/

PB96-916401

NTSB/MAR-96/01

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT REPORT

FIRE ON BOARD THE U.S. FISH PROCESSING VESSEL

ALASKA SPIRIT, SEWARD, ALASKA, MAY 27, 1995

6594A
Abstract: About 0200 on May 27, 1995, the U.S. fish processing vessel ALASKA SPIRIT

caught fire and burned while moored alongside a dock at the Seward Marine Industrial Center,

Seward, Alaska. Firefighters extinguished the fire at 1100. The master of the vessel died, and

damage to the vessel was estimated at $3 million.

The safety issues addressed in the following report are: adequacy of noncombustible

construction standards for uninspected commercial fishing industry vessels; adequacy of fire

detection and fire suppression equipment; drills and readiness of on-board firefighting hoses; and

existing vessel fire safety standards.

As a result of its investigation, the National Transportation Safety Board made safety

recommendations to the U.S. Coast Guard, The Fishing Company of Alaska, Incorporated, the

Commercial Fishing Industry Vessel Safety Advisory Committee, and the National Fire

Protection Association.

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.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza East, S.W.

Washington, D.C. 20594

(202) 382-6735

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
FIRE ON BOARD THE U.S. FISH PROCESSING

VESSEL ALASKA SPIRIT, SEWARD, ALASKA,

MAY 27, 1995

MARINE ACCIDENT REPORT

Adopted: June 11, 1996

Notation 6594A

National

Transportation

Safety Board

Washington, DC 20594

iii

CONTENTS

ACRONYMS .................................................................................................................... vi

EXECUTIVE SUMMARY.............................................................................................vii

INVESTIGATION ............................................................................................................ 1

Accident .............................................................................................................................. 1

Fire .......................................................................................................................... 5

Emergency Response and Fire Extinguishing....................................................... 11

Injuries............................................................................................................................... 14

Vessel Damage.................................................................................................................. 14

Crew Information .............................................................................................................. 15

Staffing.................................................................................................................. 15

Master.................................................................................................................... 15

Chief Engineer....................................................................................................... 15

Assistant Engineer................................................................................................. 15

Cook ...................................................................................................................... 15

Processor-deckhands ............................................................................................. 16

Watchman.............................................................................................................. 16

Vessel Information ............................................................................................................ 16

Firefighting Equipment ......................................................................................... 17

Survival Equipment............................................................................................... 17

The FCA................................................................................................................ 18

Waterway Information....................................................................................................... 18

Meteorological Information .............................................................................................. 18

Postaccident Vessel Examination...................................................................................... 19

Hull Structure and Construction............................................................................ 19

Wreckage............................................................................................................... 20

Medical, Pathological, and Toxicological Information..................................................... 24

Drills.................................................................................................................................. 25

Tests and Research ............................................................................................................ 26

Possible Ignition Sources ...................................................................................... 26

Battery Charger Examination.................................................................... 26

Cook Pot Examination .............................................................................. 26

Heat Detector Testing............................................................................................ 27

Other Information.............................................................................................................. 28

Coast Guard Regulations....................................................................................... 28

Standards Applicable to Industrial Vessels........................................................... 30

Building Codes...................................................................................................... 31
iv

Life Safety Code.................................................................................................... 31

U.S. Fishing Fleet.................................................................................................. 32

Accident Statistics................................................................................................. 33

Coast Guard Oversight of Fish Processing Vessels .............................................. 33

Survival Factors................................................................................................................. 34

Fire Control Efforts ............................................................................................... 34

Notification Procedures......................................................................................... 34

Local Contingency Planning ............................................................................................. 34

City of Seward....................................................................................................... 34

Western Alaska Marine Firefighting Contingency Plan........................................ 35

ANALYSIS....................................................................................................................... 38

General .............................................................................................................................. 38

Source of Ignition.............................................................................................................. 38

Fire Safety Standards......................................................................................................... 41

Construction .......................................................................................................... 41

Fire Detection Equipment ..................................................................................... 43

Fire Suppression Equipment ................................................................................. 44

Existing Standards................................................................................................. 45

Fire Hose ............................................................................................................... 46

Survival Factors................................................................................................................. 47

Reporting of Fire ................................................................................................... 47

Drills...................................................................................................................... 47

Significance of the ALASKA SPIRIT Investigation......................................................... 48

Toxicological Test Results................................................................................................ 48

Carboxyhemoglobin (COHb)................................................................................ 49

Alcohol.................................................................................................................. 49

CONCLUSIONS ............................................................................................................. 50

PROBABLE CAUSE ...................................................................................................... 51

RECOMMENDATIONS................................................................................................ 51
v

APPENDIXES

Appendix A -- Safety Board Investigation........................................................................ 55

Appendix B -- Crew Licensing Information .................................................................... 57

Appendix C -- Battery Charger Examination.................................................................... 59

Appendix D -- Global Fire and Safety, Inc., Heat Detector Test Report ......................... 61

Appendix E -- Building Codes.......................................................................................... 69

Appendix F -- Conditions Reported by the SVFD Fire Chief that Affected ALASKA

SPIRIT Firefighting................................................................................... 71

Appendix G -- Toxic Effects of Carboxyhemoglobin Saturation ..................................... 73

Appendix H -- Master’s Blood Alcohol Level.................................................................. 75

FIGURES AND TABLES

Figure 1 ----- Port side view of the ALASKA SPIRIT while moored at Seward, Alaska... 2

Figure 2 ----- Accident site .................................................................................................. 3

Figure 3 ----- Plan of the ALASKA SPIRIT........................................................................ 6

Figure 4 ----- Plan of the ALASKA SPIRIT (continued) .................................................... 7

Figure 5 ----- Enlarged plan view of the 02 deck................................................................. 8

Figure 6 ----- View of the deckhouse from the trawl deck .................................................. 9

Figure 7 ----- Forward bulkhead of 02 deck ...................................................................... 19

Figure 8 ----- The ALASKA SPIRIT’s fire-damaged wheelhouse.................................... 21

Figure 9 ----- 02 deck fire damage..................................................................................... 21

Figure 10---- Chase in wheelhouse.................................................................................... 22

Figure 11---- Fire pattern around cook pot........................................................................ 23

Table 1 ------ Comparison of various fire safety regulations............................................. 36
vi

ABS --------------American Bureau of Shipping

ASTM ------------American Society for Testing Materials

BAC -------------- blood alcohol concentration

BOCA ------------ Building Officials and Code Administrators International

CFR -------------- Code of Federal Regulations

CHT -------------- Center for Human Toxicology

CO ---------------- carbon monoxide

COHb ------------ carboxyhemoglobin

COTP ------------ Coast Guard Captain of the Port

DNV -------------- Det Norske Veritas

EPIRB ----------- Emergency Position Indicating Radio Beacon

FCA -------------- Fishing Company of Alaska, Inc.

ICBO ------------- International Conference of Building Officials

LSC -------------- Life Safety Code

NBC -------------- National Building Code

NFPA ------------ National Fire Prevention Association

NVIC ------------- Navigation and Vessel Inspection Circular

RPU -------------- rigid polyurethane

SBC -------------- Standard Building Code

SBCCI ----------- Southern Building Code Congress International, Inc.

SCBA------------- self-contained breathing apparatus

SECC ------------ Seward Emergency Communications Center

SMIC ------------ Seward Marine Industrial Center

SVFD ------------ Seward Volunteer Fire Department

UBC -------------- Uniform Building Code

USC -------------- United States Code

USCG ------------ United States Coast Guard

USSG ------------ United States Standard Gauge

ACRONYMS
vii

EXECUTIVE SUMMARY

About 0200 on May 27, 1995, the U.S. fish processing vessel ALASKA SPIRIT

caught fire and burned while moored alongside a dock at the Seward Marine Industrial

Center, Seward, Alaska. Firefighters extinguished the fire at 1100. The master of the

vessel died, and damage to the vessel was estimated at $3 million.

The National Transportation Safety Board determined that the probable cause of

the fire aboard the ALASKA SPIRIT was the failure of The Fishing Company of Alaska,

Incorporated, to address the inadequate fire safety conditions and practices on the vessel.

Contributing to the severity of the damage and the loss of life was the lack of fire safety

standards for commercial fishing industry vessels.

The safety issues discussed in this report are:

• Adequacy of noncombustible construction standards for uninspected

commercial fishing industry vessels.

• Adequacy of fire detection and fire suppression equipment.

• Drills and readiness of on-board firefighting hoses.

• Existing vessel fire safety standards.

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

safety recommendations to the U.S. Coast Guard, The Fishing Company of Alaska,

Incorporated, the Commercial Fishing Industry Vessel Safety Advisory Committee, and

the National Fire Protection Association.

Accident

Following a fishing voyage, the U.S.

fish processing vessel1 ALASKA

SPIRIT (see figure 1) arrived in Dutch

Harbor, Unalaska Island, Alaska, on

May 19, 1995. Prior to the vessel’s

departure, 35 crewmembers and a U.S.

National Marine Fishery Service

observer debarked, reducing the vessel

complement (including the master) to 11

persons. According to the engineroom

log, the vessel departed from Dutch

Harbor about 11002

 on May 21. It

arrived at the Seward Marine Industrial

Center (SMIC) docks (also known as the

Fourth of July docks), located north of

the Fourth of July Creek and across

Resurrection Bay from downtown

Seward (see figure 2), at 1130 on May

24. At Seward, 3 crewmembers

debarked, reducing the crew to 8

persons: the master, chief engineer,

 1A fish processing vessel is defined under

Title 46 United States Code (USC) 2101 (11b) as

“a vessel that commercially prepares fish or fish

products other than by gutting, decapitating,

gilling, skinning, shucking, icing, freezing, or

brine chilling.” Processing activities can include

mincing, filleting, preparation of fish meal,

boiling (crab), or a combination of these which

prepares the seafood for direct marketing and

often includes packaging the product. This type

of fish processing vessel also catches fish with a

trawl net and is also known as a “factorytrawler.” The term “factory” refers to the fish

processing operation, while “trawler” refers to

the method of fishing it uses. A trawler catches

fish in a net (which can be compared to a funnel)

towed astern.

2

All times noted herein are given in Alaska

daylight time.

assistant engineer, cook, and 4

processor-deckhands (deckhands).

The remaining crew stayed on board

to repair, maintain, and prepare the

vessel for the next fishing voyage, which

was scheduled for about July 1. No deck

or engineering watches were stood

during this period, but work in various

parts of the vessel was carried out during

the day. Some engineroom equipment

remained operating to provide vessel

hotel services.

A company-hired night watchman

(watchman) testified that he made

rounds about every hour from 1900 to

0700 to check on the safety and security

of the ALASKA SPIRIT and the

ALASKA RANGER.3

 The watchman

said he would meet with the ships’

master or mate and chief engineer or

assistant engineer each evening. These

officers would advise the watchman

about specific items to check on that

night and tell him who he should notify

if he found something out of the

ordinary. He would routinely adjust

mooring lines as necessary, check

operating engines, and look for

indications of flooding and any other

factors that could adversely affect the

vessels’ safety.

 3

The ALASKA RANGER was a trawler-fish

processing vessel operated by The Fishing

Company of Alaska, Inc., that was moored at an

adjacent dock, preparing for its next fishing

voyage.

INVESTIGATION
2
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0

14*S W 149-20w

Figure 2 — Accident site

3
4

After completing his security check

on the ALASKA RANGER, the

watchman would board the ALASKA

SPIRIT to conduct a similar security

check of that vessel. A complete security

check would include a walk through the

engineroom, factory deck, accessible

accommodation spaces, and the

wheelhouse. He would also check

mooring lines and the gangway. Each

round on a vessel took about 10-15

minutes. The watchman reported that,

after completing rounds on both vessels,

he would station himself in the

wheelhouse of the ALASKA RANGER.

From there, he would observe the

gangways of both vessels and stop

unauthorized persons from boarding.

According to the ALASKA SPIRIT’s

cook, on May 26 he first spoke with the

vessel’s master about 0800, when the

master came to the galley for coffee. The

cook next saw the master when he went

to the wheelhouse around 1100 or 1130

to chat. At that time, however, the

master was on the telephone to his wife,

so the cook returned below. The cook

said that he went back upstairs about

1210 to take the master his lunch. The

cook testified that the master went to

town after lunch and returned about

1500. The cook’s last conversation with

the master took place in the galley

sometime between 1700 and 1730. The

cook told the master that he would like

to go to Anchorage that evening, to

which the master replied, “Okay, James.

See you later.” The cook left the vessel

about 1810.

The chief engineer had several

conversations with the master on the day

before the accident. He stated that he

spoke with the master about 1000, when

he went to the wheelhouse to borrow a

tool, and again at 1100 when he returned

the tool to the master. After completing

work sometime after 1900, the chief

engineer and the master met on the

bridge deck, where they talked about

sport fishing. The chief engineer last saw

the master about 2000, when he went to

the master’s room to borrow a

videocassette. According to the chief

engineer, the master said that he

intended either to read a book or watch a

movie before going to bed.

The chief engineer said that after

leaving the master he watched a movie,

played an electronic game, and went into

the engineroom about midnight to check

the engineroom and operating

equipment. He found nothing out of the

ordinary. He checked the power board

(switchboard) and found no indication of

any electrical short circuits. He then

went to the galley for a snack, picked up

an audiocassette from the factory deck,

and returned to his room. He listened to

some music, played some more

electronic games, and went to sleep.

The assistant engineer testified that,

after finishing his day’s work about

1700, he went to bed and read in his

room—located forward of the galley in

the athwartships (cross) corridor. About

midnight, he went to the engine control

room and looked through some manuals.

About 0130-0145, he went to his room

and read. At no time during this entire

period did he see, hear, or smell anything

out of the ordinary.
5

About 2130 on May 26, the four

deckhands were in the port-forward

crewroom on the 02 deck (see figures 3,

4, and 5) discussing their off-duty plans

for the evening. Three of the four

deckhands decided to go into town. They

departed the vessel about 2200. The

remaining deckhand left the crewroom,

stopped briefly in the galley, and went to

his room (a four-person room on the

forward starboard side of the 01 deck) to

sleep. About 0100 on May 27, one of the

three deckhands who had gone into

Seward returned to the vessel and signed

in on a chalkboard in the galley. He

retired to his room on the 01 deck port

side aft (at the foot of the inside stairwell

to the 02 deck) and apparently went to

sleep.

Fire -- Shortly before 0200, after

completing his round on the ALASKA

RANGER, the watchman walked to the

ALASKA SPIRIT, about 500 feet away.

When asked by investigators about his

previous round that evening on the

ALASKA SPIRIT, he stated that

It just seemed like there was

nothing unusual or anything to

make me cause any attention. It

just seemed like everything was

OK that night.

 He also testified that he did not notice

anything unusual as he made his way to

the ALASKA SPIRIT and commenced

his round in the engineroom. After

checking the engineroom wearing ear

protection, he went up to the starboard

side of the factory deck and took his ear

plugs out. At this time, he heard the fire

alarm. He went up to the net retrieval

area (trawl deck) and walked toward the

chief engineer’s room on the port side aft

on the 01 deck accommodation area. He

saw the door to the chief engineer’s

room ajar, indicating to him that the

chief engineer was awake. The

watchman then went out to the trawl

deck and saw the cook.

The cook testified that he returned by

car from Anchorage at 02044

 on May 27

and parked near the ALASKA SPIRIT’s

gangway. He was walking towards the

ALASKA SPIRIT’s gangway when he

noticed flames and smoke on the 02 deck

aft port door and in the wheelhouse (see

figure 1). As the cook headed toward the

01 deck, he met the watchman, who had

just exited the engineroom stairwell on

the trawl deck. He climbed the outside

stairwell from the 01 deck and looked

into the 02 deck aft doors (see figure 6).

The cook saw flames on the port side

corridor in the overhead, and heavy

smoke about a third of the way down

from the overhead. He saw flames in the

toilet to the left and inside the port door.

The flames extended along the overhead

of the port corridor down to the toilet to

the right of the door. The stairwell to the

wheelhouse was filled with thick smoke.

On the starboard side corridor, he

noticed a little smoke along the overhead

but no fire.

The watchman left the vessel and ran

to the ALASKA RANGER, where he

telephoned the Seward Emergency

Communications Center (SECC) to

notify them of the fire. The call was

logged in about 0213.

 4

The cook noted the time from a clock in his

car. A Seward fire investigator later checked the

clock and verified that it was accurate to within

30 seconds of the dispatch clock.

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02 Deck

Toilet

P

I%dlr7 ,Fan

3-Crew

(cooks)

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Room

Figure 5 — Enlarged plan view of the 02 deck
Figure 6 — View of the deckhouse from the trawl deck, looking forward

(courtesy NFPA, Quincy, Massachusetts)

9
10

The watchman only asked if SECC

knew about the fire. After receiving an

affirmative reply, the watchman hung

up. He provided no further information,

nor did the SECC operator request that

he provide any or identify himself.

While on the ALASKA RANGER, the

watchman woke the vessel’s two

engineers, who returned with him to the

ALASKA SPIRIT to assist in the

firefighting activities.

The chief engineer testified that the

fire alarm woke him. He dressed and left

his room. He saw the assistant engineer

and a deckhand in the corridor outside

his room on the port side aft on the 01

deck. (The assistant engineer testified

that he had been reading in his room

when he heard the alarm at 0200 and got

up to investigate.) The chief engineer

attempted to go up the inside stairwell

on the port side to the 02 deck where he

noticed “smoke, fumes, and felt the heat,

and saw the glow through the smoke of

fire.” He retreated and told the assistant

engineer that “we were in trouble, we

were on fire.” The assistant went to the

engineroom and started the fire pump.

The deckhand who had not visited

Seward that evening said he was asleep

in the four-person room forward on the

starboard side of the 01 deck when the

vessel’s fire alarm woke him. He

dressed, went into the corridor, and

followed the assistant engineer aft on the

01 deck. On the way, he checked the

door to the five-person room on the port

side by the stairwell to the 02 deck and

found it locked. He smelled smoke and

remarked to the assistant engineer that

the door of the room was locked, and he

thought a deckhand was inside. The

assistant engineer kicked the door open,

removed the sleeping deckhandand

carried him to the trawl deck.

The deckhand who had been

awakened by the alarm attempted to go

up the inside stairwell to the 02 deck. He

said that he “wanted to have a look”

because he thought that the other two

deckhands might be sleeping in their

room on the port side forward. He went

up far enough to peer through the

doorway on the 02 deck. From there he

saw something burning on the deck to

the left of the doorway. He testified that

“I said burning floor, but now that I

think about it, it was probably boots,

‘cause I’d seen them in the hallway.” He

also saw a single row of flames in the

overhead of the 02 deck corridor.

He stated that “...there was black

stuff dripping5

 out of the ceiling

(overhead in the stairwell)” and “there

was a lot of heat.” The smoke was not

thick or heavy. He further stated that

“soon as I saw flames on top (overhead),

I forgot about going up there (onto the

02 deck).” He retreated down the

stairwell and exited aft on the port side

of the 01 deck. He assisted the cook in

putting water on the fire until the

shoreside firefighters arrived. He then

assisted them as requested.

The chief engineer attempted to

survey the fire from the exterior decks.

 5

Thermoplastics (such as polystyrene and

polyurethane foam insulation) will melt and drip

in a fiery environment. Also, the thin coating on

the bulkhead paneling was a plastic type of

material that, when heated, could have resulted in

a black liquid.
11

As he was climbing the exterior stairway

and approaching the 02 deck port door,

the door window blew out. He returned

to the 01 deck and attempted to survey

the fire from the trawl deck. He also had

the crew lay out (unroll) fire hoses from

the port and starboard midships fire

stations.

The ALASKA SPIRIT was equipped

with two different types of fire hose — a

1 1⁄2-inch standard hose and a

nonstandard Armtex hose. The hose6

 that

the cook selected for use on the port fire

station hydrant was an Armtex hose,

which has a nonstandard coupler,

smaller in diameter than the vessel’s

hydrant hose connection. To attach

Armtex hoses to such hydrants required

an adapter hose coupling. Recognizing

this incompatible situation, the chief

engineer immediately returned to his

room on the 01 deck and retrieved an

adapter to mate the 1 1⁄2-inch hydrant

hose connection to the smaller Armtex

coupling. The vessel carried at least

three such adapters, which were kept in

the chief engineer’s room.

The chief engineer handed the cook a

fire hose and told him to spray water

onto the 02 deck outside port door. The

cook stated that the fire intensified

within the first 5 minutes of this

spraying. About 5-10 minutes later, he

saw flashing lights from a police car;

about 5 minutes after that, he heard a fire

truck siren, signaling the arrival of

shoreside firefighters at 0220. The cook

assisted the shoreside firefighters until

the fire was extinguished.

 6

“Hose” refers to one or more sections of

hosing that may be connected to form a single

hose unit.

After handing the hose to the cook,

the chief engineer went to the

engineroom and aligned the ship’s

general service and seawater service

pumps to operate with the fire pump.

The two engineers from the ALASKA

RANGER arrived and assisted in laying

out hose and spraying water inside the

port 01 deck inside stairwell to prevent

fire from “walking down” from the 02

deck.

In the first 20 minutes after the fire

erupted and as land-based firefighters

responded, the crew of the ALASKA

SPIRIT and two engineers from the

ALASKA RANGER conducted the

firefighting operations. Guided by the

ALASKA SPIRIT’s chief and assistant

engineers, the crew attempted to spray

water into the interior stairwell between

the 01 and 02 decks using two 1 1⁄2-inch

hose lines.

The crew fought the intensifying fire

at the 02 deck port side door and at the

01 deck interior stairwell. The chief

engineer also had the two deckhands

move about 30-40 cans of oil-based

paint from the aft 01 deck corridor to the

trawl deck.

Emergency Response and Fire

Extinguishing -- About 0209, while

listening to a CB scanner, a Seward taxi

driver overheard persons aboard two

unidentified vessels discussing a fire that

they could see. According to them, the

fire appeared to be aboard a vessel at the

SMIC docks. The taxi driver phoned the

information to the SECC.

At 0211, the Seward Volunteer Fire

Department (SVFD) dispatched a fire

pump truck and a medical rescue vehicle
12

from the main fire station in Seward,

approximately 7-8 miles from the dock.

Additionally, the deputy fire chief and

four firefighters responded to the SMIC

area, where a fire pump truck and a

medical rescue vehicle were already prepositioned at a fire station within several

hundred yards of the moored ALASKA

SPIRIT. Fire response personnel drove

these units directly to the dock.

At 0217, the SVFD fire chief told the

SECC dispatcher to request mutual aid

from the Bear Creek7

 Volunteer Fire

Department. Eventually, 30 firefighters

from the two volunteer fire departments

were involved in the firefighting effort.

About 0220, the deputy fire chief of

the SVFD arrived on-scene at the

ALASKA SPIRIT dock. He observed

brownish-gray smoke coming from the

upper deck of the vessel, but no flames.

Shortly afterwards, the SVFD fire

chief arrived on-scene and saw heavy

smoke and flames coming from the 02

deck and wheelhouse access. As the

incident commander, the fire chief

boarded the vessel to assess on-board

conditions and met with the ALASKA

SPIRIT’s chief engineer. He established

a command post, manned by the deputy

fire chief, at the fire pump truck, which

was positioned at the shoreside hydrant.

The chief engineer said three

crewmembers were unaccounted for (the

master and two deckhands), and he

thought they were trapped on the 02

deck. Additionally, the chief engineer

showed the hull arrangement plan

 7

A community to the north of Seward and

about 9 miles from the fire.

entitled “safety plan” to the fire chief. He

advised the fire chief that the crew had

searched all of the lower decks, but fire

kept them from searching the

accommodation area on the 02 deck.

(Later that morning, during the shoreside

firefighting operation, the two deckhands

who had been in Seward arrived at the

vessel.) The crew continued to fight the

fire by spraying water onto the interior

port side 01 deck stairway and onto the

exterior port side 02 deck door.

Following his survey of the accident

scene, the fire chief decided:

• To use all land-based fire

suppression equipment rather

than the equipment on the

ALASKA SPIRIT, because he

did not know if the fire

suppression equipment on the

ship was reliable. In addition,

the land-based firefighters

wore self-contained breathing

apparatus (SCBAs) and were

more familiar with their own

equipment than the shipboard

apparatus. (The assistant

engineer later stated that,

although there were two

SCBAs on the ALASKA

SPIRIT, the crew had had no

time to don them.)

• To attack the fire at the port

side door on the 02 deck in an

attempt to rescue the master.

• To continue the hose attack at

the interior stairwell to prevent

the fire from walking down the

stairs to the 01 deck.

While the fire chief was making his

survey, the deputy chief pulled hoses

from the fire engines and laid a supply
13

line between the engine and the closest

fire hydrant, which was several hundred

feet away.

8

 The hoses were laid from the

engine to the gangway area to the trawl

deck. The 1 3⁄4-inch hose attack lines

were used rather than larger hose lines

because they allowed firefighters greater

mobility within the narrow corridors on

the vessel.

About 0230, firefighters preparing for

entry into the port door on the 02 deck

found the corridor filled with a “thick,

dark-black, gritty smoke” extending

from the overhead to the deck. As the

firefighters crawled into the port side

corridor, they heard crackling noises

coming from all sides, but no flames

were visible due to the heavy smoke.

About 2 feet from the assistant fish

master’s room door, the firefighters

adjusted their nozzle to provide a semifog pattern, but they could not endure the

intense heat in this area and returned to

the open deck. The firefighters attempted

two or three more attacks using various

water streams through the port door on

the 02 deck, but they could not reach the

master’s room (which was across the

corridor from the assistant fish master’s

room). The fire continued to burn out of

control.

The fire chief later stated that,

because intense heat forced the

firefighters off the 02 deck and the

firefighters on the 01 deck could not go

up the inside stairwell due to heat, they

could not reach the ship’s master at that

 8

Engine 4 laid a 5-inch supply line from the

hydrant to the pier where the vessel was moored.

The deputy chief had two 2 1⁄2-inch hose lines

laid to the deck of the vessel and connected four

1 3⁄4-inch hose lines.

time. He focused tactical efforts on fire

control.

As evidenced by the heat-caused

breaking of the wheelhouse windows,

the fire intensified in the wheelhouse and

on the 02 deck at about this time. The

fire chief decided that he could not

attack the fire in the wheelhouse because

it was being fed by the flames coming

from the 02 deck. Firefighters in the

starboard corridor saw that the steel

bulkhead on the starboard side of the

assistant fish master’s room was glowing

red. They realized that there was an

intense fire in the room.

Eventually, the vessel’s fire pump

failed, as the fire consumed the

wheelhouse and the circuitry for the fire

pump. Because responding firefighters

had already charged their hose lines from

shore, fire suppression efforts were not

interrupted. Crewmembers reported that,

with both the general service and

seawater pumps on-line, there was no

noticeable interruption in flow rate when

the vessel’s fire pump failed. They

directed hose streams on the vessel’s

fuel tank vents on the 02 deck near the

deckhouse to dissipate heat and disperse

fuel oil vapors to prevent fuel tank

ignition.

At 0326, the fire chief had the SECC

operator notify the U.S. Coast Guard

(USCG) Cutter MUSTANG, in port at

Seward, of the ALASKA SPIRIT fire

situation. He did not request Coast

Guard assistance. The cutter duty officer

in turn notified the USCG Marine Safety

Office in Anchorage, in accordance with

the Western Alaska Marine Firefighting

Plan. This plan was developed and
14

promulgated in 1987 by the Coast Guard

Captain of the Port (COTP)9 of Western

Alaska to coordinate firefighting

activities for marine disasters posing a

risk to vessels, facilities, or harbors in

the COTP’s zone.

The fire chief felt that during the first

6 hours of the effort to get the fire under

control, the unfamiliar and confined

configuration of the ALASKA SPIRIT’s

accommodation area created an

environment that taxed firefighting

resources. Of the 30 firefighters at the

scene, approximately 20 were involved

in suppression operations. The other 10

firefighters were advisory and support

personnel who performed such tasks as

refilling an estimated 100 air bottles with

the cascade air resupply system.

About 0900, the fire chief established

an arbitrary target time of 0945 for fire

control. If the team had not gained

control by that time, he planned to

remove the firefighters from the fire area

to a distance from which they could

work to suppress the fire with minimum

risk to themselves. About 0930,

firefighters controlled the fire. They

continued their suppression activities,

focusing on hot spots, for another 30 to

40 minutes. About 1100, the fire chief

declared the fire out.

At 1123, the master’s body was found

lying face-down inside the door to the

hospital adjacent to his quarters. He was

dressed in his underwear. About 1330,

 9

The Coast Guard officer (under the

command of a District Commander) so

designated by the Commandant to give

immediate direction to Coast Guard law

enforcement activities within an assigned area.

the fire department completed overhaul10

of fire debris. The fire chief set a reflash

watch on the vessel, and all units

departed the scene at 1356. (See

appendix A for Safety Board

investigation information.)

Injuries

Injuries Vessel Complement

Fatal 1

Serious 0

Minor 0

None 7

Total Crew 8

Vessel Damage

The Fishing Company of Alaska, Inc.

(FCA), owner of the ALASKA SPIRIT,

reported that damage to the vessel from

this accident was estimated at $3

million. Before the fire, the vessel had

been valued at $6 million. Replacement

cost was estimated at $14 million.

In September 1995, the vessel was

towed to Japan for repair. It returned to

service on January 18, 1996. A company

spokesman told the Safety Board that

portable heaters were not reinstalled in

crewrooms, combustible insulation was

replaced with fiberglass insulation, and a

Coast Guard-approved marine smoke

detection system was installed on the

vessel.

 10The process of moving and separating

burned material to locate any hot or smoldering

debris and to cool it or wet it down to prevent

reflash of the fire.
15

Crew Information

Staffing -- At sea, the ALASKA

SPIRIT carried a maximum crew of 48

persons—a National Marine Fisheries

Service observer and about 47

crewmembers. Of these crewmembers,

typically about 12 were in the deck

department, 2 were in the engineering

department, 31 were in the processing

department, and 2 were in the galley (the

cook and cook’s assistant). Staffing

information is approximate, as no fixed

staffing regulations are in effect for such

vessels.

Only the master, mate, chief engineer,

and assistant engineer must be licensed

by the Coast Guard on fishing vessels

over 200 gross tons. No licensed persons

were required to be on board during the

in-port period. The ALASKA SPIRIT’s

master and its two engineers were,

however, properly licensed by the Coast

Guard for operating this vessel (see

appendix B for crew licensing

information). Personnel information for

the six crewmembers who made up the

vessel’s complement at the time of the

fire and the watchman follows.

Master -- The master, age 44, began

his maritime career in 1972 as an

unlicensed seaman. He sailed in that

capacity aboard various fishing vessels

for the next 9 years. In June 1981, he

received his first license as a mate of

uninspected motor fishing vessels. He

increased the grade and scope of his

license over the next several years before

joining the FCA in May 1989.

He was initially assigned as mate to

the trawler ALASKA I. He was

reassigned to the ALASKA SPIRIT in

November 1991 and served as its master

until the accident. The National Driver

Registry has no record of suspensions or

revocations against his driver’s license.

Chief Engineer -- The chief engineer,

age 33, had held that position aboard the

ALASKA SPIRIT since joining the FCA

in March 1992. His testimony to Safety

Board investigators described a variety

of previous engineering work that he had

performed, dating to 1982. This

experience included about 1 1⁄2 years of

serving on offshore supply vessels in

construction diving support, over 4 years

of operations and maintenance on

vessels with multiple moorings

(anchors), and another 4 years on diving

support vessels.

Assistant Engineer -- The assistant

engineer, age 46, stated that he began

sailing about 1970, first on fishing

vessels out of Kodiak and then on

tankers operated by the Military Sealift

Command. From October 1976 to

December 1983, he worked as an

engineer aboard offshore supply vessels

operating in domestic and foreign

waters. He then worked about 7 years

with a towing company out of Dutch

Harbor, before joining the FCA in March

1991. He initially worked as chief

engineer on the ALASKA RANGER for

about 2 1⁄2 years, and then conducted

shipyard maintenance work and shipboard relief work for the company.

Sometime prior to the fire, he had

relieved the regular chief engineer on the

ALASKA SPIRIT. At the time of the

accident, he was relieving the regular

assistant engineer.

Cook -- The cook, age 46, began to

work as a cook aboard FCA vessels in

May 1990. After working for 6 months
16

on the ALASKA PIONEER, he

transferred to the ALASKA SPIRIT,

where he remained until the fire.

Processor-deckhands -- The two

processor-deckhands on board at the

time of the fire, aged 26 and 25, joined

the FCA in January and March 1992,

respectively. They worked in that

capacity for about 200 days each year

until the accident. The older deckhand

had no other seagoing work experience,

but the younger had in 1989 served for 5

months as a processor-deckhand aboard

a fish processing vessel owned by

another company.

Watchman -- The watchman, age 38,

had worked for the FCA intermittently

since 1988, mostly as a processordeckhand. He learned to perform his

rounds through on-the-job training. He

was taught that if he found anything

unusual, he should notify the chief

engineer, and that if he needed assistance

in adjusting mooring lines, he was to

notify the mate or the master.

Vessel Information

The ALASKA SPIRIT was originally

built in March 1974, at Lockport,

Louisiana, as a 166.4-foot-long offshore

supply vessel for the oil industry. The

vessel was named the GULF FLEET

NO. 10. The American Bureau of

Shipping (ABS) certified that the supply

vessel had been built in accordance with

ABS rules. In 1987, the vessel was taken

out of service. It was sold to the Palmco

Pacific Corporation on January 5, 1988,

converted into a trawler-fish processing

vessel (also known as a factory-trawler),

at Ishinomaki, Japan, and renamed the

NORTHERN HERO in February 1990.

During the conversion, the vessel was

lengthened by 37.3 feet to a total length

of 202.7 feet.

The vessel was not required to be

inspected by the Coast Guard to operate

as a fish processing vessel. (See section

on Coast Guard Regulations.) It was not

required to meet international Safety of

Life at Sea convention regulations

(structural fire protection, etc.) because it

was not engaged in international

voyages,11 although it fished in

international waters.

On November 25, 1991, the FCA

purchased the vessel and renamed it the

ALASKA SPIRIT. Because the vessel

was engaged in domestic voyages by sea,

it was required to have a load line.12

The Det Norske Veritas (DNV)

classification society issued a certificate

for the ALASKA SPIRIT on December

26, 1992, attesting that the vessel

complied with the International

Convention on Load Lines of 1966. The

principal characteristics of the ALASKA

SPIRIT were:

Length Overall 202.7 feet

Breadth 38.0 feet

Depth 21.6 feet

Gross Tonnage 1,418

Net Tonnage 425

Horsepower 3,600

 11Voyages between U.S. and foreign ports.

12Lines marked on the sides of a vessel that

show the maximum depths to which the vessel

may be safely loaded, as determined by the rules

of the International Convention on Load Lines.
17

From the keel up, the ALASKA

SPIRIT had five decks: the hold deck

(two freezer holds forward and

engineroom13 area aft); the factory deck

(processing area); the main or 01 deck

(galley and crew accommodations (for

28) were forward, and the trawl deck

was aft); the 02 deck (crew

accommodations for 20); and the bridge

deck.14 The only exterior openings in the

01 and 02 decks were two weathertight

doors (one on the port and one on the

starboard side) at the aft end of each

deck. These decks had no portholes or

other hull openings.

Firefighting Equipment -- A fire pump, a

general service pump, and a seawater

service pump could be connected at a

manifold that could distribute water to

fire stations throughout the vessel. A

remote control located in the wheelhouse

could start the fire pump and pressurize

the fire main.15 The fire pump and fire

stations were not required by regulation.

Seventeen portable fire extinguishers

 13It had a 20-cylinder diesel engine driving a

single propeller shaft with a controllable pitch

propeller. The vessel was also equipped with a

bow thruster.

14The navigation and communication

equipment in the wheelhouse included satellite

communication equipment, direction finders, fish

finders, echo sounders and recorders, a gyrocompass, a magnetic compass, radars, radio

telephones, electronic position fixing devices,

including global positioning system (satellite)

equipment, other electronic equipment used for

fishing or fish processing operations, and a

public address system. A console in the

wheelhouse controlled the main engine, the

propeller pitch, and the bow thruster. The

console had audio and visual alarms.

15A seawater pipeline that provides an

adequate water supply for vessel fire hydrants

and hoses.

were distributed throughout the vessel. A

fixed carbon dioxide (CO2) firefighting

system, consisting of 14 100-pound

compressed CO2 cylinders, was piped

into the engineroom spaces.

A fire detection alarm control panel,

with audio and visual alarms, was also

located in the wheelhouse on the

starboard side aft. The detection system

consisted of 27 heat detectors located in

the overhead throughout the vessel (1 in

each of the 17 crewrooms, 4 in the

galley-mess room, 1 in the processing

area, 1 in the wheelhouse, and 4 in the

engineering spaces), and 3 smoke

detectors in the freezer holds. The fire

detection system was not required by

regulation.

The heat detectors activated when the

heat in the vicinity exceeded 70 o

C (158 o

F). The circuit would remain closed

until the heat lessened to about 60 oC

(140 o

F), at which time the detector

would open and reset. It would then be

ready for reactivation if the heat rose

above the preset temperature.

Aural fire alarm warning buzzers

were located on the bulkhead in the

starboard corridor on the 02 deck outside

the assistant fish master’s room, on the

bulkhead in the port corridor on the 01

deck adjacent to the port inside stairwell

across from the galley, and in the

engineroom. A fire alarm from an

activated sensor could be heard outside

as well as inside the wheelhouse.

Survival Equipment -- The ALASKA

SPIRIT was fully equipped with all of
18

the routinely necessary survival

equipment.16

The FCA -- The FCA formed in 1985.

It purchased 1 vessel in 1986 and 10

others through 1992. At the time of this

accident, the company operated 10

vessels, including the ALASKA SPIRIT.

An 11th FCA vessel was not in service.

The company’s main office is in Seattle,

Washington, and the FCA has field

offices in Anchorage, Dutch Harbor, and

Seward, Alaska. On an annual basis, the

company employs about 2,000 people. It

has 12 employees on its management

staff and 20 in support functions.

Coast Guard records show that during

the period from 1992 through 1994, the

ALASKA SPIRIT had one reportable

personnel injury, one equipment failure,

and one pollution incident. The records

also show that between 1986 and 1994,

the 10 other vessels owned by the FCA

experienced 4 personnel injuries and 6

vessel accidents. Of the 6 accidents, 1

was a loss of engine propulsion from

equipment failure, 1 was a steering gear

equipment failure, 1 was a collision with

another vessel, and 3 were engine

reduction gear failures.

The FCA director of operations

described the operation of the ALASKA

SPIRIT in the following manner: “The

master is in charge of all operational

decisions regarding the vessel at sea and

 16The ALASKA SPIRIT carried flares, an

emergency position indicating radio beacon

(EPIRB), 4 ring life buoys with lights, 4 other

ring buoys, 2 inflatable liferafts (which could

accommodate 50 persons each), an 18-foot-long

inflatable rescue boat with a 30-horsepower

engine, 48 life preservers, and 50 immersion

suits.

in port. The fish master on the vessel is

in charge of the fishing operation...”.

The director further stated that the FCA

had no operating or safety manuals and

that the vessel was not routinely visited

by company managers. The company

provided the Safety Board with a copy of

its 1995 Human Resources and Claims

Guide.17

Waterway Information

The fire aboard the ALASKA SPIRIT

occurred while the vessel was moored at

SMIC, Seward, Alaska, at latitude

60o

05.4’ N, longitude 149o21.8’ W. The

dock is situated on Resurrection Bay,

about 2.2 miles east-southeast of midtown Seward. By road, the dock is 7-8

miles from mid-town Seward. The bay is

a deep waterway extending south from

Seward for about 16 miles to the Gulf of

Alaska.

Meteorological Information

From 0800 on May 26 to about 1400

on May 27, skies were mostly cloudy in

the accident locale. Visibility varied

from 5 to 20 miles and was generally 5

 17The guide contained sections for a sample

emergency station bill; guidelines for reporting

injuries and illnesses; guidelines for completing

Coast Guard marine accident, injury, or death

reports; guidelines for completing crew departure

forms; FCA policies against harassment;

guidelines for completing crew evaluation forms;

guidelines for completing payroll disbursement

requests; work rules and duties; employment

contracts for new employees; a copy of 46 CFR

28; and University of Alaska marine advisory

program bulletin 27 on tendinitis and related

afflictions affecting fishermen and processing

workers.

20

Sheets of polystyrene insulation

(Styrofoam) appeared to have been used

in some overhead and bulkhead

locations. In other areas, the bulkhead

had fiberglass insulation in the spaces

between the paneling and in the

overhead. The foam insulation was not

covered with noncombustible material.18

The furnishings in each room

consisted of wood cabinetry, wood

paneling, wood bunks, and wood

lockers. Rooms were not centrally

heated; instead, each room had an

electric resistance-type heater.

Investigators found the heaters in

some of the rooms, but none was found

plugged into an electrical source. An air

ventilation ducting system provided

outside air to each room.

Wreckage -- The ALASKA SPIRIT’s

entire wheelhouse, including all of its

electronic and navigation equipment,

was destroyed in the fire (see figure 8).

The hull and steel deck plating in the

area of the wheelhouse and 02 deck were

buckled and distorted, and showed

discoloration consistent with intense

heat. Masts and associated rigging in the

area of the fire sustained heat damage.

The rooms on the port, forward

center, and forward starboard sides of

the 02 deck were gutted (see figure 9).

The RPU foam insulation and woodwork

in the 02 deck were burned and, in most

areas, completely destroyed. The fish

master’s room in the starboard corridor

aft was significantly burned, but not as

 18Materials that neither burn nor produce

flammable vapor in sufficient quantity for selfignition when heated to 1350 o

F or above..

extensively as rooms on the port side.

The crew shower/toilet on the starboard

side sustained only heat and smoke

damage. The fire damage in the

starboard side corridor decreased from

forward to the aft doorway exit.

The inside stairwell to the

wheelhouse (on the port side) from the

02 deck was burned extensively and

partially collapsed. A door at the top of

this stairwell separated it from the

wheelhouse. This was not a fire door,

and crewmembers reported that it stood

open most of the time. The door

appeared to have been open during the

fire, although most of it was destroyed

by the fire. The upper bulkheads of the

inside stairwell between the 02 deck and

the 01 deck (port side) were destroyed,

but the stairwell suffered only heat and

smoke damage and remained intact and

usable. The 01 deck accommodation

area near the inside stairwell to the 02

deck (port side) sustained limited

damage, mainly caused by heat and

smoke. Some interior finish vinyl veneer

on the paneling was melted and had

dripped. The galley sustained smoke

damage from the fire and some water

damage from the firefighting operations.

The assistant fish master’s room

(center aft on the 02 deck) had steel

bulkheads and a wood door with a

louvered vent in its bottom section. The

door was completely destroyed in the

fire. A small ventilation fan (8- by 8-inch

opening) was located about 6 feet above

the deck aft of the door in the port aft

part of the bulkhead to the corridor (the

door to the master’s room was across the

corridor). A 6- by 16-inch



24

but investigators found no evidence of

electrical arcing. Power cords from

several other pieces of electrical

equipment in the accommodation space

were plugged into the multiple-plug

receptacle just inside the door.

The stairwells between the 01 and 02

decks, and between the 02 deck and the

wheelhouse, were constructed of wood

risers, treads, and stringers. Both

stairwells were finished on the interior

with plywood paneling. The stairwell

between the 02 deck and the wheelhouse

was extensively burned and partially

collapsed. The stairwell between the 01

and 02 decks exhibited heat and smoke

damage but was still intact and usable.

The corridor that led into the stairwell

between the 01 and 02 decks had heat

and smoke damage. Some of the interior

finish vinyl veneer that had been

installed over the plywood paneling was

melted and hanging down.

Medical, Pathological, and

Toxicological Information

The master lost his life in the course

of the accident. The SVFD reported that

the master’s body was located on May

27 at 1123 and removed from the vessel

at 1247. The body was found in the

hospital room just inside the closed door

from the 02 deck port corridor.

The SVFD deputy fire chief said that,

from the position of the body, it looked

as if the master had been headed back

into the hospital room when he

collapsed. The hospital room adjoined

the master’s room through an interior

door (see figure 5). Directly opposite the

corridor door to the master’s room was a

ventilation fan opening in the assistant

fish master’s room at a height of about 6

feet above the floor. Just forward of the

fan opening was the door to the assistant

fish master’s room.

The deputy fire chief reported that he

asked a crewmember what the master’s

standard response would have been if he

had heard the alarm. The crewmember

replied that the master would normally

go to the wheelhouse. The deputy fire

chief surmised that:

Assuming that he (the master) was

in his stateroom, he would go out

his stateroom door, turn to the

right and go up the stairway to the

wheelhouse; where he would go

ahead to the alarm panel and

determine where the alarm was

coming from.

The deputy fire chief also told Safety

Board investigators that:

My assumption is that if he (the

master) heard the alarm or was

woken up by smoke, he opened up

his door to go see toward the

wheelhouse, and it had a whole

bunch of smoke. He said, ‘no,

that’s not the way to go.’ (He)

closed his door, because the door

was closed. (He) went back

through the medical area and...

came up and got another blast of

air right in that passageway. (He)

turned and fell down.

On May 30, 1995, the deputy chief

medical examiner, Office of the Alaska

State Medical Examiner, autopsied the

master’s body. The autopsy report stated

that the cause of death had been smoke

inhalation. The deputy chief medical

examiner also collected a fluid blood
25

sample for toxicological analysis. The

deputy fire marshal, who attended the

autopsy, told investigators that the blood

sample had been difficult to obtain due

to coagulation. He said that neither urine

nor vitreous humor was available for

sampling. Analysis of the blood sample

found a blood alcohol concentration of

0.353 gm/dL21 and a carboxyhemoglobin

(COHb) saturation of 90.6 percent.

At the request of the Safety Board,

the Office of the Alaska State Medical

Examiner sent a portion of the master’s

blood sample to the Center for Human

Toxicology (CHT), University of Utah,

for further toxicological analysis. The

CHT findings were: blood alcohol

concentration, 0.36 gm/dL; COHb, 84

percent saturation; hemoglobin, 6.8

gm/dL; cyanide, negative; and

phenethylamine, detected as a

decomposition product. The CHT

detected no other common drugs.

The cook said that he had known the

master for 31⁄2 years and considered him

a very disciplined person who never

overreacted. He also considered the

master physically fit. The chief engineer

noted that the master would often work

out on an exercise machine or jog in

place before beginning his day

(frequently well before 0600) in the

wheelhouse. In summary, the chief

engineer said that the master “took care

of himself.” Safety Board investigators

also talked with the master’s wife about

his lifestyle. She said that he was

physically fit and that at home he only

drank socially. She also reported that her

 21Grams per deciliter.

husband did not drink on the vessel and

that he did not permit alcohol on board.

Drills

According to U.S. Coast Guard

requirements (see 46 Code of Federal

Regulations (CFR) 28.270), fishing

vessels must hold drills monthly. The

regulations list 10 contingencies that

must be covered in such drills, including

“abandon ship” and firefighting. They

also state that drills are to be conducted

as if an actual emergency exists, with the

breaking out and using of emergency

equipment. Further, they state that fire

drills should be held in different parts of

the vessel.

An ALASKA SPIRIT deckhand

stated that the drills on that vessel

consisted of mustering on the bridge

deck when the general alarm bell

sounded. The drills were held whenever

the vessel entered port and the crew

changed. (This took place about every 7-

10 days.) Fire drills were conducted

without laying out or charging the fire

hose lines from the hydrants, donning

SCBAs, or putting on firefighting

equipment. During abandon ship drills,

the crew did not don survival suits.

According to the chief engineer, each

time the ALASKA SPIRIT deployed for

a fishing trip, the ship’s officers held a

meeting, primarily to familiarize the new

personnel (such as the fish processors)

with topics such as: routine rules and

practices; general company and ship

rules regarding smoking, running, riding

conveyor belts, fighting, etc.; training

and drill procedures for fire, abandon

ship, man overboard, and flooding drills;

and the general alarm warning sound.
26

They also used the meetings to

conduct safety equipment familiarization

sessions, such as demonstrating survival

suit-wearing procedures and liferaft use;

to identify muster station locations; and

to allot emergency squad assignments

and responsibilities during firefighting

and chemical responses. According to

the engineroom log, the last fire drill on

the ALASKA SPIRIT had been held on

May 5, 1995.

Tests and Research

Possible Ignition Sources -- The Safety

Board investigated various possible

ignition sources for this fire. The sources

considered included portable electric

space heaters found in crewrooms, a

boot warmer found outside the port

forward 02 deck crewroom, (lighted)

smoking materials, battery chargers, and

the cook pot found in the assistant fish

master’s room.

The space heaters on the vessel were

rated at 5,000 watts at 220 volts. None

was found plugged into an outlet.

Investigators examined the remains of

a boot warmer found outside the fourperson crewroom on the forward port

side on the 02 deck. No evidence of

electric arcing was noted. The bottom of

the boot warmer was found on the deck

and unburned, while the top of the

appliance had been burned or melted

away.

According to crewmembers, smoking

had been permitted in the vessel’s

accommodation spaces. The four-person

crewroom forward on the port side of the

02 deck was considered a likely area for

fire origin, because a deckhand had seen

the deck near this room on fire shortly

after the fire alarm sounded. The room

had been occupied by smokers on the

night of the fire.

Battery Charger Examination --

Investigators found that Nippon Denchi

was the manufacturer of the chargers

removed for examination from the

ALASKA SPIRIT’s sister vessel, the

ALASKA VICTORY. These chargers

appeared to be identical to the heavily

fire-damaged chargers found on the

ALASKA SPIRIT. Electrical diagrams

for the chargers were not available. The

chief engineer testified that the chargers,

which he called “converters,” had been

used to convert 105 volts AC to either 12

or 24 volts DC for wheelhouse radios.

According to the chief engineer, the

chargers were permanently mounted.

During the fire investigation, it appeared

that the chargers on the ALASKA

SPIRIT had been hard-wired or

permanently wired to the radios in the

wheelhouse. On August 29, 1995, the

fire-damaged battery chargers were

examined (see appendix C),

photographed, and disassembled. No

evidence of electrical arcing was found.

Cook Pot Examination -- An

inventory of the contents of the assistant

fish master’s room provided to the

Safety Board listed an object described

as a “boiler.” This appliance was a round

cylindrical object found sitting on the

deck in this room; it was essentially a

cook pot that had been used to heat

water. The cook pot was constructed of

two concentric metal cans approximately

9 inches tall and 7 inches in diameter.

When asked if crewmembers had cooked

food in their rooms, the cook said he had

not been aware of anyone doing so.
27

The cook pot was found next to the

built-in bunk bed. A darkened burn

pattern around it trailed over to the

corner of the left battery charger. A

power cord extended from the bottom of

the cook pot forward to the center of the

forward bulkhead. The insulation on the

exposed cord and plug had been

destroyed. Because of the damage to the

room, investigators could not determine

whether the plug had been connected to

an electrical receptacle.

Investigators removed the cook pot,

along with a piece of carpeting to which

it was attached. The cook pot and the

remains of a small can next to it (stuck

to the same piece of carpeting) were sent

to the Safety Board for further analysis.

Investigators found many small tubetype fuses made of glass and screws

stuck together on the can bottom. The

can appeared to have been a receptacle

for these spare parts.

The carpeting under the cook pot was

intact and gave some evidence of heating

but none of burning. A broken glass tube

ran up the side of the cook pot between

the two concentric cans. The tube

appeared to have been used as a sight

glass to determine the water level in the

cook pot.

The power cord to the cook pot was

about 5 feet long. Part of the power cord

(about 12 inches) was coiled beneath the

cook pot. This portion of the cord was

still intact and evidenced no fire or heat

damage. The rest of the cord consisted of

two bare wires. All the electrical

insulation on this part of the cord was

missing. The plug that held the prongs

was completely destroyed, and the

prongs held the electrical leads attached

with screws. No evidence of electrical

arcing was noted on the power cord.

The bottom of the cook pot was

covered by a metal plate attached with

three screws. This plate appeared to have

been a heat reflector. About 1⁄2 inch of a

powdery material that easily crumbled

away was found on top of this plate.

Above this material were electrical

wiring and support hardware (consistent

with Bakelite22) for attaching the

electrical leads to a heating element in

the bottom of the innermost can. The

insulation on these wires was fiberglass

and it appeared to be undamaged. The

wire attachment hardware, however, was

soft and powdery. A small switch was

fastened to a recessed hole in the center

of the inner can. This switch came apart

during the disassembly, and investigators

could not determine whether it had been

functional before the fire. It appeared to

have been an over-temperature switch,

but this could not be verified, since the

cook pot manufacturer could not be

identified.

Heat Detector Testing -- The detectors

on the ALASKA SPIRIT were automatic

restorable detectors23 and were not

required equipment for this vessel.

Following the accident, a heat detector

from the ALASKA SPIRIT’s galley was

removed and tested by an independent

laboratory (see appendix D for results).

 22Trademark for any group of thermosetting

plastics having high chemical and electrical

resistance used in a variety of manufactured

articles.

23A device of which the sensing element is

not ordinarily destroyed by the process of

detecting a fire. Restoration of the device to a

detection mode may be manual or automatic.
28

The detector was found in acceptable

operating order.

The detector was set to be activated at

about 70 oC (158 oF) and to reset at

about 60 oC (140 oF). Coast Guard

regulations for heat detectors (see 46

CFR 76.27) allow a range setting from

“135 o

F (57.2 oC) to 165 oF (73.8 oC)”

for activating heat detectors.

International regulations (Safety of Life

at Sea, Chapter II-2, Part A, Regulation

13, Paragraph 3.3) allow a range from 54

o

C (129.2 oF) to 78 oC (172.4 oF).

Other Information

Coast Guard Regulations -- The

requirements for uninspected

commercial fishing industry vessels are

at 46 CFR Subchapter C (Uninspected

Vessels), which includes Part 28,

“Requirements for Commercial Fishing

Industry Vessels.”24 Subpart 28.100

requires that each commercial fishing

industry vessel meet the requirements of

Parts 24 (General Provisions), 25

(Equipment Requirements - Life

Preservers, Fire Extinguishers, and

EPIRBs) and 26 (Operations) of

Subchapter C, in addition to the

requirements of Part 28.

Fish processing vessels “of not more

than 5,000 gross tons” are exempt from

Coast Guard inspection by law.25 The

ALASKA SPIRIT was 1,418 gross tons

 24The regulations went into effect on

September 15, 1991, and were the result of The

Commercial Fishing Industry Vessel Safety Act

of 1988, Public Law 100-424 (Title 46 USC

Chapter 45).

25Title 46 USC 3302(c)(1).

and was, therefore, exempt from

inspection.

Section 28.710(a) also requires that,

every 2 years, fish processing vessels not

subject to inspection be examined for

compliance with Subchapter C.

Compliance must be certified in writing

by the ABS, a similarly qualified

organization such as the DNV, or a

surveyor of an accepted organization.26

A DNV surveyor examined the

ALASKA SPIRIT on January 16, 1994,

and found it to be in compliance with the

appropriate regulations. The surveyor

issued the vessel a Certificate of

Compliance (valid until January 16,

1996) that certified that the vessel

complied:

With the applicable requirements

of U.S. Regulations 46 CFR

Chapter C Uninspected Vessels

Part 28 as required by 46 CFR

28.710 (Lifesaving, Firefighting,

Navigation, and Other Safety

Equipment).

Coast Guard regulations require that

those vessels built or converted on or

after September 15, 1991 (the effective

date of the regulations for commercial

fishing industry vessels), “must be

constructed so as to minimize fire

hazards insofar as is reasonable and

practical.” Insulation must be

noncombustible except when used for

certain engineering applications, in cargo

holds, and in refrigerated spaces.

 26An organization that meets the requirements

of 46 CFR 28.73 and is designated by the Coast

Guard for the purpose of examining commercial

fishing industry vessels.
29

Further, on vessels operating with

more than 49 persons, the regulations at

46 CFR Part 28, Subpart D, require that

superstructures and deckhouses be

constructed of noncombustible materials.

Because the ALASKA SPIRIT was

converted in 1990 and carried fewer than

49 persons, it was not required to meet

any of these fire safety requirements.

However, the vessel’s superstructure,

deckhouse, and assistant fish master’s

room were constructed of steel (which is

noncombustible).

Regulations require that vessels

carrying 16 or more persons have an

independent modular smoke detector or

a smoke-actuated fire detecting unit in

each accommodation space. The

ALASKA SPIRIT was not required to

have smoke detectors because it was

converted before September 15, 1991,

the effective date of the regulations.

The regulations do not require

commercial fishing industry vessels to

have sprinkler systems in their

accommodation areas.

Regulations for existing fishing

industry vessels (those built or converted

prior to the effective date of the

regulations - September 15, 1991) do not

require a fire pump or that the pump be

connected to fixed piping (fire main).27

Only those vessels built or converted on

or after September 15, 1991, that are 36

feet or more in length and carry more

than 16 persons must be so equipped.

The ALASKA SPIRIT, although not

 27Regulations require that vessels with a

power-driven fire pump have a fire main system,

including fire main, hydrants, hose, and hose

nozzles.

required to have a fire pump or fire main

piping/hydrants installed, had this

equipment.

On April 29, 1980, the Coast Guard

issued Navigation and Vessel Inspection

Circular (NVIC)28 8-80 (Fire Hazard of

Polyurethane and Other Organic Foams)

“to alert vessel inspectors, designers,

builders, and operators of the potential

fire hazard of polyurethane and other

organic foam materials” because of

“serious fires” on “several ships.” These

guidelines are intended to apply to all

vessels. The NVIC states:

When organic foams (including

those described as selfextinguishing, non-burning, fire

resistant, flame resistant, and

similar terms) are exposed to fire

or heat, they may ignite and burn

with rapid flame spread, high

temperatures, toxic gases, and

voluminous quantities of smoke.

The NVIC further states that:

Whenever polyurethane or other

organic foam materials are

installed in cargo holds or other

spaces, it is recommended that a

covering of 22 United States

Standard Gauge (USSG) steel

(about 0.03 inches or about 1/32-

inch thick) or other suitable

noncombustible material, with at

least a 15-minute fire rating, be

installed over the foam insulation.

 28Published by Coast Guard Headquarters to

disseminate recommended policy, requirements,

procedures, or guidance for Coast Guard marine

safety personnel and the marine industry.
30

The ALASKA SPIRIT had RPU foam

insulation on the steel hull in the crew

accommodation areas on the 01 and 02

decks. It was not covered with a

noncombustible material, nor was it

required to be. Polystyrene blocks and

fiberglass insulation were also used

between the wooden framing and

bulkhead covering, and (apparently

randomly) in the overheads of the

accommodation spaces.

On August 18, 1986, the Coast Guard

issued NVIC 5-86 (Voluntary Standards

for U.S. Uninspected Commercial

Fishing Vessels) “In response to the poor

safety record of uninspected commercial

fishing vessels...”. NVIC 5-86 (page 3-9)

refers to NVIC 8-80 for further

information on foam insulation in

refrigerated compartments and fishholds.

NVIC 5-86 (page 3-2) recommends that:

(a) noncombustible materials should be

used for bulkheads, decks, and other

structures, in accommodations, service

areas, and control spaces; (b) smoke or

fire detection systems should be installed

to indicate the presence and location of

fire or smoke in galleys, other high risk

spaces, and accommodations, further

stating that an Underwriters Laboratoryapproved house-type smoke detector is

usually adequate for accommodations

and galleys (page 3-5); and (c)

combustible materials be limited to

reduce the amount of fuel available for a

fire. The NVIC also states that insulating

foams and plastics produce extremely

toxic products when burning and

“should not be used or at least be

reduced in quantity wherever possible”

(page 3-3), and that “insulating materials

in accommodations, service areas,

control spaces, and machinery spaces

should be noncombustible (Mineral

wool, etc.)” (page 3-11).

Three Worcester Polytechnic Institute

students, with the U.S. Coast Guard

Headquarters Marine Technical and

Hazardous Materials Division, prepared

a report29 for the Coast Guard which

examined safety factors on fish

processing vessels. Among other

findings, the report concluded that

polyurethane foam “has been shown to

consistently contribute to fires aboard

fish processing vessels.” The report

recommended that a substitute be found

for polyurethane foam insulation.

Standards Applicable to Industrial

Vessels -- Coast Guard structural fire

protection regulations for Cargo and

Miscellaneous Vessels are found at 46

CFR 92.07 and apply to industrial

vessels30 of 300 and over gross tons but

less than 4,000 gross tons contracted for

on or before July 1, 1968, which carry in

excess of 12 “industrial persons.”31 The

 29Unclassed Fish Processing Vessel Study,

October 12, 1990.

30A vessel which, by reason of its special

outfit, purpose, design, or function, engages in

certain industrial ventures. Included are such

vessels as drill rigs, missile range ships, dredges,

cable layers, derrick barges, pipe laying barges,

and construction and wrecking barges. Excluded

are vessels that carry freight for hire or are

engaged in oceanography, limnology, or the

fishing industry. (46 CFR 90.10-16)

31Any person carried on board an industrial

vessel for the sole purpose of carrying out the

industrial business or functions of the vessel.

Examples are laborers, such as wreckers and

mechanics, technicians, drilling persons, and

divers. Industrial persons and fish processing

persons are similar in training and experience

with respect to responding to emergencies aboard

vessels.
31

regulations in part require that, within

accommodation and service areas,

corridor bulkheads shall be of “A”32 or

“B”33 class construction; all other

bulkheads shall be of “A,” “B,” or “C”34

class construction. Trunks35 shall be of

“A” class construction; ceilings, linings,

and all insulation shall be

noncombustible. An approved interior

finish may be used in corridors. An

approved interior finish, as defined by

the Coast Guard, is one that is subjected

to American Society for Testing

Materials (ASTM) E8436 and develops a

flame spread of less than 20 and has

smoke development of less than 10.

 32“A” class bulkheads or decks shall be

composed of steel or equivalent metal

construction. In a standard fire test, they would be

capable of preventing the passage of flame and

smoke for 1 hour. A standard fire test is one which

develops in the test furnace a series of time to

temperature relationships as follows: 5 minutes—

1,000 o

F; 10 minutes—1,300 oF; 30 minutes—

1,550 o

F; and 60 minutes—1,700 oF.

33“B” class bulkheads shall be constructed with

approved noncombustible materials. In a standard

fire test, they would be capable of preventing the

passage of flame for 1⁄2 hour.

34“C” class bulkheads must be constructed of

approved noncombustible materials but are not

required to meet requirements for the passage of

flame.

35A passage extending through one or more

decks to provide access or ventilation to a space.

36E84 is a standard test method developed by

the ASTM. The method exposes a 24-foot by 20-

inch specimen to fire and measures the rates of

flame spread and smoke development. The

material rating (flame spread index) and smoke

number are obtained from a comparison with the

flame spread rate and smoke development of red

oak. The flame spread rates for shredded wood

fiberboard (treated with flame retardant), gypsum

board (with paper surface on both sides), and red

oak (untreated) are -20 to 25, -10 to 25, and -

100, respectively.

These requirements were in the

regulations when the structural fire

regulations were being developed for

commercial fishing industry vessels, but

they could not, by law, be incorporated

into the regulations for existing fishing

vessels. (See section on Coast Guard

Oversight of Fish Processing Vessels.) They

were only partially incorporated for

fishing vessels that operate with more

than 49 persons and were built or

converted after September 15, 1991.

Building Codes -- See appendix E for

building codes for shoreside structures.

Life Safety Code -- The National Fire

Prevention Association (NFPA)37

developed and published NFPA 101

“Code for Safety to Life from Fire in

Buildings and Structures,” known as the

Life Safety Code (LSC).38 The purpose

of the LSC, stated in Section 1.2, is:

To provide minimum

requirements, with due regard to

function, for the design, operation,

and maintenance of buildings and

structures for safety to life from

fire and similar emergencies.

 37The nonprofit NFPA advances the

development and dispersion of fire safety

standards, many of which are adopted into

Federal, State, and municipal fire codes.

Association volunteers are in such professions as

fire service, health care, business, insurance,

government, education, and industry.

38NFPA Life Safety Code, Chapter 6:

“Existing Hotels and Dormitories,” Section 6-5,

Interior Finishes. National Fire Protection

Association, Quincy, Massachusetts, 1994.
32

The LSC mainly addresses safe egress

from shoreside buildings. It also

establishes certain flammability

requirements for building structure and

interior design. For example, the LSC

requires that smoke detectors be placed

in sleeping quarters for hotels (with

more than 16 sleeping accommodations)

and dormitories (for more than 16

persons). In addition, the LSC limits the

flammability of the interior finishes on

walls and overheads of exit enclosures to

Class A or Class B materials.39

Plywood of 1⁄4-inch thickness has a

flame spread rating of 120-196,

depending on the exact type of plywood

and finish.40 The flame spread rating of

the 1⁄4-inch plywood used as interior

finish on the 02 and 01 decks on the

ALASKA SPIRIT was not available or

determined by testing. It is, however,

likely that the rating was greater than

120, based on the flame spread ratings

for plywood of 1⁄4-inch thickness.

If an approved automatic sprinkler

system is in place in a location, the LSC

states that Class C interior wall and

overhead finish materials shall be

permitted wherever Class B materials

would normally be required. Class B

interior wall and overhead finish

 39The LSC defines three classes of finish

materials, dependent on flame spread and smoke

development, as follows:

Class A — Flame spread of 0-25 and smoke

development of 0-450,

Class B — Flame spread of 26-75 and smoke

development of 0-450, and

Class C — Flame spread of 76-200 and

smoke development of 0-450.

40Flame Spread Performance of Wood

Products, National Forest Products Association,

Washington, D.C., 1992.

materials shall be permitted anywhere

Class A would normally be required.

U.S. Fishing Fleet -- The U.S. fishing

fleet numbers approximately 130,000

vessels, of which about 250 are fish

processors or combination fishing-fish

processor-type vessels. Approximately

50 fish processing and 76 combination

fishing-fish processing vessels are more

than 79 feet long.41 Only one U.S. fish

processing vessel, the 17,845-gross ton

OCEAN PHOENIX (635.5 feet long), is

required, because of its size, to be

inspected by the Coast Guard.

Approximately 1,400 U.S. fishing

industry vessels are over 79 feet long.

Crew size varies greatly for vessels over

79 feet, “from 4 to 5 for fishing vessels,

to 20 to 30 for large catcher-processors,

to well over 100 for the largest floating

processor.”42 The Coast Guard does not

maintain records of crew size for

uninspected vessels, so it does not know

how many vessels are more than 79 feet

long and carry more than 16 (or 49)

persons. Between January 1992 and

December 1995, a total of 1,167 fishing

industry vessels were newly registered

with the Coast Guard. Of these, 1,105

were less than 79 feet long, 60 were

between 79 and 100 feet long, 1 was

112.8 feet long, and 1 was 201.2 feet

long. The last vessel is similar in size to

the ALASKA SPIRIT.

 41Fishing Vessels of the United States 79'

and Over, Nautilus Publishing Co., Seattle,

Washington, 1994.

 42Fishing Vessel Safety, National Research

Council, National Academy Press, Washington,

D.C., 1991, p. 41.
33

Accident Statistics -- According to

Coast Guard records, from January 1,

1992, through March 15, 1994, a total of

2,214 fishing vessel accidents43 were

reported and investigated. Of these, 228

(10.3 percent) involved fires, of which

105 either were classed as uncontrollable

or burned themselves out. The dollar

loss of $24.8 million caused by the fires

was 29.5 percent of the total for fishing

vessel accident losses ($84.2 million)

during this period.

For the period March 16, 1994,

through 1995, records are incomplete

because of open investigations and

computer file loading in progress. One

fire on a fish processing vessel that was

not included in the statistics was the fire

on board the fish processing vessel ALL

ALASKAN in July 1994.44 The Safety

Board investigated this fire, in which one

person died and the 379.5-foot-long

vessel sustained damage in the range of

$24.3-30 million.

 43Coast Guard regulations at 46 CFR 4.05

define accidents/casualty as: a grounding; loss of

main propulsion or primary steering or any

associated component or control system; an

occurrence that adversely affects the vessel such

as fire, flooding, failure of fixed fire

extinguishing systems, life saving equipment,

auxiliary generating equipment, or bilge pumping

systems; loss of life; injury which requires

professional medical treatment beyond first aid,

or a person is unfit to perform routine vessel

duties, an occurrence not meeting the above that

results in damage to property in excess of

$25,000. (Note: Over the years, the damage

amount has been gradually increased to its

present amount.)

44Marine Accident Report -- Fire On Board

the U.S. Fish Processing Vessel ALL ALASKAN,

Near Unimak Island, Alaska, Bering Sea, July

24, 1994 (NTSB/MAR-95/02).

Coast Guard Oversight of Fish Processing

Vessels -- Uninspected vessels that must

be examined by a qualified organization

(ABS, DNV, etc.) for compliance with

regulations are not normally examined

by Coast Guard personnel. The

ALASKA SPIRIT was in this category

and was required to be examined by the

DNV biannually. If, however, the Coast

Guard had boarded the vessel at sea, an

examination could have been carried out.

The Coast Guard’s at-sea program of

boarding fishing industry vessels

operates in conjunction with search and

rescue, fisheries management, and law

enforcement boarding. The Coast Guard

does not conduct planned patrols for the

sole purpose of safety equipment

enforcement.

Title 46 United States Code (USC)

Chapter 45 is the codified law affecting

uninspected commercial fishing industry

vessels. In prescribing regulations under

this chapter, the Secretary (of

Transportation) “may not require the

alteration of a vessel or associated

equipment that was constructed or

manufactured before the effective date of

the regulation.”45 Thus, vessels are

exempt from new regulations and the

owner or operator cannot be required to

upgrade equipment or meet construction

requirements for vessels built or

converted before the regulation’s

effective date. Fire and electrical

regulations or requirements (at 46 CFR

Part 28, Subpart D), and stability

requirements (at 46 CFR Part 28,

Subpart E) are effective only for new

vessels or vessels that complete a major

 45Title 46 USC 4502(e)(2).
34

conversion46 on or after September 15,

1991. (See table 1 on pages 36-37 for

fire regulation summary and comparison

information.)

Survival Factors

Fire Control Efforts -- Conditions

reported by the SVFD fire chief that

affected the ALASKA SPIRIT

firefighting efforts appear in appendix F.

Notification Procedures -- Seward’s

emergency operators normally receive 6

weeks on-the-job training under a

supervisor. During the program, they are

instructed in gathering basic information

from callers on the nature and location of

the complaint. Seward’s emergency

operators are also trained to question

callers to determine if fire or hazardous

chemicals are involved in the complaint.

Additionally, the city of Seward has

prepared a Vessel in Distress Procedure

Manual (revised March 1995) that

identifies information that emergency

operators should gather to address a

general emergency involving a vessel at

sea (i.e., the name of the vessel, its radio

type, coordinates, survival equipment,

the number of people involved, etc.).

Among the resources available to

local planners is the Western Alaska

Marine Firefighting Contingency Plan

(see Local Contingency Planning section

 46Defined at Title 46 USC 2101 (14a) as “a

conversion of a vessel that: (A) substantially

changes the dimensions or carrying capacity of

the vessel; (B) changes the type of the vessel; (C)

substantially prolongs the life of the vessel; or

(D) otherwise so changes the vessel that it is

essentially a new vessel, as decided by the

Secretary [of Transportation - U.S. Coast

Guard].”

below). The plan provides the following

checklist for information gathering:

• What is the name and telephone

number of the person reporting?

• What is the nature of the

emergency and extent of fire?

• What is the location of the

incident?

• What is the exact location of the

fire, by compartment and deck?

• Is anyone trapped or injured?

• What is burning? (Details

regarding class of fire)

• Is any hazardous cargo in or near

the fire?

• What, if any, firefighting efforts

are in progress?

• What is the vessel’s capability to

maneuver?

• What is the amount and type of

“bunker” (fuel for ship’s

engines)?

While the Seward emergency

operators were not specifically familiar

with the plan, they were trained to obtain

basic information on the nature and

location of the fire from the initial caller.

Local Contingency Planning

City of Seward -- The Alaska Division

of Emergency Services approved the

Kenai Borough Emergency Plan, which

addresses natural disasters and

hazardous materials releases. The plan

establishes an emergency operations

center and command levels for

operations and support personnel. It also
35

lists other support agencies and

resources in the State.

The last training drill or “table-top

exercise” conducted by the Kenai

Peninsula Borough prior to the accident

took place on December 8, 1994. The

scenario addressed was the involvement

of an above-ground propane storage tank

in a fire. The last previous marine

firefighting training session for the

SVFD occurred on May 21, 1995.

Between 1984 and June 1995, the SVFD

responded to 25 marine incidents that

took place on vessels ranging in length

from 14 to 218 feet.

In summer, Seward-Anchorage is the

terminus for many of the world’s largest

cruise ships, which visit western Alaska

from the West Coast of the United States

and Canada, making approximately 185

port calls (about 125 in Seward). SVFD

personnel board all cruise ships visiting

Seward to conduct a familiarization tour

of each vessel. This is not part of the

Kenai Borough Emergency Plan. Other

than the borough emergency plan, the

SVFD does not have a local contingency

plan for dealing with shipboard fires.

Western Alaska Marine Firefighting

Contingency Plan -- According to the

Coast Guard’s Marine Safety Manual,47

each COTP must maintain a marine

firefighting contingency plan for dealing

with shipboard and waterfront fires

within their geographic area of

responsibility. Marine Safety Office

 47The manual presents the authority,

background, policy, and rationale for various

programs associated with marine safety for the

information, use, and guidance of Coast Guard

personnel assigned to carry out marine safety

duties.

Anchorage’s area is western Alaska. The

Western Alaska Marine Firefighting

Contingency Plan (dated September 18,

1987) was distributed to the harbor

masters and fire departments within the

Western Alaska Zone, namely

Anchorage, Homer, Whittier, Seward,

Kodiak, and Dutch Harbor.

The plan recommends that local fire

chiefs take charge of firefighting

operations within their jurisdictions and

that vessel masters or senior officers

serve as liaisons between the fire chief

and the vessel crew. It lists key steps that

should be taken before firefighters

arrive. The steps include sounding the

crew alarm, making an announcement on

the public address system, and notifying

the local fire department with specific

information (such as location by deck

and compartment, firefighting efforts in

progress, and personnel involved).

Under a Section 20, Fire Department

Contingency Plan recommendation:

Each fire department which is

responsible for the fighting of

shipboard fires should establish a

training program within their unit,

dealing with shipboard fires. Fire

departments should establish local

contingency plans to cover such

emergencies. A copy of this plan is

to be submitted to the COTP.

While Seward has not specifically

developed a firefighting contingency

plan to deal with shipboard fires, many

of the key steps in its firefighting

strategies and assigned individual

responsibilities are identical to those in

the Coast Guard’s Western Alaska

Marine Firefighting Contingency Plan.
Table 1 – Comparison of fire safety regulations and guidelines (all information has been revised and condensed for table inclusion)

Commercial Fishing

Industry Vessels Built or

Converted Before

September 15, 1991

46 CFR Part 28, Subparts C&D

Commercial Fishing

Industry Vessels Built or

Converted On or After

September 15, 1991

46 CFR Part 28, Subparts C&D

Industrial Vessels 300

Gross Tons (GT) and

Less than 4,000 GT

46 CFR Subparts 92, 95, & 97

U.S. Coast Guard

Voluntary Standards

NVIC 5-86

Chapter 3 - Fire Safety

Persons

on Board

16 or

fewer

More

than 16

More

than 49

16 or

fewer

More

than 16

More

than 49

In excess of 12 industrial

persons

Any number

Fire

Detection

Systems

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Each accommodation

space must be equipped

with an independent

modular smoke detector or

a smoke-actuated fire

detecting unit.

Not required, except that each

compartment containing

explosives or enclosed spaces

suited for vehicles shall be

provided with a smoke-detecting

or other suitable type of firedetecting system. However, if a

smoke-detecting system is

installed, it shall meet the

requirements of 46 CFR 76.33.

An approved house-type smoke

detector is usually adequate for

accommodations and galleys.

Machinery spaces should have fire

or smoke detectors with an audible

and visual alarm in the pilothouse

and on deck. Detectors should

indicate the presence and location

of fire or smoke in high risk areas.

Fire

Suppression

Equipment

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

A fixed gas (i.e. CO2) fire

extinguishing system is

required for all vessels 79’

long or over in a space

containing an internal

combustion engine of

more than 50 horsepower

(HP), an oil-fired boiler,

or a gasoline storage tank.

Required in cargo compartments

and tanks for combustible cargoes,

paint lockers, engine spaces on

vessels of 1,000 GT and over

containing oil-fired boilers, or

their fuel oil units, and with

engine power of 1,000 BHP or

greater. When a cargo

compartment is to be working or

living quarters, a water sprinkling

system may be required.

Machinery spaces containing oilfired boilers, fuel oil units, or

internal combustion engines

should have a fixed fire

extinguishing system.

Fire Hose NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Hoses must be connected

to hydrants whenever the

vessel is operating.

Fire hose shall be connected to the outlets at all times. However, on the

open decks where no protection is afforded to the hose in heavy

weather, or where the hose may be damaged from the handling of cargo,

the hose may be temporarily removed from the hydrant and stowed in an

accessible nearby location.
Fire Main NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Vessels 36’ or more in

length must have a fire

pump connected to fixed

piping (fire main).

One to two fire pumps, depending

on the GT of the vessel, piping

and pumping requirements

delineated.

Fire pumps and hydrants should

be provided for all vessels in

accordance with 46 CFR 95.10-5

to 15.

Structural

Fire

Protection

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Each vessel must be

constructed so as to

minimize the fire hazards

as far as it is reasonable

and practical. Insulation

must be noncombustible,

except for machinery

space pipe and machinery

lagging and cargo holds.

In addition, for more than

49 persons, the vessel’s

hull, structural bulkheads,

columns and stanchions

must be made of steel.

Deckhouse must be

constructed of

noncombustible material.

Ceilings, linings, and insulation,

including pipe and duct coverings,

shall be of incombustible

materials. Any sheathing, furring,

or holding pieces for securing any

bulkhead (BH), ceiling, lining, or

insulation shall be of

incombustible materials. BHs,

linings, and ceilings may have a

combustible veneer within a room

not to exceed 1/14” in thickness.

Combustible veneer shall not be

used in corridors. Corridors and

BHs in accommodations shall be

of “A” or “B” class construction.

Stairtowers shall be of “A” class

construction. The hull,

superstructure, structural BHs,

decks, and deckhouses shall be

constructed of steel.

Noncombustible materials should

be used for BHs, decks, and other

structures and furniture in

accommodations. Combustible

materials and insulating foams

should not be used or should be

reduced in quantity wherever

possible. For foam insulation use,

consult NVIC 8-80. Insulating

materials in accommodations

should be noncombustible.

Fire Drills Not

required

unless

vessel

operates

beyond

the

Boundary

lines.

Required once a month.

Hold in different

locations on the vessel.

Drills to be conducted as

if an actual emergency

exists. All on board

must participate, using

emergency equipment.

Same as vessels built or converted

before September 15, 1991.

Drills at least once every week and

conducted as if an actual

emergency exists. Fire pumps

started and a sufficient number of

outlets used to determine that the

system is in proper working order.

Fire drills should be realistic and

deal with an assumed outbreak of

fire in some specified part of the

vessel. Hoses should be laid out

and tested. Drills should be held at

intervals of not more than one

month.
38

ANALYSIS

General

The weather conditions at the time of

the accident were good and did not

hamper the detection of the fire or the

firefighting efforts. The engineroom

equipment functioned properly before

and during the fire. The Safety Board

therefore concludes that the weather

conditions and the vessel mechanical

systems were not factors in this accident.

Source of Ignition

Early eyewitnesses reported almost

simultaneous observations of fire in the

wheelhouse and on the 02 deck. If the

fire had started in the wheelhouse, it

would have taken some time for it to

progress downward to the 02 deck, so

witnesses could not have seen fire

simultaneously in the wheelhouse and

the 02 deck in the early stages of the

accident. In other words, had the fire

begun in wheelhouse, the wheelhouse

should have been seen to have greater

fire involvement than the 02 deck, which

is not what witnesses reported. On this

basis, investigation for an ignition source

was directed to the 02 deck.

On the 02 deck, the cook observed

heavy smoke and fire in the port corridor

2 to 3 feet down from the overhead, and

he could see only 10 to 15 feet into the

port corridor. He observed only light

smoke for the length of the starboard

corridor. If the fire had started in the

forward port corridor or the forward port

crewroom, the fire spread by smoke or

heat down the corridor should have

occurred in the athwartships (cross)

corridor and the starboard corridor, as

well as down the port corridor. Fire

damage on the 02 deck was more

extensive on the port than on the

starboard side. This pattern was most

evident in the port and starboard

corridors and living spaces along the

outer perimeters of these two corridors.

The final burn pattern was much deeper

in the port corridor and cross corridor.

Although firefighting efforts were

initiated at the 02 deck port aft door, the

intensity of the fire forced firefighters to

retreat. At this time, the port aft corridor

was already fully involved in fire.

Consequently, firefighters entered the

starboard aft door to fight the fire. Early

in the firefighting efforts, firefighters

noted that the starboard bulkhead in the

assistant fish master’s room glowed red

as viewed from the starboard corridor.

Since crewmembers had been

socializing in the port forward fourperson crewroom on the 02 deck on the

evening prior to the fire, investigators

considered the possibility that discarded

smoking materials in this location might

have ignited the fire. The duration and

intensity of the fire would have ensured

that any remaining residue from

discarded smoking material was

destroyed. However, discarded smoking

materials do not appear to have caused

ignition, given the ultimate burn pattern

and eyewitness accounts of the fire.
39

Investigation revealed numerous other

possible ignition sources on the 02 deck.

They included: a boot warmer found

outside the port forward crewroom,

space heaters in crewrooms, battery

chargers found in the assistant fish

master’s room, and a cook pot found in

the assistant fish master’s room. The

location of the ignition source must be

consistent with the following factors: (1)

the pattern of fire damage on the 02

deck, (2) the early and almost

simultaneous appearance of fire in the

wheelhouse and 02 deck, and (3) the

observation of fire in the 02 deck port

corridor, but smoke only in the starboard

corridor, early in the fire progression.

The deckhand who had been

awakened by the fire alarm stated that he

went about halfway up the stairwell to

the 02 deck before the firefighters

arrived and saw fire in the overhead and

on the deck of the forward port corridor.

He believed that he saw burning boots

on the deck. Investigation of a boot

warmer found outside the port forward

crewroom uncovered no problems with

the wiring that led over the door’s metal

threshold. Further, the boot warmer

appeared to have melted or burned from

the top down, with no indication of

ignition from the lower part of the

warmer.

These observations are consistent

with radiant heat from the fire in the

overhead having caused the boot

warmer’s melting. The investigation

could not confirm what materials the

deckhand might have seen burning on

the deck.

Each accommodation space on the

ALASKA SPIRIT appeared to have

contained an electric space heater, since

no other heat was available in the rooms.

None of the heaters located by

investigators was powered or plugged

into an electrical source.

A fire starting in the assistant fish

master’s room could easily have spread

(via the chase in the overhead above the

bed) into the wheelhouse early in the

course of the fire. Because the chase

would have acted as a chimney going

directly into the wheelhouse, fire-spread

into the wheelhouse could have occurred

before the smoke and hot gases escaped

into the corridor via the room’s light

wooden door and vent fan opening. RPU

foam lined the inside of the chase on the

ALASKA SPIRIT’s sister vessel and

remnants of RPU foam were found in the

chase on the ALASKA SPIRIT after the

fire. Such a flammable lining would

have increased the rapidity with which

the fire would have spread into the

wheelhouse by this route.

A fire initiating in the assistant fish

master’s room also could have spread to

the wheelhouse by a second route. The

burn pattern in the 02 deck corridor is

consistent with fire exiting from this

room into the port corridor. Smoke, hot

gases, and fire would have exited into

the port corridor via the fan vent opening

and the light, hollow-core wooden door

of the assistant fish master’s room. The

wooden, non-fire-rated door at the top of

the stairway to the wheelhouse was

destroyed and, according to testimony,

was probably open at the time of the fire.

This testimony is consistent with

damaged conditions found after the fire.

The wooden stair treads and wooden

paneling in the stairwell between the 02

deck and the wheelhouse were
40

extensively damaged by the fire.

Consequently, both the chase and the

stairwell were major means by which the

heat, smoke, and fire could have traveled

from the 02 deck into the wheelhouse.

The assistant fish master’s room was

of fire-resistive construction, as it had

steel bulkheads. However, the steel

bulkheads were covered, interior and

exterior, with light wooden construction

materials. The extensive destruction of

the materials in the assistant fish

master’s room indicates there was an

intense fire in this room. The red glow

that firefighters observed in the starboard

corridor on the steel bulkhead of the

assistant fish master’s room is consistent

with the burning of a high fuel load48

(bedding, clothing, wood construction

and framing material along this

bulkhead). Based on the foregoing

evidence, the Safety Board concludes

that the fire originated in the assistant

fish master’s room.

The burn pattern under and beside the

left battery charger found in the assistant

fish master’s room indicates that this

damage occurred early in the course of

the fire. That is, the fire burned the

wooden shelf that supported the chargers

before the materials (debris) fell onto

and buried this charger. Further, the

differential heat and fire damage noted in

the left battery charger, as compared to

the right charger adjacent to it, shows

that the left charger was considerably

hotter both inside and outside the

charger case. The aluminum diode

(rectifier) heat sink plates of the left

charger were melted, and some of the

 48Pounds of combustibles per square foot of

deck area.

molten aluminum was found under the

shelf. The insulation on the transformer

wires was completely burned away, but

no electrical faults or arcing could be

found in this charger. In addition, the

charger contained little fuel that could

have produced heat sufficient to melt

aluminum heat sink plates.

Another possible ignition source in

the assistant fish master’s room was the

cook pot found sitting on the deck next

to the bunk-type bed and just forward of

the battery chargers. Heat damage to the

wire tie-downs and the internal potting

material is consistent with excessively

high temperatures inside the appliance

due to overheating. Fire starting exterior

to the cook pot and then spreading to it

would have first destroyed the carpet and

power cord that was coiled beneath the

cook pot before causing internal heat

damage to the cook pot. The fact that the

carpet and power cord beneath the pot

were unburned supports the conclusion

that the fire did not start exterior to the

cook pot.

The location of this cook pot next to

the bed also made it a prime candidate as

the ignition source. In this location,

overheating of this appliance could have

ignited bedding materials. The room had

not been occupied for about 6 days. The

room contained a heat detector but no

smoke detector. Ignition of the bedding

could have occurred sometime during

the 6 days that the room had been

vacant, and a smoldering combustion

might have gone undetected for some

time. The presence of water in the cook

pot would have delayed overheating

until the water evaporated.
41

From this ignition source, the fire

could have spread to the wheelhouse via

two routes. First, the cook pot was in

close proximity to the bed. Once flames

erupted, the high fuel load in the

assistant fish master’s room would have

facilitated rapid fire growth and spread

into the chase directly above the bed.

The fire would have spread through the

chase into the wheelhouse.

Second, the combustible gases and

smoke that normally accumulate in the

ceiling area of a room of origin would

have quickly burned through the light

wooden door of the assistant fish

master’s room, creating another path by

which fire might have spread. Once the

top of this door was burned, the smoke,

heat, and combustible gases would have

rapidly spread into the corridor and up

the open stairwell to the wheelhouse.

This scenario fits the report of the first

eyewitness (the cook) that he saw flames

in the wheelhouse and 02 deck port door.

Since the door to the assistant fish

master’s room and the fan vent opening

are almost opposite the door to the

master’s room and the hospital room,

this fire propagation scenario is

consistent with the master being unable

to escape the fire. He appears to have

been overcome by the products of

combustion (principally carbon

monoxide) that would have moved

directly across the narrow corridor to the

doorways of these two rooms. Based on

the foregoing evidence, the Safety Board

concludes that the most likely ignition

source was the cook pot in the assistant

fish master’s room.

When crewmembers leave their

vessel after a voyage, they often do not

check their accommodation rooms to

verify that all electrical items have been

turned off and secured, and that smoking

materials have been removed. After

occupants vacate a room, if it is likely to

be vacant for a period of time, the room

should be checked for fire hazards. Good

marine practice calls for a responsible

measure of “good housekeeping” on

board vessels to lessen the danger of fire

or other hazards occurring unexpectedly.

Regular checking of rooms for fire

hazards is one of the best possible

safeguards against fire ignition. While

such routine checks cannot guarantee

vessel safety, they can increase the

likelihood that accidents will be

prevented.

The Safety Board therefore concludes

that, had the FCA provided written

guidance to vessel masters to check on

the fire safety condition of vacant

crewrooms and had such a review

procedure been implemented, the fire

might have been avoided. Consequently,

the Safety Board believes that the FCA

should develop written guidance for its

vessel masters to use to review the fire

safety condition of all crewrooms when

the occupants disembark from the vessel

and the room will be vacant, and should

implement a procedure whereby the

conduct of such reviews may be

documented.

Fire Safety Standards

Construction -- The extensive use of

combustible wood construction

materials, the use of unprotected, highly

flammable RPU and polystyrene

insulations, and the high concentration

of combustible bedding and furnishings

on the ALASKA SPIRIT contributed to
42

a very rapidly spreading fire that was

difficult to extinguish until much of the

combustible fuel had been consumed.

The fuel load was very high on the 02

deck because of the wood construction

and the volume of bedding, clothing, and

wood furniture in the small rooms.

All of the partition bulkheads were

constructed of wood with a vinyl veneer

that had a Class C flame spread rating.

The assistant fish master’s room had

steel bulkheads, but they were covered

with highly combustible wooden

structures. Further, all of the interior hull

and deck surfaces, the exteriors of which

were exposed to the elements, were

covered with RPU foam insulation. In

some areas, sheets of polystyrene

insulation were installed behind the

wooden bulkheads and overhead. These

combustible materials all contributed to

fuel a rapidly spreading fire.

Because of the extensive use of 1⁄4-

inch plywood over light wooden

supports in the escape corridors, the

ALASKA SPIRIT would not have met

the requirements of the Coast Guard

structural fire protection regulations for

cargo and miscellaneous vessels or the

NFPA shoreside LSC. The Safety Board

therefore concludes that the rapid fire

growth and spread were due to the high

fuel load and lack of noncombustible

construction.

The Coast Guard had established

cargo and miscellaneous vessel

structural fire regulations and later

developed the guidelines for fishing

industry vessels in the NVIC 5-86

(which refer to the cargo and

miscellaneous vessel regulations (46

CFR Subchapter I) for structural fire

protection). Most of these regulations

and guidelines were not incorporated

into commercial fishing industry vessel

regulations.

Had structural fire protection

guidelines been adopted into the

regulations for fishing industry vessels,

the FCA would still not have been

required to implement them. The

ALASKA SPIRIT was exempted from

the regulations because: (1) it carried 49

or fewer persons, and (2) it had been

operating as a fishing industry vessel

before the effective date of the

regulations. The previous owner of the

ALASKA SPIRIT apparently did not use

the information in the NVIC’s voluntary

guidelines for fire protection when

converting it into a fishing industry

vessel.

Current Coast Guard regulations for

new vessels carrying more than 16

persons require that vessels “minimize

fire hazards insofar as is reasonable and

practicable” and that “insulation be

noncombustible.” Except for NVIC 5-

86, there is no other national standard for

fishing industry vessels. This accident

highlights the need to establish structural

fire protection regulations for fishing

industry vessels that carry more than 16

persons (the same figure is used in the

LSC for shoreside buildings when more

than 16 sleeping accommodations are

available in the structure). NFPA does

not have a life safety code for vessels,

but it is working with the Coast Guard to

develop such a document.

Following its 1994 investigation of

the fire in the cargo spaces on the fish
43

processing vessel ALL ALASKAN,49 the

Safety Board recommended that the

Coast Guard:

M-95-16

Establish, in cooperation with the

National Fire Protection

Association, a national marine

safety standard on the safe use of

rigid polyurethane foam and other

organic combustible material

insulations on vessels.

The Coast Guard replied to this

recommendation that it is working with

the NFPA to develop such a standard.

The Safety Board classified this

recommendation “Open -- Acceptable

Response” on February 6, 1996. After

the same accident, the Board

recommended that the NFPA:

M-95-25

Establish, in cooperation with the

U.S. Coast Guard, a national

marine safety standard on the safe

use of rigid polyurethane foam and

other organic combustible material

insulations on vessels.

The NFPA replied that it is working

with the Coast Guard to develop such a

standard to address fire protection and

life safety aboard merchant vessels. The

new standard will be designated NFPA

301. Pending the publication of NFPA

301, the Safety Board classified the

recommendation “Open -- Acceptable

Response” on October 26, 1995.

 49Marine Accident Report -- NTSB/MAR95/02.

Seeking changes to regulations takes

time. In the interests of safety, the Coast

Guard could, in the interim, develop a

national marine fire safety standard with

the NFPA. A national marine fire safety

standard for commercial fishing industry

vessels, containing structural fire

protection standards, would improve the

level of fire safety on commercial fishing

industry vessels by reducing the amount

of highly combustible materials in vessel

living spaces and corridors.

Fire Detection Equipment -- While the

ALASKA SPIRIT’s previous owner had

installed the fire protection equipment

used on the vessel, the responsibility for

reviewing the adequacy of that

equipment to ensure the fire safety of the

vessel and the crew lay with the current

owner, the FCA. Such a review would

have revealed the need for smoke rather

than heat detectors in the vessel’s living

quarters. When the fire ignited on the

ALASKA SPIRIT, by the time that the

(properly operating) heat detectors

activated, the fire had advanced to a

point that the master could not escape

and shoreside firefighters could only

contain it to the 02 deck and

wheelhouse. The Safety Board therefore

concludes that, because heat rather than

smoke detectors were used on the

ALASKA SPIRIT, the crew was not

provided with sufficient early warning of

the fire, which led to the death of the

master and allowed the fire to go out of

control.

An operating smoke detector in the

rooms, and especially in the room of

origin, would have given warning of the

fire while it was still in the smoldering

stage. Smoldering fires can produce

smoke without significantly increasing
44

room temperature. Openings (wire chase,

wooden door with ventilation opening,

and the opening in the bulkhead for a

fan) in the room of fire origin allowed

smoke and combustible and poisonous

gases to spread quickly into other spaces

in the vessel.

Smoke-actuated fire-detecting units

or independent modular smoke detectors,

however, are only required in the

accommodation spaces of those

commercial fishing industry vessels built

or converted after September 15, 1991,

that carry more than 16 persons. The

minimal cost of these household-type

battery-operated smoke detectors, and

their ease of installation, strongly

suggests the use of this safety device on

existing vessels. The Safety Board

recognizes that the FCA has installed a

smoke detection system on the repaired

ALASKA SPIRIT and believes that the

FCA should install smoke detectors in

accommodation spaces on all its vessels,

regardless of whether heat detectors are

installed.

Fire Suppression Equipment -- By the

time the fire was discovered, it was well

established and beyond the crew’s

capability to contain it. The crew and

shoreside firefighters prevented the fire

from burning back down the port inside

stairwell to the 01 deck, and shoreside

firefighters put enough water on the 02

deck to prevent heat and flames from

propagating down to the 01 deck. Using

shoreside equipment, firefighters

working in narrow corridors and high

heat virtually controlled the fire until it

burned itself out.

The regulations for new fishing

industry vessels that are 36 feet and over

in length that carry more than 16 persons

require a power-driven fire pump and

fire main system, but no fire suppression

system in the accommodation area. The

ALASKA SPIRIT had a power-driven

pump and fire main system, which were

not required by the regulations for this

existing fishing vessel, but did not have

a sprinkler system. Although automatic

fire-extinguishing sprinkler systems are

not required in accommodation spaces,

the management of the vessel is

responsible for ensuring that fire

suppression equipment is adequate to

safeguard the crew and the vessel in case

of fire. To provide effective fire

protection to the crew and the vessel, fire

suppression equipment should be part of

the power-driven fire pump and fire

main system.

The Coast Guard should consider

requiring automatic fire-extinguishing

sprinkler systems on fish processing

vessels with accommodations that are

not of noncombustible construction.

Such vessels often carry large numbers

of people not trained as firefighters.

They also operate in areas remote from

professional firefighting assistance, in

weather and sea conditions that could

prevent help from being rendered even if

available. Sprinklers also reduce the

dependency on vessel personnel for

responding to and extinguishing a fire,

which is especially important when a

reduced crew is staffing the vessel.

The Safety Board therefore concludes

that an installed sprinkler (suppression)

system would probably have

extinguished the fire in its early stages of

development, impeded the spread of fire

in the accommodation spaces, and

possibly prevented the loss of life.
45

Therefore, in view of the fire danger

posed by the combustible materials used

in the construction of the ALASKA

SPIRIT and ALASKA VICTORY, the

Safety Board believes that the FCA

should install automatic fire suppression

systems in all its vessel accommodation

spaces that are constructed of

combustible materials.

Existing Standards -- The ALASKA

SPIRIT investigation has shown that fire

safety standards for commercial fishing

industry vessels are inadequate. In

particular, it highlighted deficiencies in

the areas of structural fire protection, fire

detection systems, and fire suppression

systems. The Safety Board therefore

concludes that the development and use

of a national marine fire safety standard

for commercial fishing industry vessels

that includes structural fire protection

standards and fire detection and

suppression systems would improve the

level of fire safety on board these

vessels. Thus, the Safety Board believes

that the Coast Guard should develop, in

cooperation with the NFPA, a national

marine fire safety standard for

commercial fishing industry vessels,

which should include structural fire

protection standards and fire detection

and suppression systems in

accommodation areas, and adopt it into

the regulations.

The Coast Guard reports that, since

January 1992, a total of 62 new fishing

vessels over 79 feet long have entered

the industry. Only two of these vessels

were over 100 feet long, and only one of

the two was over 200 feet long.

It is probable that only these 2

vessels, out of the 62 entering the

industry, will carry more than 16 persons

and so be required to meet some of the

new fire safety regulations. Even the

larger vessel will likely not carry more

than 49 persons and so will not be

required to meet the structural fire

regulations at 46 CFR 28.385.

A combination of reduced fishing

quotas, over-capitalization, and owners’

wishes to avoid costly implementation of

the safety features required by

regulations on new vessels perpetuates

the use of older, less fire-protected

vessels. These older vessels continue to

operate without safety improvements,

such as smoke detectors and the reduced

use of combustible construction

materials. By exempting these older

vessels from safety regulations, two

widely differing standards of safety for

the fishing industry are effectively

sanctioned. But all fishermen and fish

processors are exposed to the same

rigors on their jobs and should be

afforded the same level of workplace

safety.

As the result of Safety Board

recommendations, passenger vessel

safety has been improved internationally

in recent years, with the phasing in of

higher fire protection levels on vessels

built before the introduction of more

stringent fire safety regulations. The

older, less fire-protected passenger

vessels are no longer permanently

excused from meeting the higher fire

prevention standards for new vessels.

The same procedure could be used to

improve the fire safety of fishing vessels.

Under current law, existing fishing

industry vessels built before the effective

date of the regulations are permanently
46

exempted from meeting the new

regulations. Because of the prevalence of

fires that occur on fishing vessels and

their great human and economic costs,

the Coast Guard should seek legislation

that would require the phasing in of fire

safety regulations for all fishing vessels,

regardless of age. Owners of existing

fishing vessels could gradually upgrade

their vessels, in a planned cost

procedure, or defer upgrading until their

vessel is no longer permitted to operate

and then replace it with a new vessel that

would meet the higher regulatory

standards. Such action would remove

from operation those vessels currently

exempted from the safety regulations

and set a single safety standard for the

fishing industry.

The Safety Board therefore concludes

that a procedure is needed to improve

fire safety on existing fishing industry

vessels by phasing in the fire safety

regulations currently applicable only to

new vessels to all vessels, regardless of

age. Consequently, the Safety Board

believes that the Coast Guard should

promptly seek to change the law to

require the phasing in of fire safety

regulations to apply to all existing

fishing industry vessels that carry more

than 16 persons. The process of making

the same regulations applicable to all

such vessels should be completed by the

year 2010.

Fire Hose -- Because some Armtex

hoses were used on the ALASKA

SPIRIT, a special adapter was required

to connect the vessel’s hydrant outlets

with the nonstandard fitting of this hose.

The Safety Board therefore concludes

that because the ALASKA SPIRIT had

some fire hoses that were incompatible

with its hydrants, the crew was initially

delayed in its firefighting efforts. (Given

their limited resources and the rapidity of

the fire growth, however, it is doubtful

whether the ALASKA SPIRIT’s crew

could have saved the master even had

the hoses been attached to the hydrants.)

The Safety Board is deeply concerned

about the operation of a vessel with fire

hose equipment that was not only

incompatible but which had critical

components (i.e. adapter coupling)

stowed far away from the hydrants. It

seems evident that if adapters are

necessary, they should be installed. The

responsibility for ensuring the adequacy

of vessel fire hose systems and their

practical hookup lies with the vessel’s

management, in this case the FCA. The

Safety Board believes, therefore, that the

FCA should direct the masters of all its

vessels to check all fire stations on their

vessels to ensure that fire hose thread

couplers are compatible with vessel fire

hydrants and to replace incompatible

equipment as appropriate.

Coast Guard regulation 46 CFR

28.315(b)(2), requires that fire hoses be

connected to each hydrant at all times

that the vessel is operating. This

regulation, however, applies only to

commercial fishing industry vessels that

had their keels laid or were converted

after September 15, 1991, and that

operate with more than 16 individuals on

board. Coast Guard regulation 46 CFR

95.10-10, which applies to cargo and

miscellaneous vessels, was also not

applicable to the ALASKA SPIRIT. This

regulation requires that all fire station

hydrants have fire hose coupling threads

of 1 1⁄2-inch and 2 1⁄2-inch sizes. NVIC 5-
47

86 refers to the above regulation as a

voluntary standard for uninspected

commercial fishing vessels.

As part of the regulatory efforts of the

Coast Guard to ensure that fish

processing vessels meet the regulations,

every 2 years qualified organizations

must examine and certify that vessels

meet the requirements of 46 CFR

Subchapter C. To improve the level of

fire safety on board uninspected

commercial fishing industry vessels,

examiners should ensure that firefighting

hoses are attached to and fit fire hydrants

at fire stations.

Survival Factors

Reporting of Fire -- After the fire

erupted, reports of it were quickly

communicated to the SECC, via the 911

telephone number. Despite being alone,

the emergency operator performed her

duties well, not only in handling the

incoming calls but also in dispatching

police, fire, and medical units.

Nevertheless, more efficient

communication might have been

beneficial. Had the watchman identified

himself, the 911 operator could have

questioned him for additional details.

The watchman might have been a source

of specific information, such as the exact

location of the fire on the vessel and

whether individuals might have been

trapped or injured. The FCA did not

train night watch personnel in

procedures for notifying response centers

of an emergency.

The Safety Board therefore concludes

that security night watch personnel on

FCA vessels should have a checklist of

initial notification procedures to ensure

that requisite information is provided to

emergency response communicators. At

a minimum, the initial notification

procedures should address: the

emergency’s nature, location, and extent;

details as to personnel trapped or

injured; and efforts in process to

minimize the damage.

Drills -- The ALASKA SPIRIT’s

master last conducted a fire drill on the

previous fishing trip when the vessel was

at Dutch Harbor. However, the fire drill

was conducted without the crew’s laying

out or charging the ship’s fire hose lines

from any of the hydrants or donning the

SCBAs or firefighting gear. As a result,

the firefighting system was not tested

and the crew was not completely familiar

with the equipment. This accident

demonstrates the importance of holding

realistic fire training drills, designed to

improve the crew’s familiarity with the

equipment and to test the equipment’s

effectiveness. The Safety Board

therefore concludes that the lack of

realistic fire drills compromised the

vessel’s firefighting system.

Coast Guard regulation at 46 CFR

28.270, applicable to the ALASKA

SPIRIT and all documented fishing

vessels with more than 16 individuals on

board,50 requires that drills be carried out

as if:

 50On documented vessels with 16 or fewer

persons, the rule applies if the vessel operates

beyond the Boundary lines as listed in 46 CFR

Part 7. Generally, the lines are seaward of the

shorelines and cross entrances to small bays,

inlets, and rivers.
48

There were an actual emergency

and must include participation by

all individuals on board, breaking

out and using emergency

equipment, testing of all alarm and

detection systems, donning

protective clothing... .

Therefore, given the evidence that

drills on board the ALASKA SPIRIT

were not conducted as if an actual

emergency existed, the Safety Board

believes that the FCA should develop

fire contingency plans that improve the

readiness of its vessel personnel and

equipment to respond to a fire

emergency, and include provisions

concerning the duties of security watch

personnel and the training of crew in

firefighting techniques by the

implementation of realistic fire drill

procedures. To be realistic, the drills

should require that each crewmember

know where all fire and lifesaving

equipment is stowed and how to use it.

Significance of the ALASKA

SPIRIT Investigation

The issues raised by the investigation

of the fire on board the ALASKA

SPIRIT are applicable to the entire

fishing industry. Thus, to ensure that all

of the recommendations developed as a

result of the ALASKA SPIRIT

investigation receive wide dissemination

within the industry, the Safety Board

believes that the Commercial Fishing

Industry Vessel Safety Advisory

Committee (CFIVSAC)51 should inform

 51Established under the authority of Title 46

USC 4508, the 17-member CFIVSAC advises

the Coast Guard Commandant, the Secretary of

Transportation, and Congress on safety issues

related to commercial fishing industry vessels.

fishing industry vessel owners of this

accident and advise them to: install on

their vessels smoke detectors in

accommodation spaces; install automatic

fire suppression systems in

accommodation spaces that are

constructed of combustible materials;

develop written guidance for vessel

masters to review the fire safety

condition of all crewrooms when the

occupants disembark from the vessel and

the room will be vacant; direct vessel

masters to check fire stations to ensure

that fire hose couplers are compatible

with vessel fire hydrants; and develop

fire contingency plans that improve the

readiness of vessel personnel and

equipment, including provisions

addressing the duties of security watch

personnel and procedures for realistic

fire drills.

Toxicological Test Results

The CHT tested the master’s blood

sample for the presence of drugs and

found phenethylamine as a

decomposition product but detected no

other common drugs. The Safety Board

therefore concludes that drug use was

not a factor in this accident. Independent

toxicological tests conducted by the

Alaska State Medical Examiner’s Office

and the CHT both found high levels of

COHb and alcohol in the sample.

 

Committee members include crewmembers or

processors on uninspected fish processing

vessels, naval architects or marine surveyors,

manufacturers of industry equipment, industry

educators or trainers, insurance underwriters for

fishing vessels, and the general public.
49

Carboxyhemoglobin (COHb) -- The

Alaska State Medical Examiner’s Office

found that the master’s death was caused

by smoke inhalation. The results of the

CHT test for cyanide, a toxicant

sometimes found in smoke, were

negative. Another toxicant, carbon

monoxide (CO), was a component of the

smoke, as evidenced by the high levels

of COHb found in the master’s blood

sample. The Alaska Medical Examiner’s

Office and the CHT reported COHb

saturation levels of 90.6 percent and 84

percent, respectively.

According to Hill,52 the master would

have become incapacitated and lost

consciousness at 40-50 percent COHb

saturation, before succumbing at the

reported level of 84-90.6 percent COHb

saturation.

The site where the master’s body was

found—inside the hospital room door—

indicates that he had been awakened by

the fire alarm. By the time the alarm

sounded, air containing CO had probably

already circulated through the common

ventilation system and the louvered

doors on the 02 deck.

Although the concentrations of CO in

the master’s room and hospital room

when the alarm sounded cannot be

 52Hill, I.R., Aviation, Space, and

Environmental Medicine, “An Analysis of

Factors Impeding Passenger Escape from

Aircraft Fires,” March 1990, pp. 261-265.

determined with certainty, at 1-2 percent

concentration of CO in the air, an

exposed person would have had about

120 seconds before becoming

incapacitated at the level of 40-50

percent COHb saturation; at 5-10 percent

concentration in the air, incapacitation

would take about 30 seconds. In either

case, the master would have had

perilously little time for escape. (See

appendix G for more information

concerning the toxic effects of COHb

saturation.)

Alcohol -- The blood alcohol

concentration (BAC) of the master’s

blood sample was reported as 0.353

gm/dL by the Alaska Medical

Examiner’s Office and as 0.360 gm/dL

by the CHT. While this is a high BAC,

the Safety Board found that the

preponderance of evidence, both with

regard to the master’s lifestyle and the

circumstances of his death, indicates that

the high BAC was caused by

postmortem generation rather than

ingestion. (See appendix H for additional

information regarding the master’s

BAC.) The Safety Board thus concludes

that the high alcohol content in the

master’s blood sample was likely due to

postmortem generation rather than

ingestion.
50

CONCLUSIONS

1. The weather conditions and the vessel mechanical systems were not factors in this

accident.

2. The fire originated in the assistant fish master’s room.

3. The most likely ignition source was the cook pot in the assistant fish master’s

room.

4. Had the FCA provided written guidance to vessel masters to check on the fire

safety condition of vacant crewrooms and had such a review procedure been

implemented, the fire might have been avoided.

5. The rapid fire growth and spread were due to the high fuel load and lack of

noncombustible construction.

6. Because heat rather than smoke detectors were used on the ALASKA SPIRIT, the

crew was not provided with sufficient early warning of the fire, which led to the

death of the master and allowed the fire to go out of control.

7. An installed sprinkler (suppression) system would probably have extinguished the

fire in its early stages of development, impeded the spread of fire in the

accommodation spaces, and possibly prevented the loss of life.

8. The development and use of a national marine fire safety standard for commercial

fishing industry vessels that includes structural fire protection standards and fire

detection and suppression systems would improve the level of fire safety on board

these vessels.

9. A procedure is needed to improve fire safety on existing fishing industry vessels

by phasing in the fire safety regulations currently applicable only to new vessels to

all vessels, regardless of age.

10. Because the ALASKA SPIRIT had some fire hoses that were incompatible with

its hydrants, the crew was initially delayed in its firefighting efforts.
51

11. Security night watch personnel on FCA vessels should have a checklist of initial

notification procedures to ensure that requisite information is provided to

emergency response communicators.

12. The lack of realistic fire drills compromised the vessel’s firefighting system.

13. Drug use was not a factor in this accident.

14. The high alcohol content in the master’s blood sample was likely due to

postmortem generation rather than ingestion.

PROBABLE CAUSE

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

aboard the ALASKA SPIRIT was the failure of The Fishing Company of Alaska,

Incorporated, to address the inadequate fire safety conditions and practices on the vessel.

Contributing to the severity of the damage and the loss of life was the lack of fire safety

standards for commercial fishing industry vessels.

RECOMMENDATIONS

-- to the U.S. Coast Guard:

Develop, in cooperation with the National Fire Protection Association, a

national marine fire safety standard for commercial fishing industry

vessels, which should include structural fire protection standards and fire

detection and suppression systems in accommodation areas, and adopt it

into the regulations. (Class II, Priority Action) (M-96-1)

Promptly seek to change the law to require the phasing in of fire safety

regulations to apply to all existing fishing industry vessels that carry more

than 16 persons. (Class II, Priority Action) (M-96-2)

Publicize the circumstances of this fire to the fishing industry. (Class II,

Priority Action) (M-96-3)
52

-- to The Fishing Company of Alaska, Incorporated:

Develop written guidance for your vessel masters to use to review the fire

safety condition of all crewrooms when the occupants disembark from the

vessel and the room will be vacant, and implement a procedure whereby

the conduct of such reviews may be documented. (Class II, Priority

Action) (M-96-4)

Install smoke detectors in accommodation spaces on all your vessels,

regardless of whether heat detectors are installed. (Class II, Priority

Action) (M-96-5)

Install automatic fire suppression systems in all your vessel

accommodation spaces that are constructed of combustible materials.

(Class II, Priority Action) (M-96-6)

Direct the masters of all your vessels to check all fire stations on their

vessels to ensure that fire hose thread couplers are compatible with vessel

fire hydrants and to replace incompatible equipment as appropriate. (Class

II, Priority Action) (M-96-7)

Develop fire contingency plans that improve the readiness of your vessel

personnel and equipment to respond to a fire emergency, and include

provisions concerning the duties of security watch personnel and the

training of crew in firefighting techniques by the implementation of

realistic fire drill procedures. (Class II, Priority Action) (M-96-8)

-- to the Commercial Fishing Industry Vessel Safety Advisory Committee:

Inform fishing industry vessel owners of this accident and advise them to:

install on their vessels smoke detectors in accommodation spaces; install

automatic fire suppression systems in accommodation spaces that are

constructed of combustible materials; develop written guidance for vessel

masters to review the fire safety condition of all crewrooms when the

occupants disembark from the vessel and the room will be vacant; direct

vessel masters to check fire stations to ensure that fire hose couplers are

compatible with vessel fire hydrants; and develop fire contingency plans

that improve the readiness of vessel personnel and equipment, including

provisions addressing the duties of security watch personnel and

procedures for realistic fire drills. (Class II, Priority Action) (M-96-9)
53

-- to the National Fire Protection Association:

Develop, in cooperation with the U.S. Coast Guard, a national marine fire

safety standard for commercial fishing industry vessels, which should

include structural fire protection standards and fire detection and

suppression systems in accommodation areas. (Class II, Priority Action)

(M-96-10)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

June 11, 1996

55

APPENDIX A

Safety Board Investigation

Investigation

The U.S. Coast Guard notified the National Transportation Safety Board of this

accident on May 30, 1995. Four investigators from the Safety Board's Washington, D.C.,

headquarters were dispatched immediately to Seward, Alaska. They began investigation

of the accident on June 1, 1995. The Safety Board invited the National Fire Protection

Association (NFPA) to assist in the investigation, and the NFPA sent one investigator to

Seward.

The Safety Board investigated this accident independently, under the authority of

Section 304(a)(1)(F) of the Independent Safety Board Act of 1974.

The report is based on the factual information developed as a result of the

investigation and additional analyses made by the Safety Board. The Safety Board

considered all facts in the investigative record that are pertinent to its statutory

responsibility to determine the cause or probable cause of the accident and to make

recommendations.

The Fishing Company of Alaska, Inc., the U.S. Coast Guard, and the Seward

Volunteer Fire Department participated as parties to the investigation.

Hearing and Deposition

Sworn testimony regarding this accident was taken on June 2, 1995, in Seward,

Alaska, and on June 5, 1995, in Seattle, Washington. On August 28-29, 1995, two Safety

Board investigators went to San Francisco, California, to witness the testing of a heat

detector that had been removed from the ALASKA SPIRIT and to examine the battery

chargers removed from the ALASKA SPIRIT. On October 29, 1995, two investigators

went to Seattle, Washington, to visit the ALASKA SPIRIT’s sister vessel, the ALASKA

VICTORY, and to examine undamaged battery chargers taken from that vessel.

APPENDIXES

57

APPENDIX B

Crew Licensing Information

Master

ALASKA SPIRIT Master Todd M. Eggers received the original issue of his master's

license on April 3, 1989, as Master of Near Coastal Uninspected Fishing Industry Vessels

of not more than 1600 gross tons; also, Master of Near Coastal Steam or Motor Vessels

of not more than 200 gross tons. On November 19, 1990, his license was amended to

include Master of Ocean Uninspected Fishing Industry Vessels of not more than 2,000

gross tons. He renewed the license on February 23, 1994. The license included an

endorsement as a Radar Observer (Unlimited) and had an expiration date of January 6,

1998.

Chief Engineer

Richard D. Lewis, Sr., was on his third issue of a license to serve as Chief Engineer of

Limited Oceans Motor Vessels of not more than 5,000 horsepower. The license was

issued on October 19, 1994, by the U.S. Coast Guard Officer-in-Charge of Marine

Inspection (OCMI), New Orleans, Louisiana.

Assistant Engineer

Frank P. Lemacks, Jr., held a license to serve as Chief Engineer of Limited Oceans Motor

Vessels of any horsepower, as well as Second Assistant Engineer of Motor Vessels of any

horsepower. His license was issued for the fourth time on February 23, 1995, by the

OCMI, New Orleans, Louisiana.

59

APPENDIX C

Battery Charger Examination

On August 29, 1995, the two battery chargers found on the ALASKA SPIRIT

were examined, photographed, and disassembled at Fire Cause and Analysis,1

 in

Berkeley, California. (The charger found on the left side in the assistant fish master’s

room corresponded to model SP1-35-20B; the charger from the right side corresponded to

model SP1-35-30B.)

The less damaged battery charger, which had been found on the right side in the

assistant fish master's room, was examined first. Aside from the burned and melted

condition of its meters, circuit breaker switches, and other plastic-type electrical devices,

the battery charger did not show significant signs of damage. This charger had no melted

metal parts. The two aluminum heat sink plates for the rectifiers (diodes) on this charger

were intact, and the diodes were attached. The electrical insulation on the transformers in

the charger was intact, although the transformers had experienced extensive fire damage.

The investigators next examined the other (left) battery charger taken from the

assistant fish master's room. The plastic-type electrical devices on this charger were

burned more extensively than the right charger's devices. The investigators separately

removed the two transformers of the left charger from the chassis, took them apart

(removed laminated plates from the transformer coils), and examined them. All electrical

insulation had been burned from the transformers. There was no apparent arcing between

primary and secondary coils on either of the two transformers in this charger. Two

aluminum heat sink plates, on which the diodes had been mounted, had melted.

The exterior meter, switches, and connectors on the left charger were completely

destroyed by the fire. Interior fire damage was extensive. All electrical insulation on the

transformers in the left charger was destroyed. Investigators found no evidence of

electrical arcing on the transformers.

 1

An independent company hired by the FCA to perform the analysis.









69

APPENDIX E

Building Codes

The three major groups — the International Conference of Building Officials

(ICBO), the Southern Building Code Congress International, Inc. (SBCCI), and the

Building Officials and Code Administrators International (BOCA) — have developed

national model building codes. The BOCA, the SBCCI, and the ICBO publish the

National Building Code (NBC), the Standard Building Code (SBC), and the Uniform

Building Code (UBC), respectively. Each code group is a consensus of building officials

with a degree of uniformity among their model codes, although different regional and

geographic needs are met by the different code groups.

Because of the high flammability of plastic foam insulation, the U.S. model

building codes (shoreside) were modified in 1976 to limit the use of cellular plastic

materials. The NBC, SBC, and UBC require that foam plastic insulation have a flame

spread index of not more than 75 and a smoke development rating of not more than 450,

when tested in accordance with ASTM E84. In addition, when used on room side

surfaces, they either must be protected (covered) by a thermal barrier equal in fire

resistance to 1⁄2-inch gypsum board, or they may be used only in buildings that have

sprinkler systems.1

 Both requirements apply to foam more than 4 inches thick. The high

flame spread rate of RPU foam is attributed to its relatively low decomposition

temperature (about 325 oF) and high smoke emission rate (combustible gases).

In the 1960s and early 1970s, spray-on RPUs were advertised as selfextinguishing and nonflammable and were used extensively as thermal insulation in

shoreside structures. In some instances, RPU foams were involved in fires during the

construction phase.2 RPU foam flammability and its associated hazards are best

demonstrated by the full-scale room studies conducted by various investigators.

In a 1973 report by W.F. Marconi,3

 a room was completely lined with 1 1⁄2-inchthick RPU foam with a flame spread index of 200, when tested in accordance with ASTM

E84. The wall and overhead lining were ignited from a source in the corner. The fire

spread rates in this experiment exceeded the response capability of the automatic

 1

Model code provisions pertaining to foam plastics insulation. The Society of Plastics Industry,

Inc., 1990.

2

Paul, George H., Clougherty, Edward V., and Lathrop, James K., Fire Journal, “Federal Reserve

Bank - Fire in Exposed Urethane Insulation in Building Under Construction,” Boston, Massachusetts, July

1977, pp. 33-55.

3

Marconi, W.F., Fire Journal, “Large-Scale Fire Tests of Rigid Cellular Plastic Wall and Roof

Insulation,” Boston, Massachusetts, November 1973, pp. 24-26.
APPENDIX E

70

sprinkler system. In a 1986 Swedish study,4

 a room was covered with various materials,

including RPU foam, and ignition was initiated in the corner. The flash over5

 delay was

measured, and the process took 6 seconds when the room was lined with RPU foam,

compared with 157 seconds when lined with wood particle board.

 4

Sundstrom, B., Full-Scale Fire Testing of Surface Materials, Technical Report SP-RAPP

1986:45, Swedish National Testing Institute, Boras, 1986.

5

Transition from a small fire to full-room involvement.
71

APPENDIX F

Conditions Reported by the SVFD Fire Chief that Affected

ALASKA SPIRIT Firefighting

Absence of Forward Access Doors on the 02 Deck

The absence of such doors to accommodation areas limited the firefighters’ ability to

approach one side of the fire. Deeply seated fires in the master’s room and the forward

part of the 02 deck were not accessible during most of the incident due to intense heat.

Lack of Natural Ventilation in Accommodation Areas

In response to the high heat levels and volume of smoke, firefighters used blowers to

exhaust heat and smoke from the 02 deck. Also, due to the limited firefighting access to

the 02 deck, firefighters used power saws and sledge hammers to make holes in the steel

bridge deck and forward bulkhead of the 02 deck. These openings immediately began

releasing heat and smoke, which allowed the firefighters to introduce water down onto

the fire from the bridge deck and permitted firefighter entry into the confined space.

Necessity of Frequent Firefighter Rotation

The fire chief rotated his crews to provide them respite from the intense heat and allow

them to change SCBA bottles. Due to the narrowness of the corridor, the fire chief felt it

was too hazardous to have two crews of firefighters in the accommodations area

simultaneously. During the firefighting lull while crews rotated, the fire would advance

down the corridor to the point of entry. Consequently, each crew had to rebattle the fire

back to the point where the other had left it.

73

APPENDIX G

Toxic Effects of Carboxyhemoglobin Saturation

The blood component hemoglobin normally carries oxygen from the lungs to the

tissues. Hemoglobin, however, has a much greater affinity for carbon monoxide (CO)

than for oxygen. When a person inhales air containing CO, the compound

carboxyhemoglobin (COHb) is formed in the blood as CO occupies the positions on the

hemoglobin molecule normally filled by oxygen. As indicated in table 1 (below), as the

level of COHb saturation increases, the toxic effects become increasingly severe.

Table 1 — Toxic effects of Carboxyhemoglobin saturation

%COHb Saturation Effect

10 Psychomotor and judgment inefficiencies

10-20 Exertional dyspnoea (shortness of breath)

20-30 Headaches

30-40 Nausea, dizziness, and muscular weakness

40-50 Syncope (loss of consciousness, fainting)

50-60 Convulsions

60-70 Coma

80 Rapid death

The time required for an exposed person to reach an incapacitating level of COHb

saturation depends on the concentration of CO in the air. Fire-produced concentrations of

CO in the air can range as high as 10 percent. Lower concentrations generally occur in

well-ventilated fires. Higher concentrations occur in poorly ventilated fires, such as was

the case during the early stages of the smoldering combustion in the assistant fish

master’s room.

Hill’s report1 tabulated COHb levels as functions of CO concentration in the air

and exposure time. The length of time it would have taken for the master to reach an

incapacitating level of COHb saturation cannot be precisely calculated, but a range can be

derived (see table 2).

 1

Hill, I.R., Aviation, Space, and Environmental Medicine, “An Analysis of Factors Impeding

Passenger Escape from Aircraft Fires,” March 1990, pp. 261-265.
APPENDIX G

74

Table 2 — Carboxyhemoglobin saturation as a function of exposure time and

percentage of carbon monoxide in the air

% of CO % COHb Saturation

in the air 10

SECONDS

30

SECONDS

60

SECONDS

120

SECONDS

0.1 0.2 0.6 1.3 2.5

1 2.5 7.5 15.0 30.0

2 5.0 15.0 30.0 60.0

5 12.5 38.0 75.0 —

10 25.0 75.0 — —
75

APPENDIX H

Master’s Blood Alcohol Level

The blood alcohol concentration (BAC) of the master’s blood sample was

reported as 0.353 gm/dL by the Alaska Medical Examiner’s Office and 0.360 gm/dL by

the Center for Human Toxicology (CHT). The average can be expressed equivalently as

0.36 percent of alcohol by weight/volume. If the BAC was caused by ingested alcohol,

the physiological effects in an individual who had not developed a tolerance for alcohol

would have been “stupor, marked incoordination, and possibly coma.”1

Upon receipt of the master’s blood sample, the CHT staff observed that it did not

appear to be whole blood and that the sample had hemolyzed due to decomposition. The

CHT test found the sample’s blood hemoglobin concentration to be 6.8 gm/dL, which is

about 42 percent of that normally found in whole blood.

Literature on blood alcohol, forensic tests, and Government regulations on BAC

levels all refer to concentrations in whole blood. Specimens from live individuals present

no problem, but postmortem samples may have undergone extensive clotting. When some

blood solids are absent because of clotting and sedimentation, the remaining fluid blood

specimen will have a higher-than-normal water content.

Since testing detects alcohol in proportion to water content, the amount of alcohol

found is also greater than it would be in a sample of whole blood. Such was likely the

case with the master’s blood sample, since the deputy fire marshal attending the autopsy

noted difficulties in obtaining a fluid sample due to coagulation. Scientific literature2

indicates that, in these circumstances, a whole blood sample’s BAC might have been 10-

20 percent lower than in the hemolyzed specimen.

Nevertheless, even if the master’s whole blood BAC had been 10-20 percent

lower than the detected value, the physiological effects of that level of ingested alcohol

would still have been incapacitating. Consequently, the key question to consider is the

origin of the alcohol. Was it ingested or was it a consequence of postmortem generation?

Investigators found no evidence that the master had ingested alcohol on the day or

evening before the fire, although that possibility cannot be conclusively discounted.

Investigators also considered the likelihood of postmortem alcohol generation —

that is, alcohol generated by microbial action within the body after death. Confirmed

 1

Freimuth, H.C., Medicolegal Investigation of Death, 3rd ed., W.U. Spitz (Ed.), “Forensic Aspects

of Alcohol,” Springfield, Illinois, 1993, pp. 767-775.

2

Garriott, J., (Ed.), Medicolegal Aspects of Alcohol Determination, PSG Publishing, Littleton,

Massachusetts, 1988.
APPENDIX H

76

postmortem alcohol levels in excess of 0.30 percent have been reported3

 and the

condition can best be inferred by a positive finding of alcohol in blood, coupled with the

absence of alcohol in urine and/or vitreous humor. Neither urine nor vitreous humor was

available from the master’s autopsy for cross-validation of the blood sample.

Postmortem generation of alcohol is likely to occur when a body has been

exposed to elevated temperatures and time elapses between death and the collection of a

test specimen. Such conditions were present in this case. Before being removed from the

vessel, the deceased had been exposed to heightened temperatures (because of the fire)

for more than 10 hours. Further, the hemolyzed condition of the blood sample noted by

the CHT and the autopsy report’s description of the body are both indicative of

decomposition. In summary, the conditions were highly favorable for postmortem

generation of alcohol.

 3

Canfield, D.V., Kupiec, T., and Huffine, E., Journal of Forensic Sciences, 38(4),“Postmortem

Alcohol Production in Fatal Aircraft Accidents,” 1993, pp. 914-917.