actions. As a result, the Safety Board classified Safety RecommendationsM-98-125 and -126 “Closed—Acceptable Action.”The Safety Board’s investigation of the Ecstasy fire, specifically its focus on lintbuildup problems, and its Safety Recommendations M-98-125 and -126 also prompted abeneficial change to the Coast Guard’s vessel inspection guidelines. On May 21, 2000, theCoast Guard amended Marine Safety Manual, Volume II to require that, as part of a regularCVE, its inspectors examine a vessel’s laundry exhaust ducts for potential safetyproblems. In addition, the Coast Guard inspectors must review the cruise ship company’sSMS to ensure that it contains procedures for routine cleaning and maintenance of thelaundry room vents. The Coast Guard began inspecting laundry room ventilation systemsin November 1998.According to Coast Guard officials, since the cruise ship companies haveestablished procedures for inspecting and maintaining the laundry room ventilationsystems on their vessels, Coast Guard CVE inspectors reportedly have found that, in everycase, the ventilation ducts on cruise ships have had no unsafe buildup of lint.
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PB2001-916401NTSB/MAR-01/01NATIONAL
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National Transportation Safety Boar
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Contents iv Marine Accident ReportS
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viMarine Accident ReportAcronyms an
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viiiMarine Accident ReportExecutive
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Factual Information 2 Marine Accide
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Page 18 and 19: Factual Information 8 Marine Accide
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Page 75 and 76: Analysis 65 Marine Accident ReportA
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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
Page 98 and 99: Appendix C 88 Marine Accident Repor
Page 100 and 101: Appendix D 90 Marine Accident Repor
Page 102 and 103: 92 Marine Accident ReportAppendix F
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