Lessons Learned from Accident Investigations

NTSB Cites Crew for Smart Decision Making During Engineroom Fire;
Urges Fire Detection and Supression Systems on Small Passenger Vessels Carrying 
More Than 49 Passengers


"I flatly decided we weren't going to open either engineroom door. We weren't 
going to do anything to give the fire any oxygen," the master of the commuter ferry 
Massachusetts told National Transportation Safety Board investigators after a fire was 
detected in the vessel's engineroom while underway in Boston Harbor.  The vessel was 
owned and operated by Massachusetts Bay Lines, operating from Rowe's Wharf in 
Boston.
"He made the right calls. Throughout the accident, the master's prudent decisions 
promoted the safety of his passengers and crew," said NTSB Chairman Mark V. 
Rosenker. The NTSB issued a final accident report in late March.
A few weeks earlier, Rosenker and the other four NTSB Board Members rode 
another small passenger vessel navigating the same commuter route as the 
Massachusetts, operated by Boston Harbor Cruises. During the visit, Rosenker and NTSB 
board members had the opportunity to talk to the Massachusetts captain and crew.  There 
were no injures as a result of fire, but repairs were estimated at $800,000.  The 
Massachusetts repairs included the installation of engineroom fire detection and 
suppression systems, an action Rosenker called, "a smart safety and business decision."
The Massachusetts was not equipped with either an engineroom fire detection or 
suppression system, nor was it required by regulation to do so.  The NTSB has identified 
many other small passenger vessels that fall into the same category as the Massachusetts 
in not being required to have this equipment.
Because of the Massachusetts fire, the Safety Board has called on the U.S. Coast 
Guard to require fire detection and suppression systems in all existing small passenger 
vessels carrying more than 49 passengers.  The NTSB identified 49 passengers as the cut-
off for its recommendation to conform to an existing Coast Guard regulatory breakpoint 
for addressing risk based on passenger capacity.  "We want the Coast Guard to require 
these systems because we are convinced it's the right thing to do to improve safety .We 
also encourage other small passenger operators to follow the Massachusetts lead by 
installing these systems," Rosenker said. 
The recently issued report chronicles events leading up to the accident and actions 
by the crew and emergency responders following the accident.  On June 12, 2006, the 
commuter ferry Massachusetts was en route from Rowe's Wharf in Boston Harbor to 
Hingham, Massachusetts, carrying 65 passengers and 4 crewmembers. The vessel 
departed on schedule at 1600. The master delivered a passenger safety briefing over the 
vessel's public address system and told passengers about the location and type of 
lifesaving equipment on board and told them to follow crewmembers' instructions in case 
of emergency.  
Earlier that day, mechanics were asked to check out problems encountered on 
previous trips by examining the starboard outboard engine for excessive venting of 
combustion gases through the valve cover breathers; examining the port generator for 
sparking, and examining the port inboard engine, which had been idling at a higher speed 
than normal. Several repairs were made.
Soon after leaving Rowe's Wharf, the master went to the engineroom to bleed air 
from the air conditioning system. He told investigators that he did not detect anything out 
of the ordinary and returned to the pilothouse. 
Black Smoke
Fifteen minutes later, the upper deck deckhand entered the pilothouse to report 
black smoke at the vessel's stern. At the same time, the high-water temperature alarm for 
the port inboard engine sounded. The mate stopped that engine and slowed the remaining 
three engines from 2000 to 1300 rpm, as directed by the master.
The master said that when he opened the door to the starboard ladderway leading 
to the engineroom, he encountered heavy smoke and immediately closed the door.  He 
went to the phone at the main deck bar and called the pilothouse, notified the mate, and 
instructed him to shut down two of the remaining engines. The mate shut down the port 
outboard engine, which had already lost some power, and the starboard outboard engine, 
leaving only the starboard inboard engine running.
Lifejackets for Passengers 
On his way back to the pilothouse, the master directed the main deck passengers 
and the main deck deckhand to go to the upper deck, and told the deckhands to give the 
passengers lifejackets. One of the passengers was a Coast Guard officer commuting 
home. The master told the officer about the fire and asked for his help in contacting the 
Coast Guard. The officer used his cell phone to alert the local Coast Guard office.
By that time, the vessel had passed south of Boston Harbor's Long Island Bridge. 
The master relieved the mate at the helm and ordered him and one deckhand to prepare to 
drop anchor.
Passenger Evacuation
Meanwhile, the master used VHF channel 13 to contact the commuter ferry 
Laura, also operated by Boston Harbor Cruises. The Laura was about 1/2 mile away with 
three passengers on board. The Massachusetts master told the Laura master about the fire 
and asked the Laura to come alongside and receive his passengers "expeditiously." The 
Laura immediately altered course to assist the Massachusetts.
The Coast Guard officer reminded the master to turn off the engineroom's 
ventilation supply blowers.  After turning off the blowers, the master navigated the 
Massachusetts just outside the channel, and ordered the mate to drop anchor. After the 
vessel was anchored, the emergency fuel shutoff valves were closed. The deckhands 
returned to the upper deck to assist passengers, and the master turned off the inboard 
starboard engine. The generator shut down from fuel starvation about 30 seconds after the 
mate closed the emergency fuel shutoff valves. 
About 1630, the Laura tied up alongside the Massachusetts and the crew led the 
65 passengers, wearing lifejackets, down a ladder to the main deck and out through a side 
doorway directly onto the Laura.  "Our investigators credit the crew with the orderly 
transfer of passengers which they told us took about around 5 minutes," Rosenker said.  
The NTSB said the Massachusetts crew did not remember counting passengers as they 
left the vessel, but a count was taken and logged on board the Laura. At 1635, the Laura 
untied from the Massachusetts and moved to a safe distance; state police boarded and 
checked for casualties, and the Laura departed for Hingham Shipyard.  
Emergency Response
According to emergency records provided to the NTSB by the Boston Fire 
Department, the dispatch operations center received nearly simultaneous calls reporting 
the Massachusetts fire from the Coast Guard, at 1641, and Quincy, Massachusetts, police 
one minute later. At 1644, the center dispatched the fire department's marine unit to the 
Long Island Bridge from its station, about 6 nautical miles from the accident site. After 
receiving the call, marine unit personnel boarded the vessel Firefighter and were under 
way in 2 or 3 minutes, the pilot told the NTSB. After boarding the Massachusetts, 
firefighters gained access to the engine space and extinguished the blaze. The vessel was 
towed later that evening to a dock at Deer Island in Boston Harbor.
"A series of decisive action by the master, crew and emergency responders helped 
avoid what could have been a catastrophic event," Rosenker said. "I believe this accident 
serves as a good example to all small passenger vessel operators, and I hope the marine 
community will read our report and support our recommendations."
Final Actions
The Massachusetts crew, which had transferred to a Coast Guard utility boat, was 
transported to the Hingham Shipyard dock, arriving at 2130. The Massachusetts was 
taken under tow by a local harbor tug at 2240 and moved to a pier.
The report concluded that probable cause of the fire was the ignition of diesel fuel 
by contact with a hot engine surface, which occurred because a fuel line attached to a fuel 
injector was not properly connected during engine maintenance by a contract mechanic. 
Contributing to the extent of the damage was the absence of a fixed fire detection 
and suppression system, which precluded the crew from receiving timely notification of 
the fire and which allowed the blaze to spread throughout the engineroom, the report said.   
The NTSB's complete report on the Massachusetts fire can be found on their website at 
http://www.ntsb.gov/publictn/2007/MAB0701.pdf.


1