Insufficient maintenance caused passenger vessel fire

The US National Transportation Safety Board (NTSB) has said that an insufficient preventative maintenance programme and lack of guidance for responding to engine high-temperature conditions led to the January 14th 2018 fire on board small passenger vessel Island Lady in the waters of the Pithlachascotee River, near Port Ritchey, Florida.

The Island Lady was a 72ft passenger vessel operated by Tropical Breeze Casino Cruz. It was used to shuttle passengers and company employees to and from the casino boat Tropical Breeze.

On the day of the fire Island Lady was carrying 53 people, including 36 passengers. As a result of the incident 15 people were injured and transported to local hospitals. One passenger died several hours after the fire.

Damage to the Island Lady resulted in the vessel, valued at $450,000, being declared a constructive total loss.

The NTSB investigated this event as “an accident of recurring character” because there was a similar fire in 2004 on board Express Shuttle II, another of the operating company’s vessels.

At about 16:00 on the afternoon of January 14th 2018, a fire broke out in an unmanned space on the small passenger vessel near Port Richey, Florida, during a scheduled transit to a casino boat located about nine miles offshore in the Gulf of Mexico.

After receiving a high-temperature alarm on the port engine, the captain turned the Island Lady around to return to the dock. During the return trip, smoke began filling the lazarette, main deck, and engine room. The captain deliberately beached the vessel in shallow water near shore in order to evacuate the passengers.

All crewmembers, employees, and passengers evacuated the vessel by entering the water and wading/crawling ashore.

The NTSB identified the following safety issues:

Lack of company guidance regarding engine high-temperature alarms:

After the captain received a high-temperature alarm for the port engine’s jacket-water system, he did not shut down the engine but instead left it idling. Doing so allowed the overheating engine to continue to generate excessive heat, which in turn affected the exhaust tubes and ignited their surrounding structures. Tropical Breeze Casino Cruz did not provide specific guidance to its vessel captains about how to respond to high-temperature alarms.

Lack of fire-detection in unmanned spaces with exhaust tubing:

Although federal regulations required small passenger vessels to have fire detection and suppression systems in spaces containing propulsion machinery, the regulations did not require such systems in unmanned spaces with engine exhaust tubing. The fire on board the Island Lady most likely started in the lazarette – an unmanned space aft of the engine room – through which the exhaust tubes led toward the vessel’s stern. Because there was no fire in the engine room initially, activating the vessel’s fixed fire-suppression system for that space would have served no purpose; further, activation would have caused the vessel to needlessly lose all available propulsion during the emergency.

Insufficient preventive maintenance:

Although Tropical Breeze Casino Cruz stated that it implemented a preventive maintenance program after the Express Shuttle II fire (in response to an earlier NTSB safety recommendation), the quality of the programme was insufficient. The US Coast Guard does not require small passenger vessels to have preventive maintenance programs and, importantly, even when such programs are voluntarily in place, as they were in this case, the Coast Guard provides no enforcement oversight.

Insufficient crew training and documentation:

The investigation revealed that the Island Lady crew members lacked sufficient understanding of firefighting principles and that their training drills were infrequent or not completed. In addition, records pertaining to crew training drills and daily maintenance checklists were kept only on board the vessel and were lost in the fire. Inappropriate material and design of fuel tank level-indicator system:

Counter to Title 46 Code of Federal Regulations 182.440 (a)(7), the Island Lady’s fuel tanks were equipped with plastic hoses used as fuel level indicators. The system did not have automatic shutoff valves. As a result the plastic material melted during the fire and the release of diesel fuel exacerbated the fire.

As a result of its investigation, the NTSB issued four safety recommendations.

For Tropical Breeze Casino Cruz:

  1. Develop and apply an oversight system to ensure that the maintenance programme complies with the manufacturer’s recommended preventive maintenance program for the engines and associated machinery and systems on board the company’s vessels.
  2. Revise marine firefighting and job training programmes, including documenting both on board and ashore that all crewmembers are qualified and can continually demonstrate proficiency in their duties, such as firefighting techniques and other emergency situations.

For the US Coast Guard:

  1. Require fire detection systems in unmanned spaces with machinery or other potential heat sources on board small passenger vessels.
  2. Issue a Marine Safety Information Bulletin that addresses the need to use only approved material and components in fuel tank level-indicator systems.

https://www.ntsb.gov/news/events/Documents/2018-DCA18FM010-BMG-abstract.pdf

970x90 Advert