The NTSB has issued their report on the fire aboard the RO-RO ferry Caribbean Fantasy. All aboard were rescued with no serious injuries, but if this had occurred further from rescue facilities, it could have turned out tragically. You can read the abstract here.
While the Coast responded laudably, this incident was also a failure of prevention–a failure to prevent bad practices and ensure adequate training. Some of the findings:
2. The fire on the port main propulsion engine started when fuel spraying from a leaking blank flange at the end of the engine’s fuel supply line came into contact with the hot exhaust manifold and ignited.
3. Use of improper gasket material on the pressurized fuel supply end flange for the port main engine resulted in a breakdown of the gasket material and the eventual fuel spray that led to the fire.
4. The nonstandard blanking plate used on the end flange of the port main engine fuel supply system potentially exacerbated the leak that led to the fire.
5. Bolts inserted by Caribbean Fantasy engineering personnel into the quick-closing valves to prevent their closing were permanently in place for use during routine operations. (Emphasis applied–Chuck)
6. Testing during recent class surveys and port state control examinations did not adequately test the full functionality of the quick-closing valves.
9. The carbon dioxide fixed firefighting system did not extinguish the fire due to ventilation dampers that failed to properly close.
12. The abandonment process on board the Caribbean Fantasy was disorganized and inefficient.
13. Crewmembers assigned to safety-critical roles on the lifeboats were not proficient with the procedures for opening the lifeboat release hooks, which delayed the abandonment and put lives at risk.
14. The crew assigned to deploy the marine evacuation system and liferafts were not adequately trained, which delayed the abandonment.
15. The crew did not follow the manufacturer’s procedures when launching the starboard marine evacuation system liferafts, which resulted in the premature inflation of the liferafts.
16. The five ankle injuries resulted from using the marine evacuation system deployed at a steeper angle than designed.
On a positive note:
18. The presence of a passenger vessel safety specialist at Coast Guard Sector San Juan, who had trained and worked with local officials, contributed to the success of the Caribbean Fantasy mass rescue operation.
To the US Coast Guard:
1. Require operators to perform full function tests of quick-closing valves during inspections and examinations, ensuring that the associated systems shut down as designed and intended.
2. Evaluate the feasibility of creating a passenger vessel safety specialist billet at each sector that has the potential for a search and rescue activity characterized by the need for immediate assistance to a large number of persons in distress, and staff sector-level billets, as appropriate, based on the findings of that evaluation.
Thanks to Bryant’s Maritime Consulting for bringing this to my attention.