NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT REPORT

PB2001-916403

NTSB/MAR-01/02

FIRE ON BOARD THE

U.S. PASSENGER FERRY COLUMBIA

CHATHAM STRAIT

NEAR JUNEAU, ALASKA

JUNE 6, 2000

7292A

Marine Accident Report

Fire On Board the

U.S. Passenger Ferry Columbia

Chatham Strait

Near Juneau, Alaska

June 6, 2000

NTSB/MAR-01/02

PB2001-916403 National Transportation Safety Board

Notation 7292A 490 L’Enfant Plaza, S.W.

Adopted September 18, 2001 Washington, D.C. 20594
National Transportation Safety Board. 2001. Fire on Board the U.S. Passenger Ferry Columbia,

Chatham Strait, Near Juneau, Alaska, June 6, 2000. Marine Accident Report NTSB/MAR-01/02.

Washington, DC.

Abstract: This report discusses the June 6, 2000, fire that occurred on the Alaska Marine Highway System

ferry Columbia, while it was underway in Chatham Strait, near Juneau, Alaska. None of 498 people on

board the vessel was killed or sustained serious injury; however, three passengers were transported to a

shoreside hospital for medical conditions that preexisted the fire. Damages related to the accident exceeded

$2 million.

From its investigation of this accident, the National Transporattion Safety Board identified safety issues in

the following areas: the adequacy of inspection and maintenance procedures for electrical systems; the

adequacy of management safety oversight of maintenance procedures; and the adequacy of firefighting

procedures. Based on its findings, the Safety Board made recommendations to the Alaska Marine Highway

System.

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 PB2001-916403 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

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

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

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

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

Activities on Bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Fire and Rescue Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Crew Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Coast Guard Firefighting Requirements for Vessel Crews . . . . . . . . . . . . . . . . . . . . . . 10

Emergency Training and Drills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

AMHS Maintenance Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Prior Shipyard Work on Main Switchboard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Meteorology Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Medical And Pathological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Medical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Units 9 and 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Unit 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Unit 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Muster/Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Passenger Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Lifesaving Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Firefighting Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Firefighting Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Emergency Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Coast Guard Firefighting Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Passenger and Crew Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Tests And Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Johns Hopkins University-Applied Physics Laboratory Report . . . . . . . . . . . . . . . . . . 25

Safety Board Materials Laboratory Testing Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Infrared Thermographic Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Emergency Team Muster Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Public Address System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Survey of Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Contents iv Marine Accident Report

Equipment Repair and Upgrading of Columbia Systems . . . . . . . . . . . . . . . . . . . . . . . . 28

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Cause and Origin of Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

System Load Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Failure of Main Switchboard Breakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Abnormal Condition in Electrical Generation System . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Electrical Connection in Switchboard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Conductive Object . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Inspection and Maintenance Procedures For Electrical Systems . . . . . . . . . . . . . . . . . . . . . 33

Preventive Maintenance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Quality Assurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Firefighting Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Actions of the Columbia’s Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Coast Guard Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Firefighters’ Staging Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Means of Communication in Engineroom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Passenger and Crew Muster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Passenger and Crew Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
v Marine Accident Report

Acronyms And Abbreviations

AB able seaman

ABS American Bureau of Shipping

AMHS Alaska Marine Highway System 

CFR Code of Federal Regulations

MSO Marine Safety Office

SCBA self-contained breathing apparatus

SAR Search and Rescue

SOLAS International Convention for the Safety of Life at Sea

STCW International Convention on Standards of Training, Certification, 

and Watchkeeping for Seafarers
vi Marine Accident Report

Executive Summary

About 1207, Alaskan daylight time,1 June 6, 2000, a fire broke out in the main

switchboard in the engine control room of the Alaska Marine Highway System (AMHS)

ferry Columbia. The ferry, with 434 passengers, 1 stowaway,2 and 63 crewmembers on

board, was underway in Chatham Strait, about 30 nautical miles southwest of Juneau,

Alaska, on a regularly scheduled voyage from Juneau to Sitka, Alaska. As a result of the

fire, the vessel lost main propulsion and electrical power and began to drift. The

crewmembers on board the Columbia responded to the fire first. Soon thereafter, the U.S.

Coast Guard (Coast Guard) cutter Anacapa, on patrol nearby, sent a firefighting team to

the Columbia. About 1425, the fire was extinguished with no resulting injuries or deaths.

However, the Columbia remained adrift. 

Three passengers were evacuated by Coast Guard helicopter because of medical

conditions that preexisted the fire. The remaining passengers were safely transferred to

another AMHS ferry, the Taku, which had rendezvoused with the drifting Columbia.

About 2030, the Taku arrived at Auke Bay Ferry Terminal in Juneau, where the passengers

disembarked. The Columbia was towed to the same terminal, arriving at 0845, on June 7.

According to the AMHS, the cost of repairs to the ship was about $2 million. 

The National Transportation Safety Board determines that the probable cause of

the fire on the Columbia was the absence of an effective maintenance and inspection

program for the electrical switchboards, resulting in a switchboard fire by arcing, most

likely due to a faulty connection or a conductive object.

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

• Adequacy of inspection and maintenance procedures for electrical systems; 

• Adequacy of management safety oversight of maintenance procedures; and

• Adequacy of firefighting procedures.

As a result of this investigation, the National Transportation Safety Board makes

safety recommendations to the AMHS, the operator of the Columbia. 

1 All times in this report are Alaskan Daylight Time.

2 See “Passenger and Crew Accountability” for information concerning the stowaway.
1 Marine Accident Report

Factual Information

Accident Synopsis

On June 6, 2000 at 0915, the 418-foot ferry Columbia (see figure 1) departed the

AMHS’s Auke Bay Terminal north of Juneau, Alaska, en route to the AMHS terminal in

Sitka for a scheduled voyage of about 8 1/2 hours. (See figure 2.) On board were 434

passengers, 1 stowaway, and 63 crewmembers. About 1207, fire broke out in the main

electrical switchboard1 in the engine control room, knocking out power to the ship’s

electrical systems and causing the emergency generator to come on line. The ship also lost

its main propulsion. 

Personnel on board the Columbia responded to the fire first. Soon thereafter, the

Coast Guard Cutter Anacapa, on patrol nearby, sent a firefighting team to the Columbia.

Additional resources from Coast Guard Station Juneau and the State of Alaska also

responded to the emergency. About 1425, the fire was extinguished. No one was injured or

killed. However, the Columbia remained dead in the water. Another AMHS ferry, the

Taku, rendezvoused with the drifting Columbia and took on board the Columbia’s

passengers without incident or injury. About 2030, the Taku arrived at Auke Bay Ferry

Terminal in Juneau, where the passengers disembarked. The Columbia was towed to the

same terminal, arriving at 0845 on June 7. Although no injuries resulted from the fire,

three individuals were taken to a Juneau hospital for medical reasons. 

1 A switchboard supports and houses meters, circuit breakers, switches, indicator lights, rheostats,

resistors, and fuse holders. It also contains the electrical conductors interconnecting these components.

Figure 1. The Columbia.
Factual Information 2 Marine Accident Report

Figure 2. Columbiaís route to the point of the accident (circled).
Factual Information 3 Marine Accident Report

Accident Narrative

Preaccident Events

According to shipboard personnel, from the time that the Columbia departed

Juneau, at 0915, until 1130, events were routine in the engineroom. (See figure 3.) The

vessel was underway at 19.4 knots with both main engines operating. Two of the ship’s

three auxiliary generators were operating in parallel; the third generator was shut down. 

About 1130, the engineroom watch changed. The new watch included a watch

engineer, an unlicensed junior engineer, and an oiler. The junior engineer and the oiler

made inspection rounds and returned to the control room. They did not note any problems

during their rounds. While the watch engineer went on his rounds, the junior engineer and

the oiler talked near the log desk, which was on the port side of the control room. 

The Accident

The junior engineer stated that, shortly after 1200, he and the oiler heard a

“disruptive sound, [a] kind of a poof” and saw a bright electrical arc2

 and sparks emerge

Figure 3. Schematic of engineroom.

2 An electric arc is a sustained luminous discharge of electricity across a gap between two conductors

at different voltage levels. 

Port

Door

C

o

n

t

r

o

l

R

o

o

m

Escape

Scuttle

F.O.

Service

Tank

Starboard

Door

Electrical

Workshop

DN

AC Refrigeration

Machinery Room

Up

Workshop

Workshop
Factual Information 4 Marine Accident Report

from the upper portion of the main switchboard section, at its starboard end (unit 12).3

Almost immediately, unit 10 began sparking and arcing, and the noise increased. The

control room quickly filled with thick black smoke. The junior engineer and the oiler

escaped through a nearby door into the engineroom, whereupon the junior engineer told

the oiler to call the bridge and report the fire. The junior engineer then looked for the

watch engineer to inform him of the problem. According to the engineroom alarm log

printout, at 1207:48, the “Port Main Engine overspeed [alarm] tripped,” signaling a loss of

voltage to the overspeed protection device.4 Within 1 minute of the first alarm, the

monitoring system computer recorded about 30 fault alarms on various systems, and all

engineering systems lost electrical power. 

Meanwhile, the watch engineer was making an inspection round when he noticed

the ship’s No. 2 auxiliary generator surging and moving erratically on its foundation. (See

figure 4.) He stated that the generator “would go from a slower speed to a higher speed,

and it was shaking and rattling.” He went to the control room to see if he could determine

the cause of the erratic operation. On the way, he noticed that the lights were flickering.

Upon opening the door to the control room, he “saw fire coming out of the first panel

[unit] closest to the starboard door...heard a large [sic] popping sound”; he also saw what

appeared to be the panels coming off the side of the breaker board. He closed the fire

screen door to the control room and went to the auxiliary engineroom, where he shut down

the ship’s No. 2 auxiliary generator and began to stage firefighting equipment at the

starboard fire screen door of the control room. 

The off duty engineers were having lunch in the officers’ mess when the lights

began to flicker shortly after 1200. The chief engineer stated that he heard the ventilation

fan motors slowing down and the diesel emergency generator start. While the other

engineers headed for the engineroom to investigate the reason for the flickering lights, the

first assistant engineer went to the emergency generator room, which was on the same

deck as the officers’ mess, to make sure that the emergency generator was running.

Assured that it was, the first assistant engineer went to the engineroom to join the others.

When the day third assistant engineer5

 arrived in the engineroom, the oiler told

him about the fire in the control room. The engineroom had no manual fire alarm or pull

station; the only telephone in the area that could be used to call the bridge was in the

control room and was inaccessible because of the fire. As a result, the day third engineer

3 The switchboard manufacturer refers to the sections of the switchboard as units. During Safety Board

interviews, the crew referred to the units as panels. Also, the crew used a different numbering system than

the manufacturer. For example, unit 12, as indicated on the manufacturer’s drawings, was called panel 1 by

the crew. This report uses the manufacturer’s designations. 

4 The engineroom automation system controls and monitors various engineering systems. When an

abnormal condition occurs within a monitored system, an audible and visual alarm activates, and the time,

channel identification, and alarm point condition are printed on a paper alarm log and stored in the

computer’s memory.

5 The day third assistant engineer worked in the daytime only, performing maintenance work

throughout the ship, and did not stand an engineering watch. For the remainder of this report, he will be

referred to as the day third engineer. 
Factual Information 5 Marine Accident Report

had to climb up one deck to leave the engineroom and walk about 100 feet to call the

bridge from a telephone located in the vehicle stowage area on the main deck. 

When the chief engineer arrived in the engineroom, he met the watch engineer,

who had already staged several CO2 fire extinguishers near the starboard fire screen door

of the control room and was stretching out the discharge hose for the semi-portable CO2

fire extinguisher in the auxiliary machinery room. The chief engineer noticed that the

shipís No. 1 auxiliary generator was operating erratically and sounded as if it were being

overloaded. After feeling the fire screen door on the starboard side of the control room for

heat, he opened the door and saw heavy black smoke, but no fire. He immediately closed

the fire screen door and directed his and his crewís attention to checking the engineroom,

starting the fire pump, and securing the fuel oil and lube oil centrifuges and the fuel oil

isolation valves. 

Activities on Bridge 

The chief mate and the master were in the chief mateís office, working on the

computer, when they saw the lights dim. They immediately ran to the bridge. Arriving in

the wheelhouse at 1207, the master assumed command from the pilot on duty. Multiple

alarms were sounding on the bridge. The ship had lost propulsion and regular lighting and

was beginning to drift. Shortly after arriving in the wheelhouse, the chief mate got a call

from the day third engineer, informing him of the fire and requesting that the fire team

respond to the scene. After the chief mate relayed this information to the master, around

1208, the master ordered the chief mate to sound the general alarm and to announce an

emergency to the passengers and crew. Between 1208 and 1212, the chief mate sounded

the alarm and made announcements informing the passengers and crew of the fire. He

instructed the passengers to muster on the upper decks and ordered the emergency squad6

Figure 4. One of the three auxiliary diesel generators.

6 The squad consisted of 15 members of the deck department and 2 members of the engineering

department, all of which were under the command of the chief mate. 
Factual Information 6 Marine Accident Report

to muster in its designated staging area,7 which was on the starboard side of the main deck

near the main access door to the engineroom. Immediately after these announcements

were made, the public address system became inoperative. Around 1212, the chief mate,

who was responsible for supervising shipboard firefighting activities, went to muster with

the emergency squad. At 1216, the master requested assistance from another AMHS ferry,

the Taku, on VHF channel 11. The master had seen the Taku earlier in the day and knew

that it was in the area. 

Meanwhile, the emergency diesel generator started, providing emergency lighting

and giving the bridge steering control of the ship. When the master realized that the

starboard propeller was indicating astern pitch and that both engines were slowing, he

ordered the engines stopped and the rudder midships.

Fire and Rescue Response

Shipboard effort. Shortly after the fire began, the ship’s emergency squad

members donned personal protective equipment and brought fire extinguishers to the

designated staging area. Because a car was parked in the squad’s muster area, the squad

was forced to assemble around the car. Shortly after his arrival at the muster location, the

chief mate sent an able seaman (AB) to the engineroom to assess the situation. The first

assistant engineer stated that he did not want the emergency squad to enter the control

room to fight the fire; he believed that the engineers were better able to do so because of

their familiarity with the control room. As a result, the first assistant engineer asked the

AB to leave the engineroom. 

Recognizing that the engineers were more familiar with the control room, the chief

mate decided to let them fight the fire. The engineers did not don any protective clothing

but they did obtain self-contained breathing apparatuses (SCBAs)8 from the emergency

squad. The emergency squad remained in the staging area and provided support as needed

by changing SCBA air bottles as they became expended.

The chief engineer became concerned that the diesel emergency generator was

continuing to feed electrical power to the main switchboard via the emergency

switchboard; so he sent the day third engineer into the control room to open the bus tie

circuit breaker between the main switchboard and the emergency switchboard. Entering

the control room, the day third engineer stayed as low as possible to avoid the smoke that

was accumulating near the overhead. After he had advanced about 15 feet into the room,

he found that the room was so dark that he could not see the light of his own flashlight

even when he aimed it at his facemask. He did not see any flames. He became concerned

about his safety, withdrew from the control room, and requested that a lifeline be attached

to him. 

7 The staging area was in the vehicle stowage area and was an area on the deck that was outlined in

yellow. 

8 SCBAs are protective breathing equipment that protects the face and lungs from toxic gases and high

temperatures. The air supply in an open-circuit SCBA is compressed air. 
Factual Information 7 Marine Accident Report

At this time, the first assistant engineer donned an SCBA and joined the efforts of

the day third engineer to enter the control room. Before the men entered the room, the

chief engineer expressed a new concern that the ship’s No. 1 auxiliary generator might still

be powering the main switchboard. The chief engineer directed the two engineers to enter

the control room and open the bus tie circuit breaker from the emergency switchboard as

well as the circuit breakers connected to the ship’s auxiliary generators.

The two engineers entered the space through the starboard fire screen door on their

hands and knees. The watch engineer stated that when he reached out to open the bus tie

circuit breaker, a blue electric arc knocked his hand back. The first assistant engineer then

reached over the day third engineer and opened the breaker by hitting it with a flashlight.

The first engineer successfully opened another breaker with the flashlight, but, according

to his own account, when he attempted to open a third breaker, there was a “really big

spark.” At that point, the two engineers backed out of the room. They discussed the

situation with the chief engineer, who then manually shut down the ship’s No. 1 auxiliary

generator. 

The engineers attacked the fire with hand-held portable CO2 fire extinguishers.

They also unreeled a hose from a semiportable 100-pound CO2 extinguisher in the

adjacent auxiliary generator room and stretched the hose to the control room.

During this time, the chief mate kept the bridge informed of the firefighting

activities. The master stated that the chief mate had difficulty getting frequent and

accurate updates because when the engineers “surfaced for air, they were gasping and

sweating and couldn’t get time to get a report before they slapped on another bottle and

ran back down there.”

Around 1220, the engineers informed the chief mate that the fire was out. He

passed the information on to the master. At 1225, the chief mate received permission from

the master to ventilate the ship. At 1227, as a result of the fire being declared extinguished,

the chief engineer, the day third engineer, and the first assistant engineer left the

engineroom. Between 1225 and 1231, the chief mate opened the vehicle stowage area

doors to allow natural ventilation to clear the smoke from the vessel. 

Around 1240, the chief engineer reported a reflash of the fire in the main

switchboard. The master ordered the crew to close all ventilation dampers and all fire

screen doors. He also ordered the closing of all watertight doors, with the exception of

door No. 3, which was kept open to permit the passage of the hose from the semiportable

CO2 extinguisher in the auxiliary engineroom. The master shut off all fuel to the main and

auxiliary engines by remote control. Because most of the SCBA air bottles on the ship had

been used during the initial firefighting operations, the Columbia obtained additional air

bottles and SCBA units from the Taku. 

Because a Coast Guard firefighting team from the cutter Anacapa, which had been

operating nearby and had come to the assistance of the Columbia, was expected to board

the Columbia at any time, the chief engineer instructed the ship’s personnel to pull out of

the engineroom and prepare to reenter with the Coast Guard team when it arrived. 
Factual Information 8 Marine Accident Report

Coast Guard. At 1216, the Coast Guard cutter Anacapa overheard the

Columbia’s master requesting assistance from the Taku on VHF channel 11. The Anacapa

notified the search and rescue (SAR) controller at the Coast Guard District 17 Rescue

Coordination Center in Juneau, who had also overheard the conversation. At this time, the

Anacapa was about 4 miles from the Columbia. On orders from the SAR controller, the

Anacapa proceeded toward the Columbia and arrived on scene at 1230, whereupon a fourman firefighting team was dispatched in a small boat to board the Columbia. 

At 1257, the Coast Guard team boarded the Columbia and met with the

Columbia’s chief mate. He showed the Coast Guard personnel the location of fire

extinguishers and went with the Coast Guard firefighters to the control room. 

On orders from the Anacapa’s commanding officer, the senior Coast Guard

firefighter evaluated the situation to determine whether it was safe to enter the control

room. He asked the chief mate whether the Columbia’s firefighting team would assist, and

the chief mate responded that the team would remain in the vehicle stowage area to help as

needed. The senior Coast Guard firefighter stated that he assessed the space, opened the

control room’s escape hatch to vent the smoke, and stood by the control room door to

oversee operations while two Coast Guard firefighters entered the control room with CO2

extinguishers. The Coast Guard firefighters donned oxygen breathing apparatuses before

entering the control room.9

A Coast Guard firefighter asked the chief mate whether all electrical power had

been shut off to the control room. The chief mate did not know whether all of the power

had been shut off, but one of the Columbia engineers said that it had. Upon entering the

control room, around 1323, the Coast Guard firefighters noticed that some of the control

console lights were lit, indicating that the space had not been completely electrically

isolated. To remove all possible sources of voltage from control room equipment other

than the main switchboard (power to the main switchboard had already been isolated), the

chief engineer ordered the emergency generator secured about 1358. Two Coast Guard

firefighters then reentered the control room and, with the assistance of the engineers,

removed the switchboard panels while the other two Coast Guard firefighters stood near

the door, providing backup. The Coast Guard firefighters continued to fight the fire until it

was extinguished about 1425.

Because the Columbia’s engineers were not wearing proper protective gear, the

Coast Guard firefighters asked them to stay out of the control room until the fire was

extinguished. The engineers complied, except for briefly entering the area to help the

Coast Guard firefighters remove the switchboard panels. The senior Coast Guard

firefighter said that he could have used more help and would have asked the engineers to

assist if they had been wearing personal protective equipment.

The assistance provided by the Anacapa was only a part of the Coast Guard’s

response to the fire. Shortly after dispatching the Anacapa, the SAR controller notified the

9 Oxygen breathing apparatuses are closed-circuit devices that use a chemical canister to purify

recirculated air.
Factual Information 9 Marine Accident Report

Coast Guard Marine Safety Office (MSO) in Juneau of the situation. Over the next

4 hours, a Coast Guard helicopter made repeated trips to the scene, dropping off two

firefighters from Sitka to provide medical assistance and a response team consisting of an

MSO investigator, an MSO inspector, a State of Alaska fire training specialist, and an

AMHS engineer. The helicopter also transported three passengers to Bartlett Memorial

Hospital. (For more detailed information, see “Medical Findings.”) 

Taku and Tugs. Shortly after the fire began, the Columbia’s master radioed a ferry

that he had seen earlier, the Taku, to stand by for assistance. About 1400, the Taku’s master

positioned his vessel alongside the Columbia’s port side in preparation to take on the

passengers of the disabled ferry. The crews of the two vessels rigged a makeshift gangway

of aluminum staging and 4-foot by 8-foot plywood sheets between the ferries, about 8 feet

above the water. The lifejacket-clad passengers then walked over the gangway from the

Columbia to the Taku while the Taku’s chief mate stood by in a rescue boat in case a

passenger fell into the water. Six crewmembers from the Columbia also transferred to the

Taku to assist with the Columbia’s passengers.

After completing the passenger transfer at 1523, the Taku towed the Columbia

away from Admiralty Island so that the ferry would not be in danger of drifting aground.

About 1630, the tugs Banner and Ardie arrived on scene and took the Columbia in tow.

Shortly thereafter, the Banner began towing the Columbia to Auke Bay Terminal, escorted

by the tug Ardie and the Anacapa. At 1640, the Taku departed the scene with its own

passengers and crew, as well as 434 passengers, 1 stowaway, and 6 crewmembers from the

Columbia, and 2 Coast Guard medical corpsmen from the Anacapa. Early the next

morning, the tug Chahoenta relieved the Ardie and assisted in docking the Columbia. 

AMHS Command Center. An emergency response team was established at the

command center of the Alaskan Department of Transportation building in Juneau. The

AMHS emergency response team consisted of the general manager, a safety officer, and

the vessel operations manager, as well as the port captain, the assistant port captain, and

the senior port engineer. The team conferred with the master throughout the emergency

and participated in decision making, such as determining how to transfer passengers. 

Injuries

Table 1 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 appears under “Medical and

Pathological.”
Factual Information 10 Marine Accident Report

Table 1. Injuries Sustained in the Columbia Accident

Damages

According to the AMHS, the cost of repairing the ship was about $2 million. 

Crew Information

The Columbia’s crew consisted of 63 individuals, each of whom was properly

licensed or certificated by the Coast Guard to serve in his/her position. All of the officers

had completed the International Convention on Standards of Training, Certification, and

Watchkeeping for Seafarers 95 (STCW) basic safety training, which included instruction

on personal survival techniques, fire prevention, firefighting, first aid, personal safety, and

social responsibility. 

Coast Guard Firefighting Requirements for Vessel Crews 

Since 1986, most applicants for an original license10 or for a raise in grade of an

existing U.S. license have been required to complete a firefighting course that has been

approved by the Commandant of the Coast Guard.11 The training must be completed on a

one-time-only basis; no recurrent training is required for the original or upgraded license.

Type of Injurya

a. 49 Code of Federal Regulations 830.2 defines fatal injury as “any injury which results in death within 30 days of the 

accident” and serious injury as “an injury which (1) requires hospitalization for more than 48 hours, commencing within 7 

days from the date the injury was receive; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or 

nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) involves second or 

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

Passengers Crew Total

Fatal 0 0 0

Serious 1b

b. The passenger had chest pains associated with a preexisting condition. His condition might have been aggravated by the 

events surrounding the fire emergency. 

0 1

Minor 0 0 0

None 434 63 497

Total 435c

c. A stowaway onboard was added to the total number of paid passengers. Two of the passengers received medication for 

preexisting illnesses and were released from the hospital.

63 498

10 Master’s license for service on vessels of 200 gross tons or less in ocean service, all master or mate’s

licenses for over 200 gross tons; all licenses for master or mate (pilot), except apprentice mate (steersman),

for towing vessels on oceans; all licenses on mobile offshore drilling units; and all engineers’ licenses.

11 This course must meet both the basic and advanced sections of International Maritime Organization

Resolution A.437(XI) Training of Crews in Fire Fighting.
Factual Information 11 Marine Accident Report

Emergency Training and Drills

The engineers and other licensed officers had taken formal firefighting training.

According to the AMHS, weekly firefighting drills were held for all crewmembers who

had firefighting responsibilities. These drills simulated fires in various locations of the

ship. According to the AMHS, a fire drill in the engineroom had not been held within the

last 2 years before the fire. The AMHS also required that crewmembers read the handbook

“Fire Safety—There’s No Second Chance” and take a 20-question quiz on its contents. 

Because the Columbia was in domestic service, it was not required to comply with

the basic safety standards, including firefighting, contained in the STCW. Even though the

Columbia did not have to comply with these standards, the AMHS decided to apply them

to all of its vessels because it had to apply them to its five vessels that were operated in

international waters. 

Although the AMHS decided, before the fire, to require STCW basic safety

training for all of its vessels, by the time of the fire, the agency had implemented basic

safety training only for licensed crewmembers; it had not had the opportunity to

implement it for its unlicensed crewmembers.

Vessel Information 

The Columbia was one of nine passenger/car ferries owned by the State of Alaska

Department of Transportation and Public Facilities and operated by the AMHS. The ferry

was built in 1974 at Lockheed Shipbuilding, Seattle, Washington, at a cost of $22 million.

The vessel was allowed to carry up to 931 passengers and 134 vehicles during the summer

season (May 15 through October 15). The Columbia usually did not operate during the

rest of the year, when tourism decreased. When the ferry operated during the off-season, it

was limited to 527 passengers. The vessel had 91 staterooms. 

The Columbia’s principal characteristics follow:

Length 418.0 feet

Beam 85.1 feet

Depth 24.0 feet

Draft 17.4 feet (summer)

Gross tons 3,946 

Displacement tons 7,745

Horsepower 12,340

The Columbia was built of all-welded-steel construction, in accordance with the

rules of the American Bureau of Shipping (ABS), a classification society. The ABS had
Factual Information 12 Marine Accident Report

given the Columbia the highest rating for hull and machinery. The vessel had been

maintained in class ever since it was built.

The Columbia also met Federal regulations (46 CFR Parts 70-89) for domestic

passenger vessels. The Coast Guard completed an annual inspection of the Columbia in

May 2000. The inspection included an examination of the hull, machinery, and safety and

lifesaving equipment. The inspection did not include an examination of the main

switchboard, therefore the problems incidental to this accident would not have been

detected. A Coast Guard Certificate of Inspection was issued to the Columbia on May 22,

2000, upon departing the Alaska Ship and Drydock, Ketchikan, Alaska. The certificate of

inspection was issued with no major deficiencies and was valid for 1 year after the date of

issuance. 

The Columbia’s Coast Guard Certificate of Inspection stated that the “route

permitted and condition of operation” is lakes, bays, and sounds—the sheltered waters of

the west coast of North America as defined in 46 CFR 42.03-35, not international waters.

Its operating route included Bellingham, Washington, to Ketchikan, Wrangell, Petersburg,

Juneau, Sitka, Haines, and Skagway, Alaska. As the Columbia was certified for the

domestic coastwise trade, the vessel was exempt from the International Convention for

Safety Of Life At Sea (SOLAS) 1974 and its protocol, the STCW. 

The Columbia had seven decks, four of which were passenger decks containing

cabins, lounges, a children’s play area, and exercise facilities. Two enclosed decks were

used for roll-on/roll-off vehicular stowage. The bridge, with an enclosed pilothouse, was

at the forward end of the vessel on the uppermost deck. 

The Columbia had two 16-cylinder diesel main engines, one for each shaft, driving

a variable pitch propeller. The ship’s three auxiliary generators supplied all electrical

power for the vessel. An emergency generator, located on the cabin deck, supplied backup

electric power for vital loads. 

The main switchboard, located in the control room, consisted of 12 units. (See

figure 5.) The starboard-most unit was identified as unit 12 and consisted of three rows of

circuit breakers. Each row had four circuit breaker locations. Of the 12 locations, only 10

had circuit breakers. Units 8 and 10 of the main switchboard each had two rows of circuit

breaker locations. Units 8 and 10 had 8 circuit breakers installed. Units 9 and 11 were

ventilation spaces and had no circuit breakers. The three main generator circuit breakers

were in units 2, 3, and 4. 

The vessel had two 450-volt alternating current dead front12 switchboards—a main

switchboard and an emergency switchboard. The main switchboard was in the control

room, and the emergency switchboard was in the emergency diesel generator room on the

cabin deck. The location of the equipment on the switchboard was such that all

components requiring monitoring, adjusting, or manual setting could be operated from the

12 A type of electrical construction, usually a switchboard or panel board, where energized parts are not

exposed to a person on the operating side of the equipment.
Factual Information 13 Marine Accident Report

front of the switchboard without opening the hinged panels. All other components were

mounted within the switchboard. The main switchboard contained the devices for the

control and protection of the ship’s three auxiliary generators. The main switchboard and

the emergency switchboard were interconnected with an automatic bus tie circuit breaker.

During normal operation, the emergency switchboard was supplied with electrical power

from the main switchboard through the automatic bus tie circuit breaker, and the

emergency diesel generator was in standby. Upon loss of voltage at the main switchboard,

the automatic bus tie circuit breaker opened, the emergency diesel generator started, and

the emergency diesel generator circuit breaker closed, thus supplying electrical power to

the emergency switchboard. The Federal Pacific Electric Company of New Jersey had

manufactured the main and emergency switchboards, including the breakers installed on

the switchboards. The company is no longer in business.

The fire alarm system consisted of 20 manual pull stations distributed throughout

the vessel and one smoke detector in the paint locker. Each station and detector activated

audible and visual alarms on the supervisory panel in the wheelhouse. Heat detectors were

distributed throughout the ship, covering public spaces, galleys, lockers and storerooms.

The phone system consisted of four independent sound-powered systems;13 the phone

stations were installed in the main operating and crew spaces. The four systems were

designated as 1JV (six stations for vessel maneuvering, including one in the control room

and one on the bridge), 2JV (six stations for senior engineering officers’ quarters and

engineering spaces), 3JV (15 stations for senior officers’ quarters and other spaces), and

4JV (nine stations for the chief steward’s quarters and for public spaces), for a total of 36

stations.

Figure 5. Outline view of main switchboard showing arrangement of units 

3 through 12.

13 A sound-powered telephone system is one in which the operating power is derived from the speech

input only. The four systems on the Columbia were independent in the sense that the stations in one circuit

could not communicate with the stations in another circuit. For example, the stations in the 1JV circuit could

not talk with the stations in the 3JV circuit.

Generator

Breaker

Generator

Breaker

Generator

Breaker

Generator 1 Generator 1 Generator 1

P442

P456

P412

Ventilation Fans Ventilation Fans

Spare

Breakers

Breakers Breakers

Breakers

Breakers

JHU/APL

HBL, III

8/26/00

3 4 5 6 7 8 9 10 11 12
Factual Information 14 Marine Accident Report

AMHS Maintenance Policy

According to the AMHS’s ship operations manual, the engineering department on

each vessel in its fleet was required to develop a maintenance program for its equipment

and to retain maintenance records. While a vessel’s maintenance program was often

discussed with the port engineer and modified according to the engineer’s

recommendations, each vessel’s engineering department was responsible for determining

the nature and timing of its maintenance activities, including those that focused on the

main and emergency switchboards. Maintenance tasks were coordinated with the ABS

and the Coast Guard through periodic inspections and tests of the equipment and systems. 

The manufacturer’s technical manual for the Columbia’s main switchboard

recommends that operators “physically check the tightness of all electrical connections

and parts” and “ascertain that no tools or extraneous materials are adrift” and that

operators do so either annually or during shipyard overhaul, whichever occurred first.

According to the chief engineer, the Columbia’s crew had not done any maintenance or

repair work within the main switchboard or the ship’s auxiliary generators before the

accident. The AMHS management had reduced the size of the vessel crew during the layup period, leaving the chief engineer with limited crew resources to perform such work.

The chief engineer did not know when the main switchboard had last been inspected or

cleaned, but he thought it was in 1995 (there were no machinery history records). He was

also unsure of when the switchboard had last been checked for loose connections. He

added that immediately before the accident, the Columbia had not had any operational

difficulties with the switchboard.

The chief engineer stated that the vessel’s maintenance program included an

infrared thermographic inspection to identify existing or potential problems in electrical

circuitry, such as poor physical contact, overload, or load imbalances. Once a year, a

contractor boarded the vessel and inspected the distribution panels and motor controllers.

A review of the last inspection report showed that the inspection did not cover the main

switchboard or its bus bars.14 On this point, the chief engineer said:

No, they typically don’t do the main switchboard, due to the fact that, when they

do their survey, we’re usually underway and it’s too hard....we open up the panels

down there that are on hinges and that he can get to and can look at, but that’s

mainly just the gauges and stuff; it’s not the main switchboard itself. 

The main switchboard was mounted against the forward bulkhead of the control

room and, consequently, did not have access covers on its rear side. Therefore, infrared

thermographic imaging of the rear side of the bus bars was not possible. Neither Coast

Guard regulations nor ABS rules require that switchboards be accessible from the rear if

they are fully serviceable from the front side.

14 A bus bar is a solid aluminum or copper alloy bar that carries current to the branch or feeder devices

in a power panel board or switchboard. There is at least one bus bar for each phase of the incoming electrical

service. 
Factual Information 15 Marine Accident Report

Prior Shipyard Work on Main Switchboard 

Before the accident, Alaska Ship and Drydock electrical workers had worked on

the main switchboard during the winter lay-up period. The installation of rescue boats

required modifying the main switchboard so it could supply electrical power to the electric

motors and controls on the boat winches. The Coast Guard approved the modifications to

the ship’s electrical drawings,15 and a Coast Guard inspector visually examined the

completed work to ensure the modifications complied with the drawings and found the

work satisfactory. Shipyard electricians entered the main switchboard enclosure16 on three

separate occasions to complete the work. A shipyard electrical foreman supervised the

work done in the switchboard. After the first time that shipyard electricians worked on the

switchboard, the AMHS port engineer overseeing the project looked into the energized

switchboard to verify whether the connections to the new breaker had been properly made.

Following the subsequent two times that electricians worked on the switchboard, no

representatives of the AMHS or crewmembers of the Columbia inspected the work while

it was in progress or when it was completed. 

Waterway Information 

The Columbia’s usual route to Sitka began at the AMHS terminal at Auke Bay,

northwest of Juneau, and proceeded through Stephen’s Passage, Saginaw Channel, and

then south following Chatham Strait to Peril Strait, then through Neva Strait, Olga Strait

and Sitka Sound to the AMHS Sitka terminal. The trip typically took 8 1/2 hours. The

accident occurred less than 3 hours into the trip, when the ship was abeam of North

Passage Point in Chatham Strait. The width of the strait is about 8 nautical miles. 

Meteorology Information

At the time of the accident, the weather was as follows: winds–light airs; seas–1

foot; visibility–0.5 nautical miles in fog and light rain. At 1200 on June 6, the height of the

tide was approximately 0 feet and the tidal current was approximately 1 knot in an eastsoutheast direction at North Passage Point at the entrance to Freshwater Bay. At 1245,

when the Taku arrived on scene, the observed weather was wind from the southeast at less

than 5 knots, calm seas, cloudy skies, and visibility about 10 miles. 

15 Coast Guard letter dated March 13, 2000, Serial: E2-0000682.

16 A constructed case to protect personnel against contact with the enclosed equipment and to protect

the enclosed equipment against environmental conditions.
Factual Information 16 Marine Accident Report

Medical And Pathological

Medical Findings

The Coast Guard transported three passengers to shore in Juneau, where they were

taken to Bartlett Memorial Hospital. One passenger, an 80-year old man, had chest pains

associated with a preexisting illness, was admitted to the hospital on June 6, and released

on June 9. The other two passengers, a 73-year-old woman and a 45-year-old woman, had

left medications on the Columbia that needed to be replaced; the women, however, did not

suffer any injuries as a result of the fire.

Toxicological Testing 

On June 6, while the Columbia was being towed to Juneau, 13 Columbia

crewmembers who were identified as essential personnel were tested for drugs and

alcohol between 1800 and 2000, or within 6 hours of the fire. Table 2 shows the results of

the tests performed on the members of the on-watch control room and the bridge watch.

Table 2. Postaccident Drug and Alcohol Testing Results of Columbia Crewmembers.

POSITION LOCATION/DUTY

ALCOHOL

TESTED

(BREATH)

DRUG

TESTED

(URINE)

RESULTS

(All Tests)

Master Bridge X X Negative

Chief Mate Fire Team Lead X X Negative

Third Mate Bridge Watch X Negative

Pilot Bridge Watch X X Negative

AB Fire Response X Negative

AB Helm X Negative

Chief Purser Pass. Evacuation X Negative

Chief Engineer Fire Response X X Negative

l/A Engineer Fire Response X X Negative

3/A Engineer Fire Response X Negative

3/A Engineer Engine Watch X Negative

Junior Engineer Engine Control Room - Watch X X Negative

Oiler Engine Control Room - Watch X X Negative
Factual Information 17 Marine Accident Report

Wreckage

Damage to the Columbia was limited to the control room. A thin film of soot

covered nearly all the surfaces within the room, and a video monitor used for surveillance

was partially melted, as was a plastic light diffuser on one of the fluorescent light fixtures

above unit 10 of the main switchboard. The main switchboard itself suffered the most

serious and extensive damage. Most of the damage occurred in units 9, 10, 11, and 12 (all

closest to the starboard end of the switchboard). (See figure 6.) Units 1 through 8 did not

exhibit any evidence of electrical arcing and had minimal fire damage other than the

sooting mentioned above. 

Units 9 and 11

Each unit was separated by a void. Each void was designated by a number. The

space between unit 10 and unit 12 was void and was designated unit 11. Similarly, the

space between unit 10 and unit 8 was void and was designated unit 9. The surface of the

framing for unit 11 was heavily damaged. Its paint was blistered to a powdery consistency

in places, and paint around the vent in the unitís cover was burned away. The remaining

paint on the cover of unit 11 was discolored and powdery in consistency. Unit 9 exhibited

less damage, with some burned and soot-covered paint on the framing and the cover, and

limited paint blistering around the vent in the unitís cover.

Figure 6. Units 8, 9, 10, 11, and 12 of the main switchboard. 

The Safety Board investigator is examining unit 12.
Factual Information 18 Marine Accident Report

Unit 12 

The interior side of the unit was covered with soot, heavy at the top and moderate

toward the bottom. (See figure 7.) The top two-thirds of the interior had burned and

blistered paint on the framing and the sides. 

In addition, there was a 9-inch-high by 4-inch-wide spot of localized heating,

where the paint was missing. (See figure 8.) On the exterior right side of the unit, a spot of

localized heating measured 6 inches by 6 inches, and the paint was white and powdery.

The feed and load wires for the entire unit were intact, with only heat damage to the

insulation. The insulation on the wires that went to the lower row of breakers was sooted

and showed no evidence of heat damage. The unitís cover was burned and paint was

missing in places on the interior. The exterior of the cover had no significant damage.

At the top of the unit was an indicator board with 39 lights. Each of the lights was

serviced by 110-volt wires. All of the light bulbs were melted out of the panel. The

insulation on the wires was melted and charred, but the wires were otherwise intact. The

wires showed no evidence of arcing.

Unit 12 was made up of three rows of breakers. The top row had three breakers and

one blank. The left and center breakers were tripped but otherwise intact. The right

breaker was pulled down during the firefighting effort but was otherwise intact. The bus

bars and bus bar supports in the top row were also intact. 

Figure 7. Unit 12. Photograph courtesy of the AMHS.
Factual Information 19 Marine Accident Report

The middle row had four breakers. The bus bar connectors were melted except for

the bottom left stab-loc connector for the far left breaker. The wire insulation for the relay

of that breaker was melted, but the wires were intact and not damaged. The insulated bus

bar supports toward the front of the panel were delaminated, but the ones in the back were

intact. The support was fractured on the right side. The bottom row had a blank in the far

left breaker position. The breakers, bus bars, and supports were intact. 

Investigators found a 3/8-inch diameter by 1 1/4-inch long steel bolt with an

oversized flat washer and a lock washer lying on an angle support bracket on the lower

portion of the unit. Arcing, melting, or spatter marks were present on the bolt and on both

washers, and the bolt and washers appeared to have melted together.

The deck below unit 12 was swept and then vacuumed to collect small pieces of

debris. Among the items found were two pieces of plastic wiring banding material. None

of the collected material exhibited evidence of heat or fire damage. The investigators did

not find any discernable foreign objects in the debris.

Figure 8. Closeup of heat damage to unit 12. 

Photograph courtesy of the U.S. Coast Guard.
Factual Information 20 Marine Accident Report

Unit 10

The top two-thirds of the unit framing was burned and heavily sooted; the paint

was missing. (See figure 9.) The lower third was sooted but otherwise undamaged. The

compartment above the unit was warped. 

At the top of the unit was a light indicator board with 40 lights, each of which was

serviced by 110-volt wires. All of the light bulbs were melted out of the panel. The

insulation on the wires was melted, but the wires were intact. There was no evidence of

arcing on the wires. There was a 34-inch long by 3.5-inch wide hole in the 1/8-inch steel

plate that separated this area from the breaker area of the unit. (See figure 10.) The edges

were smooth. Investigators found no evidence of material drip-down on the components

below. The steel was discolored from tan to gray in some areas and to black in others.

The unit was made up of two rows of breakers. The top row had four breakers.

Four tulip-clip connectors were intactóthree on the left and one fourth from the right. The

rest of the bus bars were melted; both bus bar supports were delaminated in the front, and

the breakers were not intact. (See figure 11.) The wires servicing this row were intact, but

heat had heavily damaged the insulation.17

Figure 9. Unit 10. Photograph courtesy of the U.S. Coast Guard.

17 The bus bar ended in a male tulip connector. It was through these connectors that the circuit breakers

were attached. There were six tulip connectors for every circuit breaker.
Factual Information 21 Marine Accident Report

Figure 10. Closeup of hole in steel plate in unit 10. 

Photograph courtesy of the U.S. Coast Guard.

Figure 11. Damage to bus bars in unit 10.
Factual Information 22 Marine Accident Report

The bottom row had four breakers. The three bus bar connectors on the top were

all melted except for one. All the bottom connectors were intact. The top edge of the bus

bar was melted down to half its width in places. Insulated bus bar supports were

delaminated toward the front of the panel but were intact in the back. The wires servicing

this row had damaged insulation but were otherwise intact.

The deck underneath unit 10 was swept and then vacuumed to collect small pieces

of debris. Several pieces of wiring banding material were found. The investigators did not

find any discernable foreign objects in the debris. 

Survival Factors

Muster/Evacuation

The chief purser was in charge of mustering passengers. The Columbia had three

muster stations—the forward lounge, the snack bar, and the dining room, all located on the

boat deck. The emergency squad was directed to muster at the emergency locker in the

vehicle stowage area, one level above the engineroom, to obtain firefighting equipment. 

The chief steward directed the stewards to search passenger staterooms and put

towels on the doorknobs or at the bottom of the doors to indicate that the staterooms had

been searched. The chief steward then briefed the chief purser on the status of the search.

According to the master, after 1210, he tried to use the public address system on the

bridge; but, to his surprise, it did not work. Because he could not use either the main or the

emergency public address system, he relied on hand-held VHF radio units to communicate

directly with his crew. He used one VHF channel to communicate with the chief mate who

was in charge of fire operations. He used another channel to coordinate the evacuation

efforts, directing the pilot to relay information to and from the chief purser, the chief

steward, and the second steward, all of whom were managing the muster and evacuation

of the passengers. The master stated that using separate channels for radio communication

was a new procedure, and it worked well. Through the use of the VHF units, the master

was also able to send messages through his staff to the passengers. To help ensure that

passengers were kept informed, various crewmembers walked around relaying

instructions in loud voices; no loud hailer or similar equipment was available. The chief

steward said that some passengers complained about not being able to hear and some

passengers were confused about what to do. Other passengers were calm. The muster was

completed at 1222, after which the crew distributed lifejackets to the passengers.

The Columbia’s master coordinated the transfer of passengers and crew with the

Taku’s master, the Anacapa’s captain, the Coast Guard SAR controller, and the AMHS’s

general manager. The master of the Columbia obtained permission on his cellular

telephone from the AMHS’s general manger to bring the Taku alongside his vessel for the

transfer. The master allowed the passengers to go to their staterooms and vehicles to

obtain personal belongings and then instructed them to don their lifejackets and proceed to

the transfer point via the forward stairwell. The passenger transfer began at 1419 and was
Factual Information 23 Marine Accident Report

completed by 1523. Crewmembers were positioned along the stairwell and on the Taku to

assist the passengers. 

Passenger Questionnaires

The Safety Board mailed 327 questionnaires to passengers who, according to

company records, were on board the Columbia at the time of the accident. Eighty-one

passengers responded. Overall, passengers said that the evacuation and transfer to the

Taku went well. Fifty-three passengers stated that they heard the announcement describing

what to do in an emergency. Twenty-four stated that they did not hear the safety

announcement; some commented that they boarded late and did not recall whether such an

announcement was made. The majority of the respondents noticed the placards posted

throughout the vessel providing safety information. 

Fifty-two passengers stated that the vessel’s crewmembers gave directions during

the emergency and were well trained, helpful, professional, easily identified, and

responsive to questions. Forty-two smelled an odor in the dining room and on different

decks that seemed to be electrical in nature (like burning rubber or wires). Passengers

obtained lifejackets from their staterooms, the crewmembers, or the storage bins. Fortythree passengers stated that they had difficulty hearing announcements once the public

address system became inoperable, despite the crew’s efforts to provide information

verbally as they walked through the ship. 

Lifesaving Equipment

The Columbia had enough lifeboats and inflatable rafts to accommodate all of the

people on board, 1,054 adult-size lifejackets, 98 child-size lifejackets, 12 ring buoys, and

an emergency position indicating radio beacon. 

Firefighting Equipment

The Columbia had fire hoses, fire axes, fire pumps, and a wide range of

firefighting apparatus, including fixed extinguishing systems in the main engineroom, the

auxiliary engineroom, the emergency generator room, the paint locker, the cafeteria, the

vehicle stowage area, and the dining salon. More than 60 portable and semiportable fire

extinguishers were located throughout the ferry. According to an AMHS general manager,

at the time of the fire, the vessel carried seven firemen’s outfits, each consisting of pants, a

coat, boots, gloves, a helmet, and an SCBA. 

Firefighting Procedures

According to the Columbia’s muster list, which indicated the assignments for

crewmembers during emergencies, the emergency squad was designated to fight fires on

board the vessel. Shipboard references contained no procedures for fighting an electrical

fire in the control room or how the emergency squad and the engineers should coordinate

their firefighting efforts. 
Factual Information 24 Marine Accident Report

Emergency Procedures

According to the Columbia’s muster list, the master had overall command of the

evacuation. The chief purser was in charge of the upper deck evacuation, the chief steward

was in charge of the boat deck evacuation, and the second steward was in charge of the

cabin deck evacuation. All three of these individuals were responsible for coordinating the

muster and evacuation of passengers and crew and reporting to the master.

Placards that provided safety information on emergency signals and lifejacket

locations were posted throughout the ship and in each stateroom. Signs with arrows posted

throughout the passenger decks identified the most direct routes to the liferafts. After

passengers boarded the Columbia, they were told over the public address system what to

do in an emergency. The briefing covered locating and donning lifejackets, the safety

announcements that would be provided over the public address system, and the emergency

signal for mustering passengers and crew. 

Coast Guard Firefighting Policy 

The Coast Guard’s Marine Safety Manual18 stipulates the actions of the agency in

preventing marine casualties and incidents. Volume VI, Chapter 8, “Coast Guard Fire

Fighting Activities,” states the following, under Policy: 

Although the Coast Guard clearly has an interest in fires involving vessels or

waterfront facilities, local authorities are principally responsible for maintaining

the necessary fire fighting capabilities within U.S. ports and harbors. Additionally,

a vessel/facility’s owner and/or operator is ultimately responsible for the overall

safety of vessels/facilities under their control, including ensuring adequate fire

fighting protection. 

Chapter 8, under Restrictions, states:

Generally, Coast Guard personnel shall not directly engage in fire fighting

activities on other than Coast Guard units except when necessary to save a life or

when possible to avert a significant threat with minimal risk to Coast Guard

personnel. 

In fighting fires on vessels other than its own, the Coast Guard usually limits itself

activities to certain activities, including the following: conducting preliminary

assessments of the incident, evaluating the magnitude of the threat, developing a response

plan, monitoring response actions, contacting the owner, providing assistance as available,

and giving any necessary first aid. 

Passenger and Crew Accountability

Based on the advanced reservations made by passengers and the number of tickets

purchased before the departure from Juneau, the total number of paid passengers on board

the Columbia at the time of the fire was known. To verify that all of the passengers were

18 Commandant Instruction M16000.11.
Factual Information 25 Marine Accident Report

accounted for, an Alaska State trooper who happened to be on board worked with the chief

purser and second mate to account for passengers during the transfer to the Taku. The State

trooper took the names of the passengers as they left the Columbia, and the second mate

had a counter to help confirm the numbers. The number of passengers listed on the

manifest did not match the number of passengers counted during the transfer. The

manifest listed 434 passengers, but the actual count was 435. It was at this point that it

became known that the vessel had a stowaway. The master provided an accurate count of

the transfer to the Coast Guard, 435 passengers and 6 crewmembers. 

Tests And Research

Johns Hopkins University-Applied Physics Laboratory Report

The Safety Board contracted an expert on arcing faults19 in marine switchboards to

assist in the investigation. The contractor was an employee of the Johns Hopkins

University-Applied Physics Laboratory and had been contracted to investigate a number

of U.S. Navy switchboard fires while under contract to the U.S. Navy. 

The contractor, with the assistance of party representatives, thoroughly examined

the switchboard and all of its components. During the investigation a steel bolt was found

in unit 12 that was fused to two washers (mentioned earlier in the section on fire damage).

(See figure 12.)

In his report, dated July 27, 2000, the contractor concluded that the most likely

origin of the fire was in the vicinity of the port steering gear breaker in switchboard unit

12. The report also concluded that the most likely cause of the fire was either a faulty

connection of the switchboard bus bars or the loose bolt found during the examination of

the switchboard. Because of the bolt’s location, its appearance and other factors, the

contractor concluded that that the bolt was probably the initiator of the arcing fault that

spread through the two sections of the switchboard.

19 A high impedance connection, such as an arc through air or across insulation, between two

conductors.
Factual Information 26 Marine Accident Report

Safety Board Materials Laboratory Testing Report

The Safety Board’s Office of Research and Engineering Materials Laboratory

tested the bolt found within the switchboard to determine the nature of the deposits on the

bolt and the manner in which the two washers had bonded to the bolt. In addition,

technicians tested two other bolts as controls. The first control bolt had been removed

from the bus connection to a main switchboard breaker. This bolt was nearly intact and

identical in size and washer arrangement to the loose bolt found in the switchboard. The

second control bolt was similar in design to the bolts from the switchboard. Before testing

the second control bolt, technicians intentionally arced it by placing it across two copper

bus bar conductors and subjecting it to 240 volts direct current. 

During metallurgical tests, the three bolts and their washers were sectioned

longitudinally and polished. The cross-sections were examined using optical microscopy

Figure 12. Bolt found on front (aft side) 

framework of switchboard.
Factual Information 27 Marine Accident Report

and scanning electron microscopy. The cross-sections of the subject bolt and washers were

also examined using energy dispersive x-ray spectroscopy. Technicians determined that

the material creating the bond between the subject bolt and the washer was copper. The

profiles of the bolt and washers at the points of contact were not deformed by melting. In

contrast, the intentionally arced bolt was fused to the washer at the junction between them,

and no copper material was found within the fused area. 

Other Information

Infrared Thermographic Inspection 

Infrared thermographic inspection of electrical equipment can be used to detect

electrical overloads and poor electrical connections. It has gained increasing acceptance as

a valuable tool in the preventive maintenance of electrical equipment and is used by a

number of vessel owners as part of the condition-based preventive maintenance program. 

The Coast Guard has used infrared thermography as part of its Reliability Centered

Maintenance program aboard its newest ice-breaking cutter, the Healy. The use of infrared

thermograpy was discussed in a paper published in the Society of Naval Architects and

Marine Engineers journal Marine Technology.

20 In a 1999 Merchant Note Guidance, the

United Kingdom’s Coast Guard advised ship owners, masters, and ships officers: 

In order to identify potential overheating situations in electrical equipment,

owners are advised to consider the use of thermal-imaging techniques as a means

of verifying the security of electrical connections and pinpoint problem areas at an

early stage.21

Emergency Team Muster Location

The emergency squad muster location was a deck space painted yellow in the

vehicle stowage area; however, during the fire, a car was parked in the space, and the fire

team had to assemble around the car. Since the accident, the space has been designated a

fire lane, and cars are no longer allowed to park there. Similar areas on other AMHS

vessels have also been designated as fire lanes.

Public Address System

As a result of the accident, the AMHS purchased portable battery-powered public

address systems for all of its vessels as backups for the installed public address systems. 

20 US Coast Guard, C Healy (WAGB 20), “A Case Study for Implementing Reliability Centered

Maintenance.” Marine Technology, Vol. 37, No. 1, January 2000, pp. 50-56. 

21 Maritime and Coast Guard Agency Merchant Guidance Note 132 (M+F), December 1999. 
Factual Information 28 Marine Accident Report

Survey of Equipment 

At the Safety Board’s request, the Columbia’s engineering staff made a survey of

all motor controllers and voltage transformers. The crewmembers found no problems that

could be related to the switchboard fire.

Equipment Repair and Upgrading of Columbia Systems

The damage to the main switchboard was such that the vessel could not be

operated without extensive and lengthy repairs. The owner removed the vessel from

service. During the lay-up period, repairs to the switchboard and modifications to other

systems were made by a shipyard facility in Ketchikan. The vessel returned to service in

July 2001. Work performed during the shipyard repair period included the following:

• Replacing the switchboard, including repairing or replacing load cables within

the switchboard;

• Installing a new dial phone system (existing sound-powered system is to

remain on board);

• Replacing the public address system (According to an AMHS letter, as part of

the already scheduled $l0 million+ Federally funded modernization project, the

ship is getting an entirely new state-of-the-art, SOLAS-conforming public

address and telephone system); and

• Inspecting the electrical system.

In June 2000, the AMHS issued Engineering Policy 034, which reads, in part:

Due to the recent switchboard fire onboard the Columbia, all vessels are directed

to include switchboard maintenance in their maintenance planning systems....As

a fleet policy, cleaning and tightening fastenings of main and emergency

switchboard should be done during the overhaul period at least every other year.

On alternate years, all the electrical distribution boards should be maintained by

cleaning and tightening fastenings. This maintenance work will normally be done

by the crew.

In an April 5, 2001, letter to the Safety Board, the AMHS stated that it is installing

a computer maintenance planning system, which will present the maintenance planning

tasks in a uniform method throughout the fleet. With this program, the AMHS will have

the ability to monitor the maintenance efforts of the engineering department on board all

ships. As of the date of this report, the system has not been implemented and the AMHS

could not provide an accurate timetable for implementation. 
29 Marine Accident Report

Analysis

General

This analysis first identifies factors that can be readily eliminated as causal or

contributory to the fire and determines how the fire started. The report then discusses the

following major safety issues, which were identified during the investigation:

• Adequacy of inspection and maintenance procedures for electrical systems; 

• Adequacy of management safety oversight of maintenance procedures; and

• Adequacy of firefighting procedures.

Exclusions

The weather was mild and the seas were calm throughout the fire emergency and

did not affect the emergency response. The officers and crew were properly licensed and

certified by the Coast Guard and were fully qualified to serve in their respective positions.

Postaccident drug and alcohol screening was done in a timely manner, given the

circumstances, and the results were uniformly negative. Consequently, the Safety Board

concludes that the conditions of the weather and the sea, the qualifications of the officers

and crewmembers, and the use of drugs or alcohol were not factors in this accident. 

Cause and Origin of Fire

In its investigation of the accident, the Safety Board considered whether a fault in

one of the three areas of the electrical system (the load section, the distribution section,

and the generation section) could have caused the fire. Because the damage to the

switchboard was extensive, it is possible that important evidence might have been

consumed or altered as a result of the fire or the firefighting efforts. Nevertheless, the

Safety Board’s investigation of the electrical system provided important information that

the Board used to assess the probable cause of the fire. The investigation considered five

scenarios that focused on the main switchboard and its protective devices, the auxiliary

generators and their controls, and the electrical system equipment powered by the main

switchboard. The hypothetical situations or conditions presented in the first three

scenarios probably did not cause the fire; these situations are, therefore, discounted. The

conditions in the last two scenarios are the most likely causes of the fire.
Analysis 30 Marine Accident Report

System Load Components

According to the first scenario, a malfunction occurred in one of the system load

components. Such electrical system components include voltage transformers, motors or

their controllers, and interconnecting wiring. A malfunction, such as a short circuit, in a

connected component might have caused an increase in current flow that, in turn, might

have resulted in temperatures high enough to damage the copper conductors or their

insulation. An arc fault could have then developed and spread throughout the two

switchboard units that were damaged in the fire. 

The physical evidence does not support this scenario. After the accident, an

examination of all motor controllers and transformers did not find any abnormal

conditions that were related to the fire. Had there been a fault, evidence of its occurrence

would have been visible. Such evidence could include visibly burned or melted insulation

on wires, burned contacts in motor controllers, or damaged windings in electric motors. In

addition, an excessively high current in any of the load cables connected to the output side

of the breakers in the main switchboard would have discolored the copper conductors in

the affected cable. An inspection of those cables revealed no discoloration. The Safety

Board concludes that the fire was probably not caused by a fault in an electrical system

component that was powered by the main switchboard. 

Failure of Main Switchboard Breakers

According to the second scenario, a failure occurred in one of the main

switchboard’s breakers. For example, a breakdown in the electrical insulation between the

electrical phases of the breaker might have initiated an arcing fault that could have spread

to other areas of the switchboard bus bars. The physical evidence collected does not

support this scenario. According to the vessel’s chief engineer, most of the breakers had

been installed at the time of the vessel’s construction (1974) and had been largely trouble

free. He stated that the breakers had been inspected periodically; however, the vessel

operator did not maintain complete records of the work performed on the main

switchboard breakers. The Safety Board, therefore, has no way of verifying the accuracy

of the chief engineer’s statement. Furthermore, because the manufacturer of the

switchboard and the breakers is no longer in business, the Safety Board could not obtain

the manufacturer’s information on product reliability. Nevertheless, an inspection of the

exterior and interior of all of the breakers in the main switchboard did not reveal any

evidence of electrical arcing. The Safety Board concludes that the fire was probably not

caused by a breaker fault. 

Abnormal Condition in Electrical Generation System

According to the third scenario, an abnormal condition in the electrical system on

the main switchboard’s input side resulted in extremely high voltage or current. This could

be caused, for example, by a malfunction of a generator or one of its control devices—the

governor (speed controller), a load sharing device, or the voltage regulator. At the time of

the accident, two generators were operating in parallel. If the voltage regulator on one of

the generators malfunctioned, the generator might have become unstable or have reached

an abnormal level of excitation, possibly resulting in an abnormally high voltage output
Analysis 31 Marine Accident Report

from the generator or, if the compensation circuit was inoperative, an abnormal reactive

current flow (cross currents) between the two generators. The development of high cross

currents, however, would have required the simultaneous failure of at least two control

devices (the voltage regulator or the governor and the compensation circuit), which is

unlikely. In addition, because one of the generators became unstable first and the second

generator became unstable only after the first was shutdown, an abnormal condition in the

voltage regulators or governors probably was not responsible. If the voltage regulator or

the governor controlling one of the generators had failed, the corresponding control device

on the other generator would have acted in the opposite direction to maintain system

voltage or frequency at a set point. Moreover, because a fuse protected the voltage

regulator’s current output to the exciter, only a limited level of excitation could occur.

Consequently, the generator probably could not have developed the extremely high

voltage needed to cause a current to arc through the air between adjacent phases (a spark

jumping the gap).22 Even without a fuse, a transient voltage spike of sufficient magnitude

to create an arc that could jump the gap probably could not have been created. The

generator’s maximum output level was only slightly above 450 volts, and an output level

in excess of 10,000 volts would be required to create an arc that could jump the gap. 

Finally, if a high voltage condition had developed in the electrical system on the

input side of the switchboard, electrical equipment breakdowns would have occurred in

vessel areas away from the main switchboard. However, a postfire examination of the

Columbia’s electrical equipment found no such breakdowns. The damage was limited to

the main switchboard. The Safety Board concludes that the fire was probably not caused

by an abnormal condition on the input side of the electrical system. 

Electrical Connection in Switchboard

According to the fourth scenario, a faulty electrical connection within the main

switchboard initiated an arc fault that grew and spread throughout two units of the main

switchboard. Such a faulty connection could have resulted from a loose or corroded joint

within the bus bars or circuit breaker tulip clips. A faulty electrical connection might have

generated a high level of resistance that would have impeded current flow, causing the

temperature to rise to the conductor’s melting point. As the conductor melts, physical

separation occurs within the conductor of one phase. At the moment of separation, an arc

will develop, in a manner similar to the arc that occurs when a switch is opened while

current is flowing in a circuit. If current flow is high enough, a plasma cloud23 that

develops as a result of the arc can expand to create a conductive path to an adjacent

conductor of a different phase. The arc then becomes a phase-to-phase high impedance

short circuit because the conductive path between the two phases is the plasma cloud,

which has significant resistance. As the plasma cloud expands further, it can envelop other

adjacent conductors, which can then become involved in the event. 

22 This voltage level, known as the dielectric breakdown strength of air, is empirically known and can

be theoretically calculated using Paschen’s Law. 

23 A plasma cloud is a collection of ionized atoms exhibiting some properties of a gas but differing from

a gas in being a good conductor of electricity and in being affected by a magnetic field. A plasma cloud is

the conductive medium through which an arc’s electron flow occurs.
Analysis 32 Marine Accident Report

During postaccident examination, Safety Board investigators did not find any

loose or faulty connections within the switchboard. However, an electrical arc, such as the

type described above, probably would have destroyed the conductors in a faulty

connection. The examination revealed that the connections in the Columbia’s switchboard

were badly melted, precluding Safety Board investigators from identifying whether faulty

connections existed before the fire. Despite the lack of conclusive evidence, the Safety

Board is of the opinion that a faulty connection or connections likely caused the fire for

several reasons. 

That mechanical vibrations and thermal cycling gradually loosen electrical

connections is well known. However, investigators found no evidence that the integrity of

the switchboard’s electrical connections had been inspected during the last 5 years, despite

the switchboard manufacturer’s recommendation that an inspection be done, at a

minimum, every year or during vessel overhauls. In addition, although vessel

crewmembers had used an infrared thermographic inspection program to detect faulty

electrical connections, they had never used the program to inspect the switchboard’s

internal electrical connections. Therefore, a faulty connection within the switchboard

could have developed and remained undetected for a considerable period of time.

Before the accident, during a shipyard overhaul, the Columbia’s main switchboard

was modified to support the installation of new rescue boats. The work required that

shipyard workers open the switchboard to add electrical connections and, in the process,

disturb the connections that were already in place. The AMHS representative did not

supervise this work or inspect it upon its completion. In addition, the ship’s crew did not

check the integrity of the electrical connections, either manually or thermographically.

The modification work, therefore, could have created a faulty connection that would not

have been detected by the owner’s representative or the vessel’s crew. The Safety Board,

therefore, concludes that the fire might have been caused by a faulty connection within the

main switchboard that initiated an arc fault, which spread within the two switchboard units

and damaged them. 

Conductive Object

According to the fifth scenario, a conducting object caused a short circuit

connection between two phases in the distribution section of the electrical system. Any

conductive object, such as a metal tool or a bolt, as well as a conductive liquid, such as

seawater, could have created a conductive path. The arc would have grown and spread in

the same way as the arc described in the fourth scenario. 

The Safety Board materials laboratory performed metallurgical testing on the bolt

found in unit 12 to evaluate whether it might have caused the arcing fault that swept

through the switchboard. Of particular interest was how the washers were bonded to the

bolt. If electrical current had passed through the bolt and washers, the high temperature

would have fused them, much like welding, resulting in a layer of porous, molten steel

between the component pieces. However, the metallurgical examination revealed that a

layer of copper bonded the bolt and washers. The molten copper probably was deposited

on the junction between the bolt and washer after the arc fault began and could have
Analysis 33 Marine Accident Report

dripped down onto the bolt and washers from a unit that was higher in the switchboard.

Safety Board technicians compared a bolt that they had intentionally arced to the bolt

found in the switchboard. Although some external features of the two bolts appeared

similar, the cross sections of the bolts differed. 

For the bolt found in the switchboard, the copper that accumulated in the threads

and between the washers and the bolt had little porosity and appeared to be consistent with

molten flow. The edges of the washer and the threads were intact where the copper had

accumulated. In contrast, the beaded areas in the intentionally arced bolt were porous and

composed of molten steel. Also, the edges of the washer and the bolt’s thread peaks were

missing in locations where the molton material had accumulated, and there was an area of

contact between the washer and the bolt. Because the damage to the subject bolt and

washers was consistent with exposure to molten material, primarily copper, and did not

appear consistent with arc damage, the Safety Board concludes that the bolt found in the

switchboard was probably not the cause of the fire. 

Whether or not this particular bolt caused the fire does not eliminate the possibility

that the fire might have been caused by a conductive object falling on the bus bars.

Electricians possibly inadvertently left a metallic object inside the switchboard during the

last shipyard overhaul. Such a mistake would not have been detected because the owner’s

representative did not inspect the electricians’ work. It is also possible that a conductive

object had been left in the switchboard during some previous work period and remained

undetected. Despite the fact that the investigation did not discover any conductive objects

in the switchboard that could be definitely identified as causing a short circuit, this

scenario cannot be ruled out because the conductive object might have been destroyed or

altered beyond recognition as a result of the arcing and/or fire. The Safety Board,

therefore, concludes that the fire might have been caused by a conductive object falling

onto the switchboard bus bars. 

Inspection and Maintenance Procedures For Electrical Systems

Preventive Maintenance Plan 

Several preventive measures can be taken to discover or prevent faulty

connections before they result in a fire. For example, faulty electrical connections in a

switchboard often can be located and tightened during periodic maintenance inspections.

A valuable addition to these inspections is the use of infrared thermographic imaging

equipment that can uncover faulty connections that might not be visible to the naked eye.

The Columbia’s main switchboard had not been inspected either manually or

thermographically during the past 5 years. The chief engineer recognized the importance

of inspecting and maintaining the switchboard, and placed the tasks on his annual winter

lay-up worklist. Such tasks, however, were not given high priority and, therefore, were not

completed. According to the chief engineer’s best recollection, the last switchboard

inspection had been performed in 1995, but he was not certain whether it was done even

then. 
Analysis 34 Marine Accident Report

Infrared thermographic inspection of electrical equipment is recognized as an

important tool in locating improper connections and preventing switchboard fires. Infrared

imaging of the Columbia’s switchboard could not be readily performed because its design

arrangement prevented a full view of the electrical connections in the switchboard. Full

views of the internal connections possibly could be obtained by installing access panels on

the rear side of the switchboard. The Safety Board concludes that the use of suitably

located access panels on the Columbia’s switchboards would facilitate infrared

thermographic inspections and, therefore, help detect faulty electrical connections. 

After the accident, the AMHS issued an engineering policy letter directing the

crews of all vessels in its fleet to clean and tighten the electrical connections in the main

and emergency switchboards not less than every other year. The switchboard

manufacturer had recommended that such cleaning and tightening be performed, at a

minimum, every year or during vessel overhauls. The Safety Board recognizes that the

manufacturer’s recommended inspection interval might be based on operating time and

that the Columbia typically operates about 6 months a year. This means that it would take

the ferry 2 calendar years to attain 1 year of operating time. 

During half of the year, however, the Columbia is taken out of service, which

affords the AMHS ample time and opportunity to perform switchboard maintenance. The

Safety Board, therefore, considers an annual examination consistent not only with the

manufacturer’s recommended inspection interval but also the ferry’s operation. 

In spite of the manufacturer’s recommending an annual inspection, the AMHS had

not cleaned or tightened the switchboard connections during the 5 years before this

accident. Had the switchboard had faulty connections, they would have remained

undetected until they became apparent through an equipment malfunction or fire. Thus, it

is apparent that thorough and timely inspection of electrical switchboards is necessary for

continued safe operations. The Safety Board concludes that had the main switchboard

been subjected to thorough and timely inspections as part of an effective preventive

maintenance program, any faulty connections or conductive objects would have likely

been identified and corrected, and the fire might have been avoided. Therefore, the Safety

Board believes that the AMHS should develop an annual switchboard inspection program

that includes a thorough infrared thermographic inspection and physical examination of

components. In addition, the AMHS is in the process of implementing a computer-based

maintenance program that could address the problem of loose connections in the

switchboards. In the Safety Board’s opinion, the maintenance of switchboards should be

included in this computer-based program. The Safety Board, therefore, believes that the

AMHS should include an annual switchboard inspection program in its computer-based

maintenance planning system. 

Quality Assurance Program 

Quality assurance is the planned and systematic pattern of actions, including

inspections, performed by the vessel owner to determine whether a contractor has fulfilled

contract obligations pertaining to the quality and quantity of work.24 The AMHS included

general quality assurance requirements in its agreements with contractors; the agency
Analysis 35 Marine Accident Report

clarified the nature of the general requirements through individual specifications

associated with each work item. Because the main switchboard is the central point for

receiving and distributing all electrical power throughout a vessel, it is critical to the

vessel’s operation. Therefore, any contract work on the switchboard should be subjected

to quality assurance inspections. However, for unknown reasons, the AMHS did not

include switchboard inspections in its contract with the shipyard. The AMHS had not

required the shipyard to present the switchboard for inspection or required the vessel’s

crew or the agency’s port engineering staff to inspect the work before the switchboard was

returned to service. The shipyard’s electrical foreman stated that he inspected his

subordinates’ work upon completion; however, he did not do so at the direction of the

AMHS. The Safety Board concludes that a thorough inspection of the interior of the

switchboard by the AMHS and the port engineering staff before it was returned to service

might have detected the presence of faulty connections and/or foreign objects and led to

their correction and/or removal. Consequently, the Safety Board believes that the AMHS

should revise its procedures for accepting completed shipboard maintenance and repair

performed by outside contractors to verify that the work has been done properly. 

Firefighting Procedures

Actions of the Columbia’s Crew

Upon discovering the fire, the on-scene engineers rapidly accounted for

crewmembers in the engineroom and notified the master. They also obtained, staged, and

used the CO2 extinguishers, secured the ventilation, and isolated the smoke and fire by

closing the control room’s fire screen door. The Safety Board concludes that the initial

response to the fire by the shipboard engineers was appropriate. However appropriate the

engineers’ initial actions were in this accident, the Safety Board is concerned that the

crew’s subsequent actions were somewhat haphazard and improvised as they went along.

The crew’s actions did not reflect the type of performance that would be expected from

properly planning, training, and drilling for a fire in the control room. 

The emergency response organizational structure for the Columbia was provided

in the crew muster list, which showed each crewmember by position and identified his/her

station and duty assignment during a fire or other emergency. Generally speaking, a

muster list summarizes a crewmember’s duties and responsibilities in one line of text and

is designed to provide officers and other crewmembers with a quick guide to the

emergency duty assignments. A muster list does not go into any depth on individual roles

and responsibilities or give details about policies, procedures, and plans for responding to

shipboard fires. A prefire plan, on the other hand, provides such vital information;

however, prefire plans are not required by regulation, and not all vessels have developed

such plans. The Columbia had a prefire plan, but it was not comprehensive. The

Columbia’s fire plan merely provided a brief description of the vessel’s firefighting

resources and listed the locations of access doors and fire stations. The plan did not

24 Adapted from the quality assurance definition at 48 CFR 46.101, “Federal Acquisition Regulations.” 
Analysis 36 Marine Accident Report

describe the vessel’s firefighting organization or specify the crewmembers’ firefighting

roles and responsibilities. Moreover, the plan did not describe in detail how to fight fires in

specific parts of the vessel. 

A properly developed comprehensive prefire plan describes various fire scenarios

in different spaces on the ship and how to fight the fire in each situation. The plan fully

describes the roles and responsibilities of the emergency responders and establishes the

chain of command for firefighting operations. Responsibility for strategic and tactical

command is made clear and unambiguous for all foreseeable situations, including fires on

the decks and in the engineroom. If necessary, separate and distinct organizations are

created to respond to fires on deck and fires in the engineroom. In addition, the prefire

plan contains checklists for emergency actions, procedures for shutting down the electrical

power and closing the ventilation to the various ship areas, as well as instructions for

establishing fire boundaries and for maintaining watertight integrity. With a prefire plan,

predetermined actions for responding to a fire in a given space or compartment are

developed in a nonurgent atmosphere, where one is more likely to exercise good

judgment. Then, if a fire develops, the officers in charge can refer to the plan and take

appropriate action. However, as noted by one authority,25 “The most comprehensive and

well-designed prefire plans are of little value if they are not used for training and they are

even less valuable if they are not used when a fire actually occurs.”

The Columbia’s muster list designated the master as the person in charge from the

bridge and the chief mate as the person in charge of the emergency squad on scene, but the

list did not elaborate on their respective duties and responsibilities. The list indicated that

the emergency squad consisted of unlicensed deck crewmembers on two hose teams and

other unlicensed personnel providing backup and support. The list did not indicate that a

separate emergency squad was to respond to engineroom fires or that engineroom

personnel were assigned to hose teams. Further, the Columbia had not held a training drill

featuring a response to an engineroom fire during the 2 years before the fire.

The muster list designated the chief engineer to be “in charge” of the engineroom

and to supervise the release of the CO2 system protecting the engineroom should such

release be necessary. However, his role in responding to an engineroom fire was not

spelled out in any detail. The other engineering officers were variously designated to tend

bilge and fire pumps, operate sprinkler systems, and shut down ventilation systems, but

were not listed as having any specific firefighting responsibility. The off-watch third

assistant engineer and the off-watch junior engineer were the only engineering officers

detailed to work with the emergency squad, and their roles were limited to bringing tools

to the emergency locker. 

According to the muster list, the emergency squad, under the command of the chief

mate, should have fought the Columbia’s fire. However, the emergency squad was made

up mainly of deck department personnel who were unfamiliar with the engineroom and

who had never participated in a fire training drill in the control room. The lack of lighting

25 Marine Fire Fighting, First Edition, International Fire Service Training Association, Copyright 2000

by the Board of Regents, Oklahoma State University, pp 261.
Analysis 37 Marine Accident Report

and the presence of large quantities of black smoke, which reduced visibility in the control

room to nearly zero, complicated their firefighting efforts. The engineers, on the other

hand, were very familiar with the layout of the control room. They, logically, should have

assumed the lead in fighting this fire. However, the lack of a comprehensive prefire plan

detailing firefighting roles and responsibilities, coupled with the lack of a squad trained to

fight engineroom fires, reduced the crew’s capability to fight the fire effectively. 

In response to the fire, the chief engineer sent the day third engineer without a

lifeline into the control room to open the bus tie circuit breaker between the main

switchboard and the emergency switchboard. Upon encountering difficult conditions, the

day third engineer backed out in order to get a lifeline. He and the first assistant engineer

then entered the control room to open the circuit breaker between the main and emergency

switchboards and the circuit breakers between the ship’s auxiliary generators and the main

switchboard. Both men wore SCBAs borrowed from the emergency squad, but neither

wore protective clothing. In the Safety Board’s opinion, sending crewmembers who were

not properly clothed in protective gear into an active fire scene needlessly exposed them to

serious injury and demonstrated poor decisionmaking on the part of the chief engineer. 

The first assistant engineer opened two circuit breakers by hitting them with his

flashlight, which was an imprudent action. Considering the electrical arcing activity and

the fire in the switchboard, the poor visibility within the control room, and his choice of

tool for the job, only happenstance prevented his being seriously injured. In the Safety

Board’s opinion, the actions of the first assistant engineer indicated a lack of proper

training in fighting a switchboard fire. 

After the first assistant opened a third circuit breaker, he and the day third engineer

backed out of the control room, and the chief engineer decided to manually shut down the

No. 1 auxiliary generator, which was still powering the switchboard. In the Safety Board’s

view, manually shutting down the generator to remove electrical input to the switchboard

was the course of action that should have been taken in the first place. Manually shutting

down the generator is much safer than sending a person into a dark, smoke-filled room to

open a bus tie circuit breaker. 

Once the engineers had notified the bridge of the fire and the general alarm had

been sounded, a firefighting team that was trained in the techniques of combating an

electrical fire should have led the response to the fire in the control room. Such a team

probably would have extinguished the fire more quickly and with minimum risk. This

accident demonstrates that, because engineers have the specialized knowledge and

expertise needed to effectively fight engineroom fires, they should be an integral part of a

vessel’s firefighting team. 

In the Safety Board’s opinion, if the Columbia had had a comprehensive prefire

plan that included procedures for fighting a control room fire and if the crewmembers had

been properly trained and drilled in the execution of the plan, they would have known

exactly what to do from the outset. If the firefighting roles and responsibilities of the

various crewmembers had been predetermined and drilled, the main switchboard would

have been electrically isolated quickly and completely, and the engineers would not have
Analysis 38 Marine Accident Report

been sent into the control room without proper gear. The danger to firefighters would,

thereby, have been diminished; and the fire might well have been extinguished sooner.

The Safety Board concludes that the ability of the Columbia’s crew to respond to the fire

was less than adequate for the following reasons: the AMHS had not developed a

comprehensive prefire plan that included procedures for fighting engineroom fires, and

the AMHS, during the past 2 years, had not required that crewmembers train and drill for

an engineroom fire. Therefore, the Safety Board believes that the AMHS should develop

comprehensive prefire plans for the vessels in its fleet that include procedures for fighting

an engineroom fire and require the ships’ crews to be thoroughly drilled in using the plans.

Coast Guard Actions 

One of the primary reasons why the Columbia’s crewmembers were required to

complete firefighting training and drills was so that they could control and extinguish an

onboard fire in the absence of outside help. This ability is critical to all passenger ship

crews because, when underway, such vessels might be too far from shore or other vessels

to receive outside firefighting assistance. 

The Coast Guard cutter Anacapa just happened to be in the area and its crew not

only rendered assistance, but also extinguished the reflash of the fire. 

The Coast Guard firefighters were well organized and well prepared. They were

properly equipped with protective clothing and oxygen breathing apparatuses.

Furthermore, they assessed the fire before entering the control room, planned how they

would approach the fire, rotated fire teams to reduce each individual’s exposure and

fatigue, and maintained two firefighters at the control room door to monitor the safety of

those inside. Because the engineers were not properly outfitted with protective clothing

and gear, the Coast Guard firefighters did not allow them to remain in the control room.

The Safety Board concludes that the Coast Guard’s actions in responding to the fire were

timely and effective. 

Firefighters’ Staging Area

When firefighters assembled on the car deck, one deck above the engineroom, a

car was parked in their staging area. Before this accident, the AMHS had not designated

the space as a fire lane and had no policy precluding cars from parking in the space. After

the accident, the AMHS designated the area as a fire lane and established a policy

prohibiting cars from parking in the space. According to an AMHS representative, the

problem of allowing cars to park in the emergency squad staging area existed on other

AMHS vessels, but has since been rectified in the same manner. The Safety Board

concludes that the actions taken by the AMHS after the fire to ensure that emergency

squad muster areas were kept clear for use in an emergency were appropriate. 

Means of Communication in Engineroom 

When fire and smoke forced the oiler and junior engineer to evacuate the control

room, they were unable to alert the bridge immediately because the only telephone in the

engineroom was in the control room and no manual fire alarms were in the engineroom.
Analysis 39 Marine Accident Report

Fortunately, the oiler and the junior engineer were able to escape from the engineroom.

Subsequently, the day third engineer was able to call the bridge from the car deck. In the

Safety Board’s opinion, having a single telephone with which to communicate from the

engineroom to the bridge is inadequate to ensure communications during an emergency.

Even though the telephone system on board the Columbia has since been upgraded, the

main engineroom still has no means of communication outside of the control room. The

Safety Board concludes that the means of contacting the bridge from the engineroom was

less than adequate once the telephone in the control room became inaccessible. The Safety

Board believes that the AMHS should install a means of alerting the bridge of an

emergency from the Columbia’s engineroom in case the telephone in the control room is

inaccessible. 

Passenger and Crew Muster

Because the passengers were given a safety briefing after boarding the Columbia,

they knew how to locate and don their lifejackets and how to report to their muster stations

if the general alarm was sounded. Passengers were also provided with safety information

on placards posted throughout the ship. The muster of passengers and crewmembers was

performed in accordance with emergency procedures. Because the passengers were well

briefed on the procedures, muster leaders were able to assemble the passengers in an

orderly fashion. The master was in command of mustering operations, and the chief purser

accounted for passengers and crewmembers in accordance with her responsibilities as

indicated on the muster list. The chief steward carried out his duties by ensuring that the

cabin stewards searched cabins. Because a separate radio frequency was used to muster

the passengers and the crew, the master was able to relay information through the pilot to

the chief purser and chief steward without interfering with firefighting operations. The

Safety Board concludes that the passenger and crew muster was well coordinated.

Passenger and Crew Communication 

The public address system became inoperable after the Columbia lost power,

forcing crewmembers to provide information to the passengers by walking through the

muster stations and speaking loudly. The crewmembers did not use any portable

equipment to amplify their voices. In postaccident surveys, 43 passengers stated that they

had had difficulty hearing the crewmembers’ announcements. Following this accident, the

AMHS supplied all its vessels with portable battery-powered public address systems as

backup for the main address system. 

Before the Columbia’s fire, the AMHS had scheduled the replacement of the older

public address systems in its fleet as part of its SOLAS 2000 upgrade. After the accident,

the older public address system on the Columbia was removed and replaced with a new

system. The Safety Board is satisfied that this action will probably eliminate future public

address problems during shipboard emergencies. 
Analysis 40 Marine Accident Report

Emergency Response

An emergency response team led by the AMHS general manager assisted the

Columbia’s master, the Taku’s master, and the Coast Guard’s SAR controller in

developing a method of safely conducting and coordinating the transfer of passengers and

crew from the Columbia to the Taku. The Columbia’s crewmembers constructed a ramp

between the ships. Both sides of the ramp had safety lines, and passengers and

crewmembers were required to don lifejackets before walking over the ramp.

Crewmembers assisted passengers during the transfer. As an added safety precaution, the

Taku’s chief mate stationed himself in a small boat beneath the ramp to be in a position to

help if anyone fell into the water. The procedures worked well, as evidenced by the fact

that all passengers and crewmembers were transferred quickly and without injury. The

Safety Board concludes that the transfer of passengers between the Columbia and the Taku

was executed in a timely and effective manner and was well coordinated with shoreside

management.
41 Marine Accident Report

Conclusions

Findings

1. The conditions of the weather and the sea, the qualifications of the officers and

the crewmembers, and the use of drugs or alcohol were not factors in this

accident.

2. The fire was probably not caused by a fault in an electrical system component

that was powered by the main switchboard.

3. The fire was probably not caused by a breaker fault.

4. The fire was probably not caused by an abnormal condition on the input side of

the electrical system.

5. The fire might have been caused by a faulty connection within the main

switchboard that initiated an arc fault, which spread within the two

switchboard units and damaged them.

6. The bolt found in the switchboard was probably not the cause of the fire.

7. The fire might have been caused by a conductive object falling onto the

switchboard bus bars.

8. The use of suitably located access panels on the Columbia’s switchboards

would facilitate infrared thermographic inspections and, therefore, help detect

faulty electrical connections.

9. Had the main switchboard been subjected to thorough and timely inspections

as part of an effective preventive maintenance program, any faulty connections

or conductive objects would have likely been identified and corrected, and the

fire might have been avoided.

10. A thorough inspection by the Alaska Marine Highway System and the port

engineering staff of the interior of the switchboard before it was returned to

service might have detected the presence of faulty connections and/or foreign

objects and led to their correction and/or removal.

11. The initial response to the fire by the shipboard engineers was appropriate.

12. The ability of the Columbia’s crew to respond to the fire was less than

adequate for the following reasons: the Alaska Marine Highway System

(AMHS) had not developed a comprehensive prefire plan that included

procedures for fighting engineroom fires, and the AMHS, during the past 2

years, had not required that crewmembers train and drill for an engineroom

fire. 

13. The Coast Guard’s actions in responding to the fire were timely and effective.
Conclusions 42 Marine Accident Report

14. The actions taken by the Alaska Marine Highway System after the fire to

ensure that emergency squad muster areas were kept clear for use in an

emergency were appropriate.

15. The means of contacting the bridge from the engineroom was less than

adequate once the telephone in the control room became inaccessible.

16. The passenger and crew muster was well coordinated.

17. The transfer of passengers between the Columbia and the Taku was executed in

a timely and effective manner and was well coordinated with shoreside

management.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the fire on the Columbia was the absence of an effective maintenance and inspection

program for the electrical switchboards, resulting in a switchboard fire by arcing, most

likely due to a faulty connection or a conductive object.
43 Marine Accident Report

Recommendations

As a result of its investigation of this accident, the National Transportation Safety

Board makes the following recommendations: 

To the Alaska Marine Highway System:

Develop an annual switchboard inspection program that includes a

thorough infrared thermographic inspection and physical examination of

components. (M-01-19)

Include an annual switchboard inspection program in your computer-based

maintenance planning system. (M-01-20)

Revise your procedures for accepting completed shipboard maintenance

and repair work performed by outside contractors to verify that work has

been done properly. (M-01-21)

Develop comprehensive prefire plans for the vessels in your fleet that

include procedures for fighting an engineroom fire and require the ships’

crews to be thoroughly drilled in using the plans. (M-01-22)

Install a means of alerting the bridge of an emergency from the Columbia’s

engineroom in case the telephone in the control room is inaccessible.

(M-01-23)

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: September 18, 2001

45 Marine Accident Report

Appendix A

Investigation 

The National Transportation Safety Board was notified of this accident at 1245 on

June 7, 2000, and launched a 9-person team that arrived in Juneau, Alaska, at 0700 on

June 8. The investigative team consisted of an investigator-in-charge, an operational

specialist, a marine engineer, a fire science specialist, a human performance specialist, a

survival factors specialist, and a family affairs specialist. Also present were a public

affairs specialist and an observer from the Office of General Counsel. The on-scene

investigation was conducted between June 8 and 20, 2000. No Board Member participated

in the on-scene phase of the investigation. Assisting the Board with the investigation were

an investigator from the Anchorage Office of the Bureau of Alcohol, Tobacco and

Firearms, a fire marshall from the Alaska Department of Public Safety, and a research

engineer from Johns Hopkins University Applied Physics Laboratory who was under

contract to the Board.

The Safety Board investigated the accident under the authority of the Independent

Safety Board Act of 1997 and according to Safety Board rules. The designated parties to

the Safety Board’s on-scene investigation were the Coast Guard, the Alaska Department

of Transportation and Facilities, the Alaska Department of Public Safety (Division of Fire

Prevention), and the Alaska Ship and Drydock Company.

The team viewed the damage on the Columbia and conducted over 30 interviews

in Juneau and Ketchikan, Alaska. The witnesses included the management of the AMHS

and the Alaska Ship and Drydock Company and the officers and crew of the Columbia,

Taku, and Anacapa.