In a recent public meeting, the US National Transportation Safety Board (NTSB) determined that an insufficient preventative maintenance program and lack of guidance for responding to engine high-temperature conditions were the key causes of the fire aboard the small passenger vessel ‘Island Lady’ in January 2018, carrying over 50 people, that occurred in the waters of the Pithlachascotee River, near Port Ritchey, Florida.
The incident
On 14 January 2018, the small passenger vessel Island Lady was near Port Richey, Florida, on a scheduled transit to a casino boat located about 9 miles offshore in the Gulf of Mexico, carrying 53 people onboard. About 4:00 p.m. on the afternoon, a fire broke out in an unmanned space on the vessel. After receiving a high-temperature alarm on the port engine, the captain turned the Island Lady around to return to the dock.
During the return trip, smoke began filling the lazarette, main deck, and engine room. The captain deliberately beached the vessel in shallow water near shore to evacuate the passengers. All crewmembers, employees, and passengers evacuated the vessel by entering the water and wading/crawling ashore. Fifteen people were injured and transported to local hospitals; one passenger died in the hospital several hours after the fire. The Island Lady, valued at $450,000, was declared a constructive total loss.
Probable cause
NTSB determines that the probable cause of the fire on board small passenger vessel Island Lady was Tropical Breeze Casino Cruz’s ineffective preventive maintenance program and insufficient guidance regarding the response to engine high-temperature conditions, which resulted in the captain’s continued operation of an engine that was overheating due to a cooling water pump failure, leading to ignition of the exhaust tubing and surrounding structure. Contributing to the spread of the fire was the lack of fire detection in the vessel’s lazarette, which was not required by regulations and which allowed the fire to take hold unbeknownst to the crew.
Findings
1. Weather, fatigue, and impairment due to alcohol and other drugs were not factors in the accident.
2. The high-temperature alarm for the port engine’s jacket-water system resulted from a failure of the port engine’s raw-water pump.
3. The fire likely started in the port engine’s fiberglass exhaust tubing and spread to wood structures in the lazarette, through which the tubing transited.
4. The captain’s decision to continue to run the port engine in an overheated condition, even though the starboard engine was available and functioning normally, allowed the port engine to overheat to failure and the engine’s exhaust tubing to ignite.
5. Tropical Breeze Casino Cruz did not provide adequate guidance to its crews regarding response to engine and other machinery alarms.
6. The captain’s decisions to return the vessel to the dock after receiving the engine high-temperature alarm and to subsequently beach the Island Lady when smoke overwhelmed the vessel were prudent and increased the likelihood of survival for those on board.
7. The company’s lack of inspections and infrequent maintenance likely resulted in undetected, wear-related damage causing the port engine’s raw-water pump to fail.
8. If Tropical Breeze Casino Cruz had followed Caterpillar’s recommended maintenance schedule for the Island Lady’s propulsion engines, the failed raw-water cooling pump would have been inspected and likely replaced.
9. The Island Lady crewmembers had insufficient training in firefighting.
10. Implementing safety management systems on all domestic passenger vessels would further enhance operators’ ability to achieve the higher standards of safety that the Coast Guard requires of US oceangoing vessels in international service.
11. Had the Island Lady been outfitted with fire detectors in the lazarette, the fire and its location would have been identified earlier, providing the opportunity for swifter response.
12. The use of plastic tubing on local tank level indicators and lack of automatic shutoff valves on the fuel tanks resulted in release of diesel fuel, which contributed to the severity of the fire.
13. During an inspection of the Island Lady before the fire, the Coast Guard did not correctly assess the fuel system’s compliance with applicable regulations.
Safety issues
The NTSB identified the following safety issues:
– Lack of company guidance regarding engine high-temperature alarms;
– Lack of fire-detection in unmanned spaces with exhaust tubing;
– Insufficient preventive maintenance;
– Insufficient crew training and documentation;
– Inappropriate material and design of fuel tank level-indicator system.
Recommendations
As a result of this investigation, the National Transportation Safety Board advised the owner company to:
– Develop and apply an oversight system to ensure that your maintenance program complies with the manufacturer’s recommended preventive maintenance program for the engines and associated machinery and systems onboard vessels.
– Revise marine firefighting and job training programs, including documenting both on board and ashore that all crewmembers are qualified and can continually demonstrate proficiency in their duties, such as firefighting techniques and other emergency situations.
As a result of this investigation, the National Transportation Safety Board advised the US Coast Guard to:
– Require fire detection systems in unmanned spaces with machinery or other potential heat sources on board small passenger vessels.
– Issue a Marine Safety Information Bulletin that addresses the need to use only approved material and components in fuel tank level-indicator systems.
The official accident report will be published within a few weeks.
