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

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Factual Information 34 Marine Accident Reportprocedures, and guidance.” The manual further states that crewmembers are responsiblefor taking all reasonable care for their own health and safety and for that of all others onboard the ship and that they must cooperate with the company, master, chief engineer, andall others who are responsible for health and safety aboard ship.SMS Manual 03, Section 5, “Safety Procedures,” contains subsections on permitto-worksystems (5.7) and welding and flame cutting operations (5.13).According to the SMS manual, a permit-to-work system covers “operations onboard ship where the routine actions of one man may inadvertently endanger another.”The system identifies foreseeable hazards posed by various tasks and operatingenvironments and lists precautions and sequential actions to take when performing suchtasks. The SMS manual states, “In all instances it is necessary, before the work is done, toidentify the hazards 31 and then to ensure that they are eliminated or effectively controlled.”The manual further advises that the first and most important step in eliminating oreffectively controlling hazards is a situational assessment by the ship’s officer who isexperienced in the work and thoroughly familiar with relevant hazards. The subsectionspecific to hot or cold work stipulates that permits that grant permission for such workmust be countersigned by the chief engineer, staff chief engineer, master, or staff captain.The subsection on welding and flame cutting operations states, “No welding orflame cutting work should be undertaken unless the requirements of the ‘Hot WorkPermit’ are fully satisfied.” The manual stipulates that welding operations should beproperly supervised and kept under regular observation and that a person with a suitableextinguisher should be stationed to keep watch on areas not visible to the welder.Manual 07, “Safety of Operations—Engineering Department,” states that the staffchief engineer or engineering officer team leader must ensure that all measures andprecautions that are necessary for the safety of those concerned are taken before any repairor maintenance work begins. Investigators reviewed the Ecstasy records of hot workpermits issued for various maintenance tasks outside the ship’s machine shop andworkshop. The log and copies of approved permits do not include an application or anapproval for a welding project in the ship’s main laundry on July 20, 1998. After the fireonboard the Ecstasy, Carnival Cruise Lines revised its SMS to include safeguards againstunauthorized welding. See “Other Information,” later in this report.Manual 08, “Safety of Operations—Hotel Services,” states that the laundrymanager is responsible for, among other tasks, ensuring the safe operation of all laundryequipment and the proper cleanliness of the laundry room, laundry equipment, and thelaundry crew galley. The manual lists 17 required safety procedures for the laundry area.The procedures specify the required operating temperatures for washers, dryers, and themangle, proper handling of chemicals, and measures for handling linens, clothes, anduniforms. The laundry safety procedures also include prohibiting smoking in the laundryroom and performing a fire risk assessment at regular intervals.31 At the time of the Ecstasy accident, Manual 03 did not include a section on job hazard analysis. Sincethe accident, Carnival Cruise Lines has developed and added a chapter “Safe Systems of Work - Job HazardAnalysis.”
Factual Information 35 Marine Accident ReportAccording to Carnival Cruise Lines’ officials, at the time of the Ecstasy accident,all officers and crewmembers assigned to ships in the company’s fleet had received ageneral overview training of the SMS. Employees had been given specific training inthose areas of the SMS pertaining to their duties. The company had established a scheduleof weekly reviews of the SMS, which included departmental meetings during whichsupervisors reviewed provisions of the SMS with crewmembers.Additional Oversight PracticesAccording to Carnival Cruise Lines’ officials, to complement its SMS, thecompany retained some management oversight practices that it had in place before itdeveloped its SMS. Management representatives, typically a shoreside ship supervisor ora port engineer or port captain, visited each ship in the company’s fleet at least oncemonthly to ensure that shipboard personnel were following and practicing corporate safetymanagement policies. In addition, Carnival Cruise Lines had a quality control committee,headed by the company president, that visited each ship yearly to meet with the master,department heads, and the entire crew to answer any questions on corporate policy andvessel operations.Medical and PathologicalMedical FindingsMedical responders examined at least 70 passengers and crewmembers todetermine whether they were injured and required additional medical treatment. Sixpassengers were treated by medical personnel and local hospitals for pre-existingconditions; three passengers were treated for smoke inhalation. Fourteen crewmemberswere treated for minor injuries, including smoke inhalation, chest pain, lower back pain,cervical strain, knee pain, and a knee contusion.Toxicological TestingCarnival’s requirements. At the time of the Ecstasy accident, Carnival CruiseLines’ health and safety manual contained the following requirements pertaining to drugtesting (italics added for emphasis):1. All testing for drugs will be by the analysis of urine.2. Prospective Company seafarers may be required to undergo drug testing priorto an offer of employment being made.3. Company seafarers may be required to undergo periodic drug testing.4. Unannounced testing may be carried out at intervals, initiated by Company. Allunannounced drug testing, including urine sampling, will be carried out byshore personnel only.
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Page 4 and 5: National Transportation Safety Boar
Page 6 and 7: Contents iv Marine Accident ReportS
Page 8 and 9: viMarine Accident ReportAcronyms an
Page 10 and 11: viiiMarine Accident ReportExecutive
Page 12 and 13: Factual Information 2 Marine Accide
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Page 67 and 68: Analysis 57 Marine Accident ReportT
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Page 71 and 72: Analysis 61 Marine Accident Reports
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Page 75 and 76: Analysis 65 Marine Accident ReportA
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Page 85 and 86: Analysis 75 Marine Accident ReportI
Page 87 and 88: Conclusions 77 Marine Accident Repo
Page 89 and 90: Recommendations 79 Marine Accident
Page 91: Recommendations 81 Marine Accident
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84 Marine Accident ReportAppendix B
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Appendix B 86 Marine Accident Repor
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Appendix C 88 Marine Accident Repor
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Appendix D 90 Marine Accident Repor
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92 Marine Accident ReportAppendix F
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Fire on Board the Liberian Passenger Ship Ecstasy, Miami, Florida ...

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