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Safety Recommendation Details

Safety Recommendation M-01-001
Details
Synopsis: On the afternoon of 7/20/98, the Liberian passenger ship Ecstasy had departed the port of Miami, Florida, en route to Key West, Florida, with 2,565 passengers and 916 crewmembers on board when a fire started in the main laundry shortly after 1,700. The fire migrated through the ventilation system to the aft mooring deck where mooring lines ignited, creating intense heat and large amounts of smoke that spread to several areas in the aft two main vertical zones (MVZs) of the ship. The Ecstasy subsequently lost propulsive power and most steering and had to be towed back to Miami. During the on-board emergency, all passengers evacuated safely from the affected areas; however, two crewmembers became trapped on deck No. 2, and firefighting teams had to rescue them. Nine passengers were treated for injuries resulting from pre-existing conditions or smoke inhalation, and 14 crewmembers sustained minor injuries from firefighting activities and/or smoke inhalation. Carnival Corporation, Inc., the owner of the Ecstasy, estimated that losses from the fire exceeded $17 million.
Recommendation: TO THE UNITED STATES COAST GUARD: During control verification examinations, review a drill scenario in which one or more main vertical zones are inaccessible and evaluate the procedural effectiveness of the crew in crowd control, crisis management, lifejacket distribution, and passenger accountability.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Harbor, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA98MM035
Accident Reports:
Fire On Board Liberian Passenger Ship Ecstasy
Report #: MAR-01-01
Accident Date: 7/20/1998
Issue Date: 5/14/2001
Date Closed: 2/4/2013
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 2/4/2013
Response: The NTSB understands that, during control verification examinations, the Coast Guard reviews drill scenarios in which one main vertical zone is inaccessible and evaluates the procedural effectiveness of the crew in four areas: crowd control, crisis management, lifejacket distribution, and passenger accountability. Inspectors evaluate the procedural effectiveness of the crew in these areas by observing crew performance during drills and by asking crewmembers questions specific to these areas, and also, on occasion, a fifth area, witness passenger muster, as required by SOLAS Chapter III, Regulation 19.2.2, in accordance with Navigation and Vessel Inspection Circular 03-08. In addition, the Coast Guard reviews drill scenarios in which one main vertical zone is compromised by fire and is inaccessible; this evaluation includes questioning crew members specifically about procedures, decisions, and actions they would take were such an incident to occur. Further, the Advanced Passenger Vessel Control Verification Examination Course conducted at the Cruise Ship National Center of Expertise reinforces the concepts emphasized during course instruction. These combined actions satisfy Safety Recommendation M-01-1, which is classified CLOSED—ACCEPTABLE ACTION.

From: USCG
To: NTSB
Date: 8/15/2012
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: During control verification examinations, the Coast Guard reviews drill scenarios in which one main vertical zone (MVZ) is inaccessible and evaluates the procedural effectiveness of the crew in crowd control, crisis management, lifejacket distribution, and passenger accountability. Currently, inspectors evaluate the procedural effectiveness of the crew in crowd control, crisis management, lifejacket distribution, and passenger accountability by observing crew performance during drills and by asking crewmembers questions specific to these topics. In addition, our inspectors witness this in practice on occasions when we happen to be onboard a vessel during the passenger muster required by SOLAS Chapter III, Regulation 19.2.2, in accordance with Navigation and Vessel Inspection Circular (NVIC) 03-08. Furthermore, the Coast Guard reviews a drill scenario in which one main vertical zone (MVZ) is compromised by fire and is inaccessible. This includes questioning crew members specifically about procedures, decisions and actions they would take in such an incident. The Advanced Passenger Vessel Control Verification Examination Course conducted at the Cruise Ship National Center of Expertise reinforces the concepts noted herein during course instruction. The Coast Guard does not review a drill scenario involving more than one inaccessible MVZ. Any drill scenario involving more than one MVZ exceeds a fundamental fire safety objective of SOLAS to contain, control, and suppress fire and explosion in the compartment of origin (i.e. the standards intend to limit a fire within one main vertical zone). Furthermore, SOLAS Chapter III, Regulation 19 does not suggest such a multiple MVZ scenario. Accordingly, ships that comply with SOLAS do not drill to a multiple MVZ scenario, and to make them do so would require the entire cruise industry to change their training, decision support and safety management systems. An amendment to SOLAS or a regulatory change would be required to compel ships to drill to such a scenario and the Coast Guard does not support such action. We consider our action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
Date: 11/16/2011
Response: This letter concerns 29 open safety recommendations, enclosed, that the National Transportation Safety Board (NTSB) issued to the U.S. Coast Guard between 1995 and 2010. For some of these recommendations, the NTSB has not received an update in almost 3 years regarding the status of action either taken or planned to address the important safety issue that the recommendation addresses. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. NOTE TO FILE (not in original letter): The 29 safety recommendations are: M-95-013, M-98-033, M-98-037, M-99-001, M-00-004, M-01-001, M-02-005, M-04-003, M-05-006, M-06-001, M-06-002, M-07-001, M-07-006, M-07-007, M-08-001, M-08-002, M-09-001, M-09-002, M-09-003, M-09-004, M-09-009, M-09-010, M-09-014, M-09-015, M-09-016, M-09-017, M-10-005, M-10-002 and M-10-006.

From: NTSB
To: USCG
Date: 6/26/2009
Response: Although the NTSB is pleased that the Coast Guard indicated agreement with this recommendation in 2001 and indicates that it plans to take action as requested, the NTSB is very concerned that the Coast Guard has yet to make any progress on this relatively simple matter. The Coast Guard’s 2001, 2007, and now 2009 responses differ little in their content. The NTSB would like to suggest to the Coast Guard that there is no need to revise or issue a regulation, but only to revise the Coast Guard’s control verification examination (CVE) protocol, to satisfy the recommendation. The NTSB understands that the Coast Guard is considering expanding the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, using the scenario that a main vertical zone is inaccessible during an emergency. The NTSB reminds the Coast Guard that these checks should be done in evaluation of the procedural effectiveness of the crew in crowd control and crisis management. In light of the 8 years since the recommendation was issued and the lack of progress to address it, Safety Recommendation M-01-1 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 2/13/2009
Response: Letter Mail Controlled 2/20/2009 11:29:34 AM MC# 2090084: - Walter D. Rabe, United States Coast Guard: We are evaluating these requirements in part, in accordance with the STCW, which requires that all officers and those ratings designated to assist passengers in emergency situations must be trained in certain elements of basic safety, crowd management, crisis management and human behavior, as appropriate. During a Control Verification Examination (CVE), Coast Guard inspectors check for documentary evidence providing proof of this training and assess crew proficiency in basic safety procedures, crowd control and crisis management skills. This assessment is made by observing crew effectiveness through crew leadership, operation, team work, and communication during abandon ship and fire drills; by asking questions of crew members participating in the drills; by asking questions of crew members assembled at their muster stations and emergency stations throughout the ship; and by random questioning of crew members during a general walk around the ship. We will expand the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, given a scenario that a main vertical zone is inaccessible during an emergency. 1-30-07: No change in status since last response. The Coast Guard is evaluating these requirements in part, in accordance with the Standards for Training, Certification, and Watchkeeping Convention (STCW), which requires that all officers and those ratings designated to assist passengers in emergency situations must be trained in certain elements of basic safety, crowd management, crisis management and human behavior, as appropriate. During a Control Verification Examination (CVE), Coast Guard inspectors check for documentary evidence providing proof of this training and assess crew proficiency in basic safety procedures, crowd control and crisis management skills. This assessment is made by observing crew effectiveness through crew leadership, operation, team work, and communication during abandon ship and fire drills; by asking questions of crew members participating in the drills; by asking questions of crew members assembled at their muster stations and emergency stations throughout the ship; and by random questioning of crew members during a general walk around the ship. The Coast Guard will expand the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, given a scenario that a main vertical zone is inaccessible during an emergency.

From: NTSB
To: USCG
Date: 9/10/2007
Response: NMC# 103024: The Safety Board notes that the Coast Guard continues to evaluate the recommendation in accordance with the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended in 1995, which requires that all officers and personnel whose ratings are designated to assist passengers in emergency situations be trained in certain elements of basic safety, crowd management, crisis management, and human behavior, as appropriate. The Board is aware that during a control verification examination (CVE), Coast Guard inspectors check for documentary evidence providing proof of this training and assess crew proficiency in basic safety procedures, crowd control, and crisis management skills. This assessment is made by observing crew effectiveness through crew leadership, operation, team work, and communication during abandon ship drills and fire drills, by asking questions of crewmembers participating in the drills, by questioning crewmembers assembled at their muster stations and emergency stations throughout the ship, and by random questioning of crewmembers during the inspectors’ general walk around the ship. The Safety Board is pleased that the Coast Guard will expand the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, including an emergency drill scenario in which a main vertical zone will be inaccessible. The Board encourages the Coast Guard to expedite its action to implement the recommendation. Pending completion of these initiatives, Safety Recommendation M-01-1 is classified OPEN -- ACCEPTABLE RESPONSE.

From: NTSB
To: USCG
Date: 1/30/2007
Response: No change in status since last response. The Coast Guard is evaluating these requirements in part, in accordance with the Standards for Training, Certification, and Watchkeeping Convention (STCW), which requires that all officers and those ratings designated to assist passengers in emergency situations must be trained in certain elements of basic safety, crowd management, crisis management and human behavior, as appropriate. During a Control Verification Examination (CVE), Coast Guard inspectors check for documentary evidence providing proof of this training and assess crew proficiency in basic safety procedures, crowd control and crisis management skills. This assessment is made by observing crew effectiveness through crew leadership, operation, team work, and communication during abandon ship and fire drills; by asking questions of crew members participating in the drills; by asking questions of crew members assembled at their muster stations and emergency stations throughout the ship; and by random questioning of crew members during a general walk around the ship. The Coast Guard will expand the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, given a scenario that a main vertical zone is inaccessible during an emergency.

From: NTSB
To: USCG
Date: 10/22/2001
Response: The Safety Board understands that the Coast Guard is evaluating the recommendation, in part, in accordance with the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended in 1995 (STCW Convention), which requires that all officers and those ratings designated to assist passengers in emergency situations be trained in certain elements of basic safety, crowd management, crisis management, and human behavior, as appropriate. The Board is aware that during a control verification examination (CVE), Coast Guard inspectors check for documentary evidence providing proof of this training and assess crew proficiency in basic safety procedures, crowd control, and crisis management skills. Further, this assessment is made (1) by observing crew effectiveness through crew leadership, operation, team work, and communication during abandon ship and fire drills; (2) by asking questions of crewmembers participating in the drills; (3) by asking questions of crewmembers assembled at their muster stations and emergency stations throughout the ship; and (4) by random questioning of crewmembers during a general walk around the ship. The Safety Board is pleased that the Coast Guard will expand the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, given a scenario that a main vertical zone is inaccessible during an emergency. Pending receipt of further information from the Coast Guard on implementation of the recommendation, Safety Recommendation M-01-1 is classified OPEN -- ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 8/1/2001
Response: Letter Mail Controlled 08/10/2001 1:58:43 PM MC# 2010638 - From Paul J. Pluta, Rear Admiral, Assistant Commandant for Marine Safety and Environmental Protection: We concur with this recommendation. The Coast Guard is already evaluating these requirements in part, in accordance with the STCW Convention, which requires that all officers and those ratings designated to assist passengers in emergency situations must be trained in certain elements of basic safety, crowd management, crisis management and human behavior, as appropriate. During a Control Verification Examination (CVE), Coast Guard inspectors check for documentary evidence providing proof of this training and assess crew proficiency in basic safety procedures, crowd control and crisis management skills. This assessment is made by observing crew effectiveness through crew leadership, operation, team work, and communication during abandon ship and fire drills; by asking questions of crew members participating in the drills; by asking questions of crew members assembled at their muster stations and emergency stations throughout the ship; and by random questioning of crew members during a general walk around the ship. The Coast Guard will expand the crew assessment portion of the CVE to include evaluation of crew effectiveness in lifejacket distribution procedures and passenger accountability, given a scenario that a main vertical zone is inaccessible during an emergency. We will inform the Board when our action on this recommendation has been completed.