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

More documents

Recommendations

Info

Analysis 72 Marine Accident Reportcrewmembers in their cabins. If they did not have the time and opportunity to reach anemergency exit, it is unlikely that they had time and opportunity to locate a corridortelephone to let someone know they needed immediate help. In its report on the UniverseExplorer accident, the Safety Board discussed the simple call button system used tosummon flight attendants on commercial airlines. Hospitals and nursing facilities employa similar system to enable patients to signal for nursing assistance. The Safety Boardbelieves that cruise ship companies should install emergency call systems in passengerstaterooms and crew cabins so that people trapped during a fire emergency will have ameans of signaling their location.Emergency ResponseDespite some setbacks, including an overload of the smoke alarm system and anunusually large and intense blaze, the Ecstasy personnel conducted the onboard responseto the fire efficiently and in accordance with Carnival Cruise Lines’ procedures. Themaster effectively managed and monitored the incident by having the safety officeroversee the fire teams, by having the hotel manager maintain communications withshoreside management and the COTP, and by having the cruise director annotate timesand events on a emergency action checklist. The ship’s firefighters demonstrated theeffectiveness of their previous drills and firefighting training by quickly musteringequipped teams and containing the fire to the mooring station. With help of the tugscooling the exterior of the Ecstasy’s stern, shipboard firefighters extinguished the fire asthe fuel load was consumed. The safety officer had fire teams search the quarters in thearea affected by the fire; the teams rescued two crewmembers who were trapped in a cabinnear the laundry.The shoreside response was effective because the unified command systememploying two operating bases allowed several agencies to jointly manage the emergencyresponse. The Coast Guard and Miami Beach FD initially operated from the MSO-MiamiOperations Center, and Miami-Dade FD, Carnival, port officials, and area police operatedfrom a post established at the Port of Miami. Miami-Dade FD subsequently sent anadditional representative to the MSO-Miami location. The parties remained in telephonecommunications with each other and officers on board the Ecstasy to coordinate activitiesthroughout the incident.Shoreside officials indicated that the participation of Carnival, the Coast Guard,and local agencies in joint planning sessions and practice drills simulating accidentscenarios attributed to the good response coordination. In addition, Carnival’s crisismanagement plan, which included specific personnel assignments for managing a firecondition on the Ecstasy and for handling the safety and comfort of passengers andcrewmembers, was adequately implemented. The Safety Board concludes that theemergency response by shipboard and shoreside firefighters to the fire was timely andappropriate, resulting in the fire being properly contained and extinguished.
Analysis 73 Marine Accident ReportAdequacy Of Engineering Systems DesignThe fire on the Ecstasy caused the partial or complete failure of three systems:low-location lighting, steering, and propulsion. Although the loss of engineering andemergency systems did not ultimately endanger the ship and its passengers in thisaccident, the potential threat to vessel safety from the failure of vital systems, especiallypropulsive power, is significant.The low-location lighting system was designed to sound an alarm on the bridge inthe event of a power failure to the system. In this accident, the heat from the fire meltedthe wiring insulation on a portion of one lighting loop, triggering an alarm that the ship’sofficers considered intrusive during the emergency operations. When the nature andlocation of the failure was not readily detectable at the lighting system’s main unit, thechief electrician elected to shut down power to the system. After this accident, CarnivalCruise Lines redesigned the low-location lighting system to permit the audible alarm to besilenced without the need to shutdown the entire system.The steering system components were designed to be redundant. The system hadtwo rudder systems that were mechanically, electrically, and hydraulically independent ofeach other. The systems were housed in separate rooms on opposite sides of deck No. 3.The power and control cables for both rudder systems were routed along the overheads oftheir respective steering gear rooms. Thus, when the conflagration on the mooring deckwent unchecked and raged for more than an hour, the intense heat that was conductedthrough the overheads of the steering gear rooms melted the cables, causing the steeringsystem to fail. Despite the failure of the steering system, the crippled Ecstasy could havemaneuvered at low speeds by using the bow thrusters if the ship had not lost propulsion.The most critical system failure in this accident was, therefore, the loss of thepropulsion system. The port and starboard propulsion systems were supposed to beredundant and isolated. The Ecstasy had been built to LR regulations, which clearlystipulate the need to provide independent and isolated power supplies to essentialcomponents of the vessels engineering systems, such as propulsion. The auxiliary voltageto the high-speed breakers for both propulsion systems, however, was routed through thesame distribution panel. When this panel sustained heat damage, both propulsion systemsfailed. The Safety Board, therefore, concludes that the failure to separate the powercircuitry in the design arrangement of the auxiliary voltage supply to the high-speedbreakers of the propulsion systems resulted in inadequate isolation of essential systemcomponents, which, in turn, resulted in the shutdown of both propulsion systems when asingle distribution panel was damaged.Hazardous situations that may result from a ship losing propulsive power includevessel grounding, inability to avoid severe weather conditions, and passenger evacuationat sea. Thus, it is essential that all propulsion system components be redundant andisolated. Following the Ecstasy accident, Carnival Cruise Lines advised the Safety Boardthat it had modified the vessel’s electrical system by adding a backup circuit breaker andwiring to provide an alternate source of electrical power for the high-speed breakers.
Page 1:
PB2001-916401NTSB/MAR-01/01NATIONAL
Page 4 and 5:
National Transportation Safety Boar
Page 6 and 7:
Contents iv Marine Accident ReportS
Page 8 and 9:
viMarine Accident ReportAcronyms an
Page 10 and 11:
viiiMarine Accident ReportExecutive
Page 12 and 13:
Factual Information 2 Marine Accide
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Factual Information 10 Marine Accid
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33: Factual Information 22 Marine Accid
Page 65 and 66: 55 Marine Accident ReportAnalysisGe
Page 67 and 68: Analysis 57 Marine Accident ReportT
Page 69 and 70: Analysis 59 Marine Accident Reportf
Page 71 and 72: Analysis 61 Marine Accident Reports
Page 73 and 74: Analysis 63 Marine Accident Reporti
Page 75 and 76: Analysis 65 Marine Accident ReportA
Page 77 and 78: Analysis 67 Marine Accident ReportF
Page 79 and 80: Analysis 69 Marine Accident ReportA
Page 81: 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
show all

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

Create successful ePaper yourself

Delete template?

Save as template?