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Safety Recommendation Details

Safety Recommendation M-89-066
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 MEDIVACED 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 LLOYD'S REGISTER OF SHIPPING: AMEND SURVEY PROCEDURES FOR THE FIXED CO2 FIRE EXTINGUISHING SYSTEMS ON PASSENGER VESSELS TO INCLUDE A MORE DETAILED INSPECTION OF THE REMOTE AND LOCAL AUTOMATIC RELEASE MECHANISMS TO VERIFY THEIR OPERATION AND THE OPERATION OF THE ENTIRE SYSTEM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Marine
Location: Gulf of Mexico, GM, United States
Is Reiterated: No
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: 6/27/1990
Addressee(s) and Addressee Status: Lloyd's Register of Shipping (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Lloyd's Register of Shipping
Date: 12/6/1990
Response: Thank yolu for the Lloyd's Register of Shipping further response to the National Transportation Safety Board Safety Recommendations M-89-66 and -67. These recommendations resulted from the Safety Board investigation of the March 15, 1988 engineroom fire aboard the Bahamian flag passenger vessel SCANDINAVIAN STAR. Safety Recommendation M-89-66 asked that a more detailed inspection be included in your survey procedures for fixed CO2 fire extinguishing systems on passenger vessels. We appreciate receiving a copy of the September 29, 1989 circular issued to all surveyors outlining the circumstances of the SCANDINAVIAN STAR accident. The circular requested surveyors to exercise particular djligence in the application of the appropriate parts of the Lloyd's Register Survey Procedures Manual that involve inspection of CO2 fire extinguishing systems "to ensure that the release mechanism as a whole is in good operating condition." The Safety Board continues to believe, however, that the only way this can be accomplished is through actual testing rather than through periodic visual inspection of the release mechanism. We believe that the release mechanisms can be functionally tested without the "inadvertent discharge of the contents of the system," such as through the temporary use of a compressed air cylinder in place of the CO cylinders. Consequently, we cannot agree that your requirement for initia 7 testing at the time of c:onstruction, and your standing instructions for the subsequent visual examinations of the CO2 fire extinguishing release mechanism at periodic surveys, adequately address this matter. Therefore, Safety Recommendation M-89-66 remains classified as "Closed--Unacceptable Action." Safety Recommendation M-89-67 urged Lloyd's Register to amend its survey procedures to require verification that the emergency generator on passenger vessels is independent and not reliant on a power source from the main engineroom. We have your assurance that your existing rules require the provision of a self-contained emergency source of electrical power, and further require that a fire or other casualty in spaces containing the main source of electrical power should not interfere with the supply, control, and distribution of the emergency electrical power. Furthermore, we understand that your rules require that the satisfactory operation of all emergency sources of power be verified during periodic surveys. In addition, we note that your circular dated September 29, 1989 to all surveyors emphasizes the need for surveyors to ensure that arrangements for emergency generating sets are in full accordance with the rules in force at the date of building and the applicable regulations of the SOLAS conventions, specifically that the starting and excitation arrangements are provided without recourse to sources of power within the machinery space.. The Safety Board is now satisfied that its concerns in this matter have been adequately addressed; therefore, Safety Recommendation M-89-67 has been reclassified as "Closed--Acceptable Action."

From: Lloyd's Register of Shipping
To: NTSB
Date: 7/5/1990
Response: IN HIS LTR OF 9/12/89, SIR RODERICK MACLEOD ADVISED YOU THAT IN RESPONSE TO THE BOARD'S RECOMMENDATIONS, INSTRUCTIONS WOULD BE ISSUED TO ALL SURVEYORS AS A REMINDER OF THE IMPORTANCE OF EXERCISING SUFFICIENT DILIGENCE WHEN EXAMINING THE RELEASE MECHANISM OF CO2 SYSTEMS & THE OPERATION OF EMERGENCY GENERATOR SETS AT FUTURE SURVEYS. A COPY OF THAT CIRCULAR DATED 9/29/89 IS ATTACHED.

From: NTSB
To: Lloyd's Register of Shipping
Date: 6/27/1990
Response: We have reviewed the Lloyd.'s Register response to the National Transportation Safety Board's SafetyR ecammendations M-89-66 and -67. These safety recmmrdations resulted frm our investigation of the March 15, 1988 fire in the engineroom of the Bahamian flag passenger vessel SCANDINAVIAN STAR. With respect to Safety Recommmdation M-89-66, which proposed that you amend your survey procedures to include a more detailed inspection of the remote and local automatic release mechanism for fixed fire extinguishing systems on passenger vessels, the Safety Board continues to believe that the circumstances of this accident demonstrate that a visual inspection of these release mechanisms is not adequate. We note with interest your remark concerning the disconnecting and reinstating, for testing purposes, of the release mechanism which states, "For example, in the case of the 'Scandinavian Star' the obstructicn to the operating mechanism was (or should have been) obvious by visual inspection and a more positive survey method would have served no useful purpose. The fact that obstruction was not detected during visual inspections even though it perhaps should have been reinforces the Safety Board's position that visual inspections are inadequate. However, in view of the determined opposition of Lloyd's Register to implementing this safety recommmdation, it has been classified as 'Closed--Unacceptable Action.' With regard to Safety Remmendation M-89-67 concerning amendmnt of survey procedures to require verification that emergency generators are independent and not reliant on a power source from the main enginerom, the Safety Board is disappointed that Lloyd's Register continues to take the position that this is an unnecessary course of action. The facts of this accident clearly show otherwise. Because your position on this matter has not chang&i, we have placed this safety reunmmdation in a Closed-- Unacceptable Action status.

From: Lloyd's Register of Shipping
To: NTSB
Date: 1/30/1990
Response: THE SEPARATE QUESTIONS RAISED IN YOUR LETTER REGARDING INSPECTIONS OF CO2 RELEASE MECHANISMS AND EMERGENCY GENERATORS HAVE BEEN CLOSELY STUDIED, AND MY COMMENTS ARE AS FOLLOWS: (1) CO2 RELEASE MECHANISMS: I SYMPATHIZE WITH YOUR VIEW THAT SURVEYORS SHOULD BE REQUIRED TO VERIFY THAT REMOTE AND LOCAL AUTOMATIC RELEASE MECHANISMS ARE FULLY OPERATIONAL BY A POSITIVE METHOD NOT LIMITED TO VISUAL INSPECTIONS ONLY. THERE ARE HOWEVER PRACTICAL DIFFICULTIES IN IMPLEMENTING SUCH A REQUIREMENT AND IT IS FOR THIS REASON THAT WE LIMIT OUR SURVEY REQUIREMENT TO VISUAL INSPECTION ONLY. CLEARLY IT WOULD NOT BE GOOD PRACTICE, ON SAFETY, ENVIRONMENTAL AND COMMERCIAL GROUNDS TO TEST THE CONTROLS BY DISCHARGING THE CONTENTS OF THE SYSTEM, WHETHER IT BE CO2 OR HALON. TO DEMONSTRATE OPERABILITY BY OTHER THAN THIS DRASTIC MEANS WOULD REQUIRE THAT THE RELEASE MECHANISM BE DISCONNECTED FROM THE STORAGE CYLINDER OR CONTAINER RELEASE VALUES TO A SUFFICIENT EXTENT TO ENABLE THE SATISFACTORY OPERATION OF THE RELEASE MECHANISM TO BE DEMONSTRATED WITHOUT DISCHARGING THE SYSTEM. SUCH A DEMONSTRATION WOULD BE RQUIRED TO SHOW THAT ALL COMPONENTS OF THE RELEASE MECHANISM WERE OPERATING SMOOTHLY WITHOUT OBSTRUCTION AND THAT OPERATING STROKES OF PUSH RODS AND PULL WIRES WERE SUFFICIENTLY LONG TO COMPLETELY OPEN THE RELEASE VALVES AND ALSO ANY DIRECTIONAL VALVES FITTED WITH MECHANICAL RELEASE DEVICES. A DEMONSTRATION BY THIS MEANS IS CONSIDERED IMPRACATICAL AND UNNECESSARY BECAUSE: (I) TO DISCONNECT AND REINSTATE THE RELEASE MECHANISM IS TIME CONSUMING, COSTLY AND POTENTIALLY HAZARDOUS, I.E. AN ERROR COULD RESULT IN RELEASE OF THE CONTENTS OF FAULTY REINSTATEMENT. (II) THE NECESSARY EXPERTISE FOR SAFE DISCONNECTION AND REIN STATING MAY NOT ALWAYS BE AVAILABLE. (III) ONCE SAFELY DISCONNECTED, THE ADVANTAGES OF TESTING THE COMPONENT PARTS AS DESCRIBED IN THE FOREGOING, AS AGAINST VISUAL INSPECTION PRIOR TO DISCONNECTION ARE NOT CONSIDERED TO BE OVER WHELMING. FOR EXAMPLE IN THE CASE OF THE "SCANDINAVIAN STAR", THE OBSTRUCTION TO THE OPERATING MECHANISM WAS (OR SHOULD HAVE BEEN) OBVIOUS BY VISUAL INSPECTION AND A MORE POSITIVE SURVEY METHOD WOULD HAVE SERVED NO USEFUL PURPOSE. FOR THESE REASONS LLOYD'S REGISTER DOES NOT REQUIRE ANYTHING MORE POSITIVE THAT A VISUAL INSPECTION, AND AS FAR AS IS KNOWN, NEITHER DOES ANY OTHER CLASSIFICATION SOCIETY OR FLAG ADMINISTRATION.

From: NTSB
To: Lloyd's Register of Shipping
Date: 12/8/1989
Response:

From: Lloyd's Register of Shipping
To: NTSB
Date: 9/12/1989
Response: