Smoke billows from Ecstasy as Coastal Key West pours water on the ship’s stern. Tons of polypropylene mooring line on ship’s winches and nearby pallets fed the fire, which began in the laundry room and reached the mooring deck by way of an exhaust duct.
Ecstasy was leaving the Port of Miami, bound for Key West, Fla., July 20, 1998, when dense smoke began billowing from its stern (PM #35). The fire injured 23 people, knocked out both propulsion units, disabled one rudder and damaged the systems control to the other. Total damage from the fire has been evaluated at $17 million.
In its report, the NTSB concluded that the probable cause of the fire was “unauthorized welding by crewmembers in the main laundry that ignited a large accumulation of lint in the ventilation system and the failure of Carnival Cruise Lines to maintain the laundry exhaust ducts in a fire-safe condition.”
The role lint played in the fire may be unique in the history of maritime casualties. Investigators say they had never before encountered a ship fire that started with laundry lint. “This is the first one anyone had heard of,” said Lt. Cmdr. Robert D. Kirk, investigating officer with the U.S. Coast Guard District 7 Marine Safety Division in Miami.
The unusual circumstances complicated the investigation. Kirk said investigators had a hard time finding historical data on lint fires to help them analyze the events. “The only history was land-based,” he said.
But there was plenty of evidence from non-ship fires that lint in vents can be a serious hazard. “Laundry ducts are major causes of fires in houses,” according to Marjorie Murtagh, the director of the NTSB Office of Marine Safety. “Lint accumulation is something that needs to be dealt with.”
While the lint provided the initial fuel source for the fire, ignition came from two crewmembers using welding equipment to try to fix a broken piece of a laundry machine. The workers did not get authorization for the welding, even though the ship’s procedures required it.
A Coast Guard report on the Ecstasy fire describes how the blaze began and spread:
“At about 1630, the mangle, a machine that steam presses linens, began to malfunction. Linens fed into the mangle were bunching up. A ship’s fitter was summoned. He attempted to align the rollers of the mangle. In trying to adjust a bolt, he broke it off.”
By this time, a second fitter had arrived to help. The two went off to gather welding equipment and a fire blanket. When they returned, the first fitter spread the fire blanket over the rollers, climbed up onto the mangle and attempted to weld the bolt back on. The second fitter noticed the welding leads were too low and pulled the cables up, causing the leads to spark.
The sparks ignited a fire on the floor under the rollers. The two fitters managed to extinguish that fire with water from a sink. Then they noticed flames and smoke coming from the ventilation duct directly above the mangle. Their efforts to put the fire out with extinguishers failed and they evacuated the area.
The flames, feeding on the lint, were then making their way through the laundry’s ventilation duct, which exits in the vicinity of the ship’s aft mooring deck. It was here that the fire became most intense, feeding on the polypropylene mooring lines. About 7,200 pounds of this line was stored on three winches and five pallets. The lines on the starboard side of the deck did not burn, but the fire consumed the rest, approximately 3/4 of the total.
Investigators do not believe the fire was transmitted directly from the laundry ventilation duct to the mooring lines, because the distance from the terminus of the duct to the lines was too great. They suspect some as yet unidentified flammable material on the mooring deck served as a link between the duct and the lines.
The mooring deck and its equipment were severely damaged. About 250 passenger cabins above and forward of the mooring deck were also damaged; 70 of them had to be completely rebuilt. Key components affecting the ship’s propulsion and steering systems were damaged.
Cables supplying power to a crucial power distribution panel were located in a ventilation intake that opens onto the mooring deck. When these cables were damaged by the heat, power was cut from the high-speed breakers designed to protect the port and starboard propulsion systems. Without power, the breakers opened and both propulsion systems failed.
Similarly, the power cables for the port and starboard steering systems ran along the space above the mooring deck. The damage to these cables caused the complete loss of the port rudder. The starboard rudder could no longer be controlled from the bridge and had to be operated locally at the steering flat.
Complicating the situation still further was the failure of the fire detection system soon after the blaze began. When activated, the smoke detectors create an electrical short that sets off an alarm on the bridge. Every time a detector activates, it adds to the electric demand on the system.
The result was an overload of the system after just five detectors went off, leaving the crew unable to use the system to track the course of the fire or to detect the outbreak of any other fire elsewhere on the ship. “It got overloaded instantaneously,” Kirk said. “It wasn’t designed to handle that surge.”
No one was killed in the fire, but 23 required medical attention: six passengers for pre-existing conditions, three for smoke inhalation and 14 crewmembers for problems ranging from strains and bruises to smoke inhalation.
Murtagh noted that the ship and the people aboard were fortunate that the fire occurred close to port where help was available to put out the fire and tow the disabled ship to a safe berth. “If that casualty were under different circumstances at sea, they could be in very serious difficulty,” she said.
Immediately after the accident, the NTSB issued an urgent recommendation that ship operators inspect their laundry ventilation systems and clean out any lint accumulations found. The NTSB also urged the operators to institute continuing maintenance programs to detect and eliminate lint and any other combustible material in ventilation systems. “It’s not expensive, but something that needs to be done,” Murtagh said.
The NTSB made several other recommendations for Carnival, they included:
Instituting measures to prevent unauthorized activities, like welding, which could ignite a fire.
Modifying systems to mitigate the spread of fire and smoke from laundry rooms through ventilation ducts.
Examining propulsion systems and modifying electrical systems if necessary, so that a single failure will not lead to loss of both propulsion systems.
In directives to 13 cruise lines, the NTSB recommendations included:
Installing fire detection and suppression systems on mooring decks.
Installing automatic systems for mitigating the spread of smoke from laundry spaces through ventilation ducts.
Installing emergency call systems in passenger and crew cabins to permit occupants to signal their location in an emergency.
Developing fail-safe features in the construction of new ships by identifying components whose failure would cause loss of propulsion and steering and by mitigating the problems identified.
Murtagh noted that the NTSB is not trying to tell the cruise lines exactly what equipment or system to use to solve the problems identified. “We want them to install a system that will work for their ship,” she said.
Carnival has modified equipment and procedures on its ships in response to the NTSB recommendations, according to Jim Walsh, the line’s vice president of environmental health and safety.
The line has cleaned the laundry ventilation ducts and installed turbo lint filters on Ecstasy. Other ships in the fleet are being fitted with lint filters.
The filters “significantly cut down on lint going into the ducts,” Walsh said. The laundry staff is required to inspect the filters “five times or more a day.”
Access spaces have been cut into the laundry ventilation system of all the line’s ships to facilitate inspection of the ducts. Those ducts are to be cleaned every time the ship is dry docked, or about once every 2 to 2 1/2 years. Between dry dockings, crews are to look for any signs of lint build up in the system.
The cruise line has replaced the fire detection system with one that is not susceptible to overloading. “That was addressed immediately throughout the fleets,” Walsh said.
To prevent unauthorized hot work, welding equipment aboard Carnival ships now must be kept under lock and key.
Other measures being implemented by Carnival include:
Installing another junction box to back up the one that was damaged on the Ecstasy, tripping the high-speed breakers and disabling the propulsion systems.
Contracting a Finnish company, Delta Marin, to identify any other components whose failure would lead to the loss of crucial systems.
Installing fire suppression systems and closed-circuit television monitors on the aft mooring decks of its vessels. The systems will be installed on all ships by the end of October.
