NTSB/MAB/07-01 

E PLURIBUS UNUM

NATIONAL TRA SPORTATIO

N

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Marine Accident Brief

Accident No.: DCA-06-MF-016 

Vessel: M/V Massachusetts, 87.6 feet long, 99 gross tons, aluminum 

construction, built in 1988 

Accident Type: Engineroom fire 

Location: Boston Harbor, Massachusetts 

Date: June 12, 2006 

Time: 1615 eastern daylight time1

Owner/Operator: Massachusetts Bay Lines 

Damages: $800,000 

Complement: 4 crew, 65 passengers 

Injuries: 2 minor (passengers) 

Synopsis 

On Monday afternoon, June 12, 2006, the commuter ferry Massachusetts

(figure 1) was en route from Rowe’s Wharf in Boston Harbor to Hingham, 

Massachusetts, carrying 65 passengers and 4 crewmembers, when a fire broke out in the 

engineroom. The Massachusetts, owned and operated by Massachusetts Bay Lines, was 

inspected and certificated by the U.S. Coast Guard under the small passenger vessel 

regulations at 46 Code of Federal Regulations (CFR) Parts 114-122 (subchapter K).2 The 

vessel’s certificate of inspection (COI), valid for 5 years, was issued on November 14, 

2002.3

 The COI allowed a total of 350 persons on board, including 346 passengers (adults 

and children) and 4 crewmembers (a master and 3 deckhands). At the time of the fire, the 

Massachusetts was operating pursuant to a subcontract with Boston Harbor Cruises, 

which had a 5-year contract with the Massachusetts Bay Transit Authority to provide 

 1

 Times in this brief are given in eastern daylight time according to the 24-hour clock. 

2

 Small passenger vessels are defined by Title 46 United States Code section 2101 as vessels of less 

than 100 gross tons that carry more than 6 passengers, including at least 1 passenger for hire. “Passenger 

for hire” is defined as “a passenger for whom consideration is contributed as a condition of carriage on the 

vessel, whether directly or indirectly flowing to the owner, charterer, operator, agent, or any other person 

having an interest in the vessel.” Title 46 CFR subchapter K governs small passenger vessels that are 

certified to carry more than 150 passengers or have accommodations for more than 49 overnight 

passengers. 

3

 Sector Boston was the local Coast Guard office in charge of inspecting the Massachusetts. The 

vessel’s last drydock (hull) examination was on October 20, 2005. 
 NTSB/MAB-07/01 2

ferry service between Rowe’s Wharf and Hingham Shipyard. The contract specified that 

vessels had to comply with Coast Guard requirements. 

The Massachusetts crew was alerted to the fire about 1615, when the ferry was 

near the Long Island Bridge (figure 2), by black smoke at the stern and an engine highwater-temperature alarm. The vessel did not have, and was not required to have, an 

engineroom fire detection system. The master maneuvered the vessel into shallow water 

southeast of the bridge, anchored, and waited for firefighters. Before a fireboat from the 

Boston Fire Department’s marine unit arrived, all the passengers safely transferred to the 

Laura, another commuter vessel in the vicinity. The fireboat extinguished the fire. The 

accident did not result in any serious injuries or fatalities.4

 Damage, estimated at 

$800,000, was confined mostly to the engineroom. 

Figure 1. Commuter ferry Massachusetts at Rowe’s Wharf, Boston. (Photo courtesy 

Massachusetts Bay Lines) 

 4

 One passenger suffered an asthma attack brought on by smoke inhalation and was treated at the 

scene. Another passenger was treated and released at a local hospital for minor smoke inhalation and a 

spike in a preexisting blood pressure condition. 
 NTSB/MAB-07/01 3

Figure 2. Commuter route of Massachusetts between Rowe’s Wharf and Hingham 

Shipyard. Accident site is at anchor symbol southeast of Long Island Bridge. 

Accident Narrative 

Engine Repair. At 1230 on June 12, after completing three morning commuter 

runs and two sightseeing tours of Boston Harbor, the Massachusetts left Rowe’s Wharf 

and traveled 15 minutes away to a dock at Charlestown, Massachusetts. The master had 

arranged that morning to meet the company’s marine repair contractor at the Charlestown 

dock because the Massachusetts was experiencing a number of mechanical problems. 

The repair shop had three employees (diesel mechanic, welder, and mechanic-intraining), in addition to the owner. The diesel mechanic had been employed at the shop 

for almost 12 years and normally worked on the Massachusetts Bay Line vessels. He said 

that his knowledge of diesel repair and maintenance had been acquired solely through 

on-the-job experience and estimated that 80 percent of the diesel engines he worked 

on were manufactured by Detroit Diesel. The Massachusetts was powered by four 

675-horsepower, 12-cylinder turbocharged model 12V-71 Detroit Diesel engines and had 

two generators (see “Vessel Information” section for details). 

The diesel mechanic met the Massachusetts at the dock. The Massachusetts

master and the mechanic discussed the work to be performed—(1) examining the 

starboard outboard engine for excessive blowby (venting) of combustion gases through 
 NTSB/MAB-07/01 4

the valve cover breathers;5 (2) examining the port generator for sparking, which a 

crewmember had reported over the weekend; and (3) examining the port inboard engine, 

which had been idling at a higher speed than normal. 

For the first item, the mechanic diagnosed a leaking head gasket on the starboard 

outboard engine, which he and the master decided to defer repairing until later in the 

week.6 The owner of the repair shop arrived while the mechanic was working on the 

second item, examining the port generator. Although the mechanic found no sparking on 

the generator, the master decided to use only the vessel’s starboard generator until a 

marine electrician could examine the port generator. 

For the third item, the port inboard engine, the shop’s owner advised the 

mechanic to look for a faulty injector, which the mechanic said he agreed might be the 

cause of the high idle speed. The owner left the vessel before the mechanic started work 

on the port inboard engine. The mechanic said that he removed the inboard valve cover to 

check the six fuel injectors on that side of the engine (figure 3). His inspection revealed 

that the injector on the No. 3 cylinder was faulty. The mechanic proceeded to replace the 

injector. First, he removed the fuel supply and return lines (“jumper lines”) connected to 

the injector.7

 Then he unbolted the fasteners holding the injector to the engine, removed 

the faulty injector, and bolted another in its place. 

The mechanic stated that in replacing an injector on a Detroit Diesel engine of 

that type, no calibrations or settings were necessary once the new injector was in place. 

He had access to the manufacturer’s service manuals but said, “Generally, I don’t need 

them,” noting that he had memorized the torque specifications. He told investigators that 

he used a torque wrench to torque the rocker stand bolts to 104 foot-pounds8 and the 

injector hold-down clamp to 25 foot-pounds. He said that he did not use a torque wrench 

on the fuel lines because “If you overtighten them, you could split the side of the fuel 

line.” The engine manufacturer’s service manual warns, “When installing fuel jumper 

lines, Do Not Overtighten.”9

The mechanic told investigators that after replacing the injector on the No. 3 

cylinder, he ran the engine with the valve cover off to “inspect the fuel lines to make sure 

they’re not leaking.” The engine manufacturer’s service manual warns that leaking fuel 

oil can dilute the lubricating oil and damage the engine: 

 5

 Each of the two valve covers on each engine was fitted with a breather to release vapors that might 

build up in the crankcase. 

6

 Before leaving on the first commuter run the morning of the fire, the master had replaced the impeller 

in the cooling-water pump for the starboard outboard engine, which had been overheating. 

7

 Each injector had two steel jumper lines: one leading from the fuel supply line into the inlet side of 

the injector, and the other leading from the outlet side of the injector to the fuel return line and then back to 

the fuel tank. 

8

 One foot-pound is 1 pound of force acting through a distance of 1 foot in the direction of the force. 

9

 Detroit Diesel Corporation, V-71 Service Manual, section 2.0, “Shop Notes” (Detroit, Michigan: 

1989), p. 2-13. 
 NTSB/MAB-07/01 5

Maintenance and service personnel should be aware that severe engine damage 

could result from fuel oil leakage into the lubricating oil and should therefore 

follow proper procedures when removing, handling and installing fuel jumper 

lines . . . . 

The manual also warns specifically of the fire danger posed by undetected leaks 

in the fuel jumper lines: 

Severe fuel leakage, if not detected, can also result in an over-filled crankcase 

(oil pan) which can cause an abnormal amount of fuel and lubricating oil vapor to 

escape from the engine and crankcase breathers. An abnormal concentration of 

fuel and lube oil vapors is flammable and could ignite in a closed engine 

compartment. 

The procedure in the manufacturer’s service manual for ensuring that fuel jumper 

lines are securely in place after replacing the lines is to run the engine with the valve 

cover off, which makes it possible to observe the jumper lines for any leaks. A Detroit 

Diesel marine service engineer stated that running the engine with a disconnected fuel 

jumper line would be like “‘running a garden hose inside the engineroom.” If the valve 

cover was off, the mechanic should have been able to see fuel leaking from the jumper 

line that investigators found disconnected after the fire (see “Wreckage” section). 

 Detroit Diesel Corporation, Diesel V-71 Service Manual

Figure 3. Typical fuel injector assembly in Detroit Diesel engine cylinder.
 NTSB/MAB-07/01 6

The master said that the idle on the port inboard engine was back to normal after 

the mechanic changed the injector. The mechanic completed his work between 1430 and 

1500, according to the master, and left the vessel about 1530. The Massachusetts then 

departed Charlestown to begin its afternoon commuter schedule. The master said that he 

ran only the two outboard engines on the return trip to Rowe’s Wharf, but that he always 

used all four engines on the commuter runs. 

Departure. Back at Rowe’s Wharf, the Massachusetts boarded 65 passengers for 

the 1600 trip to Hingham Shipyard. Before departing, the master, who had been 

employed by Massachusetts Bay Lines for over 20 years, delivered a passenger safety 

briefing over the vessel’s public address system. The master informed passengers about 

the location and type of lifesaving equipment on board and told them to follow 

crewmembers’ instructions in case of emergency.10 According to data from Logan 

International Airport, about 5 miles away, skies were clear, with unrestricted visibility at 

10 miles and a broken cloud cover, the air temperature was 71° F, and winds were from 

the southeast at 12 knots. 

The Massachusetts departed the dock on schedule (1600), running on all four 

engines, with the mate at the helm. Soon after leaving Rowe’s Wharf, the master went to 

the engineroom to bleed air from the air conditioning system. He said that he did not 

detect anything out of the ordinary. He then returned to the pilothouse. 

Fire. About 1615, the upper deck deckhand entered the pilothouse to report black 

smoke at the vessel’s stern. At the same time, the high-water-temperature alarm for the 

port inboard engine sounded. The mate stopped the port inboard engine and slowed the 

remaining three engines from 2000 to 1300 rpm, as directed by the master. The master 

went to the engineroom to investigate. 

The master said that when he opened the door to the starboard ladderway leading 

to the engineroom, he encountered heavy smoke and immediately closed the door. He 

went to the phone at the main deck bar and called the pilothouse, informing the mate of 

the situation and instructing him to shut down two of the remaining engines. The mate 

shut down the port outboard engine, which had already lost some power, and the 

starboard outboard engine, leaving only the starboard inboard engine running. 

On his way back to the pilothouse, the master directed the main deck passengers 

and the main deck deckhand to go to the upper deck and told the deckhands to give the 

 10 Federal regulations at 46 CFR 122.506 require, in part, that before getting under way on a voyage or 

as soon as practicable thereafter, the master will ensure that “suitable public announcements are made 

informing all passengers” where emergency exits and lifejackets are located and how lifejackets should be 

donned. The Massachusetts carried 366 adult lifejackets and 36 child lifejackets, stored in marked 

compartments underneath the bench seats throughout the interior accommodation spaces on both decks, as 

required by regulations (46 CFR 117.78). 

Eight 22-person lifefloats were stowed on the roof of the upper deck cabin, four on each side. 

According to 46 CFR 117.204, vessels certificated to operate on a coastwise route within 3 miles of land 

“may be provided with life floats of an aggregate capacity that will accommodate at least 50% of the total 

number of persons permitted on board.” Lifefloats are buoyant apparatus that have a line attached around 

the outside. Survivors in the water can hold onto the line. The apparatus is not designed to keep survivors 

out of the water. 
 NTSB/MAB-07/01 7

passengers lifejackets. One of the passengers happened to be a Coast Guard officer 

commuting home. The master told the Coast Guard officer about the fire and asked for 

his help in contacting the Coast Guard. The officer used his cell phone to alert the local 

Coast Guard office, Sector Boston, about the fire. 

By that time, the vessel had passed south of the Long Island Bridge. The master 

relieved the mate at the helm and ordered him and one deckhand to the bow to prepare to 

drop anchor. The mate instructed the other deckhand to help. 

Passenger Evacuation. Meanwhile, the master used very-high-frequency (VHF) 

channel 1311 to contact the commuter ferry Laura, operated by Boston Harbor Cruises. 

The Laura was about 1/2 mile south, en route from Hingham to Rowe’s Wharf with three 

passengers on board. The Massachusetts master told the Laura master that his vessel had 

an engineroom fire and asked the Laura to come alongside and receive his passengers 

“expeditiously.” The Laura immediately altered course to assist the Massachusetts. 

The Coast Guard officer entered the pilothouse and reminded the master to turn 

off the engineroom’s ventilation supply blowers.12 After turning off the blowers, the 

master navigated the Massachusetts just outside the channel to the east, about 1/2 mile 

south of the Long Island Bridge (figure 2), and ordered the mate to drop the anchor. After 

the vessel was anchored, the master sent the mate to the main deck to close the 

emergency fuel shutoff valves, located in the bar area. The deckhands returned to the 

upper deck to attend to the passengers, and the master turned off the inboard starboard 

engine. The generator shut down from fuel starvation about 30 seconds after the mate 

closed the emergency fuel shutoff valves. 

About 1630, the Laura came alongside the Massachusetts and tied up on the 

starboard side. The Massachusetts crew then led the vessel’s 65 passengers, wearing 

lifejackets, down the forward starboard ladder to the main deck and out through the 

starboard forward side door directly onto the Laura. Once on board the Laura, the Coast 

Guard officer again used his cell phone to call Sector Boston about the fire. The transfer 

of passengers was orderly, taking around 5 minutes, according to crew statements. The 

Massachusetts crew did not remember counting passengers as they left the vessel, but a 

count was taken and logged on board the Laura. At 1635, the Laura untied from the 

Massachusetts and moved to a safe distance. After the state police boarded and checked 

for casualties, the Laura departed for Hingham Shipyard.13 

Crew Decision on Firefighting. Once the passengers had transferred to the 

Laura, the master and crew discussed fighting the fire themselves. The Massachusetts 

carried approved firefighting equipment, including seven fire extinguishers14 and two fire 

 11 Marine radio channel for communication between the navigation bridges of vessels. 

12 The two blowers that supplied air to the engineroom could be turned off from the bridge, but 

because the supply and exhaust ducts had no ventilation dampers, airflow through the ducts to the fire 

could not be restricted. 

13 When the passengers reached Hingham, members of the Hingham Fire Department checked them 

again for injuries. 

14 One B-I portable fire extinguisher was kept in the pilothouse, and six B-II portable fire extinguishers 

were placed throughout the ship, including two mounted in the engineroom. Class B extinguishers are 
 NTSB/MAB-07/01 8

pumps, both located in the engineroom and run by the generators,15 capable of providing 

a stream of water to any space on the ship by way of two fire stations (one behind the bar 

on the main deck and one at the top of the interior ladderway). The master stated, “I flatly 

decided we weren’t going to open either engineroom door. We weren’t going to do 

anything to give the fire any oxygen.” Throughout the accident, the master’s prudent 

decisions promoted the safety of his passengers and crew. 

Police Boat. Meanwhile, the Protector, a police boat from Quincy, 

Massachusetts,16 had been approaching the Long Island Bridge from the southwest when 

the crew observed the Massachusetts “dead in the water with smoke showing from its 

stern.” About 1635, the Protector came alongside the Massachusetts on the port side, and 

the Massachusetts mate told the Protector crew that the engineroom was on fire. Police 

on board the Protector immediately notified the Coast Guard, using VHF channel 16,17

and requested a fireboat. The Protector crew also notified Quincy police headquarters 

about the fire. At approximately 1645, at the Coast Guard’s request, the crew transferred 

from the Massachusetts to the Protector, which remained on scene but at a distance from 

the burning vessel. 

Emergency Response. According to emergency records provided by the Boston 

Fire Department, the dispatch operations center (known as “Fire Alarm”) received nearly 

simultaneous calls reporting the Massachusetts fire from the Coast Guard (at 1641) and 

Quincy police (at 1642). At 1644, the center dispatched the fire department’s marine unit 

to the Long Island Bridge from its station at Burroughs Wharf in Boston’s North End, 

about 6 nautical miles from the accident site. 

After receiving the call from the dispatch center, marine unit personnel boarded 

the vessel Firefighter and were under way in 2 or 3 minutes, according to the pilot.18 At 

1656, the dispatch center dispatched Engine Company 2 and Ladder Company 19 to the 

Paul W. Conley terminal, located at the southeast end of the reserved channel19 in South 

Boston, to be picked up by the marine unit. At 1703, the dispatch center dispatched the 

District 6 fire chief to the Conley terminal, also to be picked up by the marine unit. 

Firefighters told investigators that it took 10 minutes to load personnel and gear at the 

terminal. 

 

intended for fires involving flammable liquid, grease, or gas. B-I extinguishers hold 2.5 pounds of dry 

chemical; B-II extinguishers, 10 pounds of dry chemical. 

15 The fire pumps could be started only by entering the engineroom. Fire pumps on small passenger 

vessels built after March 11, 1996, are required to “be capable of both remote operation from the operating 

station and local operations at the pump” (46 CFR 118.300[e] and 181.300[e]). These regulations did not 

apply to the Massachusetts because it was built in 1988. 

16 A small city about 7 miles southeast of downtown Boston. 

17 Channel 16 (156.8 megahertz), which the Coast Guard monitors continuously, is the international 

calling and distress frequency. 

18 The marine unit’s other vessel, the St. Florian, was out of service because an electrical problem had 

drained its batteries. According to the marine unit’s standard operating procedures, the smaller, faster 

St. Florian would normally have been launched first, with the Firefighter following later and land 

companies deploying if necessary. 

19 A dredged, unmarked channel lined with freight terminals. 
 NTSB/MAB-07/01 9

The Firefighter (maximum speed 9 to 10 knots) arrived at the accident scene at 

1730 and approached the burning Massachusetts on its port side. All passengers and crew 

had disembarked. The Firefighter crew noted heavy black smoke coming out the vents 

and doorways at the Massachusetts’s stern. Vessels were already on scene from the 

Quincy Police Department (the Protector and the Guardian), the Massachusetts 

Environmental Police Department, the Massachusetts State Police, and the Coast Guard 

(which had launched a 41-foot utility boat from Station Pt. Allerton, about 2 nautical 

miles east of the accident site20). A MassPort fireboat21 also stood by. The District 6 fire 

chief assumed on-scene command. 

The Firefighter was secured to the Massachusetts and five firefighters went on 

board. According to the fire chief, the firefighters placed a 2 1/2-inch-diameter fire hose 

down each of the two engineroom ventilation shafts on the aft main deck, with two men 

operating each hose. Because of the intensity of the fire (the fire chief said the main deck 

had “steam coming out of the carpet”), firefighters could not enter the engineroom. They 

poured water into the engineroom and pumped firefighting foam down the port 

engineroom ventilation shaft, but their actions did not extinguish the fire. 

Firefighters sought help from the Massachusetts crew, now on the Quincy police 

boat Protector, in finding better engineroom access. The mate and two deckhands of the 

Massachusetts transferred from the Protector to the Quincy police boat Guardian, and 

the Protector delivered the master to the Firefighter. The master told the firefighters 

about “soft patches” (metal hatches) in the main deck, directly above the engines, that 

could be opened. Firefighters removed enough screws so they could pry open the hatch 

over the port inboard engine and fight the fire from above. Their efforts filled the engine 

compartment with water nearly to the main deck level, above the tops of the engines. Out 

of concern for the vessel’s stability, the fighters began pumping water out of the 

engineroom. After they had lowered the water level by 5 to 6 feet, the firefighters entered 

the engineroom and checked for hot spots. At 1848, firefighters reported that the fire 

appeared to be out but set a reflash watch in case the fire should reignite. Firefighters left 

the scene at 2040. 

Aftermath. The Massachusetts crew, which had transferred to the Coast Guard 

41-foot utility boat, was transported to the Hingham Shipyard dock, arriving at 2130. The 

Massachusetts was taken under tow by a local harbor tug at 2240 and moved to a pier at 

Deer Island (figure 2). 

Vessel Information 

The Massachusetts, a double-deck vessel constructed entirely of aluminum 

(figure 4), was built for Massachusetts Bay Lines by Gulf Craft, Inc., of Patterson, 

Louisiana. The builder began construction in 1987 and delivered the Massachusetts in 

 20 The Coast Guard utility boat arrived at the accident scene at 1649, according to the Coast Guard 

station log. 

21 A fire and rescue boat launched from Logan International Airport. 
 NTSB/MAB-07/01 10

1988. Massachusetts Bay Lines immediately put the vessel to use in the Boston Harbor 

commuter trade. 

Figure 4. Profile view of the Massachusetts. Passengers were carried in the enclosed 

cabins on the main and upper decks. 

The enclosed pilothouse at the bow of the vessel was accessed by a short ladder 

from the upper deck. The pilothouse was equipped with the following navigation and 

communication equipment: X-band and S-band Furuno® radars,22 two Raytheon® VHF 

radios, an International® depth sounder, a Magellan® global positioning system unit, a 

horn, a searchlight, and a compass. 

A control panel in the pilothouse registered alarms for high water temperatures in 

individual engines and for high water in the compartments equipped with bilge alarms. 

The pilothouse was also equipped with an engineroom air high-temperature alarm.23 A 

public address system in the pilothouse was used to communicate with passengers and 

crew throughout the vessel and to deliver predeparture safety briefings and other 

announcements. 

The upper deck contained both fixed and movable chairs for passenger seating. 

An enclosed passenger section in the middle contained a bar. The upper deck was 

connected to the main (lower) deck by an exterior ladderway (stairway) on the port side 

aft and by an interior ladderway on the starboard side forward. 

The main deck was almost entirely enclosed to protect commuters from the 

weather. Seating consisted of chairs placed throughout and fixed seats in the forward 

 22 Marine radars are available in X-band (shorter wavelength, greater resolution) and S-band (longer 

wavelength, longer range). 

23 According to the Massachusetts Bay Lines’s general manager, the device was installed as original 

equipment and intended to warn the operator if the air temperature rose in the engineroom, possibly 

signifying an overheated engine. The device was not regularly tested or logged. The vessel master was not 

certain whether the alarm sounded during the fire. 
 NTSB/MAB-07/01 11

area. A small bar/serving area was located amidships on the starboard side. Next to the 

bar were the emergency fuel shutoff levers for the propulsion engines and generators, as 

well as a fire station containing a fire hose. Restrooms were located at the aft end of the 

main deck. A small open deck aft of the restrooms allowed crewmembers to handle the 

lines during docking. Two sliding doors on each side of the main deck provided egress 

from the vessel. Passengers and crew could also exit through the door at the stern that led 

to the open deck.24 

The belowdecks area was divided into six compartments separated by transverse 

watertight aluminum bulkheads extending upward from the bilges to the main deck 

(figure 5). The forwardmost compartment (forepeak) contained anchor rope and spare 

lines. The next compartment (forward compartment) contained a sewage holding tank 

and macerator pump.25 Aft of the forward compartment was a space that was used to 

store supplies such as coffee and also contained a small workshop; it was accessible from 

the main deck by a ladderway forward of the bar area. 

Immediately behind the work/storage space was a narrow compartment that held 

the fuel tanks and potable water tanks. Aft of that was the engineroom, accessed by 

ladderways forward of the restrooms on each side of the main deck. The engineroom 

could also be accessed from the main deck by unscrewing any of four large hatches, one 

over each engine (as shown in figure 5). The aftmost belowdecks compartment (lazarette) 

contained exhaust piping, a hydraulic cylinder for the steering system, and the vessel’s 

hot water heater. Each of the belowdecks compartments contained a bilge suction well. 

The lazarette, engineroom, work/storage space, and forepeak were also equipped with 

high-water bilge alarms. 

The engineroom contained four 675-horsepower Detroit Diesel engines directcoupled to individual drive shafts through reduction gears. The two outboard engines 

were mounted approximately 2 feet higher than the two inboard engines. Each engine had 

two turbochargers, inboard and outboard, and 12 cylinders, each fitted with a fuel 

injector. No. 2 diesel fuel was drawn from the fuel tank into the fuel pump, where it was 

forced under pressure through a fuel filter and then through the fuel lines into the 

injectors. According to a Detroit Diesel marine engineer, the pressure on the fuel lines at 

the injectors ranged from 5 psi at engine idle to 55 psi at full engine throttle. Surplus fuel 

went from the injectors through return lines and back to the fuel tank. 

 24 The Massachusetts met the requirements for emergency egress applicable at the time it was built 

(46 CFR 177.15-1, in effect until March 1990) and the requirements now in effect (46 CFR 115.500). The 

earlier requirements stated: “all vessels shall be provided with not less than two avenues of escape from all 

general areas accessible to the passengers or where the crew may be quartered or normally applied, so 

located that if one is not available the other may be. At least one of the avenues of escape shall be 

independent of watertight doors. Windows and windshields of sufficient size and proper accessibility may 

be used as one avenue of escape.” Current regulations are that “each space accessible to passengers or used 

by the crew on a regular basis must have at least two means of escape, one of which must not be a 

watertight door” (46 CFR 116.500[a]). Only one means of escape is required in certain circumstances, such 

as from deck areas of less than 322 square feet (46 CFR 116.500[p]). For further information on the history 

of small passenger vessel regulations, see the “Fire Protection Regulations” section of this brief. 

25 A macerator pump breaks up waste solids and empties the sewage holding tank. 
 NTSB/MAB-07/01 12

Figure 5. Belowdecks plan of the Massachusetts showing compartments and 

equipment. Shaded areas indicate hatches (covered openings) in the main deck that 

provided belowdecks access. 
 NTSB/MAB-07/01 13

The engines were cooled by water whose temperature was automatically 

controlled by a thermostat. According to the engine manufacturer’s service manual, the 

thermostat sounded an alarm if the water temperature exceeded 215° F. Areas that were 

not water-cooled, such as the outside of the exhaust manifold, reached a maximum 

temperature of 600° F under ordinary operating conditions, according to a Detroit Diesel 

marine service engineer. 

Engine lubricating oil was drawn by suction from the oil pan and into the oil 

pump, where it was pressurized. The pressurized oil flowed to the cylinder block, 

providing lubrication for the bearings, pistons, gears, and other moving parts. In addition 

to the standard oil filters mounted on the engine block, each engine had an external oil 

filter, mounted on the engineroom bulkhead and connected to the engine by oil lines 

running along the engineroom deck. 

Electrical power was produced by two three-cylinder Detroit Diesel generators, 

each producing 30 kilowatts of power. The generators were generally used one at a time 

and were alternated daily. On the day of the fire, the starboard generator was online. The 

port generator was idle, awaiting service. 

The vessel had an electrohydraulic steering system. Rudder commands from the 

pilothouse steering wheel went to the pump control in the engineroom, which would 

change the hydraulic cylinder position in the lazarette. The hydraulic cylinder was linked 

to two rudders that would move simultaneously. Other equipment in the engineroom 

included two 12-volt battery banks (aft) and two 32-volt battery banks (forward) for 

supplying direct-current power to vessel equipment. The engineroom also contained two 

bilge pumps that could also operate as emergency fire pumps and other piping and pumps 

used in the vessel’s engineering systems. 

The engineroom ventilation system consisted of two air intake vents in the 

forward part of the engineroom, one port and one starboard, and two exhaust vents at the 

rear. The forward intake vents provided forced ventilation through aluminum ducts fitted 

with electric blowers. The rear vents, which shared the ladderway shafts, provided natural 

exhaust. 

Wreckage 

Investigators examined the wreckage of the Massachusetts between June 13 and 

June 21, first at Deer Island in Boston Harbor and then at a berth in Chelsea, 

Massachusetts, where the vessel was taken after the fire. Investigators examined the 

exterior and interior spaces of the vessel, both abovedecks and belowdecks. The engines 

and generators were inspected for the integrity of their components and the overall degree 

of fire damage. Potential sources of combustible material, such as hydraulic fluid, fuel 

distribution lines, and lubricating oils, were also examined to determine whether they 

were involved in the fire. 
 NTSB/MAB-07/01 14

Structural Damage 

The pilothouse and upper deck were not damaged by the fire. The exterior of the 

main deck exhibited soot stains at the ventilation grills on both sides of the vessel, more 

pronounced on the starboard side (figure 6). The carpet in the interior of the main deck 

was charred on the port side, next to the port engineroom air intake duct. Seven windows 

around the main deck were broken (firefighters had broken them to vent smoke while 

fighting the fire), and surfaces on the upper and main decks were dusted with soot. 

Figure 6. Smoke damage to outside of Massachusetts’s main deck, starboard side. 

In the engineroom, the pattern of damage indicated that a hot smoke layer had 

formed throughout the space and radiated heat to the components below it. Plastic light 

fixtures and the insulation on wiring cables close to the overhead (main deck) had melted, 

with similar damage on the tops of machinery and other items, such as the insulation 

lining the overhead and bulkheads. The aluminum ventilation duct to the fresh air intake 

on the engineroom’s port side had melted,26 and the blower had fallen to the deck below. 

Thermal damage was most severe above and beside the port inboard engine. 

Above the engine, aluminum bars approximately 1/4 inch thick and 2 inches deep that 

spanned the length of the overhead were melted and sagging, and a vertical aluminum 

column extending from the floor to the overhead had softened, fractured, and bent out of 

alignment. Between the port and starboard inboard engines, a hole approximately 

1 1/2 feet in diameter had melted through the aluminum decking, and the decking’s 

support structure was melted and deformed (figure 7). 

 26 Most aluminum alloys start to melt at about 1,000° F. 
 NTSB/MAB-07/01 15

Figure 7. Melted and deformed floor supports and decking next to port inboard engine, 

looking down. (Large green hose on right and small green garden hose behind it were 

inserted to control water in bilges after accident; neither was part of vessel's normal 

equipment.) 

Equipment Damage 

Engines. The most extensive fire damage was to the port inboard engine, which 

had especially severe thermal damage on the inboard side.27 In that area, the valve cover 

was deformed, and the gasket protruded from underneath (figure 8). After removing the 

valve cover, investigators found a disconnected fuel jumper line to the injector on the 

No. 3 cylinder (figure 9). 

 27 Refer to figure 5 for engineroom layout. 
 NTSB/MAB-07/01 16

Figure 8. Inboard valve cover and protruding gasket, port inboard engine. 

The wire-reinforced rubber fuel and lubricating lines on the port inboard engine 

were burned through or missing. Only the wire reinforcement remained on the fuel line at 

the top of the engine that ran to the return fuel cooler. The oil return line from the 

external oil treatment system was burned through and lying in the bilge, and an oil line 

was missing on the inboard side of the engine block. Plastic components of the fuel and 

oil filters were melted or missing, and the paint on the engine block had burned off, 

blackening the engine. 

The turbocharger on the inboard side of the port inboard engine showed severe 

damage to aluminum elements such as the air intake manifold leading away from the 

turbocharger, which was heavily oxidized, deformed, and sagging. The compressor 

blades on the inside of the inboard turbocharger were blackened and heat-deformed. 

Fire damage to the port outboard, starboard inboard, and starboard outboard 

engines was generally limited to burned-through water-coolant lines, which consisted of 

wire-reinforced rubber, and melted plastic wiring insulation. Firefighting efforts had 

filled the engine compartment with salt water and submerged all the engines, rendering 

them inoperable.
 NTSB/MAB-07/01 17

Figure 9. Disconnected fuel line on No. 3 cylinder of port inboard engine. 

Other Equipment. The wire-reinforced rubber coolant lines at the top of both 

generators were burned through, but other generator components, such as steel fuel 

supply and return lines, oil lines, wiring, and paint, were undamaged by the fire. Only the 

batteries on the forward starboard side of the engineroom showed signs of thermal 

damage. The cables to and from the battery banks had lost insulation along their runs, but 

investigators found no evidence of arcing against conductive surfaces or between the 

conductors themselves. 

The two hydraulic steering gear pumps and the four stainless-steel hydraulic lines 

that ran through the engineroom showed no signs of damage or leaks. The hydraulic 

reservoir, which was toward the rear of the engineroom, was undamaged and full of 

hydraulic fluid. 
 NTSB/MAB-07/01 18

Origin of Fire 

When investigators examined the wreckage of the Massachusetts, they 

discovered, as described above, that one of the fuel jumper lines on the port inboard 

engine was disconnected. The disconnected jumper line had been attached to the fuel 

injector on the No. 3 cylinder on the engine’s inboard side. The fuel jumper line and its 

mating surface were sent to the Safety Board’s materials laboratory in Washington, D.C., 

for examination. The examination found no mechanical damage to the threads of the 

connector fittings or any other mechanical reason for the jumper line to have become 

disconnected. Fuel leakage from the disconnected fuel jumper line would have allowed 

fuel to flow to the engine crankcase, accumulate, escape through the crankcase vent, 

contact the hot surface of the exhaust manifold below, and ignite. 

The exhaust manifold was not cooled and, under ordinary operating conditions, 

reached a temperature of about 600° F. However, the engine would have been running 

hotter than normal because the lubricating oil had been diluted by the fuel oil from the 

leaking jumper line.28 The fuel would autoignite (ignite by heat without spark or flame) at 

a temperature of 637° F, according to the product’s material safety data sheets. The fuel’s 

ignition temperature (the temperature at which spark or flame will cause fuel to burn) was 

494° F.29 The exterior of the exhaust manifold leading from the overheated engine would 

have exceeded both temperatures. 

Personnel Information 

The 55-year-old master of the Massachusetts on the day of the accident was the 

vessel’s permanent master.

30 He had worked aboard the vessel during its construction in 

the shipyard, and he had delivered it to Boston Harbor on its completion in 1988. He held 

a Coast Guard license as “master of steam, motor or auxiliary sail vessels of not more 

than 100 gross tons upon near coastal waters” reissued in February 2005. In addition to 

his duties regarding daily operation of the Massachusetts, he was responsible for the 

material condition of the vessel, arranged for repairs, and ensured that the repairs were 

satisfactory. He operated the vessel 4 days a week—Monday, Tuesday, Thursday, and 

Friday. He said that he reported to work at 0600 and generally left work about 1845. On 

weekends, he usually went to bed around 2300 and got up about 0730. He characterized 

his work/rest periods as “pretty routine” and said that there had been no events to affect 

his schedule before the accident. 

The mate, age 27, started work with Massachusetts Bay Lines as a deckhand in 

May 1997. He held a Coast Guard license as “master of steam or motor vessels of not 

 28 The Detroit Diesel service manual states (section 2.0, “Shop Notes,” p. 11): “Always check the fuel 

system for leaks after injector or fuel pipe replacement and any time the fuel connections under the rocker 

cover are suspected of leaking. Failure to correct a serious fuel leak in this area can lead to dilution of the 

fuel oil and bearing and/or cylinder kit [components] damage.” 

29 National Fire Protection Association, Guide for Fire and Explosion Investigations, NFPA 921 

(Quincy, Massachusetts: 2004). 

30 Each of the seven vessels operated by Massachusetts Bay Lines had one permanently assigned 

master who was in charge of the vessel’s operation, maintenance, and repair. 
 NTSB/MAB-07/01 19

more than 100 gross tons upon near coastal waters” reissued in March 2006 but served as 

the mate on the Massachusetts when the permanent master operated the vessel. He 

normally worked 50 to 55 hours per week. He said that 3 days before the accident 

(Friday), he went to bed about 0030. The next day, he worked two cruises, one in the 

afternoon and one that began Saturday night and lasted until 0230 Sunday morning. He 

finished work about 0400 and went to bed about 0445. He said that he went to bed about 

2200 or 2230 on Sunday and felt rested when he got up Monday morning at 0430, his 

usual time. 

The lower deck deckhand, age 55, had been employed as a deckhand for 

approximately 8 months. All his marine experience had been on the Massachusetts. His 

duties involved line handling, serving coffee to passengers on the main deck, counting 

passengers as they boarded, and checking the engineroom at the midpoint of each 

commuter trip, near the Long Island Bridge. He said that before he started the job, the 

master had taken him on a “walkthrough” of the vessel’s emergency equipment, 

engineroom, and procedures for shutting down the fuel supply in an emergency. After 

starting the job, he took part in man-overboard drills with the master and for the Coast 

Guard, and he had also watched safety training videos. 

The upper deck deckhand, age 20, had been employed by Massachusetts Bay 

Lines for 3 weeks—her first maritime employment. She said that the master had given 

her a familiarization tour of the vessel and pointed out the storage areas for the lifejackets 

and other safety equipment but that she had not yet participated in any emergency drills 

at the time of the accident. Her responsibilities included line handling, assisting 

passengers, and serving drinks at the upper deck bar. 

Toxicological Testing 

None of the crewmembers was tested for the presence of alcohol after the fire.31 

Sometime before 1700 on June 12, the general manager of Massachusetts Bay Lines 

attempted to reach the contractor who conducted toxicology testing for the company, but 

no one answered the contractor’s afterhours telephone number. When the crew arrived in 

Hingham about 2130 on board a 41-foot Coast Guard utility boat, the company president 

met them and transported them to a local hospital for testing. The hospital emergency 

room was too busy to conduct the tests, and a hospital employee advised the 

crewmembers to return the next day. 

About 0900 on the morning of June 13, the crewmembers were taken to the office 

of the testing contractor, where they provided urine specimens for drug testing. The 

contractor did not conduct alcohol testing because too much time (16 hours) had elapsed 

 31 Postaccident alcohol and drug testing is required by Federal regulations at 46 CFR 4.06 for any 

accident meeting the criteria of a serious marine incident, defined at 46 CFR 4.03-2 as (a) a marine casualty 

or accident that results in any of the following: (1) one or more deaths, (2) injury that requires medical 

treatment beyond first aid and renders the individual unfit to perform routine duties, (3) property damage 

exceeding $100,000, (4) actual or constructive total loss of an inspected vessel, or (5) actual or constructive 

total loss of any uninspected vessel that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of 

oil into U.S. waters; or (c) the release of a reportable substance into the environment of the United States. 
 NTSB/MAB-07/01 20

since the accident. Test results for all four crewmembers were negative for the five drugs 

of abuse (marijuana, cocaine, opiates, amphetamines, and phencyclidine) for which 

screening in postaccident testing is required by Federal regulations at 46 CFR 16.113 and 

elsewhere. The drug tests were administered within the required time limits. 

The Massachusetts master was not tested for alcohol within the time limits of the 

regulations, in part because he remained at the accident scene to assist the firefighters (he 

helped them gain access to the engineroom). According to 46 CFR 4.06 (“Mandatory 

Chemical Testing Following Serious Marine Incidents Involving Vessels in Commercial 

Service”), paragraph 4.06-1(d), 

The requirements of this subpart shall not prevent vessel personnel who are 

required to be tested from performing duties in the aftermath of a serious marine 

incident when their performance is necessary for the preservation of life or 

property or the protection of the environment. 

On June 20, 2006 (8 days after the Massachusetts fire), new Coast Guard 

regulations (46 CFR 4.06-3) went into effect requiring alcohol testing within 2 hours of a 

serious marine accident.32 Coast Guard headquarters informed the Safety Board on 

August 24, 2006, that the new regulations will be enforced by levying civil penalties 

against any marine employer who fails to conduct the alcohol testing as prescribed.33

Failing to collect urine specimens for drug testing within 32 hours of an accident, as 

required by the regulations, will also result in civil penalties. Since the fire, 

Massachusetts Bay Lines has acquired saliva test kits for alcohol testing and has trained 

its office staff and vessel crews to use the kits. 

The Safety Board placed the issue of improving postaccident drug and alcohol 

testing in the marine industry on its “Most Wanted” list in 2002. The list is intended to 

increase the public’s awareness of, and support for, action to adopt safety steps that can 

help prevent accidents and save lives. Because of the new Coast Guard regulations for 

crew drug and alcohol testing after serious marine incidents, the Board removed the issue 

from its “Most Wanted” list on November 14, 2006. 

Fire Protection Regulations 

The Massachusetts had the firefighting equipment (fire pumps, hoses, and 

portable extinguishers) required by its COI. The vessel was not equipped with fixed fire 

 32 The Safety Board recommended this and other improvements to the Coast Guard’s regulations 

regarding postaccident toxicological testing in a special investigation report issued in 1998 (National 

Transportation Safety Board, Postaccident Testing for Alcohol and Other Drugs in the Marine Industry and 

the Ramming of the Portland–South Portland [Million Dollar] Bridge at Portland, Maine, by the Liberian 

Tankship Julie N on September 27, 1996, Special Investigation Report NTSB/SIR-98/02 [Washington, DC: 

NTSB, 1998]). 

33 To test for alcohol, either a breath, blood, or saliva (but not urine) specimen can be collected. 

Internal Coast Guard directives require Coast Guard personnel to conduct the alcohol tests if the marine 

employer does not or cannot conduct them within 2 hours. 
 NTSB/MAB-07/01 21

suppression or detection systems in its engineroom, nor (as explained below) was it

required by Coast Guard regulations to have such systems.34

When the Massachusetts began operating in 1988, the Coast Guard inspected 

vessels of less than 100 gross tons that could carry more than six passengers (that is, 

small passenger vessels) according to regulations at 46 CFR subchapter T.35 On March 

11, 1996, after a lengthy rulemaking process, a complete revision to the regulations 

governing small passenger vessels went into effect. In its rulemaking, the Coast Guard 

significantly changed the organization of the regulations. Vessels carrying 150 or fewer 

passengers continued to be regulated by subchapter T (46 CFR Parts 175-185). New 

subchapter K (46 CFR Parts 114-122) was created for regulations pertaining to small 

passenger vessels, such as the Massachusetts, that were permitted to carry more than 150 

passengers. 

Under the revised regulations, new vessels (defined at 46 CFR 114.400 as those 

built after March 10, 1996) were required to be equipped with a fixed gas fire 

extinguishing system and an approved fire detecting system for any spaces containing 

propulsion machinery.36 Vessels built before the revised regulations took effect (“existing 

vessels”) that had a hull or machinery space boundary made of combustible material such 

as wood or fiber-reinforced plastic (fiberglass), which the Coast Guard considered a 

higher risk category, were required to be retrofitted with fixed fire extinguishing and 

detecting systems by March 11, 1999.37 The Coast Guard did not require retrofitting all 

existing vessels because “it would have a substantial cost impact on the small passenger 

vessel industry.”38

Thus, existing vessels whose hulls were made of noncombustible material such as 

steel or aluminum, including the Massachusetts, were subject to the previous regulations, 

which required a fixed fire extinguishing system in the machinery and fuel tank spaces 

only if a vessel was powered by gasoline or other fuel having a flash point of 110° F or 

lower. Because it was constructed before the revised regulations went into effect and 

 34 Massachusetts Bay Lines has had Coast Guard–approved fixed fire suppression and detection 

systems installed in the rebuilt engineroom of the Massachusetts. 35 The initial subchapter T regulations were promulgated in the Federal Register of October 5, 1957. 

Originally, subchapter T regulated vessels of 65 feet or less in length. In 1963, subchapter T was revised to 

include vessels (known as subchapter T-L vessels) that were more than 65 feet long and had a gross 

tonnage of less than 100. 

36 Title 46 CFR 118.400 (a) and (c). 

37 Federal Register, vol. 59, no. 9 (January 13, 1994), p. 2046. 

38 The original notice of proposed rulemaking required only existing fiberglass vessels to have fixed 

fire extinguishing and detecting systems. The Coast Guard stated that it had studied casualty data and 

determined that fires on fiberglass vessels accounted for 34 percent of machinery space fires from 1981 to 

1986, although such vessels composed only 20 percent of the small passenger vessel fleet, yielding a fleet 

percentage to fire percentage ratio of 1.7:1 (Federal Register, vol. 54, no. 18 [January 30, 1989], p. 4436). 

Wooden vessels were originally excluded from the requirement for fixed fire extinguishing and detecting 

systems because their ratio was lower (1.25:1), but they were added in the supplemental notice (Federal 

Register, vol. 59, no. 9 [January 13, 1994]) because of comments received. Vessels made of steel or 

aluminum were found to have “much lower” ratios and were not included in the requirement. 
 NTSB/MAB-07/01 22

because its hull was aluminum, the new fire detection and suppression requirements did 

not apply to the Massachusetts. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of 

the fire on board the Massachusetts was the ignition of diesel fuel by contact with a hot 

engine surface, which occurred because a fuel line attached to a fuel injector was not 

properly connected during engine maintenance by a contract mechanic. Contributing to 

the extent of the damage was the absence of a fixed fire detection and suppression 

system, which precluded the crew from receiving timely notification of the fire and which 

allowed the blaze to spread throughout the engineroom. 

Recommendation 

As a result of its investigation into the fire on board the Massachusetts, the 

National Transportation Safety Board makes the following safety recommendation.39

To the U.S. Coast Guard: 

Require that all small passenger vessels certificated to carry more than 49 

passengers, regardless of date of build or hull material, be fitted with an 

approved fire detection system and a fixed fire suppression system in their 

enginerooms. (M-07-1) (Supersedes Safety Recommendations M-02-6 and 

M-02-8.) 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

MARK V. ROSENKER ROBERT L. SUMWALT 

Chairman Vice Chairman 

DEBORAH A. P. HERSMAN KATHRYN O’LEARY HIGGINS 

Member Member

STEVEN R. CHEALANDER

Member 

Adopted: March 20, 2007 

 39 For more information, see the Safety Board’s safety recommendation letter to the Coast Guard, 

available on the Board’s website <www.ntsb.gov>.