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Opening Statement, Fire aboard the Roll-on/Roll-off Passengar vessel Caribbean Fantasy
Robert L. Sumwalt
Washington, DC

Good morning and welcome to the Boardroom of the National Transportation Safety Board.

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 Cruise Ferries.

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 million.

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, 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 staff.