West Coast
The diving boat Conception burns off the coast of Santa Cruz Island (Photo by Ventura Fire Department)

NTSB Suggested Tougher Standards After Fires on Two Other “Conception”-sized Passenger Vessels Showed How Flames Easily Go Undetected and Then Spread Rapidly

Fire on-board Conception dive vessels with substantial loss of life should prompt long-overdue action by NTSB

In two previous cases, on vessels similar to the dive ship Conception, the National Transportation Safety Board called for tougher fire safety and detection systems for small passenger vessels so that the crew could be warned earlier of fires developing in hard-to-access areas of the vessels.

The most recent call for improved systems came in December 2018 after the NTSB feared it was seeing repeat cases of the original 2004 casualty. The NTSB first called for tougher standards in April 2006, more than 13 years ago.

The most recent report on the Island Lady, a vessel close to the age and size of the Conception, said:

“As a result of its investigation, the NTSB issued four safety recommendations including two to the U.S. Coast Guard which seek a requirement for fire detection systems in unmanned spaces with machinery or other potential heat sources on board small passenger vessels…”

The report added:

“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 (such as in this case), the Coast Guard provides no enforcement oversight.”

IMG_2097
Caption: Island Lady Fire

The NTSB report about the January 2018 Island Lady fire was released in December 2018. — more than nine months after The Conception was inspected in February and March 2018.

It is not certain whether the findings in these two cases have a direct bearing on the “Conception,”  but the past case studies sketch a likely path of inquiry for the NTSB now. The tragedy is likely also to result in a formal Coast Guard Marine Board of Investigation — the Coast Guard’s most formal level of inquiry.

The previous NTSB  reports show vividly how fires can start on small passenger ships and spread without crew awareness if leaking lines in hidden areas spray fuel on hot manifolds or overheating engines in hard-to-reach areas of the vessel.

It is not clear whether the Coast Guard now requires fire detecting systems in areas that are hard to access as suggested by the NTSB this past December or whether the Conception was equipped with such a system — required or not. The Conception is said to have had fire suppression systems, but if not coupled with detection systems, the suppression system may not have helped.

The vessels in question were similar in age, size and purpose.  The Island Lady was 30 years old, 72 feet long  and could carry 149 passengers. She is listed at 65 gross tons. The dive ship Conception was 38 years old, rated to carry 99 passengers, was 75 feet long and listed at 97 gross tons.

If the warning systems had been present, the NTSB said, the ship’s crew of the Island Lady could have more effectively fought the fires sooner.  In both cases, one in 2004, and the other in 2018, the NTSB recommended that the Coast Guard focus on fire systems inspections and require owners to regularly maintain wiring and other systems.

The Island Lady suffered a fire on January 14, 2018 in the waters of the Pithlachascotee River, near Port Ritchey, Florida, ferrying passengers to a casino.  She was carrying 53 people including 36 passengers. One passenger died.

The NTSB investigated the Island Lady in part  because of a similar fire in 2004 on board the Express Shuttle II, another of the operating company’s casino vessels. It was more than a decade ago that the NTSB first raised the issue of fires starting in hard-to-access areas.

The Island Lady fire was discovered when the captain received a high-temperature alarm for the port engine’s jacket-water system.  But by that time, a fire was already well underway because of engine and exhaust overheating Smoke began filling the vessel and  the captain was able to deliberately beach the ship. Most passengers were able to wade ashore.

It is not known how the Conception fire started, but appears to have been discovered only after it was far advanced.  Passengers on the dive vessel passenger ship were trapped below and many are thought to have perished.

The NTSB report showed how complex systems can poentially go wrong and cause fires aboard such passenger ships as the Conception and the Island Lady.  Essentially, on the Island Lady, the engine and exhaust cooling systems failed causing the fuel tubing to degrade, resulting in leakage and ignition.

“The raw-water system cooled various components of the engine and also supplied cooling water to the wet-exhaust system tubing, which was not designed to run in a dry condition. The overheating engine, with high jacket-water temperatures and eventually a loss of jacket water from the cracked block, would have developed higher exhaust temperatures. Those elevated temperatures, plus the loss of raw water that normally cooled the wet-exhaust tubing, would have caused the internal temperatures of the tubing to rise, degrading the tubing material and eventually leading to ignition.

The NTSB’s investigation determined that lack of guidance on  engine high-temperature alarms resulted in the captain idling the engines rather than shutting them down, helping lead to the fire.  

“Moreover, the absence of fire detection and suppression systems in unmanned spaces housing exhaust tubing prevented swifter detectin and response, and the failure of the port engine’spump led to overheating the engine and exhasut tubing.

“Moreover, the use of plastic tubing on  tank level indicators with no automatic shutoff valves released diesel fuel, which made the fire worse.  The report also states that the Coast Guard did not correctly assess the Island Lady’s fuel system’s compliance with its own systems. “

In the 2004 incident, a similar chain of events lead to the fire. A fractured fuel line, improperly installed, was not detected because the fire detection system was faulty.

“The National Transportation Safety Board determines that the probable cause of the fire on board the Express Shuttle IIwas a fractured, improperly installed fuel injection line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port Richey to have a preventive maintenance program, which could have identified the company’s ongoing problem with the vessel’s fuel lines before a failed line led to the fire. Contributing to the extent of the damage were the vessel’s faulty fire detection system and the crew’s failure to employ proper marine firefighting techniques.”

Here is a link to the full Island Lady report, and below are the NTSB summaries of the two reports.

Fire On Board US Small Passenger Vessel Island Lady

Executive Summary

​About 1600 on the afternoon of January 14, 2018, a fire broke out in an unmanned space on the small passenger vessel Island Lady near Port Richey, Florida, during a scheduled transit to a casino boat located about 9 miles offshore in the Gulf of Mexico. Fifty-three people were on board the Island Lady.

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 to evacuate the passengers. All crewmembers, employees, and passengers evacuated the vessel by entering the water and wading/crawling ashore. Fifteen people were injured and transported to local hospitals; one passenger died in the hospital several hours after the fire. The Island Lady, valued at $450,000, was declared a constructive total loss.

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 require small passenger vessels to have fire detection and suppression systems in spaces containing propulsion machinery (such as engine rooms), the regulations do 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 a previous fire on board a company vessel (the Express Shuttle II) in response to an NTSB safety recommendation, the quality of the program 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 (such as in this case), the Coast Guard provides no enforcement oversight.

Insufficient crew training and documentation: The investigation revealed that the Island Lady crewmembers 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; no duplicate records were kept ashore.

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; further, the system did not have automatic shutoff valves. As a result, during the fire, the plastic material melted and the release of diesel fuel exacerbated the fire.

Based on this investigation, the NTSB makes new safety recommendations to Tropical Breeze Casino Cruz and the US Coast Guard and also reiterates existing recommendations to the Coast Guard.

Board Meeting : Fire On Board U.S. Small Passenger Vessel Express Shuttle II, Pithlachascotee River, near Port Richey, Florida, October 17, 2004

4/4/2006 12:00 AM

Executive Summary

On the morning of October 17, 2004, a fire broke out in the engineroom of the U.S. small passenger vessel Express Shuttle II while it was entering the mouth of the Pithlachascotee River near Port Richey, Florida. The shuttle was returning from the Gulf of Mexico, where it had ferried 78 passengers to an offshore casino boat, and was on its way back to the marina operated by the vessel’s owner, Paradise of Port Richey. Only the master and two deckhands were on board when the fire broke out.

None of the crewmembers activated the vessel’s fixed carbon dioxide fire suppression system. The crew attempted to fight the fire with portable extinguishers, but when the fire burned out of control, they prepared to abandon ship. A passing recreational boat rescued all three crewmembers. The master and one of the deckhands transferred to another company boat that took them ashore. The recreational boat took the other deckhand to shore, and an ambulance transported him to a local hospital. The deckhand was treated for smoke inhalation, held overnight for observation, and then released. Firefighters from Port Richey and Pasco County fought the blaze, but the vessel, valued at $800,000, was a total constructive loss.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the fire on board the Express Shuttle IIwas a fractured, improperly installed fuel injection line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port Richey to have a preventive maintenance program, which could have identified the company’s ongoing problem with the vessel’s fuel lines before a failed line led to the fire. Contributing to the extent of the damage were the vessel’s faulty fire detection system and the crew’s failure to employ proper marine firefighting techniques.

On the basis of its investigation, the Safety Board identified the following safety issues:

  • Preventive maintenance
  • Crew response to fire emergency
  • Fire detection systems

As a result of its investigation of the Express Shuttle II fire, the Safety Board makes recommendations to the U.S. Coast Guard, Paradise of Port Richey, and Caterpillar, Inc.

Recommendations

New Recommendations

As a result of its investigation into the fire on board the Express Shuttle II, the National Transportation Safety Board makes the following new safety recommendations:

To the U.S. Coast Guard:

Establish firefighting training requirements for crewmembers on board all small passenger vessels. (M-06-10)

Require that Officers-in-Charge, Marine Inspection, before issuing a certificate of inspection to a small passenger vessel that is required to have a fire detection system, verify that all system components are approved for use in fire detection systems and that the circuits of the system are electrically supervised. (M-06-11)

To Paradise of Port Richey:

Develop and implement a preventive maintenance and inspection program for systems affecting the safe operation of your vessels, including the hull and the mechanical and electrical systems. (M-06-12)

Develop and implement a training program in marine firefighting for your crewmembers. (M-06-13)

To Caterpillar, Inc.:

Revise the service manual for your marine engines to give specific instructions on how to replace a single fuel line and on where fuel line clamps should be located. (M-06-14)

Previously Issued Recommendation Classified in This Report

To the U.S. Coast Guard:

M-02-9
Establish firefighting training requirements for crewmembers on board small passenger vessels in commuter and ferry service.

Safety Recommendation M-02-9 (previously classified as “Open-Unacceptable Response”) is classified “Closed-Superseded” in the “Crew Response to Fire Emergency” section of this report.

Reiterated Recommendations

The National Transportation Safety Board also reiterates the following recommendations:

To the U.S. Coast Guard:

M-02-5
Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and mechanical and electrical systems.

M-02-10
Revise Navigation and Vessel Inspection Circular No. 1-91 so that it provides more in-depth guidance in training and drills for firefighting on board small passenger vessels.

The NTSB’s investigation determined that lack of guidance on  engine high-temperature alarms resulted in the captain idling the engines rather than shutting them down, helping lead to the fire.  

“Moreover, the absence of fire detection and suppression systems in unmanned spaces housing exhaust tubing prevented swifter detectin and response, and the failure of the port engine’spump led to overheating the engine and exhasut tubing.

“Moreover, the use of plastic tubing on  tank level indicators with no automatic shutoff valves released diesel fuel, which made the fire worse.  The report also states that the Coast Guard did not correctly assess the Island Lady’s fuel system’s compliance with its own systems. “

In the 2004 incident, a similar chain of events lead to the fire. A fractured fuel line, improperly installed, was not detected because the fire detection system was faulty.

“The National Transportation Safety Board determines that the probable cause of the fire on board the Express Shuttle IIwas a fractured, improperly installed fuel injection line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port Richey to have a preventive maintenance program, which could have identified the company’s ongoing problem with the vessel’s fuel lines before a failed line led to the fire. Contributing to the extent of the damage were the vessel’s faulty fire detection system and the crew’s failure to employ proper marine firefighting techniques.”

Here is a link to the full Island Lady report, and below are the NTSB summaries of the two reports.

Fire On Board US Small Passenger Vessel Island Lady

Executive Summary

​About 1600 on the afternoon of January 14, 2018, a fire broke out in an unmanned space on the small passenger vessel Island Lady near Port Richey, Florida, during a scheduled transit to a casino boat located about 9 miles offshore in the Gulf of Mexico. Fifty-three people were on board the Island Lady.

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 to evacuate the passengers. All crewmembers, employees, and passengers evacuated the vessel by entering the water and wading/crawling ashore. Fifteen people were injured and transported to local hospitals; one passenger died in the hospital several hours after the fire. The Island Lady, valued at $450,000, was declared a constructive total loss.

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 require small passenger vessels to have fire detection and suppression systems in spaces containing propulsion machinery (such as engine rooms), the regulations do 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 a previous fire on board a company vessel (the Express Shuttle II) in response to an NTSB safety recommendation, the quality of the program 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 (such as in this case), the Coast Guard provides no enforcement oversight.

Insufficient crew training and documentation: The investigation revealed that the Island Lady crewmembers 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; no duplicate records were kept ashore.

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; further, the system did not have automatic shutoff valves. As a result, during the fire, the plastic material melted and the release of diesel fuel exacerbated the fire.

Based on this investigation, the NTSB makes new safety recommendations to Tropical Breeze Casino Cruz and the US Coast Guard and also reiterates existing recommendations to the Coast Guard.

Board Meeting : Fire On Board U.S. Small Passenger Vessel Express Shuttle II, Pithlachascotee River, near Port Richey, Florida, October 17, 2004

4/4/2006 12:00 AM

Executive Summary

On the morning of October 17, 2004, a fire broke out in the engineroom of the U.S. small passenger vessel Express Shuttle II while it was entering the mouth of the Pithlachascotee River near Port Richey, Florida. The shuttle was returning from the Gulf of Mexico, where it had ferried 78 passengers to an offshore casino boat, and was on its way back to the marina operated by the vessel’s owner, Paradise of Port Richey. Only the master and two deckhands were on board when the fire broke out.

None of the crewmembers activated the vessel’s fixed carbon dioxide fire suppression system. The crew attempted to fight the fire with portable extinguishers, but when the fire burned out of control, they prepared to abandon ship. A passing recreational boat rescued all three crewmembers. The master and one of the deckhands transferred to another company boat that took them ashore. The recreational boat took the other deckhand to shore, and an ambulance transported him to a local hospital. The deckhand was treated for smoke inhalation, held overnight for observation, and then released. Firefighters from Port Richey and Pasco County fought the blaze, but the vessel, valued at $800,000, was a total constructive loss.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the fire on board the Express Shuttle IIwas a fractured, improperly installed fuel injection line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port Richey to have a preventive maintenance program, which could have identified the company’s ongoing problem with the vessel’s fuel lines before a failed line led to the fire. Contributing to the extent of the damage were the vessel’s faulty fire detection system and the crew’s failure to employ proper marine firefighting techniques.

On the basis of its investigation, the Safety Board identified the following safety issues:

  • Preventive maintenance
  • Crew response to fire emergency
  • Fire detection systems

As a result of its investigation of the Express Shuttle II fire, the Safety Board makes recommendations to the U.S. Coast Guard, Paradise of Port Richey, and Caterpillar, Inc.

Recommendations

New Recommendations

As a result of its investigation into the fire on board the Express Shuttle II, the National Transportation Safety Board makes the following new safety recommendations:

To the U.S. Coast Guard:

Establish firefighting training requirements for crewmembers on board all small passenger vessels. (M-06-10)

Require that Officers-in-Charge, Marine Inspection, before issuing a certificate of inspection to a small passenger vessel that is required to have a fire detection system, verify that all system components are approved for use in fire detection systems and that the circuits of the system are electrically supervised. (M-06-11)

To Paradise of Port Richey:

Develop and implement a preventive maintenance and inspection program for systems affecting the safe operation of your vessels, including the hull and the mechanical and electrical systems. (M-06-12)

Develop and implement a training program in marine firefighting for your crewmembers. (M-06-13)

To Caterpillar, Inc.:

Revise the service manual for your marine engines to give specific instructions on how to replace a single fuel line and on where fuel line clamps should be located. (M-06-14)

Previously Issued Recommendation Classified in This Report

To the U.S. Coast Guard:

M-02-9
Establish firefighting training requirements for crewmembers on board small passenger vessels in commuter and ferry service.

Safety Recommendation M-02-9 (previously classified as “Open-Unacceptable Response”) is classified “Closed-Superseded” in the “Crew Response to Fire Emergency” section of this report.

Reiterated Recommendations

The National Transportation Safety Board also reiterates the following recommendations:

To the U.S. Coast Guard:

M-02-5
Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and mechanical and electrical systems.

M-02-10
Revise Navigation and Vessel Inspection Circular No. 1-91 so that it provides more in-depth guidance in training and drills for firefighting on board small passenger vessels.

See Frump Blog article . . .