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Safety Recommendation Details

Safety Recommendation M-01-012
Details
Synopsis: THIS RECOMMENDATION ADDRESSES THE ADEQUACY OF ENGINEERING SYSTEMS DESIGN. THE RECOMMENDATION IS DERIVED FROM THE SAFETY BOARD'S INVESTIGATION OF THE FIRE ON BOARD THE LIBERIAN PASSENGER SHIP ECSTASY NEAR MIAMI, FLORIDA, ON 7/20/98, AND IS CONSISTENT WITH THE EVIDENCE WE FOUND AND THE ANALYSIS WE PERFORMED. AS A RESULT OF THIS INVESTIGATION, THE SAFETY BOARD ISSUED TWELVE SAFETY RECOMMENDATIONS, ONE OF WHICH IS DIRECTED TO THE INTERNATIONAL ASSOCIATION OF CLASSIFICATION SOCIETIES. INFORMATION SUPPORTING THIS RECOMMENDATION IS DISCUSSED BELOW. THE SAFETY BOARD WOULD APPRECIATE A RESPONSE FROM YOU WITHIN 90 DAYS ADDRESSING THE ACTIONS YOU HAVE TAKEN OR INTEND TO TAKE TO IMPLEMENT OUR RECOMMENDATION.
Recommendation: THE NTSB RECOMMENDS THAT THE INTERNATIONAL ASSOCIATION OF CLASSIFICATION SOCIETIES: RECOMMEND THAT YOUR MEMBERS REQUIRE SYSTEMS DESIGNERS, MANUFACTURERS, AND/OR SHIPYARDS TO PERFORM AND SUBMIT QUALITATIVE FAILURE ANALYSES TO ENSURE THE FAIL-SAFE OPERATION OF PROPULSION SYSTEMS ON NEW PASSENGER SHIPS.
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: 11/7/2008
Addressee(s) and Addressee Status: International Association of Classification Societies (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: International Association of Classification Societies
Date: 11/7/2008
Response: The Safety Board notes that, on June 23, 2008, IACS approved unified requirement (UR) M69, Qualitative Failure Analysis for Propulsion and Steering on Passenger Ships, which is to be uniformly implemented by IACS societies for passenger ships that are contracted for construction on or after January 1, 2010. This document details a qualitative failure analysis for propulsion and steering for new passenger vessels of 120 meters or more in length or those having three or more main vertical zones; specifically, UR M69 will consider the propulsion and steering equipment and all associated systems that might impair the availability of propulsion and steering. Because UR M69 satisfies the recommended action, Safety Recommendation M-01-12 is classified Closed Acceptable Action.

From: International Association of Classification Societies
To: NTSB
Date: 6/24/2008
Response: Letter Mail Controlled 6/24/2008 11:07:37 AM MC# 2080365: You may recall the subject recommendation made to IACS after the fire on board the cruise ship Ecstasy and our subsequent correspondence. Iam pleased to be able to send you the new IACS Unified Requirement M69 and its Technical Background document.

From: NTSB
To: International Association of Classification Societies
Date: 5/2/2008
Response: The Safety Board appreciates learning that IACS established a project team to address this recommendation and that the scope of the recommended action requires time for the team to address. The Safety Board notes that IACS’s Machinery Panel prepared a first draft of a new IACS unified requirement (UR) for Qualitative Failure Analysis for Propulsion on Passenger Ships. The Safety Board understands that the project team is reviewing comments received on the initial draft of the UR and that the individual member class societies still need to provide comments on the draft. Mr. Wright has advised the Board that IACS expects the outstanding requirements to be resolved during 2008 and that IACS will provide a further update on the progress being made to implement the Board’s recommendation once this has occurred. Pending the issuance of the UR, Safety Recommendation M-01-12 is classified Open Acceptable Response. While the Safety Board is pleased that action is now being taken to implement this recommendation, given that 7 years have passed since it was issued, the Safety Board continues to urge IACS to expedite action to complete the IACS unified requirement. We would appreciate receiving periodic updates as your efforts continue.

From: International Association of Classification Societies
To: NTSB
Date: 1/2/2008
Response: Letter Mail Controlled 1/4/2008 3:02:36 PM MC# 2070783: 1-2-8: I refer to my email of 15 October 2007 and subsequent exchanges with Steve McIntyre and can understand that our lack of feedback makes you restless. However, in the following we would like to explain the status of the work and give a brief description of what is going on within IACS's process so you hopefully understand the reasons why we are not meeting the planned target date. The NTSB Safety Recommendation M-01-12 is being addressed by the IACS Machinery Panel, a working group with representatives from all IACS members that progresses IACS development efforts on existing and new Resolutions relating to machinery and systems. Owing to the complexity of the subject matter of the Recommendation, the Machinery Panel decided to establish a dedicated Project Team with representatives from four member societies. The Project Team was of the opinion that the format could be used for other systems associated with the revised SOLAS Chapter II-2, Regulation 21 - SOLAS 2006 Amendments, Resolution MSC.216(82) for safe return to port and therefore needed some time to focus due to the scope of the original task which encompassed a wide range of accident scenarios bounded by FMEAs for different IMO regulations. The Project Team, which reports to the Machinery Panel, has prepared a first draft of a new IACS Unified Requirement (UR) for “Qualitative Failure Analysis for Propulsion on Passenger Ships”. This new draft UR identifies systems and components that should be subject to a qualitative failure analysis and specifies failure criteria. Futhermore, verification and documentation requirements are detailed. The draft UR prepared by the Project Team has been reviewed by the Machinery Panel and comments (additional proposals, requests for clarification, etc.) were passed back to the Project Team. This is an iterative process; however, it is important to recognize that all member societies should have an opportunity to provide comments and thereby shape the new UR. Issues still under consideration include functional vs. hardware requirements and documentation requirements. It is expected that the outstanding issues can be resolved early in 2008 and we are endeavoring to come to consensus and conclusion on the technical work as soon as possible and will reply to the NTSB with either IACS's formal reply or a further progress report not later than 1 March 2008. Regards, Colin Wright, Principal Technical Officer, IACS Permanent Secretariat

From: NTSB
To: International Association of Classification Societies
Date: 7/14/2006
Response: The Safety Board is disappointed to learn of the delays during restructuring of the IACS working groups in 2004 and 2005, and that the report from the project team (PT) assigned to address this issue for the IACS General Policy Group was inconclusive. We had hoped that by this time, more than 5 years after this recommendation was issued and almost 8 years after the fire that prompted it, conclusive action would have been taken by the IACS. The Board notes that a new PT is being formed to reevaluate the issue that will report initially to the machinery panel; at the same time, another PT under the same panel will undertake a comprehensive review of the scope and nature of rules for essential engineering systems and will propose a way to address this issue. When both PTs have completed their review and made task recommendations, the tasks will be added to the list on the IACS Web site. Considering the lack of progress made thus far on this safety recommendation, the Safety Board would appreciate an indication from the IACS of the importance you have placed on resolving this issue. Defining the tasks and placing them on your Web site only mark the beginning of the effort. We would also appreciate learning the anticipated schedule for the tasks, including when they will be placed on your Web site and when the General Policy Group expects the work will be completed. Pending completion of this project, Safety Recommendation M-01-12 is classified "Open-Acceptable Response." The Safety Board would appreciate receiving a copy of IACS' unified requirement when completed.

From: International Association of Classification Societies
To: NTSB
Date: 3/31/2006
Response: Letter Mail Controlled 3/31/2006 2:05:38 PM MC# 2060170: I do apologize for not having kept you up-to-date. Following a certain hiatus occasioned by the restructuring of the IACS working groups through 2004 and its implementation in 2005, the Project Team delivered its report to the IACS General Policy Group last autumn. However, its report was inconclusive and a new Project Team, with recast terms of reference, is being formed. Under the new structure, this PT will report initially to the Machinery Panel. At the same time, another PT under the Machinery Panel is to undertake a comprehensive review of the scope and nature of rules for essential engineering systems and propose a way forward. When both sets of terms of reference have been finalized, the tasks will be added to the list on the IACS website. Yours sincerely, Colin Wright, Senior Technical Officer, IACS Permanent Secretariat

From: NTSB
To: International Association of Classification Societies
Date: 3/11/2004
Response: The Safety Board is pleased to learn that IACS has assembled a special project team (PT) on failure mode and effects analysis (FMEA) made up of two formal safety assessment (FSA) experts, a machinery expert, an electrical system expert, an FSA information communications technology (ICT) and control systems expert, and a nautical systems and communication expert from a total of six member societies. Mr. Wright reports that the aims of the PT are (1) to develop necessary guidance and procedures for FMEA analysis, (2) to develop IACS unified interpretations of International Maritime Organization regulations where FMEA are called for, and (3) to develop IACS' unified requirement for systematic analysis of failures in systems for new passenger ships. Mr. Wright further reports that the PT should produce its initial report to the IACS general policy group at the end of the second quarter of 2004. Pending completion of this project, Safety Recommendation M-01-12 is classified, "Open--Acceptable Response." The Safety Board would appreciate receiving a copy of IACS unified requirement when completed.

From: International Association of Classification Societies
To: NTSB
Date: 12/22/2003
Response: Letter Mail Controlled 1/6/2004 3:33:26 PM MC# 2040006 I refer to Mr. Brown's email of 18 Dec. '03. The task was assigned originally to the IACS Working Party on Machinery, with input from other working groups. It is now being followed up by a special Project Team on Failure Mode and Effects Analysis (PT/FMEA) made up of two FSA Experts, a Machinery Expert, an Electrical System Expert, an FSA, ICT and Control Systems Expert and a Nautical Systems and Communication Expert from a total of six member societies. The Aims are: (i) To develop necessary guidance and procedures for FMEA analysis. (ii) To develop IACS Unified Interpretations of IMO regulations where FMEA are called for. (iii) To develop IACS Unified Requirement for systematic analysis of failures in systems for new passenger ships. The PT should produce its initial report to the IACS General Policy Group (GPG) at the end of 2Q 2004. For your general information, the current IACS work programme is listed on our website. Colin Wright, Senior Technical Officer, IACS Permanent Secretariat.

From: NTSB
To: International Association of Classification Societies
Date: 12/18/2003
Response: On August 17, 2001, you sent a facsimile message, updating the status of actions being taken to implement Safety Recommendation M-01-12, by tasking relevant expert working groups to consider this safety recommendation. In its January 23, 2003,reply, the Safety Board wrote that it was aware, as stated in your faxed letter, that some "member societies currently offer optional, voluntary, class notations for various levels of residual or redundant propulsion capability in the event of single point failures or accidents of defined magnitude...which require the use of qualitative failure analyses." The Board further understood that "none of the member societies currently require full propulsion redundancy and its demonstration using qualitative failure analysis as a mandatory requirement for classing new passenger ships." In determining how to address our recommendation, we encourage you not to focus solely on "redundant propulsion" systems. The Board did not recommend that redundant propulsion systems be required on new passenger vessels, nor does the Board believe that the use of qualitative failure analysis should be limited to redundant propulsion systems. Our recommendation applies to all new passenger vessels, regardless of the propulsion system used. As for the meaning of the phrase "ensure the fail-safe operation of propulsion systems," the critical term is "fail-safe." We recognize that individual components may fail. However, the failure or malfunction of an individual component should not propagate through the entire system, resulting in a complete loss of propulsive power. The Safety Board believes that qualitative failure analysis can be used to identify potential failures that could lead to a complete loss of propulsion. This information could help the designer determine what modifications could increase the reliability of the system. Although redundancy is one method that designers can use to achieve high system reliability, improving the robustness of non-redundant components might also be an effective way to achieve this objective. Pending further response by IACS of the actions taken on this issue, Safety Recommendation M-01-12 was classified "Open--Acceptable Response." The Safety Board has not received further information from IACS regarding actions being taken in response to this safety recommendation. The Board is interested in knowing whether and how its recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that might be shared with others. That is why we monitor the progress of our recommendations. We would appreciate being informed of the specific actions taken in response to this recommendation. Please address your response to Ms. Ellen Engelman Conners, Chairman, National Transportation Safety Board, and refer to the recommendation by number. A copy of the recommendation letter is enclosed for your reference.

From: NTSB
To: International Association of Classification Societies
Date: 1/23/2002
Response: The Safety Board is pleased to learn that IACS will be tasking its relevant expert working groups to consider this safety recommendation. The Board was aware, as you state in your letter, that some "member societies currently offer optional, voluntary, class notations for various levels of residual or redundant propulsion capability in the event of single point failures or accidents of defined magnitude...which require the use of qualitative failure analyses." Further, the Board understands that "none of the member societies currently require full propulsion redundancy and its demonstration using qualitative failure analysis as a mandatory requirement for classing new passenger ships." In determining how to address our recommendation, we encourage you not to focus solely on "redundant propulsion" systems. The Board did not recommend that redundant propulsion systems be required on new passenger vessels, nor does the Board believe that the use of qualitative failure analysis should be limited to redundant propulsion systems. Our recommendation applies to all new passenger vessels, regardless of the propulsion system used. As for the meaning of the phrase "ensure the fail-safe operation of propulsion systems," the critical term is "fail-safe." We recognize that individual components may fail. However, the failure or malfunction of an individual component should not propagate through the entire system, resulting in a complete loss of propulsive power. The Safety Board believes that qualitative failure analysis can be used to identify potential failures that could lead to a complete loss of propulsion. This information could help the designer determine what modifications could increase the reliability of the system. Although redundancy is one method that designers can use to achieve high system reliability, improving the robustness of non-redundant components might also be an effective way to achieve this objective. We hope this information assists you in considering how to respond to our recommendation. Until advised by IACS of the actions taken on this issue, Safety Recommendation M-01-12 is classified "Open--Acceptable Response."

From: International Association of Classification Societies
To: NTSB
Date: 8/17/2001
Response: Letter Mail Controlled 08/21/2001 1:02:48 PM MC# 2010669 I am pleased to advise that IACS will be tasking its relevant expert working groups to consider your recommendation. A number of Member Societies currently offer optional, voluntary, class notations for various levels of residual or redundant propulsion capability in the event of single point failures or accidents of defined magnitude (e.g. flooding of a space, etc.) which require the use of qualitative failure analyses. However, none of the societies currently require full propulsion redundancy and its demonstration using qualitative failure analysis as a mandatory requirement for classing new passenger ships. In addressing your recommendation, Members are considering whether IACS should develop mandatory requirements in this regard, as proposed by the Board, or whether IACS should submit the matter, with a viewpoint, for consideration and decision by the IMO, in the context of IMO's current studies of safety issues associated with large new passenger vessels. It would help in our deliberations if you would kindly provide more advice or clarification with respect to the meaning of the phrase "ensure the fail-safe operation of propulsion systems" in the context of this recommendation. For example, does the recommendation mean that if a new passenger ship opts to be classed as "redundant propulsion," then IACS members should require systems designers, manufacturers, and/or shipyards to perform and submit qualitative failure analysis to assure that the propulsion system can sustain any single failure and still retain propulsion capability (though possibly degraded). If so, then a number of IACS Societies do already offer such optional classification notations. Or, does the recommendation mean that IACS members should require all new passenger ships to have redundant propulsion, and require system designers, manufacturers, and/or shipyards to perform and submit qualitative failure analysis to assure that the propulsion system can sustain any single failure and still retain propulsion capability (though possibly degraded). More advice from the NTSB in this regard will assist us in considering how to address your recommendation. We will advise you of the outcome of IACS' deliberations when they are completed.