Factual Informati<strong>on</strong> 4 Marine Accident ReportIn <strong>the</strong> meantime, ano<strong>the</strong>r galley fitter (sec<strong>on</strong>d fitter) had finished checking a pump<strong>on</strong> <strong>on</strong>e of <strong>the</strong> ship’s Jacuzzis and was preparing to go off duty at 1730 when <strong>the</strong> galleyengineer told him to help <strong>the</strong> first fitter in <strong>the</strong> main laundry. The sec<strong>on</strong>d fitter said thatwhen he arrived in <strong>the</strong> main laundry, <strong>the</strong> first fitter was adjusting a bolt <strong>on</strong> <strong>the</strong> mangle.The sec<strong>on</strong>d fitter said that <strong>the</strong> first fitter tightened a bolt <strong>on</strong> <strong>the</strong> mangle so muchthat <strong>the</strong> bolt broke off. Both fitters testified that <strong>the</strong> first fitter decided to weld <strong>the</strong> boltback in place. They said that <strong>the</strong> first fitter went to <strong>the</strong> fitters’ workshop to get <strong>the</strong>necessary equipment, which included a portable welding machine, welding rods, helmets,gloves, and tools. The sec<strong>on</strong>d fitter said that he went to get an asbestos (fire) blanket from<strong>the</strong> machine shop area. Both fitters testified that, at this time, <strong>the</strong>y did not obtain a “hotwork permit,” as required by Carnival Cruise Lines’ Safety Management System (SMS)procedures, 4 because “it was standard procedure” to set up <strong>the</strong> equipment before calling<strong>the</strong> staff chief engineer to get a permit and to arrange for a fire watch.The first fitter said that <strong>the</strong> locati<strong>on</strong> of <strong>the</strong> bolt, between <strong>the</strong> roller bed and <strong>the</strong> endplate <strong>on</strong> <strong>the</strong> mangle cabinet, was difficult to reach for welding. The sec<strong>on</strong>d fitter statedthat when he returned to <strong>the</strong> main laundry, <strong>the</strong> first fitter was lying <strong>on</strong> top of <strong>the</strong> mangle,aligning <strong>the</strong> broken bolt. The welding machine was <strong>on</strong> a table next to <strong>the</strong> mangle. (Seefigure 3.) The sec<strong>on</strong>d fitter said, “I saw <strong>the</strong> welding unit <strong>on</strong> <strong>the</strong> table and <strong>the</strong> welding rod[cable] and ground cable were sitting <strong>on</strong> top of <strong>the</strong> panel to <strong>the</strong> mangle….” He stated that<strong>the</strong> ground cable was not c<strong>on</strong>nected to anything. The first fitter said that he had plugged<strong>the</strong> welding unit into an electrical outlet and had inserted a welding rod (electrode) into <strong>the</strong>rod holder. 5The sec<strong>on</strong>d fitter climbed <strong>on</strong> top of <strong>the</strong> table next to <strong>the</strong> mangle. He said that,because <strong>the</strong> welding rod was hanging near <strong>the</strong> deck, he pulled <strong>the</strong> cable toward him. He<strong>the</strong>n saw <strong>the</strong> welding rod come in c<strong>on</strong>tact with ei<strong>the</strong>r <strong>the</strong> grounding clamp or <strong>the</strong> mangle,causing a spark. The sec<strong>on</strong>d fitter testified that dryer lint was <strong>on</strong> <strong>the</strong> floor. The first fittersaid that while he was looking down through <strong>the</strong> rollers of <strong>the</strong> mangle, he saw “a verysmall fire” <strong>on</strong> <strong>the</strong> floor and “yelled out” about a fire <strong>on</strong> <strong>the</strong> deck. Both fitters said that <strong>the</strong>yjumped to <strong>the</strong> deck, went to <strong>the</strong> nearby sink, and got a glass of water, which <strong>the</strong>y used toput out <strong>the</strong> fire underneath <strong>the</strong> mangle.The sec<strong>on</strong>d fitter testified that he saw fire “in <strong>the</strong> middle of <strong>the</strong> mangle” andretrieved a fire extinguisher, which he directed <strong>on</strong> <strong>the</strong> mangle. The first fitter testified tha<strong>the</strong> saw “big flames” in <strong>the</strong> ventilati<strong>on</strong> duct immediately above <strong>the</strong> mangle and that he tooka CO 2 fire extinguisher and directed its spray into <strong>the</strong> overhead vent. He estimated that hebattled <strong>the</strong> fire for about 5 minutes but had to aband<strong>on</strong> <strong>the</strong> firefighting effort because <strong>the</strong>laundry room was filled with smoke. Both fitters testified that when <strong>the</strong> fire alarms beganto sound, <strong>the</strong>y left <strong>the</strong> laundry and went to <strong>the</strong>ir emergency stati<strong>on</strong>s.4 For fur<strong>the</strong>r informati<strong>on</strong> about Carnival Cruise Lines’ SMS and <strong>the</strong> required procedures for companypers<strong>on</strong>nel, see “Operati<strong>on</strong>s,” later in this report.5 The welding machine used by <strong>the</strong> fitters, a Unitor Miniweld model, did not have an <strong>on</strong>-off switch. Theunit was energized when it was plugged in. The specificati<strong>on</strong>s for <strong>the</strong> Miniweld states that it “c<strong>on</strong>forms to<strong>the</strong> Norwegian Maritime Directorate’s rules for welding apparatus <strong>on</strong> board ships.” Unitor has sincedisc<strong>on</strong>tinued manufacturing this model.
Factual Informati<strong>on</strong> 5 Marine Accident ReportFilter covers wereinstalled <strong>on</strong> <strong>the</strong>overhead exhaustvents after <strong>the</strong> fireTableOverheadexhaust ventVerticalexhaustventFigure 3. (Top) The mangle in <strong>the</strong> main laundry after Carnival made postaccident repairs to <strong>the</strong> area.The tables shown are in about <strong>the</strong> same locati<strong>on</strong> as <strong>the</strong> table <strong>on</strong> which <strong>the</strong> fitters placed <strong>the</strong> weldingmachine <strong>on</strong> <strong>the</strong> day of <strong>the</strong> fire. (Bottom left) The large uncovered opening in <strong>the</strong> overhead was <strong>on</strong>e ofthree vents above <strong>the</strong> mangle that exhausted air and lint into <strong>the</strong> ventilati<strong>on</strong> system. (Bottom right)Two fan units drew heat and lint from <strong>the</strong> pressing rollers into vertical ducts that were c<strong>on</strong>nected to<strong>the</strong> overhead ducts of <strong>the</strong> main laundry ventilati<strong>on</strong> system.
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