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Safety Recommendation Details

Safety Recommendation M-07-001
Details
Synopsis: About 1615 on June 12, 2006, the U.S. Coast Guard-inspected commuter ferry Massachusetts was en route from Rowe’s Wharf in Boston Harbor to Hingham, Massachusetts, carrying 65 passengers and 4 crewmembers, when a fire broke out in the engineroom. The master maneuvered the vessel into shallow water south of the Long Island Bridge, anchored, and waited for firefighters. Before a fireboat from the Boston Fire Department’s marine unit arrived, all the passengers safely transferred to the Laura, another commuter vessel in the vicinity. The fireboat extinguished the fire. The accident resulted in no serious injuries or fatalities. Damage, estimated at $800,000, was confined mostly to the engineroom.
Recommendation: TO THE UNITED STATES COAST GUARD: Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. (Supersedes Safety Recommendations M-02-6 and M-02-8.)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Marine
Location: Boston, MA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA06MF016
Accident Reports:
Fire on Board U.S. Small Passenger Vessel Massachusetts
Report #: MAB-07-01
Accident Date: 6/12/2006
Issue Date: 3/29/2007
Date Closed: 2/17/2017
Addressee(s) and Addressee Status: USCG (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 2/17/2017
Response: In 2014, we asked that you reconsider your position and require fire detection and suppression systems on all small passenger vessels, as recommended on the pre-1996 vessels, which comprise the majority of the metal hull fleet. We are disappointed that you have determined the costs of satisfying this recommendation outweigh the societal benefits, and you will not be taking the recommended action. We will continue to push for the same level of fire protection on all small passenger vessels, especially those built before 1996, because as vessels age, their wiring, gaskets, exhaust systems, and other systems deteriorate. We saw the value of such fire detection and suppression systems on the passenger vessel Queen of the West, on which the systems mitigated the fire damage. In the case of the Massachusetts, the owner had voluntarily installed fire detection and suppression systems on his vessel after considering their value in preventing much costlier damage from fire. Considering the risk these older vessels present to the traveling public, and because you state your action on this recommendation is complete and request that it be closed, Safety Recommendation M-07-1 is classified CLOSED--UNACCEPTABLE ACTION.

From: USCG
To: NTSB
Date: 10/18/2016
Response: -From Charles W. Ray, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: The Coast Guard has determined that requiring fixed fire detection and suppression systems for all passenger vessels regardless of age and construction is not justified after completing an economic analysis. In any rulemaking, we are required to follow the Administrative Procedures Act (APA), Executive Orders 12866, 13563, and OMB Circular A-4, and perform a cost benefit analysis of our rulemaking. This regulatory cost benefit analysis differs from the typical cost benefit analysis for a business. The Coast Guard weighs the costs and benefits on a societal level, rather than an individual or business level. Individual vessel owner losses of revenue and individual vessel repair costs do not directly translate to a societal benefit in our economic analysis, either through economic transfer or externality. Other factors such as low incident rates and lack of marine casualties limit the expected societal benefit in our economic analysis. As such, we do not believe a rulemaking on this matter can be justified or pursued per the APA at this time. The Coast Guard has already implemented regulations that address fire protection on vessels constructed after 1996 and vessels with elevated fire risk from their construction material. We consider our action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
Date: 3/11/2016
Response: This letter concerns 40 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Coast Guard between 2002 and 2015. For several years, the NTSB received an annual update on all open safety recommendations issued to the Coast Guard; however, for 25 of the 40 recommendations listed, we have received no update in over 2 years regarding the status of action either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Please respond to this letter electronically at correspondence@ntsb.gov regarding your progress in addressing these safety recommendations, and do not submit both an electronic and a hard copy of the same response. To assist with your response, enclosure (1) is a list of the 40 recommendations highlighting the recommendation number, current status, source of the recommendation, and date of the last Coast Guard update; enclosure (2) is a print-out from our database with the complete correspondence history of each open recommendation.

From: NTSB
To: USCG
Date: 5/13/2014
Response: We continue to believe that this is an important recommendation. As vessels age, their wiring, gaskets, exhaust systems, and other systems deteriorate. We have seen the value of such fire detection and suppression systems on the passenger vessel Queen of the West, on which the systems mitigated the fire damage. In addition, we saw how the owner of the Massachusetts had voluntarily installed fire detection and suppression systems on his vessel after considering its value in preventing much costlier damage from fire. Accordingly, please reconsider your position and require fire detection and suppression systems on all small passenger vessels as recommended. Pending our receipt of your reply, Safety Recommendation M-07-1 is classified OPEN—UNACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 1/28/2014
Response: -From Peter V. Neffenger, Vice Admiral, Deputy Commandant for Operations: In developing a scoping document for a regulation project to address this recommendation, the Coast Guard revisited the regulatory analysis for the current small passenger vessel regulations, and the casualty history since then. The conclusion was that the recommended new requirements could not be justified based on the costs versus the anticipated benefits, and the effort was therefore discontinued. Under the Administrative Procedures Act and related executive orders governing rulemaking, the Coast Guard cannot pursue rulemaking that cannot be justified based on cost-benefit analysis. I consider the Coast Guard's action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
Date: 7/8/2013
Response: Thank you for the April 5, 2013, letter signed by Vice Admiral Peter V. Neffenger, Deputy Commandant for Operations, to the National Transportation Safety Board (NTSB) containing your semiannual update regarding actions to address 42 safety recommendations that the NTSB issued to the US Coast Guard. To assist with future updates and to align our records, we are enclosing a copy of the NTSB’s safety recommendation database history for these 42 recommendations. This response letter will be divided into four parts: • Part 1 – Evaluation of actions to address Safety Recommendations M 09 15 and 16 and M-10-2, recommendations for which Admiral Neffenger provided a substantive update. • Part 2 – List of 6 safety recommendations previously closed. • Part 3 – List of 7 safety recommendations that were the subject of a recent Coast Guard update and that the NTSB is currently evaluating; these recommendations will be addressed in detail in separate correspondence. • Part 4 – List of 26 safety recommendations for which the Coast Guard did not provide a substantive update or for which status has not changed since the last update. Part 1 – Safety Recommendations Updated in the April 5, 2013, Letter: We issued Safety Recommendations M-09-15 and -16, stated below, to the Coast Guard on October 20, 2009, as a result of a review of the involvement of obstructive sleep apnea (OSA) in several accidents investigated by the NTSB. M-09-15 Implement a program to identify licensed mariners subject to the Navigation and Vessel Inspection Circular on Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (NVIC 04-08) and who are at high risk for obstructive sleep apnea, and require that those mariners provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. M-09-16 Develop and disseminate guidance for mariners, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that mariners who have OSA that is effectively treated are routinely approved for continued medical certification. We are encouraged that the Merchant Mariner Medical Advisory Committee is planning to review and revise Navigation and Vessel Inspection Circular 04-08, including Enclosure (4), Guidance on Specific Medical Conditions, which details the medical decision making criteria for common conditions (including sleep disorders such as OSA) as they relate to determining merchant mariner fitness for duty. Pending completion of these efforts, Safety Recommendation M-09-15 is classified “Open—Acceptable Alternate Response” and Safety Recommendation M 09-16 is classified “Open—Acceptable Response.” We issued Safety Recommendation M-10-2, stated below, to the Coast Guard on August 11, 2010, as a result of two recent maritime accidents involving Coast Guard patrol boats: the December 5, 2009, collision of the CG 25689 with the small passenger vessel Thriller 09 in Charleston, South Carolina, and the December 20, 2009, collision of the CG-33118 with a 24 foot recreational vessel in San Diego, California. M-10-2 Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. The Coast Guard’s recent revision of Coast Guard Boat Operations and Training (BOAT) manual, volume I, COMDTINST M16114.32C, section F.2, prohibits the use of cellphones/texting devices and phone applications aboard all boat force assets without the permission of the coxswain, which will only be granted on a case-by-case basis and only when operational safety is not compromised. Because this action satisfies Safety Recommendation M 10-2, it is classified “Closed—Acceptable Action.” Part 2 – Safety Recommendations Previously Closed: M-06-5 (Closed—Acceptable Action, March 14, 2011) Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. M-06-6 (Closed—Acceptable Action, March 14, 2011) Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. M-06-7 (Closed—Unacceptable Action, March 14, 2011) Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. M-06-8 (Closed—Unacceptable Action, March 14, 2011) Until such time as you revise the passenger weight standard as requested in Safety Recommendation M-06-5 and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation M-06-7, develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations. M-06-9 (Closed—Unacceptable Action, March 14, 2011) Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection. M-11-11 (Closed—Acceptable Action, November 13, 2012) Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. Part 3 – Recommendations Recently Updated and Under Evaluation by the NTSB: M-10-5 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders that meet the international performance standard on new ferry vessels. M-10-6 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders on ferry vessels built before the enactment of voyage data recorder carriage requirements that will record, at a minimum, the same video, audio, and parametric data specified in the International Maritime Organization’s performance standard for simplified voyage data recorders. M-12-1 (Open Initial Response Received; USCG Update February 12, 2013) Require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-2 (Open Initial Response Received; USCG Update February 12, 2013) Where technically feasible, require existing U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be retrofitted with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-3 (Open—Initial Response Received; USCG Update February 12, 2013) Require all operators of U.S.-flag passenger vessels to implement safety management systems, taking into account the characteristics, methods of operation, and the nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. M-12-6 (Open—Initial Response Received; USCG Update March 21, 2013) Develop and implement a policy to ensure adequate separation between vessels operating in the Bayport Channel and Bolivar Roads Precautionary Areas and any other similarly configured precautionary areas in the Houston Ship Channel. M-12-7—(Open Initial Response Received USCG Update March 21, 2013) Graphically delineate precautionary areas on appropriate Houston Ship Channel nautical charts so they are readily identifiable to mariners. Part 4 – Safety Recommendations Not Substantively Updated in the April 5, 2013, letter: M-02-5 (Open—Acceptable Response, February 4, 2013) 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 the mechanical and electrical systems. M-07-1 (Open—Acceptable Response, February 4, 2013) Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. M-07-6 (Open—Acceptable Response, February 4, 2013) Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. M-08-2 (Open—Acceptable Response, February 4, 2013) Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-4 (Open—Acceptable Response, February 4, 2013) Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. M-09-10 (Open—Unacceptable Response, February 4, 2013) Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-14 (Open—Acceptable Response, February 4, 2013) Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-09-17 (Open—Unacceptable Response, February 4, 2013) Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 (Open—Acceptable Response, February 4, 2013) Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety. M-11-4 (Open—Acceptable Response, February 4, 2013) Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue. M-11-8 (Open—Acceptable Response, November 13, 2012) Develop and implement procedures for your special purpose craft–law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. M-11-9 (Open—Acceptable Response, November 13, 2012) Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. M-11-10 (Open—Acceptable Response, November 13, 2012) Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. M-11-12 (Open—Acceptable Response, November 13, 2012) Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. M-11-13 (Open—Acceptable Response, November 13, 2012) Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, determine from that whether the risk is unacceptable, and if so, develop risk mitigation strategies. M-11-14 (Open—Acceptable Response, November 13, 2012) Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. M-11-15 (Open—Acceptable Response, November 13, 2012) Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. M-11-16 (Open—Unacceptable Response, November 13, 2012) Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. M-11-23 (Open—Unacceptable Response, June 12, 2012) Establish standards for new and existing commercial fishing industry vessels of 79 feet or less in length that (1) address intact stability, subdivision, and watertight integrity and (2) include periodic reassessment of the vessels’ stability and watertight integrity. M-11-24 (Open—Unacceptable Response, June 12, 2012) Require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use of vessel stability information regardless of plans for implementing the other training provisions of the 2010 Coast Guard Authorization Act. M-11-25 (Open—Unacceptable Response, June 12, 2012) Require each person on deck of a commercial fishing industry vessel to wear a flotation aid at all times. M-11-26 (Open—Unacceptable Response, June 12, 2012) Require owners of commercial fishing industry vessels to (1) install fall overboard recovery devices appropriate for the vessel, (2) periodically ensure the functionality of such equipment, and (3) regularly conduct drills in which crewmembers demonstrate their competence in the use of such devices. M-11-27 (Open—Unacceptable Response, June 12, 2012) Require all crewmembers to provide certification of completion of safety training before getting under way on commercial fishing industry vessels, such training to include both prevention of and proper response to emergency situations as well as actual use of emergency equipment. M-12-8 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard military personnel with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-9 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard civilian personnel, seeking appropriate legislative authority if necessary, with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-10 (Open—Await Response) Disseminate guidance within the Coast Guard so that commanding officers have unambiguous instruction detailing the requirements for timely drug and alcohol testing of Coast Guard military and civilian personnel whose work performance may be linked to a serious marine incident. Thank you for your commitment to marine safety. We look forward to receiving further updates on the action being taken to implement the following safety recommendations: M-02-5 M-07-1 M-07-6 M-08-2 M-09-4 M-09-10 M-09-14 M-09-15 M-09-16 M-11-3 M-11-4 M-11-8 M-11-9 M-11-10 M-11-12 M-11-13 M-11-14 M-11-15 M-11-16 M-11-23 M-11-24 M-11-25 M-11-16 M-11-27 M-12-8 M-12-9 M-12-10

From: USCG
To: NTSB
Date: 4/9/2013
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Please find enclosed our agreed upon semiannual update of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board and are awaiting Coast Guard response. There are currently 42 safety recommendations with an "open" status issued to the Coast Guard. Of those, we attest that our actions are complete for six, six are pending resolution, and five require long-term agency action. Updates for the remaining 25 have been or will be provided in separate correspondence. Enclosure (1) provides specific information for each recommendation. There has not been a change in the status since the last update for the following five recommendations: 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 the mechanical and electrical systems. M-07-1 Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their engine rooms (M-07-1) (Supercedes Safety Recommendations M-02-6 and M-02-8.) M-09-10 Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-17 Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety.

From: NTSB
To: USCG
Date: 2/4/2013
Response: The NTSB understands that the Coast Guard is developing a scoping document for a rulemaking project that will consider requirements for retrofitting all existing small passenger vessels certificated to carry more than 49 passengers, regardless of their hull material, with approved fixed fire detection and fixed fire suppression systems in their enginerooms. We are encouraged with this change in philosophy to consider applying the fire detection and suppression requirements to all small passenger vessels, regardless of hull material and date built; however, we remain concerned about the slow progress of effort to address this nearly 6 year-old recommendation. Because the Coast Guard has decided to reconsider requirements for retrofitting all existing small passenger vessels, pending timely progress by the Coast Guard, Safety Recommendation M-07-1 is classified OPEN—ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 8/15/2012
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: In our previous responses to this recommendation, we explained that the decision to not require fixed fire detection and fixed fire suppression systems in the engine rooms of all small passengers vessels, regardless of date of build or hull material, was based on a comprehensive analysis conducted during a rulemaking project initiated in 1989 and finalized in 1996. As a result of that analysis, we concluded that retrofitting should be required on small passenger vessels with fiberglass reinforced plastic and wooden hulls, and that the substantial cost of retrofitting was not justified on small passenger vessels with steel and aluminum hulls. Continuing discussions between our two staffs and possible changes to the data used in the previous analysis has led us to reconsider our position. As a result, we are developing a scoping document to initiate the process for a rulemaking project that will consider requirements for retrofitting all existing small passenger vessels certificated to carry more than 49 passengers, regardless of their hull material, with approved fixed fire detection and fixed fire suppression systems in their engine rooms. We will keep the Board informed of our actions for this safety recommendation.

From: NTSB
To: USCG
Date: 11/16/2011
Response: This letter concerns 29 open safety recommendations, enclosed, that the National Transportation Safety Board (NTSB) issued to the U.S. Coast Guard between 1995 and 2010. For some of these recommendations, the NTSB has not received an update in almost 3 years regarding the status of action either taken or planned to address the important safety issue that the recommendation addresses. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. NOTE TO FILE (not in original letter): The 29 safety recommendations are: M-95-013, M-98-033, M-98-037, M-99-001, M-00-004, M-01-001, M-02-005, M-04-003, M-05-006, M-06-001, M-06-002, M-07-001, M-07-006, M-07-007, M-08-001, M-08-002, M-09-001, M-09-002, M-09-003, M-09-004, M-09-009, M-09-010, M-09-014, M-09-015, M-09-016, M-09-017, M-10-005, M-10-002 and M-10-006.

From: NTSB
To: USCG
Date: 4/27/2010
Response: The NTSB is disappointed that the Coast Guard continues to dispute the value of implementing these significant safety recommendations, citing industry protest, lack of accidents, and cost as the reasons it did not include the recommended requirements in the 1997 revision of the small passenger vessel regulations. The NTSB recognizes that the U.S. fleet has a good safety record; we also recognize that accidents will occur and may result in significant cost, injury, and loss of life, especially accidents involving vessels that operate in remote locations, that offer overnight accommodations, and that employ crews that have limited training and licensing requirements. In the case of both the Massachusetts and Queen of the West accidents, under only slightly different circumstances, the results could have been catastrophic. The NTSB learned from the owner of the Massachusetts that he has installed a fire detection and suppression system on the vessel at a cost of $42,000, far less than the damages from the 2006 accident, which totaled $2.3 million ($1.3 million from damage to the vessel and $1.0 million in lost revenue). The Massachusetts owner commented that detection and suppression systems make economic sense, and he was therefore installing the systems on his entire fleet. In the case of the Queen of the West fire, the installed detection and suppression system, although not required, helped contain the fire to the engineroom, thus limiting the damage to an estimated $3.3 million. Had the fire spread beyond the engineroom, damages would have been significantly higher: the vessel is valued at $23 million and has a replacement cost of $45 million. Based on the circumstances of the Queen of the West and Massachusetts accidents and the potential for serious injuries and deaths in future accidents, the NTSB will continue advocating for detection and suppression systems in the engineroom and out-of-water flotation for all passengers and crew on board small passenger vessels. The NTSB does however, note that the Coast Guard is developing a scoping document to initiate the process for a rulemaking project that will "consider" requirements for retrofitting all existing small passenger vessels certificated to carry more than 49 passengers regardless of their hull material, with approved fixed fire detection and fixed fire suppression systems in their enginerooms. The NTSB urges the Coast Guard to expedite action on the detection and suppression systems and to reconsider its current position on out-of-water survival craft for all passengers and crew. Pending a further response indicating that the Coast Guard has taken the recommended action, Safety Recommendations M-07-1 is classified OPEN--UNACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 2/22/2010
Response: Letter Mail Controlled 3/5/2010 1:29:55 PM MC# 2100091 - From CAPT David S. Fish, Office of Investigations & Analysis: In our previous responses to this recommendation, we explained that the decision to not require fixed fire detection and fixed fire suppression systems in the enginerooms of all small passengers vessels, regardless of date of build or hull material, was based on a comprehensive analysis conducted during a rulemaking project initiated in 1989 and finalized in 1996. As a result of that analysis, we concluded that retrofitting should be required on small passenger vessels with fiberglass reinforced plastic and wooden hulls, and that the substantial cost of retrofitting was not justified on small passenger vessels with steel and aluminum hulls. Continuing discussions between our two staffs and possible changes to the data used in the previous analysis has led us to reconsider our position. As a result, we are developing a scoping document to initiate the process for a rulemaking project that will consider requirements for retrofitting all existing small passenger vessels certificated to carry more than 49 passengers, regardless of their hull material, with approved fixed fire detection and fixed fire suppression systems in their enginerooms. We will keep the Board informed of our actions for this safety recommendation.

From: NTSB
To: USCG
Date: 12/1/2009
Response: This recommendation was reiterated with the 12/1/2009 issuance of M-09-17, which was issued as a result of the April 8, 2008 engineroom fire on the Queen of the West passenger vessel near Rufus, Oregon: The NTSB directed Safety Recommendation M-07-1 toward vessels carrying more than 49 passengers because of vessel design considerations. Vessels certificated to carry fewer than 49 passengers are typically smaller, do not always have segregated engine spaces to accommodate an automatic fire detection system and a fixed fire suppression system, and are often propelled by stern-mounted outboard engines. In correspondence and at a meeting with NTSB staff to discuss Safety Recommendation M-07-1, the Coast Guard indicated that it did not concur with the recommendation, citing system costs, a lack of injuries from similar accidents, and the small number of fires that would be affected by the recommendation. As of the date of this letter, the Coast Guard has not implemented M-07-1, and the recommendation is currently classified OPEN UNACCEPTABLE RESPONE. Because the fire on board the Queen of the West illustrates how effective an automatic fire detection system and a fixed fire suppression system can be in minimizing damage and preventing injury, the NTSB reiterates Safety Recommendation M-07-1 to the Coast Guard and urges the installation of these systems to protect vessel passengers and crew.

From: NTSB
To: USCG
Date: 5/22/2009
Response: The NTSB is disappointed that, although the Coast Guard concurs with the intent of the recommendation, it has indicated that it does not intend to amend the regulations as requested, citing issues from the development of the current small passenger vessel regulations, the cost associated with a detection and suppression system, the lack of injuries, and the small number of fires and vessels that would be affected by the recommendation as the reasons for its position. The Coast Guard’s position is difficult to understand, given that its 1996 regulations require the installation of fire detection and suppression systems on all vessels built after 1996. Concerning the issue of costs related to benefits, the NTSB has learned from the owner of the Massachusetts that he has installed a fire detection and suppression system on the vessel, at a cost of $42,000. The Massachusetts owner stated that his damages from the accident totaled $2.3 million: $1.3 million from damage to the vessel and $1.0 million in lost revenue. The Massachusetts owner stated that detection and suppression systems make economic sense, and he is therefore installing the systems on his entire fleet. The NTSB is currently investigating the April 2008 engineroom fire on board the passenger vessel Queen of the West. Although not required, a detection and suppression system had been installed on this vessel, which helped the fire to be contained within the engineroom and limited the damage to an estimated $3.3 million. Had the fire spread beyond the engineroom, damages would have been significantly higher: the vessel is valued at $23 million and has a replacement cost of $45 million. In addition to the financial benefits realized from the system, it is highly probable that the early detection and suppression of the fire prevented possible crew and passenger injuries or deaths. Concerning Marine Safety Alert 13-08, the NTSB appreciates the Coast Guard’s reminder to marine inspectors and the marine industry that the small passenger vessel regulations require vent damper closures for fixed gas firefighting systems for vessels built after March 11, 1996. However, the metal hull vessels built prior to March 11, 1996, are not required to have fixed gas firefighting systems, and Marine Safety Alert 13-08 only strongly recommends that vessels so fitted have vent damper closures. In addition, there is no mention of a detection and suppression system as recommended. The NTSB urges the Coast Guard to reconsider its current position on this issue. Pending a further response indicating that it has taken the recommended action, Safety Recommendation M-07-1 is classified OPEN UNACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 2/17/2009
Response: Letter Mail Controlled 2/20/2009 11:16:05 AM MC# 2090085: - From W.D. Rabe Chief, Investigations Division: Status: As stated in our previous response, we do not intend to initiate a rulemaking project to implement this recommendation. However, on December 4,2008, we issued a safety alert to address the fire safcty issues of this recommendation. We consider our action on this recommendation complete and rcquest that it be closed.

From: USCG
To: NTSB
Date: 6/30/2008
Response: Letter Mail Controlled 7/15/2008 3:03:43 PM MC# 2080418: - From M.P. Rand, Captain, Chief, Office of Investigations and Analysis: Response: We concur with the intent of this recommendation. However, as documented in our responses to the Board’s previous recommendations on this issue, fire detection and suppression measures for small passenger vessels were subjected to a careful and comprehensive review during a rulemaking project that was initiated in 1989 and finalized in 1996. During that rulemaking, we considered retrofitting all small passenger vessels with fixed fire detection and extinguishing systems. We concluded that retrofitting should be required on small passenger vessels with fiberglass reinforced plastic and wooden hulls, and that the substantial cost of retrofitting was not justified on small passenger vessels with steel and aluminum hulls. In this recommendation, the Board essentially proposes that we require all small passenger vessels certificated to carry more than 49 passengers, including those with steel and aluminum hulls be retrofitted with fixed fire detection and extinguishing systems. Since implementing this recommendation would require a rulemaking, it would be subject to the same review as the 1996 rulemaking, and the cost of implementation would require substantial justification. A review of the 32 incidents involving fires in the engine room occurring between 1996 and 2007 on those small passenger vessels that would be affected by this recommendation shows that the property damage costs due to fires was significantly less than the estimated costs of retrofitting those vessels with fixed fire protection systems cited by the Board in its safety recommendation letter. There were no deaths and only one minor injury associated with those incidents. Accordingly, we believe it is highly unlikely that the proposed retrofitting would withstand the cost -benefit analysis of the rulemaking process. Therefore, we do not intend to initiate a rulemaking project to implement this recommendation. We believe, however, that there may be other satisfactory means to reduce the risks to passengers from engine room fires on these vessels, and would like to meet with the Safety Board’s staff in the near future to discuss a way forward.

From: NTSB
To: USCG
Date: 5/21/2008
Response: NMC# 103197: On December 5, 2007, the Coast Guard acknowledged the Safety Board’s March 29, 2007, safety recommendation letter, explaining that the Coast Guard had received it and that program managers were looking into the issue. It has now been more than a year since the recommendation was issued and, with the exception of the 2007 acknowledgement letter, the Board has received no response from the Coast Guard regarding this recommendation despite several phone calls and e-mail inquiries requesting a status report. As you know, modal administrations are required to provide an initial response within 90 days of the issuance of a safety recommendation. Accordingly, we would appreciate receiving a substantive update regarding what action, if any, the Coast Guard has initiated or planned to address this important safety issue. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all of our recommendations. For your further information, the Board is currently investigating a April 2008 engineroom fire on board the passenger vessel Queen of the West; although this vessel was not required to be fitted (it was built in 1995), it had both a fire detection system and a fixed fire-suppression system in place. These systems likely prevented more serious vessel damage and possible crew and passenger injuries during the fire. A copy of the Safety Board’s March 29, 2007, and the Coast Guard’s December 5, 2007, letters are enclosed for your review. We look forward to receiving further information regarding the Coast Guard’s action on Safety Recommendation M-07-1.

From: USCG
To: NTSB
Date: 12/5/2007
Response: Letter Mail Controlled 12/13/2007 2:07:34 PM MC# 2070742: - From W.D. Rabe Chief, Investigations Division: We have received the National Transportation Safety Board's safety recommendation letter dated March 29,2007, concerning the June 12, 2006, engineroom fire on the commuter ferry MASSACHUSETTS in Boston Harbor. As a result of its investigation, the Board issued safety recommendation M-07- 1 to the U.S. Coast Guard, which superseded recommendations M-02-6 and M-02-8. Recommendation M-07- 1: Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. Shortly after receiving this letter, we distributed it for review by U. S. Coast Guard program managers. Our review is underway, but not yet complete.