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

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Analysis 68 Marine Accident ReportLifejacket DistributionIn 1997, LR certified that the number, type, and arrangement of lifesavingequipment on board the Ecstasy met the requirements of SOLAS 74, as amended in 1998.At that time, the ship carried 4,094 lifejackets to outfit a full crew and passengercomplement of 3,560 people. The Board is pleased to note that Carnival Cruise Linessubsequently elected to exceed the minimum SOLAS requirement for extra lifejackets,increasing the number by more than 20 percent, to a total of 4,946. On the day of the fire,the ship was carrying 3,481 people, meaning that the ship had 1,465 extra lifejackets.Despite having more than enough lifejackets on board the vessel, some passengersperceived a lack of available lifejackets when the actions of the crewmembers were notconsistent with information provided at the practice drill and posted on stateroomplacards. Before the emergency, passengers were told to obtain lifejackets from theirstaterooms when the general alarm sounded and to proceed immediately to their musterstations. They were also told that if they were unable to obtain their lifejackets from theirstaterooms at the time of the alarm, they should proceed immediately to their musterstation and lifejackets would be issued to them. During the emergency, the cruise directorreinforced these instructions when he announced that passengers who could not obtaintheir lifejackets from their staterooms should proceed immediately to muster stations.The responses from the passengers who answered the Safety Board survey showedthat 79 of 126 people either obtained lifejackets from their cabin or were providedlifejackets by crewmembers. Forty-seven passengers said that they never receivedlifejackets. Two passengers stated that they became concerned when they asked forlifejackets and a crewmember started to pass them out and then reportedly was ordered tostop doing so. One passenger stated that one crewmember told her not to retrieve herlifejacket from her stateroom and later another crewmember told her to get her lifejacketfrom her cabin; however, when she attempted to do so, she could not reach her stateroombecause of the smoke.At the public hearing on the Ecstasy accident, the master testified that he wanted tomaintain a calm environment and avoid panic among the passengers by conveying theimpression that the situation was under control and did not warrant the distribution oflifejackets. While the lack of uniformity in distributing the lifejackets did not cause a masspanic, it did cause several passengers to become uneasy. Moreover, when a concernedpassenger attempted to return to her stateroom to retrieve her lifejacket, she was put at riskof potential injury. The Safety Board concludes that the lack of consistency between theinformation about lifejacket distribution provided at the practice drill and the actualprovision of lifejackets at the muster stations created unnecessary confusion among somepassengers on the Ecstasy.After the Ecstasy fire, in fall 1998, Carnival Cruise Lines began requiring itssenior deck, engineering, and other officers to attend courses in crisis management andhuman behavior and crowd management so that they met the STCW training standardsthat became effective in January 1999. The company also required crewmembers insafety-related positions to attend crowd management training.
Analysis 69 Marine Accident ReportAs part of its mandate, the Coast Guard conducts quarterly CVEs of a vessel’soperations to determine if they comply with SOLAS safety requirements. In this capacity,the Coast Guard could assist cruise ship companies in determining the effectiveness ofmuster drills addressing various contingencies. The Safety Board, therefore, believes that,as part of its quarterly CVEs, the Coast Guard should review a drill scenario in which oneor more MVZs are inaccessible and evaluate the procedural effectiveness of the crew incrowd control, crisis management, lifejacket distribution, and passenger accountability.Locally Sounding Smoke AlarmsWhen the first fire alarm sounded on the bridge, the master ordered two bridgeofficers to investigate the source of the alarm and report their findings. About 20 minuteselapsed before he ordered the aft three MVZs secured and the cruise director to announcethat passengers who were quartered in the aft areas should either leave or not return to theareas, depending upon their present location. The master did not order the general alarmuntil 50 minutes after the first fire alarm sounded on the bridge.Of 126 passengers who answered the Safety Board survey, 72 responders, or morethan half, said that they smelled or saw smoke in the staterooms and passageways beforehearing the general alarm. A few passengers indicated that they saw a television report onthe fire before receiving any emergency notification. One passenger said that, upon seeingsmoke, she returned to her stateroom to awaken a sleeping relative. A crewman becameaware of emergency conditions when smoke entered his room through a vent.Sounding the general alarm after a fire team verifies the location of the fire doesnot necessarily provide enough time to escape from a smoke-filled environment. TheVistafjord and Universe Explorer accidents demonstrated how quickly smoke could spreadduring a fire and that passengers and crewmembers needed to be warned immediately ifsmoke was in the area. As a result of its investigation of these two accidents, the SafetyBoard issued Safety Recommendations M-97-39 and -40 asking the Coast Guard topropose that the IMO require locally sounding alarms in passenger and crewaccommodation areas. The Coast Guard subsequently made the proposal to the IMO,which referred the action for consideration to an MSC subcommittee. In Spring 2000,because of the concerns of some Administrations and the technical concerns of the ICCL,the MSC did not consider the locally sounding alarm proposal. It was removed from theagenda and no further action was taken on it. The next available time that the proposal canbe introduced as an agenda item is Spring 2002. The Coast Guard is evaluating whatactions it might take on the proposal.The Safety Board also issued Safety Recommendations M-97-37 and -38 askingthat the ICCL advise its members to install locally sounding smoke alarms in passengerand crew accommodation areas. The ICCL at first advised the Safety Board that therecommendations would be an agenda item at the next meeting of its technical committeeand then later asked that the recommendations remain in an open status pending action bythe IMO.
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PB2001-916401NTSB/MAR-01/01NATIONAL
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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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Page 96 and 97: Appendix B 86 Marine Accident Repor
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Fire on Board the Liberian Passenger Ship Ecstasy, Miami, Florida ...

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