Good morning and welcome to the Boardroom of the National Transportation
I am Robert Sumwalt, and I’m honored to serve as the Chairman of the
NTSB. Joining us today are my colleagues on the Board, Member Earl Weener and
Member Bella Dinh-Zarr.
Today, we meet in open session, as required
by the Government in the Sunshine Act, to consider a fire aboard the roll-on/roll-off
passenger vessel Caribbean Fantasy
on August 17, 2016, which occurred 2 miles northwest of San Juan, Puerto Rico. The
vessel was operated by Baja Ferries and under charter agreement by America
The ship’s master ordered the burning vessel
abandoned, and all 511 passengers and crew made it safely to San Juan. Some sustained
non-life-threatening injuries during the fire and abandonment, and my
colleagues and I sincerely hope that they have fully recovered. The vessel itself
was eventually scrapped in lieu of repairs, a property loss of about $20
The purpose of today’s meeting is to learn
from this accident to prevent future accidents. And we want to learn not only what went
wrong, but those things done correctly. Honestly, it doesn’t appear that too
much went right in this case.
Today we’ll discuss why the fixed firefighting systems did not function
as intended, the lack of crew member training for emergencies and operation of
lifesaving appliances, and what could have been done better during the
abandonment of the vessel. And we’ll discuss the proximate cause of the fire.
We’ll not only discuss the proximate cause, we’ll also discuss the
organizational factors that allowed
the fire to break out, by allowing unsafe conditions.
It takes concerted, continuous effort to maintain the safety of a
transportation enterprise. It takes company leadership that actively drives
safety, and individuals on the front lines who feel empowered to report conditions
that threaten safety.
Unfortunately, as we’ll discuss, safety leadership and safety culture were
ineffective at this company, which struggled just to maintain safety
compliance—the floor, not the goal, for an operator in transportation.
Just as engineers cannot expect a safe vessel unless they actively and meticulously
maintain it, management cannot expect safe operations unless they actively manage
safety through a safety management system, or SMS. But the company’s SMS did not
translate into daily management of safety on board the vessel.
And, we’ll discuss oversight by the flag state, Panama, and the
recognized organization, RINA. Together, they were responsible for ensuring
that Baja Ferries implemented its safety management system and met all
applicable maritime safety regulations.
The Caribbean Fantasy had been
detained 3 times in the years immediately before the fire, yet no red flags
went up. The record continued to accumulate, seemingly without anybody
recognizing that one day, something was likely to go very wrong.
Fortunately, when it did, the fire took no lives, and the subsequent
grounding of the vessel did not pollute the environment.
Today, the NTSB staff will briefly present the
most pertinent facts and analysis found in the draft report. Our public docket,
available at www.ntsb.gov,
contains about 8000 pages of additional information, including factual reports,
interview and hearing testimony transcripts, maintenance information, post
casualty examination reports and crew training information.
Staff have pursued all avenues in order to propose
findings, a probable cause, and recommendations to the Board. We on the Board will
then question staff to ensure that the report, as adopted, truly provides the
best opportunity to enhance safety.
Now Managing Director Dennis Jones, if you would kindly introduce the