NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT REPORT

PB2001-916401

NTSB/MAR-01/01

FIRE ON BOARD THE LIBERIAN PASSENGER SHIP ECSTASY

MIAMI, FLORIDA

JULY 20, 1998

7357

Marine Accident Report

Fire On Board the Liberian Passenger Ship 

Ecstasy

Miami, Florida

July 20, 1998

NTSB/MAR-01/01

PB2001-916401 National Transportation Safety Board

Notation 7357 490 L’Enfant Plaza, S.W.

Adopted May 1, 2001 Washington, D.C. 20594
National Transportation Safety Board. 2001. Fire On Board the Liberian Passenger Ship Ecstasy, Miami,

Florida, July 20, 1998. Marine Accident Report NTSB/MAR-01/01. Washington, DC.

Abstract: On the afternoon of July 20, 1998, the Liberian passenger ship Ecstasy had departed the Port of Miami,

Florida, en route to Key West, Florida, with 2,565 passengers and 916 crewmembers on board when a fire started in

the main laundry shortly after 1700. The fire migrated through the ventilation system to the aft mooring deck where

mooring lines ignited, creating intense heat and large amounts of smoke. As the Ecstasy was attempting to reach an

anchorage north of the Miami sea buoy, the vessel lost propulsion power and steering and began to drift. The master

then radioed the U.S. Coast Guard for assistance. A total of six tugboats responded to help fight the fire and to tow the

Ecstasy. The fire was brought under control by onboard firefighters and was officially declared extinguished about

2109. Fourteen crewmembers and eight passengers suffered minor injuries. One passenger who required medical

treatment as a result of a pre-existing condition was categorized as a serious injury victim because of the length of her

hospital stay. Carnival Corporation, Inc., the owner of the Ecstasy, estimated that losses from the fire and associated

damages exceeded $17 million.

The National Transportation Safety Board determines that the probable cause of fire aboard the Ecstasy was the

unauthorized welding by crewmembers in the main laundry that ignited a large accumulation of lint in the ventilation

system and the failure of Carnival Cruise Lines to maintain the laundry exhaust ducts in a fire-safe condition.

Contributing to the extensive fire damage on the ship was the lack of an automatic fire suppression system on the aft

mooring deck and the lack of an automatic means of mitigating the spread of smoke and fire through the ventilation

ducts. 

The major safety issues discussed in this report are as follows: adequacy of management safety oversight, adequacy

of the fire protection systems, adequacy of passenger and crew safety, and adequacy of engineering system design.

As result of its investigation of this accident, the Safety Board makes recommendations to the U.S. Coast Guard,

American Classic Voyages, Carnival Corporation, Inc., Carnival Cruise Lines, Crystal Cruises, Disney Cruise Line,

Norwegian Cruise Line, Orient Lines, P&O Princess Cruises International, Ltd., Radisson Seven Seas Cruises, Regal

Cruises, Renaissance Cruises, Inc., Royal Olympic Cruises, Royal Caribbean Cruises, Ltd., and Silversea Cruises,

Ltd., ABB, Inc., and the International Association of Classification Societies.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2001-916401 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Marine Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Activities on the Bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Fire and Rescue Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Master . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Staff Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Safety Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chief Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Galley Fitters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Certification and Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

General Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Main Laundry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Aft Mooring Deck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Operating Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Low-location Lighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Fire Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Ventilation Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Vessel Certification and Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

International Safety Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Carnival Cruise Lines’ Safety Management System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Additional Oversight Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Medical and Pathological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Medical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Operating Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Other Damaged Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Contents iv Marine Accident Report

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Regulatory Requirements: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Emergency Procedures and Drills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Trapped Crewmen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Emergency Preparedness Drills and Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Metallurgical Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Debris Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Mooring Line Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Lint Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Examination of the Imagination and the Fantasy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Carnival Cruise Lines’ Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Related Safety Board Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Related Coast Guard Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Qualitative Failure Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Accident Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Fire Ignition and Propagation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Adequacy Of Management Safety Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Adequacy Of Fire Protection Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Sprinkler System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Ventilation System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Fire Detection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Adequacy of Passenger and Crew Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Passenger Drill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Accountability Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Lifejacket Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Locally Sounding Smoke Alarms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Means of Communication in Cabins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Adequacy Of Engineering Systems Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Previously Issued Recommendations Resulting from this Accident Investigation . . . . . . 80

Previously Issued Recommendations Classified in this Report . . . . . . . . . . . . . . . . . . . . . . 80

Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

B: STCW Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

C: Ecstasy Emergency Procedures Placard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Contents v Marine Accident Report

D: Number And Arrangement Of Lifejackets On the Ecstasy . . . . . . . . . . . . . . . . . . . . . . 89

E: Metallurgical Tests - Heat Release Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

F: Safety Recommendations on Call Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
vi Marine Accident Report

Acronyms and Abbreviations

ATF Alcohol, Tobacco, and Firearms Bureau

Btu British thermal unit

CFR Code of Federal Regulations

CO Carbon monoxide

COTP Captain of the Port

CVE Control Verification Examination

FMEA Failure Mode and Effects Analysis

FSD fire screen door

HSO Health and Safety Officer

ICCL International Council of Cruise Lines

IMO International Maritime Organization

ISM Code International Safety Management Code

LED light emitting diode

LR Lloyd’s Register of Shipping

m2 square meters

MSC Maritime Safety Committee

MSO Marine Safety Office

MVZ Main Vertical Zone

RFSA Retroactive Fire Safety Amendment

Ro-ro roll on-roll off

SMS Safety Management System

SOLAS International Convention for the Safety of Life at Sea

STCW International Convention on Standards of Training, 

Certification, and Watchkeeping for Seafarers
Acronyms and Abbreviations vii Marine Accident Report

UHF Ultra High Frequency (radio)

UTB utility boat

WTD watertight door
viii Marine Accident Report

Executive Summary

On the afternoon of July 20, 1998, the Liberian passenger ship Ecstasy had

departed the Port of Miami, Florida, en route to Key West, Florida, with 2,565 passengers

and 916 crewmembers on board when a fire started in the main laundry shortly after 1700.

The fire migrated through the ventilation system to the aft mooring deck where mooring

lines ignited, creating intense heat and large amounts of smoke. As the Ecstasy was

attempting to reach an anchorage north of the Miami sea buoy, the vessel lost propulsion

power and steering and began to drift. The master then radioed the U.S. Coast Guard for

assistance. A total of six tugboats responded to help fight the fire and to tow the Ecstasy.

The fire was brought under control by onboard firefighters and was officially declared

extinguished about 2109. Fourteen crewmembers and eight passengers suffered minor

injuries. One passenger who required medical treatment as a result of a pre-existing

condition was categorized as a serious injury victim because of the length of her hospital

stay. Carnival Corporation, Inc., the owner of the Ecstasy, estimated that losses from the

fire and associated damages exceeded $17 million.

The National Transportation Safety Board determines that the probable cause of

fire aboard the Ecstasy was the unauthorized welding by crewmembers in the main

laundry that ignited a large accumulation of lint in the ventilation system and the failure of

Carnival Cruise Lines to maintain the laundry exhaust ducts in a fire-safe condition.

Contributing to the extensive fire damage on the ship was the lack of an automatic fire

suppression system on the aft mooring deck and the lack of an automatic means of

mitigating the spread of smoke and fire through the ventilation ducts. 

The major safety issues discussed in this report are as follows:

• Adequacy of management safety oversight; 

• Adequacy of the fire protection systems; 

• Adequacy of passenger and crew safety; and 

• Adequacy of engineering system design.

As result of its investigation of this accident, the Safety Board makes

recommendations to the U.S. Coast Guard, American Classic Voyages, Carnival

Corporation, Inc., Carnival Cruise Lines, Crystal Cruises, Disney Cruise Line, Norwegian

Cruise Line, Orient Lines, P&O Princess Cruises International, Ltd., Radisson Seven Seas

Cruises, Regal Cruises, Renaissance Cruises, Inc., Royal Olympic Cruises, Royal

Caribbean Cruises, Ltd., and Silversea Cruises, Ltd., ABB, Inc., and the International

Association of Classification Societies.
1 Marine Accident Report

Factual Information

Accident Synopsis

On July 20, the Liberian passenger ship Ecstasy had departed Miami, Florida, and

was en route to Key West, Florida, with 3,481 people aboard when the bridge began

receiving a series of fire alarms. The first fire alarm, at 1710, indicated the ship’s main

laundry on deck No. 2. Within a matter of minutes, the fire alarm panel indicated heat and

smoke detector activations in the stern thruster room, air conditioning plenums, an

electrical room, and the two steering gear rooms. (See figure 1.) The bridge also began

receiving telephone calls from crewmembers reporting smoke in various aft areas of the

ship. Shortly thereafter, various sources, including a U.S. Coast Guard (Coast Guard)

watchstander who was monitoring marine traffic in the channel, observed a large amount

of smoke issuing from the stern of the Ecstasy. In compliance with Coast Guard

instructions, the vessel’s master ordered the ship to proceed to an anchorage area;

however, before reaching the anchorage, the Ecstasy lost propulsion power and steering

and began to drift. The master then radioed for assistance. A total of six tugboats

responded to help fight the fire and to tow the Ecstasy. The fire was brought under control

by onboard firefighters and was officially declared extinguished about 2109. Fourteen

crewmembers and 8 passengers suffered minor injuries. 

Accident Narrative

Preaccident Events

On July 20, 1998, the Ecstasy was moored alongside Pier 8, Port of Miami,

preparing to depart on a round-trip 4-day cruise with stops at Key West and Cozumel,

Mexico. Records indicate that, at 1500, the officer of the watch tested the navigation,

communication, and vessel control equipment, and that all equipment operated properly.

About 1550, a member of the Biscayne Bay Pilots Association arrived on board

and went to the pilothouse. The pilot stated that while waiting for passenger baggage to be

loaded, he read a completed “pilot card,” a checklist form indicating that all of the

equipment had been tested and was in good order. He also observed a muster drill.1

 He

said that he discussed the weather conditions with the master because he (the pilot) was

concerned about reaching the sea buoy, where he would disembark, before approaching

heavy rains moved into the area. In response to the master’s question of whether the ship

should delay sailing until after the rain passed, the pilot responded that if they left

immediately, the ship could complete the transit to the pilot debarkation station before

1 Regulations contained in the International Convention for the Safety of Life at Sea (SOLAS) require

that a cruise ship conduct a passenger and crew muster drill within 24 hours of departure. 
Factual Information 2 Marine Accident Report

inclement weather arrived. After the muster drill was completed, the Ecstasy departed the

Port of Miami with 2,565 passengers and 916 crewmembers on board.

After the Ecstasy departed its berth, crewmembers brought in and stowed the

synthetic mooring lines on the aft mooring station, which was on deck No. 4. A bosun did

a final inspection of the area and secured the two weather-tight doors leading from the

mooring station to the passenger stateroom area on deck No. 4. He then exited the area

using the center crew stairway. According to the bosun, the weather door to this crew

stairway was always left open. The mooring station log indicates that the mooring deck

was “all clear” and secured at 1650, meaning no machinery was in operation and no

people were in the area. The bosun stated that he noted nothing unusual on the deck when

he left.

The photograph above shows the Ecstasy after the fire. The ship area indicated by the dotted 

line is illustrated in the cutaway below.

Figure 1. On the day of the accident, the fire alarm panel on the bridge indicated that the first alarm

activated in the main laundry on deck No. 2. The ventilation system for the laundry penetrated a main

vertical zone (MVZ) and exhausted onto the mooring deck. Other early fire alarms indicated that

detectors activated in the stern thruster room, the air conditioning plenum between decks No. 4 and

6, an electrical room above the mooring deck, and both steering gear rooms below the mooring deck. 

AFT 

POOL

CONTROL 

ROOM

AIR CONDITIONER

MOORING DECK

DRY TANK

PROPULSION

 MOTOR ROOM

AFT 

ENGINE

ROOM FORWARD 

ENGINE RM.

APPARATUS ROOM

MARSHALING

AREA

LINEN

STEERING GEAR ROOMS

AIR COND.

DECK 11

DECK 12

AIR

CONDITIONER

AIR

COND.

DECK 10

AFT DINING ROOM 

CABIN 

CABIN CARGO

LIFT

ENGINE

CASING

AIR CONDITIONER

GALLEY DUCTS

GALLEY

LIFT

MACH.

POOL

MACH.

AIR CONDITIONING FAN ROOM & PLENUMS 

STORES

MAIN LAUNDRY

DECK 9

DECK 8

DECK 5

DECK 4

DECK 3

DECK 2

DECK 1

DECK 0

DECK 7

DECK 6

PASS. STAIRS & LIFTS

ELEC.

EQUIP.

ROOM

SUPPLY

EXHAUST

FAN

FAN

FRESH WATER

SUPPLY

SUPPLY

SUPPLY

Main Vertical Zone

Fire Barrier Main Vertical Zone

Fire Barrier

Smokestack

STERN THRUSTERS
Factual Information 3 Marine Accident Report

Once the master directed the maneuver of the ship from the pier to mid-channel,

the pilot began directing the passage out of the Port of Miami. The pilot stated that the

onset of the voyage was routine. He further stated that no equipment malfunctions

occurred, and the members of the bridge team performed their duties in a competent and

professional manner.

The Accident2

About 1630, a mangle3 in the Ecstasy’s main laundry (figure 2) malfunctioned.

The laundry manager telephoned a repair request to the hotel engineer, who, in turn, paged

the on-call galley fitter (first fitter). The first fitter said that he was in the fitters’ workshop

on deck No. 3, preparing to go off duty at 1730, when he was paged and told to go to the

main laundry. He said that the laundry manager told him that the mangle was not working

properly, and that its roller needed to be adjusted. 

The first fitter said that when he arrived in the main laundry, the crew was still

working and the dryers were running. He said that he tightened a bolt on the mangle’s

bridge, which directs the linen from the first roller to the second roller. He then started the

mangle to determine whether the adjustment fixed the problem. When the mangle still

would not work properly, he continued the process of tightening the bolt and starting the

machine until the bolt broke at its weld to the mangle. 

2 The Safety Board interviewed the laundry manager and the two galley fitters to determine what

occurred in the laundry room before the fire. This accident narrative is compiled using information obtained

from those interviews. Because the fitters have the same job title, this report refers to the fitter who first

arrived in the laundry as the “first fitter” and the fitter who joined him as the “second fitter.”

3 The mangle is a machine for ironing fabrics, such as table clothes and bed linen.

Figure 2. Layout of deck No. 2, aft of the smokestack. In the main laundry, the washers and dryers

were on the port side of the ship, and the mangle was on the starboard side. 

Main Laundry Crew Mess Dry Linen

Reception

Propellor

Motor

Room

Forward

Engine

Room

Engine

Control

Room

Mangle

Stern

Electrical

Workshop

and Store
Factual Information 4 Marine Accident Report

In the meantime, another galley fitter (second fitter) had finished checking a pump

on one of the ship’s Jacuzzis and was preparing to go off duty at 1730 when the galley

engineer told him to help the first fitter in the main laundry. The second fitter said that

when he arrived in the main laundry, the first fitter was adjusting a bolt on the mangle. 

The second fitter said that the first fitter tightened a bolt on the mangle so much

that the bolt broke off. Both fitters testified that the first fitter decided to weld the bolt

back in place. They said that the first fitter went to the fitters’ workshop to get the

necessary equipment, which included a portable welding machine, welding rods, helmets,

gloves, and tools. The second fitter said that he went to get an asbestos (fire) blanket from

the machine shop area. Both fitters testified that, at this time, they did not obtain a “hot

work permit,” as required by Carnival Cruise Lines’ Safety Management System (SMS)

procedures,4

 because “it was standard procedure” to set up the equipment before calling

the staff chief engineer to get a permit and to arrange for a fire watch.

The first fitter said that the location of the bolt, between the roller bed and the end

plate on the mangle cabinet, was difficult to reach for welding. The second fitter stated

that when he returned to the main laundry, the first fitter was lying on top of the mangle,

aligning the broken bolt. The welding machine was on a table next to the mangle. (See

figure 3.) The second fitter said, “I saw the welding unit on the table and the welding rod

[cable] and ground cable were sitting on top of the panel to the mangle....” He stated that

the ground cable was not connected to anything. The first fitter said that he had plugged

the welding unit into an electrical outlet and had inserted a welding rod (electrode) into the

rod holder.5

The second fitter climbed on top of the table next to the mangle. He said that,

because the welding rod was hanging near the deck, he pulled the cable toward him. He

then saw the welding rod come in contact with either the grounding clamp or the mangle,

causing a spark. The second fitter testified that dryer lint was on the floor. The first fitter

said that while he was looking down through the rollers of the mangle, he saw “a very

small fire” on the floor and “yelled out” about a fire on the deck. Both fitters said that they

jumped to the deck, went to the nearby sink, and got a glass of water, which they used to

put out the fire underneath the mangle. 

The second fitter testified that he saw fire “in the middle of the mangle” and

retrieved a fire extinguisher, which he directed on the mangle. The first fitter testified that

he saw “big flames” in the ventilation duct immediately above the mangle and that he took

a CO2 fire extinguisher and directed its spray into the overhead vent. He estimated that he

battled the fire for about 5 minutes but had to abandon the firefighting effort because the

laundry room was filled with smoke. Both fitters testified that when the fire alarms began

to sound, they left the laundry and went to their emergency stations. 

4 For further information about Carnival Cruise Lines’ SMS and the required procedures for company

personnel, see “Operations,” later in this report.

5 The welding machine used by the fitters, a Unitor Miniweld model, did not have an on-off switch. The

unit was energized when it was plugged in. The specifications for the Miniweld states that it “conforms to

the Norwegian Maritime Directorate’s rules for welding apparatus on board ships.” Unitor has since

discontinued manufacturing this model. 
Factual Information 5 Marine Accident Report

Figure 3. (Top) The mangle in the main laundry after Carnival made postaccident repairs to the area.

The tables shown are in about the same location as the table on which the fitters placed the welding

machine on the day of the fire. (Bottom left) The large uncovered opening in the overhead was one of

three vents above the mangle that exhausted air and lint into the ventilation system. (Bottom right)

Two fan units drew heat and lint from the pressing rollers into vertical ducts that were connected to

the overhead ducts of the main laundry ventilation system. 

Overhead 

exhaust vent

Vertical 

exhaust

vent

Table

Filter covers were 

installed on the 

overhead exhaust 

vents after the fire 
Factual Information 6 Marine Accident Report

A cabin steward who had gone to retrieve towels from a linen closet near the main

laundry provided a different account of events. He said that he was at the linen closet door

when he observed smoke in the main laundry. He said that when he went to investigate, he

saw the two fitters working on the inboard side of the mangle. He then saw flames on the

outboard side of the mangle, near the exhaust vents. He said that he retrieved a fire

extinguisher to fight the fire; however, when one of the fitters dumped a jug of water on

the side of the mangle where they were working, flames “appeared to jump up” to an

overhead vent. The steward said that the smoke and flames became too great for him to

fight with an extinguisher, so he activated the local fire alarm at the laundry room door.

About the same time, the laundry crew was preparing to eat when the laundry

manager noticed smoke coming from the overhead vents in the crew galley.6

 He said that

he and the assistant laundry manager went to investigate and saw smoke upon entering the

laundry. The laundry manager stated that he did not see the fitters through the smoke. The

manager and assistant manager left the laundry. The assistant laundry manager said that he

pulled the manual fire alarm in the passageway forward of the laundry and closed the

watertight door (WTD) at the laundry entrance. The manager closed the fire screen door

(FSD) next to the WTD. The two men then reported to their emergency stations.

Activities on the Bridge 

At the time that the Ecstasy departed Miami, the bridge team comprised the

master, the pilot, the staff captain, a first officer, a second officer, a third officer (observertrainee), and two quartermasters. As the Ecstasy entered the Bar Cut Channel, the pilot

requested more speed so that the ship could arrive at the pilot debarkation station7

 before

encountering the rainsquall, which was approaching from the northeast. At the pilot’s

request, the master increased the ship’s throttle setting to full ahead maneuvering speed

(110 rpm), or approximately 13 knots. 

At 1710, an alarm sounded on the fire control panel on the bridge. The first officer

said that he immediately went to the alarm panel to investigate the source of the alarm and

observed that a light on the panel indicated that the alarm was in the main laundry on deck

No. 2. He said that the first alarm was followed rapidly by alarms in the stern thruster

room, the air conditioning room, and the steering gear room. The first officer said that

when he informed the master about the alarms, the master ordered him to send the staff

captain and the safety officer to investigate the source of the alarms and to report their

findings. The first officer also sent the second officer and two roving fire patrolmen to

investigate. A timeline of events beginning with the first fire alarm appears in Table 1.

6 The laundry crew galley is located on the same deck and immediately forward of the ship’s laundry.

7 The master said that he normally disembarked pilots between buoys number 2 and 3 and the Miami

sea buoy. On this night, he went past the sea buoy because he feared that if he stopped near it, the strong

northerly current in the area of the sea buoy would cause the ship to drift into an anchorage north of the sea

buoy where two ships were anchored. The pilot said he also wanted to put the Ecstasy in a clear area because

he had traffic behind him, including an outbound passenger ship.
Factual Information 7 Marine Accident Report

Table 1. Timeline of Events Onboard the Ecstasy

TIME EVENT

1710 Fire alarm indicating the main laundry sounds on the fire control panel on the bridge.

Master instructs first officer to send the staff captain and the safety officer to the scene to 

investigate the source of the alarm and to report their findings. The first officer also orders 

the second officer and two roving fire patrolmen to investigate.

+/- 2 min. All alarms on the fire alarm panel and the sprinkler panel activate. First officer resets all 

alarms and activates low-level lighting throughout the vessel. During this time, the first 

officer begins to receive telephone calls from various crewmen reporting smoke.

+/- 5 min. Alarm on the low-level lighting panel begins to sound.

1720 Master orders ventilation shut down in the two aftermost MVZs.

1724 Master assumes the conn from the pilot after the Ecstasy passes the sea buoy.

1725 Master orders first officer to make the “Alpha Team” code announcement alerting the ship’s 

Quick Response Team. Master orders the cruise director and the hotel manager to the 

bridge to handle emergency communications.*

1728 Master instructs hotel manager to report fire to the Coast Guard. Before call can be made, 

Coast Guard Group-Miami radios the ship asking if assistance is needed. Hotel manager 

asks Coast Guard to stand by while situation is assessed.

1730 Master orders the closure, in the three aftermost MVZs, of the WTDs on decks no. 1, 2, 

and 3 and the FSDs on all decks. Upon receiving reports of a large quantity of smoke in aft 

areas, the master orders all fire teams to marshal.

1740 Master orders security officer to clear passengers and crew from the aft part of the ship 

and chief steward to verify that cabins in smoke affected areas are empty.

Fire teams are marshaled and prepared to attack the fire on the stern.

1754 Master is turning vessel to go the anchorage in compliance with the COTP order when the 

Ecstasy loses propulsion and steering and begins to drift. Chief engineer advises master 

that the computer controlling the propulsion systems is not working and his staff cannot 

determine the reason why because of the fire. Master radios the Coast Guard for 

assistance. 

1800 Master orders general alarm sounded; passengers and crew begin to muster. Cruise 

director begins making status announcements to passengers about the fire.

1815 Coast Guard boarding team arrives onboard and is briefed by the master about the fire. 

Team advises master that he must obtain permission from the Port Authority to return to 

the Port of Miami. Team then proceeds aft to evaluate fire scene.
Factual Information 8 Marine Accident Report

*The cruise director provided status announcements to passengers, and the hotel manager maintained telephone

communications with shoreside Carnival Cruise Lines officials.

The first officer stated that about 2 minutes later, all of the alarms on the fire panel

seemed to light up at the same time. In response to this, he reset the panel display. The first

officer also began to receive telephone calls from crewmembers reporting smoke in

various aft areas. Shortly thereafter, a fault alarm began to sound on the bridge for the lowlocation lighting, that is, the lighting system that illuminates the emergency escape routes

on the vessel. According to the master, the noise from this alarm, which could not be

silenced on the bridge, interfered with bridge communications. The chief electrician was

sent to check the main unit of the low-location lighting system. The electrician stated that

when he could not immediately identify what triggered the fault alarm, rather than return

to the bridge and disconnect the alarm mechanism, he shut down power to the system,

which turned off all low-location lighting throughout the ship.

Meanwhile, the safety officer descended to the marshalling area on deck No. 3,

where he observed smoke in the aft end of the passageway. He said that he immediately

radioed the bridge asking that the master make the “Alpha Team”8

 code announcement.

The staff captain stated that when he arrived at the marshalling area, he saw no flames but

observed smoke spreading upward to deck No. 4. The staff captain radioed his

observations to the master and asked that all five fire teams be alerted and that the entire

aft MVZ be secured. 

1913 All responding tugs are at the scene. Coastal Miami is made fast to the Ecstasy’s bow. 

Other tugs direct streams of water from their fire monitors at the stern of the Ecstasy.

1950 Shoreside firefighters board Ecstasy to assess fire scene.

1955 Crewmembers are released from their emergency stations

2109 Miami-Dade FD declares fire under control. 

2130 Coast Guard COTP order grants permission for the Ecstasy to enter port.

0118 Ecstasy arrives at Pier 8, Port of Miami

8 An announcement of “Alpha Team” was the signal for the quick response team to assemble in the

marshalling area. The quick response team, comprising the fire patrol chief and a 5-person environmental

team, was the onboard unit required to respond first to a fire emergency and to take action to suppress a fire

until the ship’s fire teams could arrive.

Table 1. Timeline of Events Onboard the Ecstasy

TIME EVENT
Factual Information 9 Marine Accident Report

About 1718, a pilot on an outbound vessel behind the Ecstasy observed smoke

issuing from its stern as the Ecstasy approached buoys 2 and 3. (See figure 4.) The pilot

called the Ecstasy’s pilot informing him of the smoke. The Ecstasy’s pilot replied that he

and the master were aware of a fire on board the ship.

At 1720, the master instructed the first officer to shut down all power to the

ventilation systems on the aft part of the ship, specifically MVZs 1 and 2. The first officer

also called the officer on watch in the engine control room to shut down the ventilation in

all areas aft of the engine room. Shortly thereafter, in response to an alarm indicating that

 

Figure 4. Route of the Ecstasy on the day of the accident. Buoys mark the channel to the Miami sea

buoy, where State piloting requirements end and near the area where the pilot on the outbound vessel

debarked.

ATLANTIC OCEAN

BISCAYNE 

BAY

MIAMI BEACH

MIA

MI

1654

Ecstasy

Outbound

Main Channel

PORT OF MIAMI

No. 2

No. 3

0 1 2 3 Nautical Miles 

2109

Ecstasy 

Begins Return

To Miami Under Tow

1710

First Alarm Sounds

1754

Ecstasy Loses Propulsion,

Starts Drifting North

ANCHORAGE

AREA

MIAMI 

SEA BUOY

FLORIDA

1723

Pilot Debarks 

Outbound Ecstasy 
Factual Information 10 Marine Accident Report

the No. 2 stern thruster was overheating, the engine room watch requested that the bridge

discontinue using the stern thrusters to prevent damaging them.

The Ecstasy was on a heading of 040° when it passed the sea buoy at 1723. The

master said that he then relieved the pilot of his navigational duties, and the pilot left the

bridge to disembark. At 1725, the master authorized the first officer to make the “Alpha

Team” code announcement alerting the ship’s fire teams to report to their emergency

stations and to don equipment in preparation for firefighting. 

At 1726, the pilot disembarked the Ecstasy onto a pilot boat. The Ecstasy master

said that he then ordered the vessel on a southeast course at 6 knots while the staff captain

and safety officer assessed the situation. The master said that he maintained the Ecstasy on

a heading that carried smoke away from the ship and that avoided other marine traffic. The

master called the cruise director and the hotel manager to the bridge to handle

communications. The master directed the cruise director to provide status announcements

to the passengers and the hotel manager to contact shoreside authorities, including

Carnival officials, emergency responders, and the Coast Guard.

Before the hotel manager could report the fire to the Coast Guard, about 1728, a

watchstander at Coast Guard Group–Miami who had been monitoring vessel traffic in the

channel radioed to ask about the smoke streaming from the Ecstasy’s stern and whether the

ship needed assistance. The watchstander stated that the hotel manager responded that the

ship had a fire in the laundry room but that they did not need help at that time. The hotel

manager said that he asked the Coast Guard to stand by, as the situation was being

assessed. The Ecstasy’s hotel manager maintained telephone contact with Carnival Cruise

Lines’ director of operations throughout the emergency. The company implemented its

crisis management plan, which included specific shore management assignments for

responding to a shipboard fire.

At 1730, the master issued a series of orders to secure the aft area of the Ecstasy.

He authorized the first officer to close all of the WTDs on deck Nos. 1, 2, and 3 in the aft

portion of the ship and to close all FSDs on all decks in the three after-most MVZs. He

ordered the ship’s security officer to clear passengers and crewmembers from these MVZs

and the casino manager to block the area so that no one could return to it after it had been

cleared. The master then ordered the chief steward to verify that all cabins in the smokeaffected area were empty.

Shortly after 1750, the Coast Guard Group–Miami radio watchstander relayed a

Captain of the Port (COTP)9

 order to the Ecstasy to proceed to the anchorage north of the

sea buoy and anchor. At 1754, as the master turned the vessel to head for the anchorage

area, the Ecstasy suddenly lost propulsion power and steering capability and began to

drift. When the ship lost propulsion, the master requested that the Coast Guard send tugs

to assist the vessel.

9 The COTP is an officer within a district command designated by the Commandant to direct Coast

Guard law enforcement activities within an assigned area.
Factual Information 11 Marine Accident Report

The master said that when he contacted the chief engineer about the power loss,

the chief engineer responded that his engineering staff could not determine the reason for

the problem because of the fire.

At 1800, the master ordered the general alarm sounded alerting passengers and

crewmembers to assemble at their muster stations. At the master’s direction, the cruise

director announced over the loudspeaker that there was a fire but that it was under control.

He told Safety Board investigators that he provided status announcements to passengers

about every 5-10 minutes. Upon receiving reports from crewmembers at an outside muster

station that passengers were having problems hearing the loudspeaker announcements

because news helicopters were flying close to the vessel, the cruise director radioed

muster station personnel with status information to relay to passengers.

At the master’s direction, the cruise director instructed mustered passengers not to

return to their cabins for their lifejackets if they were berthed in the aft part of the ship.

The cruise director announced that lifejackets would be provided to them at their muster

stations. At the Safety Board’s public hearing, the master testified that he did not order the

crew to hand out lifejackets when passengers were mustered because efforts to contain the

fire were successful and no one was in danger. He said that he wanted to maintain a calm

environment by conveying the impression that the situation was under control and did not

warrant the distribution of lifejackets. He therefore ordered the crew to stop distributing

lifejackets to avoid panic among the passengers.

When smoke entered some muster areas, passengers were moved to other stations.

Fire and Rescue Response

Bridge logs indicate that the “Alpha Team” announcement, which alerted the quick

response team to respond and other fire teams to prepare to marshal, was made at 1725.

The quick response team narrowed the location of the main fire and smoke source to the

aft mooring area on deck No. 4. At 1730, upon receiving reports of a large amount of

smoke, the bridge ordered all fire teams to assemble. According to the safety officer, by

1740, the fire teams had assembled at the marshalling area on deck No. 3, had donned

their gear, and had prepared for firefighting. He and the staff captain then led the teams aft

toward the stern of the vessel.

The fire teams inspected several decks in the aft part of the ship for sources of heat

and smoke but initially were unable to enter the mooring deck area because of the intense

heat from the fire. Shipboard firefighters then attempted to cool the perimeters of the aft

mooring deck by spraying water on the overhead of deck No. 3, the bulkhead forward of

the aft mooring deck (deck No. 4), and the surface of deck No. 5. Some firefighters began

boundary cooling by spraying water on the ship’s exterior shell plating. 

In the meantime, the tug Coastal Key West was tied up at Fisher Island (Miami

Harbor) when its master overheard a radio call from the Biscayne Pilots Association to

Coastal Tug and Barge, Inc., of Miami (Coastal Tug) advising of a fire on the Ecstasy. The

Coastal Tug dispatcher radioed the Coastal Key West to assist. The tug got underway
Factual Information 12 Marine Accident Report

about 1800 and arrived on scene at 1827. The Coastal Key West began directing a stream

of water from a high-pressure fire monitor at the fire on the Ecstasy’s stern. 

The Coastal Tug dispatcher dispatched three other tugs, the Coastal Florida, the

Coastal Biscayne, and the Coastal Miami, from the Port of Miami. They arrived within a

half hour of the Coastal Key West. While the Coastal Florida and Coastal Biscayne joined

the Coastal Key West in fighting the fire on the stern of the Ecstasy with their fire

monitors, the Coastal Miami went to the Ecstasy’s bow to prepare for towing the ship. The

Coastal Miami’s master also handled the radio communications between the Ecstasy and

the tugs on scene. A short time later, the tug Dorothy Moran joined the other tugs in the

firefighting efforts at the stern of the Ecstasy.

At 1835, a Coast Guard vessel carrying two representatives from the Marine

Safety Office (MSO) Miami arrived alongside the Ecstasy. The Ecstasy master said that

when the Coast Guard representatives came aboard, he gave them a status report on the

fire and the conditions on the cruise ship. The Coast Guard representatives then proceeded

aft to meet the Ecstasy’s safety officer. The safety officer said that he told the MSO

officials that the fire was limited to the aft mooring deck on deck No. 4, but the fire teams

had not been able to enter the area because of the intense heat and dense smoke.

At 1913, the tug Coastal Miami placed a towline on the Ecstasy’s bow to keep the

ship heading into the wind so that smoke moved away from the stern. The Ecstasy and

Coastal Miami drifted north due to the effects of the Gulf Stream.10 Some Ecstasy fire

teams entered the aft mooring deck from the starboard side weather door and began

cooling the area and extinguishing flames. Another fire team entered the mooring deck

from the port weather door. Shortly thereafter, the fire teams notified the master that the

fire had been extinguished. The Ecstasy fire teams continued to survey the aft decks in

MVZs 1 and 2 for any residual signs of fire.

About 1950, four members of the Miami Beach Fire Department (Miami Beach

FD), including a medical doctor, arrived aboard the Ecstasy and assisted onboard medical

personnel in tending to the ship’s firefighters and passengers. Shortly thereafter, MiamiDade Fire Rescue Department (Miami-Dade FD) personnel and Carnival’s director of

firefighting training boarded the Ecstasy. After meeting with the master and Coast Guard

personnel on the bridge, a command post was set up at the deck No. 3 marshalling area. At

1955, the crew was released from their emergency stations.

The crew firefighters led a team of Miami-Dade FD and Coast Guard personnel

through the affected areas, including the aft mooring deck. After completing its

assessment, at 2109, the team declared the fire under control. At 2130, the Coast Guard

COTP, the Miami-Dade FD, and the Port of Miami granted permission to the Ecstasy to

enter port. The cruise ship, under tow by six tugs, proceeded en route to the Port of Miami.

At 0118, July 21, the Ecstasy arrived at Pier 8. Once the vessel was secured at its berth and

the gangway was rigged, passengers began to disembark about 0220. 

10 The Gulf Stream current off the Straits of Florida flows northerly at a velocity between 2.5 to

3.5 knots.
Factual Information 13 Marine Accident Report

Injuries

Table 2 is based on the International Civil Aviation Organization’s injury criteria,

which the Safety Board uses in accident reports for all transportation modes. Additional

information about the injuries sustained by passengers and crewmembers appears under

“Medical and Pathological.”

Damages

Officials for Carnival Corporation, Inc., the Ecstasy’s owner, estimated fire and

associated damages to be $17 million. The Ecstasy was out of service for repairs until

September 1998. Additional information about the damage to the ship appears under

“Wreckage.”

Personnel Information

General

According to company officials, Carnival hired only Italian deck and engineering

officers. Its petty officers, including bosuns, carpenters, joiners, firemen, electricians, and

plumbers, typically were either Filipino or Central American. 

Table 2. Injuries Sustained in the Ecstasy Accident

Passengers Crew Total

Fatal 000

Serious 1* 0 1

Minor 8 14 22

None 2,556 902 3,458

Total 2,565 916 3,481

49 Code of Federal Regulations (CFR) 830.2 defines a fatal injury as: any injury that results in death within 30 days of

the accident. A serious injury as: an injury that requires hospitalization for more than 48 hours, commencing within

7 days from the date the injury was received; results in a fracture of any bone (except simple fractures of fingers,

toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon damage; involves any internal organ; or

involves second or third degree burns, or any burn affecting more than 5 percent of the body surface.

*As a result of this accident, one woman with chest pains and a pre-existing illness was admitted to the hospital for

more than 48 hours, which met the definition of a serious injury.
Factual Information 14 Marine Accident Report

Master 

The master, age 72, had been going to sea professionally for 52 years. He held

unlimited master’s licenses from Italy and from Liberia. He had sailed for Carnival Cruise

Lines since 1985; he had been a master on company ships for all but the first 3 months of

his time with the company. Four years before the July 20, 1998, fire, he had served as

master on the Ecstasy for 8 months. He had been on the vessel for 1 month at the time of

the fire. 

Staff Captain

The staff captain, age 52, had been going to sea professionally since 1965. He held

unlimited master’s licenses from Italy and from Liberia. He had sailed for Carnival Cruise

Lines since 1991 and had served in all officer positions from third officer to staff captain.

The staff captain also served as the ship’s Health and Safety Officer (HSO).

Safety Officer

The safety officer, age 35, had been going to sea professionally since he was 17

years old. He held unlimited master’s licenses from Italy, from Liberia, from Panama, and

from the United Kingdom. He acted as the on-scene commander of the ship’s firefighting

organization. He was also responsible for maintaining safety and firefighting equipment

and for providing onboard emergency training for the crew.

First Officer

The on-duty first officer, age 42, was one of three first officers on board the

Ecstasy. He held unlimited master’s licenses from Italy, from Liberia, and from Panama.

He had sailed on passenger ships for 6 years, exclusively with Carnival Cruise Lines.

Chief Engineer

The chief engineer, age 51, held unlimited chief engineer’s licenses from Italy and

from Liberia. He was responsible for the operation, maintenance, and repair of all

shipboard engineering systems, including propulsion, electrical, plumbing, and air

conditioning. He joined Carnival Cruise Lines in 1978 as a first engineer. He was

promoted to staff chief engineer in 1981 and to chief engineer in 1986.

Galley Fitters

The “first” galley fitter, age 35, was on his second contract11 with Carnival Cruise

Lines. He had obtained welding certification in the Philippines and training from Unitor.

He had been recently promoted to fitter from assistant fitter. 

The “second” galley fitter, age 25, went to a 3-year trade school in Peru, where he

received welding training and certification. He was hired by Carnival Cruise Lines in

December 1996 as assistant fitter and later promoted to fitter. 

11 Each contract lasts 7 months.
Factual Information 15 Marine Accident Report

Pilot

The pilot, age 38, held an unlimited master license with a Federal First Class

Pilot’s endorsement (for the Port of Miami to the sea buoy), issued by the Coast Guard,

and a State Pilot Commission (pilot’s license), issued by Florida. He was a member of the

Biscayne Bay Pilots Association and had been a Miami ship pilot since August 1989.

Certification and Training Requirements

Preaccident requirements. In 1978, the International Maritime Organization12

(IMO) and its member governments, or parties, established basic requirements for

international seafarers. The International Convention on Standards of Training,

Certification, and Watchkeeping for Seafarers (STCW), 1978, which was adopted by the

International Conference on Training and Certification of Seafarers on July 7, 1978,

became effective on April 28, 1984. Since then, amendments to the STCW were adopted

in 1991, 1994, and 1995. 

In preparation for STCW 95 requirements that became effective January 1, 1999,

representatives from the Coast Guard and five transportation organizations13 cooperated in

developing the curriculum offered at the RTM Simulation Training and Assessment

Research (STAR) Center, which is a maritime training academy located in Dania, Florida.

The coursework included training in the areas of crowd management, safety, and crisis

management and human behavior.

Carnival’s preaccident training and requirements. According to Carnival

Cruise Lines’ officials, the company sent its officers to the RTM STAR Center to meet the

requirements of STCW 95. Company documents, including personnel files, indicate that,

before the fire, the Ecstasy’s deck officers had taken bridge team resource management

training in the classroom and on a bridge simulator; the senior deck officers had taken

command shiphandling. Although not required by STCW 95, Carnival Cruise Lines also

sent its quartermasters (helmsmen) to bridge team resource management training. 

In 1995, Carnival Cruise Lines established a policy requiring that all new hires

speak English.

Firefighting training is the responsibility of Carnival Cruise Lines’ Director of

Firefighting Training. He stated that all firefighters, fire patrolmen, and officers receive

basic and advanced firefighting training, which includes using simulators and hands-on

firefighting techniques. The Ecstasy’s “flag State,”14 that is, the country in which the

vessel was registered, had approved the company’s basic and advanced courses as being in

compliance with the STCW 95 Code.

12 The IMO, a United Nations organization comprising 137 member states, establishes international

maritime standards for the ships of the nations that are signatories to its conventions.

13 Organizations that helped develop the STCW courses included Carnival Cruise Lines, Royal

Caribbean Cruise Lines, American Airlines, Det Norske Veritas, and Lloyd’s Register of Shipping.

14 Another term for flag state is flag administration. 
Factual Information 16 Marine Accident Report

Carnival Cruise Lines had no written specific qualifications for fitters and no

formal recurrent training program for ensuring that fitters were current in their welding

skills. Each chief engineer or staff chief engineer was responsible for ensuring that the

crewmembers in the engine department had the requisite skills and abilities to accomplish

their jobs. All fitters, including the two welders involved in this accident, received onboard job-specific safety training, which included a review of proper practices when

welding and procedures for obtaining a hot work permit.

Postaccident requirements. STCW 95 Section A-V/3, effective January 1, 1999,

contains minimum requirements for the training and qualifications of masters, officers,

and other crewmembers on passenger ships other than roll on-roll off (ro-ro) passenger

ships. The STCW Code requires that seafarers receive currency training at intervals not to

exceed 5 years.

The following excerpts from the STCW manual are selected training requirements

in the areas of crowd management, safety, and crisis management and human behavior. 

Crowd management training

1 The crowd management training required by regulation V/3, paragraph 4,

for personnel designated on muster lists to assist passengers in emergency

situations shall include, but not necessarily be limited to:

.1 awareness of life-saving appliance and control plans, including:

.1.1 knowledge of muster lists and emergency instructions,

.1.2 knowledge of the emergency exits; and 

.2.1 the ability to give clear reassuring orders, 

.2.2 the control of passengers in corridors, staircases and passageways,

.2.3 maintaining escape routes clear of obstructions,

.2.4 methods available for evacuation of disabled persons and persons

needing special assistance, and 

.2.5 search of accommodation spaces;

.3 mustering procedures, including:

.3.1 the importance of keeping order

.3.2 the ability to use procedures for reducing and avoiding panic,

.3.3 the ability to use, where appropriate, passenger lists for evacuation

counts, and

.3.4 the ability to ensure that the passengers are suitably clothed and

have donned their lifejackets correctly.
Factual Information 17 Marine Accident Report

Safety training for personnel providing direct service to passengers in

passenger spaces

3 The additional safety training required by regulation V/3, paragraph 6,

shall at least ensure attainment of the abilities as follows:

Communication

.1 Ability to communicate with passengers during an emergency, taking into

account:

.1.1 the language or languages appropriate to the principal nationalities

of the passengers carried 

.1.3 the possible need to communicate during an emergency by some

other means such as by demonstration, or hand signals, or calling

attention to the location of instructions, muster stations, life-saving

devices or evacuation routes, when oral communication is

impractical;

Crisis management and human behaviour training

5 Masters, chief mates, chief engineer officers, second engineer officers and

any person having responsibility for the safety of passengers in emergency

situations shall:

.1 have successfully completed the approved crisis management and human

behaviour training required by regulation V/3, paragraph 8, in accordance

with their capacity, duties and responsibilities as set out in table A-V/2;15

and

.2 be required to provide evidence that the required standard of competence

has been achieved in accordance with the methods and the criteria for

evaluating competence tabulated in columns 3 and 4 of table A-V/2. 

The RTM STAR Center manuals used to train seafarers on STCW requirements

contain the information or instructions as noted below. 

The crowd management manual, under “Maintaining Order at Muster Stations,”

states:

Accounting

Accurate accounting for passengers is extremely important. Searching for missing

persons may be initiated based on roll call at Muster Stations. Passenger lists

should be used for taking attendance; there should be a list of passengers assigned

to each Muster Station.

The crisis management and human behavior manual, under “Shipboard

Emergency Procedures,” states:

15 Excerpts from this table appear in appendix B of this report.
Factual Information 18 Marine Accident Report

Emergency Scenarios

Formalized emergency procedures should be in place to meet the particular

demands of a variety of situations. Depending on routes, passengers, ports of call,

terminal security measures, and so forth, some such scenarios might include:

• Fire (in port/at sea)

• Grounding

• Collision (in port/at sea)

• Bomb threat

• Terrorist activities

• Extreme weather

• Epidemic

• Pollution

• Emergency assistance to other ships

The crisis management and human behavior manual advises that detailed

requirements for emergency preparedness drills will be included in the company’s SMS,

and that drilling is an ideal means for determining whether in-place emergency procedures

match up with available resources. 

Carnival’s postaccident requirements. According to Carnival Cruise Lines’

officials, in fall 1998, the company began requiring its senior deck, engineering, and other

officers to attend courses in crisis management and human behavior and crowd

management. Crewmembers in safety-related positions were required to attend crowd

management training. 

Vessel Information

The Ecstasy was built in 1991 by Kvaerner Masa Shipyard (Kvaerner Masa) of

Helsinki, Finland, for Carnival Corporation. The vessel was the second of Carnival

Corporation’s “Fantasy Class” ships, a series of eight cruise liners having the same basic

design. The Fantasy class ships are typical of modern passenger cruise liners that are

designed for unrestricted international voyages. At the time of its construction, the Ecstasy

was required to comply with SOLAS 74 and its 1981 and 1983 amendments. The cruise

ship was designed, built, and maintained under the rules of the Lloyd’s Register of

Shipping (LR) classification society. The Ecstasy held the highest vessel classification for

construction. Additional information about vessel certification and inspections appears

later in this section.
Factual Information 19 Marine Accident Report

General Construction

The diesel-electric-propelled Ecstasy is 859.4 feet long, 103.4 feet wide, and

admeasures 70,367 gross tons. The vessel has 13 decks and seven MVZs, which are

separated by A-60 Class divisions. 16 (See figure 5.)

Main Laundry

The main laundry was on deck No. 2, within MVZ 2. The mangle (figure 3) was on

the starboard side of the laundry space. When operating the mangle, laundry workers

placed damp linens on the loading side of the machine. The mangle had strings coated

with wax that directed the linen through the ironing machine’s felt-covered rollers. The

steam produced by the ironing action was removed by blowers and exhausted into two

vertical ducts on the starboard side of the mangle. When workers turned off the mangle, its

rollers automatically raised, preventing damage to the roller bed. The vertical ducts that

interfaced with the mangle were attached to a main exhaust duct for the machine.

Two ventilation duct systems exhausted the air in the laundry space: one duct

system exhausted the air over the mangle and the other duct system exhausted the air near

the six dryers. The duct system dedicated to the mangle had three circular intake openings

that were set flush with the stainless steel panels of the overhead and that were not covered

by a grill or filter. The forwardmost intake opening was above the folding machine

attached to the mangle, the second intake opening was directly above the mangle’s rollers,

and the third intake opening was at the end of the mangle where the linen was loaded. 

The two exhaust systems (figure 1) were separate from each other until the ducts

exited into the aft mooring deck plenum. The blowers for each of the systems were in the

double-deck air conditioning room that extended upward from deck No. 4. According to

Carnival Cruise Lines’ records, the mangle exhaust blower had a calculated linear flow

velocity of 7.3 meters per second (m/s).17

Aft Mooring Deck

The mooring station on deck No. 4 is aft of the MVZ No. 1 forward bulkhead. The

station is a covered space that is open to the weather on the port, starboard, and aft sides.

(See figures 6a and 6b.) The station is used only when docking or undocking. The area has

three electrically controlled winches that spool the large diameter polypropylene line

(rope) that is used to moor the vessel. One winch is on the port side, one is on the

starboard side, and one is in the center of the deck. Additional coils of mooring line are

stored on wooden pallets on the mooring deck. 

16 SOLAS Regulation II-2/3.3 stipulates that A-60 class bulkheads and decks must be constructed of

steel or other equivalent materials; suitably stiffened; capable of preventing the passage of smoke and flame

for 1 hour; and insulated with approved, noncombustible materials that limit temperature increases. 

17 For a duct cross section measuring 1.03 meters, the fan capacity of the mangle blower was 7.5 cubic

meters per second; the fan capacity of the dryer blower was 6.4 cubic meters per second.
Factual Information 20 Marine Accident Report

Figure 5. Plan views of decks 1-5.

Mooring deck

Electrical equipment room

(housed distribution panel MS-21)

Air conditioning/fan room

Air conditioning/fan room

(open to Deck No.5)

Ventilation plenum

Steering gear room

Steering gear room

Main laundry

Toilet

(where crewmen were trapped)

Stern thruster room

Deck No. 4

Deck No. 5

Deck No. 3

Deck No. 2

Deck No. 4
Factual Information 21 Marine Accident Report

Figure 6a. The ventilation system for the main laundry exhausted onto the mooring deck (shown

above), where the synthetic mooring line was spooled on winches or stored on pallets.

Figure 6b. The Ecstasy’s mooring station is a covered deck area that is open to the weather on the

side and rear of the ship.

Door to crew

stairway

Laundry 

exhaust ducts
Factual Information 22 Marine Accident Report

At the time of the fire, the mooring deck had 11 lengths of line, each measuring

220-meters and weighing about 900 pounds. The lines included three lengths of

polypropylene line that were on the winch drums, seven pallets of polypropylene line, and

one pallet of nylon line.

Several air handling systems vented to the mooring deck. A discussion and an

illustration of the ventilation system appear later in this section. 

Operating Systems

Steering. The steering system consisted of two rudder systems that were

mechanically, electrically, and hydraulically independent of each other. The hydraulic

equipment for each rudder system was housed in separate compartments on deck No. 3;

one steering gear room was on the port side and the other steering gear room was on the

starboard side. The steering gear rooms were directly below the mooring station on deck

No. 4. The steering system was controlled from the bridge during normal operations, or, in

an emergency, locally from the steering gear room. 

Propulsion. SOLAS Chapter II-1, Part C, states, in part:

Administrations shall give special consideration to the reliability of single

essential propulsion components and may require a separate source of propulsion

power sufficient to give the ship navigable speed, especially in the case of

unconventional arrangements.

Means shall be provided whereby normal operation of the propulsion machinery

can be sustained or restored even though one of the essential auxiliaries becomes

inoperative.

The Ecstasy’s main power plant comprised six diesel generators that supplied all

electric power for the vessel, including propulsion. The generators produced electricity at

6,600 volts and at a constant frequency of 60 hertz. Transformers and cycloconverters

modified the voltage and frequency for use in driving the motors of the vessel’s two

propellers. (See figure 7.)

Output from the cycloconverters ran through electrical circuit breakers (called

high-speed breakers) that were designed to prevent damage to the propulsion motors in the

event of a power overload. The breakers generated a signal indicating their status, that is,

whether they were open or closed, to the propulsion system computer. If the propulsion

system computer did not receive a status indication from either of the breakers, the

computer would shut down the system power at the cycloconverters. 

The signals indicating the circuit breakers’ positions passed through a distribution

panel (MS-21) in an electric equipment room on deck No. 5, above the area where the fire

occurred. Power cables from transformers supplying the distribution panel were in the

ventilation intake plenum that was forward of the aft mooring station. 
Factual Information 23 Marine Accident Report

Figure 7. Schematic of the propulsion system’s wiring.

M M

G

G G G G G G

G

230 V Distribution

Panel MS 21

Cables damaged by 

heat from fire

T-21 (Primary) T-25 (Alternate Supply) 450V/230V

Transformers

450 V Clean Power Switchboard

MS 2 Auxiliary Voltage

to High Speed Breakers

Motor-Generator Sets

NO

Port

Cycloconverter

Propulsion

Computer

Stbd

Cycloconverter

High-Speed

Breakers

Propulsion Motors

6.6KV / 450V

Transformers

NC

450 V Swbd

MS 1

450 V Swbd

MS 1

Diesel Generators

6.6 KV Main Swbd

PS 1

6.6 KV Main Swbd

PS 1
Factual Information 24 Marine Accident Report

The propulsion system had many redundant features and isolated components

designed to provide reliability. Each propeller had an independent double-wound motor

and each propulsion motor had two cycloconverters. In the event of power failure, the

propulsion system computer had a battery backup, and each motor could use an

emergency exciter. Each of the six independent diesel generators supplied isolated main

distribution switchboards. 

The propulsion system was designed and manufactured by ABB, a subcontractor

to Kvaerner Masa, the shipbuilder. The integration of the propulsion system into the ship’s

other systems, notably the electrical distribution system, was the responsibility of

Kvaerner Masa’s designers. The specifications to the shipbuilder from ABB list the

required voltage and current supplying the propulsion system. The specifications do not

indicate that the voltage supply should be provided by independent sources. Kvaerner

Masa routed the auxiliary voltage for both high-speed breakers through a single external

interface (MS-21).

Officials for ABB, the propulsion system design company, stated that they did not

do a qualitative failure analysis18 of the propulsion system for the Fantasy class ships,

including the Ecstasy, because SOLAS, LR, and Carnival did not require that a system

performance analysis be conducted.

Low-location Lighting

SOLAS Chapter II-2, Regulation 41 requires that passenger ships constructed after

January 1, 1994, have a low-location lighting system in all accommodation area interior

passageways and stairways to assist passengers in identifying emergency escape routes

when smoke impedes visibility.19

The low-location lighting system on board the Ecstasy consisted of a series of lowvoltage, light-emitting diodes (LED) and photoluminescent signs marking exits, doors,

and stairways. The electrical power supply for the system was in the emergency diesel

generator room. In the event of a power loss from the emergency switchboard, a batterypowered DC/AC inverter provided a power backup for at least 60 minutes. 

The lighting system was designed such that the loss of a single light, lighting strip,

or power supply would not result in a system failure. The system was arranged in a series

of independent zones. Each zone had two electrical loops that were powered by

independent power transformers; the loss of a one transformer would not cause the failure

of a loop. If a condition affecting the performance of the low-location lighting system did

occur, a fault alarm would sound on the system’s control panel, which was located on the

navigation bridge. The system was designed such that the bridge watch could not silence

the audible alarm at the control panel. 

18 Information about qualitative failure analysis appears in the “Other” section of this report.

19 See IMO Resolution A.752 (18).
Factual Information 25 Marine Accident Report

Fire Protection

Fire detection. SOLAS Chapter II-2, Regulations 12 and 13 specify the minimum

design and installation requirements for a passenger vessel’s fire detection system,

including power elements, audible and visual alarms, control panels, and detectors.20

Documents indicate that LR issued an approval certificate for the Ecstasy’s fire detection

system.

Consilium Marine AB of Sweden (Consilium) supplied most of the components in

the Ecstasy’s fire detection system. According to Consilium’s technical data sheets, the

Salwico C300 that was installed on the Ecstasy is a conventional fire detection system

with a single central control unit. Group units, each containing loops of eight detectors,

can be added to extend the system’s capability. In the case of the Ecstasy, the vessel had

176 separate detector loops, each of which covered 20 to 30 cabins.

Two models of Consilium smoke detectors were installed on the Ecstasy; one type

of detector was installed in cabins and staterooms, and a second type was installed in

stairways and service spaces, including the main laundry. Manual pull alarms installed

throughout the vessel supplemented the automatic smoke and heat detectors. An

independent module, called the Detector Identification, controlled the zone or detector

address function of the system. 

The vessel’s fire alarm panel, sprinkler fire suppression panel, and various

emergency shutdown and closure controls, including the controls for the FSDs and WTDs,

were mounted on a bulkhead immediately aft of the pilothouse. The fire detection panel

had alarms that sounded and lights that illuminated to identify the loop in which an

automatic detector activated or a person pulled a manual alarm station. 

The control unit for the fire detection system was on the bridge, aft of the

pilothouse. Once an operator identified the loop on the detection panel, he could activate

the computerized video surveillance display at the control unit, which showed the area of

the activated detectors. The control unit also had the capability of indicating individual

smoke detector and circuit failure. 

The fire detection system included a printer that generated a paper log of all

activated detectors and manual pull alarms. On the day of the accident, the system logged

45 detector “events” within 2 minutes of the first alarm, between 1710 and 1712.21

The detection system printer registered alarm locations that did not exist,

indicating the system panel had malfunctioned because of an electrical overload.

Following this accident, Carnival upgraded the fire detection system on the Ecstasy to

correct this problem.

20 See SOLAS Chapter II-2, Regulation 13.

21 The time resolution for the detector log printout was to the nearest minute.
Factual Information 26 Marine Accident Report

Automatic sprinkler protection. SOLAS amendments adopted in 1992 require

that all passenger cruise vessels constructed after October 1, 1994, and carrying more than

36 passengers be protected with an automatic sprinkler system or an approved equivalent

fire suppression system for all accommodation and service spaces, stairway enclosures,

and corridors. Ships built before 1994 must be retrofitted with automatic sprinklers within

15 years of construction or 2005, whichever is later. Because the Ecstasy was constructed

in 1991, Carnival Corporation had until 2006 to comply with the SOLAS requirements for

automatic sprinklers but voluntarily installed sprinkler protection in the Ecstasy’s cabins

and staterooms at the time the ship was built. According to LR, the sprinkler protection

met SOLAS requirements.

Documents indicate that the flag administration interpreted the mooring deck

design to be a category 5, “Open Deck Space,” as defined in SOLAS regulations,22

because the space was partially enclosed and directly open to the weather. SOLAS

regulations do not require that fire detection or fire suppression equipment be installed in

an open deck space, and no such equipment was installed on the Ecstasy’s mooring deck

before the 1998 fire.

SOLAS regulations specify the minimum sprinkler coverage and application rate

for a ship’s sprinkler system. The designs of the Ecstasy’s pump and piling system indicate

that, as stipulated in SOLAS Chapter II-2, Regulation 12, the vessel’s sprinkler system

provided coverage for a minimum area of 280 square meters (m2

) at a rate of 5 liters of

water per m2

 per minute (5 l/m2/min). The system was designed to supply water for about

30 sprinklers at a time, based on a coverage rate of slightly more than 10 m2 for each

sprinkler head. 

Postaccident examination of the ship indicated that more than 60 sprinklers

activated on the Ecstasy. (See table 3.)

The first officer who was monitoring the sprinkler alarm panel, stated that he

remembered that fire zones 20 (deck No. 5, aft) and 32 (deck No. 7, aft) were the first

zones that activated on the sprinkler panel and that several other flow alarms sounded

shortly thereafter.23

Investigators observed that sprinkler zones 20 and 35 indicated a “Sprinkler

Released” status, meaning the system had a pressure drop. Fire zones 6, 14, 15, 21, 22, 26,

32 and 33 indicated a “Master Valve Closed” status, meaning the water to these zones had

been shut off. The remainder of the system was operational at about 5 bar pressure

according to the gauge on the bridge. 

22 See SOLAS Chapter II-2 Regulation 26-2.2 (5). 

23 A flow alarm is an audible alarm that sounds on the bridge when a sprinkler head starts to flow water.

The system does not record the flow alarm sequence.
Factual Information 27 Marine Accident Report

*As the temperature near the sprinkler head increases, liquid in the glass bulb expands and overstresses the glass,

ultimately causing the bulb to break at the sprinkler head’s rated temperature, in this case, 93oC. When the glass bulb

breaks, the sprinkler head opens, allowing water to flow.

Ventilation Systems

SOLAS regulation II-2/16.3.1.3 requires that ducts ventilating category A

machinery spaces, galleys, car deck spaces, ro-ro cargo spaces, or special category spaces

be fitted with automatic fire dampers at the boundary penetrations of passages through

accommodation spaces, service spaces, or control stations. Further, most ventilation ducts

with cross-sectional areas exceeding 0.075 m2

 must be fitted with automatic fire dampers

Table 3. Location of activated sprinklers.

Deck Location

Activated 

Sprinklers Observations and Comments

1 Stern thruster room None Area was protected by a carbon dioxide system.

2 Main laundry None Because the laundry had higher operating 

temperatures, it was equipped with sprinklers 

having a glass-bulb actuating device.*

3 Port-side corridor 2

Refrigerated dry stores 2

4 Mooring station None Area was not equipped with sprinklers.

Port-side corridor 3 Sprinklers were immediately forward of the WTD 

leading to the mooring station.

Aft-most outboard cabin 1

Aft-most inboard cabins 2

Central crew stairs Several

5 Cabins and adjacent 

corridors

40 Affected areas were above the mooring deck.

6 Port-side storage locker 2 Mattresses showed no evidence of dampness.

7 Aft-most cabin – port 2 Carpet was scorched.

Closet in port cabin 1

Aft-most cabin - starboard 2 Carpet was scorched.

Closet in starboard cabin 1

Starboard corridor 2
Factual Information 28 Marine Accident Report

that are capable of manual operation from both sides of the bulkhead or deck.24 Only

dampers that pass through spaces surrounded by A-class divisions without serving those

spaces and that have the same fire integrity as the divisions that they pierce are excluded

from this requirement. 

SOLAS regulations do not include main laundries as a space in which the

ventilation ducts must be equipped with automatic fire dampers. On the Ecstasy, the fire

dampers in the main laundry ducts were manually operated under normal conditions. If the

ventilation system suffered an electrical loss, the dampers would pneumatically shut.

All ventilation systems on the Ecstasy are equipped with fire dampers that close

when ventilation is secured. During postaccident repairs, technicians verified that all fire

dampers had functioned and closed when ventilation was secured from the bridge during

the fire.

As mentioned earlier, air exhaust from the laundry ventilation system exited on the

mooring deck. Intake vents on the port side of the mooring deck supplied fresh air to the

stern thruster room, which was on deck No. 1, immediately below the main laundry. 

A vertical vent duct inside the plenum penetrated decks No. 4 and 3 and then ran

forward/outboard above the potable water tanks. Once on deck No. 2, the duct ran forward

and inboard to supply the thruster room.

The supply intakes for the ship’s air conditioning system are on the ship’s transom

(stern), two decks above the aft mooring deck. These ducts run forward between decks

No. 6 and 7, and pass down through deck No. 5 and along the exposed overhead of the

mooring deck before entering the air handling room on deck No. 4. 

Vessel Certification and Inspections

General. The certification of a ship and its associated safety equipment and

machinery is the responsibility of the “flag state,” or the country in which the vessel is

registered. Liberia, the Ecstasy’s “flag state” at the time of the accident, is a signatory

nation to SOLAS 74. Like most signatory nations, Liberia has incorporated SOLAS

requirements into its national regulations. SOLAS requires that vessels meet the

requirements of a recognized classification society or equivalent.25 Liberia delegated

certification inspection authority to LR to ensure that the Ecstasy met its national statutory

requirements. 

SOLAS regulations and classification society rules are intended to be

complementary and nonduplicative. SOLAS provides detailed guidance on marine

environment protection items, safety items such as structural fire protection, subdivision,

24 SOLAS Regulation II-2/32.1 refers to the application of Regulation II-2/16; Regulation II-2/32

applies to ships carrying more than 36 passengers and Regulation 16 in its entirety does not.

25 Regulation 3-1, Part A-1, Chapter II-1 of SOLAS 74, which entered into force in July 1998, states

that, in addition to meeting applicable SOLAS requirements, ships shall be designed, constructed, and

maintained in compliance with a classification society’s structural, mechanical, and electrical requirements.
Factual Information 29 Marine Accident Report

and damage stability, and general guidance on ship construction and essential shipboard

engineering systems. A classification society provides detailed rules pertaining to ship

structural design and essential shipboard engineering systems. 

Classification. The Ecstasy was built and maintained under LR rules and held the

highest vessel classification for construction (+100 A1). LR is a United Kingdom

nongovernmental, nonprofit corporation founded in 1760 for the primary purpose of

evaluating the structural and mechanical fitness of ships and other marine structures for

their intended purpose. LR’s classification of a vessel involves establishing and

administering its standards, known as Rules and Regulations (rules), for the design,

construction, and operational maintenance of marine vessels and structures. The Ecstasy

was designed under 1987 LR rules. 

Part 6, Chapter 2-1, “Electrical Installations–Equipment and Systems Design,” of

the 1987 LR rules states that the wiring for “essential services,” that is, those services

necessary for the propulsion and safety of the ship, should be duplicated. The following

excerpts from the 1987 LR rules further define the electrical system design: 

Essential services that are duplicated are to be served by individual circuits

separated throughout their length as widely as is practicable and without the use of

common feeders, protective devices or control circuits. 

Where a duplicate supply is required, the two cables are to follow different routes

which are to be as far apart as possible. 

Cables for essential and emergency services are to be arranged, so far as is

practicable, to avoid galleys, machinery spaces, and other enclosed spaces of high

fire risk except as necessary for the service being supplied. 

The general design guidance section states, “The distribution system is to be such

that essential services, which are duplicated, are supplied from separate sections of the

switchboard.”26

As part of this investigation, the Safety Board wrote LR asking the classification

society to provide its interpretation of the rules cited above and the extent of their

applicability to the electrical arrangement for the auxiliary voltage supply to the

propulsion system’s high-speed breakers. In its letter, the Safety Board states:

Recognizing that there may be some differences between the approved as

designed drawings and the as built drawings, please comment on the applicability

of the rules to both sets of drawings, if the differences between them are

significant. If the electrical arrangement for the auxiliary voltage to the highspeed breakers complied with these rules, please discuss how the rules are

actually intended to be applied. And finally, please comment on any Lloyd’s

Register rule changes (if any) that have been made to the 1987 rules that may

26 Lloyd’s Register of Shipping Rules and Regulations for the Classification of Ships, Part 6, Control,

Electrical, Refrigeration and Fire, January 1987, Chapter 2-1 Electrical Installations – Equipment and

Systems Design, Section 2 System design – General, Subsection 2.1.6 Systems of supply and distribution.
Factual Information 30 Marine Accident Report

address the reliability problems with the high-speed breaker auxiliary voltage

supply arrangement that was installed aboard Ecstasy.

In its response, LR states:

The high speed circuit breakers to which you refer are those on the motor side of

the cycloconverters through which the motors receive their power. The voltage(s)

supplied from MS 21 appear, from the manufacturer’s data, to be primarily for the

electrical closure of the circuit breakers. 

...after this fire, we were informed that the voltage supply from MS 21 is also

used, internally within the cycloconverter, to provide a “circuit breaker closed”

signal in order to “enable” the drives to start and to continue operating. 

The details of these internal connections were not provided to LR during LR’s

plan approval, and LR’s surveys of the vessel’s construction. Therefore, LR was

not aware, prior to this casualty, that if these cables were burnt through propulsion

would be lost. 

LR receives “design” plans for consideration at or before the time of construction

of the vessel. It is these plans that our surveyors review and stamp “approved”

against applicable classification requirements. Upon completion of construction

“as built” plans are forwarded to LR for record purposes. 

We have checked the Ecstasy design plans approved by LR at the time of

construction and the “as built” plans forwarded to us for record purposes. Neither

show the detailed matters referred to in your letter. 

There have been no rule changes made since 1987 which address specifically high

speed breaker auxiliary voltage supply arrangements similar to those installed

aboard Ecstasy. However, based on the experience gained over the years of what

was in 1987 an innovative design, the Rules have been changed to take into

consideration commonality of electrical supplies.

U.S. Coast Guard Examinations. The United States requires that ships that

embark passengers from U.S. ports be examined by the Coast Guard for “substantial

compliance” with the construction, equipment, and safety requirements of SOLAS. The

Coast Guard examinations are referred to as Control Verification Examinations (CVEs).

These examination procedures are contained in the Coast Guard’s Navigation and Vessel

Inspection Circular (NVIC) No. 1-93, which provides guidance regarding examinations

for foreign cruise ship operators. The examination process involves three phases: an initial

CVE, which is a plan review of new or existing vessels; an annual CVE, which is a review

of the vessel’s firefighting, lifesaving and emergency systems; and a quarterly CVE,

which is a safety review of the vessel’s operations. As of July 1,1998, the Coast Guard’s

examination for passenger vessels included International Safety Management (ISM) Code

provisions, which are discussed later in this report, under “International Safety

Requirements.” 
Factual Information 31 Marine Accident Report

Before the July 1998 fire, the Ecstasy had undergone its last annual CVE on

May 1, 1998. Coast Guard documents indicate no discrepancies were found during the

CVE.

Waterway Information

The Port of Miami is the largest embarkation port for cruise ships in the United

States, handling more than 3.1 million passengers annually. It is home port to 18 cruise

ships. Carnival, Cunard, Norwegian Cruise Line, and Royal Caribbean International

regularly operate cruise vessels from the Port of Miami.

From Pier 8, the Ecstasy’s point of departure, to the harbor entrance, the channels

and their respective dredged depths are as follows: Main Channel, 36 feet; Inner Bar Cut,

44 feet; Outer Bar Cut, 44 feet; and Government Cut, 42 feet. The widths of the channels

vary from 400 to 600 feet. At Government Cut, two unmarked jetties protect the harbor

entrance. Strong tidal currents run between the jetties. A northerly wind in the area causes

a considerable southerly set27 across the ends of the jetties. The mean range of the tide at

the harbor entrance is 2.5 feet. Shoals extend about a mile offshore northward of the

harbor entrance. Pilotage is compulsory for all foreign-registered vessels and is supplied

by Biscayne Bay Pilots. 

Meteorological Information

At the time of the accident, the weather was cloudy with rainsqualls. Winds were

variable and out of the East/Northeast at 15-20 knots, producing waves of 1 to 2 feet.

Visibility in the rainsqualls was limited to 1-2 miles; otherwise, visibility was unlimited.

No thunderstorms were in the vicinity.

Operations

General

Carnival Cruise Lines’ parent company, Carnival Corporation, owns or has interest

in seven cruise brands that operate as separate companies. The corporation has full

ownership in Carnival Cruise Lines, Holland-America Line, Windstar Cruises, Cunard

Line, Seabourne Cruise Line, and Costa Crocierw S.p.A and minority ownership in

Airtours’ Sun Cruises. Combined, these lines operate 48 cruise ships. Carnival

Corporation is scheduled to add 13 ships to its fleet by the end of 2005.

27 Set is the direction in which the current flows.
Factual Information 32 Marine Accident Report

Carnival Cruise Lines presently runs 16 passenger vessels on pleasure cruises that

last 3 to 16 days and that include itineraries to the Bahamas, Caribbean, Panama, Mexico,

Hawaii, and Alaska. At the time of the accident, the operating company regularly ran the

Ecstasy on 3- and 4-day round-trip cruises from the Port of Miami. The 4-day cruises

departed on Monday and had stopovers at Key West and Cozumel, Mexico. The 3-day

cruises left on Friday and sailed to Nassau, Bahamas, where it docked for 1 day before

returning.

International Safety Requirements

At the 1994 SOLAS Conference, the IMO General Assembly adopted a resolution

entitled “The International Management Code for the Safe Operation of Ships and for

Pollution Prevention,” known, in brief, as the ISM Code, to encourage the continuous

improvement of safety management skills in the maritime industry. 

The ISM Code became effective on July 1, 1998, for all passenger ships and for the

following vessel types of 500 gross tonnage and over: oil tankers, chemical tankers, gas

carriers, bulk carriers, and high speed cargo ships.28

The ISM Code requires a company29 to establish and maintain a documented SMS

that, among other things, meets the following safety management objectives: 

1. Provides for safe practices in ship operation and a safe working environment; 

2. Establishes safeguards against all identifiable risks; and 

3. Continuously improves safety management skills of personnel ashore and

aboard vessels, including preparing for emergencies related both to safety and

environmental protection.

The ISM Code establishes six functional requirements for an SMS: 

• Policies for ensuring safety and protecting the environment; 

• Instructions and procedures for ensuring safe vessel operation and

environmental protection in compliance with international and domestic laws; 

• Defined levels of authority and lines of communications between and among

shipboard and shoreside personnel;30

• Procedures for reporting accidents and nonconformities; 

• Procedures for preparing for and responding to emergency situations; and 

28 The rules for all other cargo ships and MODUs of 500 gross tonnage and over enter into effect on

July 1, 2002.

29 The ISM Code defines company, in part, as “the owner of the ship or any other organization or

person...who has assumed responsibility for operation of the ship from the shipowner and who, on assuming

such responsibility, has agreed to take over all the duties and responsibility imposed by the Code.”

30 The ISM code stipulates that a company’s SMS clearly define and document the master’s

responsibilities and emphasize his authority in its SMS.
Factual Information 33 Marine Accident Report

• Internal audits and management reviews.

The procedures required by the ISM Code must be documented and compiled in a

Safety Management Manual (SMM), which must be maintained on board a company’s

ships. 

The ISM Code requires that a company provide necessary resources and shorebased support to achieve SMS objectives that includes appointing a designated person or

persons ashore having direct access to the highest level of management.

The flag state government is responsible for enforcing the ISM Code and for

issuing documentation attesting that companies are in compliance with it. A company

complying with the ISM Code is issued a Document of Compliance, a copy of which must

be kept on board the ship. Ships in compliance with the ISM Code are issued a SMS

document.

Carnival Cruise Lines’ Safety Management System

LR certified that Carnival Cruise Lines’ SMS and its vessels, including the

Ecstasy, were compliant with the ISM Code in December 1997, or 6 months ahead of the

IMO deadline.

Investigators reviewed the SMM maintained by Carnival Cruise Lines on board

the Ecstasy. The SMM defines the organization of the company’s SMS, states its policies,

and lists the various operating manuals that cover key shipboard operations. Manual 00 of

the company’s SMM, entitled “Master Safety Management System,” contains a policy

statement, which says, in part:

The main objectives of the SMS are to ensure the motivation of all CCL personnel

through effective education and training, and to outline specific responsibilities

for safety and environmental protection throughout all CCL operations.

The SMS emphasizes a pro-active attitude toward the elimination of operational

problems, such that require forward planning and prevention procedures, on the

part of all Carnival Cruise Lines personnel, will eliminate the occurrence of

problems detrimental to the standard of passenger service offered by Carnival

Cruise Lines and ensure safety at sea, personnel safety, and avoidance of damage

to the environment.

The individual manuals, in turn, identify operations that are considered special or

critical, establish safe procedures for conducting those operations, and assign qualified

individuals to perform the tasks necessary for the operations. For example, Manual 03,

“Health and Safety,” indicates that the goal of the company is to “eliminate work-related

accidents, injuries, incidents and hazardous occurrences.” Manual 03 states that

management responsibilities include providing the information, instruction, training, and

supervision necessary for compliance with health and safety requirements. The manual

lists the staff captain as the designated HSO for the vessel and states that, as such, he is

responsible for ensuring compliance with “all health and safety instructions, rules,
Factual Information 34 Marine Accident Report

procedures, and guidance.” The manual further states that crewmembers are responsible

for taking all reasonable care for their own health and safety and for that of all others on

board the ship and that they must cooperate with the company, master, chief engineer, and

all others who are responsible for health and safety aboard ship. 

SMS Manual 03, Section 5, “Safety Procedures,” contains subsections on permitto-work systems (5.7) and welding and flame cutting operations (5.13). 

According to the SMS manual, a permit-to-work system covers “operations on

board ship where the routine actions of one man may inadvertently endanger another.”

The system identifies foreseeable hazards posed by various tasks and operating

environments and lists precautions and sequential actions to take when performing such

tasks. The SMS manual states, “In all instances it is necessary, before the work is done, to

identify the hazards31 and then to ensure that they are eliminated or effectively controlled.”

The manual further advises that the first and most important step in eliminating or

effectively controlling hazards is a situational assessment by the ship’s officer who is

experienced in the work and thoroughly familiar with relevant hazards. The subsection

specific to hot or cold work stipulates that permits that grant permission for such work

must be countersigned by the chief engineer, staff chief engineer, master, or staff captain. 

The subsection on welding and flame cutting operations states, “No welding or

flame cutting work should be undertaken unless the requirements of the ‘Hot Work

Permit’ are fully satisfied.” The manual stipulates that welding operations should be

properly supervised and kept under regular observation and that a person with a suitable

extinguisher should be stationed to keep watch on areas not visible to the welder. 

Manual 07, “Safety of Operations—Engineering Department,” states that the staff

chief engineer or engineering officer team leader must ensure that all measures and

precautions that are necessary for the safety of those concerned are taken before any repair

or maintenance work begins. Investigators reviewed the Ecstasy records of hot work

permits issued for various maintenance tasks outside the ship’s machine shop and

workshop. The log and copies of approved permits do not include an application or an

approval for a welding project in the ship’s main laundry on July 20, 1998. After the fire

onboard the Ecstasy, Carnival Cruise Lines revised its SMS to include safeguards against

unauthorized welding. See “Other Information,” later in this report.

Manual 08, “Safety of Operations—Hotel Services,” states that the laundry

manager is responsible for, among other tasks, ensuring the safe operation of all laundry

equipment and the proper cleanliness of the laundry room, laundry equipment, and the

laundry crew galley. The manual lists 17 required safety procedures for the laundry area.

The procedures specify the required operating temperatures for washers, dryers, and the

mangle, proper handling of chemicals, and measures for handling linens, clothes, and

uniforms. The laundry safety procedures also include prohibiting smoking in the laundry

room and performing a fire risk assessment at regular intervals. 

31 At the time of the Ecstasy accident, Manual 03 did not include a section on job hazard analysis. Since

the accident, Carnival Cruise Lines has developed and added a chapter “Safe Systems of Work - Job Hazard

Analysis.” 
Factual Information 35 Marine Accident Report

According to Carnival Cruise Lines’ officials, at the time of the Ecstasy accident,

all officers and crewmembers assigned to ships in the company’s fleet had received a

general overview training of the SMS. Employees had been given specific training in

those areas of the SMS pertaining to their duties. The company had established a schedule

of weekly reviews of the SMS, which included departmental meetings during which

supervisors reviewed provisions of the SMS with crewmembers. 

Additional Oversight Practices

According to Carnival Cruise Lines’ officials, to complement its SMS, the

company retained some management oversight practices that it had in place before it

developed its SMS. Management representatives, typically a shoreside ship supervisor or

a port engineer or port captain, visited each ship in the company’s fleet at least once

monthly to ensure that shipboard personnel were following and practicing corporate safety

management policies. In addition, Carnival Cruise Lines had a quality control committee,

headed by the company president, that visited each ship yearly to meet with the master,

department heads, and the entire crew to answer any questions on corporate policy and

vessel operations. 

Medical and Pathological

Medical Findings

Medical responders examined at least 70 passengers and crewmembers to

determine whether they were injured and required additional medical treatment. Six

passengers were treated by medical personnel and local hospitals for pre-existing

conditions; three passengers were treated for smoke inhalation. Fourteen crewmembers

were treated for minor injuries, including smoke inhalation, chest pain, lower back pain,

cervical strain, knee pain, and a knee contusion.

Toxicological Testing

Carnival’s requirements. At the time of the Ecstasy accident, Carnival Cruise

Lines’ health and safety manual contained the following requirements pertaining to drug

testing (italics added for emphasis):

1. All testing for drugs will be by the analysis of urine.

2. Prospective Company seafarers may be required to undergo drug testing prior

to an offer of employment being made.

3. Company seafarers may be required to undergo periodic drug testing.

4. Unannounced testing may be carried out at intervals, initiated by Company. All

unannounced drug testing, including urine sampling, will be carried out by

shore personnel only.
Factual Information 36 Marine Accident Report

5. Should circumstances permit, post casualty testing for drugs must also be

carried out immediately after any safety or pollution accident or incident. The

post casualty testing must be carried out on the Master and Chief Engineer and

those other Officers and crewmembers who were performing any duty at the

time of the incident or casualty.

About 0030, July 21, 1998, while the Ecstasy was under tow from the sea buoy to

the Port of Miami, the Coast Guard notified Carnival Cruise Lines to conduct postaccident

toxicological screening for drugs and alcohol. About 0430, or about 12 hours after the fire

was detected aboard ship, technicians from Toxicology Testing Service, Inc., of Miami

began taking blood specimens for alcohol testing and collecting urine specimens for drug

screening. By 1100, the technicians had tested 79 crewmembers, including the officers and

fitters discussed earlier in this report.

The first officer who was on bridge watch at the time of the fire and a junior

electrician who was not on watch tested positive for cannabinoids. They were

subsequently dismissed by Carnival. An oiler who was on watch in the engine room tested

positive for alcohol. He stated, however, that he had consumed alcohol after the fire

emergency had subsided.

According to Carnival Cruise Lines’ officials, the company had not been

conducting random drug tests of its shipboard crews before the Ecstasy fire. Following

this accident, the company revised its hiring policies to require drug testing as a condition

for employment. The company instituted a program of random drug testing and adopted a

“zero tolerance” policy, meaning it will dismiss any employee who tests positive for

illegal drugs. 

Wreckage

Operating Systems

Propulsion system. Investigators noted that electrical cables in the ventilation

exhaust plenum near the mooring deck were burned and melted. Some of these cables

supplied voltage from an electrical distribution panel in an equipment room near the aft

mooring station to the high-speed breakers for the port and starboard propulsion systems.

Following this accident, Carnival Corporation modified the voltage supply

arrangement to the high-speed breakers aboard the Ecstasy by providing selectable

redundant voltage supplies to each set of high-speed breakers from independent power

sources. According to Carnival officials, the company also planned to modify the

arrangement aboard other vessels in the Fantasy class. 

Steering gear systems. During the accident, the port steering system completely

failed, but the starboard hydraulic system continued to operate even though the monitoring

system failed. The port and starboard steering gear rooms were on deck No. 3, directly
Factual Information 37 Marine Accident Report

below the fire on the aft mooring deck. The electrical power and control cables for the

steering systems were routed in cableways near the overheads of the steering gear rooms

on deck No. 3. Investigators observed that the control cables and control system

components in the steering gear control cabinet were burned and melted. The port steering

gear room showed evidence of greater damage to a greater extent than the starboard

steering gear room.

Stern thruster system. The temperature-sensitive equipment in the stern thruster

room, including the power supply cables to the stern thruster electric motors, were burned

and melted. Two of the three stern thruster electric drive motors were damaged by heat.

Low-location lighting. The wiring insulation on a portion of one low-location

lighting loop was melted. The system was designed to sound an alarm on the bridge in the

event of a power failure. 

Air conditioning system. Investigators observed signs of heating-flame

impingement on the transom next to the intake supply ventilators. This air conditioning

duct ran beneath cabins and storage lockers on deck No. 7, where the carpet and

furnishing sustained heat damage.

Other Damaged Areas

Table 4 summarizes the conditions and damage that investigators observed in

various areas of the vessel during their postaccident examination of the Ecstasy.

Table 4. Damage by Deck Area

Deck Location Observed Conditions and Damage

2 Laundry room Laundry space sustained no fire damage. Several areas within the 

space sustained heat and smoke damage. The mangle had smoke and 

soot on its underside. 

A light fixture near the mangle had melted.

Mangle had melted and burned insulation in the electrical control 

cables of the control panel (under the loading end of mangle) and in the 

mangle’s exhaust system.

The housings of the two mangle exhaust blowers that removed steam 

from the rollers were caked inside with partially burned lint and wax.*

Impeller blades on the aft exhaust blower fan were not attached to the 

fan motor shaft. All that was left of the fan impeller blades were rust 

colored metal flakes that were imbedded in the lint and wax. Impeller on 

the forward fan was caked with lint and wax but was otherwise intact.

The ducts attached to the two mangle blowers sustained heat damage. 

The paint on the aft exhaust duct was blistered and charred; the 

forward exhaust duct had less heat damage. Both ducts contained 

burned debris.

Felt on the loading end roller was burned on the edge nearest the aft 

blower.

Ventilation duct above the mangle contained 2-3 inches of burned 

debris.
Factual Information 38 Marine Accident Report

* The strings that directed the linens through the mangle were coated with wax.

Survival Factors

This section contains the regulatory requirements, Carnival Cruise Lines’

provisions and procedures related to shipboard emergency training and drills, passenger

feedback obtained from interviews and a survey that the Safety Board mailed to a sample

of passengers,32 and a detailed description of the actions by the emergency responders to

the incident.

Regulatory Requirements:

The following are excerpts from the SOLAS Regulations:

Regulation 18: 3.1, “Emergency Training and Drills”: 

Each member of the crew shall participate in at least one abandon drill and one

fire drill every month. The drills of the crew shall take place within 24 hours of

the ship leaving port if more than 25 percent of the crew have not participated in

abandon ship and fire drills on board that particular ship in the previous month.

The Administration may accept other arrangements that are at least equivalent for

those classes of ship for which this is impracticable.

3.2 On a ship engaged on an international voyage which is not a short

international voyage, musters of passengers shall take place within 24 hours after

their embarkation. Passengers shall be instructed in the use of the life-jacket and

the actions to take in a emergency.

Regulation 25, “Drills”:

On passenger ships, an abandon ship drill and a fire drill shall take place weekly.

2 Laundry crew galley 

(pantry)

The galley and its contents were heavily covered with soot. Area 

showed no evidence of flame exposure.

3 Refrigerators and dry 

provision stores

Vent in the overhead above a sink contained soot. 

Port side: The overhead ventilation duct showed signs of intense heat. 

Near this vent, the steel deck was buckled and its paint was charred 

and cracked. The stainless steel sheathing of the cool storage space 

was warped, discolored blue, and had pulled away from joints.

Starboard side: No visible damage. Vent covers had soot deposits.

4 Passenger cabins 

and corridors

Fire damage, which included scorched carpeting and furnishings, was 

limited to passenger cabins and corridor area nearest the WTDs.

32 See “Postaccident Survey,” which appears later in this report. 

Table 4. Damage by Deck Area

Deck Location Observed Conditions and Damage
Factual Information 39 Marine Accident Report

Regulation 53, “Muster List and Emergency Instructions”:

The muster list shall show the duties assigned to members of the crew in relation

to passengers in case of emergency. These duties shall include: warning the

passengers; seeing that they are suitably clad and have donned their lifejackets

correctly; assembling passengers at muster stations; keeping order in the

passageways and on the stairways and generally controlling the movements of the

passengers; ensuring that a supply of blankets is taken to the survival craft.

Emergency Procedures and Drills

Crew training. The Ecstasy safety officer stated that all crewmembers on board

had participated in a “vessel familiarization program,” as required by STCW. Investigators

reviewed the program curriculum and a sampling of personnel training files. The courses

provided by the safety officer included Safety Communication, Signs and Alarms; Crew

Muster Stations, How to Locate and Don Lifejackets; Man Overboard Initial Action; Fire

Emergency Initial Action; Medical Emergency Initial Action; Close and Open

Weathertight, Watertight, and Fire Screen Doors; and Vessel Familiarization Assessment. 

A station bill on board the Ecstasy specified the responsibilities and emergency

stations for each crewmember in the event of an emergency. According to the safety

officer, fire drills were held weekly and were conducted as if an actual emergency existed.

Crewmembers were required to report to fire stations with firefighting equipment and

simulate a response to a fire.

At the time of the accident, Carnival Cruise Lines had not developed a crowd

management plan, including crowd control training for crewmembers. According to the

Ecstasy’s safety officer, he and the staff captain provided instruction on proper crowd

control procedures to crewmembers who were assigned to direct passenger evacuation,

muster station leaders, lifeboat commanders, and other supervisory personnel during the

weekly emergency drills and other routine training. The safety officer stated that the Coast

Guard tested the crewmembers’ knowledge of crowd management procedures during

annual and quarterly CVEs. He indicated that, during emergencies when routine

procedures did not apply, the master or other officers provided instructions specific to the

situation.

Passenger drill. Before the Ecstasy departed Miami, passengers were required to

participate in an abandon ship, or muster, drill. According to the cruise director, he

followed a script during the drill, which contained the following instructions: 

• Crewmembers will guide passengers to their muster stations and instruct them

how to wear the lifejackets. 

• If passengers must abandon ship, lifeboats would be lowered to the

embarkation deck to allow them to board the boats. 

• If passengers do not have enough lifejackets in their cabin for the number of

occupants including children, a cabin steward will provide extra lifejackets. 
Factual Information 40 Marine Accident Report

• A placard in each passenger cabin provides emergency instructions. (See

appendix C.)

According to passengers and shipboard personnel, passengers were not told during

the drill how to determine which crewmembers would assist them. They said that, during

the drill and the actual emergency, the crewmembers having primary responsibility for

assisting passengers and distributing lifejackets did not wear any type of identification.

Passenger accountability. According to Carnival Cruise Lines’ officials,

shoreside personnel prepared a manifest, which was provided to shipboard personnel, of

all passengers who booked a cruise on the Ecstasy. As passengers boarded the vessel, they

were asked to sign for a computerized “sign and sail” card that was used to make

purchases. Shipboard personnel used the computer data to confirm which booked

passengers actually boarded the Ecstasy. Throughout the cruise, the crew used the

computerized cards to determine which passengers debarked and boarded the vessel at

travel stops. 

The lifejackets provided in each stateroom were imprinted with the letter of the

muster station to which the occupants of that stateroom were to report during a drill or an

emergency. Crewmembers in charge of the muster stations determined whether or not

passengers had reported to the correct station by the lettered lifejackets that they wore. A

list of the passengers who were supposed to report to a given muster station was not

maintained at the muster station or provided to the muster station leader. 

During an emergency, crewmembers were assigned to search each stateroom to

make sure that it was vacant and were required to place a towel around the exterior

doorknob indicating that the stateroom had been searched. 

Lifesaving equipment. An LR “Record of Equipment for the Passenger Ship

Safety Certificate,” issued May 2, 1997, indicates the Ecstasy’s lifesaving equipment met

the requirements of SOLAS 74, as amended in 1998.

The SOLAS 98 amendments stipulate the following requirements for personal

lifesaving appliances under regulation 7.2, “Lifejackets”:

2.1 A lifejacket complying with the requirements of paragraph 2.2.1 or 2.2.2 of

the Code shall be provided for every person on board the ship and, in

addition: 

.1 a number of lifejackets suitable for children equal to at least 10 percent of

the number of passengers on board shall be provided or such greater

number as may be required to provide a lifejacket for each child; and 

.2 a sufficient number of lifejackets shall be carried for persons on watch and

for use at remotely located survival craft stations. The lifejackets carried

for persons on watch should be stowed on the bridge, in the engine control

room and at any other manned watch station.
Factual Information 41 Marine Accident Report

2.2 Lifejackets shall be so placed as to be readily accessible and their position

shall be plainly indicated. Where, due to the particular arrangements of the

ship, the lifejackets provided in compliance with the requirements of

paragraph 2.1 may become inaccessible, alternative provisions shall be

made to the satisfaction of the Administration which may include an

increase in the number of lifejackets to be carried.

The SOLAS 98 amendments contain additional requirements for personal lifesaving appliances at regulation 22, which states, in part:

2.1 In addition to the lifejackets required by regulation 7.2, every passenger

ship shall carry lifejackets for not less than 5 percent of the total number of

persons on board. These lifejackets shall be stowed in conspicuous places

on deck or at muster stations.

2.2 Where lifejackets for passengers are stowed in staterooms which are

located remotely from direct routes between public spaces and muster

stations, the additional lifejackets for these passengers required under 7.2.2

shall be stowed either in the public spaces, the muster stations, or on direct

routes between them....

The LR certification attachment indicates that the Ecstasy carried the following

life-saving appliances: 10 immersion suits; 270 thermal protection aids; 18 lifeboats;

2 rescue boats, and 36 life rafts. The LR form indicates that the Ecstasy had 3,738 adult

lifejackets and 356 child lifejackets, or a total of 4,094 lifejackets, to accommodate a

maximum load of 3,560 people.

Carnival Cruise Lines’ records indicate that, on the day of the accident, the Ecstasy

carried 4,368 adult-size lifejackets and 578 child-size lifejackets, or a total of

4,946 lifejackets. (Appendix D shows the location of the lifejackets.) As indicated earlier

in this report, the ship did not sail with a maximum load. The passenger manifest listed

2,342 adults and 223 children, and the crew manifest showed 916 crewmembers. 

Postaccident survey. The Safety Board mailed questionnaires to 300 passengers

who had been on the Ecstasy asking about the muster drill and whether they encountered

any problems during the actual emergency. The Board received 126 responses, which are

summarized below.

All 126 responders indicated that they participated in the drill. Most passengers

stated that the drill proved valuable during the actual emergency in that they were able to

identify the general emergency alarm, don their lifejackets, and find their muster and

lifeboat stations. They indicated that they appreciated being told that the ship had a fire

squad and extra lifejackets on board. Seventy-nine passengers indicated that, during the

actual emergency, the ship’s crewmembers seemed well trained and organized and did a

good job. All responders said that they heard the cruise director announce “a minor fire

situation,” which was under control, and that they were to report to their muster stations.

Passengers described the crewmembers as calm and helpful in directing passengers and

addressing their questions. Responders stated that the cruise director made frequent

announcements, both in English and in Spanish, throughout the emergency. Some
Factual Information 42 Marine Accident Report

responders who initially reported to an outside muster station said that, because of

helicopters flying nearby, they occasionally had problems hearing announcements

broadcast over the loudspeaker system. They said that when they advised the

crewmembers of the problem, they notified “officials” [the cruise director], who then

relayed status accounts to muster personnel, who, in turn, provided the information to the

passengers.

Fifty-three survey responses identified various problems or situations that were not

addressed during the drill. Several people indicated that the drill did not include specific

information about fire emergencies, including what to do if they encountered smoke or

fire. A number of respondents said that they could not report to their station because of

smoke, and the drill did not provide information about what to do if a muster station was

not available. Some passengers indicated that they had problems recognizing

crewmembers to direct or assist them during the emergency. 

Several of the responders expressed dissatisfaction about the lack of consistency in

the crew’s provision of lifejackets to the mustered passengers. During the drill, the

passengers were advised that, in the event of an emergency, if they could not retrieve the

lifejackets from their staterooms, they would be provided lifejackets after reporting to

their muster stations. Seventy-nine survey responders said that they either obtained

lifejackets from their cabin or were provided lifejackets by crewmembers. Forty-seven

passengers said that they never received lifejackets. Two passengers stated that when they

asked for lifejackets, a crewmember started to pass them out and then reportedly was

ordered to stop doing so by his superiors because they were concerned that distributing

lifejackets might cause panic. One passenger stated that one crewmember told her not to

retrieve her lifejacket from her stateroom and later another crewmember told her to get her

lifejacket from her cabin; however, when she attempted to do so, she could not reach her

stateroom because of the smoke. 

Seventy-two responders, primarily those who had been in the aft section of the

Ecstasy, indicated that the emergency alarm and the announcements to muster did not

occur until after they saw or smelled smoke in their cabins and the passageways. Several

passengers estimated that the time between the first evidence of smoke and the emergency

alarm was 30 minutes or more. Other responders indicated that they first learned about the

ship’s fire from television news reports. 

Trapped Crewmen

A cabin steward whose cabin was on deck No. 2, close to the main laundry,

described to Safety Board investigators how he and another crewmember became trapped

by heavy smoke during the fire. About 1805-1810, he was in the passageway when he

heard some of the laundry crewmembers talking in Chinese. He returned to his cabin

where he smelled smoke. When he went back out into the passageway, the laundry

workers were talking, “maybe arguing.” One of the laundry workers told him to close his

door, whereupon he returned to his cabin. He then saw a small amount of smoke coming

from his vent. He returned to the passageway and saw that the laundry crew had left. He

went back into his cabin to grab a lifejacket and saw heavy gray smoke coming from the
Factual Information 43 Marine Accident Report

vent. He then realized that a fire might have broken out so he left his cabin and started

knocking on cabin doors to alert others.

The steward found one other crewmember. The steward said that the two of them

attempted to escape from deck No. 2; however, heavy smoke filled the passageways,

severely limiting their visibility. The steward said that, based on survival techniques that

he learned from the safety officer and the safety information booklet, he started to take

refuge in a common area toilet facility. He then realized that the other crewmember had

not followed him but had continued down the passageway. Holding a towel to his face, the

steward felt his way along the bulkhead in the direction of the crewman, who was

coughing and calling for help. The steward told the crewmember to calm down and follow

him. They went into the toilet facility, where the steward turned on the water in the

shower, and they soaked their hair and clothes.

The steward told the crewmember to stay low. Smoke started to enter the shower

area, whereupon the crewmember panicked and tried to open the door. The steward put his

nose toward the shower drain to get air and directed the other crewman do the same. The

steward said that, when he next opened the door to the corridor, the passageway was

totally black. He began to pound on the bulkhead to attract attention. The crewmember

went into the passageway. The steward put a towel over his nose and followed the

crewmember into the passageway, where they heard the sounds of the firefighting teams

checking the area and called out to them. The shipboard firefighters then led the two

crewmembers above deck. 

Emergency Response

The local agencies responding to the Ecstasy fire included the Coast Guard, Miami

Beach FD, Miami-Dade FD, Coastal Tug, and Moran Towing, Inc.

The response agencies were notified or learned of the Ecstasy fire from various

sources within about a half hour of each other. The MSO-Miami watchstander, after

seeing the Ecstasy with smoke streaming from its stern, telephoned and verified the

presence of a fire with the ship’s master about 1728. About the same time, vessel pilots

reported the fire to the Biscayne Pilots Association, which notified Coastal Tug. Shortly

thereafter, about 1745, Miami area residents reported a fire on board a ship in the channel

to Miami Beach FD, which contacted Miami-Dade FD.33

The COTP implemented a unified command system employing two operating

bases. Initially, the Coast Guard and Miami Beach FD operated from the MSO-Miami

Operations Center, and Miami-Dade FD, Carnival, port officials, and area police operated

from a post established at the Port of Miami. Miami-Dade FD subsequently sent an

additional representative to the MSO-Miami location. The parties remained in telephone

communications with each other and officers on board the Ecstasy to coordinate activities

throughout the incident. The specific actions of the various response agencies are

summarized below.

33 Miami-Dade FD had jurisdiction when the ship was at the Port of Miami and Miami Beach FD had

jurisdiction while the ship was in Government Cut Channel and offshore.
Factual Information 44 Marine Accident Report

Coast Guard. Upon learning of the fire on board the Ecstasy, MSO-Miami paged

the COTP, who was off duty, and radioed Coast Guard vessels to respond. The COPT said

that he immediately returned to the operations center, arriving about 1800. When the

COTP arrived at the operations center, the executive officer briefed him and advised him

that a safety zone had been established around the Ecstasy.

34 The COTP said that he

radioed the Ecstasy’s master, who told him that the fire was contained to the aft mooring

deck by the ship’s MVZ boundaries and that the crew and waterside tugs were actively

fighting the fire. 

The COPT said that when Miami Beach FD and Miami-Dade FD representatives

arrived, he implemented a unified command system at the operations center. Based on

information that the Ecstasy’s fire was contained and that no one on board had sustained a

serious injury, the COTP stated that the unified command members agreed that the first

objective was to get the fire under control and then return the ship to port to disembark the

passengers. The COTP stated that transferring the passengers to another vessel would

have “presented unwarranted danger” to them. 

In the meantime, a Coast Guard 41-foot utility boat (UTB) had arrived on scene at

the Ecstasy and was assisting a Coastal tug in spraying water on the fire. A Coast Guard

vessel carrying two MSO personnel arrived shortly thereafter. The MSO personnel

boarded the Ecstasy about 1835 and went to the bridge where the master gave them a

status report on the fire and shipboard activities. One of the MSO personnel, a chief

warrant officer, radioed the information to the MSO duty officer and then went to meet

with the ship’s safety officer in the aft section of the Ecstasy. The warrant officer said that

as he proceeded aft, he checked conditions on the ship. He said that the passengers were at

the muster stations and that they had either donned their lifejackets or had them nearby. He

noted that the low-level lighting was not illuminated. While the warrant officer was

examining conditions below deck, the other MSO employee remained on the bridge,

relaying information to the unified command center.

At 2100, upon receiving a report from Coast Guard personnel on the Ecstasy that

the fire was under control, the COTP and the Miami-Dade FD made a unified decision to

bring the ship back to the Port of Miami. Pilots who had been sent to the Ecstasy to assess

the piloting requirements for the cruise ship directed the positioning of tugs at the bow,

stern, and both sides of the vessel. The ship was then turned and maneuvered back toward

the entrance channel to Miami. By 2400, the Ecstasy had been towed back to the sea buoy

area. Upon being advised by the pilot that the ship was handling well, the COPT granted

permission for the Ecstasy to berth, which was accomplished about 0130 July 21, 1998, at

Pier 8, Port of Miami. After discussions with Carnival Cruise Lines officials and Miami

Dade FD, the COTP ordered that all passengers be disembarked as soon as possible. 

Local fire departments. Upon receiving several 911 calls from area residents

reporting a possible ship fire, the Miami Beach FD contacted the fire dispatch office and

34 33 CFR 165.20: A Safety Zone is a water area, shore area, or water and shore area to which, for safety

or environmental purposes, access is limited to authorized persons, vehicles, or vessels. It may be stationary

and described by fixed limits or it may be described as a zone around a vessel in motion.
Factual Information 45 Marine Accident Report

was told that the Coast Guard was in radio communication with the Ecstasy and that the

fire was reportedly under control. Based on area television coverage of the fire, an FD

division chief later telephoned the Coast Guard to report that the fire did not appear to be

controlled and then went to the Coast Guard operations center to participate in the unified

command operations. Once there, he contacted the Miami-Dade FD to join the unified

command structure and to request shipboard firefighting resources. 

By 1930, the two fire departments had assembled and dispatched two strike teams

on Coast Guard cutters to the Ecstasy. Strike team No. 1 consisted of Miami-Dade FD

firefighters35 who were to assess the fire conditions and advise the unified command

whether the Ecstasy should be allowed into port. Strike team No. 2 consisted of Miami

Beach FD firefighters and medical personnel who were to triage and treat the injured. 

Once on the Ecstasy, the strike team No. 1 leader conferred with the Coast Guard

representatives, the master, and Carnival Cruise Lines’ firefighting safety training director

about the heat and smoke conditions, and all agreed that the ship could not return to port

until the fire was confirmed out. They established a fire operations center in the

marshaling area near the stern on deck No. 3 and developed an action plan to

systematically assess the fire area by searching all 10 decks in the aft section of the ship.

While the strike team No. 1 leader remained at the marshaling area, the strike team

members attempted to enact the plan to confirm the status of the fire but could not do so

because of the heat and smoke conditions. The fire team members were then stationed at

the fire doors to monitor the affected areas and check for developing fires while the

passageways were ventilated, thereby dissipating some of the heat and smoke.

After strike team No. 1 completed its assessment, the strike team leader briefed the

COTP, Carnival Cruise Lines representatives, and other personnel about the status of the

fire. At his recommendation, the firefighters continued to ventilate the affected areas and

selected teams continued to monitor conditions on decks No. 5, 6, and 8. The Miami-Dade

hazardous materials team monitored the entire ship for transfer of carbon monoxide from

the fire area. About 2109, the fire was declared extinguished. 

While the fire was being assessed, strike team No. 2 examined and treated at least

70 patients and arranged transport for those requiring further medical treatment at area

hospitals. Strike team No. 2 also established a rehabilitation area to examine the Ecstasy

crew firefighters as they completed their firefighting operations.36

Emergency Preparedness Drills and Exercises

On October 3, 1997, representatives from Carnival Cruise Lines, the Port of

Miami, the Biscayne Pilots, area emergency response agencies, and the Coast Guard

participated in a marine firefighting table-top exercise that simulated a fire on board the

Ecstasy.

35 Strike team No. 1 was a firefighting suppression team.

36 The strike teams did not participate in any active firefighting. All shipboard firefighting efforts were

undertaken by Ecstasy crewmembers.
Factual Information 46 Marine Accident Report

On December 16, 1997, Carnival Cruise Lines held a Crisis Management Team

exercise to practice the company’s Crisis Management Plan for responding to emergencies

on its cruise ships. The exercise was a simulation of a crisis aboard a Carnival Cruise

Lines’ vessel that focused on the assembly of the Crisis Management Team. Carnival

Cruise Lines conducted notifications according to the Crisis Management Plan. The

exercise scenario involved a fire in the ship’s laundry spaces. Carnival Cruise Lines

representatives attended a High Capacity Passenger Vessel Incident Response, Planning

and Risk Management Workshop on September 20-21, 1995, sponsored by the Coast

Guard and Massachusetts Maritime Academy.

Tests and Research

Metallurgical Testing 

After the accident, Safety Board investigators examined the welding unit because

of the second fitter’s statement about witnessing an arc. Three beads of weld-like material

were found on the ground clamp. The Safety Board performed metallurgical tests on the

beads found on the ground clamp, on welding rods from the vessel’s shop, and on the rod

found in the welding machine after the fire. The material in the beads was found to be

consistent with the material found in the welding rod in the electrode.

Debris Testing

Safety Board investigators collected mooring line remnants and debris samples

from the surface of the mooring deck to send for testing at the Bureau of Alcohol,

Tobacco, and Firearms (ATF) laboratory in Atlanta, Georgia. No accelerant material was

found in any of the samples. 

Mooring Line Testing 

The Safety Board contracted testing to determine the combustibility of the

polypropylene line used on the mooring deck. The line material had heat applied to it at a

constant rate (three different heat fluxes/amounts were tested). The amount of heat given

off was measured. The testing determined that the average heat of combustion37 for the

line was 18,217 Btu (British thermal units) per pound (Btu/lb). The average heat of

combustion for gasoline is about 19,000 Btu/lb. The minimum amount of applied heat

required to ignite the line in 14 seconds was 80 kW/m2

. A table in appendix E lists the heat

release rate information in more detail.

Lint Testing

Because fire consumed the lint on the Ecstasy, Safety Board investigators collected

lint samples for combustibility testing from the laundry exhaust system of a sister ship, the

Fantasy. (The examination of sister ships is discussed in the next section.) Tests conducted

37 The heat of combustion is the amount of heat that the material gives off when it burns.
Factual Information 47 Marine Accident Report

by ATF fire specialists showed that the lint was ignited easily by a spark and burned for

several seconds, leaving little residual material behind. The minimum heat flux for an

ignition was equal to 11.5 kW/m2. 

Other Information

Examination of the Imagination and the Fantasy

After the Ecstasy fire, Safety Board investigators examined the Imagination and

the Fantasy, two Fantasy line ships having the same basic arrangement as the Ecstasy. 

The mangles on the Imagination and the Fantasy differed from the mangle on the

Ecstasy. The Imagination’s mangle was built by the same company; however, the machine

was a later model, and its exhaust system was configured differently. The mangle in the

Fantasy’s main laundry was manufactured by a different company

The main laundry ventilation system on the Imagination varies slightly from that

on the Ecstasy and the Fantasy. The plenum is divided into two sections: lower section for

accommodation exhaust and upper section for laundry exhaust. In addition, the dryers on

the Imagination had been fitted with a “centrifugal” filter. The air from the dryers is

vented into this filter and then sent out the exhaust vent. According to the laundry

manager, the filter removes a large amount of lint and is cleaned about every 3 hours, or

about four times a day, during laundry operation. He stated that the filter does not

completely remove lint from the air exhausted out on to the mooring deck. 

On the mooring deck, investigators removed the louvers on the exhaust plenum

and observed lint accumulated in the plenum as well as the intake filters for the thruster

room. They also noted that lint had collected on stored rope on the deck and on the

spindled rope on the winches. Further examination revealed that the lint was forced down

into the fibers of the rope. According to shipboard officials, the mooring crew washed

down the deck about once a week. 

During inspections of the Fantasy, investigators noted that the centrifugal filter

used on the Imagination was not yet in place on the Fantasy or on the Ecstasy. The mangle

and the dryer had separate duct systems similar to the Ecstasy. The Fantasy had a large

amount of accumulated lint. According to the Fantasy’s chief engineer, the accessible

areas of the exhaust ducts and plenum are cleaned about every 20 days, and the ducts and

plenum had been cleaned about 4 or 5 days before this inspection. Investigators observed

several inches of accumulated lint in the dryer ducts and plenum. The mangle duct

contained about 1⁄2 of an inch of lint that was coated with a waxy or oily substance. 

On the mooring deck, the stored rope had accumulated large piles of lint.

Investigators noted that the lint had become embedded into the rope fibers. 
Factual Information 48 Marine Accident Report

Carnival Cruise Lines’ Postaccident Actions

On August 10, 1998, Carnival Cruise Lines, as part of its SMS program, issued to

its fleet Operations Safety Bulletin (OSB) No 04-98, which states, in part:

DESCRIPTION: Lint and other fibrous material might collect in the ship’s

exhaust system and can pose a serious fire hazard. Even with our filtering system,

a certain amount can get past the present filters. This OSB is being provided to

alert the vessels to this potential fire risk.

ACTION REQUIRED: Immediately conduct an extensive examination of all

ducts that are part of the exhaust system which originates from or near the

laundry. You are to remove all panels that are necessary to enable personnel to

determine the amount of lint in the duct system. Any lint found is to be removed

by all available means including but not limited to, vacuuming, sweeping, hand

cleaning, washing, etc. You are to take photos prior to cleaning as well as after the

cleaning to establish the status before and after.

As the SMS requires, all dryer filters are to be inspected, cleaned and logged. The

filter cleaning schedule is to be posted with records for signatures as per previous

instructions. A thorough fire risk and cleanliness inspection of all areas of the

laundry and adjacent spaces are to be completed on a regular basis and logged.

Ensure that any outstanding work order for laundry equipment repairs be

completed, especially any dryer thermostats.

ATTENTION ENGINEERING: Effective immediately, locate a suitable space to

lock up all portable welding machines to prevent unauthorized use. Continue to

use the Hot Work Permit as required by the SMS.

COMPLETION REPORT REQUIRED: When finished with your examination,

forward a report of your findings, including photos to the attention of Director of

Fleet Safety. The time for completion is 15 September 1998.

Carnival Cruise Lines made procedural changes to facilitate the ready

identification of crewmembers whose primary emergency duties involved crowd

management. According to the ship’s safety officer, before the Ecstasy accident, he had

procured bright green hats, imprinted with the word “crew,” to issue to employees who

were in charge at muster stations. He had not had the opportunity, however, to distribute

the hats before the Ecstasy sailed on July 20. At the suggestion of Safety Board

investigators, Carnival Cruise Lines revised the information presented at its emergency

drills to include an announcement advising passengers that crewmembers wearing the

green hats were proficient in English and were specifically assigned to assist passengers

during an emergency.

Carnival Cruise Lines installed equipment and made system modifications to

reduce the amount of lint buildup in the ventilation ducts. The company added lint screens

to all exhaust louvers in the main laundry and installed turbo-filters on the laundry dryers

to reduce the amount of lint entering the exhaust ducts. The company also modified the

exhaust plenums and fire dampers on the Ecstasy as well as other Fantasy Class ships in

its fleet.
Factual Information 49 Marine Accident Report

After the Ecstasy fire, Carnival Cruise Lines modified to the design of the MV

Paradise, a ship that was under construction, to include the addition of sprinklers on the

vessel’s covered mooring decks. The company also began a program of retrofitting the

mooring decks of its existing cruise ships with deluge sprinkler systems. According to

Carnival Cruise Lines’ senior officials, the aim of the company is to install sprinkler

protection on the mooring decks of all its ships by the end of 2001.

Related Safety Board Actions

Locally sounding smoke alarms. As a result of fires on board the cruise ships

Universe Explorer in 1996 and Vistafjord in 1997,38 the Safety Board, in April 1997,

issued the following safety recommendations to the International Council of Cruise Lines

(ICCL39):

M-97-37

Without delay advise members to install automatic smoke alarms that sound

locally in crew accommodation areas so that crews will receive immediate

warning of the presence of smoke and will have the maximum available escape

time during a fire.

M-97-38

Without delay advise members to install automatic smoke alarms that sound

locally in passenger accommodation areas so that passengers will receive

immediate warning of the presence of smoke and will have the maximum

available escape time during a fire.

Concurrently, the Safety Board issued the following safety recommendations to

the Coast Guard:

M-97-39

Propose that the IMO require all passenger vessels to have automatic smoke

alarms that sound locally in the crew berthing areas so that crews will receive

immediate warning of the presence of smoke and will have the maximum

available escape time during a fire.

M-97-40

Propose that the IMO require all passenger vessels to have automatic smoke

alarms that sound locally in the passenger accommodation areas so that

passengers will receive immediate warning of the presence of smoke and will

have the maximum available escape time during a fire.

38 (a) National Transportation Safety Board, Fire on Board the Panamanian Passenger Ship Universe

Explorer in the Lynn Canal Near Juneau, Alaska, July 27, 1996, Marine Accident Report

NTSB/MAR-98/02 (Washington, DC:NTSB, 1998). (b) National Transportation Safety Board, Fire Aboard

the Passenger Ship Vistafjord, near Grand Bahama Island, Bahamas, April 6, 1997, Marine Accident

Report NTSB-MAB-98/01 (Washington, DC:NTSB, 1998).

39 ICCL is an industry association comprising the 16 largest cruise lines that call on major ports in the

United States and abroad. Each year ICCL’s cruise vessel operators carry more than 5 million U.S.

passengers on 93 ships.
Factual Information 50 Marine Accident Report

On May 5, 1997, the ICCL responded that it had distributed Safety

Recommendations M-97-37 and -38 to its members for review and consideration and that

the recommendations would be an agenda item at the next meeting of its technical

committee. Based on these actions, the Safety Board classified Safety Recommendations

M-97-37 and -38 “Open—Acceptable Response,” pending further action by the ICCL on

the issue. 

On July 25, 1997, the Coast Guard responded that it concurred with Safety

Recommendations M-97-39 and -40. The agency subsequently made a proposal in May

1998 to the IMO asking that the fire safety amendments to SOLAS 74 be revised to

require automatic locally sounding smoke alarms on passenger ships. The IMO, in May

2000, referred the action for consideration to a subcommittee of its Maritime Safety

Committee (MSC). Based on the Coast Guard’s actions, the Safety Board classified Safety

Recommendations M-97-39 and -40 “Open—Acceptable Response.”

In October 1999, the ICCL wrote the Safety Board asking that Safety

Recommendations M-97-37 and -38 remain in an open status pending final action by the

IMO’s MSC on the Coast Guard proposal. The ICCL subsequently presented to the MSC

on December 17, 1999, an issue paper opposing the Coast Guard’s proposal that focused

on two propositions: false alarms and crowd management. The ICCL stated that on a daily

basis as many as 20 or more false alarms occur as a result of normal sensitivity of smoke

detectors. With regard to the issue of crowd management, the ICCL maintained that

automatic local-sounding smoke alarms would increase the risk of mass panic by

passengers and impair effective crowd control by ship crews. 

In April 2001, a Coast Guard official advised the Safety Board that, as a result of

concerns from some Administrations and the technical questions raised by the ICCL, the

proposal for locally sounding alarms was removed from the MSC agenda and not

considered. The Coast Guard is presently evaluating whether to again introduce the

proposal as an agenda item at the next meeting of the MSC, which is spring 2002.

In the 25 months following the Safety Board’s issuance of Safety

Recommendations M-97-37 and -38, the Board investigated three cruise ship fires,

including the 1998 accident on the Ecstasy. The other accidents are summarized below.

On September 19, 1999, a fire broke out in the engineroom of the Liberian cruise

ship Tropicale in the Gulf of Mexico. The fire was restricted to the engineroom and smoke

did not enter the accommodation spaces; therefore, no one sustained smoke inhalation

injuries. However, 1,096 passengers and 605 crewmembers were put at risk. 

On May 20, 2000, a fire broke out in a crew cabin on the Netherlands cruise ship

Nieuw Amsterdam in Glacier Bay, Alaska. While the fire was restricted to one deck,

smoke from the fire progressed upwards through nine decks. A passenger was forced to

crawl on his hands and knees along the passageway outside his cabin due to the heavy

smoke. The cruise ship was carrying 1,201 passengers and 566 crewmembers. 
Factual Information 51 Marine Accident Report

Following the Nieuw Amsterdam accident investigation, the Safety Board elected

to classify Safety Recommendations M-97-37 and -38 “Closed—Reconsidered” and

issued the following safety recommendations to 18 individual cruise ship owners and their

operating companies on July 11, 2000:

M-00-6

Without delay, install automatic local-sounding smoke alarms in crew

accommodation areas on company passenger ships so that crews will receive

immediate warning of the presence of smoke and will have the maximum

available escape time during a fire.

M-00-7

Without delay, install automatic local-sounding smoke alarms in passenger

accommodation areas on company passenger ships so that passengers will receive

immediate warning of the presence of smoke and will have the maximum

available escape time during a fire.

As of March 2001, 12 companies, representing about 86 percent of the North

American trade,40 had responded to the Safety Board regarding the installation of locally

sounding alarms in both crew and passenger accommodation areas. 

One company, Celebrity Cruises, indicated that it had installed locally sounding

alarms in accommodation areas as requested. The Safety Board, therefore, classified

M-00-6 and -7 “Closed—Acceptable Action” for Celebrity Cruises. 

Eleven companies, including Carnival Cruise Lines, responded that they supported

the recommendations and intended to install locally sounding smoke alarms on their

cruise ships. As a result, the Safety Board classified M-00-6 and -7 “Open—Acceptable

Response” for the following companies: American Classic Voyages, Carnival Cruise

Lines, Crystal Cruises, Disney Cruise Line, Holland-America Line, Westour, Inc.,

Norwegian Cruise Line, Princess Cruises, Radisson Seven Seas Cruises, Renaissance

Cruises, Royal Caribbean International, and Seabourne Cruise Line (Cunard Cruise

Lines). The Safety Board classified M-00-6 and -7 “Closed—No Longer Applicable” for

Premier Cruises because the company is no longer in operation.

In July 2000, at the same time that the Safety Board made recommendations for

locally sounding alarms directly to the cruise ship companies, the Board issued the

following recommendations to the ICCL:

M-00-8

Withdraw your opposition to the amendment of the Safety of Life at Sea

Convention chapter II-2 to require automatic local-sounding smoke alarms in

crew accommodation spaces on board passenger ships and support a full

discussion of the technical issues and any further U.S. Coast Guard actions on this

matter before the IMO. 

40 At the time of the accident, about 99 cruise ships operated out of North America. The 12 responding

companies owned 85 of the 99 vessels.
Factual Information 52 Marine Accident Report

M-00-9

Withdraw your opposition to the amendment of the Safety of Life at Sea

Convention chapter II-2 to require automatic local-sounding smoke alarms in

passenger accommodation spaces on board passenger ships and support a full

discussion of the technical issues involved and any further U.S. Coast Guard

actions on this matter before the IMO. 

On October 13, 2000, the ICCL responded that it did not oppose the technical

discussion of audible smoke alarms in its paper to the IMO and was concerned by the

interpretation of the paper. The ICCL letter further stated that member operators had

agreed to install in new and existing ships audibly sounding smoke detectors that would

“immediately alert persons to the presence of smoke in their cabin or stateroom or in the

corridor outside.” 

In a follow-up letter on November 7, 2000, the ICCL President enclosed a standard

for locally sounding smoke detectors that had been adopted by the ICCL Board of

Directors, which represented all 16 member operators. The ICCL President indicated that

the adopted policy was ICCL’s response to safety recommendations M-00-8 and -9. 

In a February 7, 2001, press release announcing the adoption of the mandatory

industry standards, the ICCL stated that member lines would integrate the industry

standards into their SMS to ensure compliance through internal and external audits.

On April 19, 2001, the Safety Board responded to the ICCL:

The Safety Board is pleased that on November 1, 2000, the ICCL adopted a policy

to member cruise line companies to install audibly sounding smoke alarms in both

crew and passenger spaces. The Board is further pleased that the ICCL will

continue to support full and open discussion of technical and operational issues

associated with any proposal directed toward the enhancement of safety on board

passenger ships....

The Safety Board’s November 1, 2000, advisory acknowledged four of your

member organizations (Disney, Radisson, Crystal, and Holland-America) for

taking the initiative to install smoke alarms on their vessels, and the ICCL for

developing its policy for smoke alarms on member cruise vessels. 

However, the ICCL has not complied with the recommended action because the

ICCL is on record at the IMO objecting to locally sounding alarms per its issue

paper dated December 17, 1999. Until this paper is superceded, ICCL has not

formally withdrawn its opposition at IMO, which is the subject of the M-00-8 and

M-00-9. The Safety Board suggests that ICCL submit to IMO its new policy in

support of locally sounding alarms. Accordingly, until the ICCL has superceded

its December 17, 1999, issue paper, Safety Recommendations M-00-8 and -9 are

classified ‘Open—Acceptable Response.’

Inspection and maintenance of ventilation ducts. As a result of the Ecstasy

fire, on October 20, 1998, the Safety Board issued the following safety recommendations

to cruise vessel owners and operators embarking passengers from United States ports:
Factual Information 53 Marine Accident Report

M-98-125

Immediately inspect, within your fleet of ships, the laundry ventilation systems,

including ducts, plenums, and exhaust terminuses, for any combustible material,

such as lint, and clean the systems, as necessary, to reduce the risk of fire.

(Urgent)

M-98-126

Institute a program to verify on a continuing basis that the laundry ventilation

systems, including ducts and plenums, remain clean and clear of any combustible

material that poses a fire hazard on your vessels. 

Of the 22 recipients, all but one responded that they had taken measures and had

initiated on-going inspection programs to comply with the recommended actions.41 As a

result, the Safety Board classified Safety Recommendations M-98-125 and -126

“Closed—Acceptable Action.” 

Related Coast Guard Actions

Regulatory changes. Based on findings in the Ecstasy accident investigation, the

Coast Guard, on May 21, 2000, amended its Marine Safety Manual, Volume II, adding the

following information on laundry room exhaust ducts and requiring inspectors to examine

those ducts for potential safety problems (amendments italicized).

Galley and Laundry Room Exhaust Ducts: A number of shipboard fires have

originated in the exhaust ducts of galley ranges and fryers, and recently in laundry

room ventilation systems. These fires have resulted in serious damage, injury, and

loss of life aboard the vessels involved. Unmaintained exhaust duct work will

become saturated with cooking grease and pose a fire hazard. Unfortunately, such

areas have been overlooked during vessel inspections. The following procedures

shall be followed during biennial and mid-period inspections of U.S. vessels and

during SOLAS verification examinations of foreign vessels:

All vessels: a. (6) Examine laundry room vents, ask if the company has a cleaning

and maintenance program (check records–part of ISM/SMS responsibility).42

Postaccident findings. According to Coast Guard officials, MSO-Miami began

inspecting laundry room ventilation systems as part of regular CVEs in November 1998.

Since that time, Coast Guard inspectors reportedly have found that, in every case, the

ventilation ducts on the inspected cruise ships have had no unsafe lint buildup and that the

41 The cruise lines that responded favorably include the following: American Hawaii Cruises and Delta

Queen Steamboat Company, Carnival Cruise Lines, Commodore Cruise Lines, Crystal Cruises, Celebrity

Cruises, Inc., Costa Cruise Lines, Cunard Lines, Ltd., Disney Cruise Line, Holland-America Line,

Norwegian Cruise Line, Premier Cruises, Radisson Seven Seas Cruises, First European Cruises,

Mediterranean Shipping Company, Orient Lines, Inc., Princess Cruises, Regal Cruises, Inc., Renaissance

Cruises, Inc., Royal Olympic Cruises, Royal Caribbean International, and Silver Sea Cruises, Ltd. The

cruise line that has yet to respond is Bergen Line Services.

42 USCG Marine Safety Manual, Vol. II: Material Inspection, Section B: Domestic Inspection Program,

Chapter 1: Inspection of Vessels for Certification (21 May 2000): B1-79. 
Factual Information 54 Marine Accident Report

companies have revised their SMS to include procedures for maintaining the ventilation

ducts in a fire-safe condition. 

Qualitative Failure Analysis 

Regulatory requirements. In 1988, the Coast Guard issued regulations

(46 CFR 62, “Vital System Automation”43) requiring the use of a qualitative failure

analysis of certain automated systems, including propulsion control systems. In proposing

the regulatory requirement that designers, manufacturers, and/or shipyards perform and

submit system failure analysis, the Coast Guard stated that the use of advanced automation

technologies such as electronics and microprocessors made it increasingly difficult, “at

times impossible, for the Coast Guard, ship owners/operators, and classification societies

to evaluate safety.” The Coast Guard further stated: 

The Coast Guard has chosen to propose safety performance standards that, to the

greatest extent practicable, state the desired operation or function without

addressing detailed design criteria...As an alternative to detail evaluation, the

Coast Guard proposes (to require) a failure analysis of the design and a selfcertification of design compliance to certain...standards. [This process]

emphasizes the responsibility of the parties most familiar with any automation

system, i.e., the designer and manufacturer, to evaluate and certify the safety of

the system. It also provides an evaluation means that is suited to technological

changes. In most cases, the failure analysis will identify a preferred fail-safe state.

Systems that would be required to be independent, that is, have arrangements that

provide a level of safety and reliability equivalent to complete duplication,

include:

• Controls systems

• Alarms and instrumentation (monitoring systems)

The IMO subsequently adopted regulations requiring that a failure modes and

effects analysis (FMEA)44 be performed for the machinery and control systems of highspeed vessels.45 The IMO and classification societies presently do not require the use of

FMEA for passenger vessel propulsion system designs.46

43 Subpart 62.10 defines system as an arrangement of elements that interact to perform a specific

function and vital system as that which is essential to the safety of the vessel, its passengers, and its crew. 

44 An FMEA is an inductive approach to identifying engineering design deficiencies by examining each

individual component or process in a system to determine how its failure or deviation from intended

performance might affect the entire system. By conducting a FMEA, engineers can modify the design of a

system before it is built to avoid catastrophic or significant system failures.

45 The International Code of Safety for High Speed Craft, adopted in 1994, mandated the use of FMEA

because these craft employed new technologies.

46 LR’s Propulsion and Steering Machinery Redundancy contains provisional rules that are in addition

to the classification society’s Rules and Regulations for the Classification of Ships. LR’s provisional rules,

which are optional for vessel owners, stipulate the use of FMEA in designing propulsion systems, electrical

power supplies, essential services, control systems, and steering arrangements. According to LR’s

provisional rules, the FMEA report must show that a single failure in the propulsion and related auxiliary

systems will not cause loss of all propulsion or steering capability. 
55 Marine Accident Report

Analysis

General

This analysis first identifies factors that can be readily eliminated as causal or

contributory to the fire and determines where and how the fire started and how it spread.

The report then discusses the following major safety issues, which were identified during

the investigation: 

• Adequacy of management safety oversight; 

• Adequacy of fire protection systems;

• Adequacy of passenger and crew safety; and 

• Adequacy of engineering systems design.

This report also discusses the effectiveness of the emergency response effort. 

Exclusions

The weather was not a factor in this accident. The vessel’s navigation, propulsion,

and steering systems had no bearing on the cause of the fire. No engineering difficulties

occurred before the outbreak of the fire. From documents and statements, the Safety

Board determined that all officers were properly licensed and certified by the Liberian

government and were qualified to serve in their positions. Postaccident drug and alcohol

screenings of 79 crewmembers were negative for 76 individuals. The first officer tested

positive for marijuana, indicating that he had used the drug sometime in the weeks before

the fire occurred. However, based on witnesses’ descriptions of the first officer’s actions

on the bridge during the emergency, no behavioral evidence indicated that he was

impaired by drugs at the time of the fire. Because the personnel who tested positive for

drugs have been dismissed from service and because of the improvements that Carnival

Cruise Lines has made to its drug-testing program since this accident, the use of drugs and

postaccident testing will not be discussed further in this report.

Accident Analysis

The Ecstasy experienced a major fire at the aft end of the ship that affected two

MVZs. A combination of fire, heat, and smoke damaged the main laundry room, the stern

thruster room, an air conditioning room, an electrical equipment room, the aft mooring

deck, and the steering gear room. In addition, some passenger staterooms and crew cabins

on deck Nos. 2, 4, 5, and 6 sustained heat and smoke damage. The cruise ship
Analysis 56 Marine Accident Report

subsequently lost propulsive power and most steering and had to be towed back to Miami.

During the onboard emergency, all passengers evacuated safely from the affected areas;

however, two crewmembers became trapped on deck No. 2, and firefighting teams had to

rescue them. Nine passengers were treated for injuries resulting from pre-existing

conditions or smoke inhalation, and 14 crewmembers sustained minor injuries from

firefighting activities and/or smoke inhalation. 

Fire Ignition and Propagation

Although Safety Board investigators found evidence of fire damage, smoke

damage, or both in several aft areas of the Ecstasy, they readily narrowed the potential

origin of the fire to either the aft mooring deck or the main laundry. 

The Safety Board examined the mooring deck because of the extensive fire

damage to the area. Investigators considered various sources of ignition, including

electrical malfunctions, discarded smoking materials, and accelerants. Electrical

malfunctions could have occurred in the three control boxes for the winches. The wiring in

the control boxes had been exposed to intense heat and the insulation on the wires in the

boxes burned away. Investigators found no evidence of arcing or failure, however, in any

of the wiring. Examination of the motor controller panels for the winches, located in the

steering gear room on deck No. 3, also revealed no failures. 

Investigators found no evidence that smoking materials had been discarded or any

inflammable liquids had been stored on the deck. Moreover, ATF testing of the debris

samples collected after the fire showed no evidence of any accelerant used to intentionally

set the fire (arson). The prolonged fire on the mooring deck might have destroyed any

evidence of ignition caused by smoking material or accelerants. Other evidence, however,

indicates that the fire did not originate on the mooring deck. Support for this contention is

based on the dynamics of air flow in the ventilation systems connecting the mooring deck

to the laundry room, the condition of the ventilation systems, and the events that took

place in the main laundry room before the sounding of the first fire alarm. 

A pathway was necessary for fire to have spread from the mooring deck to the

main laundry. Conditions existed, however, that would have prevented the fire from

spreading in this manner. Before the master ordered the shut down of the power

ventilation system in MVZs 1 and 2, two ventilation duct systems from the main laundry,

separately servicing the dryers and the mangle, exhausted air into the mooring deck at a

rate of roughly 7 meters per second. If the fire had originated in the mooring deck and

spread to the main laundry, the flames would have had to travel through one or both of the

duct systems in the opposite direction of the exhaust airflow. Based on Safety Board

calculations and in accord with current research on flame movement, the flames could not

have traveled against an airflow of such velocity.

47

47 A.C. Fernandez-Pello and T. Hirano, “Controlling Mechanisms of Flame Spread,” Combustion

Science and Technology, Vol. 32, (1983): 1-31. 
Analysis 57 Marine Accident Report

The condition of the ventilation duct systems also supports the contention that the

fire did not spread from the mooring deck to the main laundry. Had such spreading

occurred, fire damage would have been evident in both the dryer and the mangle

ventilation duct systems, since at their terminus on the mooring deck they come together;

therefore, both vent systems would have been equally subject to any source of fire on the

mooring deck and equally susceptible to fire damage. This was not the case. Although the

mangle’s ventilation system exhibited extensive fire damage, the dryer’s ventilation

system was virtually unscathed. Using fiber optic scope technology, the investigators

detected unburned lint inside of the dryer ventilation system and no evidence of fire or

fire-related damage. The Safety Board concludes that although the Ecstasy’s mooring deck

sustained the heaviest fire damage, it was not the point of origin for the fire. 

Events occurring in the main laundry room further support the finding that the fire

did not originate on the mooring deck but, instead, began in the laundry room. The second

fitter testified that he and the first fitter were setting up welding equipment to repair the

mangle in the laundry room when a welding rod that was dangling near the deck came in

contact with either the grounding clamp or the mangle, causing a spark. The second fitter

also stated that, at the time the spark occurred, dryer lint covered the deck. Both fitters

testified that a “small” fire started on the deck and that a fire on the mangle and a fire in

the overhead duct subsequently occurred. 

A cabin steward who was retrieving towels from a nearby linen closet observed

smoke in the main laundry. He said that when he went to investigate, he saw the two fitters

working on the inboard side of the mangle and observed flames on the outboard side of the

mangle, near the exhaust vents. He said that he retrieved a fire extinguisher to fight the

fire; however, when one of the fitters dumped a jug of water on the side of the mangle

where they were working, flames “appeared to jump up” to the overhead vent. The smoke

and flames became too great for him to fight with an extinguisher, so he activated the local

fire alarm at the laundry room door. The first officer confirmed that the first fire alarm,

which sounded on the fire control panel at 1710, indicated the main laundry. Alarm

printouts show, however, that the first fire alarm was automatically activated. 

The Safety Board found that the fire and smoke damage supported all or portions

of the witnesses’ testimonies. The evidence of fire in the main laundry was limited to the

area of the mangle. Metallurgical analysis showed that the welding deposits on the

grounding clamp were similar to the material in the electrode’s welding rod, which

confirmed that the welding rod had struck the ground clamp. Examination of other

electrical appliances in the laundry revealed no evidence of arcing. Moreover,

investigators found no evidence of discarded smoking materials or accelerants that might

have served as an ignition source in the laundry. The Safety Board concludes that the fire

on board the Ecstasy started in the main laundry and was ignited by an arc from a welding

machine. 

Fire damage to the mangle power cables and soot deposits on the loading end of

the mangle showed that the fire spread across the floor up onto the mangle. Damage to the

aft roller and melted wax from the mangle strings showed that the fire spread onto the

roller. The fitters had turned off the mangle to work on it. As a result, the rollers were in a
Analysis 58 Marine Accident Report

raised position, which left a gap between the rollers and the entry housing to the adjacent

exhaust ducts. This gap allowed the fire to spread into the roller exhaust ducts, which was

evidenced by heat damage to the paint on the exhaust ducts. In addition, the roller exhaust

ducts contained several inches of burned debris. 

Postaccident examination of the mangle blowers revealed that they were caked

with partially burned lint and wax. The impeller on the aft fan had disintegrated, leaving

rust-colored metal flakes imbedded in the lint and wax. The absence of an operational fan

in this duct allowed more lint to accumulate in it than in the forward duct, which resulted

in the aft duct sustaining far greater heat damage. 

In addition to the damage in the mangle’s vertical exhaust ducts, investigators

found 2-3 inches of burned debris in the main ventilation duct above the machine. Fire

damage was present throughout the mangle exhaust duct system of the Ecstasy, indicating

the fire probably proceeded through this system into the air conditioning room where it

spread through the plenum exhaust ducts onto the mooring deck. The fire then ignited lint

that had been exhausted to the mooring deck and that had become imbedded in the

mooring line. The burning lint, in turn, ignited the mooring lines, which fueled a large,

intense fire that raged for more than 2 hours, damaging deck areas above, forward, and

below the mooring deck. Hot gases and smoke transferred from the mooring deck to other

areas of the vessel through the air conditioning ventilation system before bridge personnel

secured the system. The ventilation supply intakes for the stern thruster room, which are

next to the laundry room’s exhaust plenum on the mooring deck, transferred smoke and

heat from the fully developed fire through the vent ducts into the stern thruster room,

causing extensive damage there. Hot gases and smoke traveling through the ventilation

ducts also caused extensive heat damage and sooting in the steering gear rooms, several

passenger cabins on decks Nos. 4, 5, 6 and 7, and the laundry crew galley. The injection of

smoke and fire gases from the mooring deck fire into the intake systems caused the almost

simultaneous activation of smoke detectors on four different decks.

Based on the amount of burned lint debris on the Ecstasy, investigators examined

the main laundries of other Fantasy vessels and found large lint accumulations in their

laundry exhaust systems, particularly the mangle exhaust ducts next to and above the

machine. On one such ship, the Fantasy, the chief engineer stated that he had initiated a

program of cleaning the exhaust ducts and plenum about every 20 days after he had

experienced a problem closing a damper and had found the ducts clogged with lint.

Although crew personnel had cleaned the ducts 4-5 days before the Safety Board’s

inspection, investigators found several inches of lint buildup in the dryer ducts and the

plenum. They also found that the mangle duct contained about 1⁄2 of an inch of lint and was

coated with a waxy/oily substance. On the mooring deck, investigators found that lint

exhausted through the ventilation system had settled on and become imbedded in the

mooring lines. 

Flammability tests of lint collected from the sister ships showed that the material

was ignited easily by a spark and burned for several seconds, leaving little residual

material behind. Therefore, the large lint buildup in the exhaust vents and the ventilation

system represented such a hazard that a fire might have occurred even if the fitters had
Analysis 59 Marine Accident Report

followed the required welding permit procedures and had arranged to have a vessel safety

officer present. Upon observing the laundry area, a safety officer probably would have

required the fitters to eliminate the obvious lint that was on the deck and, possibly, the lint

on the mangle. At the time of the accident, Carnival Cruise Lines’ SMS did not contain

procedures for inspecting or maintaining the laundry exhaust vents. The safety officer

probably would not have examined the vents in the overhead and identified the greatest

fire risk. Thus, when the fitters began to work, the sparks shooting upward from their

welding might still have ignited a blaze that crewmembers could not put out with the

available fire extinguishers. The Safety Board concludes that the lint that accumulated in

the ventilation duct of the main laundry created a serious fire hazard on the Ecstasy.

As a result of the Ecstasy fire, on October 20, 1998, the Safety Board issued the

following safety recommendations to cruise vessel owners and operators embarking

passengers from United States ports:

M-98-125

Immediately inspect, within your fleet of ships, the laundry ventilation systems,

including ducts, plenums, and exhaust terminuses, for any combustible material,

such as lint, and clean the systems, as necessary, to reduce the risk of fire.

(Urgent)

M-98-126

Institute a program to verify on a continuing basis that the laundry ventilation

systems, including ducts and plenums, remain clean and clear of any combustible

material that poses a fire hazard on your vessels. 

Of the 22 recipients, all but Bergen Line Services responded that they had taken

measures and had initiated on-going inspection programs to comply with the

recommended actions. As a result, the Safety Board classified Safety Recommendations

M-98-125 and -126 “Closed—Acceptable Action.” 

The Safety Board’s investigation of the Ecstasy fire, specifically its focus on lint

buildup problems, and its Safety Recommendations M-98-125 and -126 also prompted a

beneficial change to the Coast Guard’s vessel inspection guidelines. On May 21, 2000, the

Coast Guard amended Marine Safety Manual, Volume II to require that, as part of a regular

CVE, its inspectors examine a vessel’s laundry exhaust ducts for potential safety

problems. In addition, the Coast Guard inspectors must review the cruise ship company’s

SMS to ensure that it contains procedures for routine cleaning and maintenance of the

laundry room vents. The Coast Guard began inspecting laundry room ventilation systems

in November 1998. 

According to Coast Guard officials, since the cruise ship companies have

established procedures for inspecting and maintaining the laundry room ventilation

systems on their vessels, Coast Guard CVE inspectors reportedly have found that, in every

case, the ventilation ducts on cruise ships have had no unsafe buildup of lint.
Analysis 60 Marine Accident Report

The Safety Board concludes that the procedures and standards for inspecting and

maintaining laundry ventilation systems adopted by the marine industry and government

agencies following the Ecstasy fire will improve safety on cruise ships.

Adequacy Of Management Safety Oversight

The presence of lint in the main laundry and the mooring deck, specifically the

buildup in the mangle exhaust ducts and the particles imbedded in the mooring line,

represented a fire hazard that could have been ignited by any number of sources. However,

the decision of the fitters to weld before arranging for a shipboard safety official to assess

the area for risks raised questions about the adequacy of Carnival Cruise Lines’ SMS. 

When the first galley fitter broke the mangle bolt, he decided to weld it back in

place. He returned to the fitter workshop to obtain a portable welding machine and related

equipment while the second fitter obtained a fire blanket. After setting up the welding

equipment, the fitters energized the welding machine and inserted an electrode into the

electrode holder. For safe operations, a welding machine should not be energized until

immediately before welding. 

Carnival Cruise Lines’ SMS manual contains numerous safety procedures for

workers performing welding operations, including a prohibition against undertaking

welding “unless the requirements of the ‘Hot Work Permit’ are satisfied.” The permit

requirements for welding include applying in writing to the duty engineering officer, who,

before approving the application, must assess the intended work area for hazards and

either eliminate them or take precautions to control the risk, such as posting a fire guard.

Neither fitter followed the hot work permit procedures. They both testified that they were

aware of the requirement to obtain a hot work permit and that they intended to apply for

one after setting up the welding equipment. They also admitted that, when they energized

the welding machine, they were not following proper welding procedures that they learned

in welding school or during their service on Carnival’s vessels. The Safety Board

concludes that the fitters’ (welders’) lack of full compliance with the hot work permit

procedures in Carnival Cruise Lines’ SMS manual increased the risks of fire in the main

laundry. 

Following this accident, Carnival Cruise Lines revised its SMS to require that

engineering supervisors secure all portable welding machines to prevent employees from

circumventing required safety procedures. Now, the welding machines are not released to

fitters until a hot work permit is issued.

Although Carnival Cruise Lines’ SMS manual contained extensive procedural

safeguards for welding, it did not prevent unauthorized welding. Carnival Cruise Lines is

one of several subsidiaries of Carnival Corporation. The Safety Board is concerned that

the SMS procedures and manuals for the other vessels in Carnival Corporation’s fleet may

not contain processes to prevent employees from performing unauthorized hot work. The

Safety Board believes, therefore, that, for the ships in its fleet, Carnival Corporation
Analysis 61 Marine Accident Report

should revise the SMS to include processes for preventing unauthorized flame cutting,

grinding, or other activities that might ignite a fire. 

Adequacy Of Fire Protection Systems

Sprinkler System

Sprinkler systems are designed to provide an appropriate level of protection for the

space that they occupy and the amount of combustibles that are present. On the Ecstasy, a

passenger cruise ship, sprinklers were installed mainly in accommodation areas, including

staterooms and cabins. The sprinkler system, therefore, was designed for spaces that

contained furniture, carpeting, paneling, and so forth. 

In the Ecstasy accident, however, conditions occurred that put unusual demands on

the sprinkler system. In the main laundry on deck No. 2, the fire’s area of origin, the

ignition of the comparatively small amount of lint across the floor released insufficient

heat to trigger the heat-activated sprinklers in the overhead. The small flames spread first

to the mangle’s vertical exhaust ducts and then its overhead exhaust ducts where the high

lint buildup fueled a larger fire. The mangle’s overhead exhaust duct, constructed of

noncombustible metal, contained the fire, and the air flow within the duct carried the fire

from the laundry to the exhaust plenum on the mooring deck. The fire exited onto the

mooring deck, which lacked fire protection, and ignited the lint debris that, in turn, led to

the development of the major conflagration.

Before the ventilation system in MVZs 1 and 2 was shut down, ventilation fans

drew intense heat from the large fire on the mooring deck to various ship areas that were

protected by sprinklers, which caused them to activate. In addition, the heat from the

mooring deck fire was so great that it triggered sprinklers in deck areas immediately above

and forward of the mooring deck. Although the sprinkler discharge in areas that were

remote from the mooring station had no effect on the fire and heat source, the discharges

prevented the spread of fire further into the vessel.

The discharge area, that is, the number of sprinklers discharging water, was twice

as great as the design capabilities of the ship’s water delivery system. Even though the

number of sprinklers that opened created a demand for water that taxed the water supply,

the sprinkler system provided proper protection in this accident. The Safety Board

concludes that the vessel’s automatic sprinkler system limited the spread of fire from the

mooring station to adjoining decks, thereby preventing a significantly worse fire that

would have caused greater damage and perhaps additional injuries. 

When the Ecstasy was built in 1991, Carnival Cruise Lines had until 2006 to

comply with SOLAS requirements for automatic sprinklers. Nevertheless, the company

elected to install sprinkler protection in the Ecstasy’s cabins and staterooms at the time of

construction. After the fire on board the Ecstasy, Carnival Cruise Lines modified the fire

suppression system of the MV Paradise, one of its ships under construction, to include
Analysis 62 Marine Accident Report

sprinkler coverage of the vessel’s mooring decks. The company also began a program of

retrofitting the mooring decks of its existing cruise ships with deluge sprinkler systems.

According to Carnival Cruise Lines’ senior officials, the aim of the company is to install

sprinkler protection on the mooring decks of all its ships by the end of 2001. The Safety

Board applauds Carnival Cruise Line’s past and continuing efforts to improve fire safety

on the ships in its fleet. 

The flag administration for the Ecstasy before the accident had categorized the

vessel’s mooring station as an open deck, which meant that the area was not required to

have smoke detectors or sprinklers. If the mooring station had been equipped with

detectors, the bridge would have received earlier notification of a fire site. In addition, if

sprinklers had been installed and had activated on the mooring deck, the water may have

extinguished the ignited lint before the mooring line caught fire. At the least, water from

activated sprinklers would have knocked down the flames of the mooring deck fire, which

probably would have enabled shipboard firefighters to enter the mooring station and

combat the fire. The Safety Board concludes that if an automatic fire suppression system

had been installed on the mooring deck, the fire on the Ecstasy would have been located

and extinguished much sooner, thereby minimizing the extent of fire damage on the vessel

and aft mooring deck. 

As it was, the high fuel load on the mooring deck caused extensive damage. The

mooring station had 11 mooring lines, each measuring 220-meters and weighing about

900 pounds. The line itself is not easy to ignite. Inspection of a sister vessel showed that

large amounts of easily ignitable lint had accumulated on the mooring deck and had

become imbedded in the stored mooring lines. Assuming that the Ecstasy had a similar

accumulation of lint, the fire venting from the mangle exhaust plenum probably ignited

the lint, which, in turn, ignited the polypropylene mooring line. The Safety Board

contracted independent tests by Omega Point Laboratories, which determined that the

polypropylene line had an average heat of combustion of about 18,217 Btu per pound.

Thus, the consumption of the polypropylene line on this deck could have yielded as much

as 150 million Btu of heat. Once ignited, the amount of heat released from polypropylene

rope per pound is equivalent to that of a comparable amount of gasoline. 

The investigation showed that the fire consumed most of the fuel (polypropylene

line) on the mooring deck before firefighters were able to reach the deck and extinguish it.

A pallet of nylon line survived the fire but was melted. Two lengths of polypropylene rope

were partially consumed and the others were completely destroyed. 

In the past, cruise ships typically were designed with mooring decks having either

no overhead or an overhead and large permanent openings in the vessel’s side shell.

Because the mooring deck area was open to the weather elements, the risk of fire was low;

therefore, SOLAS did not require mooring decks to have fire protection. Modern cruise

ship design, such as that of the Fantasy Class vessels, typically incorporates the mooring

station into the superstructure, often below accommodation and service spaces. Many

mooring stations have openings that can be closed with hatches or covers. Despite this loss

of openness, SOLAS still categorizes these mooring stations as open decks that are not

required to have fire protection systems. Some newer ship designs also place ventilation
Analysis 63 Marine Accident Report

inlets and outlets on the mooring decks. The Coast Guard, recognizing the safety issues

inherent in the design arrangement, has proposed that the IMO clarify the category for

mooring decks such as the type on the Ecstasy. The Coast Guard recommended that, for

all new construction, a partially covered mooring deck be categorized as an auxiliary

machinery space. This categorization would not only require fire protection systems

(detection and suppression) but also prohibit using the space as a ventilation terminus. 

The status of the Coast Guard’s proposal at IMO is pending. Regardless of whether

the IMO does or does not agree to categorize mooring decks as recommended by the

Coast Guard, any action taken by the IMO will not take effect immediately and may affect

only certain cruise ships. The Safety Board is convinced that all efforts should be made

without delay to minimize the potential for fire on mooring decks that are incorporated

into the vessel structure, such as the mooring decks on the Fantasy Class cruise ships. The

Board recognizes that some mooring decks are used to store only anchors or small

combustibles or both and, thus, might not warrant fire protection. To optimize safety,

cruise ship companies need to examine their mooring stations for fire risk and determine

the need for detection and suppression systems. The Safety Board believes, therefore, that

the cruise ship companies should, for existing vessels having mooring deck arrangements

similar to Carnival Cruise Lines’ Fantasy Class ships, install automatic fire suppression

systems on mooring decks that contain high fire loads and presently have no automatic

fire protection. 

Ventilation System

SOLAS II-2 Regulation 16 requires that the ventilation systems for high-risk areas

such as category A machinery spaces and galleys have an automatic fire damper where a

duct crosses an A-class boundary to mitigate the spread of smoke and fire. SOLAS does

not include laundries in the category of high-risk areas, despite the fact that laundry

ventilation systems can accumulate appreciable amounts of ignitable lint. 

Fires in laundry facilities, including associated storerooms, can generate

significant amounts of heat and smoke, frequently with lethal consequences, as the Safety

Board discovered during its investigation of fires on board the Universe Explorer and the

Vistafjord. Based on its findings in these two accidents, which killed 6 people and injured

72 others, the Safety Board determined that timely isolation of a fire is crucial to

mitigating the effects of heat and smoke.

The ventilation ducts in the Ecstasy’s main laundry had fail-safe fire dampers;

however, if the ventilation system did not lose power, the dampers had to be shut by

someone present in the area or by someone on the bridge. In this accident, if the fire in the

overhead had triggered the closure of the laundry fire dampers, the shutdown would have

occurred several minutes before the bridge personnel secured the ventilation system,

which would have resulted in appreciably less heat, smoke, and flame escaping from the

main laundry and spreading to the mooring deck. 
Analysis 64 Marine Accident Report

A passive means for actuating the closure of fire dampers in certain areas is

required by various interpretations of SOLAS, including Coast Guard regulations.48 The

most commonly required passive closure mechanism is a weight- or spring-activated

fusible link that melts at a given temperature, allowing the fire damper to close. A fusible

link can be designed to actuate at various temperatures, depending on the metal used in the

mechanism. It potentially offers a more fail-proof method of closure and, consequently, a

greater margin of fire safety because an external power source is not needed to drive the

damper.

The Safety Board concludes that if the main laundry’s fire dampers had been

equipped with a passive means of closure, such as a fusible link, the heat from the fire

would have caused the dampers to shut sooner, which, in turn, might have prevented the

spread of fire beyond the laundry area. 

While automatic fire dampers with passive actuating mechanisms are one way to

effectively stem the spread of smoke and fire through ventilation systems in high-risk

areas, such dampers are not the only method of mitigating the danger. The Board

considers the individual cruise ship companies best qualified to analyze their vessels’

design and engineering arrangements and to devise measures for dealing with the

problem. The Safety Board, therefore, believes that Carnival Cruise Lines should, for the

vessels in its fleet, engineer, design, and implement system modifications to mitigate the

spread of smoke and fire from the laundry rooms through the ventilation ducts to other

areas of the vessel. Further, cruise ship companies should, for existing vessels with

ventilation system arrangements similar to Carnival Cruise Lines’ Fantasy Class ships,

install an automatic method or system to mitigate the spread of smoke and fire from

laundry spaces through the ventilation ducts to other vessel areas. 

Fire Detection System

During the Ecstasy fire, many smoke detectors activated within a few minutes. The

time and sequence of the first five recorded smoke detector alarms are consistent with

reports of where the fire started and how the fire and smoke spread through the ventilation

system. The first smoke alarm indicated the main laundry room. The next alarms indicated

the stern thruster room, the air conditioner room, and the portside steering gear room.

According to the first officer, about 2 minutes after the first alarm, all the detector alarms

on the fire panel appeared to activate at the same time, and, as a result, he reset the system.

The activation of all alarms on the fire panel resulted from an electrical overload of the

system. Despite the overload, the fire detection system provided an early warning of a fire,

correctly identifying not only the fire zone but also the time and location of the first

detectors. The Safety Board concludes that the fire detection system performed properly

by providing an early indicator of a fire. 

48 NVIC No. 09-97.
Analysis 65 Marine Accident Report

Adequacy of Passenger and Crew Safety

Although no one was seriously hurt in the Ecstasy accident, the Safety Board

identified several areas in which improvements could be made to the safety practices on

the ship. 

Passenger Drill 

SOLAS requirements stipulate “musters of passengers shall take place within 24

hours after their embarkation.” Carnival Cruise Lines conducted an emergency drill for

the Ecstasy’s passengers before the vessel sailed, which, in this case, was beneficial, given

that the fire broke out within a half hour of the ship’s departure from port. Passengers

received instructions in English and Spanish to prepare them for an evacuation, including

information on how to don their lifejackets and on where to assemble in the event of an

emergency. During the drill, the bridge sounded the general alarm signal, and passengers

had to practice the route to their assigned muster stations as if they were participating in a

real emergency. 

Of the 300 passengers surveyed by the Safety Board about the emergency, 126

responded. More than half of the respondents, or 79 passengers, indicated that the drill

was valuable in preparing them for the actual emergency. The remaining survey

respondents identified various problems or situations that were not addressed during the

drill. Several people indicated that the drill did not include specific information about fire

emergencies, including what to do if they encountered smoke or fire. A number of

respondents who had to move to a different muster station because of smoke said that the

drill did not provide information about what to do if a muster station was not available.

One person stated that she did not hear any instructions from the crewmembers at her

muster station but followed the crowd when everyone started leaving the station. Several

passengers commented that they could not readily distinguish those crewmembers who

were trained to assist them because vessel personnel all wore the same uniforms.

For an emergency drill involving several thousand people to be effective, the

information disseminated must be concise and essential for survival. The Safety Board

notes that, in addition to the practice drill, Carnival Cruise Lines provides passengers with

emergency information in a variety of ways. The company broadcasts general cruise

information, including emergency procedures, on television monitors at the embarkation

point where passengers line up to board the ship. In the staterooms, Carnival Cruise Lines

posts evacuation procedures on placards and broadcasts emergency procedures on a

television channel devoted to cruise information. The company has television monitors at

the bars in passenger lounges to disseminate announcements and other information. 

Safety Board investigators reviewed the drill script used by the Ecstasy’s cruise

director as a reference for necessary subjects to cover in the drill. The script makes no

mention of actions that passengers should take if they see smoke or if their muster station

is not available. 
Analysis 66 Marine Accident Report

The Safety Board concludes that although most survey respondents indicated that

the Ecstasy practice drill adequately prepared them for the actual fire emergency, the drill

content lacked information about actions to take if you see smoke or fire or if your muster

station is unavailable that might have better prepared some passengers who encountered

such conditions. 

Before the Ecstasy fire, the vessel safety officer had purchased bright green hats

for crewmembers in safety sensitive positions to wear to distinguish them from other

crewmembers. He had not had the opportunity to distribute the hats before the ship sailed.

At the suggestion of Safety Board investigators, Carnival Cruise Lines revised its vessel

emergency drill procedures to advise passengers that crewmembers wearing the green hats

are specifically assigned to assist them during an emergency. Based on the survey

responses from Ecstasy passengers, the company needs to provide passengers with

additional safety information. The Safety Board, therefore, believes that Carnival Cruise

Lines should revise the safety information disseminated to passengers to include actions to

take if they encounter smoke or fire and/or if their muster station is not available. 

Immediately following the accident, a party to the investigation questioned

whether the noise generated by local news helicopters created communications problems

between the crew and passengers during the emergency. All survey respondents indicated

that they heard frequent announcements. Some respondents who were assigned to the

outside muster station stated that when they advised crewmembers that the helicopter

noise made it difficult to hear the loudspeakers announcements, the crewmembers quickly

notified the bridge, and the cruise director then relayed necessary information and status

accounts by having his assistants go to the muster station. The smoke from the fire

subsequently necessitated moving the passengers at the outside muster station, which

eliminated the problem. The Safety Board concludes that although the noise from the

news helicopters may have interfered somewhat with the communications with passengers

on the outside deck, crewmembers were able to effectively communicate with the

mustered people and manage the emergency. 

Accountability Procedures

Shipboard personnel used two methods to account for passengers during the fire

emergency. At the muster stations, the crewmembers noted the letters imprinted on the

lifejackets worn by passengers to ensure that they had reported to the correct station. The

muster station crews did not have a list, by name, of passengers assigned to the respective

stations. In the passenger accommodation areas, crewmembers checked each stateroom to

determine whether it was empty. They then wrapped a towel around the doorknob to show

other searchers that the stateroom had been checked. Neither of these procedures provides

assurance that the vessel has accounted for all passengers. Depending upon the time and

location of a fire or emergency condition, passengers might not be able to report to their

muster station. In this accident, three MVZs were closed as a result of the fire and

passengers had to go to other MVZs to find a muster station. 

Identifying which people are missing by searching the staterooms and cabins

assumes that an occupant will remain in his or her quarters and not go to another location.
Analysis 67 Marine Accident Report

Further, this method of accounting for individuals can be dangerous, depending on the

emergency conditions. In this accident, two crewmen who were unable to exit their deck

because of heavy smoke initially sought refuge in a crew cabin. They were following

survival techniques in a shower when one of the men panicked because of worsening

smoke conditions. He left the toilet facility and began feeling his way along the bulkhead

of the smoke-filled passageway. The other crewman followed the first man to try and

convince him to return to the safety of the shower. The severity of the smoke-inhalation

injuries that they sustained was limited only because fire team members searching the area

happened upon the crewmembers. (Additional analysis of the trapped crewmen’s situation

appears later in this report.) The Safety Board concludes that the procedures used by the

Ecstasy’s shipboard personnel did not adequately account for passengers and

crewmembers during the emergency. 

SOLAS leaves the method of devising procedures to account for passengers and

crew during an emergency up to the companies. The ISM Code presently stipulates the

need for cruise ship companies to account for passengers and crewmembers. Courses

developed by the Coast Guard and the marine industry to meet the emergency

preparedness requirements contained in amendments to the STCW stipulate that the

preferred method of accounting for people at muster stations is by name so that rescue

crews can employ more systematic methods of searching for missing persons. 

The Safety Board is aware that the Ecstasy maintained an electronic manifest of all

passengers on the ship. When passengers boarded the ship, their names were entered into a

computer and they were issued magnetic cards that tracked their purchases and their

debarkations and embarkations at travel stops. Given the advancements in computer

technology, magnetic cards or other computer-based devices and equipment could be used

to quickly determine who has not mustered during an emergency. 

Because even short delays in identifying missing people can have fatal

consequences, it is essential for companies to have systematic procedures to account for

people by name. Further, the Ecstasy accident demonstrates that accounting procedures

must address different emergency scenarios. As mentioned previously, the location and

movement of the fire forced the closure of three MVZs, and, as a result, some Ecstasy

passengers had to be moved to other muster stations. Depending on the time of the alarm

and the location of passengers and crewmembers, several hundred people might be forced

to report to an alternate muster station. 

The Safety Board is aware that Holland-America, another subsidiary of Carnival

Corporation, accounts for its passengers by taking roll at muster stations. Despite its

experiences in the Ecstasy accident, however, Carnival Cruise Lines has not indicated that

it intends to change its accountability procedures. The Safety Board is convinced that,

during a fire emergency, an accurate accounting by name is essential for passenger and

crew safety. The accounting methods used on a ship should be incorporated into the SMS

procedures presently required by SOLAS. The Safety Board believes, therefore, that, for

the ships in its fleet, Carnival Corporation should develop plans to account for all

passengers in common emergency scenarios, in particular, a situation involving the

inaccessibility of one or more MVZs and/or muster stations. 
Analysis 68 Marine Accident Report

Lifejacket Distribution 

In 1997, LR certified that the number, type, and arrangement of lifesaving

equipment on board the Ecstasy met the requirements of SOLAS 74, as amended in 1998.

At that time, the ship carried 4,094 lifejackets to outfit a full crew and passenger

complement of 3,560 people. The Board is pleased to note that Carnival Cruise Lines

subsequently elected to exceed the minimum SOLAS requirement for extra lifejackets,

increasing the number by more than 20 percent, to a total of 4,946. On the day of the fire,

the ship was carrying 3,481 people, meaning that the ship had 1,465 extra lifejackets. 

Despite having more than enough lifejackets on board the vessel, some passengers

perceived a lack of available lifejackets when the actions of the crewmembers were not

consistent with information provided at the practice drill and posted on stateroom

placards. Before the emergency, passengers were told to obtain lifejackets from their

staterooms when the general alarm sounded and to proceed immediately to their muster

stations. They were also told that if they were unable to obtain their lifejackets from their

staterooms at the time of the alarm, they should proceed immediately to their muster

station and lifejackets would be issued to them. During the emergency, the cruise director

reinforced these instructions when he announced that passengers who could not obtain

their lifejackets from their staterooms should proceed immediately to muster stations.

The responses from the passengers who answered the Safety Board survey showed

that 79 of 126 people either obtained lifejackets from their cabin or were provided

lifejackets by crewmembers. Forty-seven passengers said that they never received

lifejackets. Two passengers stated that they became concerned when they asked for

lifejackets and a crewmember started to pass them out and then reportedly was ordered to

stop doing so. One passenger stated that one crewmember told her not to retrieve her

lifejacket from her stateroom and later another crewmember told her to get her lifejacket

from her cabin; however, when she attempted to do so, she could not reach her stateroom

because of the smoke.

At the public hearing on the Ecstasy accident, the master testified that he wanted to

maintain a calm environment and avoid panic among the passengers by conveying the

impression that the situation was under control and did not warrant the distribution of

lifejackets. While the lack of uniformity in distributing the lifejackets did not cause a mass

panic, it did cause several passengers to become uneasy. Moreover, when a concerned

passenger attempted to return to her stateroom to retrieve her lifejacket, she was put at risk

of potential injury. The Safety Board concludes that the lack of consistency between the

information about lifejacket distribution provided at the practice drill and the actual

provision of lifejackets at the muster stations created unnecessary confusion among some

passengers on the Ecstasy. 

After the Ecstasy fire, in fall 1998, Carnival Cruise Lines began requiring its

senior deck, engineering, and other officers to attend courses in crisis management and

human behavior and crowd management so that they met the STCW training standards

that became effective in January 1999. The company also required crewmembers in

safety-related positions to attend crowd management training.
Analysis 69 Marine Accident Report

As part of its mandate, the Coast Guard conducts quarterly CVEs of a vessel’s

operations to determine if they comply with SOLAS safety requirements. In this capacity,

the Coast Guard could assist cruise ship companies in determining the effectiveness of

muster drills addressing various contingencies. The Safety Board, therefore, believes that,

as part of its quarterly CVEs, the Coast Guard should review a drill scenario in which one

or more MVZs are inaccessible and evaluate the procedural effectiveness of the crew in

crowd control, crisis management, lifejacket distribution, and passenger accountability. 

Locally Sounding Smoke Alarms

When the first fire alarm sounded on the bridge, the master ordered two bridge

officers to investigate the source of the alarm and report their findings. About 20 minutes

elapsed before he ordered the aft three MVZs secured and the cruise director to announce

that passengers who were quartered in the aft areas should either leave or not return to the

areas, depending upon their present location. The master did not order the general alarm

until 50 minutes after the first fire alarm sounded on the bridge. 

Of 126 passengers who answered the Safety Board survey, 72 responders, or more

than half, said that they smelled or saw smoke in the staterooms and passageways before

hearing the general alarm. A few passengers indicated that they saw a television report on

the fire before receiving any emergency notification. One passenger said that, upon seeing

smoke, she returned to her stateroom to awaken a sleeping relative. A crewman became

aware of emergency conditions when smoke entered his room through a vent.

Sounding the general alarm after a fire team verifies the location of the fire does

not necessarily provide enough time to escape from a smoke-filled environment. The

Vistafjord and Universe Explorer accidents demonstrated how quickly smoke could spread

during a fire and that passengers and crewmembers needed to be warned immediately if

smoke was in the area. As a result of its investigation of these two accidents, the Safety

Board issued Safety Recommendations M-97-39 and -40 asking the Coast Guard to

propose that the IMO require locally sounding alarms in passenger and crew

accommodation areas. The Coast Guard subsequently made the proposal to the IMO,

which referred the action for consideration to an MSC subcommittee. In Spring 2000,

because of the concerns of some Administrations and the technical concerns of the ICCL,

the MSC did not consider the locally sounding alarm proposal. It was removed from the

agenda and no further action was taken on it. The next available time that the proposal can

be introduced as an agenda item is Spring 2002. The Coast Guard is evaluating what

actions it might take on the proposal.

The Safety Board also issued Safety Recommendations M-97-37 and -38 asking

that the ICCL advise its members to install locally sounding smoke alarms in passenger

and crew accommodation areas. The ICCL at first advised the Safety Board that the

recommendations would be an agenda item at the next meeting of its technical committee

and then later asked that the recommendations remain in an open status pending action by

the IMO. 
Analysis 70 Marine Accident Report

The Safety Board subsequently investigated the May 20, 2000, fire on board the

Netherlands cruise ship Nieuw Amsterdam in which a passenger was forced to crawl on his

hands and knees along the passageway outside his cabin due to the heavy smoke. As a

result of this and previous accident investigations, on July 11, 2000, the Safety Board

elected to classify Safety Recommendations M-97-37 and -38 “Closed—Reconsidered”

and issue safety recommendations directly to the individual cruise ship companies serving

North America. Safety Recommendations M-00-6 and -7 asked that cruise companies,

without delay, install locally sounding alarms in accommodations areas to afford people

the maximum available escape time during a fire. 

The Safety Board has been very pleased by the response of the cruise ship industry.

As of April 2001, 12 companies, representing about 85 percent of the North American

trade,49 had responded to the Safety Board regarding the installation of locally sounding

alarms in both crew and passenger accommodation areas. One company, Celebrity

Cruises, indicated that it had installed locally sounding alarms in accommodation areas as

requested. The Safety Board, therefore, classified M-00-6 and -7 “Closed—Acceptable

Action” for Celebrity Cruises.

Eleven companies responded that they supported the recommendations and

intended to install locally sounding smoke alarms on their cruise ships. The eleven

companies included American Classic Voyages, Carnival Cruise Lines, Crystal Cruises,

Disney Cruise Line, Holland-America Line/Westour, Inc., Norwegian Cruise Line,

Princess Cruises, Radisson Seven Seas Cruises, Renaissance Cruises, Royal Caribbean

International, and Seabourne Cruise Line (Cunard Cruise Lines). One respondent, Disney

Cruise Line, indicated that, pending identification of the technology needed to modify its

existing smoke detector systems, it had equipped its vessels with a system that triggers a

special ring on the telephone in guest and crew cabins when smoke is detected. As a result,

the Safety Board classified M-00-6 and -7 “Open—Acceptable Response” for these

companies. The Safety Board classified M-00-6 and -7 “Closed—No Longer Applicable”

for Premier Cruises because it is no longer in operation.

On January 22, 2001, the Safety Board requested information about the status of

M-00-6 and -7 to the following companies: Costa Cruise Lines, Orient Lines, Regal

Cruises, Royal Olympic Cruises, and Silver Sea Cruises. To date, the Board has yet to

receive a response. The Safety Board has, therefore, classifies M-00-6 and -7 “Open—

Unacceptable Response” for these five companies.

On February 7, 2001, the ICCL issued a press release indicating that its member

lines had unanimously agreed to establish mandatory industry standards stipulating,

among other requirements, that the vessels of each ICCL member have “smoke alarms

that sound in all passenger and crew staterooms and adjacent corridors as well as on the

bridge.” The ICCL release further stated that, for most guidelines, member lines would

integrate the industry standards into their SMS to ensure compliance through internal and

external audits. 

49 At the time of the accident, about 99 cruise ships operated out of North America. The 11 responding

companies owned 83 of the 99 vessels.
Analysis 71 Marine Accident Report

Means of Communication in Cabins

A cabin steward was in his cabin when he smelled smoke and saw smoke coming

from a vent. He left his quarters and was knocking on other cabin doors to alert other

crewmembers when he heard the general alarm. Another crewmember joined the cabin

steward and the two men attempted to leave the deck only to be blocked by dense smoke. 

The crewmembers made their way into a cabin shower where they stayed until one

of the men became alarmed by the smoke buildup. He tried to escape by leaving the cabin

and feeling his way along the passageway bulkhead. The cabin steward went after the first

man and tried to convince him to return to the safety of the shower. About this time, a

firefighting team responding to the fire in the main laundry happened upon the men and

directed them to safety. The cabin steward later stated they were only able to avoid serious

injuries because they followed emergency survivability procedures, such as soaking

themselves in a shower and breathing air from the shower drain. The crewmembers’

accommodation areas had no call system by which the men could signal for help. The

Safety Board concludes that the lack of a means to call for help from the crew cabins

delayed the rescue of two crewmembers and contributed to the severity of their smoke

inhalation injuries. 

The Safety Board had addressed the need for passenger and crew cabins to be

equipped with a means of signaling for emergency assistance for more than 8 years. (A

summary of the safety recommendations issued and actions taken appears in appendix F.)

Following its investigation of the fire on the Universe Explorer, the Safety Board asked

that both the Coast Guard and the ICCL take actions regarding emergency call systems on

cruise ships. The Safety Board issued Safety Recommendation M-98-32. On October 16,

1998, the Coast Guard responded that it would discuss the available options for any

necessary improvements with the SOLAS working group on fire protection and would

propose changes to the IMO, if appropriate. Based on this action, the Safety Board

classified Safety Recommendation M-98-32 “Open—Acceptable Response.” The Safety

Board issued Safety Recommendation M-98-59 to the ICCL asking that it recommend that

member passenger ship companies install emergency call systems. The Safety Board

subsequently advised the ICCL that the Board was disappointed that the association had

not taken the recommended action and, on February 18, 1999, classified Safety

Recommendation M-98-59 “Closed—Unacceptable Action.” 

The crewmembers’ inability to signal for help in the Ecstasy fire demonstrates

again that existing SOLAS requirements for emergency communication are not adequate.

Even though the Ecstasy’s passageways had telephones, their accessibility depended upon

a person being able to reach a telephone. In this accident, the cabin steward who first

smelled and saw smoke tried to alert crewmembers in nearby cabins of the fire. Conditions

worsened considerably during the brief time that he knocked on cabins doors, and dense,

suffocating smoke prevented his and another crewmember’s escape. The men did not have

the option to walk to or spend time on a corridor telephone. 

A similar situation occurred in the Universe Explorer accident, but with fatal

consequences. Rescuers found three dead crewmembers in the passageway and two dead
Analysis 72 Marine Accident Report

crewmembers in their cabins. If they did not have the time and opportunity to reach an

emergency exit, it is unlikely that they had time and opportunity to locate a corridor

telephone to let someone know they needed immediate help. In its report on the Universe

Explorer accident, the Safety Board discussed the simple call button system used to

summon flight attendants on commercial airlines. Hospitals and nursing facilities employ

a similar system to enable patients to signal for nursing assistance. The Safety Board

believes that cruise ship companies should 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. 

Emergency Response

Despite some setbacks, including an overload of the smoke alarm system and an

unusually large and intense blaze, the Ecstasy personnel conducted the onboard response

to the fire efficiently and in accordance with Carnival Cruise Lines’ procedures. The

master effectively managed and monitored the incident by having the safety officer

oversee the fire teams, by having the hotel manager maintain communications with

shoreside management and the COTP, and by having the cruise director annotate times

and events on a emergency action checklist. The ship’s firefighters demonstrated the

effectiveness of their previous drills and firefighting training by quickly mustering

equipped teams and containing the fire to the mooring station. With help of the tugs

cooling the exterior of the Ecstasy’s stern, shipboard firefighters extinguished the fire as

the fuel load was consumed. The safety officer had fire teams search the quarters in the

area affected by the fire; the teams rescued two crewmembers who were trapped in a cabin

near the laundry. 

The shoreside response was effective because the unified command system

employing two operating bases allowed several agencies to jointly manage the emergency

response. The Coast Guard and Miami Beach FD initially operated from the MSO-Miami

Operations Center, and Miami-Dade FD, Carnival, port officials, and area police operated

from a post established at the Port of Miami. Miami-Dade FD subsequently sent an

additional representative to the MSO-Miami location. The parties remained in telephone

communications with each other and officers on board the Ecstasy to coordinate activities

throughout the incident.

Shoreside officials indicated that the participation of Carnival, the Coast Guard,

and local agencies in joint planning sessions and practice drills simulating accident

scenarios attributed to the good response coordination. In addition, Carnival’s crisis

management plan, which included specific personnel assignments for managing a fire

condition on the Ecstasy and for handling the safety and comfort of passengers and

crewmembers, was adequately implemented. The Safety Board concludes that the

emergency response by shipboard and shoreside firefighters to the fire was timely and

appropriate, resulting in the fire being properly contained and extinguished.
Analysis 73 Marine Accident Report

Adequacy Of Engineering Systems Design

The fire on the Ecstasy caused the partial or complete failure of three systems:

low-location lighting, steering, and propulsion. Although the loss of engineering and

emergency systems did not ultimately endanger the ship and its passengers in this

accident, the potential threat to vessel safety from the failure of vital systems, especially

propulsive power, is significant. 

The low-location lighting system was designed to sound an alarm on the bridge in

the event of a power failure to the system. In this accident, the heat from the fire melted

the wiring insulation on a portion of one lighting loop, triggering an alarm that the ship’s

officers considered intrusive during the emergency operations. When the nature and

location of the failure was not readily detectable at the lighting system’s main unit, the

chief electrician elected to shut down power to the system. After this accident, Carnival

Cruise Lines redesigned the low-location lighting system to permit the audible alarm to be

silenced without the need to shutdown the entire system.

The steering system components were designed to be redundant. The system had

two rudder systems that were mechanically, electrically, and hydraulically independent of

each other. The systems were housed in separate rooms on opposite sides of deck No. 3.

The power and control cables for both rudder systems were routed along the overheads of

their respective steering gear rooms. Thus, when the conflagration on the mooring deck

went unchecked and raged for more than an hour, the intense heat that was conducted

through the overheads of the steering gear rooms melted the cables, causing the steering

system to fail. Despite the failure of the steering system, the crippled Ecstasy could have

maneuvered at low speeds by using the bow thrusters if the ship had not lost propulsion. 

The most critical system failure in this accident was, therefore, the loss of the

propulsion system. The port and starboard propulsion systems were supposed to be

redundant and isolated. The Ecstasy had been built to LR regulations, which clearly

stipulate the need to provide independent and isolated power supplies to essential

components of the vessels engineering systems, such as propulsion. The auxiliary voltage

to the high-speed breakers for both propulsion systems, however, was routed through the

same distribution panel. When this panel sustained heat damage, both propulsion systems

failed. The Safety Board, therefore, concludes that the failure to separate the power

circuitry in the design arrangement of the auxiliary voltage supply to the high-speed

breakers of the propulsion systems resulted in inadequate isolation of essential system

components, which, in turn, resulted in the shutdown of both propulsion systems when a

single distribution panel was damaged. 

Hazardous situations that may result from a ship losing propulsive power include

vessel grounding, inability to avoid severe weather conditions, and passenger evacuation

at sea. Thus, it is essential that all propulsion system components be redundant and

isolated. Following the Ecstasy accident, Carnival Cruise Lines advised the Safety Board

that it had modified the vessel’s electrical system by adding a backup circuit breaker and

wiring to provide an alternate source of electrical power for the high-speed breakers. 
Analysis 74 Marine Accident Report

Carnival Cruise Lines owns seven other Fantasy Class ships that may have similar

propulsion system arrangements as the Ecstasy. In correspondence to Safety Board

investigators, the cruise ship company did not indicate whether it had examined or

intended to examine its other vessels to identify design problems in their propulsion

systems. The Safety Board, therefore, believes that Carnival should examine the

propulsion systems on the ships in its fleet and, if necessary to provide redundancy,

modify the arrangement of the auxiliary voltage circuitry to the high-speed breakers where

a single source supplies both port and starboard propulsion systems. 

The company that designed the Ecstasy’s propulsion system, ABB, is a major

supplier of cycloconverter propulsion systems to marine customers. Consequently, other

vessels might be operating with an ABB propulsion system similar in design to that on the

Ecstasy. The Safety Board, therefore, believes that ABB should advise its customers with

ships having the same propulsion system design arrangements as the Ecstasy of the

potential for system failure from the loss of auxiliary voltage to the high-speed breakers

and recommend design changes to the propulsion system that would minimize these

effects. 

Even though the Ecstasy’s propulsion system had a number of design features that

were intended to reduce the likelihood that both port and starboard systems would fail as a

result of single fault, the importance of isolating the auxiliary voltage source to the highspeed breakers was not identified before or during the vessel construction. ABB officials

stated that they did not do a formal failure analysis, such as an FMEA, of the propulsion

system design because SOLAS, LR, and Carnival did not require them to perform one.

A qualitative failure analysis, such as the FMEA method, can identify potential

failures and rank them according to the probability of occurrence, the severity of effects,

and the probability of detection. System failure analyses are widely used in many other

industries as part of the overall movement toward quality improvement in processes and

products. In addition, IMO now requires that a failure analysis be performed during the

design of navigation equipment and bridge systems. The Coast Guard has required the use

qualitative failure analysis techniques in evaluating the reliability and safety of vital

system automation on U.S. flag vessels since 1988. In proposing the regulatory

requirement that designers, manufacturers, and/or shipyards perform and submit system

failure analysis, the Coast Guard stated that the use of advanced automation technologies

such as electronics and microprocessors made it increasingly difficult, “at times

impossible, for the Coast Guard, ship owners/operators, and classification societies to

evaluate safety.”

Classification societies, however, have not seen the need to require failure analyses

on vital automation systems in spite of the fact that these systems are becoming even more

complex and difficult to evaluate. The LR stated that during its plan approval and surveys

of the Ecstasy’s construction, it was not provided details of the propulsion system’s

internal connections. Therefore, LR was not aware, prior to the casualty, that the

propulsion would be lost if the cables to the high-speed breakers were burned through. 
Analysis 75 Marine Accident Report

If a qualitative failure analysis of the Ecstasy’s propulsion system had been

performed during its design phase, the failure probability of the single power source may

have been rated low. However, the high severity of the failure effect, that is, the total loss

of the propulsion system, should have led the designers to implement design

modifications. 

The Safety Board is aware that qualitative failure analysis typically is not applied

to existing systems because analyzing and changing system arrangements after

construction is often difficult and costly. However, a qualitative failure analysis can be an

important technique to maximize the reliability and safety of a system before it is built,

when changes can be easily made. The Safety Board concludes that, to ensure the highest

levels of safety and reliability, ship owners should use qualitative failure analysis

techniques in the design and construction of their vessels. The Safety Board, therefore,

believes that, in the construction of new passenger ships, owners should use qualitative

failure analysis techniques to identify system components whose failure might cause a

complete loss of propulsive power and take action to mitigate identified problems. The

Safety Board also believes that the International Association of Classification Societies

(IACS) should recommend that its members require systems designers, manufacturers,

and/or shipyards to perform and submit qualitative failure analyses to ensure the fail-safe

operation of propulsion systems on new passenger ships. 
76 Marine Accident Report

Conclusions

Findings

1. Although the Ecstasy’s mooring deck sustained the heaviest fire damage, it was not

the point of origin for the fire. 

2. The fire on board the Ecstasy started in the main laundry and was ignited by an arc

from a welding machine. 

3. The fitters’ (welders’) lack of full compliance with the “hot work” permit procedures

in Carnival Cruise Lines’ safety management system manual increased the risks of

fire in the main laundry. 

4. The lint that accumulated in the ventilation duct of the main laundry created a serious

fire hazard on the Ecstasy.

5. The procedures and standards for inspecting and maintaining laundry ventilation

systems adopted by the marine industry and government agencies following the

Ecstasy fire will improve safety on cruise ships.

6. If an automatic fire suppression system had been installed on the mooring deck, the

fire on the Ecstasy would have been located and extinguished much sooner, thereby

minimizing the extent of fire damage on the vessel and aft mooring deck. 

7. The vessel’s automatic fire sprinkler system effectively limited the spread of fire from

the mooring station to adjoining decks, thereby preventing a significantly worse fire

that would have caused greater damage and perhaps additional injuries. 

8. If the main laundry’s fire dampers had been equipped with a passive means of

closure, such as a fusible link, the heat from the fire would have caused the dampers

to shut sooner, which, in turn, might have prevented the spread of fire beyond the

laundry area. 

9. The fire detection system performed properly by providing an early indicator of a fire. 

10. Although most survey respondents indicated that the Ecstasy practice drill adequately

prepared them for the actual fire emergency, the drill lacked information about actions

to take if you see smoke or if your muster station is unavailable that might have

assisted passengers who encountered conditions or situations contrary to those during

the drill. 

11. Although the noise from the news helicopters may have interfered somewhat with the

communications with passengers on the outside deck, crewmembers were able to

effectively communicate with the mustered people and manage the emergency.
Conclusions 77 Marine Accident Report

12. The procedures used by the Ecstasy’s shipboard personnel did not adequately account

for passengers and crewmembers during the emergency. 

13. The lack of consistency between the information provided at the practice drill about

the provision of lifejackets and the procedures that crewmembers followed in

distributing lifejackets during the actual emergency created unnecessary confusion

among some passengers on the Ecstasy. 

14. The lack of a means to call for help from the crew cabins delayed the rescue of two

crewmembers and contributed to the severity of their smoke inhalation injuries. 

15. The emergency response by shipboard and shoreside firefighters to the fire was

timely and appropriate, resulting in the fire being properly contained and

extinguished. 

16. The failure to separate the power circuitry in the design arrangement of the auxiliary

voltage supply to the high-speed breakers of the propulsion systems resulted in

inadequate isolation of essential system components, which, in turn, resulted in the

shutdown of both propulsion systems when a single distribution panel was damaged. 

17. To ensure the highest levels of safety and reliability, ship owners should require the

use of qualitative failure analysis techniques in the design and construction of their

vessels. 

Probable Cause

The National Transportation Safety Board determines that the probable cause of

fire aboard the Ecstasy was the unauthorized welding by crewmembers in the main

laundry that ignited a large accumulation of lint in the ventilation system and the failure of

Carnival Cruise Lines to maintain the laundry exhaust ducts in a fire-safe condition.

Contributing to the extensive fire damage on the ship was the lack of an automatic fire

suppression system on the aft mooring deck and the lack of an automatic means of

mitigating the spread of smoke and fire through the ventilation ducts. 
78 Marine Accident Report

Recommendations

As a result of its investigation of this accident, the National Transportation Safety

Board makes the following recommendations:

New Recommendations

To the U.S. Coast Guard:

During control verification examinations, review a drill scenario in which

one or more main vertical zones are inaccessible and evaluate the

procedural effectiveness of the crew in crowd control, crisis management,

lifejacket distribution, and passenger accountability. (M-01-1)

To Carnival Corporation: 

For the ships in your fleets, revise the safety management system to include

processes for preventing unauthorized flame cutting, grinding, or other

activities that might ignite a fire. (M-01-2)

For the ships in your fleets, develop plans to account for passengers and

crewmembers in common emergency scenarios, in particular, a situation

involving the inaccessibility of one or more main vertical zones and/or

muster stations. (M-01-3)

To Carnival Cruise Lines:

For the ships in your fleet, engineer, design, and implement system

modifications to mitigate the spread of fire and smoke from the laundry

rooms through ventilation ducts to other areas of the vessel. (M-01-4)

Examine the propulsion systems on the ships in your fleet and, if necessary

to ensure redundancy, modify the arrangement of the auxiliary voltage

circuitry to the high-speed breakers where a single source supplies both

port and starboard propulsion systems. (M-01-5)

Revise the safety information disseminated to passengers to include actions

to take if they encounter smoke or fire and/or if their muster station is not

available. (M-01-6)
Recommendations 79 Marine Accident Report

To American Classic Voyages, Carnival Corporation, Inc., Crystal Cruises, Disney

Cruise Line, Norwegian Cruise Line, Orient Lines, P&O Princess Cruises

International, Ltd., Radisson Seven Seas Cruises, Regal Cruises, Renaissance

Cruises, Inc., Royal Olympic Cruises, Royal Caribbean Cruise Lines, and Silversea

Cruises, Ltd.:

For existing vessels with ventilation system arrangements similar to

Carnival Cruise Lines’ Fantasy Class ships, install an automatic method or

system to mitigate the spread of smoke and fire from laundry spaces

through the ventilation ducts to other vessel areas. (M-01-7)

For existing vessels with mooring deck design arrangements similar to

Carnival Cruise Lines’ Fantasy Class ships, install fire detection and

suppression systems on mooring decks that carry high fire loads and

presently have no automatic fire protection. (M-01-8)

In the construction of new passenger ships, use qualitative failure analysis

techniques to identify system components whose failure might cause a

complete loss of propulsive power and take action to mitigate identified

problems. (M-01-9)

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-01-10)

To ABB, Inc.:

Advise your customers owning ships with the same propulsion system

design arrangements as the Ecstasy of the potential for system failure from

the loss of auxiliary voltage to the high-speed breakers and recommend

design changes to the propulsion system that would minimize these effects.

(M-01-11)

To the International Association of Classification Societies:

Recommend that your members require systems designers, manufacturers,

and/or shipyards to perform and submit qualitative failure analyses to

ensure the fail-safe operation of propulsion systems on new passenger

ships. (M-01-12)
Recommendations 80 Marine Accident Report

Previously Issued Recommendations Resulting from this 

Accident Investigation

M-98-125

Immediately inspect, within your fleet of ships, the laundry ventilation

systems, including ducts, plenums, and exhaust terminuses, for any

combustible material, such as lint, and clean the systems, as necessary, to

reduce the risk of fire. (Urgent)

M-98-126

Institute a program to verify on a continuing basis that the laundry

ventilation systems, including ducts and plenums, remain clean and clear

of any combustible material that poses a fire hazard on your vessels. 

Previously Issued Recommendations Classified in this Report

The following Safety Recommendations were issued to 18 cruise line companies

on July 11, 1990: 

M-00-6

Without delay, install automatic local-sounding smoke alarms in crew

accommodation areas on company passenger ships so that crews will

receive immediate warning of the presence of smoke and will have the

maximum available escape time during a fire.

M-00-7

Without delay, install automatic local-sounding smoke alarms in passenger

accommodation areas on company passenger ships so that passengers will

receive immediate warning of the presence of smoke and will have the

maximum available escape time during a fire.

Based on no response from five cruise line companies, the Safety Board, therefore,

classifies, in this report, the safety recommendations as indicated: 

M-00-6 (previously classified “Open—Acceptable Response”) is classified

“Open—Unacceptable Response” for Costa Cruise Lines, Orient Lines, Regal

Cruises, Royal Olympic Cruises, and Silver Sea Cruises in the section of this

report entitled “Locally Sounding Alarms.”

M-00-7 (previously classified “Open—Acceptable Response”) is classified

“Open—Unacceptable Response” for Costa Cruise Lines, Orient Lines, Regal

Cruises, Royal Olympic Cruises, and Silver Sea Cruises in the section of this

report entitled “Locally Sounding Alarms.”
Recommendations 81 Marine Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

CAROL J. CARMODY

Acting Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: May 1, 2001

83 Marine Accident Report

Appendixes

Appendix A

Investigation

The Safety Board first became aware of the accident through national media

coverage on the evening of July 20, 1998. Later that evening, the Safety Board dispatched

a 12-person team from Washington, D.C. The team arrived in Miami shortly after

midnight and boarded the Ecstasy when it docked. Safety Board investigators met with

Carnival representatives, the Coast Guard, and local emergency response agencies. Later

in the morning of July 21, investigators began examining the fire scene and interviewing

witnesses. The initial on-scene investigation lasted from July 21-26; investigators returned

to the Ecstasy on three occasions while it underwent repairs. The on-scene investigation

ended on August 24, 1998.

The following organizations were parties in the investigation: Carnival Cruise

Lines, the Republic of Liberia, the U.S. Coast Guard, the Miami-Dade Fire Rescue

Department, and the Florida Division of State Fire Marshall.

The Safety Board held a public hearing in regard to the accident in Miami on

February 17-18, 1999. 
84 Marine Accident Report

Appendix B

STCW Code

Specification of minimum standard of competence

in crisis management and human behavior

Competence Knowledge, understanding 

and proficiency

Methods for

demonstrating 

competence

Criteria for

evaluating 

competence

Organize 

shipboard 

emergency 

procedures

Knowledge of:

.1 the general design and 

layout of the ship

.2 safety regulations

.3 emergency plans and 

procedures

The importance of the principles 

for the development of shipspecific emergency procedures, 

including:

.1 the need for pre-planning 

and drills of shipboard 

emergency procedures

.2 the need for all personnel to 

be aware of and adhere to 

pre-planned emergency 

procedures as carefully as 

possible in the event of an 

emergency situation.

Assessment of evidence 

obtained from approved 

training, exercises with one or 

more prepared emergency 

plans and practical 

demonstration

The shipboard emergency 

procedures ensure a state 

of readiness to respond to 

emergency situations

Optimize the 

use of resources

Ability to optimize the use of 

resources, taking in account:

.1 the possibility that resources 

available in an emergency 

may be limited

.2 the need to make full use of 

personnel and equipment 

immediately available and, if 

necessary, to improvise

Ability to organize realistic drills to 

maintain a state of readiness, 

taking into account lessons learnt 

from previous accidents involving 

passenger ships; debriefing after 

drills.

Assessment of evidence 

obtained from approved 

training, practical 

demonstration and shipboard 

training and drills of 

emergency procedures

Contingency plans 

optimize the use of 

available resources

Allocation of tasks and 

responsibilities reflects 

the known competence of 

individuals

Roles and responsibilities 

of teams and individuals 

are clearly defined
Appendix B 85 Marine Accident Report

Control 

response to 

emergencies

Ability to make an initial 

assessment and provide an 

effective response to emergency 

situations in accordance with 

established emergency 

procedures

Leadership skills

Ability to lead and direct others in 

emergency situations, including 

the need:

.1 to set an example during 

emergency situations

.2 to focus decision making, 

given the need to act quickly 

in an emergency

.3 to motivate, encourage and 

reassure passengers and 

other personnel

Stress handling

Ability to identify the development 

of symptoms of excessive 

personal stress and those of 

other members of the ship’s 

emergency team

Understanding that stress 

generated by emergency 

situations can affect the 

performance of individuals and 

their ability to act on instructions 

and follow procedures

Assessment of evidence 

obtained from approved 

training, practical 

demonstration and shipboard 

training and drills of 

emergency procedures

Procedures and actions 

are in accordance with 

established principles and 

plans for crises 

management on board

Objectives and strategy 

are appropriate to the 

nature of the emergency, 

take account of 

contingencies and make 

optimum use of available 

resources

Actions of crewmembers 

contribute to maintaining 

order and control

Competence Knowledge, understanding 

and proficiency

Methods for

demonstrating 

competence

Criteria for

evaluating 

competence
Appendix B 86 Marine Accident Report

Control 

passengers and 

other personnel 

during 

emergency 

situations

Human behaviour and responses

Ability to control passengers and 

other personnel in emergency 

situations, including:

.1 awareness of the general 

reaction patterns of 

passengers and other 

personnel in emergency 

situations, including the 

possibility that:

.1.1 generally it takes some time

before people accept the fact 

that there is an emergency 

situation

.1.2 some people may panic and 

not behave with a normal 

level of rationality, that their 

ability to comprehend may 

be impaired and they may 

not be as responsive to 

instructions as in nonemergency situations

.2 awareness that passengers 

and other personnel may, 

inter alia:

.2.1 start looking for relatives, 

friends, and/or their 

belongings as a first reaction 

when something goes wrong

.2.2 seek safety in their cabins or 

in other places on board 

where they think that they 

can escape danger

.2.3 tend to move to the upper 

side when the ship is listing

.3 appreciation of the possible 

problem of panic resulting 

from separating families

Assessment of evidence 

obtained from approved 

training, practical 

demonstration and shipboard 

training and drills of 

emergency procedures

Actions of crewmembers 

contribute to maintaining 

order and control

Establish and 

maintain 

effective 

communications

Ability to establish and maintain 

effective communications, 

including:

.1 The importance of clear and 

concise instructions and 

reports

.2 The need to encourage an 

exchange of information 

with, and feedback from, 

passengers and other 

personnel

Assessment of evidence 

obtained from approved 

training, exercises and 

practical demonstration 

Information from all 

available sources is 

obtained, evaluated and 

confirmed as quickly as 

possible and reviewed 

throughout the 

emergency

Competence Knowledge, understanding 

and proficiency

Methods for

demonstrating 

competence

Criteria for

evaluating 

competence
87 Marine Accident Report

Appendix C

Ecstasy Emergency Procedures Placard

Emergency Procedures

Emergency Drills are held on board according to international maritime laws and

are compulsory: All passengers must participate. The purpose of the drills is to acquaint

all passengers with the correct procedure to be followed in the unlikely event of an

emergency during the voyage.

There are six muster stations which are identified and located as follows:

Muster Station [A] Blue Sapphire Lounge (Atlantic Deck Forward)

Muster Station [B] City Lights Blvd. (Promenade Deck Forward)

Muster Station [C] City Lights Blvd. (Promenade Deck Midship)

Muster Station [D] Stripes Discotheque (Promenade Deck Midship)

Muster Station [E] Starlight Lounge (Promenade Deck Midship)

Muster Station [F] Patio Pool Area (Lido Deck Midship)

The purpose of assembling all passengers at the muster station is to clear the decks

of all people enabling the crew to prepare the boats and at the same time, passengers are

comfortably standing by near the embarkation stations to which they will be led according

to the orders given by the master and his officers in charge. No suitcases, bags, parcels or

articles of any kind, except blankets, can be taken to muster stations and into the lifeboats.

DO NOT PANIC!

Don’t use the elevators

Avoid Useless Confusion and/or Noise.

Emergency Signals

Fire on board

Two long blasts of the ship’s whistle supplemented by a continuous two-tone alarm

signal over the loudspeakers.

Abandon ship

Seven or more short blasts followed by one long blast of the ship’s whistle

supplemented by the same signal over the loudspeakers.
Appendix C 88 Marine Accident Report

Whenever either of the above alarms is given, passengers shall go to their cabins,

put on their lifejackets and then proceed calmly to their muster station, using whenever

possible, the most direct route following the coloured muster station arrows via the main

exits. Otherwise a secondary escape route via emergency exits may be used. The room

steward will provide lifejackets for children at the start of each voyage.

How to put on your lifejacket:

1. Place lifejacket overhead

2. Bring strap around body and fasten closure

3. Adjust to a snug fit by pulling free end of strap

4. Cross arms across chest and enter water feet first

In darkness, pull orange plastic ring to start light.

Your muster station is [example] Muster F Station
89 Marine Accident Report

Appendix D

Number And Arrangement Of Lifejackets On the Ecstasy

Checklist for Lifejackets Section C 8

# Location Total Type Remarks

1 Lido Deck-Locker Near L/Boat # 4 89 Adult To Be Used for Distribution During Pax Boat Drill

2 Lido Deck-Locker Near L/Boat # 4 92 Child To Be Used for Distribution During Pax Boat Drill

3 Lido Deck-Locker Near L/Boat # 4 7 Infants To Be Used for Distribution During Pax Boat Drill

4 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

5 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

6 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

7 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

8 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

9 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

10 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

11 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

12 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

13 Lido Deck-Bench By L/Boat # 4 18 Adult Spare Requested by SOLAS

14 Lido Deck-Bench By L/Boat # 4 14 Child Spare Requested by SOLAS

15 Lido Deck-Bench By L/Boat # 4 14 Child Spare Requested by SOLAS

16 Lido Deck-Bench By L/Boat # 4 14 Child Spare Requested by SOLAS

17 Lido Deck-Bench By L/Boat # 4 14 Child Spare Requested by SOLAS

18 In Front of Cab. R-53 37 Child Spare Requested by SOLAS

19 In Front of Cab. R-187 38 Child Spare Requested by SOLAS

20 In Front of Cab. M-83 37 Child Spare Requested by SOLAS

21 In Front of Cab. M-205 38 Child Spare Requested by SOLAS

22 In Front of Cab. U-45 37 Child Spare Requested by SOLAS
Appendix D 90 Marine Accident Report

*Column adds up to 4,936.

Total Adult Spares Requested by SOLAS = 5% of 3,560 = 178 (See Lines # 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 - 11 - 12)

Total Children Spares Requested by SOLAS = 10% of 2,634 = 264 (See Lines # 13 - 14 - 15 - 16 - 17 - 18 - 19 - 20 - 21 - 

22 - 23 - 24)

23 In Front of Cab. U-179 38 Child Spare Requested by SOLAS

24 In Front of Cab. E-64 37 Child Spare Requested by SOLAS

25 In Front of Cab. C-153 38 Adult Spare Requested by SOLAS

26 Verandah Deck 68 Adult Pax Cabins

27 Lido Deck 67 Adult Crew Cabins

28 Lido Deck (Bridge) 4 Adult For Personnel on Watch

29 Empress Deck 618 Adult Pax Cabins

30 Upper Deck 532 Adult Pax Cabins

31 Main Deck 686 Adult Pax Cabins

32 Riviera Deck 640 Adult Pax Cabins

33 Deck #3 175 Adult Crew Cabins

34 Deck #2 484 Adult Crew Cabins

35 Deck # 1 301 Adult Crew Cabins

36 Tender # 7 – 8 - 14 - 15 - 16 - 17 480 Adult For Tender Service

37 Tender # 7 – 8 - 14 - 15 - 16 - 17 48 Child For Tender Service

38 Deck #2 – Bosun Store 48 Adult Spare

39 Deck #2 – Bosun Store 50 Child Spare

40 Atlantic Deck – By Children 

Playroom

11 Child Spare

Total Lifejackets On Board = 4,946*

Checklist for Lifejackets Section C 8

# Location Total Type Remarks
91 Marine Accident Report

Appendix E

Metallurgical Tests - Heat Release Table

*HRR: Heat release rate

Average HRR* (kW/m2) Heat Flux Applied

in the Following Times 25 kW/m2 50 kW/m2 75 kW/m2

60 seconds 104.4 142.2 234.3

180 seconds 177.8 241.8 403.7

300 seconds 266.6 319.3 598.7
92 Marine Accident Report

Appendix F

Safety Recommendations on Call Systems

In a 1993 special investigation report concerning passenger ship accidents,50 the

Board made the following safety recommendation to the Coast Guard:

M-93-39

Analyze the desirability and feasibility of equipping passenger staterooms with an

emergency call system by which trapped passengers can signal their plight. 

The Coast Guard ultimately advised the Safety Board that it had discussed the

desirability and feasibility of installing emergency call systems in passenger staterooms

with the SOLAS Working Group on Fire Protection and, based upon that discussion,

determined that “an additional emergency call system would not improve passenger-tocrew communications and would require additional maintenance.” 

The Safety Board disagreed with the Coast Guard’s actions and, on May 21, 1997,

classified Safety Recommendation M-93-39 “Closed—Unacceptable Action,” based, in

part, on the Coast Guard’s failure to perform the analysis requested.

Following its investigation of the fire on the Universe Explorer, the Safety Board

asked that both the Coast Guard and the ICCL take actions regarding emergency call

systems on cruise ships. The Safety Board issued the following recommendation to the

Coast Guard: 

M-98-32

Recommend to the IMO 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.

On October 16, 1998, the Coast Guard responded that it would discuss the

available options for any necessary improvements with the SOLAS working group on fire

protection and will propose changes to the IMO, if appropriate. The Safety Board

followed up by advising the Coast Guard that the current regulations were not sufficient in

the event of a fire with heavy smoke. Based on the Coast Guard’s indicating that it would

work with the SOLAS working group, the Safety Board classified M-98-32 “Open—

Acceptable Response.”

The Safety Board issued the following recommendation to the ICCL:

50 For additional information, read Special Investigation Report—Accidents Involving Foreign Passenger Ships

Operating from U.S. Ports 1990-1991 (NTSB/SIR-93/01).
Appendix F 93 Marine Accident Report

M-98-59

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. 

The ICCL responded that it had distributed the recommendation to its members for

review and consideration. The Safety Board followed up by urging specific action to

encourage the installation of emergency call systems as requested in the recommendation.

The ICCL subsequently advised that SOLAS requirements and recent amendments

stipulated a number of fire safety improvements addressing, among other measures,

means of escape, low-location lighting, and smoke alarms. Moreover, SOLAS required

cruise ship companies to train and designate crewmembers to search the ship for people

who might be in their cabins or in non safety-designated locations.

On February 18, 1999, the Safety Board responded that it was disappointed that

the ICCL had not recommended that member companies install emergency call systems.

The Board stated:

A telephone system might not be able to handle the number of calls that might be

made in an emergency. An emergency call system could identify the stateroom in

which a passenger or crewman is trapped. Because the ICCL has only discussed

this recommendation with its technical committee and has not recommended that

member companies install emergency call systems, M-98-59 has been classified

‘Closed—Unacceptable Action.’