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Safety Recommendation Details

Safety Recommendation M-02-006
Details
Synopsis: On the evening of November 17, 2000, the U.S. small passenger vessel Port Imperial Manhattan, with three crewmembers and eight passengers on board, was en route to Weehawken, New Jersey, from the borough of Manhattan in New York City, New York, when a fire broke out in the engine room. Crewmembers attempted to extinguish the fire with portable extinguishers, with no success. The fire burned out of control, causing the vessel to lose power and forcing the crew and passengers to abandon the interior spaces. The crew and passengers were rescued by another NY Waterway passenger vessel, and the burning vessel was towed to Manhattan, where the New York City Fire Department extinguished the fire. One passenger was treated for smoke inhalation. No deaths resulted from this accident. The estimated cost to repair the vessel was $1.2 million.
Recommendation: TO THE UNITED STATES COAST GUARD: Require that all small passenger vessels in commuter and ferry service, regardless of their date of build, be fitted with a fire detection system in the engineroom. (Superseded by M-07-001)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Marine
Location: River, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA01MM008
Accident Reports:
Fire on Board the Small Passenger Vessel Port Imperial Manhattan
Report #: MAR-02-02
Accident Date: 11/17/2000
Issue Date: 7/3/2002
Date Closed: 3/29/2007
Addressee(s) and Addressee Status: USCG (Closed - Superseded)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 3/29/2007
Response: On November 21, 2003, in a letter updating its position on open safety recommendations that had been issued by the Safety Board, the Coast Guard stated that it did not concur with Safety Recommendations M-02-6 or M-02-8 and requested that the recommendations be closed. With regard to Safety Recommendation M-02-6, the Coast Guard noted that after a careful and comprehensive review during the rulemaking process culminating in 1996, it had concluded that "while there was sufficient reason to require retrofitting on small passenger vessels with fiberglass reinforced plastic and wooden hulls, the substantial cost was not justified on small passenger vessels with steel and aluminum hulls." The Coast Guard stated further that extending the requirements for fire detection systems to vessels engaged in commuter and ferry service was not justified because those vessels accounted for only 8.4% of the fire casualties suffered by small passenger vessels from 1992 through 2000. With regard to Safety Recommendation M-02-8, the Coast Guard stated that it considered its action complete: "During the rulemaking, retrofitting of all existing small passenger vessels with fixed extinguishing systems was considered. This included response programs, including risk-based preparedness planning with maximum stakeholder involvement. Additionally, contingency planning guidance . . . includes contingency planning for passenger vessel incidents as one of the three top contingency planning priorities." On April 7, 2005, the Safety Board responded to the Coast Guard that it continued to believe in the validity of its recommendations and classified Safety Recommendations M-02-6 and M-02-8 as Open-Unacceptable Response. With regard to Safety Recommendation M-02-6, the Board stated, Because new, small passenger vessels are required to have fire detection systems to protect their enginerooms but older existing vessels in the same service are not, two standards of safety exist. More importantly, the vessels with higher risk are permitted to adhere to a lower standard. Concerning Safety Recommendation M-02-8, the Board cited the difference between the outcomes of the Port Imperial Manhattan and Seastreak New York fires noted earlier, and stated that because [small passenger] vessels are not required to have fire suppression systems in their enginerooms, the passengers on board are at increased risk. The Safety Board is aware that the Coast Guard is reluctant to extend its fire protection regulations to all small passenger vessels built before March 1996 because of the cost of retrofitting. The Board does not consider that the costs of retrofitting are prohibitive, particularly for the larger vessels that carry more passengers. According to a manufacturer’s representative, the cost of installing a fire protection system in the engineroom ranges from $2,000 to $50,000, depending on the type of system and who installs it. The Board is aware that repairing the damage to the Massachusetts cost the vessel’s owners $800,000, and that the estimated cost to repair the Port Imperial Manhattan was even more, $1.2 million. By contrast, estimated damages to the Seastreak New York, which was equipped with a CO2 fire suppression system in its engineroom, were $81,000. More recently, an engineroom fire on board the small passenger vessel Express Shuttle II, which was equipped with a CO2 fire suppression system that the crew failed to activate, resulted in the total constructive loss of the vessel, valued at $800,000.9 The Safety Board does not regard the date of build, conversion, or certification to be an appropriate determinant of whether a vessel should be required to have an installed fire detection and suppression system. The primary reason for requiring such systems should be the risk factors involved. The engineroom is the location of the greatest fire risk on a vessel. Although no lives have been lost in any engineroom fires on small passenger vessels to date, the potential for loss of life in such an accident cannot be ignored. According to Coast Guard data, nearly 6,000 small passenger vessels, including both subchapter T (5,500) and subchapter K (437) vessels, were subject to Coast Guard inspection as of June 2006. One-third (1,770) of the subchapter T vessels and 76 percent (332) of the subchapter K vessels were built before 1996 and have noncombustible hulls (aluminum, steel, etc.), which exempts them from the current requirements for fixed fire detection and suppression systems. Thus, as of June 2006, over 2,000 U.S. small passenger vessels were not required to have fixed fire protection systems in their enginerooms. In the Massachusetts fire, no lives were lost and no one suffered serious injuries. The master and crew saw to it that the passengers donned lifejackets and transferred safely to the commuter ferry Laura, which had come alongside to rescue them within 10 minutes of the fire’s being noticed. Environmental conditions were ideal, with good visibility and calm water, and the similar configurations of the two ferries made it easy for passengers to transfer from one to the other. However, such ideal conditions cannot be counted on in a fire emergency, and in adverse weather or when no other vessel is close by, the safest option may be to remain with the vessel. Thus, early warning of a fire on board a vessel is of paramount importance to protect against injuries or loss of life. As it was, one of the deckhands was the first to notice black smoke coming from the stern of the Massachusetts, and the fire had been in progress for several minutes before the high water temperature alarm for the port inboard engine alerted the pilothouse to a problem in the engineroom. The Massachusetts crew had limited firefighting equipment on board. Because the Laura happened to be close by, passengers had to remain on the burning vessel only a short time before being rescued. However, if passengers and crew had had to remain longer on board, their lives might have been endangered. In its supplemental notice of proposed rulemaking to revise the small passenger regulations, the Coast Guard acknowledged that threats to human life can develop early in a fire, before involvement of the hull and structure, due to the accumulation of smoke and toxic gases. This rapidly developing hazard is similar for all vessels regardless of the construction material. An engineroom fire detection system would have provided early and definitive warning of the fire on board the Massachusetts. And because early detection is critical to extinguishing a fire, a warning about the fire at its early stages might have given crewmembers time to initiate a response before it spread out of control. Further, if the Massachusetts had been equipped with a fixed fire suppression system in the engineroom, the system could have extinguished the fire before it spread, thus limiting the damage to the vessel and the threat to the people on board. The Massachusetts fire, as well as the previous fires on the Port Imperial Manhattan and Seastreak New York, demonstrates that fires are a risk to small passenger vessels, regardless of hull material or date of build. In the Safety Board’s opinion, fire detection and suppression systems are essential safety components that should be on board all passenger vessels that carry a large number of passengers. In its supplemental notice of proposed rulemaking to revise the small passenger vessel regulations, the Coast Guard discussed the graduated system by which requirements generally become more stringent as a vessel exceeds certain thresholds or breakpoints.11 The breakpoints, which vary according to such factors as passenger capacity, vessel length, presence of overnight accommodations, and route, can be viewed as measures of the risk involved in operating a small passenger vessel. In its supplemental notice, the Coast Guard supported the idea that the number of passengers carried should be the primary factor in determining safety requirements. The Safety Board agrees that passenger capacity should receive foremost consideration in determining suitable measures of addressing risk for small passenger vessels. The Coast Guard has established safety requirements for small passenger vessels certificated to carry over 49 passengers (comprising about 1,550 of the approximately 5,500 subchapter T vessels inspected by the Coast Guard and all vessels regulated under subchapter K) that are stricter than the requirements for passenger vessels that carry fewer than 49 passengers. Included are the requirements for fire pumps (46 CFR 181.300[a][ii]), bilge pumps (46 CFR 182.520), collision bulkheads (46 CFR 179.210[b][I]), and watertight bulkheads for subdivision (46 CFR 179.212). These requirements exist regardless of date of build or hull material. Setting 49 passengers as the breakpoint for requiring existing small passenger vessels to install fixed fire suppression and detection systems would thus be consistent with the intent of current regulations for other safety measures. Safety Recommendations M-02-6 and M-02-8 to the Coast Guard regarding fixed fire detection and suppression systems applied only to vessels in commuter and ferry service. Five years have passed since those safety recommendations were issued, and the Massachusetts accident has focused the Safety Board’s attention on the most important aspect of the original recommendations: the at-risk population. In the Board’s opinion, all small passenger vessels certificated to carry more than 49 passengers, including existing as well as new vessels, should be equipped with fixed fire detection and suppression systems in their enginerooms. Further, vessels that were grandfathered in 1996 are now 10 years older than when they were exempted from the requirements at 46 CFR 118.400 and 181.400 and therefore may be at greater risk of a casualty such as a fire.13 The National Transportation Safety Board therefore recommends that the Coast Guard take the following action: Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. (M-07-1) (Supersedes Safety Recommendations M-02-6 and M-02-8.) In light of the new recommendation issued above, the National Transportation Safety Board classifies the following previously issued recommendations to the Coast Guard as Closed-Unacceptable Action/Superseded: Require that all small passenger vessels in commuter and ferry service, regardless of their date of build, be fitted with a fire detection system in the enginerooms. (M-02-6) Require that all small passenger vessels in commuter and ferry service, regardless of their date of build, be fitted with a fixed fire suppression system in their enginerooms. (M-02-8)

From: NTSB
To: USCG
Date: 4/7/2005
Response: The Safety Board notes that fire detection measures for small passenger vessels were the subject of a comprehensive review and revision through rulemaking finalized in 1996. During this rulemaking, the retrofitting of all existing small passenger vessels with fixed detection systems was considered, using an analysis of casualty data from 1981 through 1986. While there was sufficient reason to require retrofitting on small passenger vessels with fiberglass-reinforced plastic and wooden hulls, the Coast Guard determined that the substantial cost was not justified on small passenger vessels with steel and aluminum hulls. The Coast Guard further concluded that since vessels engaged in commuter and ferry service have accounted for only 8.4 percent of the fire casualties suffered by small passenger vessels from 1992 through 2000, it did not believe that extending these requirements to those vessels was justified. In this accident, the fire on the Port Imperial Manhattan was probably in an incipient stage for some time before entering the free-burning phase. Unfortunately, the crewmembers did not become aware of the fire until it was fully involved in the engineroom. A fire detection system in the engineroom would probably have detected the fire in the incipient phase and would have alerted the crewmembers while the fire was still small enough to extinguish. However, because the Port Imperial Manhattan did not have a fire detection system for its engineroom, once the fire reached the free-burning stage, crewmembers were faced with a much more serious, life-threatening blaze. According to Federal regulations, a vessel that was constructed, converted, or issued an initial certificate of inspection (COI) on or before March 10, 1996, is exempt from the requirement for fire detection systems unless the vessel's hull or machinery space boundary bulkhead or deck is composed of wood or fiber-reinforced plastic or its interior is sheathed with fiber-reinforced plastic. Because the Port Imperial Manhattan was built of aluminum in 1987, it was not required to have a fire detection system. The Safety Board does not believe that the date of build should be the only factor for determining whether a vessel should or should not be required to have an installed fire detection system. The sole reason for requiring the installation of such a system should be the risk factors involved. As is the case with most small passenger vessels, the engineroom on the Port Imperial Manhattan was unmanned; no one was in the space to continuously monitor fire-safe conditions. Because the engineroom is the location of most ignition sources for fires, including hot surfaces, fuel and lubricating oils, and electrical equipment, this is the location of greatest fire risk on a vessel. Moreover, as the service life of a vessel increases, the potential for failure or breakdown in system components increases. Over time, engine hoses deteriorate, electrical parts fail, and the overall condition of an engineroom declines. Because new, small passenger vessels are required to have fire detection systems to protect their enginerooms but older existing vessels in the same service are not, two standards of safety exist. More importantly, the vessels with higher risk are permitted to adhere to a lower standard. In the Port Imperial Manhattan report, the Safety Board concluded that the lack of fire detection systems for enginerooms on existing small passenger vessels in commuter and ferry service presents an unacceptable risk to passengers and crewmembers. Consequently, the Board continues to believe in the validity of this recommendation, and pending action from the Coast Guard to comply with this recommendation, Safety Recommendation M-02-6 is classified "Open--Unacceptable Response."

From: USCG
To: NTSB
Date: 11/21/2003
Response: Letter Mail Controlled 11/24/2003 12:14:53 PM MC# 2030577 We do not concur with this recommendation. Fire detection measures for small passenger vessels were subjected to a careful and comprehensive review and revision through a rulemaking that was initiated in 1989 and finalized in 1996. During the rulemaking, the retrofitting of all existing small passenger vessels with fixed detection systems was considered. This included an analysis of casualty data from 1981 through 1986. While there was suufticitnt reason to require retrofitting on small pessenger vessels with fiberglass reinforced plastic and wooden hulls, the substantial cost was not justified on small passenger vessels with steel and aluminum hulls. Since vessels engaged in commuter and ferry service have accounted for only 8.4% of the fire casualties suffered by small passenger vessels from 1992 through 2000, we do not believe that extending these requirements to those vessels is justified. We intend to take no further action on this recommendation and request that it be closed.