NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT BRIEF REPORT

PB2001-916402

NTSB/MBR-01/01

FIRE ON BOARD THE NETHERLANDSREGISTERED PASSENGER SHIP

NIEUW AMSTERDAM

GLACIER BAY, ALASKA

MAY 23, 2000

7377

Marine Accident Brief Report

Fire On Board the NetherlandsRegistered Passenger Ship

Nieuw Amsterdam

Glacier Bay, Alaska

May 23, 2000

NTSB/MBR-01/01

PB2001-916402 National Transportation Safety Board

Notation 7377 490 L’Enfant Plaza, S.W.

Adopted July 24, 2001 Washington, D.C. 20594
National Transportation Safety Board. 2001. Fire On Board the Netherlands-Registered Passenger

Ship Nieuw Amsterdam, Glacier Bay, Alaska, May 23, 2000. Marine Accident Brief Report

NTSB/MBR-01/01. Washington, DC.

Abstract: This report discusses the May 23, 2000, fire that occurred on the Netherlands-registered passenger ship

Nieuw Amsterdam, while it was en route to Glacier National Park. None of 1,169 passengers and 542 crewmembers

on board the vessel was killed or sustained serious injury; however, one passenger suffered smoke inhalation injuries

requiring evacuation to a shoreside hospital for additional medical treatment. Damages related to the accident exceed

$360,000.

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

following areas: the adequacy of shipboard training and drills in firefighting management for masters and other

officers; the adequacy of Holland Americaís policies, procedures, training, and drills for limiting and controlling the

spread of smoke during a fire; and the adequacy of Holland Americaís safety management oversight of shipboard

firefighting operations. Based on its findings, the Safety Board made recommendations to the U.S. Coast Guard,

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

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

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

Cruises, Ltd

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 LíEnfant 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 PB2001-916402 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

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Initial Response to Smoke Detector Alarm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Firefighting Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Actions on Bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Passenger Muster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Safety Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1 Marine Accident Brief Report

Executive Summary

On the morning of May 23, 2000, while the Netherlands-registered passenger ship

Nieuw Amsterdam was en route to Glacier National Park with 1,169 passengers and

542 crewmembers on board, a fire broke out in a crew cabin. A premature effort to

extinguish the fire by officers lacking proper gear and backup contributed to the spread of

fire and smoke. The fire did not spread beyond the deck of origin; however, the untimely

closing of fire screen doors allowed the smoke to migrate up eight decks, creating

hazardous conditions in crew and passenger accommodations. Properly outfitted and

equipped shipboard firefighting teams subsequently extinguished the fire. One passenger

sustained smoke inhalation injuries requiring evacuation to a shoreside hospital for

additional medical treatment. Property damage to the vessel was estimated at more than

$360,000. 

Accident Description

On May 23, 2000, the Netherlands-registered passenger ship Nieuw Amsterdam,

operated by Holland America Line Westours, Inc. (Holland America), was carrying

1,169 passengers and 542 crewmembers while en route to Glacier National Park as part of

a 7-day cruise between Vancouver, British Columbia, and Seward, Alaska. (See figure 1.)

At 0911, when the ship was about 5 miles north of Russell Island, in the Tarr Inlet, an

alarm sounded on the bridge’s fire detection system console, indicating that a smoke

detector in a crew cabin on D deck had activated.

Figure 1. Approximate location of the Nieuw Amsterdam when the fire broke out.

Tarr Inlet GLACIER BAY

Muir Inlet

Russell 

Island

UNITED STATES

CANADA

ALASKA

GULF OF ALASKA

JUNEAU

Boxed area is enlarged above
Accident Description 2 Marine Accident Brief Report

At the time of the fire alarm, senior officers with emergency command and control

responsibilities, as listed in Holland America’s Safety Management System (SMS), were

in various areas of the ship. The master, who had responsibility for the safety of the ship,

was on the bridge. The chief officer, who had responsibility for directing firefighting

command and control operations, was in his cabin, aft of the pilothouse. The safety

officer, who had responsibility for the firefighting drills and training and the command of

one of the two fire squads, was doing routine maintenance on D deck. The chief engineer,

who had responsibility for ensuring the safe operation of the propulsion, steering, and

other engineering systems, was in the engine control room. The second engineer, who was

the commander of the second fire squad, as well as the operational backup for the chief

engineer, was also in the engine room.

Initial Response to Smoke Detector Alarm

In addition to the master, the on-duty bridge crew included two deck officers, two

quartermasters, a lookout, and an Alaska State-licensed pilot.1

 The on-duty third officer

stated that when the alarm sounded, he followed company procedures and informed the

master of a possible fire on D deck and ordered one of the quartermasters to investigate to

ensure that it was not a false alarm. He advised the quartermaster to carry a full-face

cartridge respirator (smoke mask), as well as a UHF radio so he could report his findings.

The quartermaster descended to D deck, eight decks below the navigation deck,

and proceeded aft about 250 feet to the area where the smoke detector had activated. (See

figure 2.) After passing fire screen door (FSD) D1, he observed smoke overhead and

donned his smoke mask. (See figure 3.) Upon arriving at cabin D98, he saw smoke

coming through the ventilation louvers in the lower section of the cabin door. He tried the

door, but it was locked. He said that he immediately radioed a report of his observations to

the third officer on the bridge, who, in turn, informed the master that smoke was coming

from cabin D98.2

Based on the third officer’s description of the quartermaster’s account, the master

called the chief officer, who was in his cabin on the navigation deck, and directed him to

investigate the fire on D deck. The chief officer later stated that he knew that Holland

America’s SMS procedures stipulated that, in the event of a fire, he was to command

firefighting operations from the bridge. However, at the direction of the master, he went to

D deck to investigate the fire. 

1 The pilot was a member of the Alaska Coastwise Pilots Association.

2 Because of its date of construction, the Nieuw Amsterdam was not required by the International

Convention for the Safety of Life at Sea (SOLAS) to have fire sprinklers in its crew and passenger

accommodations areas. 
Accident Description 3 Marine Accident Brief Report

Meanwhile, the quartermaster on D deck started alerting off-duty crewmembers by

yelling “fire” and “smoke” and by pounding on the cabin doors in the affected area.3 He

said that he met a crewman who had retrieved a dry chemical extinguisher from an

adjacent passageway and a room steward who happened to have a passkey to cabin D98.

The quartermaster opened the cabin door, and the crewman discharged the dry chemical

extinguisher into the room. The quartermaster said that “a lot of smoke” came out of the

cabin, whereupon he immediately closed the door to contain the smoke. 

At this time, several officers were either on or entering nearby areas of D deck.

The safety officer and another deck officer were doing routine maintenance on watertight

door (WTD) WD19. An officer who had been recently assigned as a fourth officer4

 on the

ship was walking through the area to join the other officers. In response to the smoke or to

the quartermaster’s shouts of “fire,” the officers ran toward D98. The fourth officer

arrived first and directed two crewmen to help her retrieve a fire hose. She said that as they

were unrolling the hose, the safety officer arrived and ordered her to call the bridge and

report the fire. At the direction of the bridge, the officers and crewmen then left the

smoke-filled cabin area and reported to either a marshalling area or an emergency station. 

Figure 2. When the first alarm sounded on the fire detection system control panel, the 

third officer ordered a quartermaster who was on duty on the bridge to go to the affected 

area (indicated by the circle) to determine whether the alarm was false. The dotted line 

shows the route of the quartermaster from the bridge to cabin D98.

3 The Nieuw Amsterdam did not have locally sounding smoke alarms in the accommodations areas.

4 The fourth officer is a junior deck officer on the ship.

Sun Deck
Accident Description 4 Marine Accident Brief Report

 Upon receiving the officer’s report of the fire and learning that the crewmembers

had not been successful in their firefighting efforts, the master, at 0919, ordered the

general alarm sounded. The general alarm alerted passengers of the need to proceed to

their muster stations and shipboard firefighting teams of the need to marshal at their

assigned staging areas. The master did not radio the chief officer to return to his

emergency station on the bridge. Instead, the master assumed the command and control of

firefighting operations; the duties of this position required him to coordinate the onboard

firefighting, control the spread of smoke and fire, handle the internal communications, and

coordinate the evacuation of passengers and crewmembers. He was still responsible for

performing his regular duties as master, as well as his own emergency command duties,

which, in this case, included making announcements to the passengers, identifying and

Figure 3. Plan view of a portion of D deck. The fire started in cabin D98. Within

6 minutes of the initial smoke alarm activation at 0911,detectors began to activate near

the crew stairwell forward of FSD D1.
Accident Description 5 Marine Accident Brief Report

navigating to a safe area to anchor, and handling the external communications with the

U.S. Coast Guard (Coast Guard), shoreside emergency response agencies and Holland

America’s shoreside offices.

As the chief officer was descending from the navigation deck to the area of the

fire, he said, he heard the general alarm and smelled smoke on C deck. He did not contact

the bridge to confirm whether he should report to his emergency station or to tell the

master that smoke had spread beyond D deck. When he reached D deck, he met the

quartermaster in the stairwell, standing by FSD D1, which was slightly open. The chief

officer grabbed and donned the quartermaster’s smoke mask and instructed him to keep

the door closed. 

The chief officer said that when he entered the main passageway, he observed “a

small amount of smoke.” He then walked through the passageway and adjacent corridors,

pounding on doors and yelling for people to evacuate. He said that while he walked along

the passageway toward cabin D98, he could feel heat radiating from the cabin’s inboard

bulkhead. He then saw “thick, white smoke” streaming through the louvers of the D98

door and observed that a layer of smoke about 1 meter thick had filled the upper area of

the passageway. He stated that he crouched beneath the layer of smoke and continued his

sweep of the area, checking to ensure that no crewmembers were in their cabins. He said

that as he approached WD15,5

 the WTD at the main vertical zone bulkhead, he found the

door partially open and an uncharged fire hose on the deck.

The chief engineer was in the engine control room when the first 0911 alarm

sounded indicating a smoke detector had activated in D98. When the general alarm

sounded at 0919, he checked the operation of the fire pump and mustered engineering

personnel. He said that he then left his emergency station to check the area of the activated

smoke detector because he had noted on the fire detection system’s repeater in the engine

room that the detector was not far from the engine room. Once on D deck, he saw the chief

officer near the partially open WD15. The chief engineer said that the chief officer told

him to stand by a fire hydrant valve. The chief officer then picked up the uncharged hose

and, crouching under the thickening layer of smoke, proceeded forward toward cabin D98.

(See figure 4.) Neither of the men had fire protection gear, such as a self-contained

breathing apparatus (SCBA), fire suit, gloves, or helmets. The only gear that the chief

officer wore was the smoke mask that he had taken from the quartermaster.

After positioning himself near the closed door of D98, the chief officer shouted at

the chief engineer to pressurize the hose line. The chief officer said that, while he stood in

front of cabin D98, he could feel intense heat radiating from it, an indication that the fire

was now fully developed. He partially opened the cabin door and could hear the fire, but

could not see any flames. He bent down low to the deck and sprayed a straight stream of

water into the cabin for about 30-40 seconds. He said that intense heat, white smoke, and

steam came rushing out of the cabin door, forcing him back, whereupon he dropped the

charged hose and retreated to WD15. He and the chief engineer then exited the area,

5 WD15 also serves as the FSD in this fire boundary.
Accident Description 6 Marine Accident Brief Report

closing the WTD behind them. Although the chief officer could not remember whether he 

had closed the door to cabin D98, subsequent events showed that he had not.

Firefighting Efforts

When the general alarm sounded, the ship’s firefighting assets mobilized, which

involved donning full fire protection gear at their assigned muster area. Holland America’s

emergency procedures for the Nieuw Amsterdam establish two onboard firefighting

organizations, Alpha squad and Bravo squad. (See table 1.) 

Each squad was to be composed of two attack teams. The Alpha squad was

responsible for vessel spaces outside engineering, which included the crew

accommodations areas, and the Bravo squad was responsible for the engineering spaces.

Figure 4. The attempt to extinguish the fire by the chief offier and the chief engineer.

D98

D1

WD15

The chief officer and the chief engineer did 

not don protective fire gear or arrange for 

backup in their attempt to extinguish the 

fully developed fire in crew cabin D98. 

When the chief officer directed a spray of 

water into the cabin, heat, smoke, and 

steam rushed out, causing the chief officer 

to drop the fire hose. He retreated to WD15 

without closing the door to D98 Chief Engineer

Chief Officer
Accident Description 7 Marine Accident Brief Report

The bridge ordered the Alpha squad to position itself forward of WD16 in

preparation for the assault on the fire. Only one of the two Alpha attack teams proceeded

to the area of the fire. This unit, the Alpha 1 attack team, had three, rather than four,

members and consisted of the fourth officer and two crewmen on the hose line. While the

Alpha 1 attack unit proceeded to D deck, it was joined by the Alpha squad commander and

assistant commander. On C deck, the group encountered smoke and donned SCBAs

before continuing. Once the group members reached D deck, they rigged a hose line. The

Alpha squad assistant commander then returned to C deck to turn off the electrical power

to WD15 and WD16 so that the fire teams could open them. The Alpha squad commander

and assistant commander both had UHF radios with which they could communicate with

the bridge and with the Bravo squad.

Table 1. Nieuw Amsterdam’s Firefighting Assetsa

a. Personnel records indicate that all Nieuw Amsterdam personnel designated as having a command or 

support role in a fire emergency had attended firefighting training, as required by the International

Convention on Standards of Training, Certification, and Watchkeeping for Seafarers. All unlicensed

personnel and deck officers had attended the basic firefighting course. In addition; all officers had attended

the advanced firefighting course, which discusses principles of command and control. Typically, the

recommended practice is for deck and engineering officers to direct the actions of the fire teams and not take

a lead position in firefighting activities such as handling the fire hoses. The ship’s log indicates that the

Nieuw Amsterdam conducted periodic emergency fire drills, as required by International Convention for the

Safety of Life at Sea (SOLAS).

Alpha Squad Bravo Squad

Commander Senior Second Officer (Safety Officer) Second Engineer

Asst. Cmdr. Third Officer Third Engineer

Responsibility All vessel spaces outside engineering Engineering spaces

Squad

Composition

Two attack teams

 • Alpha 1

 • Alpha 2

Hose preparation team

Staging area team

Two attack teams

 • Bravo 1

 • Bravo 2

Hose preparation team

Staging area team

Attack team 

composition

Four members

 Deck officer

 Three unlicensed crewmembers

 • Two attend the hose line

 • One serves as backup, assisting as 

 needed with donning and hoses

Four members

 Engineering officer

 Three unlicensed crewmembers

 • Two attend the hose line

 • One serves as backup

Fire gear Team members who are for entry and attack are fully suited in fire turnout gear and 

SCBA. The squad commanders and the attack team commanders carry UHF radios.
Accident Description 8 Marine Accident Brief Report

In the meantime, the master ordered the Bravo squad to position an attack unit at

WD15 and to backup the Alpha 1 team. The Bravo squad commander (the second

engineer) chose to have the Bravo 1 attack team consist of himself, the assistant squad

commander (the third engineer), and a day engineer. The third engineer had a UHF radio

with which to communicate with the master and with the Alpha squad. The Bravo 1 attack

team rigged a fire hose to extend from the boiler room toward WD15. While the team

members were proceeding down from C deck, they met the chief officer and the chief

engineer. The chief officer told the second engineer where the fire was and that a charged

hose line was unrolled on the deck, forward of WD15. The chief engineer returned to his

emergency station in the engine control room and the chief officer returned to the bridge to

assume the command of the firefighting efforts from the master. The chief officer said that

while he was en route to the navigation deck, he observed smoke on both C and B decks. 

About 0929, the Alpha 1 attack team and the Bravo 1 attack team both radioed the

master that they were in position, forward of WD16 and aft of WD15, respectively. The

master ordered the Alpha 1 team to attack the fire. The Alpha squad commander said that

he opened WD16 and a lot of black smoke rushed out, reducing visibility to almost zero.

The hose team advanced through FSD D1 into the passageway, giving shorts blasts of

water to the overhead and bulkhead panels. (See figure 5.) The team leader (the fourth

officer) followed the hose team. The squad commander indicated that because the team

leader was new to the ship, he followed her to monitor her actions. When the attack team

Figure 5. The Alpha 1 attack team’s effort to fight the fire was abandoned when the 

team’s leader, the fourth officer, collapsed.

D98

D1

WD15

When the Alpha 1 attack team entered 

the smoke-filled area through FSD D1, 

the fourth officer collapsed. The Alpha 

squad commander picked her up, 

carried her back through WD16 (not 

shown), and took her above deck. 

The other Alpha 1 team members also 

withdrew through WD16.

Fourth 

Officer
Accident Description 9 Marine Accident Brief Report

members were a few feet into the passageway, the team leader collapsed,6 and the squad

commander picked her up and carried her back through WD16. The rest of the Alpha team

followed, and they closed WD16 behind them. The squad commander then directed the

squad assistant commander to take command of the hose team and stand by while he took

the team leader to B deck. When the team leader appeared to be all right, the Alpha squad

commander later returned to D deck. 

At 0930, upon overhearing radio communications between the Alpha squad and

the bridge, the Bravo 1 attack team radioed the bridge that it was entering the area through

WD15. The second engineer said that he took the fire hose nozzle and led the attack. He

had the day engineer serve as backup on the hose and the third engineer follow with a

flashlight and a UHF radio. (See figure 6.)

The Bravo 1 attack team members entered the passageway on their knees. The

second engineer said that the main passageway was filled with thick black smoke but had

a light draft of air moving through it. He said that when he sprayed the overhead, he saw

burned paint hanging down but no flames. He did not see any flames in the passageway;

6 The fourth officer later stated that she believed that she must have panicked and passed out.

Figure 6. Upon hearing that the Alpha 1 attack team had withdrawn, the backup unit, in 

this case the Bravo 1 attack team, entered the area to fight the fire.

D1

WD15

The Bravo 1 attack team, comprised of the 

second engineer, the third engineer, and a 

day engineer entered through WD 15. 

The second engineer, on the hose nozzle, 

did not immediately see flames in the 

passageway. As he approached D98, 

however, he realized that the fire had 

spread beyond its compartment of origin.

D98
Accident Description 10 Marine Accident Brief Report

however, he heard a noise in the area of the overhead, which he thought was the bubbling

sound of paint burning. 

As the Bravo 1 attack team approached cabin D98, the second engineer realized

that the fire had progressed outside the cabin of origin. He said that he felt an increase in

temperature and could see flames on the deck in the main passageway and in a portside

corridor. He found the door to D98 open and saw flames inside the cabin. He said that,

while approaching cabin D98, he was spraying water in the main and other passageways

when he discovered that the hose line from the boiler room would reach no farther. He

retrieved the charged hose line that the chief officer had abandoned and resumed spraying

the decks and overheads. He then attacked the fire inside cabin D98. He said that after he

sprayed water into the cabin for several minutes, the flames were no longer visible. 

While the Bravo 1 attack team was fighting the cabin fire, the Bravo 2 attack team,

carrying a second hose line from the boiler room, arrived at WD15 and began working its

way forward toward FSD D1, spraying water on the fires in the passageways. A member

of the Bravo 2 team relieved the day engineer, who then returned to the engine room to

start the ventilation fans. When the low-pressure alarm sounded on the second engineer’s

air bottle, the third engineer relieved him. The hose teams continued spraying water until

all flames were extinguished on D deck. Shortly before 1000, all ventilation was restored

to evacuate the smoke and improve visibility, and the Alpha squad commander reported to

the bridge that the fire was under control. The teams continued with overhaul operations

and stood by for re-flash until about 1022, when the fire was declared out. (See figure 7.)

Figure 7. The gray area in this illustration shows the fire and smoke damage on D deck.

D

D1

WD15

At 1022, a little more than an hour 

after the first smoke alarm activated 

on the bridge, the fire was declared 

out. In this accident, smoke migrated 

up eight decks from D deck within 15 

minutes of the first detector activation.

98
Accident Description 11 Marine Accident Brief Report

Actions on Bridge

On the bridge, about the time when the quartermaster made his first report, the fire

control panel began indicating that multiple smoke alarms had activated. Between

0911, when the first smoke detector activated, and 0919, when the master ordered the

general alarm sounded, 15 smoke detectors activated on D deck. Of these, two detectors

were in the crew staircase by FSD D1. 

Upon receiving the report of a fire from the officer on D deck, the master made the

following announcements7 to the passengers and the crew, at 0920 and 0921, respectively:

Ladies and gentlemen, may I have your attention. This is your captain with an

important announcement for all guests and crew. We just received a fire alarm on

the D deck. We just received a fire alarm on D deck. Our fire squads are currently

checking out the situation. Please cooperate closely with the officers and crew in

following their instructions. There is no cause for alarm. We will keep you closely

informed.

This is an announcement for crew. There has been a fire reported on the D deck

aft; please evacuate the D deck; please evacuate the D deck. Fire squads report to

your fire stations, medical teams report to the infirmary, lowering squads report to

the bridge wings, passenger-assist team report to housekeeping office, traffic

directors report to dining room forward.

At 0923, a smoke detector activated in a crew stairwell on C deck. About 0925, the

master secured ventilation throughout the ship, closed the FSDs on D deck, and closed

WD15 and WD16. He next ordered all elevators secured, the engine room placed on

stand-by, and the emergency fire pump started. 

At 0928, a smoke detector activated in a crew stairwell on B deck. Shortly after

0930, the master began receiving reports from crewmembers that smoke was spreading

upward to decks C, B, and A. He conferred briefly with the Alaska State pilot on an

appropriate location to anchor the vessel in the event that the fire adversely affected

propulsion or steering. During this discussion, the pilot offered to call the Coast Guard

while en route to the anchorage, and the master accepted his offer. The pilot, however, had

problems contacting the Coast Guard because high mountains in the area interfered with

the VHF radio transmissions. A staff officer offered to help the pilot and attempted to send

a message via the ship’s satellite communication system; however, the staff officer was

not familiar with the equipment because operating it was not one of his duties. He

inadvertently sent a message with a distress priority without the master’s knowledge or

approval.8

 Another Holland America vessel in the area received the message and radioed

both the company’s shoreside office and the Coast Guard with news of the fire. At

1015, the Coast Guard radioed the Nieuw Amsterdam to determine the status of the fire. 

7 Taken from transcripts of recordings provided by Holland America

8 As a result of this incident, Holland America now requires that certain staff officers become qualified

in operating the ship’s satellite communication system.
Accident Description 12 Marine Accident Brief Report

At 0932, the fire detection panel indicated that a smoke alarm had activated in a

crew staircase on the main deck. At this time, about 20 minutes after the first smoke alarm,

the master began broadcasting announcements to clear some of the affected areas. After

ordering the low-location lighting turned on, he announced that all passengers on C deck

should move to a higher deck and that passenger-assist teams should check that all cabins

on C deck had been evacuated. The master then instructed the cruise director to assume

responsibility for making the evacuation announcements. By this time, the fire detection

panel indicated that a smoke detector had activated at 0936 in a crew stairwell on the

promenade deck. Shortly thereafter, about 25 minutes after the first smoke alarm, the chief

officer returned to the bridge and assumed the command of firefighting operations from

the master.

At 0941, or a half hour after the first alarm, the cruise director announced that all

passengers and crewmembers should move from C deck, B deck, A deck, and the main

deck to a higher-level deck. He then ordered the ship’s rescue squad to ensure that decks B

and A had been evacuated. Shortly after 0947, at the master’s instructions, the cruise

director announced that all passengers should move from inside the vessel to an outside

deck. He also directed passenger-assist teams and evacuation teams to check and, if

necessary, move anyone from the interior areas of the decks to an outside deck.9

Passenger Muster

According to shipboard personnel, when the general alarm sounded at 0919, most

passengers were either on the promenade deck (deck No. 7) or the sun deck (deck No. 10),

where they were observing the glaciers and listening to a commentary being given by a

ranger from the National Park Service. Some passengers were in their cabins, and “a small

number of passengers” were eating breakfast in the restaurant on the lido deck. 

Shipboard personnel said that, at the sounding of the general alarm, most

passengers listening to the commentary on the upper decks proceeded to their muster

stations, as directed in the practice drill held when the ship departed Vancouver.10 Also,

most passengers who were in their cabins retrieved their lifejackets and proceeded directly

to their stations. Some passengers returned to their cabins to retrieve their lifejackets. One

couple in the lido deck restaurant first finished their breakfast and then went to their cabin,

which was on B deck, to retrieve their lifejackets, medicine, and valuables. They said that

they also wanted to obtain warm clothing for the outside air. The couple said that when

they reached B deck, they observed the passageway was “a little smoky.” They estimated

that they stayed in their cabin about 6-7 minutes.

9 In postaccident interviews, the master stated that his primary concern during the emergency was to

move passengers outside and away from any smoke.

10 The Nieuw Amsterdam had conducted an emergency drill, which is required by SOLAS, shortly after

the ship left Vancouver. According to Holland America officials, during the drill, passengers had been told

that, if they heard the general alarm, they should retrieve their lifejackets and proceed to their muster

stations. They also had been told that, if they were not in their cabins, they should proceed immediately to

their muster areas and that lifejackets would be provided to them. 
Accident Description 13 Marine Accident Brief Report

Meanwhile, at the muster stations, crewmembers took roll of the assembled

passengers, as required by Holland America’s SMS, and informed the master that

passengers from a cabin on B deck and a cabin on main deck could not be accounted for.

The master then ordered evacuation teams with SCBAs to check the two cabins and decks

for the missing people. 

About this time, the two passengers who had returned to their cabin on B deck

exited their room and encountered thick smoke that severely reduced visibility. The

woman put her jacket over her face and moved aft along the passageway. She said that her

husband told her to get down near the deck. He followed her and shouted for help. She

said that as she neared a doorway and stairs, a crewmember grabbed her and led her to the

crew mess hall and then to the promenade deck. She then advised the crewmembers that

her husband was still on B deck.

According to the husband, when he crouched to move along the deck, he became

disoriented. He thought that he might have passed some exit doors (FSDs that were

closed) and that he might have blacked out at one point. He said that a crewmember

grabbed him and helped him up the stairs first to the crew mess hall and then to the

promenade deck to rejoin his wife. A shipboard medical team examined the couple to

determine the scope of their injuries. They were later evacuated by medical helicopter to a

hospital in Juneau, where the husband was admitted for treatment of injuries.11

About 1100, after the fire had been declared out, the passengers were moved inside

to the lounges and public spaces, which had been ventilated and cleared of smoke. About

an hour later, after all cabins on the lower decks had been checked, the passengers were

allowed to return to their rooms. The Nieuw Amsterdam weighed anchor and continued

with the cruise. However, when the bridge requested medical evacuation for the injured

couple who had been stranded on B deck, the Coast Guard asked the Nieuw Amsterdam to

proceed south. The ship subsequently received a Coast Guard Captain of the Port (COTP)

order to anchor in Bartlett Cove for a Coast Guard inspection. After officials from the

Alaska State Fire Marshal’s Office and the Coast Guard inspected the ship, Marine Safety

Office-Juneau issued a COTP order granting permission for the ship to resume its voyage. 

On May 25, when the Nieuw Amsterdam arrived in Seward, investigators from the

Safety Board and the U.S. Treasury Department’s Bureau of Alcohol, Tobacco, and

Firearms (ATF) boarded the vessel. Investigators interviewed the four crewmembers who

had occupied cabin D98. One crewmember stated that he had returned to his cabin to have

a cup of tea and had plugged in a coffee maker to heat the water when he was called back

to work. He said that he had switched off the coffee maker but had not unplugged it. He

recalled that all other electrical appliances were turned off. 

11 As a result of the investigations of the Nieuw Amsterdam fire and two prior fires on passenger ships,

the Safety Board issued recommendations regarding the installation of locally sounding smoke alarms to 18

cruise ship lines in July 2000. The text of the safety recommendation letters is on the Web at

<http://www.ntsb.gov.>
Accident Description 14 Marine Accident Brief Report

The ATF conducted a systematic examination of cabin D98 to determine the origin

and cause of the fire.12 Investigators observed burn patterns on the cabin bulkheads and

furnishings, indicating that the greatest heat and flame damage came from a point near a

small round table in the middle of the room, near the starboard bulkhead. (See figure 8.) In

examining the debris in this area, investigators found the remains of a coffeemaker and a

hot water kettle (electric). The ATF’s examination of the coffeemaker showed damage

indicative of heating and melting from the exterior to the interior of the appliance. The

coffeemaker’s internal heating element and associated electrical components were

undamaged. The remnants of the hot water kettle heating element showed metal distortion

indicative of internal heat damage that extended from the inside to the outside of the

appliance. Investigators eliminated other possible sources of ignition, including any other

electrical source and smoking materials, in this cabin area and concluded that the hot

water kettle was the source of the fire.

12 For further information, read: Department of the Treasury, Bureau of Alcohol, Tobacco and Firearms

Report of Investigation on the Nieuw Amsterdam Ship Fire, Case No. 787010-00-0070 (Washington, DC:

ATF 2000).

Figure 8. Plan view of crew cabin D98.

Area of Coffee Maker

and Hot Kettle

V

T

Area of

Electrical Outlets

Forward

Aft

Table

Double

Bunk

Double Bunk

Locker

Locker

Locker

Sink Locker
15 Marine Accident Brief Report

According to the ship’s safety officer, Holland America has had a long-standing

policy prohibiting cooking and water heating appliances in crew berthing areas. As a

result of the Nieuw Amsterdam fire and a fire on another Holland America ship, the

company issued a fleet advisory stating that any crewmember found to be cooking or in

possession of a cooking appliance in a crew cabin would be immediately terminated. The

advisory also stipulated that the masters of all vessels were required to have weekly

inspections, as well as unannounced, periodic random searches, of crew cabins to check

for cooking appliances.

Safety Issues

In its analysis of the Nieuw Amsterdam accident, the Safety Board identified the

following safety issues: the adequacy of shipboard training and drills in firefighting

management for masters and other officers; the adequacy of Holland America’s policies,

procedures, training, and drills for limiting and controlling the spread of smoke during a

fire; and the adequacy of Holland America’s safety management oversight of shipboard

firefighting operations. 

Company files indicate that all Nieuw Amsterdam officers and crewmembers

having a command or support role in a fire emergency, including the principals in this

accident, had attended firefighting training, as required by the International Convention

on Standards of Training, Certification, and Watchkeeping for Seafarers. The unlicensed

crewmembers had taken basic firefighting training, and the officers had taken basic and

advanced firefighting training. Holland America’s SMS, together with the Nieuw

Amsterdam’s station bill, established the shipboard organization and specified the

responsibilities of personnel during a fire emergency. Further, the vessel had conducted

the periodic crew fire drills required by SOLAS 74, as amended. 

Despite having received proper training and having performed frequent drills,

several key individuals, in particular, officers with command responsibilities during a fire,

did not follow accepted marine firefighting protocol and company shipboard procedures

during the actual emergency. When the fire on board the Nieuw Amsterdam was detected,

the fire was contained within cabin D98. Had several officers handled the emergency

differently, the fire might never have escaped from the confines of the cabin. Additionally,

the spread of smoke might have been curtailed, which would have reduced the risk of

injuries to passengers and crewmembers. 

Some crewmembers followed Holland America’s procedures during the

emergency. When the smoke alarm activated, the third officer in the pilothouse

immediately notified the master and dispatched one of the duty quartermasters to

investigate whether the alarm was false. The third officer advised the quartermaster to

carry a UHF radio and a smoke mask. The third officer’s actions were both timely and

appropriate for the circumstances and indicated that he knew how to respond to the

situation. The communication and personal protective equipment that the quartermaster

carried was adequate to reconnoiter the general area of the fire. The bridge officers,
Safety Issues 16 Marine Accident Brief Report

however, did not provide the quartermaster with a passkey that would have enabled him to

gain access to the cabin. 

When the quartermaster arrived on D deck and entered the passageway leading

toward cabin D98, he observed a light amount of smoke. He donned his smoke mask, a

prudent response to the conditions. At the door of cabin D98, he saw smoke issuing from

the ventilation louvers. He tried the door but found it locked, whereupon he immediately

radioed a report of his observations to the third officer on the bridge. The quartermaster’s

actions, therefore, provided the timely notification that should have enabled officers

having command responsibilities during fire emergencies to marshal shipboard

firefighters and systematically deal with the fire and smoke. 

The quartermaster then correctly attempted to clear personnel from the affected

area by shouting “fire” and pounding on the cabin doors to alert crewmembers of the need

to exit D deck. Only happenstance enabled the quartermaster to determine the scope of the

fire. His shouts alerted a cabin steward who happened to have a passkey and unlocked the

door of cabin D98. The quartermaster teamed with another crewman who had retrieved a

dry chemical extinguisher. After the men determined that it was safe to open the door, they

did so and discharged the extinguisher into the room. When a large volume of smoke

began to escape through the open doorway, they promptly closed the door. The

quartermaster radioed the bridge to report that he had not been able to extinguish the fire.

The actions of the quartermaster and the crewman were appropriate. Upon encountering

conditions that were not imminently dangerous, they tried to extinguish the fire; however,

upon finding the fire beyond their ability to extinguish, they immediately closed the door,

which contained the fire and most of the smoke.

The breakdown in the systematic handling of the emergency began with the

master’s initial response on the bridge. When the third officer told the master of the

quartermaster’s account of the smoke, the master’s first action was to violate his own

shipboard fire plan. He ordered the chief officer to go to the fire scene to investigate the

report instead of having him immediately report to the bridge, his assigned duty station in

the event of a fire. As the person in charge of the command and control of shipboard

firefighting operations, the chief officer belonged on the bridge, where he had access to

communications equipment, vessel plans, fire detection and suppression systems, and

remote controls for the ventilation systems, FSDs, and WTDs. From this central location,

he could receive reports from the fire squads on scene, assess the situation, and plan the

proper course of action. The master assumed the chief officer’s responsibilities, as well as

his own, which included the safe navigation of the ship, the internal and external

communications, and the overall management of the shipboard emergency to ensure the

safety of the passengers and crewmembers.

Holland America’s shipboard emergency procedures were based on the

assumption that the existence of a fire would be verified before the ship’s firefighting

assets were mobilized. In this case, the quartermaster had been appropriately tasked with

this responsibility. However, despite the quartermaster’s providing an early confirmation

of the fire and follow-up calls advising the bridge on the status of the fire, the master did

not immediately react. He did not sound the general alarm signaling the fire teams to
Safety Issues 17 Marine Accident Brief Report

marshal or broadcast a message alerting crewmembers on D deck to evacuate their

accommodations until he received a call several minutes later from an officer who

happened to be on D deck.

While the master was trying to juggle his own responsibilities and those of first

officer, additional crucial actions were not executed in a timely manner. The master lost

some degree of control over external communications and did not ensure that the Coast

Guard was contacted in a timely manner. Indeed, about an hour elapsed after the first

smoke alarm sounded before the Coast Guard received a relayed distress message from

another Holland American vessel and responded to the Nieuw Amsterdam emergency. If

the fire on the ship had been beyond the capabilities of the shipboard firefighters, the delay

in contacting the Coast Guard and arranging for additional resources could have had tragic

consequences.

Inefficient management contributed to the spread of smoke beyond the area of the

fire and increased the risk of injury to passengers and crewmembers. Following the

quartermaster’s report of the fire, the master continually received alarms indicating

worsening smoke conditions, yet he did not immediately order the progressive clearing of

the decks by the crew, the closing of FSDs as the smoke migrated to other decks, and the

ventilation secured in any area of the ship. Any of these actions could have dramatically

curtailed the spread of smoke throughout the Nieuw Amsterdam.

The master’s orders to secure certain areas were interspersed among his alerts to

passengers, communications with the fire squads, and other tasks, the result being that

decks were secured after, rather than before, they filled with smoke. For example, between

the time that the master alerted passengers to the fire (0920) and the time that he began

fielding communications from the fire attack squads (0929), smoke detectors had

activated in the crew staircase near FSD D1 on C deck and B deck, at 0923 and

0928, respectively. Yet, the master did not order passenger-assist teams to begin

evacuating decks and securing the areas until after the smoke had reached the main deck,

at 0932, more than 20 minutes after the initial alarm, at 0911.

If the chief officer had been on the bridge performing his command and control

duties, he or the master could have reviewed the printout from the fire detection panel and

determined that the crew staircase by FSD D1 was acting like a chimney, funneling smoke

to the upper decks. The printout, however, was not used to document and plan deck

closings. In addition, passenger-assist teams were not ordered into position at the fire

doors in a timely manner nor were they used as monitors to report on the effectiveness of

the deck clearing and door closings. 

The number of concurrent tasks that the master was trying to perform probably

adversely affected his ability to control the spread of smoke. If, however, Holland

America, and, in this case, the Nieuw Amsterdam, had had a systematic plan or specific

procedures for controlling the spread of smoke, the evacuation of the decks and the

appropriate management of door closings might have been achieved. Timely door closings

could have significantly limited, if not eliminated, the spread of smoke to other decks and

the consequent injury of a passenger whose cabin was two decks above the fire. At the
Safety Issues 18 Marine Accident Brief Report

very least, established shipboard procedures for controlling smoke would have enabled the

officers to monitor and manage smoke control measures. 

Smoke control problems were not limited to the bridge. Some crewmembers did

not recognize the importance of promptly reporting smoke. For example, the chief officer,

during his descent to D deck, failed to alert the bridge that he smelled smoke on C deck.

Such information might have assisted the master in directing smoke control activities. The

Safety Board notes that the ship’s log indicates that the Nieuw Amsterdam conducted

periodic fire drills as required by SOLAS and that Coast Guard reports indicate that

shipboard personnel had performed satisfactorily during a fire drill that was conducted as

part of the Coast Guard’s last quarterly examination.13

The focus during fire drills, however, is typically on firefighting. To maximize

safety on a passenger ship, procedures for managing the evacuation of passengers and

crew and for managing the control of smoke need to be established. For example,

crewmembers need to be trained to immediately report any progression of smoke, to

rapidly evacuate any passengers and crew from smoke-threatened areas, and to close

FSDs to prevent the migration of smoke any farther. Officers, too, need to be trained to

take proactive measures to prevent the migration of smoke and to direct the clearing of

decks where passengers and crewmembers might be located. Officers should be able to

use the fire control plan so that they can anticipate where smoke might migrate. They

should interactively coordinate with crewmembers to clear the decks and close FSDs.

They should be able to activate or shut down ventilation as appropriate. Follow-up drills

should be devised and practiced to feature different scenarios that test the abilities of the

officers and crew to respond to different smoke conditions. The Safety Board, therefore,

believes that Holland America should revise shipboard procedures for controlling smoke

to incorporate proactive measures that ensure the rapid clearing of passengers and crew

from decks and that prevent the migration of smoke. Further, Holland America needs to

devise and practice drills that feature different scenarios that test the abilities of officers

and crew to respond to varying smoke conditions.

During the early stages of the fire, the chief officer and the chief engineer

essentially abandoned their command roles, choosing to make a premature attack on the

fire without obtaining proper gear and arranging for backup. Their inappropriate actions

directly contributed to the spread of fire and smoke. 

While en route to D deck, the chief officer heard the general alarm, an indication

for the fire squads to marshal and don their gear. The Safety Board realizes that the chief

officer was directed by the master to investigate the fire. Given the chief officer’s

command position and duties in shipboard firefighting, however, he should have been

alerted by the general alarm to radio the bridge and verify whether he should return to the

bridge or continue to D deck to assess the fire. When the chief officer reached C deck and

encountered smoke, he failed to alert the bridge to the worsening conditions and to the

need to secure the ventilation and the FSDs in the affected areas. He also did not ensure

that WD15 and WD16 were secured to prevent the migration of smoke.

13 The examination was conducted on May 21, 2000.
Safety Issues 19 Marine Accident Brief Report

At FSD D1, the chief officer met the quartermaster, donned the latter’s smoke

mask, and proceeded toward cabin D98. While he walked toward cabin D98, the chief

officer encountered clear indications that the fire in the area was now fully developed.

Heat was radiating from the cabin’s inboard bulkhead, and thick, white smoke streaming

through the louvers of cabin D98’s door had filled the upper half of the passageway. He

then met the chief engineer who had left his emergency station in the engine control room

to check out the area where the smoke alarm had sounded. Neither man had protective fire

gear. They decided to fight the fire without obtaining proper clothing and equipment or

arranging for a backup hose team. When the chief officer sprayed water into the cabin,

intense heat, white smoke, and steam came rushing out of the cabin door, driving him back

and causing him to drop the hose. He retreated and rejoined the chief engineer, leaving the

door to cabin D98 ajar, which allowed the fire and smoke to escape its compartment of

origin and spread to the adjoining passageways. The chief officer and the chief engineer

then exited the area to return to the bridge and the engineroom, their respective emergency

stations. 

While the chief officer and the chief engineer were making their unsupported and

precipitate attack on the fire, some of the ship’s firefighting personnel had marshaled in a

timely manner and taken up positions forward and aft of the affected area. In fact, after his

abortive attempt to fight the fire, the chief officer met the Bravo 1 attack team members

near WD15 as they were descending from C deck. 

Some firefighting personnel handled the firefighting effectively, albeit not in

accordance with the ship’s station bill. The performance of the ship’s Bravo squad

members in attacking the fire demonstrated that they were trained and properly equipped

to extinguish the fire. They used proper technique in approaching the fire, backed one

another up during the evolution of the fire, and maintained effective radio

communications with each other and with the bridge. Their efforts resulted in the fire

being extinguished in short order, with no injury to any of the firefighters. Had the chief

officer and the chief engineer not acted precipitately during the early stages of the fire and

left the door to cabin D98 ajar, the regularly constituted and properly outfitted fire teams

would probably have extinguished the fire inside the cabin, and it might not have spread to

the adjoining passageways. The chief officer and the chief engineer took actions that

compromised the effectiveness of the ship’s firefighting capability, needlessly endangered

themselves, and risked the safety of the passengers and crew. 

The Safety Board is concerned that the chief officer, the chief engineer, and the

firefighting squad officers elected to serve as firefighters in this accident. The Board

recognizes that the chief officer and the chief engineer probably were motivated by the

desire to extinguish the fire as quickly as possible; however, their actions were ill advised

and actually made the situation worse, rather than better. Had either one of these two

officers been injured in their firefighting effort, the ship would have lost the benefit of his

knowledge and expertise during the emergency.

The same is true for the officers on the Bravo squad. Despite the fact that the

Bravo teams performed well and ultimately extinguished the fire quickly, the Safety Board

is concerned about the officers’ assuming forward attack positions without having
Safety Issues 20 Marine Accident Brief Report

replacements in their command and control positions. The Safety Board recognizes that

shipboard managers should have the discretion to organize the fire teams as they see fit.

Fire squad and fire team leaders should be able to use their firefighting assets where and

how the fire and smoke warrant. In this accident, however, if the officers saw the need to

personally attack the blaze, they should have arranged to have command and control

replacements, i.e., an acting squad commander and an acting assistant squad commander.

In particular, the squad leaders’ alignment in the attack order potentially jeopardized any

effort at effective command and control. By virtue of their regular shipboard assignments,

junior officers and unlicensed crewmembers lack the authority to order a senior officer out

of a potentially dangerous situation. If the second engineer and the third engineer had been

seriously injured or overcome by smoke, the handling of the emergency might have been

adversely affected. 

The Safety Board is somewhat reluctant to find fault with the actions of the Bravo

squad leaders because their attack teams were not intended to be the primary firefighters

in this accident. The Alpha squad, which was responsible for all ship areas other than

engineering, was first ordered to attack the fire. The management and the composition of

the Alpha unit, however, were not adequate for the emergency. The squad commander,

who was also the safety officer for the ship, did not position two attack teams. The attack

team that led the initial assault on the fire had an inexperienced leader. When she panicked

and fainted, the squad leader did not have the necessary people in position to handle the

setback. After he carried her out of the smoke-filled passageway, he chose to take her

above deck, thus removing himself from his command and control position. He should

have directed another person to attend to her and remained with the Alpha 1 team. Instead,

he left the management of the attack team to his second in command (the third officer);

however, the Alpha squad assistant commander did not have an officer to lead the attack

team or other resources adequate to safely continue the firefighting. The Alpha unit,

therefore, had to abandon its role as the primary firefighting unit. 

The Nieuw Amsterdam held regular fire drills in accordance with regulatory

requirements. While the training may have prepared the shipboard personnel to attack a

fire, the drills apparently did not adequately prepare some officers to appropriately assess

and manage a fire emergency.

The Safety Board considers it essential to the safe operation of ships that masters

and officers be able to fulfill their proper command and control functions during shipboard

fires. The Safety Board, therefore, believes that Holland America should revise shipboard

training and drills for its masters and other officers to include emphasis on their

management responsibilities during a fire emergency and the principles of command and

control of onboard firefighting activities. 

The International Management Code for the Safe Operation of Ships and for

Pollution Prevention14 requires that shipping companies conduct periodic internal and

external audits, i.e., management oversight, to ensure the continued adequacy of their

safety programs and to identify nonconformities that must be corrected to improve safety.

Shoreside management should be aware of whether shipboard activities during an

emergency are being conducted in accordance with the company’s written policies,
Safety Issues 21 Marine Accident Brief Report

procedures, and other directives, such as station bills. Only days before this accident, the

company conducted a fire training drill aboard the Nieuw Amsterdam in which company

officials evaluated the shipboard response as being in accordance with their policies,

procedures, and directives. During a real-life situation, however, the ship’s officers

seriously deviated from procedures. In particular, two senior officers attempted to fight a

fire without protective equipment or gear and failed to secure a smoke-filled area, thus

permitting smoke to travel upward through multiple decks. Because its most recent

oversight review did not reveal deficiencies that could, in another emergency, seriously

affect the safety of passengers, crew, and its ship, Holland America needs to reexamine its

process for evaluating how its shipboard management team fights fires and controls

smoke. The Safety Board, therefore, believes that Holland America should review and

revise, as necessary, its safety oversight procedures for assessing the effectiveness of its

training and drills for firefighting command and control and the effectiveness of its

procedures for controlling the spread of smoke during a shipboard fire.

About a month before the Nieuw Amsterdam accident, Holland America had a

crew cabin fire on another company vessel. During the postaccident examination of the

crew quarters following that fire, company officials found not only that some

crewmembers had been using prohibited cooking appliances in their cabins, but also that

some individuals had tampered with the cabin’s smoke detectors so that they would not

activate. Following the Nieuw Amsterdam fire, on May 25, 2000, the company issued a

fleet advisory stating that any crewmember found to be cooking or in possession of a

cooking appliance in a crew cabin would be immediately terminated. Further, any

crewmember found to have tampered with a smoke detector would be immediately

terminated. The advisory also stipulated that the masters of all vessels were required to

have weekly inspections as well as unannounced, periodic random searches of crew cabins

to check for cooking appliances and disabled smoke detectors. The Safety Board considers

the actions taken by Holland America to be appropriate. 

The events of the Nieuw Amsterdam accident, in particular, the poor handling of

the fire and smoke, the breakdown in firefighting command and control, and the

inadequate control of the crewmembers’ use of prohibited electrical appliances offer

lessons that, in the Safety Board’s opinion, might benefit other passenger ship companies.

The Safety Board believes that the cruise line companies, including their subsidiary

operating cruise lines, should review the circumstances of the May 23, 2000, fire on board

the Netherlands-registered passenger ship Nieuw Amsterdam, in particular, the

unauthorized use of electrical appliances by the crew and the company’s smoke control

management policies and procedures. Based on their review, the companies should make

changes, as appropriate, to improve fire safety on their ships

The Safety Board is aware that the International Maritime Organization’s Maritime

Safety Committee has established a working group to consider safety on large passenger

14 In 1994, the IMO adopted the ISM Code that, among other requirements, stipulated that

ship-operating companies establish an SMS that sets forth procedures for conducting normal shipboard

operations, as well as procedures for responding to potential shipboard emergencies, including fires. The

ISM Code became effective for passenger ships on July 1, 1998.
22 Marine Accident Brief Report

ships. The working group is considering safety on existing and future large passenger ship

from a global perspective, that is, from an overall systems-safety approach. In reviewing

large passenger ship safety issues, the working group is also considering matters related to

the human element, such as operations, management, and training. The Safety Board

believes that the Coast Guard should submit the lessons learned from the Nieuw

Amsterdam’s accident, in particular the need for proper firefighting management and the

need to control the spread of smoke, to the IMO working group for its consideration. 

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the fire on board the Nieuw Amsterdam was the unauthorized use of an electrical appliance

that had been left unattended and plugged into an electrical outlet in a crew cabin.

Contributing to the extent of the fire damage and spread of smoke was a breakdown in

firefighting command and control by the vessel’s master and senior officers.

Recommendations

As a result of its investigation of this accident, the National Transportation Safety

Board makes the following recommendations:

To the U.S. Coast Guard:

1. Submit the lessons learned from the National Transportation Safety Board’s

investigation of the Nieuw Amsterdam accident, in particular, the need for

proper firefighting management and the need to control the spread of smoke to

the International Maritime Organization’s Working Group on Large Passenger

Ship Safety for their consideration.

To Holland America Lines, Inc.:

2. Revise shipboard training and drills for your masters and other officers to

include emphasis on their management responsibilities during a fire emergency

and the principles of command and control of onboard firefighting activities.

3. Revise shipboard procedures for controlling smoke to incorporate proactive

measures that ensure the rapid clearing of passengers and crew from decks and

that prevent the migration of smoke. 

4. Devise and practice drills that feature different scenarios that test the abilities

of officers and crew to respond to varying smoke conditions.
Recommendations 23 Marine Accident Brief Report

5. Review and revise, as necessary, your safety oversight procedures for assessing

the effectiveness of your training and drills for firefighting command and

control and the effectiveness of your procedures for controlling the spread of

smoke during a shipboard fire.

To American Classic Voyages, Carnival Corporation, Inc., Crystal Cruises, Disney

Cruise Line, Norwegian Cruise Line, Orient Lines, P&O Princess Cruises

International, Ltd., Radisson Seven Seas Cruises, Regal Cruises, Renaissance

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

Cruises, Ltd.:

6. Review the circumstances of the May 23, 2000, fire on board the Netherlandsregistered passenger ship Nieuw Amsterdam, in particular, the unauthorized use

of electrical appliances by the crew and the company’s smoke control

management policies and procedures. Based on your review, make changes, as

appropriate, to improve fire safety on your ships.

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: July 24, 2001