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

Analysis 67 Marine Accident ReportFurther, this method of accounting for individuals can be dangerous, depending on theemergency conditions. In this accident, two crewmen who were unable to exit their deckbecause of heavy smoke initially sought refuge in a crew cabin. They were followingsurvival techniques in a shower when one of the men panicked because of worseningsmoke conditions. He left the toilet facility and began feeling his way along the bulkheadof the smoke-filled passageway. The other crewman followed the first man to try andconvince him to return to the safety of the shower. The severity of the smoke-inhalationinjuries that they sustained was limited only because fire team members searching the areahappened upon the crewmembers. (Additional analysis of the trapped crewmen’s situationappears later in this report.) The Safety Board concludes that the procedures used by theEcstasy’s shipboard personnel did not adequately account for passengers andcrewmembers during the emergency.SOLAS leaves the method of devising procedures to account for passengers andcrew during an emergency up to the companies. The ISM Code presently stipulates theneed for cruise ship companies to account for passengers and crewmembers. Coursesdeveloped by the Coast Guard and the marine industry to meet the emergencypreparedness requirements contained in amendments to the STCW stipulate that thepreferred method of accounting for people at muster stations is by name so that rescuecrews can employ more systematic methods of searching for missing persons.The Safety Board is aware that the Ecstasy maintained an electronic manifest of allpassengers on the ship. When passengers boarded the ship, their names were entered into acomputer and they were issued magnetic cards that tracked their purchases and theirdebarkations and embarkations at travel stops. Given the advancements in computertechnology, magnetic cards or other computer-based devices and equipment could be usedto quickly determine who has not mustered during an emergency.Because even short delays in identifying missing people can have fatalconsequences, it is essential for companies to have systematic procedures to account forpeople by name. Further, the Ecstasy accident demonstrates that accounting proceduresmust address different emergency scenarios. As mentioned previously, the location andmovement of the fire forced the closure of three MVZs, and, as a result, some Ecstasypassengers had to be moved to other muster stations. Depending on the time of the alarmand the location of passengers and crewmembers, several hundred people might be forcedto report to an alternate muster station.The Safety Board is aware that Holland-America, another subsidiary of CarnivalCorporation, accounts for its passengers by taking roll at muster stations. Despite itsexperiences in the Ecstasy accident, however, Carnival Cruise Lines has not indicated thatit intends to change its accountability procedures. The Safety Board is convinced that,during a fire emergency, an accurate accounting by name is essential for passenger andcrew safety. The accounting methods used on a ship should be incorporated into the SMSprocedures presently required by SOLAS. The Safety Board believes, therefore, that, forthe ships in its fleet, Carnival Corporation should develop plans to account for allpassengers in common emergency scenarios, in particular, a situation involving theinaccessibility of one or more MVZs and/or muster stations.