Near Juneau, Alaska
July 27, 1996
NTSB Number: MAR-98-02
NTIS Number: PB98-916402
Adopted April 14, 1998
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Early on July 27, 1996, while the Panamanian passenger ship Universe Explorer was en route from Juneau, Alaska, to Glacier Bay, Alaska with 1,006 people aboard, a fire started in the main laundry. Dense smoke and heat spread upward to a deck on which crew quarters were located. Five crewmembers died from smoke inhalation, and 55 crewmembers and 1 passenger sustained minor or serious injuries. One passenger required medical treatment as a result of a preexisting condition. Sixtynine people were transported to area hospitals, where 13 of the injured were admitted for further treatment. The estimated damage to the vessel was $1.5 million.
The National Transportation Safety Board determines that the probable cause of this accident was a lack of effective oversight by New Commodore Cruise Lines, Ltd., and the predecessor of V. Ships Marine, Ltd. (International Marine Carriers, Inc.), who allowed physical conditions and operating procedures to exist that compromised the fire safety of the Universe Explorer, ultimately resulting in crewmember deaths and injuries from a fire of undetermined origin in the vessel's main laundry. Contributing to the loss of life and injuries was the lack of sprinkler systems, the lack of automatic local-sounding fire alarms, and the rapid spread of smoke through open doors into the crew berthing area.
The major safety issues discussed in this report are the adequacy of shipboard communications; the adequacy of fire prevention, detection, and control measures; the adequacy of emergency procedures; and the adequacy of oversight.
As a result of its investigation of this accident, the Safety Board makes recommendations to the U.S. Coast Guard, New Commodore Cruise Lines, Ltd., V. Ships Marine, Ltd., the International Council of Cruise Lines, and the American Bureau of Shipping.
Recommendations
As a result of its investigation, the National Transportation Safety Board makes the following recommendations:
To the U.S. Coast Guard:
Propose to the International Maritime Organization that passenger ships be required to institute procedures, upgrade equipment, or do both to establish reliable internal radio communications from anywhere inside a vessel during an emergency. (M-98-31)
Recommend to the International Maritime Organization that passenger and crew cabins on cruise ships be required to be equipped with an emergency call system so that people trapped during a fire emergency have a means of signaling their location. (M-98-32)
Conduct research with the passenger ship industry and the National Fire Protection Association on the adequacy of heat and smoke detectors for use in high-fire-risk areas, including laundry spaces, of passenger ships; and, based upon your findings, propose to the International Maritime Organization equipment or procedural guidelines for improving the reliability of fire alarms. (M-98-33)
Propose to the International Maritime Organization that passenger ships be required to integrate heat and/or smoke detectors with automatic fire door release switches so that the doors in the immediate area of a fire will close automatically when the detectors are activated. (M-98-34)
Propose to the International Maritime Organization that periodic instruction or drills be provided to all crewmembers on passenger ships to reinforce the familiarization training required of new seafarers by the 1995 Amendments to the Standards for Training Certification and Watchkeeping Convention. (M-98-35)
Propose to the International Maritime Organization that specially trained and suitably equipped rescue teams be required on board all passenger ships. (M-98-36)
Recommend to the International Maritime Organization that passenger ship companies be required to equip each onboard medical staff member with a portable radio with a dedicated frequency for use during an emergency. (M-98-37)
Revise your control verification examination procedures to include a more detailed review of structural fire protection features on board foreign passenger ships. (M-98-38)
Require that each foreign passenger vessel operating from U.S. ports periodically undergo a periodic structural fire protection plan review and vessel examination to verify that it is being maintained in accordance with approved plans. (M-98-39)
In cooperation with maritime industry representatives, establish specific criteria for identifying those individuals who should undergo drug and alcohol testing after a serious marine incident, and establish procedures to ensure that such identification and subsequent testing is conducted in a timely manner. (M-98-40)
Submit a copy of the National Transportation Safety Board's report of the fire on board the Universe Explorer to the International Maritime Organization for distribution and discussion. (M-98-41)
To New Commodore Cruise Lines, Ltd. and to V. Ships Marine Ltd.:
Improve the means of radio communications between shipboard command and emergency responders and among emergency response groups on board your passenger ships. (M-98-42)
Review and, if necessary, revise shipboard communication procedures to ensure that watch officers and the fire watch maintain effective communications at all times, especially when the fire watch enters a suspected fire area. (M-98-43)
Equip crew cabins on company passenger ships with an emergency call system so that people trapped in their cabins during a fire emergency can signal their location. (M-98-44)
Modify the fire control systems on company passenger vessels, integrating heat and/or smoke detectors with automatic fire door release switches. (M-98-45)
Provide each member of the medical staff on board company passenger ships with a portable radio for use in shipboard emergencies. (M-98-46)
Review the adequacy of the fire detection systems presently protecting laundry spaces on board company passenger ships, and, based on that review, install improved detection systems or institute improved surveillance procedures to improve fire detection capability. (M-98-47)
Implement procedures to improve the oversight of the fire watch on board company passenger ships. (M-98-48)
Review and revise as necessary the operating procedures followed by the navigation watch officer to ensure that fire screen doors are closed immediately upon receipt of a fire alarm. (M-98-49)
Revise passenger fire drills and stateroom placards to advise passengers what to expect in a fire emergency. Include an explanation that fire doors shut automatically and instructions for opening them. (M-98-50)
Revise procedures for announcing emergency status updates to passengers assembled at muster stations so as to assuage their concerns. (M-98-51)
Provide periodic instruction or drills on alternate escape routes to all crewmembers on company passenger vessels to reinforce the familiarization training required of new seafarers by the 1995 Amendments to the Standards for Training Certification and Watchkeeping Convention. (M-98-52)
Establish improved procedures for crewmembers to follow in locating fires on board company passenger ships. (M-98-53)
Establish for each company vessel a rescue team dedicated to locating trapped passengers and crew during a fire emergency, and provide the team members with recurrent search and rescue training. (M-98-54)
Review the contents of passenger vessel emergency medical kits to ensure they contain adequate medical supplies to meet an emergency, such as the fire on board the Universe Explorer. (M-98-55)
Address the safety issues identified in this report in the safety program that you are developing for compliance with the International Safety Management Code. Further, increase the shoreside management's oversight of fire safety conditions on board your vessels by initiating the following measures, at a minimum: periodic fire safety vessel examinations and periodic instruction for the ships' crews on maintaining a fire-safe vessel. (M-98-56)
Immediately install automatic sprinkler systems in accommodation areas, stairway enclosures, and corridors on company ships. (M-98-57)
To the International Council of Cruise Lines:
Advise member companies of the circumstances of this accident and recommend that they institute procedures and, if necessary, upgrade equipment to establish reliable internal radio communications from anywhere inside a vessel during an emergency. (M-98-58)
Recommend that member passenger ship companies install emergency call systems in passenger staterooms and crew cabins so that people trapped during a fire emergency will have a means of signaling their location. (M-98-59)
Inform member companies of the importance of providing each member of the shipboard medical staff with a reliable radio and communications training for emergencies. (M-98-60)
Remind member companies of the possible need to institute improved surveillance measures for high-fire-risk areas on their ships. (M-98-61)
Recommend that member companies integrate heat and/or smoke detectors with automatic fire door release switches so that the doors in the immediate area of a fire will close automatically when the detectors are activated. (M-98-62)
Recommend that member companies review and, if necessary, revise passenger fire drills and stateroom placards to advise passengers what to expect in the event of a fire emergency. (M-98-63)
Recommend that member companies provide periodic instruction or drills on alternate escape routes to all crewmembers on passenger ships to reinforce the familiarization training required of new seafarers by the 1995 Amendments to the Standards for Training Certification and Watchkeeping Convention. (M-98-64)
Encourage member companies to establish specially trained and equipped shipboard rescue teams to conduct rescue operations from smoke-filled areas. (M-98-65)
In consultation with member passenger ship operators, determine the amount and type of medical equipment and medicines needed during an emergency and recommend that such supplies be maintained in suitable locations outside of the ship's hospital in case the hospital becomes inaccessible. (M-98-66)
Remind member companies of the degradation to structural fire protection that can result from altering fire control boundaries and of their responsibility to maintain the accuracy of vessel fire control plans. (M-98-67)
To the American Bureau of Shipping:
Analyze your plan review procedures and improve them to ensure that a ship plans submitted for approval accurately depict the configuration of the vessel. (M-98-68)
