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

Analysis 60 Marine Accident ReportThe Safety Board concludes that the procedures and standards for inspecting andmaintaining laundry ventilation systems adopted by the marine industry and governmentagencies following the Ecstasy fire will improve safety on cruise ships.Adequacy Of Management Safety OversightThe presence of lint in the main laundry and the mooring deck, specifically thebuildup in the mangle exhaust ducts and the particles imbedded in the mooring line,represented a fire hazard that could have been ignited by any number of sources. However,the decision of the fitters to weld before arranging for a shipboard safety official to assessthe area for risks raised questions about the adequacy of Carnival Cruise Lines’ SMS.When the first galley fitter broke the mangle bolt, he decided to weld it back inplace. He returned to the fitter workshop to obtain a portable welding machine and relatedequipment while the second fitter obtained a fire blanket. After setting up the weldingequipment, the fitters energized the welding machine and inserted an electrode into theelectrode holder. For safe operations, a welding machine should not be energized untilimmediately before welding.Carnival Cruise Lines’ SMS manual contains numerous safety procedures forworkers performing welding operations, including a prohibition against undertakingwelding “unless the requirements of the ‘Hot Work Permit’ are satisfied.” The permitrequirements for welding include applying in writing to the duty engineering officer, who,before approving the application, must assess the intended work area for hazards andeither eliminate them or take precautions to control the risk, such as posting a fire guard.Neither fitter followed the hot work permit procedures. They both testified that they wereaware of the requirement to obtain a hot work permit and that they intended to apply forone after setting up the welding equipment. They also admitted that, when they energizedthe welding machine, they were not following proper welding procedures that they learnedin welding school or during their service on Carnival’s vessels. The Safety Boardconcludes that the fitters’ (welders’) lack of full compliance with the hot work permitprocedures in Carnival Cruise Lines’ SMS manual increased the risks of fire in the mainlaundry.Following this accident, Carnival Cruise Lines revised its SMS to require thatengineering supervisors secure all portable welding machines to prevent employees fromcircumventing required safety procedures. Now, the welding machines are not released tofitters until a hot work permit is issued.Although Carnival Cruise Lines’ SMS manual contained extensive proceduralsafeguards for welding, it did not prevent unauthorized welding. Carnival Cruise Lines isone of several subsidiaries of Carnival Corporation. The Safety Board is concerned thatthe SMS procedures and manuals for the other vessels in Carnival Corporation’s fleet maynot contain processes to prevent employees from performing unauthorized hot work. TheSafety Board believes, therefore, that, for the ships in its fleet, Carnival Corporation