PB98-916402NTSB/MAR-98/02
NATIONALTRANSPORTATIONSAFETYBOARDWashington, D.C. 20594
MARINE ACCIDENT REPORT
Fire On Board the Panamanian Passenger ShipUniverse Explorer in the Lynn Canal Near Juneau, AlaskaJuly 27, 1996
6743D
Abstract: This report explains the fire on board the Panamanian cruise ship Universe Explorerin the Lynn Canal near Juneau, Alaska, on July 27, 1996. Five people were killed and 56 peoplesustained minor to serious injuries as a result of this fire. The estimated vessel damage exceeded$1.5 million.
From its investigation of this accident, the Safety Board identified the following safetyissues: the adequacy of shipboard communications; the adequacy of fire prevention, detection,and control measures; the adequacy of emergency procedures; and the adequacy of oversight.Based on its findings, the Safety Board made recommendations to the U.S. Coast Guard, theNew Commodore Cruise Lines, Ltd., V. Ships Marine, Ltd., the International Council of CruiseLines, and the American Bureau of Shipping.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting avia-tion, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agencyis mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportationaccidents, determine the probable cause of accidents, issue safety recommendations, study transportationsafety issues, and evaluate the safety effectiveness of government agencies involved in transportation. TheSafety Board makes public its actions and decisions through accident reports, safety studies, specialinvestigation reports, safety recommendations, and statistical reviews. Information about availablepublications may be obtained by contacting:
National Transportation Safety BoardPublic Inquiries section, RE-51490 L'Enfant Plaza East, S.W.Washington, D.C. 20594(202) 314-6551
Safety Board publications may be purchased, by individual copy or by subscription, from:
National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(703) 605-6000
NTSB/MAR-98/02 PB98-916402
NATIONAL TRANSPORTATIONSAFETY BOARD
Washington, D.C. 20594
MARINE ACCIDENT REPORT
Fire On Board the Panamanian Passenger ShipUniverse Explorer in the Lynn Canal Near Juneau, Alaska
July 27, 1996
Adopted: April 14, 1998Notation 6743D
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EXECUTIVE SUMMARY ................................................................................................... vii
INVESTIGATION .................................................................................................................. 1Accident Narrative ..................................................................................................................... 1Injuries ...................................................................................................................................... 6Damages .................................................................................................................................... 6Personnel Information ............................................................................................................... 6
General ..................................................................................................................................... 6Master ....................................................................................................................................... 7Staff Captain ............................................................................................................................. 7Safety Officer ............................................................................................................................ 7Senior Second Officer ................................................................................................................ 7Junior Second Officer ................................................................................................................ 7
Vessel Information .................................................................................................................... 8History ...................................................................................................................................... 8General Construction ................................................................................................................. 9Modifications ............................................................................................................................ 9Main Laundry ......................................................................................................................... 10Missing Bulkhead .................................................................................................................... 10Laundry Equipment ................................................................................................................. 12Welding Machines ................................................................................................................... 12Postaccident Area Inspection ................................................................................................... 12Fire Systems and Equipment .................................................................................................... 13Certification and Inspection of Vessels ..................................................................................... 15Classification Society Surveys ................................................................................................. 15Coast Guard Examinations ...................................................................................................... 17
Waterway Information ............................................................................................................. 20Operations ............................................................................................................................... 20
General ................................................................................................................................... 20Management Oversight ............................................................................................................ 20Fire Response Procedures ........................................................................................................ 22Fire Watch .............................................................................................................................. 22
Medical Findings ..................................................................................................................... 23Fatalities ................................................................................................................................. 23Toxicological Testing .............................................................................................................. 23
Wreckage ................................................................................................................................ 24Main Laundry ......................................................................................................................... 24Stairways and Aloha Deck ....................................................................................................... 24
Survival Factors ...................................................................................................................... 25Regulatory Requirements ............................................................................................................... 25Emergency Information and Drills .................................................................................................. 25Vancouver Drill ............................................................................................................................. 26General Response by Crew ............................................................................................................ 26Passenger Notification ................................................................................................................... 27
CONTENTS
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Response by Hospital Staff ............................................................................................................ 28Crew Escape .................................................................................................................................. 28Rescue Efforts ............................................................................................................................... 29Response by Local Agencies ........................................................................................................... 29Hospital Response ......................................................................................................................... 30Contingency Plan ........................................................................................................................... 31
Other Information ................................................................................................................... 31Vessel Smoking Policy ................................................................................................................... 31FBI Case ....................................................................................................................................... 31New Certification Requirements for Crews...................................................................................... 31Retroactive Fire Safety Amendments .............................................................................................. 32
ANALYSIS ............................................................................................................................. 33General ................................................................................................................................... 33Exclusions ............................................................................................................................... 33Accident Synopsis ................................................................................................................... 33The Fire ................................................................................................................................... 34
Area of Origin ................................................................................................................................34Type of Fire ................................................................................................................................... 34Cause of Fire ................................................................................................................................. 34
The Aftermath ......................................................................................................................... 36Adequacy of Communications ................................................................................................. 37
Contact Between Bridge and Fire Watch ........................................................................................ 37Means of Communications in Crew Cabins .................................................................................... 38Radios for Medical Staff ................................................................................................................ 39
Adequacy of Fire Prevention, Control, and Detection Measures ............................................... 40Bulkhead Removal ......................................................................................................................... 40Effectiveness of Fire Detectors ....................................................................................................... 40Lack of a Sprinkler System ............................................................................................................ 41Effectiveness of Electromagnetic Fire Doors ................................................................................... 42Compromise of Fire Door Effectiveness ......................................................................................... 44Effectiveness of Alarms ................................................................................................................. 44
Adequacy of Emergency Procedures ....................................................................................... 47Watch Officer’s Initial Response .................................................................................................... 47Passenger Drill .............................................................................................................................. 48Status Announcements ................................................................................................................... 49Crew Drills .................................................................................................................................... 49Fire and Rescue Search .................................................................................................................. 50Availability of Medical Supplies .................................................................................................... 52
Adequacy of Oversight............................................................................................................. 53Company Oversight ....................................................................................................................... 53Class and Coast Guard Oversight ................................................................................................... 55
Toxicological Testing .............................................................................................................. 56Emergency Actions by Local Responders ................................................................................ 57
Coast Guard Response ................................................................................................................... 57Local Agency Response ................................................................................................................. 57Coast Guard Contingency Plan ....................................................................................................... 57
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CONCLUSIONS ................................................................................................................... 58Findings .................................................................................................................................. 58Probable Cause ........................................................................................................................ 60
RECOMMENDATIONS ...................................................................................................... 61
APPENDIXESAppendix A — Investigation .............................................................................................. 65Appendix B — Duties of the Universe Explorer Fire Watch ................................................ 67Appendix C — Retroactive Fire Safety Amendments for Existing Passenger Ships .............. 69
ACRONYMS AND ABBREVIATIONS IN THIS REPORT .............................................. 75
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Early on July 27, 1996, while the Pan-amanian passenger ship Universe Explorer wasen route from Juneau, Alaska, to Glacier Bay,Alaska with 1,006 people aboard, a fire started inthe main laundry. Dense smoke and heat spreadupward to a deck on which crew quarters werelocated. Five crewmembers died from smokeinhalation, and 55 crewmembers and 1 passengersustained minor or serious injuries. Onepassenger required medical treatment as a resultof a pre-existing condition. Sixty-nine peoplewere transported to area hospitals, where 13 ofthe injured were admitted for further treat-ment. The estimated damage to the vessel was$1.5 million.
The National Transportation Safety Boarddetermines that the probable cause of this acci-dent was a lack of effective oversight by NewCommodore Cruise Lines, Ltd., and the prede-cessor of V. Ships Marine, Ltd. (InternationalMarine Carriers, Inc.), who allowed physicalconditions and operating procedures to exist that
compromised the fire safety of the UniverseExplorer, ultimately resulting in crewmemberdeaths and injuries from a fire of undeterminedorigin in the vessel’s main laundry. Contributingto the loss of life and injuries was the lack ofsprinkler systems, the lack of automatic local-sounding fire alarms, and the rapid spread ofsmoke through open doors into the crew berthingarea.
The major safety issues discussed in thisreport are the adequacy of shipboard communica-tions; the adequacy of fire prevention, detection,and control measures; the adequacy of emergencyprocedures; and the adequacy of oversight.
As a result of its investigation of this acci-dent, the Safety Board makes recommendationsto the U.S. Coast Guard, New CommodoreCruise Lines, Ltd., V. Ships Marine, Ltd., theInternational Council of Cruise Lines, and theAmerican Bureau of Shipping.
EXECUTIVE SUMMARY
On July 27, 1996, shortly before 0300,1 afire started in the main laundry of the Pan-amanian passenger ship Universe Explorer (fig-ure 1), which was en route from Juneau, Alaska,to Glacier Bay, Alaska, with 1,006 peopleaboard. Dense smoke and heat spread upwardtwo levels from the deck on which the mainlaundry was located to a deck on which crewquarters were located. Five crewmembers diedfrom smoke inhalation, and 55 crewmembers and1 passenger sustained minor or serious injuries.One passenger required medical treatment as aresult of a pre-existing condition. Sixty-ninepeople were transported to area hospitals, where13 victims of serious injuries were admitted forfurther treatment. The following narrative isbased on interviews with crewmembers andsurveys with passengers.
Accident NarrativeOn July 23, 1996, the Universe Explorer
departed Vancouver, British Columbia, with 732passengers and 274 crewmembers on board for apleasure cruise of Alaskan waters. The cruiseitinerary was north, through the Inside Passage,to Ketchikan, Juneau, Glacier Bay, Wrangell,and then back to Vancouver.
About 1030, on July 26, the Universe Ex-plorer arrived at the Juneau, Alaska, MunicipalDock, where it remained moored all day.According to the master, the trip from Vancouverwas without incident. He received no reports ofmechanical problems with the ship or with anyequipment aboard the ship, including themachinery in the ship’s main laundry. Thelaundry manager stated that he personallycleaned the clothes dryers’ lint traps about 1745in preparation for shutting down the main laun-dry for the night at 1800. He said that aftershutting off all machinery, the entire laundry
1 All times are local, based on a 24-hour clock.
crew left the laundry area together. They then atedinner as a group and went ashore for asightseeing excursion in Juneau.
Figure 1—The Universe Explorer
About midnight, the cruise ship departedJuneau bound for Glacier Bay. The masterretired to his cabin about 0240 on July 27, 1996,leaving instructions with the watch officer to callhim at 0500 or earlier should any problem occur.The master said that when he left the bridge, noproblems of any kind had been reported on theship. After the master left, the navigation watchconsisted of a pilot, the second officer, ahelmsman, and a lookout. About this time, theship had rounded Retreat Point and was enteringthe Lynn Canal (figure 2).
About 0250, the fire watch returned to thenavigation bridge after completing his 0200-round of the ship and reported that everythingwas “okay” to the watch officer. Shortly before0300, the fire watch left the bridge on his next
INVESTIGATION
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round. At 0259,2 an audible heat-detector alarmsounded on the fire alarm panel on the bridge(figure 3). The second officer said he noted thatthe panel indicated the activated heat detectorwas in the main laundry on E-deck (figure 4).Thinking it might be a false alarm, he used aUHF radio to call and instruct the fire watch toinvestigate the alarm source in the main laundry.The fire watch said that he was on the Prome-nade deck near the swimming pool when hereceived the call and that, after acknowledgingthe radio transmission, he started toward themain laundry.
The second officer said that he had started tocheck the ship’s navigational position when asecond audible alarm on the fire alarm panelsounded less than a minute later. He said that hebecame highly concerned because a second alarmtypically did not sound in a false alarm situation;he immediately focused his attention on the firealarm panel. The alarm printout indicated that asmoke detector had activated in the fan room onthe Aloha deck near break no. 1 (figure 5). Usinga UHF radio, the second officer called the firewatchman, but heard no response, although thefire watch had heard and acknowledged thetransmission from the bridge. The second officer
2 The fire alarm panel printout indicates that this alarmsounded at 0256. According to the vessel operator, the firealarm panel clock was about 3 minutes slow.
then transmitted, “If you can hear me, report [byradio] to the bridge and then go to the Aloha deckfan room.” He said that when he did not receiveany response, he repeated the message.
The second officer said that multiple firealarms then began to activate on the fire alarmpanel faster than he could read the printout. Heimmediately telephoned the master, the staffcaptain, and the safety officer to come to thebridge. He said all three officers arrived on thebridge within a minute. The master said thatwhen he arrived on the bridge, he immediatelyordered the engines stopped, the remotelyoperated fire doors closed, the power ventilationshut down, and the code phrase “Mr. Skylight”3
announced over the public address system.
Meanwhile, in response to the second offi-cer’s second radio call, the fire watch had gonedown to the Main deck. The fire watch said hewas walking forward, intending to go to the fanroom as instructed; however, he could not reachbreak no. 1 because he encountered thick smoke.He said that he realized his radio was ineffectivefrom his location, so he tried to use the ship’s
3 “Mr. Skylight” was a code phrase broadcast to alert thecrew to report to their emergency stations. The UniverseExplorer had two fire teams, each consisting of 10 people,including a fire team leader. Fire team no. 1 wascomposed of deck department personnel, and fire team no.2 was composed of engineering department personnel.
Figure 2—Location of the Universe Explorer when the fire occurred.
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telephone to inform the watch officer of thesmoke. The telephone to the bridge was busy, sohe began running to the bridge. He said thatbefore reaching the bridge, he heard the “Mr.Skylight” announcement and immediately went tohis emergency station.
After noting the indicated location of theactivated fire detectors, the safety officer left thebridge and proceeded to the emergency gearlocker at fire station no. 1 on the Boat deck toobtain a breathing apparatus. There he met thejunior second officer, who was the leader of fireteam no. 1, and instructed him to assemble histeam in the foyer near the purser’s office.
The safety officer then left fire station no. 1alone to begin searching for the exact location ofthe fire. As he was descending the forwardpassenger stairway, he encountered smoke at theMain deck level, whereupon he radioed thebridge. The master then ordered the generalalarm4 sounded and radioed the Coast Guard 17th
District Command Center in Juneau that thevessel had a fire on board.
The safety officer exited the forward pas-senger stairwell on Aloha deck and proceeded
4 Seven short blasts and one long blast on the ship’swhistle supplemented by the same signal on the ship’sgeneral alarm bell. The staff captain stated that hesounded this signal twice to ensure that everyone on boardheard it.
Figure 3—(Left) The fire alarm panel on the bridge showed a plan view of each deck. When an“addressable” fire detector was triggered, a corresponding panel light turned on, indicating the location ofthe detector. The panel generated a paper log of all activated fire detectors. The tape shown (left of thedeck plans) is of the alarms logged during the Universe Explorer fire. (Right) Table shows order of alarms.
Log of Activated DetectorsTime of
Activation Location of Alarm
0256:42 Main Laundry - E deck
0257:32 Fan Room - Aloha deck
0257:35 Stairwell - Aloha deck
0257:44 Conveyor room - Aloha deck
0257:48 Break no. 1, port side - Aloha deck
0257:53 Main laundry, port side - E deck
0258:01 Spiral stair near break 1 - Aloha deck
0258:26 Corridor near print shop - Aloha deck
0258:41 Main laundry starboard side - E deck
0300:30 Corridor to crew cabins - Aloha deck
Between 0300:31 and 0301.50, 23 smoke detectorsactivated, of which 11 were in stairways and corridors.
0301:51 Crew cabin CA 14 - Aloha deck
0301:53 Crew cabin CB 5 - Bali deck
0301:55 Crew cabin CB 14 - Bali deck
A total of 64 smoke alarms sounded within 7 minutesof the first heat detector alarm. Note: Times are basedon the tape printout and have not been corrected for a3-minute discrepancy. Consequently, the times are 3minutes slow.
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forward through the port side passageway to theclosed fire door at break no. 1. He said that whenhe opened the fire door, he encountered heavyblack smoke and “tremendous” heat. He im-mediately closed the door and returned to thefoyer area where fire team no. 1 had assembledon the Main deck. He instructed the team toprepare to make entry once he had located thefire source and told the team leader to accompanyhim to find the exact location of the fire.
The safety officer and the fire team no. 1leader provided different estimates of how longthe two of them searched before finding thesource of the fire. The safety officer estimatedthat they discovered the fire about 35 minutes
after they began searching; the fire team leaderestimated that they found the fire about 45minutes after they began searching.
The two men first descended to Aloha deckand went forward through the starboard-sidepassageway. When they opened the closed firedoor at break no. 1, they were driven back by“tremendous smoke.” They then descended toBali deck, where they noted high levels of heat,especially near the hospital, but less smoke andno flames. They proceeded to the forward-moststairway on Bali deck and ascended to Alohadeck, where they heard people calling for help.They located 10 crewmembers trapped in theircabins by heavy smoke and led them to safety.
Figure 4—Side cutaway view of the Universe Explorer. The fire was in the main laundry on E deck,next to an open door to a spiral stairwell. The electromagnetic fire doors on E deck and Aloha deckremained open until the master ordered all fire doors closed. The crew deaths occurred in cabinsand passageways forward of the spiral stairwell on the Aloha deck level.
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The safety officer then received a radio callfrom the bridge to proceed to the crew galley onBali deck, where fire team no. 2 had assembled.
After complying with the radio call, thesafety officer and the leader of fire team no. 1descended a stairway aft of the galley to E deckand walked forward to the watertight door aft ofthe main laundry. When they opened the door,they encountered “heavy black smoke,” whichthey walked through. Upon entering the mainlaundry, they saw flames on the steam napkinpress and in laundry bins next to the forwardbulkhead of the laundry. The safety officer said
that material in the laundry bins was on fire andthat there were large volumes of black smoke.
The safety officer and the fire team no. 1leader began to battle the blaze using extin-guishers and charged fire hoses from fire sta-tions near the main laundry. The safety officerradioed a report of the fire location to thebridge, instructing the staff engineer to have theelectrician shut off the electricity to the mainlaundry and to have fire team no. 2 come to thelaundry. The safety officer and the fire team no.1 leader then took turns directing the water fromone hose while fire team no. 2 personnel
The deceased crewmembers were assignedto Aloha deck cabins (CA) 28, 22, 18, and 14.
Figure 5—Plan view of Aloha deck. The second fire alarm that sounded on thebridge was triggered by a smoke detector in the fan room near break no. 1, anathwartship passageway. The nearby spiral staircase extended down from theAloha deck to the Hold deck. On E deck, this stairway accessed the forwardportion of the main laundry. The doors to the spiral stairway were remotelyoperated fire doors that remained open until closed by the bridge.
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directed water from the second hose on the fireuntil they brought it under control, which wasbetween 0410 and 0415. The vessel firefightersextinguished the fire by 0615.
After examining the main laundry and sur-rounding areas, the safety officer set up a reflashwatch. About 0730, he noticed white smokeemanating from wiring in the overhead. Eventhough he did not see any sparks or flames, as aprecaution, he radioed the bridge to report areflash of the fire. Meanwhile, the fire team no.1 leader discharged several portable CO2 fireextinguishers on the smoking wiring, and theelectrician completely shut off all electric powerto main vertical zones (MVZs)5 nos. 1 and 2,except for the emergency lights. Following thedischarge of the CO2 extinguishers, the wiresstopped smoking.
As soon as the fire was discovered, themaster ordered the vessel to proceed to anchor-age in Auke Bay, where passengers and injuredcrew were transferred ashore. The fire resulted
5 A vessel’s hull, superstructure, and deckhouses are sec-tioned into main vertical zones, which generally do notexceed a mean length of 131 feet on any one deck andwhich are divided by fire-resisting bulkheads. Additionalinformation about the structural requirements of MVZsappears under Vessel Information.
in the death of five crewmembers on Alohadeck. Rescuers found the bodies of threedeceased crewmen in the passageway about0325 and two deceased crewmen in their cabinsabout 0540. A total of 67 crewmembers and 2passengers were transported to area hospitalswhere, after preliminary examination, 57 re-quired treatment.
InjuriesTable 1 is based on the injury criteria of the
International Civil Aviation Organization, whichthe Safety Board uses in accident reports for alltransportation modes.
DamagesA representative for the operating company
of the Universe Explorer estimated the totaldamages to the vessel at $1.5 million.
Personnel InformationGeneral —According to the official crew
list, the Universe Explorer was staffed by amultinational crew of 274 individuals. Themaster was a U.S. citizen; the staff captain was aNorwegian citizen; and most of the otherlicensed officers were Greek, Philippine, or U.S.
Table 1—Injuries Sustained in Universe Explorer Accident
PASSENGERS CREW TOTAL
FATAL 0 5 5
SERIOUS 1 12 13
MINOR 1 43 44
NONE 730 214 944
TOTAL 732 274 1,006
49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as “any injury which results in death within 30 days of theaccident” and serious injury as “an injury which: (1) requires hospitalization for more than 48 hours, commencing within 7days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, ornose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) involves second- orthird-degree burns, or any burn affecting more than 5 percent of the body surface.”
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citizens. About half of the crewmembers werePhilippine citizens; the rest were of variousnationalities. The common language for com-munication was English. All were properlylicensed or certificated under Panamanian law.Information about crew training in emergencyresponse and evacuation procedures appears inthe Survival Factors section of this report.
The Safety Board examined the certificationand work experience for the five licensed offi-cers who had prominent roles in the response.
Master —The Universe Explorer master,age 56, began sailing in 1958. He received hisoriginal (German) master’s license in 1969 andhad accumulated 15 years’ experience as amaster at the time of the accident. He had beenmost recently licensed as a master of ocean-going vessels of any gross tonnage on August12, 1993, by the Republic of Panama. His pastexperience included duty assignments as safetyofficer and staff captain on various vessels anddirector of marine operations for CommodoreCruise Lines. Before joining the UniverseExplorer on July 19, 1996, he served as masterof a sister ship, the Enchanted Isle, fromFebruary to June 1996.
Staff Captain —A duty of the staff cap-tain, age 53, was to serve as rescue coordinatorduring emergencies. He began sailing when hewas 16 years old and received his original (Nor-wegian) master’s license in 1974. He had beenmost recently licensed as a master of ocean-going vessels of any gross tonnage on October22, 1992, by the Republic of Panama. He hadsailed as chief officer, staff captain, and masterof several different types of cargo and passengervessels. From 1986 to 1992, he was vice presi-dent of operations for Palm Beach Cruises. Hereturned to sea in 1992, serving in succession onthe following vessels: the Enchanted Isle, theCrown Dynasty, the Crown Jewel, and the Uni-verse Explorer.
Safety Officer —During emergencies, thesafety officer, age 34, served as the on-scenecommander. He began sailing on cargo ships in
May 1982, following his graduation from theCroatian Maritime Academy in September 1981.Between August 1985 and May 1990, heworked ashore. He resumed sailing in 1990 andhad served on cruise ships since then. He hadbeen most recently licensed as a first officer ofocean-going vessels of any gross tonnage onJanuary 17, 1995, by the Republic of Panama.
In July 1991, the safety officer completed a7-day course in Coast Guard-approved basic andadvanced shipboard firefighting conducted byDelgado Community College in New Orleans,Louisiana. He had served as the safety officer onthe Universe Explorer since November 1994,which required that he maintain the lifesavingequipment and train the crew in emergencyresponse procedures.
Senior Second Officer —On the eve-ning of the accident, the senior second officer,age 41, was standing the 0000-0400 watch. Hebegan sailing in May 1980, following his gradu-ation from the California Maritime College. Hereceived his original master’s license (U.S.) in1988 and had sailed for 5 years as master oncruise ships and cargo ships. He had been mostrecently licensed as master of ocean-going ves-sels of any gross tonnage on March 24, 1995, bythe Republic of Panama. He joined the UniverseExplorer as senior second officer on July 20,1996.
Junior Second Officer —A secondaryduty of the junior second officer, age 31, was toserve as the leader of fire team no. 1. Hegraduated from the State University of NewYork Maritime College in January 1990 with aB.S. degree in electrical engineering and duallicenses as third mate and third assistant engi-neer. His cadet training also included fire-fighting training. He had been most recentlylicensed as first officer of ocean-going vesselsof any gross tonnage on July 17, 1996, by theRepublic of Panama. Since his graduation fromcollege, he had served in a variety of assign-ments for several companies. On July 20, 1996,he joined Commodore Cruise Lines as juniorsecond officer on board the Universe Explorer.
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Vessel InformationHistory —The Universe Explorer was built
as a combination passenger/cargo ship in 1958by Ingalls Shipbuilding Corporation in Pas-cagoula, Mississippi. Named the SS Brasil by itsoriginal owner, Moore-McCormack Lines, thevessel sailed under U.S. registry until 1972, whenits then new owner, Holland America Lines,placed it under Netherlands Antilles registry andrenamed it the Volendam.
The ship has been sold and renamed severaltimes. After Holland America, the followingcompanies purchased the vessel in the yearsindicated: Banstead Shipping Ltd., 1987; OrleyShipping Company, Inc., 1987; Bermuda StarLine, Inc., 1989; Brazil Caribbean Shipping Co.,Inc., 1993; and Azure Investments, Inc., 1995.According to the American Bureau of Shipping(ABS), with which the vessel was classed at thetime, the ship was placed under Panamanian flagin September 1975. The vessel transferred classto Lloyd’s Register of Shipping (LR) in 1976and returned to ABS class in 1984. In 1990,Bermuda Star Line, Inc., which operated thevessel under the name the Queen of Bermuda,consolidated with Commodore Cruise Lines,and the ship was renamed the Enchanted Seas.From 1990 until April 1995, Commodore CruiseLines operated the vessel on weekly pleasurecruises from New Orleans. The vessel was thentaken out of service and placed in a lay-up statusuntil it was sold to its present owner.
Before purchasing the vessel, representa-tives for the prospective owner, Azure Invest-ments, Inc., a Panamanian corporation, andCoast Guard officials discussed its compliancewith amendments to The International Conven-tion for the Safety of Life at Sea, 1974 (SOLAS74), requirements established by the Interna-tional Maritime Organization (IMO).6 CoastGuard files contain a record of a March 29,1995, telephone conversation with the prospec-
6 The IMO, a United Nations organization comprising 137member states, establishes international maritime safetystandards for the ships of nations that are signatories to theSOLAS conventions.
tive owner’s representative indicating that thevessel would comply with applicable fire safetyrequirements adopted by IMO in May 1992.
In April 1995, representatives for AzureInvestments, met with senior Coast Guardofficials to discuss possibly reflagging thevessel under U.S. flag. Toward this effort, theyasked that the Coast Guard provide a copy of itscomplete file of records concerning the Uni-verse Explorer, then named the Enchanted Seas.
The prospective owner subsequently hadinspections of the vessel performed by variousmarine technical specialists, who determinedthat the vessel could be returned to U.S. flag, in-cluding making upgrades to bring it into compli-ance with SOLAS requirements effective inOctober 1997, at a cost that the owner termed a“reasonable expense.” The new SOLAS require-ments, commonly known as the Retroactive FireSafety Amendments (RFSAs), are discussed inthe Other section of this report.
For the project of complying with theRFSAs, Petrochem Marine Consultants (PMC),whose principals were three former Coast Guardtechnical staff members, was designated as thedesign agent and point of contact.
On July 15, 1995, Azure Investments, thepresent owner, purchased the vessel andchanged its name to Universe Explorer.7 Sometime after purchasing the vessel, the vesselowner elected to put the proposed reflaggingproject “on hold.”
Azure Investments chartered the vessel toNew Commodore Cruise Lines, Ltd. (NewCommodore), a Bermuda corporation, whichoperated as Commodore Cruise Lines. NewCommodore, in turn, contracted International
7 In addition to the names listed above, the ship has sailed
as the Canada Star, the Liberte, the Island Sun, and theMonarch Sun.
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Marine Carriers, Inc., a New York corporation,to manage and operate the ship.8
The Universe Explorer remained out ofservice another 6 months. Between October1995 and January 1996, it underwent modifi-cations to prepare it for operating under charterto the Institute for Shipboard Education, whichoperates a college program in association withthe University of Pittsburgh. The vessel’s casinowas converted into a library and computercenter, and other areas were partitioned forclassrooms.
In November 1995, officials from the CoastGuard Marine Safety Center (MSC) wrote thevessel operator reminding the company that allpassenger vessels constructed before October 1,1994, were subject to the RFSAs. The CoastGuard enclosed a copy of the new requirementsand a copy of guidelines for meeting therequirements.
In January 1996, the Universe Explorer wasreturned to service, sailing on a Caribbeanpleasure cruise, which ended February 3, 1996.The vessel then departed on its first semestervoyage for the Institute for Shipboard Educa-tion, which ended in mid-May. On May 21,1996, the vessel departed Ensenada, Mexico, ona summer semester voyage, which ended on July19, 1996, in Seattle, Washington.
After disembarking university students,faculty, and administrative staff in Seattle, theUniverse Explorer went to Canada, from whereit departed Vancouver on July 23, 1996, for apleasure cruise of Alaskan waters. During this
8At the time of the accident, International Marine Carriers,
Inc., was in the process of forming a joint venture companywith V. Ships Marine, USA. Because International MarineCarriers, Inc., no longer exists, this report henceforth refersto V. Ships Marine, Ltd. (V. Ships) as the vessel operatingcompany. V. Ships is a large ship management companywith offices in Europe, the Middle East, and North andSouth America employing 250 shore-based staff and morethan 4,500 seafarers. The company manages various typesof merchant ships, including container ships, tankers, bulkcarriers, and cruise ships.
cruise, the fire that is the subject of this reportoccurred in the main laundry on E deck.
General Construction —The steam-turbine-propelled Universe Explorer is 617.5feet long, 84 feet wide, and has a displacementof 22,526 tons. The vessel has 10 decks (fig-ure 4) and is vertically divided by 5 MVZ bulk-heads that are “A-class divisions,” meaning theyare insulated steel barriers designed to preventthe passage of smoke and flame from a fire for 1hour.
The vessel was built to SOLAS 1948 re-quirements and to U.S. standards (46 CFR Parts70 to 89). It was designed according to “MethodI” construction, meaning that “noncombustible”materials were to be used and that structural fireboundaries were to be built throughout thevessel to ensure any fire would be restricted toits compartment of origin. The method Istandards require strict attention to constructiondetails and certification of the noncombustiblenature of the materials used. To maintain thestructural fire protection afforded by thismethod of construction, all modifications to thevessel have to be made either to originalconstruction standards or to higher structuralstandards in effect at the time of themodification. No structural alteration can bemade that may reduce the level of fire safety. Amethod I-built ship was not required to have,and the original owner of the vessel did notinstall, automatic sprinkler systems.
Modification s—Coast Guard corres-pondence indicates the vessel underwentstructural modifications in Baltimore, Maryland,between 1962 and 1963 to U.S. standards, inBremerhaven, Germany, between 1972 and1973 to SOLAS 60 standards, in HamptonRoads, Virginia, between 1974 and 1978 toSOLAS 60 standards, in Sasebo, Japan, in 1985to SOLAS 74 standards, and in Avondale,Louisiana, in 1990 to SOLAS 74 standards. TheCoast Guard files do not indicate the nature andextent of the modifications.
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A copy of 1964 plans obtained from theU.S. Maritime Administration (MarAd) archivesshows that at that time the vessel had two cargohatches forward of the deckhouse and one hatchaft of the deckhouse. Current plans show thatthe cargo hatch areas have been converted to of-fices and crew accommodation spaces on theMain, Bali, and Aloha decks. Structural modi-fications have been made to the Boat deck,Promenade deck, and Upper deck, the latter ofwhich now has a 75-foot extension. Numerousmodifications have been made to interior spacesand furnishings.
In 1989, the Universe Explorer’s sister ship,which was built to the same method I con-struction standards, suffered a major fire thatdamaged 22 cabins while the vessel was under-going shipyard repairs. As a result of the fire,Coast Guard inspectors determined that bothvessels had combustible insulation throughouttheir interiors. The Coast Guard subsequentlyrequired that this insulation be removed fromboth vessels as a condition of their being allow-ed to continue embarking passengers in theUnited States.9 Further, as an interim measure,the Coast Guard required that additional smokedetectors be installed and that the number ofroving fire patrols be increased until the insula-tion removal was completed. Coast Guardrecords indicate that the removal project wascompleted for both vessels in January 1991.However, the records also note that some insu-lation could not be removed because it was ininaccessible areas.
Main Laundry —The fire on the UniverseExplorer ignited in the main laundry on E deckwithin MVZ no. 2. The main laundry area wasaccessible by two stairways, each of which wasenclosed in a vertical A-class trunk. Both stair-wells extended from Hold deck to Aloha deck.The stairwell opening onto the aft end of thelaundry also opened onto Bali deck and
9 The type and scope of Coast Guard examinations arediscussed in greater detail later in this section.
Aloha deck. The spiral stairway opening ontothe forward end of the laundry also opened ontothe Hold deck and the Aloha deck.
The steel fire screen doors in these stair-ways were electromagnetically controlled. Dur-ing normal operations, a magnetic field createdby an electric current held the doors open. In theevent of an emergency, the fire screen doorscould be closed either remotely from the bridgeor at the door position by a person shutting offthe electrical current switch. The fire screendoors then shut under their own weight, assistedby a spring-loaded closing mechanism.
The aft access to the main laundry had apower-activated sliding watertight door that wasoperable locally and remotely from the navi-gation bridge. The laundry manager said that thelaundry doors were not locked after the laundrycrew went off duty so that crewmembers couldbring soiled uniforms and linen to the laundryafter operations had ceased for the day. Roomsfor linen storage and cleaning and valet servicewere along the port side of the laundry.
The laundry manager stated that the doors tothese linen and service rooms were usuallyclosed when the rooms were not in use. Anunused parcel lift and a mail chute were near thespiral stairway. Safety Board investigators foundthe access hatches to both the lift and the chutetightly closed after the fire.
Missing Bulkhead —Original vesselconstruction plans show that the main laundrywas on the port side of the ship and enclosed bybulkheads (figure 6). The 1958 plans indicatethe presence of a bulkhead in the main laundrythat created a corridor from the spiral stairwayon the forward end to the stairway on the aft endof the compartment, separating the storage andlaundry areas from the stairways in accordancewith 46 CFR 72.05-20 (f), which states thefollowing:
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Insofar as is reasonable and practicable,Types 1 & 2 stairways10…should notgive direct access to accommodations orother enclosed spaces in which a firemay originate [footnote added].
The 1964 plans from the MarAd archives,which reflect the structural modifications madein Baltimore, indicate that the main laundrybulkhead forming the corridor between theforward and aft stairways was still in place,although the access door into the storage areahad been moved.
The Universe Explorer’s fire control plan,which had been approved by the ABS in January1991, also indicates the presence of the mainlaundry corridor bulkhead. SOLAS require-ments at Regulation 20, “Fire control plans,”stipulate, in part:
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Type 1 stairways are enclosed stair towers borderingMVZs. Type 2 stairways are enclosed stairways other thantype 1.
In all ships general arrangement plansshall be permanently exhibited for theguidance of the ship’s officers, showingclearly for each deck the control sta-tions, the various fire sections enclosedby ‘A’ class divisions, the sectionsenclosed by ‘B’ class divisions togetherwith particulars of the fire detection andfire alarm systems…. Plans…shall bekept up to date, any alterations beingrecorded thereon as soon as practicable.
During postaccident examination, SafetyBoard investigators observed that most of thecorridor bulkhead had been cut away; only thetop 12 to 18 inches of the bulkhead extendeddown from the overhead structural deck. Vesselofficers had no information about when or whythis bulkhead had been removed. V. Ships, theUniverse Explorer operator, subsequently pro-vided information stating that the main laundryarea was modified between 1972 and 1974 at theLloyd-Werft Shipyard, when the ship was beingoperated by Holland America Lines. The SafetyBoard found no records showing the nature of themodifications or when they were made. Lloyd’s
Figure 6—(Left) Main laundry layout as originally designed with a bulkhead forming a corridor between theforward and aft stairways and separating the storage and laundry areas from the stairways in accordance with 46CFR, the U.S. interpretation of SOLAS 48. (Center) Layout as modified in 1964 and as shown on the vessel controlplan. (Right) Layout of the main laundry as found during the postaccident examination.
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Register of Shipping (LR) advised the SafetyBoard that its file records indicate that “thecorridor bulkhead was in place during the periodof Classification by LR” and that none of itssurvey reports note its removal. The ABS statedthat its files had no correspondence, drawings, orinformation indicating that it was ever advised thebulkhead was going to be or had been removedand that it did not know when the bulkhead wasremoved. However, the ABS further advised thatthe bulkhead was not required to be in place tocomply either with the ABS classificationrequirements or the statutory requirements of theflag administration, Panama, at the time of thecasualty. The ABS stated:
This ship complies…with SOLAS 74/78,as amended, as an existing ship11 usingMethod I Fire Protection as a basis whenbuilt plus SOLAS amendments, asapplicable [footnote added].
After this accident, the Universe Explorerowner installed a bulkhead isolating the mainlaundry from direct access to both stairwells incompliance with the RFSAs.
Laundry Equipment —The laundrymachinery, which included five washers andseven dryers (figure 7), was electrically poweredindustrial equipment. Other machinery includeda steam napkin press and a large roller press.According to the laundry manager, the napkinpress was not turned on or used the day beforethe accident occurred. The laundry manager alsostated that, in accordance with regular operatingprocedures, all laundry machinery was turned offat 1800 on the eve of the accident.
Three large, solid-sided cylindrical fiber-glass bins, each about 4 feet high and 30 inchesin diameter, and four oblong solid-sided alumi-num bins, each about 3 feet high, 3 feet wide,and 30 inches deep, were used as hampers fordirty linen, including uniforms, table linens, bed
11 An “existing ship” means a vessel having a keel that islaid on or after the effective date of the particular Con-vention.
linens, towels, and washcloths. The laundrymanager said that when he left the laundry at1800 on the evening before the fire, all of thebins were piled high with soiled laundry, but nolaundry was lying on the deck. During its post-accident examination of the area, the SafetyBoard was unable to verify whether the linenwas clean or soiled or where it had been becausefirefighters had scattered the unburned linen toensure that the fire was extinguished.
Welding Machines —To facilitate ship-board maintenance and repair, electric weldingmachines were stationed at various locations onthe Universe Explorer. In the weeks before thefire, a welding machine had been in the mainlaundry for repair of a sewage tank below themain laundry, in the Hold. The welding machinewas fastened to the deck and immediatelystarboard of the spiral stairway. Hot-workpermits issued by the staff engineer indicate thatwelding was performed in the forward sewagetank area between June 26 and July 15, 1996.Various company employees stated that no hot-work permits were issued and no cutting orwelding was done in or near the main laundryon the day before the fire.
According to the ship’s hotel manager,before the Universe Explorer arrived in Seattle,Washington, on July 19, 1996, the main laundryhad received a general inspection by the masterand was found to be in a satisfactory condition.The hotel manager further stated that no writtenreport was made of these inspections. Accordingto V. Ships, a written report typically is notprepared unless the master notes defects thatrequire correction.
Postaccident Area Inspection —Inthe forwardmost cleaning room of the laundry,Safety Board investigators observed that thebulkhead had a new coat of paint and that anopen can of waterbased paint and nonflammablepainting and cleaning materials were on thedeck. A description of the fire damage appearsin the Wreckage section of this report.
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Fire Systems and Equipment —TheUniverse Explorer was equipped with a firedetection and alarm system throughout the ac-commodation and services spaces. Componentsof the system are described below.
Fire detection system —The vessel’s firedetection system used heat-actuated, smoke-actuated, and flame-actuated sensor devices, eachof which was depicted on the Fire Detection Plan.Smoke detectors were installed in the crewcabins, crew corridors, and crew service spaceson the Aloha and Bali decks and in the passengercabins, passenger corridors, and public spaces onall other decks. Heat detectors were in the crew’sgalley, the main galley, and the main laundry.
Flame detectors were in the boiler room, whichextends between E deck and Bali deck.
Whenever a detector activated, an indicatorlight was displayed and an alarm sounded on thefire alarm panel on the bridge; no local alarmautomatically sounded in the area of the activateddetector. Some detectors were “addressable” de-vices, which indicate their location; others were“nonaddressable,” which indicate only their iden-tification number. To determine the location of anactivated nonaddressable detector, one had torefer to the Fire Detection Plan. The fire alarmsystem recorded the time and location of acti-vated addressable detectors. The bridge also mon-itored the opening and closing of the fire doors.
The laundry manager said that when he completed work on July 26, 1996, four bins full of dirty linen were pushed upagainst the forward bulkhead near the doorway to the spiral stairway. Three laundry bins were near the steam press.The spiral stair led from the Hold to the Aloha deck, where crew quarters were located.
Figure 7—Main laundry area, showing the location of equipment.
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During its postaccident investigation of themain laundry, the Safety Board noted that thearea not only had addressable heat detectors butalso several disconnected smoke detectors in theoverhead that were not depicted on either the firedetection plan or the fire control plan. Accordingto the vessel operator, the disconnected detectorswere part of the original fire detection system thatwas replaced by the heat detector system in 1972-1974, when the main laundry was converted froma clean-linen storage area.
Detector limitations —The Safety Board ex-amined fire industry literature and conferred withan electrical engineer specializing in fire detec-tion equipment regarding fire detection devices.The following paragraphs summarize recognizedlimitations inherent in the heat and smoke detec-tor models installed on the Universe Explorer.
Smoke detectors—The Universe Explorer hadphotoelectric (or optical) smoke detectors, whichactivate when a substance obscures a light beamfrom reaching the sensory cell. Smoke detectorscan detect an early (incipient) fire when it beginsto smolder, before it becomes fully developed(free burning). They can be susceptible to falsealarms in laundry facilities because water vapor(humidity) or minute solid particles (lint anddust) can act like smoke in blocking the sensorand activating the device. Operators of com-mercial facilities having smoke detectorstypically perform frequent maintenance of thedevices to reduce the incidence of false alarms.
Heat detectors—A fixed-temperature heatdetector, such as the type installed in the mainlaundry of the Universe Explorer, operates onlywhen the detector itself, not the surrounding air,reaches a preset temperature, in this case 700 C(1570 F). Heat detectors lack the ability to detecta fire during its incipient stage because very littleheat emanates from a smoldering fire that has notreached a free-burning stage. If the fire starts onor near the deck and the heat sensor is in the over-head, as was the case with the heat detector in themain laundry, the time it takes for the heatdetector to actuate can be considerable.
Generally, heat detectors are less susceptibleto false alarms than most smoke detectors. Whenthe main laundry was revamped in the early1970s, the smoke detectors were replaced withheat detectors. According to the manufacturer’srepresentative, however, the model of heatdetector used on the Universe Explorer is subjectto false alarms if moisture accumulates on theelectrical contacts at the base of the device.
Fire alarms —The vessel had manual firealarms in the passenger and crew accommodationspaces on the vessel. The crew accommodationarea forward on the Aloha deck had two pull-cable-type manual alarms that register an audibleand visual alarm only on the navigation bridge,and one push-button-type manual fire alarm thatactivates two local fire alarm bells. None of themanual alarms in the crew berthing area on theAloha deck was activated by crewmembersduring the fire.
Fire doors —All fire doors to the stairwayswere electromagnetically controlled. Power-actu-ated watertight doors were installed at eachpassage through a watertight boundary, includingthe bulkhead separating the main laundry fromthe aft stairwell, as required by SOLAS. All firedoors could be controlled remotely from thebridge. The master stated that he ordered the staffcaptain to close all power-actuated doors when heordered the sounding of the ship’s general alarmat 0305.
On the Universe Explorer, fire doors with aspring-closure mechanism were at all entrances topassenger and crew cabins, offices, and servicespaces; the junctions of all corridors with publicspaces; and the intersections of the longitudinalcrew corridors with the breaks on Aloha deck.
During postaccident inspection of the vessel,Safety Board investigators found no soot evi-dence indicating that smoke entered the cabinsfrom the ventilation system. Investigators ob-served pieces of twine attached to handrails nearthe door knobs for the two Aloha deck corridordoors leading forward from the break no. 1 pas-sageway to the crew accommodations area where
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the fatalities occurred. The fire alarm printoutindicates that a smoke detector in the Aloha deckcorridor leading forward from these doors intothe crew quarters activated within 4 minutes ofthe first heat detector fire alarm sounding on thebridge.
Equipment —The Universe Explorer was cer-tified as meeting applicable SOLAS requirementsfor firefighting equipment and lifesaving equip-ment. When not in use, passengers’ lifejacketswere stored under the beds in each stateroom
Certification and Inspection ofVessels —Certification of ships and theirsafety equipment is the responsibility of thegovernment of the country in which the vessel isregistered, known as the flag state. The govern-ments of countries that are signatory to theSOLAS convention enact national regulationsthat conform to IMO requirements. Flag statescan and do delegate vessel certification in-spections to classification societies.
Given the nature of the regulations, thenumber of countries signatory to SOLAS, andthe number of different organizations that coun-tries authorize to certify compliance with theregulations on their behalf, the interpretation ofSOLAS requirements and, consequently, thedetermination of a vessel’s compliance withsafety standards, can vary. Therefore, countrieshave established their own regulatory interpre-tations and inspections to safeguard their portsand citizens. The Coast Guard, as the U.S. rep-resentative, has developed interpretations ofSOLAS requirements and submitted them in of-ficial position papers to the IMO. These U.S.regulatory interpretations are consolidated intothe Coast Guard SOLAS Guidance Document,12
which is used as a reference by Coast Guard ex-aminers to ensure consistency during inspec-tions of foreign flag vessels. The following sec-tions explain the surveys conducted by classi-fication societies, particularly the ABS, which
12 The latest version of the SOLAS Guidance Document isrevision 1, dated September 1994.
classed the Universe Explorer and which lastissued a SOLAS Passenger Ship Safety Certi-ficate to the vessel before the casualty, and thecontrol verification examinations (CVEs) per-formed by the Coast Guard.
Classification Society Surveys —Classification societies, such as the ABS, arepaid by vessel owners to survey their merchantships. The ABS is a not-for-profit organization.The marine insurance industry relies on classifi-cation societies to establish and certify a ves-sel’s compliance with hull strength and majorengineering systems standards, which are con-tained in the societies’ rules; many marine insur-ance policies include a provision requiring theinsured vessel to be maintained in class with aclassification society acceptable to the insurer.
The classification society surveys the majorelements of ship design and operation, includingthe materials used in construction, the size anddistribution of structural members, and the ves-sel machinery for compliance with the society’srules. “Classification” with a society evidencescompliance with those rules. One observer hascharacterized classification as evidencing “thesoundness of design for the service for whichthe vessel is intended.” 13
Quality assurance standards —Since the1970s, the role of the classification societies inensuring marine safety has grown. Lord Don-aldson’s report notes that the demand forservices resulted in an increase in the number ofclassification societies, some of which lackedthe resources or expertise to fulfill all the dutiesexpected of them. With the growth in thenumber of classification societies, some ship-owners increasingly put economic pressures oncertifying officials, threatening to deal withanother society that might not interpret theclassification standards as stringently. As aresult, in 1994, the International Association ofClassification Societies (IACS), which com-
13 Safer Ships, Cleaner Seas—Report of Lord Donaldson’sinquiry into merchant shipping pollution prevention. Pub-lished by HMSO London, Cm. 2560. May 1994.
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prises 11 member and 2 associate societies thatclass over 90 percent of the world’s merchanttonnage,14 initiated the Quality System Certifi-cation Scheme (QSCS) establishing commonstandards for IACS classification societies. TheABS is a member of IACS.
The American Bureau of Shipping —TheUniverse Explorer was built to ABS classifica-tion requirements and classed by ABS upon itsdelivery in 1958. The vessel transferred to LRclassification in September 1976 and transferredback to ABS classification in March 1984. TheABS has technical staff and surveyors stationedin principal U.S. ports and in many ports aroundthe world. Its procedures for the various surveysrequired to maintain a vessel in class are pub-lished annually in its Rules for Building andClassing Steel Vessels.
The ABS classification process typicallybegins when a ship owner submits an ABS Re-quest for Classification Agreement. For a newship being built to ABS class, the shipyard thensubmits plans and material specifications for theABS to review. The ABS technical staff reviewthe plans and specifications and completecalculations to ensure that the proposed shipwill be built in accordance with ABS rules.
After the plans and specifications have beenapproved, they are sent to an ABS field surveyorwho travels to the shipyard where the ship willbe built to oversee the construction to ensurethat the ship is built in compliance with theapproved plans and ABS rules. In rare cases, aperson qualified in both the plan approval andsurvey processes may perform both the technicalreview and approval and the on-board verifi-cation.
Surveyors visit the vessel throughout theconstruction process, periodically checking theship for compliance. When construction iscompleted, the vessel and its machinery are as-
14 IACS press release, May 1997. The merchant tonnagereferred to is self-propelled, sea-going merchant ships of100 gross tons or greater.
signed an ABS classification, and the vesselthen enters into a periodic survey schedule.
The ABS classification survey rules havechanged over the years. The ABS surveys appli-cable to the Universe Explorer at the time of thiscasualty were as follows:
1. Annual Class Surveys—ABS Rules1/3.1.3 stipulate that inspections of hull,machinery, automation, and cargorefrigeration are to be made within 3months before or after each annualanniversary date of the crediting of theprevious Special Periodical Survey ororiginal construction date.
2. Special Periodical Surveys—ABS Rules1/3.1.5 state that these examinationsmust be completed within 5 years afterthe date of build or after the previousSpecial Periodical Survey. Becausethese surveys include inspecting thescantlings, the ship must be placed indrydock for this type of survey.
3. Other Surveys—If an ABS-classedvessel sustains or is suspected to havesustained damage or undergoes modi-fications that may affect the vessel’sclassification, the master is responsiblefor notifying the ABS so that appro-priate surveys may be performed.
The ABS checks a vessel’s internal arrange-ments against relevant vessel plans when theship is taken into ABS classification or whenABS-approved modifications are being made tothe vessel. The owner or master is obligated toadvise ABS in advance of planned modificationsso that necessary reviews, approvals, andsurveys may be performed. During subsequentperiodic inspections, ABS surveyors are notrequired to check the vessel’s internal arrange-ments against approved plans to identify anymodifications that may have been made withoutABS knowledge or approval, although surveyorsmay identify such modifications in the course ofsuch surveys.
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The ABS advised the Safety Board thatwhen the vessel returned from LR to ABS classin 1984, “Initial issuance of SOLAS certificatesby ABS in 1985 was based on prior approvalsby the previous certifiers,” including the CoastGuard, the Netherlands Antilles, and the LR onbehalf of Panama, and the ABS plan review ofthe ship as configured in 1985, and ABS survey.
Between 1985 and the time of this fire, theABS reviewed and approved a number of opera-tional plans for and conducted a number of sur-veys of the Universe Explorer. A DamageControl Plan approved by the ABS in 1985 anda Lifesaving Plan approved by the ABS in 1990each show the main laundry without the corridorbulkhead. In 1991, the ABS approved the FireControl Plan that showed the corridor bulkheadin the main laundry. On May 24, 1995, the ABS,acting on behalf of Panama with respect to sta-tutory certification, issued the Universe Explorera Loadline Certificate, which was valid untilJanuary 31, 2000. The ABS conducted an annu-al loadline survey and issued a Passenger ShipSafety Certificate, which was valid for 1 yearfrom date of issue, on behalf of the PanamanianGovernment on January 12, 1996, in NewOrleans.
According to the present Universe Exploreroperator, the bulkhead in the main laundry wasremoved with ABS approval during a con-version completed in the early 1970s while thevessel was being operated by another company.However, the operator has not been able to pro-vide the Safety Board with a copy of any classi-fication society document approving the bulk-head removal. The ABS advised the Board thatit has no evidence in its files that it was “in-formed of, aware of, or approved” the removalof the bulkhead. In correspondence with theBoard, the ABS further stated, “This bulkheadwas not required to be in place for compliancewith ABS classification requirements or thestatutory requirements of the flag Adminis-tration, Panama, at the time of the casualty.”The ABS said that it based its argument onSOLAS 48, Chapter II, Regulation 33(a)(ii),“Protection of Vertical Stairways,” which states:
Stairway enclosures shall have directcommunication with the corridors andbe of sufficient area to prevent con-gestion having in view the number ofpersons likely to use them in an emer-gency, and shall contain as little accom-modation or other enclosed space inwhich a fire may originate as practi-cable.
Coast Guard Examinations —As aport state, the United States requires that anyforeign cruise ship that is to embark passengersfrom U.S. ports must be examined by the CoastGuard for “substantial compliance” with thesafety, construction, and equipment require-ments in applicable conventions.
Current Coast Guard procedures, containedin the agency’s Navigation and Vessel Inspec-tion Circular (NVIC) No. 1-93, effective Jan-uary 21, 1993, provide guidance regardingnecessary Coast Guard examinations for foreigncruise ships operators. Parts A, B, and C provideguidance on the initial CVE process, on annualCVEs, and on quarterly CVEs, respectively.
Initial CVE (Part A of NVIC 1-93)—TheCoast Guard conducts a plan review and exam-inations of foreign vessels meeting one of thefollowing criteria:
1. The vessel (new or existing) intendsto embark passengers for the firsttime from a U.S. port;
2. The vessel has undergone a modi-fication or alteration of a “majorcharacter” as defined by SOLAS74;15
3. The vessel returns to service morethan 1 year after its annual ControlVerification Certificate has expired
15 SOLAS 74, Chapter II-2, Part A, Regulation 1 defines amodification of a “major character” as being any changethat substantially alters the dimensions of a ship, thatsubstantially alters the passenger carrying capacity of aship, or substantially increases a ship’s service life.
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and the vessel has not received aplan review by the Coast Guard’sMSC within 5 years; or
4. The vessel is selected for suchexamination by the Commandant ofthe Coast Guard for some otherreason.
The plans submitted to the Coast GuardMSC for review must reflect the “as fitted” con-dition of the vessel and be approved by the flagstate administration or a recognized organizationacting on behalf of the flag administration. Thesubmission must include a written summaryexplaining any special considerations, such asequivalencies or exemptions, approved by theflag administration. The fire control plans mustshow the location of all MVZ boundaries, theinsulation value of bulkheads and decks, and thenumerical fire risk designation for applicableareas as required by SOLAS. The MSC ex-amines the plans for completeness and certifica-tion and adds the Coast Guard stamp and date ofreview.
After the MSC has conducted the plan re-view, the ship owner must next arrange forCoast Guard inspectors to perform a verificationexamination of the vessel itself. Except for ini-tial CVEs conducted while the vessel is stillunder construction, the Coast Guard will not ex-amine the vessel unless it has been issued aSOLAS Passenger Ship Safety Certificate at-testing compliance with all applicable interna-tional treaties by the flag administration or itsagent.
The Coast Guard circular advises ownersand agents to allow up to 4 days in port for aninitial CVE, depending upon the size of thevessel and the complexity of its systems. Theprimary focus of an initial CVE is on structuralfire protection, fire protection systems, means ofescape, lifesaving equipment, engineering sys-tems, emergency fire and boat drills, and theresolution of plan review comments. Becausethe purpose of the examination is to verify “sub-stantial” compliance, Coast Guard inspectors are
not required to check 100 percent of the appli-cable equipment or construction features listedin figure 8; they can check a random sampling.However, if they have reason to believe thevessel’s safety equipment or material conditionis substandard, they have the option ofexamining the vessel in greater detail.
Upon successful completion of the initialexamination, the Coast Guard issues a ControlVerification Certificate that is valid for up to 1year; it usually is dated to expire on the expira-tion date of the Passenger Ship Safety Certi-ficate issued by the flag administration.
As mentioned earlier, the Universe Exploreroriginally was a U.S. flag vessel whose con-struction was certified by the Coast Guard ascomplying both with SOLAS 48 requirementsand U.S. standards. In 1972, it left U.S. registryand began operating as a foreign flag ship.
1. Enclosed Escape Stairways2. Escape Routes3. Division Penetrations4. Fire and Smoke Damper Arrangements5. Draft Stops6. Automatic Sprinkler Systems (if applicable)7. Fire Pumps and Hydrants8. Fixed Smoke and Heat Detection Systems9. Fire Doors and Watertight Doors10. Engineering Systems11. Emergency Lighting12. Proliferation of Combustible Construction13. Lifesaving Systems14. Reduced Lifeboat Capacity (where applicable)15. Passenger Launches16. Counter Flooding Systems17. Training and Drills18. Pollution Prevention19. Navigation Safety, including tests of
equipment and verification of charts andpublications
20. Housekeeping
Figure 8—Features and equipmenttypes checked during an initial CVE.
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Between 1980 and 1985, the Coast Guard didnot require that a foreign passenger ship apply-ing to embark passengers from a U.S. portundergo a plan review as part of the initial CVEprocess. When the Volendam (now the UniverseExplorer) applied for an initial CVE in 1983, theCoast Guard did not conduct a plan review aspart of its examination. After adopting a revisedNVIC in 1985 requiring a plan review for aninitial CVE, the Coast Guard did not require thatforeign passenger ships already operating fromU.S. ports undergo an initial CVE with planreview.
After the 1996 fire, the Coast Guard MSO-Juneau commanding officer revoked the Uni-verse Explorer’s control verification certificateand required that the vessel undergo an initialCVE (with plan review) as a condition for certi-fying it to embark passengers from U.S. ports.
The vessel proceeded to a shipyard in Van-couver, Canada, where repairs were completed.While the ship was in the Canadian shipyard,Coast Guard inspectors journeyed from theSeattle office to conduct the initial CVE. Norecord indicates that the company submitted anyplans to the MSC for an initial CVE as specifiedby NVIC 1-93. Examination documentationstates that Coast Guard inspectors referred tovessel plans while checking the structural fireprotection features of the vessel; the source ofthe plans is not identified. Inspectors selectedoverhead panels for removal at random to spot-check MVZ penetrations and penetrations ofstair tower boundaries. They found areas wherepenetrations were not properly insulated tomaintain the integrity of the fire boundaries;they required that these areas be corrected.Inspectors noted fire doors that did not operateproperly; after being closed, the doors could notbe easily opened by one person. Inspectors alsonoted that a new bulkhead separating the E deckmain laundry from the stairways had beeninstalled.
Records indicate that the Coast Guard com-pleted its initial CVE of the Universe Exploreron August 13, 1996. After all noted deficiencies
were corrected, the Coast Guard inspectorsissued the vessel a new control verification cer-tificate and it resumed operations.
Annual CVE (Part B of NVIC 1-93)—Inorder to continue embarking passengers fromU.S. ports, foreign flag vessels are required torenew their verification certificates annually.The NVIC 1-93 stipulates that the purpose ofthe annual CVE is to “focus on the vessel’sfirefighting, lifesaving, and emergency sys-tems.” It also states:
The vessel should be checked to ensureno modifications have been made whichwould affect the vessel’s structural fireprotection, which have not been ap-proved by the vessel’s flag state, andreviewed by the MSC.
The annual certification examination has 13categories, most of which deal with randomtesting of systems and with observing the conductof fire and boat drills. The first check in theexamination process is a review of requireddocuments and certificates. The NVIC 1-93 doesnot stipulate how detailed the review should be.Such detail is left to the inspector’s discretion.The procedures dealing with the structural checkof the vessel stipulate that the inspector conduct awalk-through of the vessel to ensure that “no newadditions have been made without approvedplans” and that stairways and escape routes areproperly marked and free of blockage.
Upon successful completion of an annualCVE, the Coast Guard issues a new control veri-fication certificate that is good for up to 1 year.Before the accident, the Coast Guard last issuedthe Universe Explorer a control verificationexamination certificate on January 12, 1996.
Quarterly CVE (Part C of NVIC 1-93)—Thestated purpose of the quarterly examination, is “toensure the vessel is operated in a safe manner.”The quarterly examination focuses on the trainingand knowledge of the ship’s officers and crew inregard to the vessel’s emergency procedures, fire-fighting procedures, and lifesaving systems. The
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examination includes evaluating the crew’s per-formance during drills and reviewing instructionsand manuals for completeness. The extent of thevessel examination is “at the discretion of theattending inspectors” and is determined by theobserved condition of the ship. Instructions for ageneral walk-through state that the inspectorsshould check the engine room, machinery spaces,and accommodation spaces. The NVIC 1-93states that any modifications to the vessel sinceits last examination should be pointed out toinspectors. Upon completion of a quarterly CVE,the inspector records the date of the examinationin the Coast Guard data base and on a Vessel In-spection Record maintained on board the vessel.
Records indicate that before the fire, the lastquarterly control verification examination of theUniverse Explorer was performed in Seattle,Washington, on July 20, 1996. During this exami-nation, Coast Guard inspectors witnessed a drillsimulating a fire in the main laundry and deter-mined that the drill procedures were satisfactory.The Universe Explorer subsequently underwentroutine quarterly CVEs in December 1996, May1997, and August 1997. Table 2 details the date,location of the Coast Guard office conductingthe examination, and type of examination con-ducted on board this vessel from April 1987 toAugust 1997.
Waterway InformationWhen the fire was discovered, the Universe
Explorer had just entered the Lynn Canal, adeep fjord in southeast Alaska that provides aprotected waterway inshore of the ChilkatMountain Range. The canal extends in a roughlynorthwesterly direction for about 80 miles fromJuneau to Skagway, Alaska. In 1996, 36 cruiseships carrying more than 425,000 passengersoperated in the waterway.
OperationsGeneral —As mentioned earlier, the Uni-
verse Explorer alternates between serving as aclassroom facility for college students enrolled
in the Institute for Shipboard Education and as acruise ship for passengers on pleasure excur-sions. V Ships, the vessel operator, states that itallows a transition period between schoolsessions and cruises for flag state or classifica-tion society surveys and needed repairs to beperformed, crew changes to take place, newcrewmembers to receive required training, anduniversity staff and students to be indoctrinatedabout shipboard operations. The transitionperiod length varies depending upon the itineraryof the ship. During transition periods, two orthree shoreside management representativestypically are on hand to oversee operations.
The V. Ships operations manager said thatthe Universe Explorer is required to maintaincommunications with shoreside managementthroughout its voyages. Vessel personnel musttransmit via telex and fax daily reports of thevessel’s position, speed, and weather. Further,they are required to immediately notify shore-side management of any particular problem onboard the vessel. The operations manager statedthat when the ship is on an extended voyage of100 days, V. Ships requires vessel personnel tosubmit detailed monthly reports, which includesuch information as engine performance.
Management Oversight —The V.Ships operations manager stated that shoresidemanagement representatives regularly visit theUniverse Explorer during the vessel’s transitionperiods, at which time they have formal man-agement review meetings with the ship’s masterand officers. Moreover, shoreside managers areactively involved in ship repairs and mainte-nance overhauls, and they attend classificationsociety or flag state surveys and Coast Guardverification examinations of the vessel.
Shoreside managers typically travel to andboard the vessel during a voyage only if signifi-cant repairs have to be made or if a seriousproblem occurs on the ship while it is at sea.Shoreside managers do not routinely meet theship at each port of call.
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Table 2—Coast Guard Control Verification Examinations of the Universe Explorer*
Date Coast Guard Office Examination Type
August 12, 1997 Seattle, Washington Quarterly
May 12, 1997 Seattle, Washington Quarterly
December 23, 1996 Miami, Florida Quarterly
August 13, 1996 Seattle, Washington Initial with no plan review
July 20, 1996 Seattle, Washington Quarterly
May 14, 1996 Seattle, Washington Quarterly
January 12, 1996 New Orleans, Louisiana Annual
March 18, 1995 New Orleans, Louisiana Quarterly
December 17, 1994 New Orleans, Louisiana Annual
October 8, 1994 New Orleans, Louisiana Quarterly
April 9, 1994 New Orleans, Louisiana Quarterly
January 17, 1994 New Orleans, Louisiana Annual
August 7, 1993 New Orleans, Louisiana Quarterly
May 1993 New Orleans, Louisiana Quarterly
February 13, 1993 New Orleans, Louisiana Quarterly
September 12, 1992 New Orleans, Louisiana Quarterly
June 13, 1992 New Orleans, Louisiana **
March 15, 1992 New Orleans, Louisiana **
July 20, 1991 New York, New York **
April 6, 1991 New Orleans, Louisiana **
January 26, 1991 New Orleans, Louisiana **
October 16, 1990 New York, New York **
July 20, 1990 New York, New York **
January 20, 1990 New Orleans, Louisiana **
December 2, 1989 New Orleans, Louisiana **
September 2, 1989 New York, New York **
February 4, 1989 New Orleans, Louisiana **
September 3, 1988 New York, New York **
June 25, 1988 New York, New York **
December 5, 1987 New Orleans, Louisiana **
September 4, 1987 Providence, Rhode Island **
April 16, 1987 San Francisco, California **
* Source: U.S. Coast Guard MSIS Data Base
** Data does not indicate whether the examination was a quarterly or an annual.
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V. Ships indicated that it has begun theprocess for gaining certification under the Inter-national Safety Management (ISM) Code, whichmust be completed by July 1998 for passengerships. Under the ISM Code, each company mustdevelop a documented safety program that sup-ports and encourages the development of asafety culture to ensure safety at sea, preventionof human injury or loss of life, and avoidance ofdamage to the environment and to property.
Ships operated by companies that fail tocomply with the ISM Code will be considered inviolation of SOLAS and may be prevented fromtrading. The ISM Code requires each shipownerto establish a safety management system ap-proved by maritime authorities and to receive aDocument of Compliance for the shore-basedorganization and an individual Safety Manage-ment Certificate for each ship. Nonconformancewith the ISM Code may result in revocation ofthese certificates.
Fire Response Procedures —Thevessel operator provided the Safety Board withthe written procedures that the watch officer isto follow in the event of a fire (figure 9).
Fire Watch —SOLAS 74, Chapter II-2,Regulation 40 (6), states:
For ships carrying more than 36 pas-sengers, an efficient patrol system shallbe maintained so that an outbreak of firemay be promptly detected. Each mem-ber of the fire patrol shall be trained tobe familiar with the arrangements of theship as well as the location and oper-ation of any equipment he may be calledupon to use.
In accordance with SOLAS regulations, theUniverse Explorer maintained a fire watch,which entailed a crewmember’s making hourlyrounds of the vessel to check 40 designatedlocations. Each station had a numbered key per-manently attached to it by a chain. The watchcarried a recording clock into which he insertedand turned the numbered key. Each key made a
unique impression on a paper disk from whichthe time of insertion could be determined. Eachdisk contained the fire watch record for 1 day;disks were kept on permanent file for the vesselsafety officer to review to ensure that the firewatches were making their rounds correctly.
The fire watch route typically began withstation no. 1, which was on the navigationbridge, and proceeded in order of numbered sta-tions from the Observation deck to the Sundeck, Upper deck, Main deck, Bali deck, Aloha
FIRE ALARM SOUNDS ON BRIDGE.
1. Immediately acknowledge the alarm.
2. Send watch rating or Quartermaster on dutyto the place the alarm comes from, equippedwith a radio, flashlight, and master key.
3. Check the fire pump is running; if not, start itfrom the emergency generator room.
4. Upon arrival at the fire zone, the ratingreports status of the fire. If possible, he triesto extinguish the fire and rescue any trappedpersons. (When the fire groups arrive, therating can return to the bridge.)
5. As soon as a fire has been confirmed, theWatch Officer announces Mr. Skylight overthe P.A., indicating where the fire groupsmust report.
6. The Watch Officer checks that the fire screendoors are closed.
7. The Master, Staff Captain, Safety Officer,Chief Engineer, Hotel Manager, enginecontrol room, and the front desk are informedof the status of the fire.
8. The Watch Officer takes out relevant safetyplans.
9. The Watch Officer directs the firefightingfrom the bridge until the fire chief (StaffCaptain) takes over.
10. When the Master arrives on the bridge, theWatch Officer gives a status report, and whenthe Command Group is assembled, goes toMr. Skylight post.
Figure 9—Required responseprocedures of the bridge watch.
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deck, E deck, and Hold deck, respectively. Uponinspecting the Hold deck, the watch returned tothe bridge. Each tour started on the hour andtypically took about 45 minutes. According tothe vessel operator, the fire watch’s duties(appendix B) included ensuring that fire screendoors were not blocked or lashed open.
The fire watch usually took a staircase aft ofthe main laundry to descend from Aloha deck toE deck and then walked forward into the mainlaundry. After checking station no. 36 in themain laundry, he continued forward to the spiralstaircase at frame 65 to descend to the Holddeck. After checking the station on the Holddeck, he reversed his route, which meant hewalked through the laundry twice within amatter of minutes. Based upon the impression onthe paper disk from his clock, the watchman waslast in the main laundry about 0229.16
Medical Findings
Crewmembers and passengers who weredeemed to require additional medical attentioninitially were transported to Bartlett MemorialHospital. Four of these patients were taken bymedical evacuation flight to either the VirginiaMason Medical Center or the Harbor ViewMedical Center in Seattle, Washington (table 3).
Fatalities —Records of the general post-mortem examinations performed by the State ofAlaska Medical Examiner in Juneau, Alaska, onJuly 28, 1996, indicate that all five men diedfrom “asphyxia due to smoke inhalation.”
Toxicological Testing —Regulatory re-quirements at 46 CFR Part 4 stipulate that themarine employer shall ensure that toxicologicalspecimens are collected as soon as practicalfrom an individual on board the vessel “who is
16 The disk impression indicated the fire watch checked themain laundry at 0236. According to a representative for themanufacturer of the clock, it may have been 7 minutes fast,which would have made the time closer to 0229. SafetyBoard investigators found no evidence indicating the Detexclock disk had been altered or fabricated after the fire.
determined to be directly involved in a seriousmarine incident.” The main laundry fire occur-red when the area was not staffed. Moreover,the area was not locked and was accessible toeveryone on the ship.
When Safety Board investigators arrived atJuneau in the late evening of July 27, 1996, theyfound that the vessel operator had not arrangedfor any crewmember to be tested; investigatorsthen asked the operator’s representative to haveseveral of the deck and engineering officerssubmit to routine testing. He agreed and madearrangements to have a technician travel to thescene from Ketchikan, Alaska. The technicianarrived aboard the vessel on July 28, 1996, andcollected specimens between the hours of 1340and 1730 on July 28, 1996, from the followingofficers: master, staff captain, safety officer,senior second officer, junior second officer,third officer, chief engineer, staff chief engineer,and second engineer. The nine specimens wereshipped that day to a Federally certified labora-tory. Drugs test results were negative in eachcase. Because more than 34 hours had elapsedsince the accident and because some personnelhad been off-duty during that time, tests foralcohol were not conducted.
During postmortem examinations on July28, 1996, the State of Alaska Chief MedicalExaminer obtained specimens from the fivedeceased crewmen, which were sent to the Uni-versity of Utah’s Center for Human Toxicology(CHT) for analysis. All test results for alcoholand illicit drugs were negative. Because thedeceased were fire victims, the CHT conductedtests for two toxic combustion products, carbonmonoxide (as measured by percentage of car-boxyhemoglobin in the blood) and cyanide. Allspecimens had carboxyhemoglobin saturationlevels generally considered to be lethal, from alow of 64 percent to a high of 87 percent.17 Cya-nide was not detected in any specimen.
17 Stewart, R. D. The effect of carbon monoxide on hu-mans. Journal of Occupational Medicine, 18:304-309,1976.
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Wreckage
Main Laundry —Most fire damage waslocalized within the main laundry. During itspostaccident examination of the UniverseExplorer, from July 28 through 30, 1996, theSafety Board found that the forward area of thelaundry contained heavy charring and soot onthe bulkheads and on the ceiling, including theoverhead duct work, pipes, and electrical cables.Several overhead electrical cables were charredwhite and crumbled when touched. The insula-tion on two cables had holes exposing the cop-per wires. Small beads of copper were on theedges of the holes and the exposed wires. Adryer exhaust duct had warped upward. Investi-gators found small bits of charred plywoodinside the duct.
The 38-year-old vessel had been paintedmany times as part of routine maintenance.Much of the paint on the ceiling and bulkhead inthe forward part of the laundry was burned off.On other areas of the bulkhead surface, thickpieces of crisp, charred paint had peeled awayand were hanging down. The flakes of paintreadily crumbled when touched.
Some areas of the forward bulkhead surfacehad large areas on which the paint was intact orless damaged, as if protected by some object.During later interviews, the Safety Board deter-mined that laundry bins had been against thebulkhead, but had been removed during fireextinguishing operations.
The welding machine in the laundry areasustained extensive exterior heat damage, inclu-
ding the loss of the plastic cover on its controlwheel and most of its surface paint. Theinsulation on a ground wire and on anothercable wire had burned off, exposing the wires;however, the bare wires showed no indication ofelectrical arcing. A large electrical circuitbreaker panel was scorched and covered withsoot. The Safety Board found all panel switchesin the “off” position and covered with soot.
Heavy soot covered the surface of theforward bulkhead. The deck area with theheaviest char and ash was immediately starboardof the welding machine. The forward portcorner of the laundry had a narrow-angle “V”soot pattern18 extending upward from the areawhere the Safety Officer observed the fire.
Stairways and Aloha Deck —The aftstairway to the main laundry contained heavysoot on the stairway landings and bulkheads onthe E deck level. The aft entrance also containedheavy soot on the bulkheads, deck, and ceiling.The enclosure bulkheads to the spiral stairwayshowed extensive heat and flame damage, withmost of the paint burned off the bulkheads. In-
18 As a general rule, the wider the angle of a V pattern, thelonger the burned material has been subjected to heating;however, the angle of a V pattern on a vertical surface is aresult of the size of a fire, burning rate, ventilation, and thecombustibility of the vertical surface. Tracing the soot linesof the V pattern from higher to lower levels generally leadsto the area of origin for the fire. See National FireProtection Association publication 921, Guide for Fire andExplosion Investigation, the Factory Mutual EngineeringCorporation’s Guide to Arson and Fire Investigation, andthe National Fire Academy Training Manual forFire/Arson Investigation.
Table 3—Hospitals that Treated Universe Explorer Casualties
HOSPITAL CREW PASSENGERS TOTAL
Bartlett Memorial Hospital, Juneau, AK 63 2 65
Virginia Mason Medical Center, Seattle, WA 3 0 3
Harbor View Medical Center, Seattle, WA 1 0 1
TOTAL 67 2 69
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vestigators found heavy soot on the inside jamsof the door casing and on the edges of the door.The spiral staircase, railings, and inside surfacesof the enclosure bulkheads also contained heavysoot deposits.
The electromagnetically controlled fire dooropening on Aloha deck at the top of the spiralstairway had heavy soot on its edges and sides.The athwartships corridor area near the openfire door to the stairway had heavy soot and firedamage, including charred and peeling paint onceiling panels.
Two spring-activated fire doors leadingfrom the athwartships corridor to the crew ac-commodations area had heavy soot on the edgesand sides. Investigators found remnants of stringor twine tied on the handrails adjacent to eachdoor. The deck, ceiling, and bulkheads in thecrew corridors had accumulated soot, the portcorridor more so than the starboard corridor.The paint on the port corridor bulkhead near thefire door was burned off.
Survival Factors
The first part of this section contains thestandards and regulatory requirements related toemergency training and drills and the on-boardprovisions and procedures established by vesselor shoreside management. The second sectioncontains a narrative account of the actual eventson the morning of the accident, usingcrewmember statements from interviews andpassenger statements from a survey that theSafety Board mailed to a sample of passen-gers.19 The last section summarizes the responseeffort by the Coast Guard and local agencies.
Regulatory Requirements —The SO-LAS regulation governing emergency trainingand drills for passenger and cargo ships requiresthat vessels conduct musters and drills; it states
19 In August 1996, the Safety Board mailed aquestionnaire to a sample of 330 passengers. Of those, 283responded.
Each member of the crew shallparticipate in a least one abandon shipdrill and one fire drill every month. Thedrills of the crew shall take place within24 hours of the ship leaving a port ifmore than 25 percent of the crew havenot participated in abandon ship and firedrill on board that particular ship in theprevious month. The Administrationmay accept other arrangements that areat least equivalent for those classes ofship for which this is impracticable.…Fire drills should be planned in such away that due consideration is given toregular practice in the various emer-gencies that may occur depending onthe type of ship and its cargo.
Emergency Information andDrills —In accordance with SOLAS, a stationbill specifying the emergency stations, assign-ments, and lifeboat locations for each crew-member on board was posted in crew areasthroughout the vessel. In addition to the crew’semergency assignments, the station billdescribed the whistle signal and alarm bells fordifferent emergencies. Crewmembers were toreport to their emergency stations whenever thecode word “Mr. Skylight” was broadcast overthe public address system. The company alsoprovided each new crewmember with a bookletdescribing the emergency procedures.
Placards providing directions and safetyinformation were posted throughout the ship.Figure 10 shows the instructions on the placardthat was in each passenger cabin. The placardalso provided visual and written instructions fordonning life jackets. The information providedto passengers contained no instructions abouthow to open and close the fire screen doors.
Crewmembers indicated they participated inweekly emergency drills, which included re-porting to fire stations and performing dutieslisted on the station bill, mustering crew-members and passengers, and using firefightingand emergency equipment. A utility crewmanstated that during previous drills, he and his
26
roommate always had used the passagewaytoward the galley. They had never practicedusing an alternate escape route.
Crewmembers and passengers stated thatthey participated in an “abandon ship” drillbefore leaving Vancouver on July 23, 1996. Theship’s master stated that passengers wereadvised what the signal would be for anemergency and that they were to don their lifejackets and proceed to muster stations whenthey heard the alarm. He indicated that theywere told how to follow the arrows in thepassageways to locate their muster stations.Passengers were also told when the abandonship drill would be conducted and instructed notto use elevators during an actual emergency.
Vancouver Drill —Passengers stated thatupon boarding the Universe Explorer, they re-ceived an announcement that a drill would beconducted to provide information about what todo in the event of an emergency. They said theywere instructed to read the notice in their cabins,
don the life jackets stored in their cabins, andreport to their assigned lifeboat stations.
About 70 percent of the passengersresponding to the Safety Board survey statedthat the instructions given during the drill wereof great value and prevented panic and chaosduring the actual fire. About 65 percent of thepassengers characterized the drill as very realis-tic. One passenger said that the emergency madeher realize how important to her personal safetythe drill had been.
Thirty percent of the respondents said thatthe drill instructions were inadequate becausethey were disorganized and incomplete, lackinginformation such as how to operate the firescreen doors. About 25 percent of the respond-ers described the drill as minimally realisticbecause many passengers who knew thescheduled time of the drill went in advance totheir lifeboats, using the elevators to reach theirstations. Several passengers characterized thedrill as unrealistic because the crew had laid outthe passengers’ life jackets on their beds inpreparation for the drill; whereas they had tohunt for their jackets, which were stowed underbeds or in closets, during the actual emergency.
Only 50 passengers responding recalledseeing a placard explaining what to do in theevent of an actual fire. Most responders—219passengers—said the oral instructions theyreceived during the drill did not include infor-mation on what they should do if they saw afire, smelled smoke, or had to open a fire screendoor. One passenger said, “We were never eventold about the fire screen doors or that, in thecase of a fire, the fire screen doors would close,and we might have our passage to the boatstation blocked by them.”
General Response by Crew —Thestation bill for the Universe Explorer lists allcrewmember positions and their respectiveassignments in the event of an emergency. Theship’s hotel manager is responsible for coor-dinating the passenger evacuation effort. He was
Your Lifeboat Station Number IS…Learn To Find Your Way To Your LifeboatStation.This symbol shows you the way to the lifeboatstations…The general alarm signal is seven or more shortblasts followed by one long blast of the ship’swhistle and general alarm system as represented bythis signal…When the general alarm sounds, prepare to reportto your lifeboat station:
1. Under no circumstances use the elevators.2. Go to your cabin.3. Dress warmly.4. Put on your life jacket according to
instructions.5. Take a blanket with you.6. Leave your luggage behind.7. Follow the symbols…to your lifeboat station.8. If smoky, the best air is at floor level.9. Further instructions will be given by the crew
at your lifeboat station.
Figure 10—Information on theplacard in each passenger cabin.
27
not wearing or carrying a breathing apparatuswhen he attempted to go forward on the Maindeck to begin a search of the cabins. Uponopening a door on the port side, he encountered“a lot of black smoke” that stung his eyes andmade it difficult for him to breathe. He thenwent aft on the port side and was joined by othercrewmembers.
As the crew searched passenger staterooms,they put a towel on the knob of each exteriordoor to indicate that the cabin had beenchecked. They next wrapped towels around theirfaces to protect them from the smoke andproceeded to the Aloha deck to check theaccommodations areas. They found a crewmanovercome by smoke, put him on a stretcher, andcarried him to the Promenade deck.
Passenger Notification —More than270 passengers surveyed said they were in theircabins when they became aware of the fire.Some smelled smoke in their cabins; others sawsmoke in the passageways when they openedtheir doors in response to the sounds of acommotion in the corridors, the ringing of theemergency alarm, or someone yelling “fire.”
Within minutes of being notified about thefire, the cruise director reported to the bridge,where he began making announcements over thepublic address system to keep passengers calmand to instruct them in reporting to their musterstations. Several survey respondents stated thatthey did not hear a public address announce-ment. Others reported hearing the cruise directorannounce that there was a fire and that passen-gers should report to their muster stations. Manyof those passengers who recalled the announce-ment were already at their muster stations, whileothers were just leaving their cabins. Onerespondent said, “There was no communicationfrom the ship’s captain or any officer of thecrew until several passengers challenged anofficial from the cruise line to inform us of thesituation, 4 to 5 hours after the initial fire.”
More than half of the passengers reportedthat they saw a “slight” or “moderate” amount
of smoke or smelled smoke in the corridors;other passengers reported that they saw nosmoke. Passengers who had cabins in the lowerand forward sections of the ship reported thathallways were filled with “thick, heavy, andvery black” smoke and that visibility was “low”or “about 40 feet.” Respondents described thehallway lighting as adequate.
Forty-eight passengers stated that during theemergency, they had difficulty moving to andopening fire screen doors. One handicappedpassenger could not open the door by herselfand had to be assisted by another passenger.One passenger said that he encountered anotherpassenger who panicked when the fire screendoor closed; together they read the instructionson the door and were able to open it. Severalpassengers on the Observation deck reportedhaving problems with the fire screen doors. Anelderly couple and a young couple said theycould not open either the port or aft fire screendoor for about 10 minutes. Another coupleencountered two sets of closed fire doors and aman yelling, “We’re trapped and can’t get out!”The woman who was able to open the doorrecalled that because the handle was recessed, itwas difficult to see how it worked. On the Balideck, a passenger reported having troubleopening the fire doors because no instructionswere on or near them. Another passenger saidthat when she encountered a closed fire door,she proceeded through a “crew exit” door andencountered a vessel firefighter, who directedher to the lifeboat station.
Most survey respondents characterized theoverall behavior of passengers as disciplinedand civil and praised the crewmembers’ diligentand professional concern for the passengers,describing them as very efficient, reassuring,helpful, and understanding.
Muster leaders took roll and were able to ac-count for all passengers but not all crewmem-bers. The master said that passengers remainedcalm and that after the fire was extinguished,they were allowed to return to their cabins topack in preparation for leaving the vessel.
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Response by Hospital Staff —Themedical staff on the Universe Explorer com-prised a doctor and two nurses, whose cabinswere located near the ship’s hospital on the Balideck. Because the hospital was located directlyabove the main laundry, it was subjected to highlevels of heat during the fire.
The doctor stated that because of the thickblue-black smoke, he could not reach any medi-cal equipment; he was only able to “grab” themedical staff’s one portable radio before goingto his boat station on the Main deck. Thevessel’s medical staff assisted passengers andcrew with smoke inhalation injuries in variouslocations throughout the ship. The doctor statedthat because they only had one radio, the nurseshad to report in person to him to determinewhere their assistance was most needed. Thedoctor was able to obtain one additional radio,which he gave to one of the nurses, tocoordinate their response.
The doctor said that he retrieved the extramedical kit that is maintained on the bridge, butfound it of marginal use because it lacked theoxygen needed to treat smoke inhalation vic-tims. Because the hospital was filled withsmoke, the medical staff set up a triage area inthe lounge on the Promenade deck. Threepassengers with medical training—a firefighterand two nurses—assisted the ship’s medicalstaff in attending to the passengers with heartproblems and the crewmembers suffering fromsmoke inhalation. When Coast Guard personnelboarded the Universe Explorer about 0657, themedical officer and three emergency medicaltechnicians (EMTs) from the Coast Guard cutterWoodrush provided oxygen for the smokeinhalation victims. The ship’s doctor stated thathe was able to obtain medical supplies from thehospital after the fire had been extinguished,about 5 or 6 hours after the initial alarm.
Crew Escape —Safety Board investi-gators interviewed a number of crewmemberswho escaped from Aloha deck cabins near thesites where fatalities occurred. All survivorsinterviewed said that they were asleep when
they were awakened by people shouting andknocking on cabins doors. One crewman saidthat when he heard a knock, he checked hiswatch and the time was shortly before 0300.
All Aloha deck survivors indicated thatpassageways were filled with black smokebefore the bridge made the “Mr. Skylight” an-nouncement or sounded the general alarm. Anassistant cook said that he had already climbedup an escape hatch and was pausing to catch hisbreath on the Upper deck when he heard the“Mr. Skylight” announcement. He estimatedthat about 5 or 6 minutes elapsed between thetime he was awakened and the time he reachedthe open deck. A sanitation operator said that hehad started to move aft through the port sidepassageway when he stumbled over someonelying on the deck. He said that he then heard the“Mr. Skylight” announcement.
A utility man stated that when he wasawakened about 0300 and opened his cabindoor, he panicked at the sight of the thicksmoke. He and his roommate first tried to movetoward the main galley, but the heat was toointense, so they turned around. They then be-came separated. The utility man said he was inthe crew laundry when he heard “Mr. Skylight”and the general alarm. He then found a stairwayto the upper decks. Rescue teams later found theroommate dead on the floor of a cabin, a victimof smoke inhalation.
Another crewman said that he tried tofollow other people, but the smoke was too thickto see them. He tried to walk aft toward themain galley; but because of the heat and smoke,he had to turn around and proceed forward. Hesaid he stumbled around in the dark passagewayand into the crew laundry and then heard the“Mr. Skylight” announcement. He said he wastrying to feel his way forward to an exit when hefound a cabin in which five crewmembers weregathered near an open porthole taking turnsbreathing fresh air from it. He said as he wasbreathing out the porthole, he saw a CoastGuard vessel and tried to get its attention bywaving a towel out the porthole. He estimated
29
that about 3 hours passed before he heard peoplesearching for survivors. He said that when heand the other five crewmembers heard searchersnearby, they began pounding on the bulkheadand yelling for help to get their attention, but noone immediately came to their aid.
Rescue Efforts —In response to thegeneral alarm, shipboard firefighters reported tothe fire station at the forward part of the Boatdeck. About 0320-0325, the staff captain in-structed a member of fire team no. 1 to donequipment, which included a self-containedbreathing apparatus (SCBA) and protectivegear,20 and search the crew berthing area onAloha deck. He said that after descending toAloha deck, he opened the fire door to theberthing area and encountered intense andblinding smoke. He saw three crewmemberslying in the passageway and heard peoplepounding on bulkheads and calling for help. Heshined his flashlight down the passageway andyelled in the direction of the noise, but could seenothing but smoke. He went into the passage-way to check the three crewmen lying on thedeck; they showed no signs of life. He estimatedthat he returned to the Main deck about 0335-0340 and reported his findings to the staffcaptain, who told him to return to Aloha deckand bring back the fallen crewmen. The teammember told the staff captain that he could notdo it alone because of the smoke from the ragingfire. The staff captain instructed a secondcrewmember to accompany the team member.The second crewman obtained an SCBA about0350, and the two firefighters and the staffcaptain returned to Aloha deck to recover thethree bodies in the corridor.
The leader of fire team no. 1 said that hewas informed about 0540 that a crewman was incabin CA-22. He stated that when he and otherrescuers checked the cabin, which was full ofsmoke, they found the crewman “curled up in afetal position under the sink.” They then heard
20 A firefighter’s outfit consists of protective clothing,boots, helmet, flashlight, axe, and an approved breathingapparatus, such as an SCBA.
someone pounding on the bulkhead of the cabinnext door. Upon checking the cabin next door,they found a trapped crewman who had openeda porthole to get air. The fire team leader saidthey then moved the CA-22 occupant, whoshowed no signs of life, to the cabin with theopen porthole and began administering cardio-pulmonary resuscitation (CPR); however, theycould not revive him. Fire team members thencarried the surviving crewman to the Main deckfor medical treatment.
Response by Local Agencies —Eight local, State, and Federal agencies fromsurrounding areas responded to the accident onboard the Universe Explorer. They included theCoast Guard, the Capital City Fire and Rescueof Juneau, the Juneau Police Department, theDepartment of Public Safety for the State ofAlaska, the Alaska State Troopers, the State FireMarshal, the Coroner’s Office for the State ofAlaska, and the State Medical Examiner’sOffice. Their response actions are summarizedbelow.
Coast Guard —About 0300, while moni-toring channel 16, the navigation watch on theCoast Guard cutter Sweetbrier overheard theUniverse Explorer reporting the fire and thevessel location to the Coast Guard’s 17thDistrict command center Search and Rescue(SAR) Coordinator in Juneau. The Sweetbrierthen notified the SAR Coordinator that it was enroute to the Universe Explorer to assist. At thesame time, the Liberian passenger ship StarPrincess overheard the radio transmissions andproceeded en route to assist. About 0321, theSAR Coordinator notified the Juneau CoastGuard station to stand by until the SAR com-mand center had received an update about thefire. At 0324, a Coast Guard 41-foot patrol boat(41328) departed Station Juneau for the scene.
About 0341, the Universe Explorer masterradioed the SAR Coordinator that vessel fire-fighters were unable to enter the laundry spaceand were directing fire hoses on the outside ofthe compartment to cool the bulkhead so theycould enter the space. The SAR command center
30
arranged for a commercial tugboat and a CoastGuard helicopter to respond to the scene.
The Sweetbrier arrived on scene about0413; its commanding officer assumed respon-sibility as the on-scene commander. Patrol boat41328 arrived on scene about 0437. The CoastGuard vessels then escorted the Universe Ex-plorer to Auke Bay, where the Coast Guardcutter Woodrush relieved the Sweetbrier andtook command of the on-scene response. At0657, the medical officer and three emergencymedical technicians from the Woodrush boardedthe Universe Explorer to assess passenger andcrew injuries. Coast Guard personnel then pro-vided security for the Universe Explorer andtransportation for passengers, crewmembers,firefighters, and equipment until about 1800.
Capital City Fire and Rescue —About0500, the Capital City Fire and Rescue (CCF/R)fire chief was at home when he was notified ofthe Universe Explorer fire. He proceeded to theCCF/R-Glacier District, about 4 miles fromAuke Bay, where he assumed the role of inci-dent commander, established a command post,and implemented the local contingency plan. Hehad all local fire departments alert their person-nel who had had shipboard firefighting trainingto assemble with their equipment at the CCF/R-Auke Bay District, where they were briefed by afire training specialist and formed into threeteams based on their past experience. Theincident commander ordered the fire teams toreport to the Auke Bay Harbor parking lot,where, at 0845, they boarded a tugboat thattransported them to the Universe Explorer.When they arrived on board, CCF/R fire teamleaders met with the master, who told them thatthe fire was already extinguished and that thearea was secured. The CCF/R firefighters pro-ceeded to the laundry to examine the fire sceneand to ensure that the fire was completely out.While checking for “hot spots” in the laundry,CCF/R firefighters found still-smolderingdebris, which they extinguished. The CCF/R fireteam leaders kept the incident commanderinformed of the activities onboard the ship viaradio and cellular telephone.
The CCF/R firefighters remained on boardthe Universe Explorer until late in theafternoon. While on board, they maintained areflash watch, monitored the air quality insmoke-affected areas, and provided conditionassessments to the Coast Guard and the ship’smaster. About 1645, the CCF/R firefightersdeparted the vessel and returned to shore.
Juneau Police Department —The CCF/Rnotified the Juneau Police Department of thefire at 0506, whereupon the department’s oper-ations commander reported to the incident com-mand post at CCF/R-Glacier District, arrivingabout 0535. He and the incident commanderdiscussed transporting the cruise ship’s pas-sengers to shoreside hotel accommodations anddecided to bus passengers to Centennial Hall, acivic center in Juneau. Police officers providedsecurity, controlled traffic, managed the shelter,and oversaw bussing until the last passenger leftCentennial Hall at 1800.
Department of Public Safety —The AlaskaDepartment of Public Safety dispatch centernotified the State Troopers Office of a cruiseship fire about 0605 and the State FireMarshal’s office at 0720. Shortly after 0800, astate trooper and a fire marshal arrived at AukeBay, where the Universe Explorer was an-chored, and boarded the vessel to begin theirinvestigation. A Coast Guard representative ad-vised them that a marine chemist was scheduledto arrive from Seattle, Washington, about 1730to certify that the air in fire areas was safe tobreathe. Pending the chemist’s arrival, the statetrooper and fire marshal helped firefightersidentify the deceased crewmen and prepare thebodies for transport to the Alaskan ParkMortuary for examination.
Hospital Response —Upon being ad-vised of the number and scope of injuries, thestaff of Bartlett Memorial Hospital in Juneauimplemented the hospital disaster plan about0745 and dispatched ambulances to Auke Bay.Five ambulances and three buses transported 69patients from Auke Bay, about 9 miles from the
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hospital. The first patient arrived at 0925 byambulance, and the last patient arrived at 1210.Four of the more seriously injured casualtieswere evacuated by medical flight to Seattle.
Contingency Plan —As required by theCoast Guard’s Marine Safety Manual, the MSOhad developed a Fire Contingency Plan for thePort of Juneau. At the time of the UniverseExplorer fire, the medical and evacuation sec-tions containing procedures for responding to ashipboard fire had not been developed. LocalCoast Guard port officials stated that they hadconducted numerous discussions with localemergency agencies about procedures to followin the event of a shipboard fire. After this acci-dent, Coast Guard personnel met with localresponders several times to identify ways toimprove their emergency response capabilityand to complete the unfinished sections of theplan. Participants discussed the need to updatethe Fire Contingency Plan annually, to purchasemore cellular telephones, and to maintain a listof translators who could conduct crewinterviews, if necessary. They also scheduledfuture meetings.
Before the Universe Explorer accident, the17th Coast Guard District had last held adisaster drill simulating a passenger vessel fireand grounding on March 19 and 20, 1996. Theexercise, which was a table-top drill conductedat the Federal Building in Juneau, was dividedinto two phases, SAR and oil spill response.About 200 people participated, includingpersonnel from the Coast Guard, the State ofAlaska, local emergency response agencies, andsix cruise lines. During a debriefing on March21, an evaluation team critiqued the exerciseand made several recommendations for im-provement, one of which was that a workinggroup consisting of representatives from allagencies with a medical role during a majormarine incident establish a plan to deal withmedical issues during an emergency. Theevaluation team further recommended that “this[medical] plan should be considered forincorporation in the Unified Plan.”
Other Information
Vessel Smoking Policy —Accordingto the vessel operator, smoking on the UniverseExplorer is restricted. The crew is allowed tosmoke only in a designated area in the crewlounge. Cruise passengers are allowed to smokein their own rooms, on the open deck, and in adesignated smoking area in each of the twococktail bars. The ship’s officers enforce thecrew smoking policy. Crewmembers accused ofviolating the vessel smoking rules are subject tofines or, depending upon the circumstances,such as repeated violations, discharge fromservice.
FBI Case—On August 1, 1996, theFederal Bureau of Investigation (FBI), under itsauthority to investigate crime on the high seas,began a preliminary arson/homicide investi-gation of the Universe Explorer fire. The SafetyBoard provided the FBI with samples of debrisfrom the fire scene for laboratory analysis. TheFBI laboratory tests found no presence of anignitable liquid or other material that could beused as an accelerant. The FBI investigation didnot find sufficient evidence on which to base acriminal prosecution, and on February 13, 1997,the agency released copies of its investigationrecords to the Safety Board to assist in theBoard’s investigative process.
New Certification Requirementsfor Crews —The Standards for Training Certi-fication and Watchkeeping (STCW) 1995Convention adopted amendments establishingnew training and certification requirements forseafarers that went into effect on February 1,1997.21 The STCW Convention requires thatship companies document the training and cer-tification of crewmembers employed on theirships. Moreover, the amendments require thatbefore being assigned to shipboard duties, allcrewmembers who are new to a seagoing shipmust receive familiarization training in personalsurvival techniques including identifying emer-gency escape routes and muster and embarka-
21 Chapter VI, Section A-VI/1.
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tion stations, or receive sufficient informationand instructions to be able to perform certaintasks depending on their job titles, such as ad-vanced firefighting, medical care, and operatinga survival craft or rescue boat.
Retroactive Fire Safety Amend-ments —Since at least 1980, the Safety Boardhas repeatedly identified such issues as equip-ment operations, personnel training, and firesafety deficiencies on existing cruise ships in itsmajor marine accident reports.22 In addition, theBoard’s 1989 Safety Study, Passenger VesselsOperating from U.S. Ports (NTSB/SS-89/01),called for additional fire safety improvementson cruise ships operating from U.S. ports.
In 1990, the IMO’s Subcommittee on FireProtection was reviewing the need for additionalfire protection requirements for new ships when,on April 12, the passenger ship ScandinavianStar suffered a fire that resulted in the deaths of
22 Fire Onboard the Italian Passenger Ship AngelinaLauro, Charlotte Amalie Harbor, St. Thomas, U.S. VirginIslands, March 30, 1979 (NTSB/MAR-80/16); FireOnboard the Bahamian Passenger Vessel M/V Scandina-vian Sea, Cape Canaveral, Florida, March 9, 1984(NTSB/MAR-85/03); Fire Onboard the Bahamian Passen-ger Ship M/V Scandinavian Sun, Port of Miami, Miami,Florida, August 20, 1984 (NTSB/MAR-85/08); Fire andExplosions Onboard the Panamanian Passenger ShipEmerald Seas in the Atlantic Ocean near Little Stirrup Cay,Bahamas, July 30, 1986 (NTSB/MAR-87/04); and FireOnboard the Bahamian Passenger Ship Scandinavian Starin the Gulf of Mexico, March 15, 1988 (NTSB/MAR-89/04).
158 people. The IMO’s Maritime Safety Com-mittee subsequently revised chapter II-2, “Con-struction—Fire Protection, Fire Detection andFire Extinction” of the SOLAS Convention inMay 1992. These amendments, which were tobe phased in over a 16-year period beginning inOctober 1994, applied to both new and existingpassenger vessels and addressed many safetyrecommendations issued by the Safety Board inits accident reports and studies.23 The portion ofthe requirements applicable to existing vesselsare the RFSAs. Among other safety measures,the RFSAs require that existing passenger shipshave fixed automatic sprinkler systems, fixedautomatic smoke detection systems, and low-location lighting systems by specified dates.Further, spaces containing combustibles, inclu-ding accommodation areas and service spaces,such as laundries, are not permitted to have directaccess to stairway enclosures. Appendix C con-tains some of the RFSAs applicable to existingpassenger vessels such as the Universe Explorer.
23 The Safety Board also outlined needed safety measuresin its 1993 Special Investigation Report, Accidents In-volving Foreign Passenger Ships Operating from U.S.Ports, 1990-1991 (NTSB/SIR-93/01), which containedinformation from prior Safety Board reports of thefollowing cruise ship fires: Regent Star (DCA90MM037),Sovereign Of The Seas (DCA91MM023), Britanis(DCA92MM007), and Song of America (DCA92MM008).
GeneralThis analysis is divided into three main
sections. In the first part, the Safety Boardidentifies factors that can be readily eliminatedas causal or contributory to the accident. In thesecond section, the Board provides a synopsis ofthe accident and considers where and how thefire may have started. In the final section, theBoard discusses the following major safetyissues, which were identified during this investi-gation:
• Adequacy of shipboard communi-cations;
• Adequacy of fire prevention, detection,and control measures;
• Adequacy of emergency procedures;and
• Adequacy of oversight.
The analysis also discusses toxicologicaltesting criteria, the emergency response effortby Coast Guard, State, and local agencies, andthe Coast Guard contingency plan.
ExclusionsNeither the navigation or propulsion sys-
tems nor the personnel qualifications of theofficers and crew had a bearing on the cause ofthe fire. The ship experienced no mechanicaldifficulties of any type during its voyage. Fromdocuments and statements, the Safety Boarddetermined that all officers were properlylicensed and certificated by the Panamaniangovernment and were qualified to serve in theirpositions.
Toxicological test results show that drugsdid not affect the performance of the nine offi-cers who were tested and that drugs and alcoholdid not affect the performance of the five
deceased crewmembers. However, the Boardhas concerns about the conduct of postaccidenttoxicological testing, which will be addressedlater in this report. The Safety Board thereforeconcludes that factors related to the vesselnavigation system, propulsion system, andmechanical equipment neither caused nor con-tributed to the accident; that all officers wereproperly licensed and qualified to serve in theirpositions, and that no available evidence indi-cated that drugs or alcohol affected the perfor-mance of those officers and crewmemberstested.
Accident SynopsisAvailable evidence indicates the fire in the
main laundry originated near the spiral staircase,was fast burning, and generated a tremendousamount of smoke that was drawn into the spiralstairway and up to the decks above, where crewcabins were located. The system of electro-magnetic fire doors was not wired so that localsmoke or heat detectors would automaticallyclose the fire doors in an affected area. Theelectromagnetic fire doors could only be closeduniversally from the bridge, which meant thatthey were not closed until personnel on thebridge became aware of the emergency. Somefire doors near crew areas were tied open, asafety hazard that was not corrected by the firewatchmen. Although the bridge watch initiatedvessel fire response procedures immediatelyupon receiving the second alarm, a lethalamount of smoke probably had already spreadthrough the open doors and filled the crew areaon the Aloha deck. The smoke alarms in thearea did not sound locally to alert sleepingcrewmen to the emergency. Further, the crewcabins had no telephones or means by whichcrewmembers could either alert the bridge of thefire or that they were trapped by smoke or fireconditions. As a result of the crew berthingarea’s filling with smoke, 5 crewmembers died
ANALYSIS
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and 55 crewmembers sustained minor or seriousinjuries from smoke inhalation.
During its on-scene investigation, the SafetyBoard determined that overhaul24 operations byshipboard and municipal firefighters and otherfactors adversely affected investigators’ effortsto identify the exact cause of the fire. Thefollowing section discusses the Board’s findingsand conclusions about the area of origin, pos-sible causes, and nature of the fire.
The FireArea of Origin —From examination of
the fire damage and information provided by thevessel’s crew, the Safety Board determined thatthe fire started next to the bulkhead in the for-ward portion of the main laundry, close to thedoorway to the spiral stairway. A “V”-shapedsoot pattern was in this immediate area. Burnpatterns on the forward bulkhead matched theoutlines of laundry bins that had been next tothe forward bulkhead before firefighters movedthem. Further, the vessel’s safety officer, whofirst witnessed the fire scene, stated that heobserved most of the fire in this area. Twolaundry bins, one of which was aluminum andone fiberglass, that had been closest to thewelding machine were severely damaged in theblaze, indicating prolonged exposure to fire.Safety Board investigators found meltedaluminum on the deck only in this area of thelaundry, an indication that the hottest burningoccurred there. Investigators also observedsevere localized heat damage in the overheadand a heat-distorted dryer duct in the area. TheSafety Board concludes that the fire on boardthe Universe Explorer originated in one of thelaundry bins that had been against the forwardbulkhead of the main laundry.
Type of Fire —All available evidencesuggests that the fire developed rapidly.Damage to the overhead was localized in one
�� Overhaul is the process of moving and separating burnedmaterial to locate any hot or smoldering debris and to coolit or wet it down to prevent a reflash of the fire.
area—the forward part of the main laundry—rather than evenly distributed throughout thelaundry. The narrow angle of the “V”-pattern onthe bulkheads in the forward area of the laundryalso indicates a fast-burning fire. Further, thetime that elapsed between the watch’s checkingthe main laundry and the first heat detector firealarm sounding on the bridge was at most 27minutes, which does not support the scenario ofa slow-developing fire.
Cause of Fire —The Safety Board exam-ined whether several conditions were presentthat could have resulted in the fire: discardedsmoking material, electrical short circuit, con-tact of combustible material with a hot surface,spontaneous combustion, and a deliberatehuman act.
Discarded cigarette —According to docu-mentation from the National Fire Academy, fora discarded cigarette to ignite a furniture item orbedding, the smoking material must be insulatedagainst air that normally dissipates the heat. If alit cigarette becomes wrapped and thereby insu-lated within a layer of combustible material,such as linen, an open flame can develop within20 minutes to a couple of hours. In addition, firedevelopment can be accelerated if the insulatingmaterial is soiled with an ignitable substance,such as food grease, candle wax, or other sub-stances that are frequently spilled on table linen.
The Universe Explorer’s operating companyhas a policy restricting smoking to selectedareas of the ship, which does not include themain laundry. Moreover, the vessel hotelmanager stated that all laundry workers werenonsmokers. The main laundry is neither a hightraffic area when operations are shut down nor adesirable place to loiter or to grab a quicksmoke. Between the time laundry operationswere shut down for the day at 1800 and the heatdetector actuated—about 9 hours—the firewatches observed no one smoking in the laundryand no evidence of smoke or fire. The SafetyBoard found no physical evidence, such ascigarette butts or cigarette packages, that indi-cated discarded smoking material caused the
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fire. However, these materials could have beenpresent at the time of the fire and dispersed orinadvertently removed from the laundry duringfire extinguishing and overhaul operations.
Despite the statements of the fire watch andthe lack of physical evidence, a burning ciga-rette as the source of ignition cannot be dis-counted. The main laundry area was not lockedor staffed after 1800. A waiter, another crew-member, or a fire watch could have beensmoking in the laundry and carelessly disposedof a burning cigarette, which ended up in a pileof linen. Had it become insulated within thematerial, whether the linen was soiled or clean,the burning cigarette could have smoldered for awhile without emitting observable amounts ofsmoke. Between the time the fire watch was lastin the main laundry and the time of the first firealarm (20 to 27 minutes), a burning cigarettecould have ignited the linen, and the open flamecould have grown into a fully developed fire.
Electrical short circuit —During postacci-dent examination of the overhead near the fire’sarea of origin, the Safety Board found anelectrical cable with holes covered with beads ofcopper,25 indicating the wires had been ener-gized. Molten copper falling into a laundry bincould have ignited the linen. At the request ofthe Safety Board, the vessel’s chief electriciantraced the overhead cable and found that itpowered the general alarm bell in the mainlaundry space. This wiring is energized bymanual activation of the general alarm, whichoccurred only after the fire was discovered.
The laundry manager stated that he shut offall laundry machinery at 1800 on the eve of thefire. The fire watch stated that no machinerywas operating when he passed through the laun-dry shortly before the fire. During postaccidentexamination, investigators found the circuitbreakers to electrical laundry equipment and thepower control switch to the electric weldingmachine in the “off” position. The Safety Boardfound no indication that faulty electrical wiring
�� The melting point of copper is 1,981o F.
or equipment shorted out, causing enough heatto start a fire that spread to the linen stored inlaundry bins and the paint on the bulkheads.
Hot air or surface —While examining thedistorted dryer exhaust duct, investigators deter-mined that access covers to the duct had beenmade of plywood that was burned away in thefire. The presence of small bits of charred woodinside the duct holes indicated that the plywoodmost likely was burned from the outside and thatsmall pieces of the plywood were sucked intothe duct by smoke-filled air drafting into andthrough the exhaust duct. Because the clothesdryers were off at the time of the fire, the SafetyBoard discounted the possibility that hot airfrom the dryers ignited the plywood accesscovers on the dryer exhaust duct.
The Safety Board considered whether thefire may have occurred from linen coming incontact with hot operating machinery or steampipes. The welding machine that was near thebins that burned had not been used for severaldays before the accident and, therefore, wouldnot have presented a hot surface. The laundrymachinery was shut off about 1800 on July 26,1996, allowing more than sufficient time for themachinery to cool before the fire began almost 9hours later. The steam presses were not near thefire’s area of origin. Further, one of the steampresses was not used the day before the fire. Nosteam pipes were near where the fire originated.
The Safety Board concludes that accidentalignition sources, such as faulty electrical equip-ment, wiring arcing, or contact with a hotsurface or air, did not cause the fire aboard theUniverse Explorer.
Spontaneous combustion —According to asenior investigator of hotel fires, spontaneouscombustion fires are not uncommon in industriallaundry facilities. Today’s detergents oftencontain an oxidant. The linen to be launderedoften is soiled with organic substances, such asanimal fat or grease, that may not completelywash out, leaving an organic residue. When awashed linen load of mostly organic material,
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such as cotton or natural fiber, is dried andstacked, the heat absorbed by the material be-comes concentrated and insulated. This canresult in the organic residue reacting chemicallywith the oxidant, creating an increase in heat.When insulated with a natural fiber material,which has a thicker thread, the heat builds untilthe material gets hot enough to ignite. Theoxidant then continues to feed the flame.
Spontaneous combustion fires typically areslow to ignite. However, once ignited they canburn rapidly. The first heat detector activated onE deck at 0256:42. Within a minute (0257:32),smoke detectors were activating on Aloha deck.The fire watch had made hourly rounds of theship, including the main laundry area, and de-tected no signs of smoke or fire. The Detexclock used to record the times at the fire stationsreportedly was 7 minutes fast. However, evenallowing for the time discrepancy, the watchprobably passed the fire’s point of origin threetimes within the 20 minutes before the first firealarm sounded on the bridge.
National Fire Academy documentation indi-cates that a free-burning fire can develop quick-ly from the spontaneous ignition of grease andother organic material that is well insulated bytightly packed cotton or natural fiber linen thathas been washed and dried and placed into alaundry bin. The fire that erupted in the Uni-verse Explorer main laundry originated in anuncovered solid-sided aluminum laundry bin.Although crewmembers stated that all materialin the bins was soiled laundry to be washed,investigators could not verify this during the on-scene investigation. However, the Safety Boarddoubts that shipboard staff would have mixedsoiled linen with clean linen. Postaccident in-vestigation could not verify whether washed anddried linen had been in the laundry bins; there-fore, spontaneous combustion cannot be elimi-nated as a possible cause of the fire.
Deliberate act —The Safety Board con-sidered factors that may have led to someonedeliberately setting the fire. The FBI conductedan arson investigation of this accident and found
insufficient evidence of criminal action. FBIlaboratory tests of a fire debris sample showedno presence of an ignitable liquid or othermaterial that could be used as an accelerant.Safety Board investigators also found no evi-dence that the fire was deliberately set.
Nevertheless, conditions existed that wereconducive to an undetected, deliberately set fire.The main laundry was located in an isolatedarea that was not locked or staffed after 1800.The time that elapsed between the fire watchlast checking the laundry area and the heatdetector actuating would have been sufficientfor someone to start a fire. The laundry con-tained large quantities of readily combustiblematerials. Due to the flammability of most linen,no accelerant would have been needed to start afire in the material. However, had the residue ofan accelerant existed, it could have beendestroyed during firefighting operations.
The Safety Board concludes that neitherdiscarded smoking material, spontaneous com-bustion, nor a deliberate act can be ruled out aspossible causes of the Universe Explorer fire.
The AftermathWhen audible alarms sounded on the fire
alarm panel on the navigation bridge, the officeron watch initiated actions in accordance withcompany emergency procedures, dispatching thefire watch to investigate and telephoning themaster, the staff captain, and the safety officer,who, in turn, began procedures for evacuatingpassengers and crew and for determining thelocation of the blaze. Fire teams reported totheir muster stations in a timely manner, and,once a path to reach the fire was identified,quickly brought the blaze under control andextinguished it.
Despite what might seem to have beentimely alert and response actions, 5 crewmem-bers died, and 55 crewmembers sustained inju-ries from smoke inhalation. One passenger wasinjured, and another passenger with a pre-existing medical condition required treatment.
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The Safety Board examined factors contributingto the injuries and identified several safety is-sues in the areas of communications, fire detec-tion and control measures, and emergency pro-cedures that affected survivability.
Adequacy of CommunicationsIneffective communications affected every
phase of this accident, including fire detection,crew escape, and medical treatment of casu-alties.
Contact Between Bridge and FireWatch —When the second officer initially con-tacted the fire watch by UHF radio, the firewatch was on the open deck. He acknowledgedthe transmission, which the second officerheard, and started to descend to E deck to checkin the main laundry. After the second alarm, thesecond officer again radioed the fire watch butheard no response, although the fire watch didreceive and acknowledge the transmission. Thesecond officer then transmitted in the blind,beginning his statement with “If you can hearthis, go ….” When the fire watch heard thesecond officer transmit in this manner, herealized that his radio transmissions were inef-fective from his location. He therefore tried totelephone the bridge watch officer when he, thefire watch, encountered heavy smoke on theMain deck. However, the telephone line wasbusy. The fire watch then started to run to thebridge to make his report, but, upon hearing the“Mr. Skylight” announcement, instead went tohis emergency station, never reporting his obser-vations about the smoke conditions on the Maindeck to the bridge watch officer.
The communications between the bridgeand the watch on the Universe Explorer repre-sent a breakdown in two ways: the instrumentused was ineffective in the environment, and theprocedures followed did not result in the bridgereceiving timely information about shipboardconditions. The adequacy of the company oper-ating procedures for emergency response will beexamined later in this analysis.
Inadequate equipment —The Universe Ex-plorer is typical of vessels whose steel structureresults in “dead spots” where UHF radios be-come ineffective. In an emergency situation, it isabsolutely essential that personnel who may begoing into harm’s way be able to receive andtransmit messages. Had the fire watch, who wasacting alone, been seriously injured or trappedand in need of assistance, he could not havenotified the bridge. Additionally, had he hadvital information about the progress of thesmoke, the fire, the safety of the crew, or thesafety of the passengers, he could not havetransmitted it to the watch officer. The SafetyBoard concludes that the UHF radio alone didnot provide the communications capability toensure the safety of the fire watch, which, inturn, was needed to ensure the safety of pas-sengers and crewmembers.
The Safety Board is aware that the U.S.Navy has addressed the problem of effectiveinternal shipboard radio communications byinstalling an internal radio antenna networkthroughout its vessels. This type of system elim-inates blind spots, enabling crewmembers tocarry out communications with no interruptionsduring an emergency. The Safety Board con-cludes that if the Universe Explorer had beenequipped with an internal radio antenna networksystem, radio communications would have beenmore effective during the fire emergency. TheBoard believes that New Commodore, and itsoperating company, V Ships, should provide areliable means of internal radio communicationsbetween the shipboard command and emergencyresponders and between the separate groups ofemergency responders on board company-oper-ated passenger ships.
The Safety Board also believes that theCoast Guard should propose that the IMOrequire passenger ships to institute procedures,install upgraded equipment, or do both to ensurethat reliable two-way internal radio com-munications may be maintained throughout avessel during an emergency. In the interim, theInternational Council of Cruise Lines (ICCL)
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should advise its member companies of the cir-cumstances of this accident, recommend thatthey examine their shipboard procedures andcommunications equipment, and, if necessary,make improvements to ensure that reliable two-way internal radio communications can be main-tained throughout their passenger ships duringan emergency.
Inadequate procedures —During this emer-gency, when the second officer received noresponse to his transmissions, he did not initiatemeasures to determine what had happened to thefire watch. For his part, the fire watch did notadvise the bridge about his status or the condi-tions on the Main deck and left his fire patrolpost without first communicating with and ob-taining permission from the watch officer. TheSafety Board concludes that the communicationprocedures between the bridge officer and thewatchman during the emergency were inade-quate. The Safety Board believes that NewCommodore, its operating company, V. Ships,and the Universe Explorer master should reviewand improve communications procedures usedduring shipboard emergency responses, particu-larly the communication between the bridgewatch and fire watch when the latter is sent toinvestigate a fire alarm.
Means of Communication in CrewCabins —The crew berthing areas lacked tele-phones or other means of communication withwhich crewmembers could signal their locationsor call for help. Crewmen tried to signal theirneed for assistance by waving a towel out of aporthole, by banging on walls, and by yelling forhelp; however, their efforts were ineffective.Because of the vessel’s steel construction, nois-es either migrated or were not audible, making itdifficult for rescuers to accurately determinewhere trapped crewmen were located. Had somestranded crewmen not found a room with aporthole through which they could take turnsbreathing fresh air, the number of fatalitieswould have been higher.
Rescuers did not locate several trappedcrewmen until about 0540, more than 2 ½ hours
after the fire started. Had the stranded men had ameans by which they could signal their location,rescuers could have determined that locationand helped them sooner, thereby reducing thenumber and severity of injuries to the trappedcrewmen and exposing the search teams tofewer risks.
As a result of past investigations, the SafetyBoard has been a proponent of emergency callsystems in passenger staterooms on cruise shipsfor several years. In a 1993 special investigationreport concerning passenger ship accidents,26
the Board made the following safety recom-mendation to the Coast Guard:
M-93-39
Analyze the desirability and feasibilityof equipping passenger staterooms withan emergency call system by whichtrapped passengers can signal theirplight.
On October 18, 1993, the Coast Guardresponded that it was not convinced that incor-porating an emergency call system into theexisting telephone system would provide a signi-ficant benefit:
The majority of passenger vessels havetelephone systems in staterooms whichpassengers may use in the event of anemergency. The proposed call systemwould not improve passenger-to-crewcommunications, but would be redundantand require additional, unnecessarymaintenance. Furthermore, during anemergency, passengers are required to goto an assigned muster station and crewmembers search all passenger state-rooms. This procedure is an effective,reliable method to identify passengersthat may be trapped in their staterooms.
On February 10, 1994, the Safety Boardwrote the Coast Guard, stating: “The point of the
�� For additional information, read Special InvestigationReport—Accidents Involving Foreign Passenger ShipsOperating from U.S. Ports 1990-1991 (NTSB/SIR-93/01).
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recommendation was not to require a redundantsystem, but to require a means whereby passen-gers trapped in their staterooms can summonhelp.” The Board advised that Safety Recom-mendation M-93-39 was classified�Open—Un-acceptable Response,” pending the Coast Guard’sreconsideration of its position.
On August 6, 1996, the Coast Guard advisedthe Safety Board that it had discussed thedesirability and feasibility of installing emergen-cy call systems in passenger staterooms with theU.S. SOLAS Working Group on Fire Protectionand, based upon that discussion, determined that“an additional emergency call system would notimprove passenger-to-crew communications andwould require additional maintenance.” Theletter further stated, “Since the Coast Guard hascompleted the recommended analysis, werequest that the status of the recommendation bechanged to Closed, Acceptable Action.”
On May 21, 1997, the Safety Board wrotethat it was disappointed with the Coast Guard’sactions, stating:
The Safety Board disagrees with theCoast Guard position that telephones instaterooms will serve in an emergencysituation, because telephone systems donot easily accommodate simultaneousmultiple calls. If passengers are trappedin a stateroom and get a busy signalwhen they call for help, they may panicand could take inappropriate action.
Because the Coast Guard has onlydiscussed this recommendation with theSOLAS Working Group on Fire Pro-tection and has not done any analysis asrequested, Safety Recommendation M-93-39 has been classified ‘Closed—Unacceptable Action.’
The Safety Board notes that the UniverseExplorer had telephones in passenger state-rooms. The Universe Explorer fire watch got abusy signal when he tried to contact the bridge
by telephone. Had passengers been trapped andtried to use their telephones, they likely wouldhave had similar difficulties. As this accidentdemonstrates, all accommodation areas shouldhave a means by which individuals can signaltheir locations during a fire emergency to facili-tate rescue operations. Even a simple system,such as the flight attendant call button systemused on commercial airlines, would probably besufficient to signal a location. The Safety Boardconcludes that the lack of a means to call forhelp delayed the rescue of trapped crewmen andcontributed to the severity of their injuries. TheSafety Board believes that New Commodore,and its operator, V. Ships, should equip thepassenger and crew cabins on company cruiseships with an emergency call system so thattrapped individuals can signal their location.
The Safety Board also believes that the CoastGuard should recommend that the IMO requirepassenger ships to equip passenger and crewcabins with emergency call systems so that trap-ped individuals can signal their location. Further,the ICCL should propose that its membercompanies install emergency call systems inpassenger and crew cabins.
Radios for Medical Staff —The doctorand two nurses had to treat passengers and crewlocated throughout the ship who were sufferingfrom various injuries, some very serious. TheUniverse Explorer medical staff had only oneradio, which meant that the nurses repeatedlyhad to go to the doctor to determine where theirassistance was most needed. The doctor wasable to obtain one additional radio, which hegave to one of the nurses, to coordinate theirresponse, but the lack of effective communica-tions interfered with their ability to render treat-ment to injured passengers and crewmembers.Had each member of the medical staff had aradio and a separate frequency on which tocommunicate so as not to interrupt other emer-gency transmissions, the doctor and nursescould have conferred over the radio withouthaving to leave patients; as a result, more injuryvictims could have received better care by virtueof being treated sooner. The Safety Board
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concludes that the inability of the shipboardmedical staff to communicate by radio nega-tively affected the timeliness of the care pro-vided to people injured in this accident.
The Safety Board believes that New Com-modore, and its operator, V. Ships, should pro-vide each medical staff member on companypassenger vessels with a portable radio for usein shipboard emergencies. In addition, the Safe-ty Board believes that the Coast Guard shouldpropose to the IMO that passenger ship com-panies be required to equip each on-boardmedical staff member with a portable radio thathas a dedicated radio frequency for use duringemergencies. Further, the ICCL should proposethat its member passenger ship operators pro-vide each shipboard medical staff member witha radio and communications training for emer-gencies.
Adequacy of Fire Prevention,Control, and DetectionMeasures
The Safety Board determined that severalmeasures affecting the fire safety of the vesselwere either lacking, inadequate, or compro-mised. Any one of these factors could affect orcontribute to the migration and propagation ofsmoke in the crew berthing area; together, theyallowed a lethal amount of smoke to quicklyaccumulate in the crew quarters. This sectiondiscusses the following problems identified bythe Safety Board:
• Bulkhead removal;
• Effectiveness of fire detectors;
• Lack of a sprinkler system;
• Effectiveness of electromagnetic firedoors;
• Misuse of fire doors; and
• Lack of automatic local fire alarms.
Bulkhead Removal —The vessel nowknown as the Universe Explorer was built in1958 to SOLAS 48 requirements as interpretedby 46 CFR. The CFR states, “Insofar as isreasonable and practicable, Types 1 and 2 stair-ways … should not give direct access to accom-modations or other enclosed spaces in which afire may originate.” Original plans indicate abulkhead that essentially creates a corridorisolating the laundry work area from the stair-ways (figure 6). Later plans, including the firecontrol plan on the ship at the time of the fire,also indicate the presence of the bulkhead.During postaccident examination of the laundry,Safety Board investigators observed that thebulkhead had been removed.
The presence of the bulkhead itself wouldnot necessarily have prevented a fire fromstarting; however, had the structure been inplace, conditions would have been present thatwould have affected the timely detection of thefire and the propagation of smoke and heat. Hadthis bulkhead been in place and the corridorbeen maintained properly, no or few combusti-ble items would have been in the walkway. Hadthe fire started in the laundry area, the bulkheadwould have mitigated the effects of the fire.Even if the doors to the corridor and the stair-ways were open, the amount of smoke enteringthe stairways would have been less, resulting inproportionately less smoke migrating to theAloha deck berthing area. The Safety Boardconcludes that removing the corridor bulkheadin the main laundry was an alteration to thevessel that seriously degraded the fire safetycondition of the Universe Explorer. Further dis-cussion of the bulkhead removal and theoversight by the owner, the flag state, and theCoast Guard appears later in this analysis.
Effectiveness of Fire Detectors —When Safety Board investigators examined themain laundry after the fire, they noted that thesmoke detectors were not connected to the firedetection system. The only active fire detectiondevices in the area were heat detectors. Recordsdo not indicate why the smoke detectors weredisconnected. However, from discussions with
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people experienced in laundry operations, fireexperts, and detector manufacturers, the SafetyBoard determined that moisture, dust, and lint inthe air of a laundry facility can trigger smokedetector sensors, resulting in false alarms, unlessthe devices are properly maintained. Heat-actuated detectors require more time than smokedetectors to actuate because a minimum level orminimum rate of heating must occur in the areaof the device’s sensor before the detector acti-vates.
The limitations of each type of detectorcould be reduced by establishing systems usingboth types of devices. Moreover, combining thesystem of detection with an automatic sprinklersystem, which is discussed in the next section ofthis report, would provide a greater measure ofsafety by limiting the spread of fire. The SafetyBoard concludes that greater fire protection canbe attained in laundry facilities by using a com-bination of different types of detection devices,as well as an automatic suppression system.
The Safety Board is aware of other fire de-tection systems that are in development, inclu-ding infrared and ultraviolet flame detectors andcarbon monoxide detection systems. Some ofthese systems are currently available, and othersare still being tested. Research at the NationalFire Academy has shown that alarm verificationand cross zoning of fire detectors are designfeatures used in buildings to significantly reducerandom false alarms. Alarm verification utilizesa time (15-30 seconds) to reset and verify adetector once it goes into alarm; if the activateddetector does not reset, the alarm is processed asa valid alarm.
Cross zoning is another self-verificationfeature using adjacent detectors on independentzones or circuits. In a cross-zoned system, if onefire detector activates and an adjacent detectordoes not, the probability is high that a falsealarm has occurred. If both detectors activate,the probability that a false alarm has occurred islow, and the alarm is processed as a valid alarm.Any type of fire detection system can be de-
signed to reduce false alarms by employingeither of these features.27
Given the high fire risk in laundry opera-tions, improved methods of monitoring suchareas are essential. Augmenting smoke and heatdetectors with better surveillance measures, in-cluding installing video cameras in high-riskareas, may increase the level of safety aboardthe Universe Explorer. The Safety Board con-cludes that improved surveillance of high-fire-risk areas would enhance the fire safety condi-tion on board the Universe Explorer. The SafetyBoard therefore believes that the New Commo-dore, and its operator, V. Ships, should reviewthe adequacy of the fire detection systems pres-ently protecting high-fire-risk areas, includinglaundries, on company passenger ships, and,based on that review, install improved detectionsystems or institute improved surveillance pro-cedures to improve fire detection capability.
Further, the Coast Guard should conductresearch with the passenger ship industry andthe National Fire Protection Association on theadequacy of heat and smoke detectors for use inhigh-fire-risk areas, including laundry spaces,and, based on the findings, propose to the IMOequipment or procedural guidelines for improv-ing fire alarm reliability. In the interim, theICCL should advise member companies of thepossible need to improve surveillance measuresfor high-fire-risk areas on their ships.
Lack of a Sprinkler System �At thetime of this accident, the main laundry on theUniverse Explorer was not equipped with, andwas not required by SOLAS to have, an auto-matic fire sprinkler system. In this fire a tremen-dous, lethal amount of smoke was producedwhen the many layers of paint on the stairwell
�� W. Nelson, “Methods of Reducing False Alarms in FireAlarm Systems,” Applied Research Project, National FireAcademy, RR No. 14213, November 1989. J. Boccio, I.Asp, and R. Hall, “Acceptance and Verification for EarlyWarning Fire Detection Systems,” Reactor EngineeringAnalysis Group, Department of Nuclear Energy, Brook-haven National Laboratory, Upton, New York. Prepared forU.S. Nuclear Regulatory Commission, May 1980.
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bulkheads ignited. If the main laundry had beenequipped with automatic sprinklers, they prob-ably would have activated and extinguished thefire during its early development, preventing orat least mitigating the spread of smoke into thespiral stairway. The Safety Board concludes thatif the Universe Explorer had been equipped withan automatic sprinkler system, the large quanti-ties of smoke and resulting loss of life may havebeen avoided.
Effectiveness of ElectromagneticFire Doors —The Universe Explorer had elec-tromagnetic fire doors on all stairway enclosuresand main vertical zone boundaries, including theforward bulkhead of the main laundry. Thesefire doors did not close automatically; they hadto be released either by someone pushing a localswitch or by someone on bridge remotelyclosing them.
According to the laundry manager, the firedoor leading to the spiral stairway forward ofthe main laundry was always kept open. The firewatch stated that the forward and aft fire doorsof the main laundry were open when he passedthrough on his rounds and that no one had everinstructed him to close them. Soot on the doors,door jambs, and adjacent bulkheads indicate thatthe fire doors were open during the fire.
Records indicate that on the morning of theaccident, all fire doors, including the spiral stair-well access doors on E deck and Aloha deck,were closed within less than 10 minutes of thefirst fire alarm. Nevertheless, during postac-cident examination of the vessel, Safety Boardinvestigators found soot and debris patternsindicating that the fire doors, while open, hadallowed the smoke and heat from the fire toenter the stairway, which then served as a flue,transmitting smoke and hot gases upward toother decks. The open fire door at the top of thespiral stairway on the Aloha deck allowed mas-sive quantities of smoke to enter the break no. 1passageway and migrate into the crew accom-modation area forward of the break.
Had the doors leading from the main laun-dry to the stairways automatically closed whenthe fire started, the smoke and heat of the firewould probably have been contained within themain laundry long enough for the crew to havebeen warned of the fire and to have escapedfrom their cabins. The Safety Board concludesthat had automatic closure of the fire doors beenincorporated in the fire detection system, the firedoors in the area where the fire broke out wouldhave shut immediately when nearby detectorsactivated, thereby restricting the spread of lethalamounts of smoke to the crew berthing areas onthe Aloha deck.
The Safety Board has identified the need forautomatic closure of fire doors since the mid-1980s, following its investigation of the August20, 1984, fire on board the Bahamian passengership Scandinavian Sun while it was docked atthe Port of Miami, Florida. At the time the fireerupted, the fire control system was in manualmode, rather than automatic mode, meaning thata person on the bridge had to activate the con-trols to shut down the ventilation system and toclose the fire doors. When the detection systemsignaled the fire, the bridge was not staffed. Bythe time a staff officer arrived on the bridge andclosed the fire doors, smoke from the fire hadentered a stairwell and spread onto two deckswhere passengers were gathering to disembark.Of the 731 people on board, 1 passenger and 1crewman died from smoke inhalation, 4 peoplesuffered minor injuries, and 58 people neededtreatment for smoke inhalation.
As a result of its investigation of the Scandi-navian Sun fire, the Safety Board concluded, inpart, that the fire could have been isolatedearlier had the fire control system, including thefire doors, activated automatically. Based on itsfindings, the Safety Board issued the followingsafety recommendations to the Coast Guard:
M-85-60
Propose to the IMO an amendment toSOLAS 74 to require that heat or smokedetectors be made a part of each auto-
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matic fire door release switch onpassenger ships so that the door willclose when the detector is activated.
M-85-61
Propose to the IMO an amendment toSOLAS 74 to require that all passengerships carrying more than 36 persons oninternational routes have an automaticmanual fire control system in the pilot-house that integrates the fire detectors,the automatic fire door controls, theventilation system controls, and the gen-eral alarm into a unified system.
In response, the Coast Guard concurred withSafety Recommendation M-85-60, stating thatsuch systems were currently available commer-cially for land-based installations.
The Coast Guard further stated that while itconcurred with the intent of Safety Recom-mendation M-85-61, such a system was notcommercially available; however, “The techni-cal feasibility of such a system is well within therealm of available technology and has thepotential for improving shipboard safety.” TheCoast Guard said that it would present SafetyRecommendations M-85-60 and -61 at theFebruary 1986 meeting of the IMO FireProtection Subcommittee for discussion. Basedupon the Coast Guard response, the Boardplaced both recommendations in an “Open—Ac-ceptable Response” status. The IMO sub-sequently took no action on the proposals.
The Safety Board revisited the issue of im-proved fire protection measures in a 1989 safetystudy, Passenger Vessels Operating from U.S.Ports. In the study report, the Safety Boardsuperseded Safety Recommendations M-85-60and -61 with Safety Recommendations M-89-124 and -125, asking the Coast Guard to pro-pose that the IMO, in part, require passengerships operating from U.S. ports and embarkingU.S. passengers to have the following fireprotection measures:
M-89-124
A centralized automatic/manual firecontrol system on the navigation bridgethat integrates the fire detector, auto-matic fire door controls, the ventilationsystems controls, and general alarm intoa unified system.
M-89-125
Integrated heat and/or smoke detectorswith automatic fire door release switch-es so that the doors will close automati-cally when the detectors are activated.
In 1992, the IMO enacted amendments tothe SOLAS 74 fire safety regulations that inclu-ded improved measures for fire doors. Require-ments contained in chapter II-2 stipulate thatnew passenger ships must have fire doors cap-able of remote and automatic release from acontinuously staffed central control station, aswell as from a position at both sides of eachindividual door. The release mechanism must bedesigned so that a door will automatically closeshould a disruption of the control system orcentral power supply occur. Further, Regulation41-2 requires that the stairway enclosures, MVZbulkheads, and galley boundaries on existingpassenger vessels be fitted with self-closing firedoors capable of being released from a centralcontrol station and from each door.
The Safety Board reviewed the amendmentsto SOLAS 74, considered the measure requiringremote release from a centrally manned locationto be in compliance with the intent of the recom-mendations, and classified Safety Recommen-dations M-89-124 and -125 “Closed—Accept-able Alternate Action.” Following its investi-gation of the fire on the Universe Explorer, theBoard has reconsidered its opinion. As thisaccident demonstrates, having a central stationinitiate the closure of fire doors does not affordthe maximum measure of safety and can resultin delays that prove fatal. The Safety Boardbelieves that New Commodore, and its operatingcompany, V. Ships, should modify the fire con-
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trol systems on company passenger vessels, inte-grating heat and/or smoke detectors withautomatic fire door release switches. Further,the Coast Guard should propose to the IMO thatpassenger ships be required to integrate heatand/or smoke detectors with automatic fire doorrelease switches so that the doors in the im-mediate area of the fire will close automaticallywhen the detectors are activated. Also, the ICCLshould recommend that member companies inte-grate heat and/or smoke detectors with auto-matic fire door release switches.
Compromise of Fire Door Effec-tiveness —During postaccident examination,Safety Board investigators found evidence,including soot on the door jambs and remnantsof string on the corridor handrails near thedoors, that the fire doors opening into the ber-thing area corridors on Aloha deck had been tiedopen during the fire. Investigators noted thatthese doors were on a direct route between thecrew cabins, a galley, and various job sites. TheBoard surmised that the crew had to open andclose these doors repeatedly, which probably be-came at least an annoying chore and perhaps adifficult task if they were carrying items. Bytying the doors open, they gained freer move-ment to and from commonly used areas.
The soot markings and fire damage indi-cated that when the smoke and heat rose in thespiral stairway forward of the main laundry, itexited through the open stair door on Alohadeck into the break no. 1 area, from which itspread into the corridors of the crew accommo-dations area. The fire doors to the crew berthingcorridors were the last barrier between thesleeping men and the deadly smoke. Had thesefire doors been closed instead of tied open, theywould have blocked the entry of smoke into theberthing area, and the crew could have escapedby alternate routes. The Safety Board concludesthat the effectiveness of the fire doors to thecrew corridors on Aloha deck was compromisedby their being tied open, degrading crew safetyand permitting lethal amounts of smoke tospread to the crew berthing areas.
One of the specific duties assigned to thefire watch was to ensure that all fire doors werenot blocked or lashed open. Because some firedoors were lashed open during the fire, the firewatch’s execution of assigned duties and thesafety officer’s oversight of the fire watch wereobviously less than adequate. The Safety Boardtherefore concludes that improved oversight ofthe fire watch is needed to improve the level offire safety on board the Universe Explorer. TheSafety Board believes that the New Commo-dore, and its operating company, V. Ships,should institute procedures to improve the over-sight of the fire watch on board companypassenger ships.
Effectiveness of Alarms —When theheat detector in the main laundry detected thefire, it activated an alarm on a panel on the navi-gation bridge. No alarm automatically soundedin the area of the activated heat detector. Whensmoke from the fire traveled up the spiral stairand into the Aloha deck berthing area, it alsotriggered smoke detectors, setting off alarms onthe bridge fire alarm panel. However, no smokealarm automatically sounded on Aloha deck,where the crew was sleeping.
To warn the sleeping crewmen on Alohadeck of the fire, the alarm had to be manuallysounded from the bridge, or a manual pushbutton alarm had to be activated from a locationin break no. 1. The lack of an automatic alarmsystem in the crew berthing area delayed thenotification and hindered the safe evacuation ofcrewmembers. Smoke had already entered andfilled the Aloha deck berthing area before bridgepersonnel sounded the alarm. A number ofsurviving crewmen stated that they stumbledover crewmembers who had collapsed in thepassageway before the “Mr. Skylight” an-nouncement was made. One crewman said thathe had already escaped to an open deck and waspausing to breathe fresh air when he heard the“Mr. Skylight” announcement. Had the crewbeen alerted earlier, they would have encoun-tered less smoke and had less risk of beingovercome by smoke during their escape.
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The bridge watch officer, following com-pany procedures, wanted to verify the existenceof a fire before sounding the general alarm. Hetherefore dispatched the fire watch to verify thealarm panel indication and then called themaster to the bridge. While these actions weretaking place, no fire alarm was sounded in thecrew berthing area. The general alarm was notsounded until the master arrived on the bridgeand ordered it sounded. Crewmembers in theAloha deck berthing area could not activate themanual alarm because it was located in thebreak no. 1 area, which was inaccessible be-cause of high levels of heat and smoke. TheSafety Board concludes that the lack of an auto-matic smoke alarm that sounded locally in thecrew berthing area delayed prompt notificationto the crew of the fire and the need to evacuate.Had the crewmembers who died received earlierwarning, they may have escaped.
Less than 9 months after this accident, theSafety Board investigated another fatal cruiseship fire in which the smoke from a minor blazecaused multiple injuries and death. On April 6,1997, a fire broke out on board the Bahamianflag passenger ship, Vistafjord, which wasunderway from Fort Lauderdale, Florida, to theAzores with 569 passengers and 422 crewmem-bers. The ship’s crew was able to control andextinguish the fire; however, one crewman diedas a result of smoke inhalation while trying toescape from the crew berthing area. Six othercrewmembers and four passengers receivedsmoke inhalation injuries during the fire.
As a result of the Universe Explorer andVistafjord accidents, the Safety Board issued thefollowing urgent safety recommendations onApril 24, 1997:
To New Commodore Cruise Lines, Inc., and toCunard Lines Ltd.:
M-97-35
Without delay install automatic smokealarms that sound locally in crew ac-commodation areas so that crews will
receive immediate warning of the pres-ence of smoke and will have the maxi-mum available escape time during a fire.
M-97-36
Without delay install automatic smokealarms that sound locally in passengeraccommodation areas so that passengerswill receive immediate warning of thepresence of smoke and will have themaximum available escape time duringa fire.
To the ICCL:
M-97-37
Without delay advise members to installautomatic smoke alarms that soundlocally in crew accommodation areas sothat crews will receive immediatewarning of the presence of smoke andwill have the maximum available escapetime during a fire.
M-97-38
Without delay advise members to installautomatic smoke alarms that soundlocally in passenger accommodationareas so that passengers will receiveimmediate warning of the presence ofsmoke and will have the maximumavailable escape time during a fire.
To the Coast Guard:
M-97-39
Propose that the IMO require allpassenger vessels to have automaticsmoke alarms that sound locally in thecrew berthing areas so that crews willreceive immediate warning of thepresence of smoke and will have themaximum available escape time duringa fire.
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M-97-40
Propose that the IMO require allpassenger vessels to have automaticsmoke alarms that sound locally in thepassenger accommodation areas so thatpassengers will receive immediatewarning of the presence of smoke andwill have the maximum available escapetime during a fire.
In May 1997, the ICCL wrote that it haddistributed information related to the accidentsand the resulting recommendations to itsmembers for review and consideration. Further,the ICCL Technical Committee was includingthe recommendations for discussion on theagenda for its August 1997 meeting. New Com-modore also responded in May, indicating itbelieved that the safety recommendations hadmerit and that its vessel manager would bediscussing the recommended actions at theICCL Technical Committee’s meeting. TheSafety Board therefore classified Safety Recom-mendations M-97-35 and -36 to New Commo-dore and M-97-37 and -38 to the ICCL “Open—Acceptable Response” in June 1997. After theSafety Board sent a follow-up letter to the cruiseline on December 17, 1997, Cunard respondedon February 2, 1998, stating,
We do not feel that your recommenda-tions add substance to the internationalregulations imposed by IMO. On thecontrary, we believe that smoke de-tectors sounding locally in crew and,much worse, in passenger areas riskpanic in a disorganised evacuation….We feel that hurried unilateralreactions to specific incidents might, infact, damage rather than improve safetyonboard.
The Safety Board is disappointed byCunard’s position and has subsequently classi-fied Safety Recommendation M-97-35 and -36to the cruise line “Closed—Unacceptable Re-sponse.”
In a letter dated July 25, 1997, the CoastGuard Commandant stated:
We concur with these recommenda-tions. The IMO Sub-Committee on FireProtection at its 36th Session discussedthe possibility of requiring audiblesmoke alarms on passenger vesselsduring the development of the 1992 FireSafety Amendments, but decided to re-quire that all fire alarms panels beplaced in a continuously manned controlstation instead. Concern had been ex-pressed, by several member govern-ments and the industry, that activatedsmoke detectors are frequently falsealarms, and therefore the bridge shouldalways investigate a smoke alarm firstbefore any emergency alarms are sound-ed. However, this is exactly what hap-pened aboard the Universe Explorer, andby the time the roving patrol arrived atthe scene to investigate, several crewmembers had already been overcome bysmoke.
The Coast Guard will revisit the issue ofrequiring audible smoke alarms in thepassenger and crew areas at a futuremeeting of the IMO Sub-Committee onFire Protection. We will submit a paperon this issue to the next session of theIMO Maritime Safety Committee inMay 1998, looking toward considera-tion of an appropriate fire safety amend-ment at the 453rd Session of the Sub-Committee on Fire Protection in early1999. In the meantime, we will workwith industry through the SOLASworking group to develop the proposaland draft text. Our initial contacts withindustry representatives after the Uni-verse Explorer incident indicate someconcerns with false alarms, passengerand crowd control, and panic withrespect to locally sounding automaticsmoke alarms. We will keep the Boardinformed of our progress on this issue.
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In a September 11, 1997, letter to the CoastGuard, the Safety Board wrote that it waspleased with the actions taken and that, pendingcompletion of the projects, Safety Recom-mendations M-97-39 and -40 were classified“Open—Acceptable Response.”
Adequacy of EmergencyProcedures
Most passengers were asleep in their state-rooms when the fire was discovered. The masterordered the emergency signal sounded on theship’s whistle and the general alarm systemsounded within about 7 minutes of the firstsensor alarm. Survey respondents generally hadhigh praise for crewmembers’ efforts to alertpassengers and evacuate all staterooms. Thecruise director arrived on the bridge shortly afterthe initial sensor alarm and began making an-nouncements instructing the passengers to re-main calm and to proceed to their muster sta-tions. Meanwhile, crewmembers proceeded inan orderly and efficient manner from stateroomto stateroom, knocking on cabin doors to ensurethat passengers were awake and to inform themto go immediately to their muster stations.Survey respondents described the crew as help-ful and caring. The follow-up action of crew-members to ensure each stateroom had beenvacated was particularly noteworthy. Afterchecking a stateroom, they closed the stateroomdoor and placed a towel around the exterior doorknob to indicate to other crewmembers that theroom had been checked and was empty.
The Safety Board concludes that the crew-members’ implementation of evacuation proce-dures was effective in maintaining calm andorder and in ensuring that passengers vacatedtheir cabins and assembled at their musterstations.
Despite the efficient actions of crew-members in evacuating passengers, the SafetyBoard identified a number of deficiencies in on-board emergency procedures.
Watch Officer’s Initial Response —In accordance with the operating �������
written procedures, the watch officer acknow-ledged the fire alarm when it sounded on thenavigation bridge and sent the fire watch to thearea of the activated alarm to investigate. Theprocedures further called for the watch officer towait until after the fire watch confirmed the firebefore closing the fire screen doors from thebridge. In this case, however, when the watchofficer began to receive multiple fire alarms onthe bridge, he did not wait for the fire watch toreport back. He immediately called the master tothe bridge but he did not immediately close thefire doors. The fire screen doors were not closeduntil 0305, after the master had arrived on thebridge and ordered them closed.
The method of ship construction used inbuilding the Universe Explorer is designed toconfine a fire to its compartment of origin byuse of structural fire boundaries. Fire screendoors are an important feature of these fireboundaries because they maintain the fire integ-rity when closed. In the Board’s view, closingthe fire doors ought to be the first action takenon a method I constructed ship when a firealarm activates. To do otherwise allows moretime for the heat and smoke of a fire to escapefrom its compartment of origin and to spread toother parts of the vessel. In this instance, thefirst alarm sounded at 0259, and the doors werenot closed until 0305. During this 6-minuteinterval, smoke and heat from the fire in themain laundry continued to flow outward andupward through the laundry stairwells to otherdecks of the ship. If the fire screen doors hadbeen immediately closed when the fire alarmwas received, the amount of smoke that ulti-mately reached the Aloha deck crew berthingarea may have been significantly reduced. TheSafety Board concludes that the Universe Ex-plorer’s operating procedures that the watchofficer is supposed to follow when a fire alarmactivates are less than adequate to ensure thetimely establishment of fire boundaries restrict-ing the spread of heat and smoke. Consequently,the Safety Board believes that New Commodoreand its operating company, V. Ships, should re-
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vise their passenger ship operating procedures torequire that the navigation watch officer imme-diately close the fire screen doors upon receiptof a fire alarm.
Passenger Drill —The Universe Explor-er conducted a passenger fire drill in a timelymanner; that is, shortly after everyone hadboarded the vessel in Vancouver. Because a firecan occur at any time, the sooner passengers areprovided with emergency instructions and par-ticipate in a drill, the better.
After the fire, most passengers surveyedindicated that they found the drill to have beenvery helpful. Based on the passengers’ com-ments, the Safety Board identified several waysin which the drill could be improved. Somesurvey respondents stated that the drill consistedof providing them with instructions on how todon a life preserver and on how to locate theirmuster stations. A large majority of those re-sponding indicated that passengers were not toldwhat to do should they see a fire or smellsmoke. Passengers were particularly critical ofthe lack of information provided about the firedoors. About one-fourth of the responders char-acterized the drill as unrealistic because manypassengers who knew the scheduled time of thedrill went in advance to their lifeboats, using theelevators to reach their stations. One passengercomplained that the drill did not prepare him tolocate his life preserver because it had beenplaced on his bunk for the drill, whereas it wasstowed in his room when he needed it during theactual emergency.
To have the maximum effectiveness, firedrills should be as realistic as possible. Whendealing with a large group—in this case, 732passengers—undoubtedly some individuals willbecome agitated or frightened during an actualemergency. When events occur for which pas-sengers are not prepared, such as magneticdoors suddenly slamming shut, the likelihoodincreases that they will panic. Such reactionsclearly support the need for passenger fire drillsand for placards in staterooms that containadequate instructions about fire emergencies.
The content of the Universe Explorer drillleft many passengers unprepared to meet thedemands of the actual fire emergency. Allowingpassengers to use elevators to reach their assem-bly stations during a drill does not prepare themto identify a safe route of escape. Further, notrequiring passengers to observe approved safetyprocedures during drills may lead them toattempt the same shortcuts during the actualemergency, perhaps with tragic results. To beeffective, a drill must provide passengers withthe basic information, including:
• how to report a fire;
• what to expect if a fire occurs, such astypical announcements, actions of thecrew, operation of the emergency lights,and operation of fire doors;
• the location and meaning of emergencysigns;
• the description of emergency signals;
• if incapacitated, how to call forassistance; and
• the route to take from their stateroom totheir assembly area.
As this accident demonstrated, informationabout remotely operated fire doors is particu-larly important during a drill because the suddenclosing of these doors may lead uninformedpassengers to conclude erroneously that escapeavenues are blocked and that they are trapped.Passengers need to be advised that the doorswill close in the event of a fire, to be informedthat the heavy doors are not locked, and to beshown how to open a closed magnetic door.
The Safety Board concludes that althoughthe passenger fire drill held on the UniverseExplorer was conducted in a timely manner, thecontent of the exercise did not fully preparemany passengers to meet the demands of anactual fire emergency. The Safety Board be-lieves that New Commodore and its operatingcompany, V. Ships, should revise the requiredcontent of passenger fire drills to include infor-
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mation about what to expect in the event of afire, with particular emphasis on the operationof fire doors. The Safety Board also believesthat the ICCL should advise its member com-panies to review and, if necessary, revise theirpassenger fire drill procedures to ensure thatthey include information about what to expect inthe event of a fire, with particular emphasis onthe operation of fire doors.
Status Announcements —Passengersindicated that although announcements weremade over the public address system askingthem to remain calm while they were at theirmuster stations, they were not adequatelyinformed about the progress of the situation.They said they were never told how long theymight have to remain at the assembly areas.Further, they felt that someone in authority, suchas the master or another officer, should havegiven them status updates. One passenger stated,“There was no communication from the ship’scaptain or any officer of the crew until severalpassengers challenged an official from thecruise line to inform us of the situation, 4 to 5hours after the initial fire.”
During an emergency, it is vital to passen-gers’ peace of mind to receive periodic infor-mation about the status of the situation, particu-larly any progress in overcoming a threat tosafety. Further, receiving such reports from arecognized authority figure, such as the ship’smaster, is more reassuring. Understandably, themaster’s and officers’ primary concern was toextinguish the fire. Nonetheless, providing peri-odic assurances to passengers during prolongedemergencies is important so that order and dis-cipline can be maintained. The Safety Boardconcludes that the Universe Explorer crew didnot adequately address passenger concernsabout the fire and the seriousness of the situa-tion while they were assembled at their musterstations. The Safety Board believes that NewCommodore, and its operating company, V.Ships, should revise company procedures re-garding muster assemblies to improve periodicannouncements made to passengers about thestatus of an ongoing shipboard emergency.
Crew Drills —The Universe Explorer con-ducted weekly shipboard emergency drills asrequired by SOLAS. The drills did not include,and were not required to include, identifyingalternate escape routes from cabins and worksites. The Aloha deck berthing area where thefatalities occurred is forward of the crew galleyand most work areas; therefore, crewmembersroutinely walked aft every day to eat meals andreport to work. When alerted to the fire, they re-acted according to habit in attempting to escape.
Survivors from Aloha deck said they firsttried to walk aft in the port corridor but couldnot continue because the intensity of the heatand smoke increased as they neared break no. 1,forcing them to turn around to find alternativeescape routes. They said the heavy smoke stungtheir eyes and severely limited their visibility,requiring that they feel their way along the cor-ridors until they found an exit. Although thecrew had several other means of escape 50 to 60feet away, locating an exit quickly was difficult.The position of the three deceased crewmen’sbodies in the passageways indicates that theyprobably were overcome by the heavy, toxicsmoke while trying to find an escape route.
The Safety Board identified a similar situ-ation during its investigation of the October 8,1994, engineroom fire on board the Liberiantankship Seal Island.28 In that accident, a sprayof lubricating oil was ignited and immediatelyerupted into a large blaze, generating a tre-mendous amount of thick smoke that completelyobscured visibility. Of the nine crewmembers inthe engineroom, three died and six wereseriously injured. Several of the casualtiesresulted from the crewmen becoming disori-ented in the smoke and not being able to imme-diately locate an exit. Two of the crewmemberswho escaped attributed their survival to specialtraining that familiarized them with alternativeemergency exit routes on the tankship.
�� For additional information, read Marine Accident ReportEngineroom Fire on Board the Liberian Tankship SealIsland While Moored At the Amerada Hess Oil Terminal InSt. Croix, U.S. Virgin Islands, October 8, 1994(NTSB/MAR-95/04).
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The 1995 amendments to the STCW Con-vention that became effective February 1, 1997,recognize the need for improved survival train-ing. The amendments require that before crew-members who are new to a seagoing ship areassigned to shipboard duties, they must receivefamiliarization training in personal survivaltechniques or receive sufficient information tobe able to perform certain tasks, includingidentifying emergency escape routes and musterand embarkation stations.
As the Universe Explorer fire and other acci-dents demonstrate, knowledge of alternateescape routes is critical to the survival of crew-men during a fire emergency. While the SafetyBoard is pleased with the IMO’s initiative toimprove survivability training for new seafarers,it is concerned that comparable instruction andrefresher training is not available for all crew-members. The Safety Board recognizes theimpracticality of requiring today’s passengerships to drill their entire crews weekly on identi-fying and using alternate escape routes fromwork and berthing areas. Nevertheless, crew-members need more than a one-time trainingsession in survivability, especially if, as newemployees, they receive such instruction whilehaving to familiarize themselves with othervessel operations.
The Safety Board concludes that some ofthe deceased crewmembers on the UniverseExplorer may not have survived the fire becausethey lacked sufficient knowledge of alternateescape routes from their berthing area.
While the 1995 amendments to the STCWConvention will ensure that new seafarers arefamiliar with escape routes on vessels at thetime they first come on board, these require-ments do not provide a mechanism for periodicreinforcement of the initial training. Withoutperiodic reinforcement of the training throughfurther instruction or drills, the value of theinitial training will degrade over time. TheSafety Board therefore believes New Com-modore, and its operating company, V. Ships,should provide periodic instruction or drills to
all crewmembers on company passenger vesselsto reinforce the familiarization training requiredof new seafarers by the 1995 amendments to theSTCW Convention. Moreover, the ICCL shouldrecommend that its member companies conductsuch reinforcement training for crews as de-scribed. Lastly, the Coast Guard should proposeto the IMO that vessel owners and operators berequired to conduct periodic reinforcementtraining and/or drills in survivability to ensurethat the crewmembers are familiar with infre-quently used alternate avenues of escape. Con-duct of the training could be facilitated bydesignating fire wardens for each berthing areawho would be responsible for providing peri-odic survivability training, including routes ofescape, to each individual assigned to the area.
Fire and Rescue Search —Followingthe “Mr. Skylight” announcement, the ship’stwo fire teams assembled, donned protectivegear, and marshaled firefighting equipment. Thesafety officer took charge of the search for thefire while the staff captain directed the search ofthe crew berthing area. Despite the promptaction, the searches did not result in timelylocation of either the fire or the trapped men.
Fire search —After donning an SCBA, thesafety officer began searching alone for avenuesof approach to the fire, leaving the fire teamsstanding by. He first tried to proceed forward onAloha deck along the portside passageway, butwhen he opened the portside door at break no. 1,the smoke and the heat prevented him fromcontinuing. He returned to Main deck and in-structed the fire team leader to accompany him.Together, they went back to Aloha deck andtried the starboard side door to break no.1 andwere driven back by the smoke and the heat.They then went down to Bali deck and wentforward until they reached a stairway to Alohadeck. When they ascended to Aloha deck, theyfound trapped crewmen, whom they directed tosafety. They then received a radio call from thebridge to go to the crew galley. They nextdescended a stairway aft of the galley to E deckand proceeded forward on E deck until theyentered the crew laundry and saw the fire.
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The safety officer’s attempt to locate the firealone was ill-advised. Had he run into difficultywhile searching for the fire, he had no backupwith him who could have either aided him orobtained additional help. Although he wascarrying a portable UHF radio with which hecould have summoned help, the radio’scapability to transmit from different parts of theship was suspect, as the breakdown in communi-cations between the second officer and the firewatch demonstrated. After finding his initialroute to the fire location blocked by heat andsmoke, the safety officer wisely returned to theMain deck and had the fire team leader accom-pany him on subsequent attempts to locate thefire. The two men continued using a trial-and-error method to locate the fire. On this ship,even the most stoutly constructed fire boundaryis designed to prevent the passage of heat andsmoke for only 60 minutes; therefore, timelylocation of a fire is paramount. Although ulti-mately successful, the men did not find the firefor 30 to 45 minutes. During this time, the firecontinued to burn freely, producing increasingamounts of toxic smoke.
Given his knowledge of the ship’s layout,the safety officer could have organized a moremethodical approach to locating the fire byassigning one or more search teams to check outpossible avenues simultaneously. The SafetyBoard concludes that using this approach, theofficers might have located the fire sooner.
The Safety Board has investigated a numberof passenger ship fires in which the on-boardfirefighters’ speed in locating the source of thefire was an issue. The most recent case involvedan August 19, 1994, fire on board the RegalEmpress, which was carrying 1,394 passengersand crewmembers and was en route fromCanada to New York, New York. About 0630, acrewman discovered light smoke coming from acleaning gear room. The safety officer tried tofind the source of the fire himself but wasunsuccessful. About 0707, the master activatedthe ship’s firefighting teams and initiated mea-sures to isolate the fire. By the time the shipdocked more than a hour later, the vessel fire
teams still had not found the fire. The fire wasnot located and extinguished until 0953, afterFire Department of New York personnel hadboarded the vessel and joined the search. The“small” fire ultimately resulted in almost$250,000 damage because of the protracted timerequired to identify the seat of the fire.
Had the smoke and fire conditions in theUniverse Explorer accident been different, speedin locating the fire could have had far greaterimportance. The Safety Board believes that NewCommodore, and its operating company, V.Ships, should institute improved procedures forlocating fires to improve survivability aboardtheir vessels.
Rescue efforts —The staff captain directedone fire team member to don breathing equip-ment and search the crew berthing area onAloha deck. Upon opening the fire screen doorto the berthing area, he encountered intense andblinding smoke. He saw three fallen crewmem-bers who showed no signs of life and heardpeople pounding on bulkheads and calling forhelp. He yelled out to the trapped people andshined his flashlight down the corridor, but sawnothing but smoke. He estimated that hereturned to the Main deck between 0335 and0340 to brief the staff captain, who told him togo back and recover the fallen crewmen. Theteam member told the staff captain that he couldnot do it alone because of the smoke and nearbyfire. Shortly after 0350, the staff captain, thefirst searcher, and a second fire team membertogether went down to the Aloha deck andremoved the fallen crewmen. No one rescuedthe crewmen who were trapped in cabins untilabout 0540.
As noted in previous sections of this report,having a lone individual—in this case the fireteam member—search an area of a vessel duringa fire was ill-advised and dangerous. Thesearcher could have needed help himself orcould have encountered people who neededassistance that was beyond the ability of oneperson to provide. Despite reports as early as0335 that crewmen were yelling and pounding
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on bulkheads, no organized, systematic searchof crew cabins on Aloha deck took place then orafter the bodies of the fallen men had beenretrieved. The crewmembers remained trappedfor 2 ½ more hours. Fortunately, some crewmenhad access to an open porthole from which theywere able to breathe fresh air. During their per-iod of entrapment, the men frantically butunsuccessfully tried to signal nearby vessels forhelp by waving towels out the porthole.
The Safety Board concludes that efforts tolocate and rescue trapped crewmembers werenot initiated in a timely manner. The delayedsearch of Aloha deck crew cabins prolonged thetrapped crewmen’s exposure to smoke andcontributed to the severity of their injuries.
The delay and lack of systematic effort inrescuing trapped crewmembers demonstratesthat the Universe Explorer crew was not ade-quately prepared to conduct rescue operations.The Safety Board concludes that if the UniverseExplorer had had a properly equipped rescueteam that was trained in locating and recoveringpeople trapped in smoke-filled areas, the crew-men probably would have been rescued soonerand would have sustained less severe injuries;moreover, fewer crewmen may have died. TheSafety Board believes that New Commodore andits operating company, V. Ships, should estab-lish for each company vessel a team dedicated tolocating trapped crewmembers or passengersand provide the team with recurrent search andrescue training.
The 38-year-old Universe Explorer is asmall vessel by current industry standards.Larger passenger vessels typically carry hun-dreds of crewmen and thousands of passengers.With so many people on board, the probabilityis relatively high that some passengers orcrewmembers will become trapped during a fireemergency. Without properly trained and equip-ped search and rescue teams, such trappedpersons may well become fatalities. The SafetyBoard considers dedicated rescue teams neces-sary on all passenger ships. The Safety Board
therefore believes that the ICCL should encour-age its member companies to establish speciallytrained and equipped shipboard rescue teams.Further, the Coast Guard should propose to theIMO that specially trained and suitably equip-ped rescue teams be required on board allpassenger ships. Members of such teams shouldbe provided with specialized equipment, such asSCBAs, radios, lifelines, and so forth, and beproperly trained in its use. They also should berequired to become familiar with all areas of theship so that they can conduct a safe rescue inany section. Further, the training should includedrills simulating rescues in smoke-filled areas.
Availability of Medical Supplies —The fire occurred below the hospital, forcing theship’s doctor and nurses to evacuate immediate-ly. Fire conditions prevented anyone from ac-cessing the medical supplies stored in the hospi-tal. The bridge maintained an emergency medi-cal kit, but it did not contain oxygen to treat thecrewmembers who sustained smoke inhalationinjuries. The Safety Board concludes that thelack of a secondary supply of oxygen limited themedical staff’s ability to treat the injured.
Although inadequate medical supplies didnot cause or contribute to loss of life in thisaccident, insufficient medical stocks could havedetermined whether an injured person lived ordied had the casualties been more severe. TheSafety Board believes that the New Commodoreand its operating company, V. Ships, shouldensure that all emergency medical kits on com-pany passenger ships contain adequate medicalsupplies to handle emergency conditions, suchas those experienced during the Universe Ex-plorer fire. Further, the ICCL should, in con-sultation with member passenger ship operators,determine the amount and type of medicalsupplies needed during an emergency andrecommend that such supplies be maintained insuitable locations outside the ship’s hospital inthe event it becomes inaccessible.
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Adequacy of OversightEarlier in this analysis, the Safety Board dis-
cussed how the removal of the corridor bulk-head in the main laundry seriously degraded thefire safety condition of the Universe Explorer. Inthe course of determining when and who mighthave authorized the removal of a bulkhead thatwas required by U.S. standards and SOLAS reg-ulations as part of the ship’s original method Iconstruction design, the Safety Board identifiedproblems in oversight, not only by the ownerand operating company, but also the ABS andthe Coast Guard, who were responsible forcertifying the safety of the vessel.
Company Oversight —Copies of origi-nal construction plans, 1964 plans, and the 1991vessel fire control plan, which were approved bythe ABS, all indicate a corridor bulkhead in themain laundry. According to the present owner,the bulkhead was removed by a previous ownerin the 1970s; after discussing the missing bulk-head with Safety Board staff, the owner’s agentwrote the Board that the bulkhead was not“pivotal” in the case in that it was “not requiredby flag, class, or IMO rules.” In another letter,the ship’s operator stated, “This vessel has beenrepeatedly and routinely inspected by its own-ers, flag state, ABS, USCG and other port states,and found in regulatory compliance regardingstructural fire protection ….”
The Safety Board finds this argumentdistressing. SOLAS requirements at regulation20 stipulate that general arrangement plansindicating bulkhead divisions are to be perma-nently exhibited for the guidance of the ship’sofficers and that the plans should be kept up todate with any alterations being recorded thereonas soon as practicable. Having an inaccurate firecontrol plan compromises the ability of officersto direct operations during a fire emergency,which, in turn, places crewmembers andpassengers at risk. Given the time and oppor-tunity that the present owner had to eitherreinstall the bulkhead or correct the fire plans,the Safety Board questions the company’scommitment to maximizing fire safety.
Months before Azure Investments purchasedthe ship, company representatives discussed itscompliance with the RFSAs with Coast Guardofficials. Coast Guard files contain a record of aMarch 29, 1995, telephone call from theprospective owner’s agent indicating the vesselwould comply with the RFSAs.
In April 1995, the prospective owner’srepresentatives met with senior Coast Guardofficials and “knowledgeable inspectors” to dis-cuss possibly reflagging the vessel under U.S.flag. Toward that effort, they asked that theCoast Guard provide them with a copy of theagency’s entire file on the Universe Explorer.The Coast Guard also provided copies of itsexamination findings of a 1989 fire on board thevessel’s sister ship; the findings indicated that,contrary to method I construction standards,both ships had combustible insulation material,some of which could not be removed.
In May 1995, the prospective owner hadvarious marine technical specialists, includingmarine engineers and naval architects, performextensive onboard inspections of the UniverseExplorer to determine its condition. About thesame time, the vessel’s operating company con-tracted with a consulting company whose prin-cipals included former Coast Guard technicalstaff members for the project of bringing theship into compliance with the RFSAs. OneRFSA that was scheduled to become effective inOctober 1997 prohibited any space containingcombustibles from opening directly into astairway. A thorough examination of the vesselby expert consultants would have included themain laundry and, therefore should have identi-fied that the laundry layout was not inaccordance with the fire control plan. TheUniverse Explorer remained out of servicebetween July 1995 and January 1996, whilecompany officials had it modified for operatingunder charter to the Institute for ShipboardEducation. Thus, the company had ample time,documentation, and technical expertise withwhich to identify and correct unsafe conditions,including either replacing the bulkhead or cor-recting the fire control plan.
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The 7-month period that the vessel was outof service also afforded the company ampleopportunity to develop effective fire safetypolicies and procedures, yet, as this case demon-strates, the Universe Explorer did not have themin place at the time of the fire. As describedearlier in this analysis, the company had poorpolicies and procedures in the following areas:
• Alert— Activated alarms first soundedon the bridge, delaying early emergencynotification to those endangered.
• Fire doors—Emergency proceduresrequired that the presence of a fire beverified in person by a watchman beforeclosing the fire doors.
• Communications—The UHF radiosprovided to emergency responders didnot provide the communications capa-bility to ensure the safety of the firewatch and fire teams, which, in turn,was needed to ensure the safety ofpassengers and crewmembers.
• Tracking of Responders—The firewatch and the safety officer did nothave a person assigned to back them up,placing them at increased risk if theywere injured during response activities.
• Fire Locating—The officers directingthe fire search did not use a methodicalapproach employing more than onesearch team, resulting in a delay inlocating the fire.
• Search and Rescue—Vessel manage-ment did not have a systematic methodfor locating trapped crewmembers andthus prolonged their exposure to smokeand contributed to the severity of theirinjuries.
• Fire Watch Supervision—The ship-board manager did not properly monitorthe work of the fire watch, who wasrequired to ensure that fire doors werenot tied open.
• Fire Drills— Crew emergency drills didnot stress using alternate routes; as a re-sult, panicking crewmen failed to locatean alternate egress timely or at all. Pas-senger drills were not realistic and didnot include information about safetyfeatures, such as the fire doors, causingsome passengers to panic.
According to the company, its shoresideofficials periodically visit the ship to conferwith vessel officers and attend classificationsociety surveys and Coast Guard examinations.In the Board’s opinion, these actions alone arenot sufficient to provide adequate managementoversight and to ensure effective fire safetyaboard the vessel. These meetings typically ex-clude personnel who are not in upper shipboardmanagement. Effective management oversightmust extend beyond upper shipboard managersto include personnel from all levels in theshipboard organization. Only through inclusionmay commitment to safety be attained in alllevels of the shipboard organization. If moreeffective management oversight of safety hadbeen exercised on the Universe Explorer, crew-members would not have compromised the ef-fectiveness of the fire doors by tying them open,the fire watch would have been more mindfulthat he needed to report his findings to thewatch officer, and the watch officer would havebeen more concerned about the safety of the firewatch. The company needs to foster the attitudeamong its crews that fire safety is preeminent inits vessel operations and that their actionsdirectly affect the safe operation of the ship.
The Safety Board concludes that shoresidemanagement did not exercise effective oversightof fire safety on the Universe Explorer.
V. Ships, the operator of the Universe Ex-plorer, has advised the Safety Board that it isdeveloping a safety management system for itspassenger ships as required by the ISM Code.The Board questions whether this system willaddress the safety management deficienciesnoted in this report. The Safety Board thereforebelieves that the New Commodore, through its
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operator, V. Ships, should address the safetyissues identified in this report in its ISM system.Moreover, it should increase the managementoversight of fire safety on board companyvessels by initiating, at a minimum, the follow-ing measures: establishing procedures for per-iodic fire safety vessel examinations by shore-side management officials, revising fire alarmresponse procedures to require immediate clos-ing of remotely activated fire doors, andperiodically instructing ships’ crews on main-taining a fire-safe vessel.
Class and Coast Guard Over-sight —This accident raises questions about theadequacy of the ABS survey and Coast Guardcontrol verification procedures and the resultingthoroughness of their inspections.
ABS reviews —The ABS checks an ABS-classed vessel’s approved plans against itsinternal arrangements when a new owner ini-tially applies for classification or after a struc-tural modification authorized by the ABS hasbeen made to the vessel, but not during itsroutine annual surveys. The ABS exercised theprimary inspection responsibility over theUniverse Explorer. Not only did it conduct an-nual and special surveys for the purpose of con-firming that the vessel met classification rulesfor insurance purposes, it also acted in a regu-latory capacity on behalf of the flag admin-istration (Panama) to ensure that the vesselcomplied with applicable SOLAS requirements.
In 1991, the ABS approved a fire controlplan for the Universe Explorer that incorrectlyshowed a corridor bulkhead in the main laundry.The Safety Board is concerned that the ABSapproved a vessel plan, especially a plan ascritical as the fire control plan, that did notaccurately depict the ship’s configuration. If theclassification society’s survey procedures wereefficient, its surveyors should have found thisdiscrepancy and, at a minimum, required the firecontrol plan be corrected in 1991. In cor-respondence with the Safety Board after the fire,the ABS stated that it had no documents on fileregarding the bulkhead and did not know when
it had been removed. The Safety Board con-cludes that the ABS’s process for approving aplan or for verifying that submitted plans areaccurate is not as rigorous as it ought to be. TheBoard therefore believes that the ABS shouldevaluate its plan review procedures and instituteimproved safeguards to ensure that ship planssubmitted for approval accurately depict theactual vessel configuration.
In postaccident communication with SafetyBoard staff, the ABS stated that the laundrybulkhead did not have to be in place for the vesselto comply with ABS classification requirementsor the statutory requirements of the flag adminis-tration, Panama, at the time of the casualty. TheABS cited SOLAS 48 as the basis for its con-tention. In fact, SOLAS 48, as interpreted by CFR46, stipulates that type 2 stairways should notgive direct access to enclosed spaces in which afire may originate. The original owner and theCoast Guard considered the main laundrycorridor bulkhead not only practicable but neces-sary to achieve an adequate measure of fire safetyon the vessel. The ABS classed the newly con-structed vessel. With the exception of the 8-yearperiod when the ship was classed by LR, the ABSsurveyed and classed the ship throughout its life,reviewing and approving various fire controlplans, all of which indicate that the main laundryhad a corridor bulkhead. After the fire, when ad-vised that the bulkhead had been removed, anABS official maintained that the bulkhead wasnot required by SOLAS 48. The Safety Board isdisturbed by the ABS’s postaccident interpreta-tion of the international requirements. Removingthe bulkhead reduced the level of fire safety,which is not permitted by SOLAS. For the ABSto interpret that the laundry bulkhead once re-quired by SOLAS 48 can be removed indicatesthat the classification agency has effectivelyaccepted the degradation of fire safety on thispassenger vessel.
Coast Guard reviews —The Coast Guardcurrently checks a foreign-registered passengervessel’s approved plans when the vessel firstenters service in the United States or when itundergoes a major structural modification. In
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the case of the Universe Explorer, the vesselhappened to first enter U.S. service as a foreignpassenger ship during a 5-year period when theCoast Guard did not require a plan review aspart of the initial CVE. Since the late 1980s, theCoast Guard had regularly conducted annualand quarterly CVEs of the Universe Explorer.NVIC 1-93, which contains the procedures thatCoast Guard inspectors are to follow when con-ducting CVEs, does not specifically describehow and to what extent they should check fireboundaries. For example, instructions for thequarterly CVE state that the extent of the vesselexamination is “at the discretion of the attendinginspectors” and is determined by the observedcondition of the ship. Instructions for a generalwalk-through stipulate only that the inspectorsshould check the engine room, machinery spaces,and accommodation spaces.
On July 20, 1996, one week before the fatalfire, Coast Guard inspectors conducted aquarterly CVE during which they held a firedrill in the main laundry, yet they did not noticethat the bulkhead shown on the fire control planwas not in place. This raises the question ofwhether the inspectors even referred to the planin the course of conducting the drill. The SafetyBoard concludes that the Coast Guard planreview and examination procedures of foreignpassenger vessels do not adequately address theneed to verify structural fire protectionboundaries. The Safety Board therefore believesthat the Coast Guard should revise its controlverification procedures to include a moredetailed review of structural fire protectionfeatures on board foreign passenger ships. TheBoard further believes that the Coast Guardshould require that foreign passenger shipsoperating from U.S. ports undergo a periodicstructural fire protection plan review and vesselexamination. Further, the ICCL should remindmember passenger ship operators of the degra-dation to structural fire protection that resultsfrom removing or altering fire control boun-daries and of their responsibility to maintain thefire safety of their vessels in accordance withapproved fire control plans.
Toxicological TestingAs mentioned earlier, crewmembers who
were tested showed no indication of having useddrugs or alcohol. In this case, the fire watch,who was known to have been in the mainlaundry within 20 minutes of a fire detectoractivating in the area, was not tested for eitherdrugs or alcohol. Company officials did notdesignate any crewmember for testing until lateJuly 27, 1996, and only then at the request ofSafety Board investigators. Specimens were notcollected from the designated individuals untilat least 34 hours after the accident.
In reviewing the regulatory requirements fortesting, the Safety Board found that the wordingin the CFR regarding who should undergopostaccident toxicological testing is not specific.The regulations at 46 CFR Subpart 4.06 statethat following a serious marine incident, “themarine employer shall take all practicable stepsto have each individual engaged or employed onboard a vessel who is directly involved in theincident chemically tested for evidence of drugand alcohol use” and to ensure that specimensare collected “as soon as practicable.” The termindividual directly involved in a serious marineincident is defined at 46 CFR 4.03-4 as “anindividual whose order, action or failure to act isdetermined to be, or cannot be ruled out as, acausative factor in the events leading to orcausing a serious marine incident.” The SafetyBoard concludes that, in the absence of specificcriteria, an immediate determination of theindividual(s) directly involved in a seriousmarine incident who should be considered fordrug and alcohol testing is sometimes difficult.
The Board has long been concerned aboutthe timeliness and adequacy of postaccidentdrug and alcohol testing in the maritime industryand will address those issues in its forthcomingreport of the Julie N tankship collision with ahighway bridge in Portland, Maine. In theinterim, the Board believes that the Coast Guardshould meet with maritime industry representa-tives to establish specific criteria for identifyingthose individuals who should undergo drug and
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alcohol testing after a serious marine incidentand to establish procedures to ensure that suchidentification is made and subsequent testing isconducted in a timely manner.
Emergency Actions by LocalResponders
Coast Guard Response —The Uni-verse Explorer radioed the 17th Coast GuardDistrict within minutes of discovering the fire.Coast Guard vessels were dispatched expedi-tiously and arrived in time to be effective duringthe emergency. The Coast Guard cutter Sweet-brier, which had overheard the emergency trans-mission and had radioed the SAR coordinatorthat it was immediately proceeding to assist,reached the passenger ship within about 1 hour.The Sweetbrier commanding officer assumedthe role of on-scene coordinator for the CoastGuard. The cutter then escorted the UniverseExplorer to Auke Bay, where the Sweetbrier’screw assisted in transporting breathing appara-tus and oxygen to the passenger vessel. Mean-while, shoreside Coast Guard personnel coor-dinated the response of local agencies to theemergency.
Local Agency Response —Upon re-ceiving notification of the fire emergency onboard the Universe Explorer, area police, firedepartments, and rescue agencies respondedpromptly. The CCF/R fire chief implementedthe local contingency plan and arranged for areafirefighters trained in marine firefighting toreceive a briefing about the fire on the UniverseExplorer before the vessel reached Auke BayHarbor. When the local firefighters arrived onboard the passenger ship, they examined the firescene and verified that the fire was completelyout. They then briefed Coast Guard and vesselofficers about their findings, monitored the air
quality in smoke-affected areas, and maintaineda reflash watch.
The resources involved in the response wereadequate to meet the needs of the emergency.All injured people were treated and transportedin a timely manner to appropriate medicalfacilities in Juneau or Seattle. Uninjured passen-gers were safely and efficiently transported tolodgings or to alternative transportation ashore.
The Safety Board concludes that the re-sponse by the Coast Guard and the local authori-ties to the Universe Explorer fire was timely andappropriate.
Coast Guard Fire ContingencyPlan�At the time of this accident, the CoastGuard Fire Contingency Plan was incomplete.Although committees had been formed to pre-pare certain parts of the plan, the sections deal-ing with the evacuation and treatment of mul-tiple casualties from a major cruise ship acci-dent had not been developed. Consequently, theevacuation and treatment of injured people fromthe Universe Explorer were conducted in an adhoc manner. However, about 4 months beforethe Universe Explorer fire, the Coast Guard hadheld a command post exercise designed to testand evaluate existing plans, procedures, sys-tems, and interactions. This exercise, whichFederal, State, local, and cruise industry offi-cials attended, simulated a fire on and thegrounding of a large foreign cruise vessel, withresulting injuries and pollution. The March 1996table-top exercise gave the Coast Guard andemergency responders an opportunity to consi-der and discuss what assistance was neededshould a major cruise ship accident occur in thelocal area. This exercise may have preparedresponders to perform effectively in thisincident, even though their formal response planhad not been set in writing.
Findings
1. Factors related to the vessel navigationsystem, propulsion systems, and mechanicalequipment neither caused nor contributed tothe accident. All officers were properlylicensed and qualified to serve in their posi-tions. No available evidence indicated thatdrugs or alcohol affected the performance ofthose officers and crewmembers tested.
2. The fire on board the Universe Exploreroriginated in one of two laundry bins thathad been against the forward bulkhead ofthe main laundry.
3. Accidental ignition sources, such as faultyelectrical equipment, wiring arcing, or con-tact with a hot surface or air, did not causethe fire aboard the Universe Explorer.
4. Neither discarded smoking material, spon-taneous combustion, nor a deliberate act canbe ruled out as possible causes of the fire onboard the Universe Explorer.
5. The UHF radio alone did not provide thecommunications capability to ensure thesafety of the fire watch, which, in turn, wasneeded to ensure the safety of passengersand crewmembers.
6. If the Universe Explorer had been equippedwith an internal radio antenna system, radiocommunications would have been moreeffective during the fire emergency.
7. The communication procedures between thebridge officer and the watchman during theemergency were inadequate.
8. The lack of a means to call for help delayedthe rescue of trapped crewmen and con-tributed to the severity of their injuries.
9. The inability of the shipboard medical staffto communicate with each other by radionegatively affected the timeliness of the careprovided to people injured in this accident.
10. Removing the corridor bulkhead in the mainlaundry was an alteration to the vessel thatseriously degraded the fire safety conditionof the Universe Explorer.
11. Greater fire protection can be attained inlaundry facilities by using a combination ofdifferent types of detection devices as wellas an automatic suppression system.
12. Improved surveillance of high-fire-risk areaswould enhance the fire safety condition onboard the Universe Explorer.
13. If the Universe Explorer had been equippedwith an automatic sprinkler system, thelarge quantities of smoke and resulting lossof life may have been avoided.
14. Had automatic closure of the fire doors beenincorporated in the fire detection system, thefire doors in the area where the fire brokeout would have shut immediately whennearby detectors activated, therebypreventing the spread of lethal amounts ofsmoke to the crew berthing areas on theAloha deck.
15. The effectiveness of the fire doors to thecrew corridors on Aloha deck was compro-mised by their being tied open, degradingcrew safety and contributing to the numberof deaths in the accident.
16. Improved oversight of the performance ofthe fire watch is needed to ensure an ac-ceptable level of fire safety on board theUniverse Explorer.
CONCLUSIONS
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17. The lack of an automatic smoke alarm thatsounded locally in the crew berthing areadelayed prompt notification to the crew ofthe fire and the need to evacuate. Had thecrewmembers who died received earlierwarning, they may have escaped.
18. The crewmembers’ implementation of evac-uation procedures was effective in main-taining calm and order and in ensuring thatpassengers vacated their cabins and assem-bled at their muster stations.
19. The Universe Explorer’s operating pro-cedures that the watch officer is supposed tofollow when a fire alarm activates are lessthan adequate to ensure the timely estab-lishment of fire boundaries restricting thespread of heat and smoke.
20. Although the passenger fire drill held on theUniverse Explorer was conducted in a time-ly manner, the content of the exercise didnot fully prepare many passengers to meetthe demands of an actual fire emergency.
21. The Universe Explorer crew did notadequately address passenger concernsabout the fire and the seriousness of thesituation while they were assembled at theirmuster stations.
22. Some of the deceased crewmembers on theUniverse Explorer may not have survivedthe fire because they lacked sufficientknowledge of alternate escape routes fromtheir berthing area.
23. Had the officers directing the fire searchused a more methodical approach em-ploying more than one search team, theymight have located the fire sooner.
24. Efforts to locate and rescue trapped crew-members were not initiated in a timelymanner. The delayed search of Aloha deckcrew cabins prolonged the trapped crew-men’s exposure to smoke and contributed tothe severity of their injuries.
25. If the Universe Explorer had had a properlyequipped rescue team that was trained inlocating and recovering people trapped insmoke-filled areas, the crewmen probablywould have been rescued sooner and wouldhave sustained less severe injuries; more-over, fewer crewmen may have died.
26. The lack of a secondary supply of oxygenlimited the medical staff’s ability to treat theinjured.
27. Management did not exercise effective over-sight of fire safety on the Universe Explorer.
28. The American Bureau of Shipping’s processfor approving a plan or for verifying thatsubmitted plans are accurate is not asrigorous as it ought to be.
29. The Coast Guard procedures used inconducting control verification examina-tions of foreign passenger vessels do notadequately address the need to verifystructural fire protection boundaries.
30. In the absence of specific criteria, an imme-diate determination of the individual(s)directly involved in a serious marine inci-dent who should be considered for drug andalcohol testing is sometimes difficult.
31. The response by the Coast Guard and localauthorities to the Universe Explorer fire wastimely and appropriate.
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Probable Cause
The National Transportation Safety Boarddetermines that the probable cause of this acci-dent was a lack of effective oversight by NewCommodore Cruise Line, Ltd. and the predeces-sor of V. Ships Marine, Ltd. (International Ma-rine Carriers, Inc.), who allowed physical con-ditions and operating procedures to exist that
compromised the fire safety of the UniverseExplorer, ultimately resulting in crewmemberdeaths and injuries from a fire of undeterminedorigin in the vessel’s main laundry. Contributingto the loss of life and injuries was the lack ofsprinkler systems, the lack of automatic local-sounding fire alarms, and the rapid spread ofsmoke through open doors into the crew berth-ing area.
As a result of its investigation, the NationalTransportation Safety Board makes the follow-ing recommendations:
—To the U.S. Coast Guard:
Propose to the International MaritimeOrganization that passenger ships berequired to institute procedures, upgradeequipment, or do both to establish relia-ble internal radio communications fromanywhere inside a vessel during anemergency. (M-98-31)
Recommend to the International Mari-time Organization that passenger andcrew cabins on cruise ships be requiredto be equipped with an emergency callsystem so that people trapped during afire emergency have a means of sig-naling their location. (M-98-32)
Conduct research with the passengership industry and the National FireProtection Association on the adequacyof heat and smoke detectors for use inhigh-fire-risk areas, including laundryspaces, of passenger ships; and, basedupon your findings, propose to theInternational Maritime Organizationequipment or procedural guidelines forimproving the reliability of fire alarms.(M-98-33)
Propose to the International MaritimeOrganization that passenger ships berequired to integrate heat and/or smokedetectors with automatic fire doorrelease switches so that the doors in the
immediate area of a fire will close auto-matically when the detectors are acti-vated. (M-98-34)
Propose to the International MaritimeOrganization that periodic instruction ordrills be provided to all crewmemberson passenger ships to reinforce the fa-miliarization training required of newseafarers by the 1995 Amendments tothe Standards for Training Certificationand Watchkeeping Convention.(M-98-35)
Propose to the International MaritimeOrganization that specially trained andsuitably equipped rescue teams berequired on board all passenger ships.(M-98-36)
Recommend to the International Mari-time Organization that passenger shipcompanies be required to equip each on-board medical staff member with a port-able radio with a dedicated frequencyfor use during an emergency. (M-98-37)
Revise your control verification exami-nation procedures to include a moredetailed review of structural fire pro-tection features on board foreignpassenger ships. (M-98-38)
Require that each foreign passengervessel operating from U.S. ports peri-odically undergo a periodic structuralfire protection plan review and vesselexamination to verify that it is beingmaintained in accordance with approvedplans. (M-98-39)
RECOMMENDATIONS
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In cooperation with maritime industryrepresentatives, establish specific cri-teria for identifying those individualswho should undergo drug and alcoholtesting after a serious marine incident,and establish procedures to ensure thatsuch identification and subsequenttesting is conducted in a timely manner.(M-98-40)
Submit a copy of the NationalTransportation Safety Board’s report ofthe fire on board the Universe Explorerto the International Maritime Organiza-tion for distribution and discussion.(M-98-41)
—To New Commodore Cruise Lines, Ltd.and to V. Ships Marine Ltd.:
Improve the means of radio commun-ications between shipboard commandand emergency responders and amongemergency response groups on boardyour passenger ships. (M-98-42)
Review and, if necessary, revise ship-board communication procedures to en-sure that watch officers and the firewatch maintain effective communica-tions at all times, especially when thefire watch enters a suspected fire area.(M-98-43)
Equip crew cabins on company passen-ger ships with an emergency call systemso that people trapped in their cabinsduring a fire emergency can signal theirlocation. (M-98-44)
Modify the fire control systems on com-pany passenger vessels, integrating heatand/or smoke detectors with automaticfire door release switches. (M-98-45)
Provide each member of the medicalstaff on board company passenger ships
with a portable radio for use in ship-board emergencies. (M-98-46)
Review the adequacy of the firedetection systems presently protectinglaundry spaces on board company pas-senger ships, and, based on that review,install improved detection systems orinstitute improved surveillance pro-cedures to improve fire detection capa-bility. (M-98-47)
Implement procedures to improve theoversight of the fire watch on boardcompany passenger ships. (M-98-48)
Review and revise as necessary theoperating procedures followed by thenavigation watch officer to ensure thatfire screen doors are closed immediatelyupon receipt of a fire alarm. (M-98-49)
Revise passenger fire drills and state-room placards to advise passengerswhat to expect in a fire emergency.Include an explanation that fire doorsshut automatically and instructions foropening them. (M-98-50)
Revise procedures for announcingemergency status updates to passengersassembled at muster stations so as toassuage their concerns. (M-98-51)
Provide periodic instruction or drills onalternate escape routes to all crewmem-bers on company passenger vessels toreinforce the familiarization trainingrequired of new seafarers by the 1995Amendments to the Standards for Train-ing Certification and WatchkeepingConvention. (M-98-52)
Establish improved procedures forcrewmembers to follow in locating fireson board company passenger ships.(M-98-53)
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Establish for each company vessel arescue team dedicated to locating trap-ped passengers and crew during a fireemergency, and provide the team mem-bers with recurrent search and rescuetraining. (M-98-54)
Review the contents of passenger vesselemergency medical kits to ensure theycontain adequate medical supplies tomeet an emergency, such as the fire onboard the Universe Explorer. (M-98-55)
Address the safety issues identified inthis report in the safety program thatyou are developing for compliance withthe International Safety ManagementCode. Further, increase the shoresidemanagement’s oversight of fire safetyconditions on board your vessels by ini-tiating the following measures, at a min-imum: periodic fire safety vessel exami-nations and periodic instruction for theships’ crews on maintaining a fire-safevessel. (M-98-56)
Immediately install automatic sprinklersystems in accommodation areas, stair-way enclosures, and corridors on com-pany ships. (M-98-57)
—To the International Council of CruiseLines:
Advise member companies of the cir-cumstances of this accident and recom-mend that they institute procedures and,if necessary, upgrade equipment toestablish reliable internal radio com-munications from anywhere inside avessel during an emergency. (M-98-58)
Recommend that member passengership companies install emergency callsystems in passenger staterooms andcrew cabins so that people trappedduring a fire emergency will have a
means of signaling their location.(M-98-59)
Inform member companies of the im-portance of providing each member ofthe shipboard medical staff with a relia-ble radio and communications trainingfor emergencies. (M-98-60)
Remind member companies of thepossible need to institute improvedsurveillance measures for high-fire-riskareas on their ships. (M-98-61)
Recommend that member companiesintegrate heat and/or smoke detectorswith automatic fire door release switch-es so that the doors in the immediatearea of a fire will close automaticallywhen the detectors are activated.(M-98-62)
Recommend that member companiesreview and, if necessary, revise passen-ger fire drills and stateroom placards toadvise passengers what to expect in theevent of a fire emergency. (M-98-63)
Recommend that member companiesprovide periodic instruction or drills onalternate escape routes to all crewmem-bers on passenger ships to reinforce thefamiliarization training required of newseafarers by the 1995 Amendments tothe Standards for Training Certificationand Watchkeeping Convention.(M-98-64)
Encourage member companies to estab-lish specially trained and equippedshipboard rescue teams to conduct res-cue operations from smoke-filled areas.(M-98-65)
In consultation with member passengership operators, determine the amountand type of medical equipment andmedicines needed during an emergencyand recommend that such supplies be
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maintained in suitable locations outsideof the ship’s hospital in case the hospi-tal becomes inaccessible. (M-98-66)
Remind member companies of thedegradation to structural fire protectionthat can result from altering fire controlboundaries and of their responsibility tomaintain the accuracy of vessel firecontrol plans. (M-98-67)
—To the American Bureau of Shipping:
Analyze your plan review proceduresand improve them to ensure that a shipplans submitted for approval accuratelydepict the configuration of the vessel.(M-98-68)
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
JAMES E. HALLChairman
ROBERT T. FRANCIS IIVice Chairman
JOHN A. HAMMERSCHMIDTMember
JOHN J. GOGLIAMember
GEORGE W. BLACKMember
April 14, 1998
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APPENDIX A
INVESTIGATION
The Safety Board was notified of this acci-dent on the morning of July 27, 1996. Fiveinvestigators from the Safety Board’s Washing-ton, D.C., headquarters were dispatched toJuneau, Alaska, arriving that same night. In-vestigators immediately met with representa-tives of local emergency response agencies, theU.S. Coast Guard, and the operator of the Uni-verse Explorer and made arrangements to boardthe vessel early the next morning to begin inter-viewing witnesses and examining the fire scene.The on-scene investigation continued untilAugust 3, 1996.
The following organizations were parties inthe investigation:
New Commodore Cruise Lines, Ltd., repre-senting the owner of the Universe Explorer;
International Marine Carriers, Inc., whichwas the operator of the Universe Explorer atthe time of the accident;
U.S. Coast Guard;National Institute of Occupational Health &Safety (NIOSH);State of Alaska;City of Juneau; andRepublic of Panama.
The Safety Board investigated this accidentunder the authority of the Independent SafetyBoard Act of 1974.
The report is based on the informationdeveloped as a result of the investigation and onadditional analysis done by the Safety Board. TheSafety Board has considered all facts in theinvestigative record that are pertinent to its statu-tory responsibility to determine the cause or prob-able cause of the accident and to make recom-mendations.
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APPENDIX B
DUTIES OF THE UNIVERSE EXPLORER FIRE WATCH
1. Work directly under the command of theSafety Officer/Watch Officer.
2. Ensure the completion of all fire roundswithin the specified periods, punching theclock at all assigned locations. (Each roundshould take about 50 minutes.) Anydivergence from the usual round (or missingcheckpoints) should be recorded in the FirePatrol log.
3. Use the UHF radio provided to com-municate with the bridge, the Safety Officer,or the Security Officer. Perform “radiochecks” with the watch officer on eachround, from different locations throughoutthe vessel. The radio carried by thepatrolman must be set on channel 4 at alltimes, and have its volume set to a level atwhich the patrolman will not miss anycommunication from the bridge.
4. Be alert and vigilant at all times; use allsenses to try to detect smoke or fire (e.g.from the smell of smoke or other unusual
odors, feeling excessive heat or hearingstrange sounds).
5. Report to the bridge directly following eachround. Keep the watch officer informed ofany problems encountered. The followingsituations should be immediately reported tothe Safety Officer/Watch Officer:
• Fights, brawls, or vandalism;
• Passengers/crew involved insuspicious/illegal activities, such asdrugs or lethal weapons;
• Passengers/crew in off-limits areas;
• Crewmembers in passenger cabins;
• Discrepancies in safety equipment(ensure that all fire screen doors,including permanently closed doors, arenot blocked or lashed open).
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APPENDIX C
RETROACTIVE FIRE SAFETY AMENDMENTSFOR EXISTING PASSENGER SHIPS
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Adoption of amendments to chapter II-2 ofthe International Convention for the Safetyof Life at Sea, 1974
Fire safety measuresfor existing passenger ships
The MARITIME SAFETY COMMITTEE,
RECALLING Article 28(b) of the Conventionon the International Maritime Organizationconcerning the functions of the Committee,
RECALLING FURTHER Article VIII(b) of theInternational Convention for the Safety of Lifeat Sea, 1974, hereinafter referred to as “theConvention,” concerning the procedures foramending the annex to the Convention, otherthan the provisions of chapter I,
BEING CONCERNED about recent serious firecasualties resulting in the loss of human life,
RECOGNIZING that there is a compelling andurgent need to improve the fire safe measuresfor existing passenger ships,
HAVING CONSIDERED at its sixtieth sessionamendments to the Convention proposed andcirculated in accordance with article VIII(b)(i)thereof,
1. ADOPTS, in accordance with articleVIII(b)(iv) of the Convention, the amendmentsto the Convention, the text of which is set out inthe annex to the present resolution;
2. DETERMINES, in accordance with articleVIII(b)(vi)(2)(bb) of the Convention, that theamendments shall be deemed to have beenaccepted on 1 April 1994 unless, prior to thatdate, more than one third of the ContractingGovernments to the Convention, or ContractingGovernments the combined merchant fleets ofwhich constitute not less than 50 percent of thegross tonnage of the world’s merchant fleet,
have notified their objections to the amend-ments;
3. INVITES Contracting Governments to notethat, in accordance with article VIII(b)(vii)(2) of the Convention, the amendments shallenter into force on 1 October 1994 upontheir acceptance in accordance with para-graph 2 above;
4. REQUESTS the Secretary-General, in con-formity with article VIII(b)(v) of the Con-vention, to transmit certified copies of thepresent resolution and the text of the amend-ments contained in the annex to all Con-tracting Governments to the Convention;
5. FURTHER REQUESTS the Secretary-Gen-eral to transmit copies of the resolution toMembers of the Organization which are notContracting Governments to the Conven-tion.
Annex
Amendments to chapter II-2 of theInternational Convention for the Safety of
Life at Sea, 1974
Regulation 1
Application
1 Existing paragraph 3 is renumbered as para-graph 3.1 and the following new paragraph isinserted after paragraph 3.1:
“3.2 Notwithstanding the provisions of para-graph 3.1, passenger ships carrying more than36 passengers when undergoing repairs, altera-tions, modifications and outfitting relatedthereto shall comply with the following:
.1 all materials introduced to these shipsshall comply with the requirementswith regard to material applicable to
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ships constructed on or after 1 October1994; and
.2 all repairs, alterations, modificationsand outfitting related thereto involvingthe replacement of material of 50tonnes or above, other than thatrequired by regulation 41.1, shall com-ply with the requirements applicable tosuch ships constructed on or after 1October 1994.”
Regulation 3
Definitions
2 The following new paragraphs 22-1 and 22-2are inserted after paragraph 22:
“22-1 Central control station is a control stationin which the following control and indicatorfunctions are centralized:
.1 fixed fire detection and alarm system
.2 automatic sprinklers, fire detection andalarms system;
.3 fire door indicator panel;
.4 fire door closure;
.5 watertight door indicator panel;
.6 watertight door opening and closing;
.7 ventilation fans;
.8 general/fire alarm;
.9 communication systems including tele-phones; and
.10 microphone to public address system.
22-2 Continuously manned central controlstation is a central control station which iscontinuously manned by a responsible memberof the crew.”
Regulation 17
Fireman’s Outfit
3 The following sentence is added at the end ofexisting paragraph 1.2.2:
“In passenger ships carrying more than 36passengers, at least two spare charges for eachbreathing apparatus shall be provided, and all aircylinders for breathing shall be interchange-able.”
4 The following sentence is added at the end ofexisting paragraph 3.1.1:
“In passenger ships carrying more than 36 pas-sengers, two additional fireman’s outfits shall beprovided for each main vertical zone.”
5 The following sentence is added at the end ofexisting paragraph 4:
“At least two fireman’s outfits shall be stored ineach main vertical zone.”
6 The following new regulations are inserted afterexisting regulation 41:
“Regulation 41-1Upgrading of passenger ships carrying morethan 36 passengers constructed before 1 October1994
1 This regulation shall apply to passengerships carrying more than 36 passengers con-structed before 1 October 1994.
2 Passenger ships which do not complywith all the requirements of chapter II-2 appli-cable to ships constructed on or after 25 May1980 (requirements of chapter II-2 of SOLAS1974, as adopted by the InternationalConference on Safety of Life at Sea, 1974,applicable to new passenger ships) shall complywith the following:
.1 paragraph 1 of regulation 41-2 not laterthan 1 October 1994; and
.2 paragraphs 2, 3, 4 and 5 of regulation41-2 not later than 1 October 1997; and
.3 paragraph 6 of regulation 41-2 not laterthan 1 October 2000; and
.4 all the requirements of chapter II-2applicable to ships constructed on orafter 25 May 1980 (requirements ofchapter II-2 of SOLAS 1974, asadopted by the International Confer-ence on Safety of Life at Sea, appli-cable to new passenger ships) not laterthan 1 October 2010.
3 Passenger ships which comply with allthe requirements of chapter II-2 applicable toships constructed on or after 25 May 1980 (re-quirements of chapter II-2 of SOLAS 1974, asamended by resolutions MSC.1(XLV),
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MSC.6(48), MSC.11(55), MSC.12(56),MSC.13(57) and MSC.22(59) shall comply withthe following:
.1 paragraph 1 of regulation 41-2 not laterthan 1 October 1994; and
.2 paragraphs 2 and 4 of regulation 41-2not later than 1 October 1997; and
.3 paragraph 6 of regulation 41-2 not laterthan 1 October 2000; and
.4 paragraph 5 of regulation 41-2 not laterthan 1 October 2005 or 15 years afterthe date of construction of the ships,whichever is later.
4 For the purpose of this regulation,passenger ships complying in their entirety withall the requirements of part H of chapter IIcontained in amendments to the InternationalConvention for the Safety of Life at Sea, 1960,adopted by the Assembly of the Organization byresolution A.122(V), may be regarded aspassenger ships complying with therequirements applicable to passenger shipsconstructed on or after 25 May 1980(requirements of chapter II-2 of SOLAS 1974,as adopted by the International Conference onSafety of Life at Sea, applicable to newpassenger ships).
“Regulation 41-2Requirements for passenger ships carrying morethan 36 passengers constructed before 1 October1994
1.1 Plans and booklets required by regulation 20shall provide information regarding fireprotection, fire detection and fire extinctionbased on the guidelines developed by theOrganization.∗
1.2 Each member of the fire patrol shall beprovided with a two-way portable radiotele-phone apparatus.
1.3 Water fog applicators shall be provided asrequired in regulations 7.6, 17.3.2 and 37.1.5.1.
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1.4 Portable foam applicators shall be providedas required in regulations 7.1, 7.2.2. and37.1.5.2.
1.5 All hose nozzles provided shall be of anapproved dual-purpose type (i.e. spray/jet type)incorporating a shutoff.
2 All accommodation and service spaces,stairway enclosures and corridors shall beequipped with a smoke detection and alarmsystem of an approved type and complying withthe requirements of regulation 13. Such systemneed not be fitted in private bathrooms andspaces having little or no fire risk such as voidsand similar spaces. Detectors operated by heatinstead of smoke shall be installed in galleys.
3 Smoke detectors connected to the smokedetection and alarm system shall also be fittedabove ceilings in stairways and corridors in theareas where ceilings are of combustible con-struction.
4.1 Hinged fire doors in stairwaysenclosures, main vertical zone bulkheads andgalley boundaries which are normally kept openshall be self-closing and be capable of releasefrom a central control station and from aposition at the door.
4.2 A panel shall be placed in a continuouslymanned central control station to indicatewhether the fire doors on stairway enclosures,main vertical zone bulkheads and galley boun-daries are closed.
4.3 Exhaust ducts from galley ranges wheregrease or fat is likely to accumulate and whichpass through accommodation spaces or spacescontaining combustible materials shall beconstructed of “A” class divisions. Each galleyrange exhaust duct shall be fitted with:
.1 a grease trap readily removable forcleaning, unless an alternative greaseremoval process is fitted;
.2 a fire damper located in the lower endof the duct;
.3 arrangements operable from with thegalley for shutting off the exhaust fans;
.4 fixed means for extinguishing a firewithin the duct; and
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.5 suitably located hatches for inspectionand cleaning.
4.4 Only public toilets, lifts, lockers of noncom-bustible materials providing storage for safetyequipment and open information counters maybe located within the stairway enclosure bound-aries. Other existing spaces within the stairwayenclosure:
.1 shall be emptied, permanent closed anddisconnected from the electrical sys-tem; or
.2 shall be separated from the stairwayenclosure by the provision of “A” classdivisions in accordance with regulation26. Such spaces may have direct accessto stairway enclosures by the provisionof “A” class doors in accordance withregulation 26, and subject to a sprinklersystem being provided in these spaces.However, cabins shall not open directlyinto the stairway enclosure.
4.5 Spaces other than public spaces, corridors,public toilets, special category spaces, otherstairways required by regulation 28.1.5, opendeck spaces and spaces covered by paragraph4.4.2 are not permitted to have direct access tostairway enclosures.
4.6 Existing machinery spaces of category (10)described in regulation 26.2.2 and existing backoffices for information counters which opendirectly into the stairway enclosure may beretained, provided that they are protected bysmoke detectors and that back offices forinformation counters contain only furniture ofrestricted fire risk.
4.7 In addition to the emergency lighting re-quired by regulations II-1/42 and III/11.5, themeans of escape including stairways and exitsshall be marked, at all points of the escape routeincluding angles and intersections, by lighting orphotoluminescent strip indicators placed notmore than 0.3 m above the deck.
4.8 A general emergency alarm system shall beprovided. The alarm shall be audible throughoutall the accommodation and normal crew work-ing spaces and open decks, and its sound pres-
sure level shall comply with the standard de-veloped by the Organization.∗∗ The alarm shallcontinue to function after it has been triggereduntil it is manually turned off or is temporarilyinterrupted by a message on the public addresssystem.
4.9 A public address system or other effectivemeans of communication shall be available andaudible throughout the accommodation, publicand service spaces, control stations and opendecks.
4.10 Furniture in stairway enclosures shall belimited to seating. It shall be fixed, limited to sixseats on each deck in each stairway enclosure,be of restricted fire risk, and shall not restrictthe passenger escape route. The Administrationmay permit additional seating in the mainreception area with stairway enclosures, if it isfixed, non-combustible, and does not restrict thepassenger escape route. Furniture shall not bepermitted in passenger and crew corridorsforming escape routes in cabin area. In additionto the above, lockers of non-combustiblematerial, providing storage for safety equipmentrequired by regulations, may be permitted.
5 Accommodation and service spaces,stairway enclosures and corridors shall be fittedwith an automatic sprinkler, fire detection andfire alarm system complying with the require-ments of regulation 12 or the guidelinesdeveloped by the Organization* for an approvedequivalent sprinkler system. A sprinkler systemneed not be fitted in private bathrooms, andspaces having little or not fire risk such as voidsand similar spaces.
6.1 All stairways in accommodation and servicespaces shall be of steel frame constructionexcept where the Administration sanctions theuse of other equivalent material, and shall bewithin enclosures form of “A” class divisions,with positive means of closure at all openings,except that:
.1 a stairway connecting only two deckneed not be enclosed, providing the
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integrity of the deck is maintained byproper bulkheads or doors in one‘tween-deck space. When a stairway isclosed in one tween-deck space, thestairway enclosure shall be protected inaccordance with the tables for decks inregulation 26;
.2 stairways may be fitted in the open in apublic space, provided they lie whollywith such public space.
6.2 Machinery spaces of category A shall be fit-ted with a fixed fire-extinguishing system com-plying with the requirements of regulation 7.
6.3 Ventilation ducts passing through divisionsbetween main vertical zones shall be equippedwith a fair-safe automatic closing fire damperwhich shall also be capable of being manuallyclosed from each side of the division. In addi-tion, fair-safe automatic closing fire damperswith manual operation from within the enclo
sure shall be fitted to all ventilation ductsserving both accommodation and service spacesand stairway enclosures where they pierce suchenclosures. Ventilation ducts passing through amain fire zone division without serving thatenclosure need not be fitted with dampers pro-vided that the ducts are constructed andinsulated to A-60 standard and have no openingswithin the stairway enclosure or in the trunk onthe side which is not directly served.
6.4 Special category spaces and ro-ro cargospaces shall comply with the requirements ofregulations 37 and 38, respectively.
6.5 All fire doors in stairway enclosures, mainvertical zone bulkheads and galley boundarieswhich are normally kept open shall be capableof release from a central control station andfrom a position at the door.”
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ACRONYMS AND ABBREVIATIONS IN THIS REPORT
ABS American Bureau of Shipping
ACP Alternate Compliance Program
CCF/R Capital City Fire and Rescue
CFR Code of Federal Regulations
CVE Control Verification Examination
EMT emergency medical technician
EPIRB emergency positioning indicating radio beacon
FSD fire screen door
ICCL International Council of Cruise Lines
IMO International Maritime Organization
ISM Code International Safety Management Code
LR Lloyd’s Registry of Shipping
MVZ main vertical zone
MarAd U.S. Maritime Administration
NVIC Navigation and Vessel Inspection Circular
RFSA Retroactive Fire Safety Amendment
SAR Search and Rescue
SCBA self-contained breathing apparatus
SCTW Standards for Training Certification and Watchkeeping
SOLAS Safety of Life at Sea
WTD watertight door
