Letter Mail Controlled 09/13/2001 4:46:06 PM MC# 2010732 We see the benefit in informing all of our fleet and your report on the incident has been forwarded to all Masters of our fleet together with the attached memo, which serves as explanation on how we have addressed this situation.
To: MASTERS ALL VESSELS
FROM: STEN BERGQVIST
DATES: SEPTEMBER 10, 2001
RE: NTSB REPORT, SAFETY DRILLS
Please find attached report from NTSB pertaining to the fire onboard the MV "Nieuw Amsterdam." After reviewing the mentioned fire incident, I felt it prudent to send this memo to all of our vessels. The report addresses several issues, which I will mention in chronological order ending with my own comments.
The fire started with a fire in an unattended coffee maker in a crew cabin.
I want to Stress the importance of the cabin inspections already included in our SMS. Also, please note that soonest you will receive a revision of the Operations Manual saying ? any unauthorized cooking facility in crew cabins as well as any deliberate tampering with fire detection material or safety equipment will render immediate dismissal.
The Quartermaster, who was sent to investigate an activated smoke detector, was the first person to notice smoke coming through the louvers from the mentioned cabin.
When smoke of the magnitude like in this case is observed. The Fire Screen Doors should have been closed, ventilation closed down and the area evacuated Size importance of securing the f re area, in an instance like this cannot be stressed enough. As soon as smoke is detected Juice Screen Doors need to be closed, something that need to be practiced during fire drills. Also remember that Water Tight Doors Are Fire Screen Doors and need to he closed in order to prevent the spreading of smoke. I suggest that in a case like this, effected Water Tight Doors be closed locally. Another very important part in preventing the spreading of smoke, is the closing down of ventilation, which needs to be done al an early stage. Again, finis also needs to be part of the drill.
Make closing of all Fire Screen Doors and closing down of ventilation a realistic part of the drill integrated in the whole emergency procedure.
The person, sent to investigate the situation, who must be in contact with the bridge via radio informing about his progress, is the one to firstly initiate these steps, which include: securing of the area. Alerting people in the area and try to extinguish the fire, using hand held fire extinguisher. As soon as this person reports that he alone cannot handle the situation`, the 1st step of the emergency plan, "Mr. Skylight," must be activated, in order not to delay the extinguishing of the fire. Should he encounter excessive spread of smoke, He /5' step of the emergency plan must be activated and no attempt should be made to extinguish the fire by anybody who is not fully equipped for the task.
When the Master arrived on the bridge, he ordered Be Chief Officer to investigate the area In doing so he delayed the process both ~ extinguishing of the fire as well as other parties to be assembled at their stations
If like in this case the Quartermaster is being sent to the aria his reporting of the situation should have triggered: actions according to the emergency plan If his evaluation of the situation were nor to be taken seriously, he should not have been sent to the area in the first place. According to our Emergency plan, as soon as the Quartermaster reported the seriousness of this situation, Mr. Skylight should have been alerted
In sending the Chief Officer to the location of the fire, the Master took too much responsibility upon himself. This also included a delay in reporting to Port State.
Please remember that in our emergency plan both the Master and the Staff Captain/Chief Officer Depending on the vessel) have their emergency stations on the bridge. The Second in command should be the person in charge of the emergency operation and the blaster should overlook the operation and only intervene when he deems so is needed
Please follow the contingency plan and report to all involved parties, such as Port State, when such is required.
When the Chief Officer approached the area of fire, he did not report the spread of the smoke.
Remember to stress this in your drills, with every crewmember. It can easily be trained with the involvement of the smoke machine.
By trying to extinguish the fire the Chief Engineer and the Chief Officer delayed actions according to the emergency plan. Fire squad "Bravo" successfully extinguished the fire, but probably would have done so before it had spread to adjacent areas? If the Chief Engineer and the Chief Officer had let the emergency plan take its normal course. However, they did not act properly in having both the squad leader and his deputy fighting the fire actively, jeopardizing breakdown of the squad, should something happened to both of them.
Again, remember to activate the emergency plan as early as possible, when the Quartermaster was unsuccessful in his efforts to extinguish the f re, no further attempt should have been made until the arrival of the proper fire group, but the door to the cabin should have been kept closed, which would have prevented, although not being an A60 door, the spread of the fire. Further more the two of Dicers put themselves in danger by trying to extinguish the fire without being properly equipped.
At times during CV exams, the USCG officer has requested the officer at the location of the fire to be considered a casualty This is a very important part of the training A fire group needs to function with a shortfall of anybody including the leader of the group. Please stress this in your further trainings.
As you can see in the report, crewmembers had been tampering with smoke detectors in order for them not to be caught, cooking in the cabins.
Please have the checking of smoke defectors to be part of your scheduled crew cabin inspection and again I stress the importance of checking for unauthorized cooking facilities and over self rigged electrical installations in the crew cabins.
Additionally, to the comments by NTSB, I take this opportunity to mention a few other areas of concern pertaining to the emergency plan and muster list.
Evacuation of passengers and crew is a very important part of the emergency plan. In this case, as soon as smoke is observed, this area should be evacuated. When it is determined that an official announcement has to be naiads, it is important to have the announcement repeated at intervals of about 2 minutes or so in order to make sure that everyone has been properly advised about the situation. Remember the importance to have all persons out of the area and eventually all assembled at their muster stations, to have all persons accounted for, the importance of evacuation groups in achieving this, the proper use of the search and rescue groups to ascertain that all areas have been properly evacuated. Always have tile latest update of passenger and crew lists, including all late cabin changes.
We understand that a certain number of crewmembers need to be excused from the drills for practical purposes. A good training would be to make sure that the crewmembers, who are on the excuse list, are being located by the search and rescue groups.