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Safety Recommendation Details

Safety Recommendation M-89-044
Details
Synopsis: ABOUT 2325 ON MARCH 15, 1988, A FIRE OCCURRED IN THE ENGINE ROOM OF THE BAHAMIAN FLAG PASSENGER VESSEL SCANDINAVIAN STAR. AT THE TIME OF THE FIRE, THE SHIP WAS ABOUT 50 NMI NORTHEAST OF CANCUN, MEXICO, EN ROUTE FROM COZUMEL, MEXICO, EN ROUTE FROM COZUMEL, MEXICO, TO ST. PETERSBURG, FLORIDA, WITH 439 PASSENGERS AND 268 CREWMEMBERS ON BOARD. THE MASTER BROADCAST A DISTRESS MESSAGE AND ORDERED THE EVACUATION OF PASSENGERS TO THE FOUR MUSTER STATIONS ON THE SHIP. THE LOSS OF MAIN GENERATOR AND EMERGENCY GENERATOR ELECTRICAL POWER AND THE MALFUNCTION OF THE SHIP'S FIXED CO2 FIRE FIGHTING SYSTEM HINDERED EFFORTS TO FIGHT THE FIRE. THE INABILITY OF CREWMEMBERS TO COMMUNICATE WITH EACH OTHER AND WITH PASSENGERS CREATED CONFUSION DURING THE FIREFIGHTING AND EVACUATION ACTIVITIES. TWO CREWMEMBERS RECEIVED MINOR INJURIES DURING THE EMERGENCY. TWO PASSENGERS WERE MEDI VACED FROM THE VESSEL AND FLOWN TO A HOSPITAL IN ST. PETERSBURG, FLORIDA, WHERE THEY WERE TREATED AND LATER RELEASED. DAMAGE AND REPAIR COSTS WERE ESTIMATED AT $3.5 MILLION.
Recommendation: THE NTSB RECOMMENDS THAT THE U.S. COAST GUARD: SEEK LEGISLATIVE AUTHORITY TO REQUIRE THAT ALL PASSENGER VESSELS OPERATING FROM U.S. PORTS EMBARKING U.S. PASSENGERS INTEGRATE SMOKE DETECTORS INTO LOCAL VENTILATION SYSTEMS TO SHUT DOWN THE VENTILATION SYSTEM AUTOMATICALLY WHEN THE DETECTOR IS ACTIVATED TO PREVENT THE SPREAD OF SMOKE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Marine
Location: Gulf of Mexico, GM, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA88MM038
Accident Reports: Fire on Board the Bahamian Passenger Ship The Scandinavian Star
Report #: MAR-89-04
Accident Date: 3/15/1988
Issue Date: 8/8/1989
Date Closed: 11/28/1994
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 11/28/1994
Response: RECOMMENDATION M-89-44, SIMILAR TO M-89-124, WAS ISSUED AS A RESULT OF THE 1989 SAFETY BOARD PASSENGER SHIP SAFETY STUDY. M-89-124, WAS CLASSIFIED "CLOSED--ACCEPTABLE ACTION" IN THE 1993 SAFETY BOARD SPECIAL INVESTIGATION ON ACCIDENTS INVOLVING FOREIGN PASSENGER SHIPS OPERATING FROM US PORTS. IN THE 1993 SPECIAL INVESTIGATION REPORT THE SAFETY BOARD WROTE, "IN ADDITION TO THE SAFETY IMPROVEMENTS FOR EXISTING SHIPS THE AMENDMENTS RESULTING FROM THE MSC'S 60TH AND 61ST SESSIONS ALSO REQUIRE NEW PASSENGER VESSELS BE EQUIPPED WITH AUTOMATIC SPRINKLERS, FIRE DETECTION SYSTEMS, & FIRE ALARM SYSTEMS TO PROTECT CORRIDORS, STAIRWAYS, & ESCAPE ROUTES WITHIN ACCOMMODATION SPACES. IN ADDITION NEW PASSENGER SHIPS CARRYING MORE THAN 36 PASSENGERS MUST ALSO PROVIDE AUTOMATIC SPRINKLER, FIRE DETECTION, & FIRE ALARM SYSTEM COVERAGE TO ALL SERVICE SPACES, CONTROL STATIONS, & ACCOMMODATIONS SPACES. EXISTING PASSENGER VESSELS MUST HAVE A CONTINUOUSLY STAFFED CENTRAL CONTROL STATION WHERE CONTROL OF FIRE DETECTION SYSTEMS, FIRE ALARMS SYSTEMS, AUTOMATIC SPRINKLERS, WATERTIGHT & FIRE DOOR CONTROLS VENTILATION CONTROLS, & COMMUNICATIONS & PUBLIC ADDRESS SYSTEM CAN BE MAINTAINED." THEREFORE, BASED ON THE USCG ACTION AT THE IMO MSC 60TH/61ST SESSIONS & THE BOARD'S ACTION ON M-89-124, M-89-44 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: USCG
To: NTSB
Date: 3/23/1994
Response: DURING THE THIRTY-FOURTH SESSION OF THE IMO SUBCOMMITTEE ON FIRE PROTECTION, A MULTINATIONAL WORKING GROUP WAS ESTABLISHED TO CONSIDER PASSENGER VESSEL FIRE PROTECTION SYSTEMS. ONE OF THE ISSUES SPECIFICALLY CONSIDERED WAS A U.S. PROPOSAL (FP 34/12/3) TO REQUIRE AUTOMATIC VENT SHUTDOWN UPON DETECTION OS SMOKE. THE WORKING GROUP WAS NOT CONVINCED THAT THIS DEGREE OF AUTOMATION WAS WARRANTED BECAUSE CURRENT TECHNOLOGY UTILIZES THE HEATING, VENTILATION, & AIR CONDITIONING SYTSEMS TO PRESSURIZE SPECIFIC SHIPBOARD SPACES TO PREVENT SMOKE FROM ENTERING. SEVERAL REPRESENTATIVES SUCCESSFULLY ARGUED THAT SHUTDOWN OF AN ENTIRE VENTILATION SYSTEM DURING A FIRE IS NOT ALWAYS THE BEST COURSE OF ACTION. USE OF THE VENTILATION SYSTEM FOR SMOKE CONTROL HAS TECHNICAL MERIT & IS BEING INVESTIGATED FURTHER. SMOKE CONTROL ON PASSENGER VESSELS REMAINS AN AGENDA ITEM FOR THE NEXT SESSION OF THE SUBCOMMITEE ON FIRE PROTECTION. IN VIEW OF THESE EFFORTS, I BELIEVE THAT UNILATERAL DOMESTIC LEGISLATION MAY COMMIT US TO A COURSE OF ACTION THAT IS NOT FULLY RESEARCHED &, PERHAPS IS NOT BEST. I WILL KEEP THE BOARD INFORMED OF THE WORKING GROUP'S PROGRESS REGARDING SMOKE CONTROL.

From: NTSB
To: USCG
Date: 8/21/1991
Response: Safety Recommendation M-89-44 asked the Coast Guard to seek legislative authority to require that all passenger vessels operating from U.S. ports embarking U.S. passengers integrate smoke detectors into local ventilation systems to shut down the ventilation system automatically to prevent the spread of smoke when the detector is activated. We note that during the 34th session of the International Maritime Organization (IMO) Subcommittee on Fire Protection, a working group of the subcommittee considered a proposal by the United States to require automatic ventilation shutdown upon detection of smoke. However, it was argued that shutting down the entire ventilation system during a fire may not always be the best course of action. We understand that smoke control on passenger vessels was an agenda item at the 59th session of the IMO Subcommittee on Fire Protection in May 1991. We also understand that during this meeting a working group on fire protection was established to develop regulation changes for passenger vessels encompassing, among other items, the requirements of this safety recommendation. We note that the working group met again in June 1991 to continue these efforts, and intends to submit to the Maritime Safety Committee (MSC) its proposed changes to the fire protection regulations at the April 1992 IMO meeting in London, England. The Safety Board has classified Safety Recommendation M-89-44 as "Open--Acceptable Alternate Response" pending a report from the Coast Guard on the results of the April 1992, MSC meeting.

From: USCG
To: NTSB
Date: 10/25/1990
Response: I PARTIALLY CONCUR WITH THIS REC. DURING THE 34TH SESSION OF THE IMO SUBCOMMITTEE ON FIRE PROTECTION, A MULTINATIONAL WORKING GROUP WAS ESTABLISHED TO CONSIDER PASSENGER VESSEL FIRE PROTECTION SYSTEMS. ONE OF THE ISSUES SPECIFICALLY CONSIDERED WAS A U.S. PROPOSAL TO REQUIRE AUTOMATIC VENT SHUTDOWN UPON DETECTION OF SMOKE. THE WORKING GROUP WAS NOT CONVINCED THAT THIS DEGREE OF AUTOMATION WAS WARRANTED BECAUSE CURRENT TECHNOLOGY UTILIZES THE HEATING, VENTILATION, & AIR CONDITIONING SYSTEMS TO PRESSURIZE SPECIFIC SHIPBOARD SPACES TO PREVENT SMOKE FROM ENTERING. SEVERAL REPRESENTATIVES SUCCESSFULLY ARGUED THAT SHUTDOWN OF AN ENTIRE VENTI LATION SYSTEM DURING A FIRE IS NOT ALWAYS THE BEST COURSE OF ACTION. USE OF THE VENTILATION SYSTEM FOR SMOKE CONTROL HAS TECHNICAL MERIT & IS BEING INVESTIGATED FURTHER. SMOKE CONTROL ON PASSENGER VESSELS REMAINS AN AGENDA ITEM FOR THE SUBCOMMITTEE ON FIRE PROTECTION. IN VIEW OF THESE EFFORTS, I BELIEVE THAT UNILATERAL DOMESTIC LEGISLATION MAY COMMIT US TO A COURSE OF ACTION THAT IS NOT FULLY RESEARCHED. I WILL REPORT THE PROGRESS OF THE WORKING GROUP REGARDING SMOKE CONTROL TO THE SAFETY BOARD.

From: NTSB
To: USCG
Date: 10/11/1989
Response: From the safety study Passenger Vessels Operating from U.S. Ports (NTSB/SS-89/01). The Board adopted this report on 10/11/1989. Also as a result of this safety study, the National Transportation Safety Board reiterated to the U.S. Coast Guard the following safety recommendations applicable to the foreign flag passenger vessels: M-85-59, M-89-43, and M-89-44.