NTSB Cites Ineffective Preventive Maintenance as Probable Cause of Casino Boat Fire
At its meeting Dec. 11 on this investigation, the safety board cited the lack of fire detection in the boat's lazarette as contributing to the spread of the fire.
The National Transportation Safety Board has concluded ineffective preventive maintenance and insufficient guidance regarding the response to engine high-temperature conditions are the probable cause of the Jan. 14, 2018, fire aboard the casino shuttle boat Island Lady in the waters of the Pithlachascotee River near Port Richey, Fla. One passenger died and 14 others were treated at area hospitals in the incident, which left the vessel so damaged that it was declared a constructive total loss.
At its meeting Dec. 11 on this investigation, the safety board cited the lack of fire detection in the boat's lazarette as contributing to the spread of the fire.
The boat had 53 people aboard when, at about 4 p.m., the captain received a high-temperature alarm for the port engine's jacket-water system. The captain turned the vessel to return to the dock, according to the safety board. During the return trip, smoke began filling the lazarette, main deck spaces, and the engine room. The captain then intentionally beached the vessel close to shore in shallow water, and all passengers, crew, and company employees evacuated the Island Lady by jumping off the burning vessel and wading or crawling ashore.
A passenger named Carrie Dempsey, 42, was pronounced dead at 10:42 p.m. Jan. 14 while being treated at Bayonet Point Regional Medical Center, the Tampa Bay Times reported.
The safety board found that the decision to return to the dock and beach the vessel were prudent and increased the likelihood of survival for passengers. But it also found that Tropical Breeze Casino Cruz didn't provide adequate guidance to its crews on responding to engine and other machinery alarms, and that "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." The fire likely started in the port engine's fiberglass exhaust tubing; the captain's decision to continue to run the port engine in an overheated condition, even though the starboard engine was functioning normally, allowed the port engine to overheat to failure and the engine's exhaust tubing to ignite, the board found.
New recommendations from the safety board to Tropical Breeze Casino Cruz, LLC are to develop and apply an oversight system to ensure its maintenance program complies with manufacturers' recommendations for engines and associated machinery, and also to revise its marine firefighting and job training programs, including documenting both on board and ashore that all crew members are qualified and can demonstrate proficiency in their duties, such as firefighting techniques and other emergency situations. The Island Lady crew members had insufficient training in firefighting, the board found.
The U.S. Coast Guard is the lead investigative federal agency for the accident. Parties to the NTSB's investigation of it include Tropical Breeze Casino Cruz, LLC, Ring Power Corporation (the propulsion engine manufacturer's service representative), and the U.S. Coast Guard.
Robert L. Sumwalt, the board's chairman, reminded the parties Dec. 11 that NTSB previously issued recommendations to the company after a 2004 fire on board another vessel in virtually the same location. "After that earlier fire, the NTSB issued recommendations regarding preventive maintenance and firefighting training for crew members. The company agreed to implement these recommendations, but today we will discuss whether what they did was enough," Sumwalt said. "Crew members on board the Island Lady were not only untrained in firefighting; except for the captain, none of them had any formal marine training."
"All over the country this morning, crew training is either being conducted or it is being neglected. Vessels are being made safer by preventive maintenance, or their safety is being left to chance. Manufacturers' manuals are being followed or disregarded. Warning signs are being followed-up on until their cause is known, or they are being ignored," he added. "Safety isn't something you have -- it's something you do. Are we requiring vessel operators to do it?"
In his closing remarks, Sumwalt said, "Today we saw a vessel that passed inspection with level indicators constructed of plastic tubing, when regulations clearly demand heat resistant material. We hope that our recommendation for a Marine Safety Information Bulletin helps to prevent such practices. More broadly, we hope that our recommendations for required preventive maintenance programs, crew firefighting training, fire detection systems in unmanned spaces, and safety management systems (SMS) are acted upon. And a word on SMS: 'Safety Management System' is three straight nouns. It makes us expect that we can buy a binder stamped 'SMS' and be done with it. We can't. Let's dig out the hidden verb: An SMS is a business process for managing safety. Written documents are necessary for an SMS, but they are not sufficient.
"Safety is not something you have -- it is something you do. And it's something you must do continually," Sumwalt continued. "The recommendations issued and reiterated today, if acted upon, will result in continual efforts toward better-maintained vessels, better-trained crews, and better safety management."