From SN Guides
Costa Concordia is the largest passenger ship ever lost
This series of articles provides a listing of all major passenger ships that have been lost in service. For comparison, there are also articles covering some the most significant losses of passenger vessels and ferries that were smaller than 10,000 GRT. The articles also provide commentary on some of the most significant incidents.
For practical and technical reasons, the Articles are presented in the following parts: -
- Part 1. Definitions and the Development of International Passenger Ship Regulations
- Part 2. Fire
- Part 3. Collision,
- Part 4. Other Navigational Error
- Part 5. Structural Failure and Foundered
- Part 6. Hostilities – World War 1 and the Spanish Civil War
- Part 7. Hostilities – World War 2
- Part 8. Ship Safety Analysis – Passenger vessels over 10,000 GRT
- Part 9. Some smaller passenger vessel losses
- Part 10. Some losses of ferries below 10,000 GRT in European Waters
- Part 11. Some losses of ferries below 10,000 GRT in USA, Canada & Australasia
- Part 12. Some losses of ferries below 10,000 GRT in South East Asia & Africa
Safety Analysis – Passenger vessels over 10,000 GRT
Ignoring Brunel’s Great Eastern white elephant, the first passenger ship to exceed 10,000 GRT was Inman’s City of New York, which was delivered by J & G Thomson’s Clydebank shipyard in 1888. Her sister, City of Paris followed a year later, but it was not until 1892 that another vessel of this size was delivered. From this slow start, a flood of new ships of this size followed and 10,000 GRT soon became the minimum acceptable size for an ocean liner. The earlier parts of these Articles deal with the individual reasons why some of these ships were lost, or were written-off as Constructive Total Losses. Tragically 45 ships were lost though hostilities during the First World War while a further 11 passenger ships were taken over by the military and not returned to passenger operations. During the Spanish Civil War 3 passenger ships were lost and 142 were lost during the Second World War, plus 30 that were taken over by the military and not returned to passenger operations. The ever increasing destructive power of modern armaments will always be able bring about the loss of merchant shipping. This Article is therefore confined to the effects of improvements in passenger ship safety and survivability during peacetime.
Photo 1: Inman Line’s City of New York, just prior to her launch from J & G Thomson’s Clydebank shipyard on 15 March 1888.
Photo 2: City of Paris, the 1889 sister of City of New York. Both ships were transatlantic Blue Riband holders.
Excluding the effects of hostilities, the world fleet of large passenger ships has suffered a total of 116 losses in the 125 years since the first ship over 10,000 GRT entered service. Of these 43 ships were lost to fire while in port (at a cost of 5 lives) and 73 at sea from all causes (7,301 lives). The broad reasons for these ship losses are: -
Losses of Large Passenger Ships
|Other Navigational Error
International Passenger Ship Regulations
Given the size of the fleet of passenger vessels over 10,000 GRT, a total of 73 losses at sea and 43 in port in 125 years is perhaps not too disastrous a record. As will be seen from an examination of the earlier Articles in this series, the problem has been that the total includes some major tragedies. An early example of this was the loss of Titanic in 1912. It was rapidly realised that because shipping is an international operation, international regulation is required, in an attempt to ensure passenger safety. The first International Convention for the Safety of Life at Sea met in 1914, in response to the Titanic disaster. Subsequent conventions followed the same international conference style and met in 1929, 1948, 1960 and 1974.
The main objective of SOLAS Conventions has always been to specify minimum standards for the construction, equipment and operation of ships, compatible with their safety. The 1948 Convention decided to create a new United Nations body, the International Maritime Organisation to develop and maintain a comprehensive regulatory framework for shipping. One of IMO’s duties was to act as a co-ordinating body for the development of maritime safety. The intention was to keep the Convention up to date by periodic amendments, but in practice the amendments procedure proved to be very slow. As the IMO had to obtain agreement amongst its 168 members, it became clear that it would be impossible to secure the entry into force of amendments within a reasonable period of time. As a result the 1974 Convention adopted a completely new procedure, which is designed to ensure that changes can be made within a specified (and acceptably short) period of time. As a result the 1974 Convention has been updated and amended on numerous occasions. The newest applicable regulations have usually been referred to as “SOLAS, 1974, as amended”.
The effectiveness of the SOLAS regulations can be initially judged by examining the number of accidents over time.
Losses by period
|Period of loss of Large Passenger Ships
|Total Losses in 125 Years
At first glance these figures fail to demonstrate any meaningful improvement in maritime safety. The overall totals require further analysis however, to show the effects of: -
- The delayed impact of many new regulations
- The changing nature of the passenger ship fleet
- The size of the fleet
The delayed impact of new regulations
Historically SOLAS regulations have generally been introduced to counter weaknesses exposed by specific Maritime disasters. As a result new regulations lag behind the incidents that are recorded in these Articles. Furthermore, in order to achieve approval by the 168 IMO member nations, it has frequently been necessary to stipulate that new regulations will only apply to ships built after the date that the proposed changes are first promulgated. The effectiveness of SOLAS in the reduction of passenger ship losses should therefore be judged by examining the incidents by the year of build of the vessels lost.In doing so however, it will be seen that the loss of Costa Concordia illustrates that extreme recklessness can defeat the most sophisticated safety provisions.
Losses by period of build
|Period of build of Passenger Ships
The changing nature of passenger shipping
In the second half of the Twentieth Century changing technology had a dramatic impact upon passenger shipping.
Despite the fact that passenger liners were the only means of intercontinental travel, virtually no passenger service was profitable. As a result almost every ocean passenger service was subsidised by governments that required the route to be operated. A consequence of this situation was that liner companies paid some attention to the standards of accommodation expected by government leaders and the wealthy travelling in first class, but they subjected the lower class passengers to very spartan living conditions. When intercontinental air travel became a practical alternative, passengers abandoned sea travel. The politicians and wealthy who travelled in first class, valued the speed of air travel. Those who travelled in lower classes were eager to accept an hour of discomfort in an aircraft for every day of discomfort they would suffer in a ship. Ocean passenger travel volumes collapsed during the 1960s and 1970s, driving up the subsidy required to maintain services governments no longer needed. Throughout the world ocean passenger services began closing down. Some of the ships involved were redeployed as cruise ships, but unless a very large investment was made in upgrading accommodation they were unsuccessful and were soon scrapped. As a result a large number of older, less safe ships were removed from the fleet. By building new ships to meet the accommodation standards demanded by its customers, the cruise industry boomed and a new fleet of very much safer cruise ships entered service.
At the same time, the considerable post World War 2 expansion in motor vehicle ownership led to a growing demand for passenger/vehicle ferry services, which resulted in vessels being introduced that were 10,000 GRT and larger. Initially these ro-ro vessels were converted passenger liners, cargo ships and even tankers. The first was Aquarama a converted C4 cargo ship that entered service on Lake Eire in 1956. The first new-build was Empress of Australia, which entered service in 1965.
Photo 3: The Great Lakes vehicle ferry Aquarama, which was converted from a WW2 C4 cargo ship.
Essential service requirements for these vessels were speed of loading and unloading of vehicles, together with unrestricted vehicle decks. It became increasingly clear that these requirements created considerable safety hazards. The large access doors compromised the watertight integrity of the hull and full width vehicle decks were a major threat to stability. The ships became classic examples of Free Surface Effect danger. The total weight of a couple of inches of water on the vehicle deck can be several hundred tons that will rush in the direction of the vessel’s roll and can cause a rapid capsize.
These weaknesses caused a series of disasters, culminating in the sinking of the 7,951 GRT Herald of Free Enterprise in 1987 (Passenger Ship Disasters - Part 10) with the loss of 193 lives, which led to the rapid implementation of a wide range of SOLAS modifications to the design of ferries built after 1990. Thankfully these moves have been effective and have been subsequently strengthened.
A further factor is that older ferries over 10,000 GRT are being sold for domestic service by Third World operators. These are only covered by domestic regulations, but in some countries their regulations are not obeyed or properly enforced. The effect of ferry disasters on large passenger ships lost figures since 1950 can be seen from the following table: -
Losses by type of Passenger Ship
|Type of large passenger ships built 1950/1969
|Passenger Liners & Cruise Ships
|Total built 1950/1969
|Type of large passenger ships built 1970/1989
|Passenger Liners & Cruise Ships
|Total built 1970/1989
|Type of large passenger ships built 1990/2009
|Passenger Liners & Cruise Ships
|Total built 1990/2009
|Type of large passenger ships built 2010/2014
|Passenger Liners & Cruise Ships
|Total built 2010/2014
One of the three 1970/1989 built Passenger Liner losses was Mikhail Lermontov that was sunk because the incompetence of an arrogant New Zealand pilot, which resulted in an event outside of the coverage of SOLAS. See Passenger Ship Disasters - Part 4 The second incident was the Constructive Total Loss of the 1972 built cruise ship Cunard Ambassador, after she suffered an engine room fire (without loss of life) in 1974. The ship was sold and rebuilt as a livestock carrier. It is generally believed that Cunard were somewhat dissatisfied with the design of their first, small, new-built cruise ships, as they sold Cunard Ambassador’s 1971 built sister, Cunard Adventurer, 5 years later in 1977, to the Kloster’s struggling Norwegian Caribbean Line. The third ship was also built for Cunard, as the Cunard Countess of 1976. After a long and successful career, she caught fire on 30 November 2013, whilst laid-up for the winter in Chalkis, Greece. The damage was so severe that she was also declared a Constructive Total Loss.
Photo 4: Cunard Ambassador on fire in the Caribbean in 1974
The 1970/1989 built Ferry losses includes the Philippine ship SuperFerry 14, which sank in 2004 with the loss of 116 lives, because of a fire started by an on-board terrorist bomb explosion.
The 1990/2009 Passenger Liner Loss is the Costa Concordia.
The size of the fleet
The following table shows the size of the worldwide operational fleet of passenger vessels over 10,000 GRT, at twenty year intervals from 1890 to 2009; plus the fleets at the outbreak of the two World Wars and in 2014. It will be seen that there was a steady growth in numbers and tonnage up to 1939. The ocean liner and cruise ship fleet has never regained its numerical strength since 1939, but because of the booming cruise industry, fleet numbers have started to recover strongly in the period 1990 to 2014. More significantly the 2014 cruise ship total tonnage is almost three times the 1939 passenger liner and cruise ship total tonnage. The interesting figures that emerge from the table are those for ferries over 10,000 GRT; from their first appearance in 1969 with 5 vessels, to 468 ships in 2009 and then falling back to 426 in 2014 although the tonnage is stable.
Operational Large Passenger Ships
||Liners and Cruise Ships||Ferries||Total
- The above figures exclude ships laid-up on the relevant dates in the table
- The figures include the 16 US Shipping Board 535ft Class and 7 of their 502 ft Class from their construction in 1920 while they remained in commercial passenger service.
- Except for one that was converted into a commercial passenger ship, the figures do not include the US WW2 troopships, which were built in the following classes: -
- C3-IN-P&C (4 Ships)
- C3-S1-A3 (2 Ships)
- C4-S-A1 (30 Ships)
- P2-S2-R2 (11 Ships)
- P2-SE2-R1 (8 Ships)
- C4-S-A3 (15 Ships)
During the age of the classical ocean liners, the ultimate passenger ships were those ships that measured over 40,000 GRT. Only 24 were built between 1911 and 1969. Of these 7 were built after the end of WW2 and they all had an uneventful (if sometimes short) operational life. Remarkably 6 of the earlier 17 ships had to be scrapped because of fire damage – 35% of these vessels. The happier experience of the later ships is further indication of the effectiveness of the continued development of the SOLAS regulations.
Photo 5: Classic British transatlantic liners of the 1920s in Southampton. From the left the ships are; Mauretania, Berengaria, Homeric, Majestic and Olympic
- Olympic: White Star; 1911; 45,324 GRT; Scrapped 1935; 18 years revenue service
- Titanic: White Star; 1912; 46,329 GRT; Sank after hitting an iceberg 1912; No revenue service.
- Imperator/Berengaria: HAPAG/Cunard; 1913; 52,117 GRT; Fire 1938; 17 years revenue service
- Vaterland/Leviathan: HAPAG/United States Lines; 1914; 54,282 GRT; Scrapped 1937; 9 years revenue service
- Aquitania: Cunard; 1914; 45,647 GRT; Scrapped 1949; 21 years revenue service
- Britannic: White Star; 1915; 48,158 GRT; Sunk by mine 1916; No revenue service
- Majestic/HMS Caledonia: White Star/Cunard White Star/British Admiralty; 1922; 56,551 GRT; Fire 1939; 14 years revenue service
- Ile de France: CGT; 1927; 43,153 GRT; Scrapped 1959; 21 years revenue service
- Bremen: North German Lloyd; 1929; 51,636 GRT; Fire 1941; 10 years revenue service
- Europa/Liberté: North German Lloyd/CGT; 1930; 49,746 GRT; Scrapped 1962; 20 years revenue service
- Empress of Britain: Canadian Pacific; 1931; 42,348 GRT; Bombed & torpedoed 1940; 8 years revenue service
- L’Atlantique: Cia Sudatlantique; 1931; 42,512 GRT; Fire 1933; 2 years service
- Rex: Italia; 1932; 51,062 GRT; Air attack 1944; 8 years revenue service
- Conte di Savoia: Italia; 1932; 48,502 GRT; Air attack 1944; 7 years revenue service
- Normandie/Lafayette: CGT/US Navy; 1935, 79,280 GRT; Fire 1942; 4 years revenue service
- Queen Mary: Cunard; 1936; 80,774 GRT; Laid-up as hotel and museum 1967; 23 years revenue service
- Queen Elizabeth/Seawise University: Cunard/C Y Tung; 1940; 83,673; Fire 1972; 22 Years revenue service
- United States: United States Lines; 1952 53,329 GRT; Laid-up 1969; 17 years revenue service
- Oriana: Orient Line/P&O; 1960; 41,915 GRT; Laid-up as hotel 1986; 26 years revenue service
- Canberra: P&O; 1961; 45,270 GRT; Scrapped 1997; 36 years revenue service
- France/Norway: CGT/NCL; 1962; 66,348; Boiler explosion 2003; 36 years revenue service
- Michelangelo: Italia; 1965; 45,911 GRT; Laid-up as barracks 1976; 10 years revenue service
- Raffaello: Italia; 1965; 45,933 GRT; Laid-up as barracks 1976; 10 years revenue service
- Queen Elizabeth 2: Cunard; 1969; 64,863 GRT; Laid-up as hotel 2008; 38 years revenue service
- The tonnage figures given above are the applicable figures at the time of the ship’s delivery
- Revenue Service is the period the ship’s spent in commercial passenger service and excludes years in lay-up, war service, major refit and any other non-passenger service periods.
Photo 6: Seawise University (ex Queen Elizabeth) on fire in Hong Kong at the end of her conversion
These giant ships had little impact upon the average passenger ship size, which was 14,000 GRT in 1914 and 16,000 in 1939. The change came through the ever increasing size and number of cruise ships. Royal Princess, the first new-built cruise ship over 40,000 GT to enter service, was delivered to Princess Cruises in 1984. A steady stream of new large cruise ships followed, so that by 1989 the average size of liners and cruise ships over 10,000 GRT exceeded 20,000 GRT for the first time. In 2009 the average size had climbed to 61,000 GT and 71,000 GT by 2014. The 2014 cruise fleet includes 180 ships over 40,000 GT, of which 101 ships are over 80,000 GT; 59 over 100,000 GT and 34 are over 120,000 GT. There are 40 ferries over 40,000 GT, the largest being Color Magic of 75,156 GT.
Photo 7: Colour Magic is currently the largest ferry in the world
In the past 50 years, ship size has emerged as a major factor in improved vessel safety and survivability. The greater number of watertight compartments in a big ship is clearly beneficial in the event of a collision or other navigational error, but the greatest advance has been in the new giant vessels’ ability to combat fire at sea.
The usual land-based response to fire is to evacuate the area and contain the fire, with fire-fighters often being obliged to allow the fire to burn itself out. In the past, a similar fire at sea has required the passengers and crew to abandon ship. The modern approach is to create a number of totally self-sustaining fire zones in the ship, with multiple, independent safety systems. The aim is to quickly detect and isolate an outbreak of fire, responding with automatic water mist systems. If these systems fail to immediately quench the fire, the effected zone will be evacuated to the other zones in the ship while the crew and the automatic systems continue the fight the fire, the ship proceeds to port. The SOLAS 2010 rules include requirements that the ships essential systems must remain operational in the event that any one main vertical zone is unserviceable due to fire. The survival advantage that big ships enjoy is that they contain a greater number of zones, so that a fire in one zone is confined to a smaller proportion of the ship.
Ships that Survived Intense Fires
Fire in a ship is always a serious incident, but as a result of the latest safety developments, fires that would have destroyed a ship 50 years ago are now successfully extinguished. In the process new weaknesses are sometimes discovered and new regulations are introduced to cover these safety gaps. Two major examples of this are the reactions to fires on-board the cruise ships Ecstasy and Star Princess. Unlike the incidents recorded in Part 2, these vessels survived their major fires, enabling full investigations to be carried out. The following detailed descriptions of these two events are based on official reports of US and UK Government investigations into the incidents.
Ecstasy is the second of eight Fantasy class cruise ships that were constructed for Carnival Cruise Lines by Kvaerner Masa Yards, in Helsinki, Finland. Ecstasy entered service in 1991, one year after Fantasy. All eight ships have the same 70,367 GT hull, although each have different internal decor. The final two ships, Elation and Paradise, were delivered in 1998 and differ from the other ships of the class in that they were the first large ships to be fitted with Azipod azimuth pods in place of propellers. At the time of its construction, Ecstasy was required to comply with SOLAS 74 and its 1981 and 1983 amendments. The cruise ship was designed, built, and maintained under the rules of the Lloyd’s Register of Shipping (LR) classification society. Ecstasy held the highest vessel classification for construction.
Photo 8: Carnival Cruise Lines’ 70,367 tons ship Ecstasy in Cozumel
The Start of the Voyage
On the afternoon of 20 July 1998 Ecstasy completed a muster drill and departed the Port of Miami, Florida, en route to Key West, Florida and Cozumel, Mexico, with 2,565 passengers and 916 crewmembers on board. After Ecstasy departed her berth, crewmembers brought in and stowed the synthetic mooring lines, including those on the aft mooring station, which is on deck No. 4 in the first of the ships seven fire zones. Although there are passenger areas above the aft mooring deck, the deck itself is open to the weather on three sides. Before the accident the flag administration for Ecstasy had categorized the vessel’s mooring station as an open deck, which meant that the area was not required to have smoke detectors or sprinklers. The aft station is used only when docking or undocking. The area has three electrically controlled winches that spool the large diameter polypropylene line that is used to moor the vessel. One winch is on the port side, one is on the starboard side, and one is in the centre of the deck. Additional coils of mooring line are stored on wooden pallets on the mooring deck. A bosun carried out a final inspection of the area and secured the two weather-tight doors leading from the mooring station to the passenger stateroom area on deck No. 4, then exited the area. The mooring station log indicates that the mooring deck was “all clear” and secured at 16:50.
Photo 9: Ecstasy arriving at Long Beach in the early morning. The four ship side openings of her stern mooring deck are just above the shore mooring dolphin structure.
The Cause of the Fire
About 16:30, the mangle in Ecstasy’s main laundry malfunctioned. The laundry manager telephoned a repair request to the hotel engineer, who, in turn, paged the on-call galley fitter (first fitter) and instructed him to go to the main laundry and carry out the necessary adjustments.
The main laundry is on deck No. 2, within the second fire zone. The mangle is a large machine (about man height) for ironing table cloths and bed linen, located on the starboard side of the laundry space. When operating the mangle, laundry workers place damp linen on the loading end of the machine. The mangle has strings coated with wax that move the linen through the ironing machine’s felt-covered rollers. The steam produced by the ironing action is removed by blowers and exhausted into two vertical ducts on the starboard side of the mangle. When the mangle is turned off, its rollers automatically rise, preventing damage to the roller bed. The vertical ducts that interface with the mangle are attached to a main exhaust duct for the machine.
When the first fitter arrived in the main laundry, the crew were still working and the six dryers were running. He tightened a bolt on the mangle’s bridge, which directs the linen from the first roller to the second roller. He then started the mangle to determine whether the adjustment fixed the problem. When the mangle still would not work properly, he continued the process of tightening the bolt and starting the machine. In the meantime the hotel engineer sent another galley fitter (second fitter) to help the first fitter in the main laundry. The second fitter said that when he arrived in the main laundry, the first fitter was adjusting a bolt on the mangle. The second fitter said that the first fitter tightened a bolt on the mangle so much that the bolt’s securing nut broke off at its weld to the mangle body. The first fitter decided to weld the nut back in place. The first fitter went to the fitters’ workshop to get the necessary welding equipment. The second fitter went to get an asbestos fire blanket from the machine shop area. Both fitters later testified to the US National Safety Board that they did not obtain a “hot work permit,” as required by Carnival Cruise Lines’ Safety Management System procedures, because “it was standard procedure” to set up the equipment, before calling the staff chief engineer to obtain a permit to begin work and to arrange for a fire watch.
The second fitter stated that when he returned to the main laundry, the laundry crew had left for a meal break and the first fitter was lying on top of the mangle trying to align the bolt for welding. He saw that the welding machine was on a table next to the mangle, the welding cable and earth (ground) cable were lying on top of a panel that had been removed from the mangle but the earth cable was not connected to anything. The first fitter said that he had plugged the welding unit into an electrical outlet and had inserted a welding electrode into the rod holder. The Unitor Miniweld welding machine used by the fitters does not have an on-off switch. The unit is energized when it is plugged in. The specifications for the Miniweld state that it “conforms to the Norwegian Maritime Directorate’s rules for welding apparatus on board ships.” Unitor has since discontinued manufacturing this model.
The second fitter climbed on top of the table next to the mangle. He said that, because the welding rod holder was hanging near the deck, he pulled the cable toward him. He then saw the welding rod come in contact with either the earth clamp or the mangle, causing a spark. The second fitter testified that dryer lint was on the floor. The first fitter said that while he was looking down through the rollers of the mangle, he saw “a very small fire” on the floor and called out a warning. Both fitters said that they jumped to the deck, went to the nearby sink, and got a jug of water, which they used to put out the fire underneath the mangle.
A cabin steward who was collecting towels from a linen closet near the main laundry provided a different account of events. He said that he was at the linen closet door, when he observed smoke in the main laundry. He went to investigate and saw the two fitters working on the inboard side of the mangle. He then saw flames on the outboard side of the mangle, near the exhaust vents. He said that he retrieved a fire extinguisher to fight the fire; however, when one of the fitters dumped a jug of water on the side of the mangle where they were working, flames “appeared to jump up” to an overhead vent. The steward said that the smoke and flames became too great for him to fight with an extinguisher, so he activated the local fire alarm at the laundry room door.
The second fitter testified that he saw fire “in the middle of the mangle” and picked up a fire extinguisher, which he directed on the mangle. The first fitter testified that he saw “big flames” in the ventilation duct immediately above the mangle and that he took a CO² fire extinguisher and directed its spray into the overhead vent. He estimated that he battled the fire for about 5 minutes but had to abandon the fire-fighting effort because the laundry room was filled with smoke. Both fitters testified that when the fire alarms began to sound, they left the laundry and went to their emergency stations.
Two ventilation duct systems exhausted air from the laundry space: one system over the mangle and the other near the six dryers. The duct system dedicated to the mangle had three circular intake openings that were set flush with the stainless steel deckhead and were not covered by a grill or filter. The forward intake opening was above the folding machine attached to the mangle, the second intake opening was directly above the mangle’s rollers and the third intake opening was at the loading end of the mangle. The two laundry exhaust systems were separate from each other and were routed upwards to blowers for each system in an air conditioning room on deck No. 4 and finally exhausted to the atmosphere through a large single plenum in the forward bulkhead of the aft mooring deck next to the stored mooring ropes.
After Ecstasy cleared Miami port area and entered the Bar Cut Channel, her master increased speed to 13 knots. At 17:10, an alarm sounded on the fire control panel on the bridge. The first officer investigated the source of the alarm and found that it was from the main laundry on deck No. 2. The first alarm was followed rapidly by alarms in the stern thruster room, the air conditioning room, and the steering gear room. The master ordered him to send the staff captain and the safety officer to investigate the source of the alarms and to report their findings. The first officer also sent the second officer and two roving fire patrolmen to investigate.
The first officer also began to receive telephone calls from crewmembers reporting smoke in various aft areas. Meanwhile, the safety officer descended to the marshalling area on deck No. 3, where he observed smoke in the aft end of the passageway. He immediately radioed the bridge asking that the master make the “Alpha Team” code announcement (the signal for the quick response team to assemble in the marshalling area). When the staff captain arrived at the marshalling area, he saw no flames but observed smoke spreading upward to deck No. 4. The staff captain radioed his observations to the master and asked that all five fire teams be alerted and that the entire aft fire zone be secured.
At 17:20, the master instructed the first officer to shut down all power to the ventilation systems on the aft part of the ship, specifically Fire Zones 1 and 2. The first officer also called the officer on watch in the engine control room to shut down the ventilation in all areas aft of the engine room. Ecstasy was on a heading of 040° when it passed the sea buoy at 17:23. At 17:25, the master authorized the first officer to make the “Alpha Team” code announcement alerting the ship’s fire teams to report to their emergency stations and to don equipment in preparation for fire-fighting.
At 17:26, the pilot disembarked Ecstasy onto a pilot boat. Ecstasy’s master then ordered the vessel on a southeast course at 6 knots, on a heading that carried smoke away from the ship and avoided other marine traffic while the staff captain and safety officer assessed the situation. The master called the cruise director and the hotel manager to the bridge to handle communications directing the cruise director to provide status announcements to the passengers and the hotel manager to contact shore-side authorities, including Carnival officials, emergency responders, and the Coast Guard. Before the hotel manager could report the fire, Coast Guard Group–Miami radioed at about 17:28, to ask about the smoke streaming from the Ecstasy’s stern and whether the ship needed assistance. The hotel manager responded that the ship had a fire in the laundry room and asked the Coast Guard to stand by, as the situation was being assessed.
At 17:30, the master issued a series of orders to secure the aft area of Ecstasy. He authorized the first officer to close all water tight doors on deck Nos. 1, 2, and 3 in the aft portion of the ship; to close all fire screen doors on all decks in the three after-most fire zones; he ordered the ship’s security officer to clear passengers and crewmembers from these zones and the casino manager to block the area so that no one could return to it after it had been cleared. The master then ordered the chief steward to verify that all cabins in the smoke affected area were empty. During the onboard emergency, all passengers evacuated safely from the affected areas; however, two crew members became trapped on deck No. 2, and fire fighting teams had to rescue them.
The quick response fire team narrowed the location of the main fire and smoke source to the aft mooring area on deck No. 4. At 17:30, upon receiving reports of a large amount of smoke, the bridge ordered all fire teams to assemble. By 17:40, the fire teams had assembled at the marshalling area on deck No. 3, had donned their gear, and had prepared for fire-fighting. The safety officer and the staff captain then led the teams aft toward the stern of the vessel. The fire teams inspected several decks in the aft part of the ship for sources of heat and smoke but initially were unable to enter the mooring deck area because of the intense heat from the fire. Shipboard fire-fighters then began to cool the perimeters of the aft mooring deck by spraying water on the overhead of deck No. 3, the bulkhead forward of the aft mooring deck (deck No. 4), and the surface of deck No. 5. Some fire-fighters began boundary cooling by spraying water on the ship’s exterior shell plating.
Shortly after 17:50, the Coast Guard Group–Miami Captain of the Port order to Ecstasy to proceed to the anchorage north of the sea buoy and anchor. At 17:54, as the master turned the vessel to head for the anchorage area, Ecstasy suddenly lost all propulsion power and steerage and began to drift. The chief engineer informed the master that his staff could not determine the reason for the power loss because of the fire. The master requested that the Coast Guard send tugs to assist the vessel.
At 1800, the master ordered the general alarm to be sounded alerting passengers and crew members to assemble at their muster stations. The cruise director provided loudspeaker status announcements to passengers about every 5-10 minutes. Passengers at an outside muster station had problems hearing the loudspeaker announcements because of the noise from news helicopters flying close to the vessel, so the cruise director radioed muster station personnel with status information to relay to passengers. When smoke entered some muster areas, passengers were moved to other stations.
In the meantime the Biscayne Pilots Association informed Coastal Tug and Barge, Inc., of Miami (Coastal Tug) of a fire on Ecstasy. The Coastal Tug dispatcher radioed the tug Coastal Key West, which was tied up at Fisher Island (Miami Harbour) to assist. The tug got underway about 1800 and arrived on scene at 18:27. The Coastal Key West began directing a stream of water from a high-pressure fire monitor at the fire on Ecstasy’s stern mooring deck. The Coastal Tug dispatcher ordered three other tugs from the Port of Miami and they arrived within a half hour of Coastal Key West. While two joined Coastal Key West in fighting the fire on the stern of Ecstasy with their fire monitors, the third, Coastal Miami, went to Ecstasy’s bow to prepare for towing the ship. The Coastal Miami’s master also handled the radio communications between Ecstasy and the tugs on scene. A short time later, the tug Dorothy Moran joined the other tugs in the fire fighting efforts at the stern of the Ecstasy.
At 18:35, a Coast Guard vessel carrying two representatives from the Marine Safety Office (MSO) Miami arrived alongside Ecstasy. They received a status report then proceeded aft to meet Ecstasy’s safety officer who told the MSO officials that the fire was limited to the aft mooring deck on deck No. 4, but the fire teams had not been able to enter the area because of the intense heat and dense smoke.
At 19:13, the tug Coastal Miami secured a towline to Ecstasy’s bow to keep the ship heading into the wind so that smoke moved away from the stern. Ecstasy and Coastal Miami drifted north due to the effects of the Gulf Stream. Some Ecstasy fire teams then entered the aft mooring deck from the starboard side weather door and began cooling the area and extinguishing flames. Another fire team entered the mooring deck from the port weather door. Shortly thereafter, the fire teams notified the master that the fire had been extinguished. The Ecstasy fire teams continued to survey the aft decks in Zones 1 and 2 for any residual signs of fire.
About 19:50, shore Fire Department staff, including a medical doctor, began arriving on Ecstasy and assisted onboard medical personnel in tending to the ship’s fire fighters and passengers.
After completing an assessment, the authorities agreed that the fire had been extinguished and at 21:30, Ecstasy was granted permission to enter port. The cruise ship, under tow by six tugs, arrived at Pier 8 Miami at 01:18, 21 July. Once the vessel was secured at its berth and the gangways were rigged, passengers began to disembark about 02:20.
Medical responders examined at least 70 passengers and crew members. Six passengers were then treated by medical personnel and local hospitals for pre-existing conditions; three passengers were treated for smoke inhalation. Fourteen crew members were treated for minor injuries, including smoke inhalation.
The evidence of fire in the main laundry was limited to the area of the mangle. Metallurgical analysis confirmed that the welding rod had struck the welding equipment earth clamp. Fire damage to the mangle power cables and soot deposits on the loading end of the mangle showed that the fire spread across the floor up into the mangle. Damage to the aft roller and melted wax from the mangle strings showed that the fire spread onto the roller. The fitters had turned off the mangle to work on it. As a result, the rollers were in a raised position, which left a gap between the rollers and the entry housing to the adjacent exhaust ducts. This gap allowed the fire to spread into the roller exhaust ducts, which was evidenced by heat damage to the paint on the exhaust ducts. In addition, the roller exhaust ducts contained several inches of burned debris.
Flammability tests of lint showed that the material was ignited easily by a spark and burned for several seconds, leaving little residual material behind. Post-accident examination of the mangle blowers revealed that they were caked with partially burned lint and wax. In addition to the damage in the mangle’s vertical exhaust ducts, investigators found 2-3 inches of burned debris in the main ventilation duct above the machine. This quantity of debris indicated that there must have been a large volume of lint present before the fire. The large lint build up in the exhaust vents and the ventilation system represented such a hazard that a fire might have occurred even if the fitters had followed the required welding permit procedures and had arranged to have a vessel safety officer present.
Based on the amount of burned lint debris on Ecstasy, investigators examined the main laundries of other Fantasy Class vessels and found large lint accumulations in their laundry exhaust systems, particularly the mangle exhaust ducts next to and above the machine. Substantial volumes were present even in ships where the ducts had been cleaned only two or three days prior to inspection. Fire damage was present throughout the mangle exhaust duct system of Ecstasy, indicating the fire probably proceeded through this system into the air conditioning room where it spread through the plenum exhaust ducts onto the mooring deck.
The mooring station had 11 mooring lines, each measuring 220-meters and weighing about 900 pounds. The line itself is not easy to ignite. Inspection of a sister vessel showed that large amounts of easily ignitable lint had accumulated on the mooring deck and had become imbedded in the stored mooring lines. Assuming that Ecstasy had a similar accumulation of lint, the fire venting from the mangle exhaust plenum probably ignited the lint, which, in turn, ignited the polypropylene mooring line. Once ignited, the amount of heat released from polypropylene rope per pound is equivalent to that of a comparable amount of petrol. The investigation showed that the fire consumed most of the 5 tons of polypropylene line on the mooring deck before fire fighters were able to reach the deck and extinguish it. A pallet of nylon line survived the fire but was melted. Two lengths of polypropylene rope were partially consumed and the others were completely destroyed creating a large, intense fire that lasted for more than 2 hours, damaging deck areas above, forward, and below the mooring deck.
Ventilation system intakes, which are next to the laundry room’s exhaust plenum on the mooring deck, transferred hot gases and smoke back into other areas of the vessel through the air conditioning system until bridge personnel secured the system. Hot gases and smoke travelling through the ventilation ducts caused extensive heat and soot damage in the stern thruster room, the steering gear rooms, an electrical equipment room, several passenger cabins on decks Nos. 4, 5, 6 and 7, and the laundry crew galley. The ingestion of smoke and fire gases from the mooring deck fire into the intake systems caused the almost simultaneous activation of smoke detectors on four different decks.
Loss of Propulsion Power
The ship’s propulsion system had many duplicated features and isolated components designed to provide reliability, so the complete loss of power during the fire was very disconcerting. Ecstasy’s main power plant comprised six diesel generators that supplied all electric power for the vessel, including propulsion. The generators produced electricity at 6,600 volts and at a constant frequency of 60 hertz. Transformers and cycloconverters modified the voltage and frequency for use by the motors driving each of the vessel’s two propellers. Each independent double-wound motor had two cycloconverters. In the event of power failure, the propulsion system computer had a battery backup, and each motor could use an emergency exciter. Each of the six independent diesel generators supplied isolated main distribution switchboards.
Output from the cycloconverters ran through electrical circuit breakers (called high-speed breakers) that were designed to prevent damage to the propulsion motors in the event of a power overload. The breakers generated a signal indicating their status (whether they were open or closed) to the propulsion system computer. If the propulsion system computer did not receive a status indication from either of the breakers, the computer would shut down the system power at the cycloconverters. The signals indicating to the computer the circuit breakers’ status passed through a distribution panel in an electric equipment room on deck No. 5, above the area where the fire occurred. Both the cables supplying power to the distribution panel and the auxiliary back up power cables were routed through the ventilation intake plenum forward of the aft mooring station and both were destroyed by the ingested hot gasses before the ventilation system was secured. Without power the distribution panel was unable to relay the circuit breaker status and the propulsion system computer shut down the motors.
The propulsion system was designed and manufactured by ABB, a subcontractor to Kvaerner Masa, the shipbuilder. The integration of the propulsion system into the ship’s other systems, including the electrical distribution system, was the responsibility of Kvaerner Masa’s designers. The specifications to the shipbuilder from ABB listed the required voltage and current supplying the propulsion system. The specifications did not indicate that the voltage supply should be provided by independent sources.
ABB stated that they did not do a qualitative failure analysis of the propulsion system for the Fantasy class ships, including Ecstasy, because SOLAS, Lloyds Register and Carnival did not require that a system performance analysis be conducted. In 1988, the Coast Guard issued regulations requiring the use of a qualitative failure analysis of certain automated systems, including propulsion control systems. In proposing the regulatory requirement that designers, manufacturers, and/or shipyards perform and submit system failure analysis, the Coast Guard stated that the use of advanced automation technologies such as electronics and microprocessors made it increasingly difficult, “at times impossible, for the Coast Guard, ship owners/operators, and classification societies to evaluate safety.” The IMO subsequently adopted regulations requiring that a failure modes and effects analysis (FMEA) be performed for the machinery and control systems of high-speed vessels. The use of FMEA for passenger vessel propulsion system designs was not however a requirement at the time of the Ecstasy fire.
Steering System Failure
The ship’s steering gear had two rudder systems that were mechanically, electrically, and hydraulically independent of each other. The systems were housed in separate rooms on opposite sides of deck No. 3, below the mooring deck. The power and control cables for both rudder systems were routed along the overheads of their respective steering gear rooms. When the intense fire on the mooring deck went unchecked for more than an hour, the heat that was conducted through the overheads of both steering gear rooms melted the cables, causing both steering system to fail. Despite the failure of the steering system, the crippled Ecstasy could have manoeuvred at low speeds by using the twin propellers and bow thrusters if the ship had not lost propulsion.
When Ecstasy was built in 1991, Carnival Cruise Lines had until 2006 to comply with SOLAS requirements for automatic sprinklers. Nevertheless, the company elected to install sprinkler protection in Ecstasy’s cabins and staterooms at the time of construction. After the fire on board Ecstasy, Carnival Cruise Lines modified the fire suppression system of Paradise, one of her sister ships under construction, to include sprinkler coverage of the vessel’s mooring decks. The company also began a program of retrofitting the mooring decks of its existing cruise ships with deluge sprinkler systems by the end of 2001. The US Safety Board report applauded Carnival Cruise Line’s past and continuing efforts to improve fire safety on the ships in its fleet.
Sprinkler systems are designed to provide an appropriate level of protection for the space that they occupy and the amount of combustibles that are present. On Ecstasy, sprinklers were installed mainly in accommodation areas, including staterooms and cabins. The sprinkler system, therefore, was designed for spaces that contained furniture, carpeting, panelling, etc.
In the Ecstasy accident, however, conditions occurred that put unusual demands on the sprinkler system. In the main laundry on deck No. 2, the fire’s area of origin, the ignition of the comparatively small amount of lint across the floor released insufficient heat to trigger the heat-activated sprinklers in the overhead. The small flames spread first to the mangle’s vertical exhaust ducts and then its overhead exhaust ducts where the high lint build-up fuelled a larger fire. The mangle’s overhead exhaust duct, constructed of non-combustible metal, contained the fire, and the air flow within the duct carried the fire from the laundry to the exhaust plenum on the mooring deck. The fire exited onto the mooring deck, which lacked fire protection, and ignited the lint debris that, in turn, led to the development of the major conflagration.
Before the ventilation system in Fire Zones 1 and 2 was shut down, ventilation fans drew intense heat from the large fire on the mooring deck to various ship areas that were protected by sprinklers, which caused them to activate. In addition, the heat from the mooring deck fire was so great that it triggered sprinklers in deck areas immediately above and forward of the mooring deck. Although the sprinkler discharge in areas that were remote from the mooring station had no effect on the fire and heat source, the discharges prevented the spread of fire further into the vessel.
The number of sprinklers discharging water was twice as great as the design capabilities of the ship’s water delivery system. Even though the number of sprinklers that opened created a demand for water that taxed the water supply, the sprinkler system provided proper protection in this accident. The Safety Board concluded that the vessel’s automatic sprinkler system limited the spread of fire from the mooring station to adjoining decks, thereby preventing a significantly worse fire that would have caused greater damage and perhaps additional injuries.
As a result of its investigation, the National Transportation Safety Board made a number of recommendations to the US Coastguard, Carnival Corporation, other cruise lines operating out of US ports and the classification societies. These recommendations covered the control of welding and cutting equipment; the introduction of a continuing programme of clearing of combustible material from laundry exhaust air ducting; the installation of automatic systems to prevent smoke and fire passing through ventilation system; to install fire detection and suppression systems on mooring decks; to use qualitative failure analysis techniques to identify system components whose failure might cause a complete loss of propulsive power and take action to mitigate identified problems in the construction of new passenger ships.
As mentioned above, Carnival immediately introduced programmes to follow the Board’s recommendations. It must be emphasised that the Board can only make recommendations and five companies (mainly operating older and smaller ships) failed to agree with specific proposals. Only SOLAS regulations are mandatory and finalisation often take some years. Proposals to amend SOLAS regulations to extend the fire protection requirements to semi-enclosed external areas used as restaurants, swimming pools, mooring decks, and galleys, were still being discussed when the IMO fire protection sub-committee met in February 2006.The proposals were not finalised due to time constraints, and the matter remained open pending further discussion.
Star Princess is the last of three Grand class cruise ships, which were built for Princess Cruise Lines in the Monfalcone shipyard of Fincantieri-Cantieri Navali Italiani. All Grand class ships have the same 108,977GT hull, although each have different internal decor. Six larger ships, that are based on developments of the design, have been ordered by Princess and its sister company, P&O Cruises. During construction, Star Princess was registered with the Liberian administration, and was required to comply with SOLAS 74 as amended. The vessel was designed and built under the rules of both Lloyds Register of Shipping, and Registro Italiano Navale (RINA). Lloyds Register was responsible for the certification of all statutory requirements on behalf of the Liberian register. As the ship was to be used to embark passengers from US ports, she was also subjected to Control Verification Examinations (CVEs) by the US Coast Guard before entering service, and periodically thereafter. This was to demonstrate ‘substantial compliance’ with the construction, equipment, and safety requirements of SOLAS. Before entering service in 2002, the vessel was transferred to the Bermuda Register of Shipping and maintained under the rules of RINA alone.
Photo 10: Star Princess in Messina. The photograph provides a good indication of the great size of the vessel and the extensive area given over to cabin balconies.
On 23 March 2006 Star Princess was on passage from Grand Cayman to Montego Bay, Jamaica with 1,123 crew and 2,690 passengers on board. The vessel was on a course of 102° at a speed of 17.7kts. The true wind was north east, force 4, and the relative wind was between 20° and 30° on the port bow at a speed of between 25 and 30kts. The sea was calm, the visibility was good, and it was dark. The air temperature was 25°C, and the relative humidity was 92%.
At 02:50, a security patrol smelled burning amidships on the port side of deck 14. The smell was reported to the Officer of the Watch (OOW) by telephone, and the area was checked. Nothing was found, but the security patrol was instructed by the OOW to include the area during its overnight rounds. At 03:09 the OOW was alerted by a manual call point alarm. The alarm had been activated in fire zone 2 on deck 11. Almost simultaneously, the bridge lookout reported he could see a fire on the port side of the ship’s superstructure. The OOW immediately made a broadcast over the PA system for the assessment party to proceed to deck 11, fire zone 2, port side. The location was also passed to the assessment party via personal pagers.
The manual call point alarm was activated by a passenger in stateroom B254, who saw an orange glow from his balcony. The glow was on a balcony below and to his left. By the time he had alerted friends in the next stateroom, the glow had turned into a fully blown fire. The occupants of adjacent staterooms on deck 11 were then alerted by the banging on doors and shouting. One passenger was also able to inform the customer service desk by dialling 911, the ship’s medical emergency number.
When the first of the assessment party arrived on deck 11, passengers were leaving their staterooms sited on the port side of zone 3. The party entered one of the outboard staterooms in the vicinity of B302, and from its balcony, saw the fire on balconies further aft. The OOW was contacted by VHF radio at 03:12, and informed that the fire was in the vicinity of staterooms B306 and B308. When the senior first officer, who was in charge of the assessment party, arrived at the scene and saw the scale of the fire, he immediately requested the bridge to broadcast the crew alert.
On hearing the OOW’s announcement for the assessment party, the captain and staff captain went to the bridge. From the port bridge wing, they saw that the fire appeared to be located mainly on the outside of the ship, and its flames were moving from forward to aft. The staff captain then proceeded to the safety centre, from where the crew alert signal was activated at 03:13, and the fire screen doors in fire zones 1, 2 and 3 were closed at 03:14. The ventilation was also stopped by using master switches for each of the affected zones. This was in addition to a pre-programmed smoke strategy, which automatically activated in the local deck and zone areas where the initial smoke detectors were triggered.
At 03:17, the captain reduced speed, and then altered course towards the north in order to reduce the wind over the deck. During this manoeuvre, which was requested by the senior first officer via the staff captain, the relative wind shifted to the starboard bow at 03:20, and the flames became more vertical. The senior first officer also requested that General Emergency Stations (GES) be initiated. The signal for GES was sounded at 03:20, after which the passengers were instructed to go to their muster stations. The lifeboats and liferafts were then prepared. Because the fire was on the outside of the ship’s port side, the port boats were not put out until adequate protection from fire hoses had been provided, and only the starboard liferafts were inflated.
Immediately following crew alert, six hoses were rigged on deck 14 to cool the deck, which was getting very hot. Boundary cooling was also quickly established on deck 7 in way of the port lifeboats. By 03:26, the deck fire party had entered zone 3 from forward. Two, three-man teams of fire-fighters with breathing apparatus (BA) were used in rotation, which searched only the outboard staterooms as they advanced. Priority was given to controlling the fire, by fighting it from intact balconies, and through broken balcony doors. A hose party wearing smoke respirators, which were found to be very useful in the smoky conditions, was deployed on the forward balconies to play water onto the balconies on deck 10 immediately aft, and below, the advancing BA team. Hoses were also deployed on balconies forward and aft of the fire as boundary cooling and the engine room fire party started to fight the fire from as close as possible on decks 9 to 12. Access between the balconies was impeded where the keys to the doors in the balcony partitions were not readily available. Difficulty was also encountered in handling fire hoses around the partitions.
The fire continued to move quickly aft, and by 03:40 at least seven hoses had been rigged in zones 3, 4, and 5 on deck 15, to direct water onto the fire below. A port list had been applied in order to allow the large amount of water being put on to the fire to run over the ship’s side. From 04:00, the fire appeared to start to reduce in size, and at 04:36, the captain informed the passengers, by a public announcement, that the fire was out.
Photo 11: The considerable external damage caused by the balcony fire on Star Princess
Rescue of passengers
Between 03:44 and 04:02, the engine room fire party recovered two male passengers from the alleyway in zone 3 on deck 12; the first was semi-conscious, and the second, unconscious. Shortly after, a further two passengers, who were able to walk, were rescued from stateroom A340 in the same area. At 04:25, the unconscious casualty was pronounced dead by a ship’s medical officer.
The deceased passenger was a 72 year old American, weighing about 242 lbs. Following an autopsy in Montego Bay on 24 March 2006, the immediate cause of death was attributed to:
Asphyxia secondary to inhalation of smoke and irrespirable gases as products of incomplete combustion, in an elderly individual with evidence of Atherosclerotic Cardiovascular Disease in conjunction with Chronic Glomerular Nephritis.
A further 13 passengers, suffering from effects of smoke inhalation, were treated in the ship’s medical centre. Eleven of these passengers had been located on the port side of deck 12, of which eight occupied staterooms in zone 3, including the passengers rescued from A340. Following the ship’s arrival in Montego Bay, the injured male passengers from A320 and A402 were taken by air ambulance to a clinic in Florida. Another four passengers were landed to a local hospital.
The search of the fire-affected internal areas was completed at 06:41. By this time, the captain had decided that it was safe to resume passage to Montego Bay, and had adjusted course and increased speed accordingly. As the fire-damaged areas were cooled and dampened, fires re-ignited in staterooms C402 and C510, which were quickly detected and extinguished. The ship arrived in Montego Bay at 09:45, and at 09:54, the identity of the deceased passenger was confirmed. As all passengers and crew were now accounted for, the passengers were then allowed to leave their muster stations.
The passengers on board Star Princess were disembarked in Montego Bay, and the ship sailed for the Bahamas on the evening of 25 March. Following temporary repairs in the Bahamas to the fire damaged areas the ship proceeded to Bremerhaven, Germany, for permanent repair. The ship re-entered service on 15 May 2006.
Photo 12: Repair work being carried out to Star Princess at Bremerhaven
Post-Fire Damage Survey
Following the fire, representatives from the MAIB and the US Coast Guard, NTSB and
FBI attended the vessel to investigate the fire.
Fire damage extended over the balconies and outboard staterooms in the central third of the ship’s length, in Fire Zones 3, 4 and 5 on the port side. The most severe damage was on decks 10, 11 and 12 in which 79 outside staterooms were seriously damaged by fire. A further 218 were damaged by fire, smoke, or water. One balcony on deck 9 was seriously damaged by fire, and numerous others sustained minor damage caused by falling debris. Semi enclosed public areas on the port side of deck 14 were damaged by heat and smoke. Minor smoke damage and debris of the products of combustion was evident on deck 15. The fire generated sufficient heat to melt the aluminium structure of decks 11 and 12. The heat also caused glass in the balcony balustrades and doors to shatter, which allowed the fire to penetrate into the outside staterooms. At the outer boundaries of the damaged areas, the balcony partitions were charred and melted, and sagged under their own weight. Where this occurred, it was possible to see that the partitions had burned before their aluminium frames distorted. In all other places, the partitions were reduced to ash and their frames partially or totally melted. The plastic balcony furniture and deck tiles were mostly reduced to ash within the fire affected area, and were melted and scorched at its outer boundaries.
The only electrical fitting provided on each of the balconies was an exterior light sited over the balcony doors. There was no evidence of any electrical failure or arcing on these fittings. There was also no evidence that accelerants were used to intentionally start the fire.
Fire damage in the staterooms was worst immediately inside their balcony doors, and reduced towards their interior. A rapid reduction in temperature was shown by undamaged chocolates found on many bedside tables, and bedding and furnishings, which looked charred, but were in many cases only stained with heavy soot washed from the smoke by the water mist. The most severe damage to a stateroom was in C510, where the water mist head was found on the deck, having failed to activate. The heat generated had buckled the stateroom’s deckhead panels, and its door to the alleyway was also badly buckled and very nearly breached. Soot deposits indicated that smoke entered the ship and reached internal alleyways in accommodation spaces through staterooms via open balcony doors. Although soot stains were evident in zone 3 on deck 12, they were less evident in zone 4.
The regulations covering ‘Construction – Fire protection, fire detection and fire extinction’ are in SOLAS Chapter II-2, in which Regulation 9 (Containment of fire) states:
The purpose of this regulation is to contain a fire in the space of origin. For this purpose, the following functional requirements shall be met:
- the ship shall be subdivided by thermal and structural boundaries;
- thermal insulation of boundaries shall have due regard to the fire risk of the space and adjacent spaces; and
- the fire integrity of the divisions shall be maintained at openings and penetrations
In general terms, the regulation requires that in ships carrying more than 36 passengers, the hull, superstructure and deckhouses are to be sub-divided into main vertical and horizontal zones by A-60 class divisions. It also specifies standards for bulkheads not required to be A-60 class divisions and the division standards required between decks.
As a result of the Ecstasy fire described above, proposals to amend Regulation 9 of SOLAS II-2 to extend the fire protection requirements to semi enclosed external areas used as restaurants, swimming pools, mooring decks, and galleys, were under discussion. Following the Ecstasy fire the US authorities’ recommendations were immediately implemented by Carnival and most other larger operators, but changes to the SOLAS regulations had not been finalised, largely due to the concerns of the operators of older, smaller vessels. The matter remained pending further discussion, almost 8 years later at the time of the Star Princess fire. It should be noted however that balcony fire protection was not being considered by the IMO fire protection sub-committee.
Categorisation of balconies
Star Princess has 15 decks and seven main vertical zones. A structural fire plan was provided by Fincantieri, which was approved by Lloyds Register of Shipping and RINA. The structural fire plan shows that the external balconies were categorised as open deck spaces (category 5) which SOLAS defines as:
Open deck spaces and enclosed promenades clear of lifeboat and liferaft embarkation and lowering stations. To be considered in this category, enclosed promenades shall have no significant fire risk, meaning that furnishings shall be restricted to deck furniture. In addition, such spaces shall be ventilated by permanent openings.
Staterooms were categorised as accommodation spaces of moderate fire risk (category 7). During the course of the MAIB investigation, discussions with industry bodies, including ship builders, classification societies, and national maritime administrations, indicated that this practice has been consistently used since the first ships with external balconies were built in the mid 1980’s. They also indicated that the doors between the balconies and the accommodation spaces did not have to be fire-rated, or self closing, because of an exemption provided in SOLAS II-2 Regulation 9.
Design and construction
Star Princess is typical of modern cruise ship design in having a large number of balconies outside passenger staterooms. The majority of her balconies run along most of the ship’s length on decks 9 to 12. The balconies on decks 9 and 10 were constructed on a steel deck, and those on decks 11 and 12 were made from lightweight extruded aluminium, attached to the steel superstructure with transition pieces and supported by aluminium brackets in a cantilever. Stainless steel tie bars linked the outboard edges of decks 11 and 12 to the steel deck of deck 14 above
The balconies on deck 10, which contributed to the strength of the vessel’s structure and those on deck 9, which were directly above the lifeboats and liferafts, were considered to meet the applicable regulations and were approved by Lloyds Register and RINA. The structural aspects of the technical specification for the balconies on decks 11 and 12, which neither contributed to the strength of the vessel’s structure, nor had to meet prescribed fire protection requirements, were also examined and found acceptable by the classification societies.
Access to the balconies from the staterooms was via sliding glass doors similar to those used in many domestic homes. The glass used in the balcony doors was double glazed and mounted in an aluminium frame with an overall dimension of 1870mm x 716mm, and a thickness of 25mm. The glass used was 5mm toughened ‘float clear’ glass, which had been impact tested in accordance with BSI 6202, but was not fire rated.
Balconies were separated by vertical partitions, which had small gaps at the deck and deckhead. The partitions provided privacy and shelter, and were fitted with a door, which could be locked by a universal square-ended ‘T’ bar shaped key. The partitions were constructed from 8mm polycarbonate sheet, secured in an aluminium framework. This was one of several types of material used by Fincantieri for balcony partitions, and Star Princess was one of 19 ships on which it had used the material. The materials the shipbuilder used on the balconies of other vessels included: acrylic, acrylic –polycarbonate mixtures, and aluminium composite. Materials known to be used for balcony partitions by other ship builders includes glass, steel, high pressure laminated boards, galvanised sheet, and plywood.
The decks of the balconies on board Star Princess were covered with a polypropylene tile. On decks 9 and 10, the tile was laid on top of a flexible screed coated with polyurethane self-levelling paint, but on decks 11 and 12 it was laid on top of a painted metal deck. Polypropylene tiles were laid on top of the deck coatings to provide a non slip finish and allow surface water to drain. This was one of three types of deck covering used by Fincantieri for this purpose; the others were teak, and a teak effect resin. A balustrade was fitted at the outboard edge, consisting of glass panels topped with a hardwood rail.
The selection of the material used for the partitions and deck covering was determined by a number of factors, including: durability in a marine environment, weight, aesthetics, cost, and availability. The characteristics of the materials used, regarding combustibility and toxicity when burning, were not a consideration. Regulations 3 and 6 of SOLAS Chapter II-2 detail the requirements for the use of non-combustible and combustible materials, and smoke generation potential and toxicity, respectively. The purpose of the latter is to reduce the hazard to life from smoke and toxic products generated during a fire in spaces where persons normally work or live, but the requirements are applicable only to internal spaces.
Lightweight plastic chairs, table and footstools of the type commonly available for outdoor recreational use were provided for each balcony. The first heat detectors to activate were in staterooms C316 and C318. Items on the balcony of stateroom C316 at the time, included two large cotton towels provided by the ship and draped over the plastic chairs, a bathing suit and a pair of water shoes, all of which had been on the balcony for several hours. The passengers in C318 were smokers, and the last occasion a cigarette was smoked on the balcony was shortly after midnight. The cigarette end was then extinguished in an ashtray. The passengers in C316 were non-smokers and were travelling companions of the passenger in C318. The door in the partition between the stateroom balconies was unlocked, but it is not certain whether it was open or closed.
Star Princess was fitted with a Consilium Salwico CS3000 Fire Detection System, Hi-Fog control and Fire Patrol System, which was type approved by a number of Classification Societies including Lloyds Register and RINA. Sensors fitted throughout the ship had unique identities, which enabled the system to interpret the location and type of each alarm that was triggered. Sensor faults were also detected. The system was interfaced with the:
- General alarm system
- Ventilation and damper system
- Safety Management System (SMS)
- Machinery control system
The fire detection system monitored the presence of smoke and heat separately, via individual and combined smoke and heat detectors. Combined heat and smoke alarms were fitted in passenger accommodation areas, and emitted an audible alarm when activated. This was a single tone, which stopped when an alarm was reset by an operator. Audible alarms were fitted in response to a NTSB recommendation following its investigation into the fires on board Ecstasy in 1998.
Heat detectors were triggered at 57°C, or where the rate of temperature rise exceeded 3°C per minute. Operation of an alarm initiated a predefined sequence leading to the automatic operation of fire doors, dampers, and the shutdown of the ventilation systems, in its deck and zone. The manual call points in public areas only provided an alarm; they did not trigger an automated response or provide an audible alarm at the point of activation. During the first 10 minutes after the operation of the manual call point at 03:09, 215 alarms were recorded.
The ship’s firemain was supplied by three 230m³/hr pumps operating in automatic or manual modes to maintain a system pressure of 10.5 Bar. An additional 25-40m³/hr pump maintained the system pressure under standby conditions. Water pressure was maintained at between 8 and 8.5 Bar during the fire-fighting operation, using the small and one large fire pump.
A Marioff Hi-Fog water mist system was fitted throughout the ship’s internal spaces. The system complied with SOLAS requirements and was type approved by a number of classification societies. It was also designed and maintained in accordance with the US National Fire Protection Association standard NFPA750. The water mist system appears similar to a typical sprinkler, but operates at a significantly higher pressure, which forces water through specially designed nozzles to produce a fine mist. The system pipe work fitted in the accommodation areas was filled with fresh water at a standby pressure of 25 Bar, and connected to an automatic water mist head in each stateroom. Each head is activated by a heat frangible bulb, filled with an alcohol based liquid, which shatters at 57°C and allows water to flow from the head at a pressure of between 60 and 135 Bar. They provide effective coverage of an area up to 16m². Flow detectors in the distribution system detect the initial flow, which automatically starts high pressure pump units to provide a system pressure of up to 140 Bar.
During the fire on 23 March 2006, an estimated 168 water mist heads were activated, and were kept running for over 4 hours in order to cool the fire-affected areas. The water mist system used about 300 tonnes of fresh water over 3 decks and 3 fire zones during the 4 hour operating period.
Cause of ignition
The time lapsed from the smell of burning first being reported to the OOW at 02:50 and the manual call point being activated at 03:09 indicates that the fire probably smouldered for about 20 minutes before flames developed. This was consistent with the fire being started by a discarded lighted cigarette end landing on combustible materials.
The dangers of the casual discarding of cigarette ends, which have not been properly extinguished, are well acknowledged by many shipping companies. Although passengers on board Star Princess were instructed in the safety video shown throughout the day of embarkation and in the safety literature provided in the staterooms, to properly extinguish cigarette ends in the ash trays provided, the cigarette ends found on balconies after the fire and the scorching of a plastic chair by a discarded cigarette end, indicates that this instruction was not always adhered to. As the last cigarette to be smoked on the balcony of C318 was nearly 3 hours before the smell of burning was reported and an ash tray was used on the balcony, it is highly probable that the cigarette end igniting the fire was discarded elsewhere.
The smoke and heat detector alarm sequence records indicate the fire spread from a balcony in the middle of zone 3 on deck 10, to balconies and staterooms on decks 10, 11 in zones 3 and 4 within 6 minutes, and to zone 5 in almost exactly 30 minutes. Analysis indicates that the fire spread rapidly due to two major factors. First, the materials in the balcony furniture, deck tiles, and partitions were readily ignitable by flame, and generated large amounts of heat. The screed beneath the deck tiles was also likely to have contributed to the fire load and localised combustion. Second, once fire was established, the strong wind over the deck provided ample oxygen, spread molten and burning debris, and generated local ‘blow-torch’ effects in the gaps above and below the partitions which increased the temperature of the fire in these areas.
Although manoeuvring of the ship was initiated within 5 minutes of the captain arriving on the bridge, this was 8 minutes after the alarm had been raised, and it took until 03:20 for the relative wind to shift to the starboard bow, thus sheltering the fire. During this period, the fire had already covered about half of the final damaged area. The frequency of alarms reduced significantly after 03:20, which highlights the importance of the relative wind in the development and growth of external fires and the need to consider manoeuvring as soon as possible.
Marine Accident Investigation Branch Findings
The following major safety issues were identified as a result of the MAIB investigation. They are not listed in any order of priority:
- The fire started on the balconies in the vicinity of staterooms C316 and C318, on deck 10, and was probably ignited by a cigarette end discarded elsewhere.
- The fire spread rapidly across zones and decks because of the combustible materials on the balconies, and the strength and direction of the wind over the deck.
- The balconies on board Star Princess were categorised as ‘open deck spaces’ to which the prevailing fire protection regulations did not prescribe the combustibility, smoke generation potential, and toxicity of materials used.
- Smoke entered the alleyway in zone 3 on deck 12 through outside staterooms, preventing a number of passengers from evacuating safely, and resulting in the death to one passenger, and serious injury to others.
- The use of door wedges in self-closing doors, and leaving such doors ajar, has the potential to breach openings in fire class divisions.
- The probability that passengers were trapped only became fully apparent when the staff engineer recovered two passengers from a stateroom at the forward end of the alleyway on deck 12, zone 3, shortly after arriving at the scene at 03:35.
- Passengers trapped in A340 were not able to alert the crew to their situation by calling 911 from their stateroom telephone, because the customer service desk was not manned after the crew alert was signalled.
- The initial actions taken after the alarm was raised at 03:09, including the calling of the assessment party, and the signalling of the crew alert and GES, were prompt and in accordance with the ship’s written procedures.
- As the fire was difficult to access, had not been drilled, and was already well established by the time the fire-fighting effort was started, the application and energy of the ship’s crew to bring it under control in about 1 hour, merits commendation.
- The combined effect of the water mist system and the restricted use of combustible materials in staterooms prevented the fire from spreading further into the ship, despite temperatures on the balconies reaching in excess of the 550°C.
- Had a roll call initially been started with the passengers from the staterooms in the fire affected areas, rather than the entire ship, a more rapid and accurate determination of those missing might have been possible.
Recommendations and Regulatory Change
As a result of its investigation the MAIB made a number of recommendations to the International Maritime Organisation (IMO), the International Council of Cruise Lines (ICCL), Flag States, Princess Cruise Lines, other cruise lines operating ships fitted with balconies and the classification societies. The ICCL was the most pro-active body and issued a safety notice dated 13 April 2006 to notify its members of the preliminary indications from the fire on board Star Princess and to urge immediate action. This action included the aim of replacing combustible balcony partitions with non-combustible partitions within 6 months. The MAIB formally supported this ICCL initiative and urged regulatory action by IMO.
On 1 October 2006, ICCL confirmed that 14 of its member companies (including Princess Cruise Lines) had implemented the immediate actions and conducted the fire risk assessments of balcony areas as recommended in its Safety Notice. ICCL also confirmed that its members had all developed plans of action for the replacement of identified combustible balcony partitions with suitable non-combustible materials. In this respect, the Carnival Corporation completed this work on all 26,400 balconies on its 81 ships by the end of December 2006.
The IMO Maritime Safety Committee (MSC) in December 2006 adopted amendments to SOLAS chapter II-2 and to the International Code for Fire Safety Systems (FSS Code) to strengthen the fire protection arrangements in relation to cabin balconies on passenger vessels. The amendments were aimed at ensuring that existing regulations 4.4 (Primary deck coverings), 184.108.40.206 (Ceilings and linings), 5.3.2 (Use of combustible materials) and 6 (Smoke generation potential and toxicity) are also applied to cabin balconies on new passenger ships. For existing passenger ships, relevant provisions require that furniture on cabin balconies be made of restricted fire risk material, unless fixed water spraying systems, fixed fire detection and fire alarm systems are fitted and that partitions separating balconies be constructed of non combustible materials, similar to the provisions for new passenger ships. The amendments entered into force on 1 July 2008.
The adoption followed agreement in May 2006 of approved draft amendments to SOLAS chapter II-2 and the FSS Code to strengthen the fire protection arrangements in relation to cabin balconies on passenger vessels, to fast track the work carried out by ICCL and MAIB. Even fast-track changes to SOLAS regulations take a considerable time to implement. The major owners are much more responsive and organisations like MAIB encourage this by posting compliance details on their websites. Unfortunately few prospective passengers consult this before booking a voyage.
The work of the Regulatory Authorities
Since the first International Convention for the Safety of Life at Sea met in 1914 various regulatory authorities have been engaged in a continuous effort to improve all aspects of maritime safety. These Articles merely address the SOLAS work concerning passenger ship regulation, but IMO are equally active in the regulation of all types of maritime activity. It must be recognised however that sea transportation is an international activity and national safety authorities have a limited ability to influence all 168 IMO members.
In Britain the Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to, or on board, UK vessels worldwide and other vessels in UK territorial waters. As far as the MAIB is concerned, the sole objective of investigating an accident is to determine its circumstances and causes, with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose of MAIB to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame. The MAIB do not enforce laws or carry out prosecutions. Within the British area of jurisdiction the Maritime and Coastguard Agency ensures the application of all IMO regulations.
Similarly in the USA the National Transportation Safety Board examines and investigates all types of marine accidents to, or on board, US vessels worldwide and other vessels in US territorial waters. Its recommendations are passed to the US Coastguard, the International Council of Cruise Lines (which, despite its name is mainly made up of companies operating out of America) and individual cruise companies. Again these are merely recommendations and are often rejected by some operators. The US Coastguard essentially ensures that ships trading in US waters substantially comply with SOLAS regulations.
Like many UN agencies, the IMO is obliged to work within the confines of defining regulations that will be accepted by its member states. As a result many enhanced safety regulations are only applicable to ships built after specified dates and the older, existing vessels are not required to comply. The travelling public are usually unaware of the dangers they may face when boarding the oldest vessels.
Whilst the application of safer international regulations can be frustratingly slow, safety considerations are often virtually non-existent for national passenger and ferry services in many third-world countries. In recognition of the considerable loss of life experienced in this sector, the IMO and the non-governmental industry organization Interferry, signed a Memorandum of Understanding on 20 January 2006, formalizing the two Organizations' intent to work together towards enhancing the safety of non-Convention ferries by collaborating, through IMO's Integrated Technical Co-operation Programme, on related capacity-building activities within developing countries. The next step is to conduct a detailed, research-based analysis of the problems, prior to the establishment of a working group in Bangladesh, the selected pilot country, in which a variety of stakeholders, as well as experts, have been invited to participate. Progress appears to be very slow, in the meanwhile more and more old, unsuitable and unsafe ferries continue to end their lives in developing countries.
No article on passenger ship safety would be complete without reference to the Philippine ferry operator Sulpicio Lines, which has arguably the worst peacetime safety record of any shipping company in history.
Sulpicio Lines Ferry Losses
||Princess of the Orient
||Princess of the World
||Princess of the Stars
It is worth noting that in 21 years Sulpicio Lines’ ships have killed 5,718 people, while the total peacetime fatalities since 1905, from every other maritime disaster involving passenger ships over 10,000 GRT is 6,291.
Dona Paz, as Himeyuri Maru had a passenger capacity of 608 people for Japanese domestic ferry service. The Philippine authorities allowed this to be increased to 1,424 persons. The generally accepted estimated is that 4,314 lives were lost in the sinking of Doña Paz, making it the world's worst peacetime sea tragedy. See Passenger Ship Disasters - Part 11
Photo 13: Sulpicio’s Dona Paz in 1984
In an attempt to lessen ferry casualties the Philippine authorities ban ferry traffic in severe storm conditions. Sulipicio also appears to have taken a relaxed view of the application of this regulation, resulting in the 2008 loss of Princess of the Stars. See Passenger Ship Disasters - Part 5
Photo 14: Princess of the Stars
It must be emphasised that Sulipicio Lines has never been held liable in the Philippine Courts. After the sinking of Princess of the Stars however, the Philippines Board of Marine Inquiry initially recommended that the Maritime Industry Authority “consider the suspension of the Certificate of Public Convenience (CPC) of Sulpicio Lines in accordance with existing laws, rules and regulations (and its criminal liability for the sinking)." The final report blamed human error in the part of the ship’s missing, presumed dead captain. As a result of this ruling, Sulipicio has sold some of its ferries to other Philippine operators.
Photo 15: Cebu Princess. Sold by Sulpicio to Roble Shipping
In November 2009 Sulpicio Lines were once again granted a passenger licence by the Philippine authorities, although for the present this is restricted to a single ferry – Princess of the South.
Photo 16: Sulpicio’s re-licensed Princess of the South. Her permanent external stairways are a common feature on Philippine ferries.
A complete Bibliography for all of these Articles is given at the end of Part 12. The official Ecstasy fire report referred to in this Article is:
- NATIONAL TRANSPORTATION SAFETY BOARD - MARINE ACCIDENT REPORT
PB2001-916401 - NTSB/MAR-01/01: Adopted May 1, 2001
The official Star Princess report is:
- DEPARTMENT FOR TRANSPORT – MARINE ACCIDENT INVESTIGATION BRANCH
Report No 28/2006: October 2006
Many of the photographs used to illustrate this article are from the Ships Nostalgia Galleries, which are available for use in the Directory. Others are from Wikimedia Commons or are in the public domain. The individual photographs used in Part 8 have been provided as follows: -
Frontispiece - Ships Nostalgia - visualships
- Ships Nostalgia – stein
- Ships Nostalgia – dom
- Ships Nostalgia – Bruce Carson
- Ships Nostalgia – linerrich
- Ships Nostalgia – qm2qe2qv
- Ships Nostalgia – Jan H
- STX Europe
- Ships Nostalgia – OlympicNut
- Ships Nostalgia – Punta secca
Article written and compiled by Fred Henderson