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Safety Recommendation Details

Safety Recommendation M-17-019
Details
Synopsis: On September 7, 2015, about 1133 local time, a fire broke out in the engine room aboard cruise ship Carnival Liberty. At the time, the vessel was alongside the dock in the Port of Charlotte Amalie, St. Thomas, US Virgin Islands. The master ordered the passengers aboard the vessel to evacuate to the dock. The crew used the ship’s water mist- and carbon dioxide (CO2) firefighting systems to extinguish the fire. No one was injured, nor was any environmental damage reported. Fire damage to the ship was estimated at $1.725 million.
Recommendation: TO CARNIVAL CORPORATION: Develop and/or improve procedures to manage and account for all persons aboard in the event of a mass evacuation of a ship while in port.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Marine
Location: St. Thomas, CB, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA15FM035
Accident Reports: Engine Room Fire Aboard Cruise Ship Carnival Liberty
Report #: MAB-17-21
Accident Date: 9/7/2015
Issue Date: 6/29/2017
Date Closed:
Addressee(s) and Addressee Status: Carnival Corporation (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Carnival Corporation
Date: 1/18/2018
Response: Your response to this recommendation has a technology component as well as a process component. With regard to the technology component, in January 2016, you began implementing a new electronic muster and accountability system, the Mobile Assembly Suite (MAS), across your fleet. Based on your description of the MAS, it appears likely to address many of the issues related to passenger accounting that arose during the Carnival Liberty fire incident. We note that you plan to have MAS on all of your ships by the end of 2017. In terms of the process component, we note that you are developing a common outline to standardize the communications, “people flow,” guidance, and consolidation of muster information in a pier-side ship evacuation. Further, a fleet-wide safety officers meeting will develop process templates by ship class for pier-side evacuation using the new MAS technology. Once complete, these class-specific procedures will be included in an update to each ship’s emergency response procedures. Pending completion of these revisions, Safety Recommendation M-17-19 is classified OPEN--ACCEPTABLE RESPONSE.

From: Carnival Corporation
To: NTSB
Date: 9/28/2017
Response: -From Martin Landtman, Senior Vice President, Marine Operations: There are two key elements in response to this recommendation; a technology component and a process component. Carnival previously recognized the need for better muster station accountability and was already pursuing a technology enhancement when the Liberty fire occurred. This electronic muster and accountability system, the Mobile Assembly Suite (MAS), began fleet-wide implementation in January 2016. To date, 23 of 25 ships in the Carnival Cruise Line fleet are complete and implementation will conclude in December 2017. The MAS includes handheld tablets that can be used to verify and check-in each person (guest and crew) by name at muster and evacuation stations, either on board or ashore. Each tablet can store the accountability information locally, can share with other tablets via Bluetooth capability, and can link to a central database on board the ship via WiFi connectivity. The system uses a common database with the electronic gangway program to ensure both systems seamlessly recognize guests and crew who may already have gone ashore while in port. Future enhancements include visibility into muster and accountability data at remote command and decision locations. With the majority of the fleet achieving MAS implementation, the second component, the process function, is in development. A common outline is being developed to standardize the communications, "people flow," guidance, and consolidation of muster information in a pierside ship evacuation. In late September, 2017, a workshop involving fleet-wide Safety Officers will develop process templates by ship-class to accommodate a smooth pier side evacuation using the new MAS technology enhancement. Once complete, these class-specific procedures will be included in an update to the ship's emergency response procedures. Implementation and crew training is planned for Ql 2018.

From: NTSB
To: Carnival Corporation
Date: 6/29/2017
Response: On June 21, 2017, we adopted our marine accident brief concerning the September 7, 2015, engine room fire aboard cruise ship Carnival Liberty. Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, www.ntsb.gov, under report number NTSB/MAB-17/21. As a result of this investigation, we issued three new safety recommendations, including one to the Cruise Lines International Association, and the following two recommendations to Carnival Corporation & PLC.