National 

Transportation

Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

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NTSB

Permit No. G-200

Marine Accident Report

Fire On Board U.S. Small Passenger Vessel

Express Shuttle II

Pithlachascotee River Near Port Richey, Florida

October 17, 2004

NTSB/MAR-06/02

PB2006-916402 National Transportation Safety Board

Notation 7770A 490 LíEnfant Plaza, S.W.

Adopted April 4, 2006 Washington, D.C. 20594
National Transportation Safety Board. 2006. Fire On Board U.S. Small Passenger Vessel Express 

Shuttle II, Pithlachascotee River Near Port Richey, Florida, October 17, 2004. Marine Accident 

Report NTSB/MAR-06/02. Washington, DC.

Abstract: This report discusses the fire that destroyed the small passenger vessel Express Shuttle II on 

October 17, 2004, at the mouth of the Pithlachascotee River near Port Richey, Florida. The vessel was 

returning from the Gulf of Mexico after shuttling 78 passengers to an offshore casino boat. Only the master 

and two deckhands were on board when the fire broke out. None of the crew was seriously injured, 

although one of the deckhands was treated for smoke inhalation. Firefighters from Port Richey and Pasco 

County fought the blaze. The vessel, valued at $800,000, was a total loss.

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

the following areas: preventive maintenance, crew response to fire emergency, and fire detection systems.

On the basis of its findings, the Safety Board made recommendations to the U.S. Coast Guard, Paradise of 

Port Richey, and Caterpillar, Inc.

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

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

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

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

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

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Records Management Division, CIO-40

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

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

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

purchase this publication, order report number PB2006-916402 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

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

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

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

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

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

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Events Preceding Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Master . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Deckhand No. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Deckhand No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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

Construction and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Propulsion System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Fixed Fire Suppression System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Fire Detection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Certification and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

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

Structural Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Engine Compartment Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Company Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Day-to-Day Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Vessel Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Firefighting Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Lifesaving Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Federal Regulations Pertaining to Vessel Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . 36

Passenger Vessel Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Cause and Origin of Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Contents iv Marine Accident Report

Preventive Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Express Shuttle II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Previous Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Previous Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Crew Response to Fire Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Fire Detection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Previously Issued Recommendation Classified in This Report . . . . . . . . . . . . . . . . . . . . . . 55

Reiterated Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
v Marine Accident Report

Acronyms and Abbreviations

CFR Code of Federal Regulations

CO2 carbon dioxide

COI certificate of inspection

COTP captain of the port

MSO Marine Safety Office

NVIC navigation and vessel inspection circular

OCMI Officer-in-Charge, Marine Inspection

PRFD Port Richey Fire Department

PVA Passenger Vessel Association

SIP Streamlined Inspection Program

UL Underwriters Laboratory
vi Marine Accident Report

Executive Summary

On the morning of October 17, 2004, a fire broke out in the engineroom of the U.S. 

small passenger vessel Express Shuttle II while it was entering the mouth of the 

Pithlachascotee River near Port Richey, Florida. The shuttle was returning from the Gulf 

of Mexico, where it had ferried 78 passengers to an offshore casino boat, and was on its 

way back to the marina operated by the vesselís owner, Paradise of Port Richey. Only the 

master and two deckhands were on board when the fire broke out.

None of the crewmembers activated the vesselís fixed carbon dioxide fire 

suppression system. The crew attempted to fight the fire with portable extinguishers, but 

when the fire burned out of control, they prepared to abandon ship. A passing recreational 

boat rescued all three crewmembers. The master and one of the deckhands transferred to 

another company boat that took them ashore. The recreational boat took the other 

deckhand to shore, and an ambulance transported him to a local hospital. The deckhand 

was treated for smoke inhalation, held overnight for observation, and then released. 

Firefighters from Port Richey and Pasco County fought the blaze, but the vessel, valued at 

$800,000, was a total constructive loss.

The National Transportation Safety Board determines that the probable cause of 

the fire on board the Express Shuttle II was a fractured, improperly installed fuel injection 

line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the 

engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port 

Richey to have a preventive maintenance program, which could have identified the 

companyís ongoing problem with the vesselís fuel lines before a failed line led to the fire. 

Contributing to the extent of the damage were the vesselís faulty fire detection system and 

the crewís failure to employ proper marine firefighting techniques.

On the basis of its investigation, the Safety Board identified the following safety 

issues:

ï Preventive maintenance

ï Crew response to fire emergency

ï Fire detection systems

As a result of its investigation of the Express Shuttle II fire, the Safety Board makes 

recommendations to the U.S. Coast Guard, Paradise of Port Richey, and Caterpillar, Inc.
1 Marine Accident Report

Factual Information

Background

The Express Shuttle II was a 65-foot, twin-propeller, double-deck U.S. small 

passenger vessel (figure 1) inspected by the U.S. Coast Guard and owned by Paradise of 

Port Richey, operator of the SunCruz Port Richey Casino off Floridaís Gulf Coast. Port 

Richey is at the mouth of the Pithlachascotee River in Pasco County, Florida (figure 2). 

The casino is part of the Florida day-cruise, or casino cruise, gambling industry. Florida 

does not have legalized casino gambling. The gambling industry, however, operates casino 

boats offshore, in international waters outside Floridaís jurisdiction.

Figure 1. Express Shuttle II en route near Port Richey, Florida.

Casino boats that operate off Floridaís west coast ìcruiseî 9 nautical miles into the 

Gulf of Mexico, beyond the Florida state line,1 where passengers can gamble. Small 

passenger vessels like the Express Shuttle II board patrons at onshore facilities and shuttle 

them to the casino boats. Throughout the day, the shuttle boats return to the casino boats 

1 In accordance with the Submerged Lands Act of 1953, the state waters of most coastal states extend 3 

nautical miles from the coastline, as do those on Floridaís east coast. For historical reasons, however, the 

state waters on Floridaís west coast extend 3 leagues, approximately 9 nautical miles (10.376 statute miles), 

into the Gulf of Mexico.
Factual Information 2 Marine Accident Report

and transport the patrons ashore. According to an online publication of the casino trade, in

2004, the Florida Day Cruise Association operated 17 casino boats in the state.2 The same 

publication indicates that casino cruises also operate in Georgia, Massachusetts, South 

Carolina, and Texas.

Figure 2. Accident site and other locations referenced in this report.

Toll 

Toll 

Apalachee 

Bay

Tarpon Springs

New Port Richey

Port Richey

Tampa

Clearwater

Millers

Bayou

19

Dredged Channel

Port Richey

S-turn

Daybeacon 12

Port Richey Casino Dock 

Bridge

Pithlachascotee River

Harborpointe

Accident Site

PASCO CO.

GA

FL

GULF OF MEXICO

FLORIDA

2 As reported in Gamingfloor.com <www.gamingfloor.com/DayShips/html> (accessed August 31, 2005).
Factual Information 3 Marine Accident Report

Events Preceding Fire

On October 12, 2004 (5 days before the fire), while transporting passengers from 

Port Richey to the casino boat Royal Casino I, one of the Paradise of Port Richey masters3

reported to the companyís port captain that ìgrayishî smoke was coming out the Express 

Shuttle IIís starboard engine exhaust port. After the Express Shuttle II docked in Port 

Richey, the port captain took the vessel out of service and contacted Ring Power 

Corporation (authorized local representative of Caterpillar, Inc., manufacturer of the 

Express Shuttle IIís engines).

On October 13, Ring Power Corporation sent two service technicians to investigate 

the Express Shuttle IIís starboard engine. When interviewed postaccident by Safety Board 

investigators, one of the technicians said that after the port captain ran the starboard engine 

for ìa second or two,î they discovered that the fuel delivery line to the engineís No. 6 

cylinder was ìbrokenî and leaking fuel oil. The technician said that no support clamps were 

installed on the broken fuel line.4 In bold type at two places in the service manual for its 

high-performance marine engines provided by Caterpillar, Inc., is the following warning:

Be sure the fuel injection line clamps are installed in the correct location. 

Incorrectly installed clamps may allow the fuel injection lines to vibrate and 

become damaged. The damaged lines may leak and cause a fire.

Caterpillarís service manual also contains several instances of the following 

warning:

Fuel leaked or spilled onto hot surfaces or electrical components can cause a fire.

The port captain retrieved a replacement fuel line from the Express Shuttle IIís 

onboard stock, and the field technicians installed it. When the starboard engine was started 

again, its No. 1 cylinder misfired. The technicians discovered carbon buildup in the 

engineís No. 1 cylinder and also a crack in the engine cylinder head between the valves on 

the No. 5 cylinder. The port captain brought a replacement cylinder head from the 

companyís stock but it was inappropriately configured for the Express Shuttle II engine, so 

one of the technicians took the cylinder head to Ring Power Corporationís machine shop 

in Tampa to have it reworked.

Both technicians returned the next day (October 14) with the reworked cylinder 

head and reassembled the starboard engine. The technicians and the port captain, 

accompanied by another Paradise of Port Richey employee, took the Express Shuttle II

into the Gulf of Mexico to test the engine. It did not perform satisfactorily, but after the 

technicians adjusted the valves back at the dock, a second trial was successful. One of the 

technicians told investigators that they did not install any clamps on the replaced fuel line 

before they left the scene.

3 At the time of the accident, Paradise of Port Richey employed two shuttle boat masters.

4 The clamps, separate pieces of equipment that hold two lines together for mutual support, consist of two 

plates with grooves where the lines are inserted and a screw that can be tightened to hold the plates together.
Factual Information 4 Marine Accident Report

On October 15, according to a Ring Power Corporation service report, the 

company was called again to reassess the Express Shuttle IIís starboard engine because it 

was running at less than full power. The Ring Power technician who made the service call 

told investigators that he noticed that some of the support clamps on the engineís fuel lines 

were not attached. He said that he informed a Paradise of Port Richey employee who was 

helping him about the clamps. The employee said that he ìnoticed that there was no fuel 

line clamps on the fuel lines . . . and went ahead and put the fuel line clamps onî while the 

Ring Power technician was present. The technician, however, said that when he left the 

vessel, he was not sure whether all the clamps were on.

On Saturday evening, October 16 (the night before the fire), while transporting 

passengers to the casino boat, the Express Shuttle II master who on October 12 had 

reported smoke coming from the starboard engineís exhaust noticed a ìsudden loss of 

powerî that he ìdetermined . . . was probably a fuel line, with the experience of that boat, 

a fuel injector line.î The master told investigators that after his passengers had 

disembarked onto the casino boat, he shut down the vesselís engines and replaced a 

leaking fuel line on the outboard side of the starboard engine. He said that he completed 

the repairs about 2000,5 while the Express Shuttle II was alongside the casino boat.

The master said that this was the third time in 6 months that he had replaced a 

broken fuel line on the Express Shuttle IIís starboard engine, and that all three fuel lines 

had broken clean at their connection to either the engine or the fuel pump. He also told 

investigators that other company masters had had the same problem with the starboard 

engine. Invoices obtained from Ring Power Corporation indicate that Paradise of Port 

Richey had purchased 13 fuel lines between January 26 and October 13, 2004, on 11 

different dates (table 1). The Express Shuttle II was the only one of Paradise of Port 

Richeyís vessels equipped with Caterpillar engines, which had external fuel lines (eight on 

each engine).6 According to company records, the Express Shuttle IIís port engine was 

rebuilt in February 2004. Company employees told investigators that they did not work on 

the port engine after it was rebuilt, so all 13 new fuel lines were intended for the Express 

Shuttle IIís starboard engine.

Ring Power Corporation technicians told investigators that ordinarily, the fuel 

lines were ìvery durableî and seldom failed. One of the technicians said that it had been 

ì5 or 6 yearsî since he had seen a broken fuel line, and that the line had failed because of 

a loose clamp.

5 All times are eastern standard time, based on a 24-hour clock.

6 For further information about the vesselís propulsion system, including an engine schematic, see 

ìVessel Informationî section.
Factual Information 5 Marine Accident Report

Table 1. Fuel lines purchased by Paradise of Port Richey during 2004 for Express Shuttle 

IIís starboard engine.

Invoice Date

Number of 

Lines Part Number Cylinder

January 26, 2004 1 4P-7678 8

February 3, 2004 1 4P-7678 8

February 10, 2004 1 4P-7678 8

March 26, 2004 1 4P-7675 5

April 1, 2004 1 4P-7671 1

May 17, 2004 1 4P-7678 8

July 23, 2004 1 4P-7671 1

1 4P-7676 6

September 14, 2004 1 4P-7676 6

1 4P-7677 7

September 21, 2004 1 4P-7671 1

September 23, 2004 1 4P-7677 7

October 13, 2004 1 4P-7676 6

 Total 13 -- --

Accident Narrative

At 0930 the morning of October 17, 2004, the Express Shuttle II departed the 

Paradise of Port Richey marina carrying 78 passengers into the Gulf of Mexico, where the 

Royal Casino I was waiting (2 hours earlier, the shuttle had transported the Royal Casino Iís 

crew and employees to the casino boat). The shuttle boat took about 30 minutes to reach the 

casino boat. After the passengers disembarked, the Express Shuttle II began the return trip to 

the marina. According to the master, the Express Shuttle IIís engines ran without difficulty 

until the vessel reached an area in the dredged channel known as the S-turn (figure 2).

As the vessel neared daybeacon 12, where a posted no-wake zone began, the 

master said he reduced both engines to idle (about 5 knots). Moments later, the vesselís 

starboard engine surged to full throttle, then returned to idle. Seconds later, the starboard 

engine surged again, then shut down, causing a loss of power to the starboard propeller 

shaft. The master said that when the engine surged, he noticed that the low-voltage 

annunciator on the instrument panel was blinking.

Powered only by the port engine, the master then began the turn at daybeacon 12. 

Moments later, he lost power to the port engine. The vessel was about 100 yards from 

shore. The master said that he continued to turn the vessel, intending to beach it on a 

sandbar outside the channel. At that point, he said, both deckhands came to the pilothouse 

and told him that smoke was coming from the engineroom.

Investigators received a slightly different account of events from the deckhands. 

They said that they were completing their assigned cleanup tasks when they smelled smoke. 

Deckhand No. 1 said he heard a noise ìlike something dropped, or . . . grinded,î and both 
Factual Information 6 Marine Accident Report

deckhands looked aft and saw white smoke coming from the small hatch astern of the 

starboard engine (see ìVessel Informationî section for construction details). They lifted up 

the hatch and smoke poured out. Although one deckhand said they closed the hatch, the 

other said he could not remember whether they had closed it. Deckhand No. 1 said that he 

then ran to the pilothouse and told the master there was smoke in the engineroom.

Deckhand No. 1 told investigators that when he came back to the main deck, he and 

the other deckhand moved the tables and chairs out of the way of the larger hatches over the 

engineroom (the tables and chairs were not fastened to the deck). The deckhands went to 

the hatch over the starboard engine and when they lifted it, ìfire shot out.î Deckhand No. 2 

ran back to tell the master they had ìa bigger situation than we thought,î while deckhand 

No. 1 retrieved a portable fire extinguisher. Neither the deckhands nor the master recalled 

hearing an alarm go off in the pilothouse or anywhere else on the vessel before or during 

the fire, and none of them attempted to activate the Express Shuttle IIís manually operated 

carbon dioxide (CO2) fire suppression system, located in the fuel compartment, forward of 

the engine compartment (see ìVessel Informationî section for details about the fire 

detection and fire suppression systems). According to investigatorsí interviews with the 

crewmembers, the master was aware of the CO2 system but the deckhands were not.

The master said that he came down to the cabin and so much smoke was coming 

out of the small engineroom hatch that he ìcouldnít go down there.î He and deckhand No. 

2 then tried to lift the larger hatch over the starboard engine so deckhand No. 1 could 

direct the portable extinguisher at the fire, but flames and black smoke poured out. The 

master said they lifted the hatch 1 1/2 to 2 inches and that the flames were ìlike a 

blowtorch.î They dropped the hatch back over the opening. The master said the cabin was 

so full of smoke ìyou couldnít hardly breathe.î

The master then went forward to retrieve the fire hose from its rack and directed 

deckhand No. 1 to turn on the fire pump switch, located at the rear of the cabin. The 

master then realized that without the engine running, the fire pump would not operate (the 

pump was driven by one of the engines7). Deckhand No. 1 reported feeling dizzy, and all 

three crewmembers left the cabin and went to the vesselís bow. By that time, they said, 

flames were climbing up the starboard cabin bulkhead and into the pilothouse.

At this point, the operator of a passing recreational boat, who happened to be an off-duty 

Coast Guard rescue swimmer, came alongside the Express Shuttle II and offered assistance. The 

master and deckhands abandoned the Express Shuttle II and boarded the recreational boat. 

(Crewmembers estimated that this was about 20 minutes after they first noticed the fire.) Shortly 

thereafter, a smaller Paradise of Port Richey boat arrived and the master and deckhand No. 2 

climbed on board. The recreational boat took deckhand No. 1 to a dock at a commercial 

establishment, from where he was transported by ambulance to a local hospital.

Fire and rescue units from Port Richey and Pasco County responded to the fire, as 

detailed in the ìSurvival Factorsî section of this report. Firefighters extinguished the fire 

by about 1530 that afternoon.

7 Federal regulations for vessel fire-protection equipment at Title 46 Code of Federal Regulations

(CFR) part 181.300(d) state: ìA fire pump may be driven by a propulsion engine.î
Factual Information 7 Marine Accident Report

Injuries

Safety Board reports of marine accidents classify injuries according to the criteria of 

49 CFR 830.2. None of the three crewmembers on board the Express Shuttle II sustained an 

injury meeting the criteria for fatal or serious injuries. Deckhand No. 1 was taken to Morton 

Plant North Bay Hospital in New Port Richey, 2 miles from Port Richey, where he was 

treated for smoke inhalation and held overnight for observation. The master and the other 

deckhand did not seek medical attention. No firefighter injuries were reported.

Damages

As a result of the fire damage, the ownerís insurance underwriter declared the 

Express Shuttle II a total constructive loss. The vesselís declared value was $800,000.

Personnel Information

Small passenger vessels carrying more than six passengers for hire8 may not 

operate without a valid Coast Guard certificate of inspection (COI), which is issued by the 

Coast Guard Officer-in-Charge, Marine Inspection (OCMI), for a given marine inspection 

zoneóin this case, Tampa, Florida. The COI stipulates a number of operating 

requirements, including minimum crew size and qualifications.

When determining the number and competencies of crewmembers, the OCMI 

considers, among other things, the size of the vessel, its route, the type and horsepower of 

the vesselís propulsion machinery, the number of passengers the vessel will carry, the type 

and location of lifesaving equipment installed on the vessel, and the hazards associated 

with the route and service. According to its COI, the Express Shuttle II was required to 

carry a crew consisting of one master and two deckhands.

Master

The master on the day of the fire,9 age 64, had 30 yearsí experience on shrimp boats 

and tugboats. He told investigators that he had been employed by Paradise of Port Richey for 

almost 2 years. He held a current Coast Guard license as ìmaster of steam or motor vessels 

of not more than 100 gross registered tons (domestic tonnage) upon near coastal waters.î 

The masterís license was issued on April 17, 2002, and was due to expire on April 17, 2007.

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

than 100 gross tons that carry more than six passengers, including at least one passenger for hire. ìPassenger 

for hireî is defined as ìa passenger for whom consideration is contributed as a condition of carriage on the 

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

having an interest in the vessel.î

9 A different master from the one who experienced problems with the Express Shuttle II in the days 

before the fire.
Factual Information 8 Marine Accident Report

The master stated that he had rested well in the 72 hours before the accident. He 

told investigators that he was a ìborderline diabeticî and took glucose every morning to 

control the disease. He also said that he took medication for his prostate and an antibiotic 

for rosacea. He told investigators that he knew of no side effects of those medications that 

would affect his ability to operate the vessel.

Deckhand No. 1

Deckhand No. 1, age 19, had worked for Paradise of Port Richey for 2 months at 

the time of the accident. He told investigators, ìIíve been on boats my entire life.î He did 

not hold and was not required by Federal regulations to hold any Coast Guard documents 

(see discussion of regulatory requirements under ìTraining,î below). He stated that he had 

received no formal maritime training before joining the company and that he trained as a 

deckhand on the job. He told investigators that he had been present when the other master 

changed the fuel line on the Express Shuttle II the night before the fire.

Deckhand No. 2

Deckhand No. 2, age 32, had worked for Paradise of Port Richey for less than 

1 month. He did not hold and was not required by Federal regulations to hold any Coast 

Guard documents. He had no formal maritime training; his most recent job was in retail 

sales. He told investigators that he was present when the Ring Power Corporation 

technicians worked on the Express Shuttle IIís starboard engine 4 days before the fire.

Training

Regulatory Requirements. To be certified as the master of a small passenger 

vessel, an individual must serve for at least 1 year on the type of vessel for which he or she 

is seeking licensure and must pass a license examination. To pass a licensing test, an 

individual must demonstrate that he or she is conversant in a number of subjects, 

including, but not limited to, piloting, shiphandling, watchkeeping, first aid, fire 

prevention and firefighting appliances, and emergency procedures. After passing the test, 

a master is not required to undergo periodic training or to be tested on subject-matter 

knowledge, except as a participant in drills conducted by the Coast Guard as part of its 

annual inspections (see ìVessel Certification and Inspectionî for more information).

The CFR does not require deckhands on small passenger vessels to hold Coast 

Guard licenses or documents or to possess formal qualifications for their positions. 

Regarding emergency duties such as firefighting, abandoning ship, and rescuing people in 

the water, 46 CFR 185.420 stipulates the following, in part:

The owner, charterer, master or managing operator shall instruct each 

crewmember, upon first being employed and prior to getting underway for the 

first time on a particular vessel and at least once every three months, as to the 

duties the crew member is expected to perform in an emergency including, but not 

limited to, the emergency instructions listed on the emergency instruction placard 

required by 185.510 of this part. . . .
Factual Information 9 Marine Accident Report

In addition, the master of the vessel is required to conduct emergency drills, as 

stipulated by 46 CFR 185.520:

The master shall conduct sufficient drills and give sufficient instructions to make 

sure that all crewmembers are familiar with their duties during emergencies that 

necessitate abandoning ship or the recovery of persons who have fallen 

overboard.

The master is also required by 46 CFR 185.524 to

conduct sufficient fire drills to make sure that each crew member is familiar with 

his or her duties in case of a fire.

Title 46 CFR 185.520(f) and 46 CFR 185.524(d) require that abandon ship/manoverboard drills and fire drills be logged or otherwise documented for review by the Coast 

Guard on request. The records must include the date of the drill and a general description 

of the drill scenario and the training topics discussed.

Navigation and Vessel Inspection Circular 1-91. In February 1991, the Coast 

Guard issued a navigation and vessel inspection circular (NVIC) recommending 

qualifications and training for deckhands on small passenger vessels. The NVIC (No. 

1-91) states, in part,

The Coast Guard and the industry recognize that a Small Passenger Vesselís 

licensed officer(s) would be unable to navigate the vessel and effectively respond 

to emergencies such as fire, engineering casualties, collision, flooding, medical 

emergencies, man overboard, etc., without the assistance of trained and qualified 

deckhands.

The NVIC further states, ìThe employment and training of qualified deckhands is 

the responsibility of the marine employer (46 CFR 15.103)î and ìthe Coast Guard is 

responsible for determining that Small Passenger Vessels are manned with competent 

crews.î

The stated intention of the NVIC was to provide guidance for marine employers 

and masters of small passenger vessels to use when structuring training programs for 

deckhands. The circular was further intended as guidance for Coast Guard OCMIs during 

inspections for certification and reinspections, when evaluating training programs, and 

during drills conducted to ensure crew competency.

Regarding firefighting, the NVIC recommends that every deckhand ìshould be 

familiar withî the following:

ï Fire detection and alarm systems.

ï Classes of fires and the appropriate firefighting technique.

ï Location and operation of firefighting equipment.

ï Location and operation of power, ventilation, and fuel shutoffs.
Factual Information 10 Marine Accident Report

ï Location and operation of watertight doors, hatches, fire-screen doors, and 

escapes.

ï Procedures for mustering passengers.

ï Station bill assignment and duties.

Company Training. The deckhands of the Express Shuttle II and their supervisors 

told investigators that all their maritime training had been obtained on the job, either at 

Paradise of Port Richey or with previous employers (see ìCompany Operationsî for more 

information on the companyís shoreside employees). The deckhandsí duties involved 

cleaning the vessel, handling the lines during docking and undocking, pumping the bilges, 

and so forth. The deckhandsí training consisted of an orientation meeting during which 

they were informed about their duties and responsibilities. The company also gave 

employees a five-page handbook entitled ìShuttle Proceduresî that listed daily procedures 

for cleaning the vessel, for checking its lines, and for ensuring that the vessel was refueled 

every morning by leaving a ìfuel noteî at the end of each day. The handbook contained no 

emergency procedures.

The master and deckhands of the Express Shuttle II on the day of the fire were not 

required by the Coast Guard to complete formal firefighting training and according to 

interviews with Safety Board investigators, none had done so. The master said he had had 

a ìlittle bitî of firefighting training before he obtained his marinerís license. He told 

investigators that he was familiar with the vesselís fixed firefighting system (described 

below) but said he thought there were two 100-pound ìbottles.î10 Neither deckhand could 

tell investigators what kind of portable extinguisher he had used in fighting the fire on the 

Express Shuttle II, and neither knew about the vesselís fixed CO2 extinguishing system.

Regarding the emergency drills required by 46 CFR 185.520, the master told 

investigators, ìI do a fire drill and a man-overboard drill at least once a month, and when 

we get new deckhands, I do it more often.î He said that he made sure the deckhands knew 

how to turn on the fire hose and where to direct passengers in case of fire (to the bow if the 

fire was in the stern and vice versa). He also said that he had never conducted a drill with 

either of the deckhands who were on the Express Shuttle II the day of the fire ìbecause 

they were new.î The master said the emergency drills were documented in a logbook that 

stayed with the vessel, and that the company did not keep a duplicate record in the office. 

The fire destroyed the logbook.

10 Cylindrical pressure containers of compressed gas are commonly called bottles. Such containers, 

filled with compressed CO2, are commonly used in fixed fire suppression systems. The Express Shuttle IIís 

fixed fire suppression system is discussed in detail in the next section.
Factual Information 11 Marine Accident Report

Vessel Information

The Express Shuttle II was a double-deck, single-hull fiberglass vessel built in 

1997 by Arro Yachts Beaver Shipworks, Inc., of Arundel, Maine.11 The vessel was 

originally named the Gosnold Spirit. Vessel particulars are as follows:

Length: 65 feet

Beam: 22 feet

Depth: 4 1/2 feet

Gross tonnage: 43

Crew: 3 (1 master, 2 deckhands)

Passenger capacity: 149

Propulsion: Twin 800-horsepower Caterpillar model 3408 turbocharged 

diesel engines, two propellers, two rudders

Construction and Equipment

According to the vesselís as-planned drawings and a marine survey conducted in 

2000 by Marine Surveys, Inc., of Holiday, Florida, the hull of the Express Shuttle II was 

molded fiberglass with fiberglass-covered stringers,12 3-inch-thick floor timbers, and 

fiberglass-covered plywood bulkheads. Both decks were made of fiberglass-covered 

plywood, supported by 4-by-4-inch fiberglass-covered spruce stringers.

The enclosed pilothouse was on the forward section of the vesselís upper deck 

(figure 3). Behind the pilothouse was an open deck with seating for passengers. The lower, 

or main, deck contained the foredeck, enclosed cabin space for passengers, toilets, and aft 

deck. Sliding doors on both sides provided egress from the passenger cabin. Exits on the 

port side of the main deck led to the stern and bow. Inside stairways led to the upper deck 

from the starboard bow and stern.13

The belowdecks area was subdivided by watertight bulkheads into six 

compartments that contained the fuel tanks, engines, generators, water and waste tanks, 

fire suppression apparatus, and other equipment (figure 4). The engineroom had a small 

access hatch in the main deck between the generators and a larger access hatch over each 

engine. Each of the other compartments also had an access hatch. The vessel had a fire 

pump driven by a pulley connected to the forward end of the port engine. The vessel had 

11 The company is no longer in business.

12 A stringer is a supporting brace that runs the length of the hull.

13 According to 46 CFR 177.500(a), ìeach space accessible to passengers or used by the crew on a 

regular basis must have at least two means of escape, one of which must not be a watertight door.î Only one 

means of escape is required in certain circumstances, such as from deck areas of less than 322 square feet 

(46 CFR 177.500[o]).
Factual Information 12 Marine Accident Report

one bilge pump, driven by a pulley on the forward end of the starboard engine. The bilge 

pump could also operate as an emergency fire pump

Figure 3. Profile view of Express Shuttle II. Passengers were carried in the enclosed 

cabin or on the open part of the upper deck. The maximum number of passengers 

allowed on the upper deck was 64.

Upper deck

Open deck

Pilothouse

Aft deck

Belowdecks

Main deck/passenger cabins

Foredeck

Sliding door

According to the 2000 marine survey, the Express Shuttle IIís navigation 

equipment included an autopilot, a 24-mile radar, global positioning system instruments, 

depth-meter, fish-finder, and compass. The vessel was also equipped with two VHF radios 

and a Nextel cellular telephone.

Propulsion System

The Express Shuttle II was powered by two Caterpillar eight-cylinder, 800-

horsepower model 3408 diesel engines. The Express Shuttle II was the only Paradise of 

Port Richey vessel with Caterpillar engines. Each engine had two turbochargers, inboard 

and outboard, and was equipped with aftercoolers.14 Fuel was delivered from the fuel 

tanks to the engine cylinders through a series of fuel supply lines (figure 5 illustrates the 

layout of the Express Shuttle IIís engines, including the configuration of the fuel lines). 

Each engine was coupled to a shaft and a four-bladed propeller by means of an 

electrohydraulic transmission system. The master controlled forward and reverse engine 

speeds by moving levers on the pilothouse console.

14 A turbocharger compresses the air that is forced into the cylinders. The denser air entering the 

cylinders increases the efficiency with which the engine burns fuel, resulting in increased power output. 

According to the Caterpillar service manual for the 3408 diesel engine, an aftercooler, essentially a radiator, is 

positioned between the turbocharger and the engine to cool the air. The air from the turbocharger compressor 

flows into the aftercoolers and passes through the core assembly, which contains coolant. The cooled air flows 

out of the aftercooler and into the air chamber, and from there through ports into the cylinder heads.
Figure 4. Belowdecks plan of Express Shuttle II, showing compartments and equipment 

(fuel tanks, engines, generators, fixed fire suppression apparatus, potable water and 

wastewater tanks). The collision bulkheads were watertight partitions installed to protect 

the vessel from flooding in case of damage to the bow or stern. Shaded areas indicate 

hatches (covered openings) in the main deck that provided access to the hull 

compartments.

Forward collision bulkhead

Fuel room bulkhead

Forward Stowage Space

Fuel tank Fuel tank

Stop valve CO2 discharge

delay device

Engines

Generators

Engineroom

Water and Waste Tank

Compartment

Lazarette

CO2 discharge nozzles Forward engineroom bulkhead

Aft engineroom bulkhead

Aft collision bulkhead

Forepeak

Fuel Room

CO2 tank

Potable

H2O

Waste

H2O

Access hatch

Fire pump Bilge pump

Factual Information 13 Marine Accident Report
Factual Information 14 Marine Accident Report

Ring Power Corporation supplied the Safety Board with the following information 

regarding the model 3408 Caterpillar engine:

ï Average internal operating temperature with engine running at full speed 

= 1,100° F.

ï Average temperature on engine surface = 180° F.

ï Pressure in fuel lines = 1,800 psi at valve openings.

Figure 5. Layout of the Express Shuttle IIís engines. Arrow points to the broken fuel 

delivery line identified during the accident investigation (see ìWreckageî and ìTests 

and Researchî sections).

1 3 5 7

1 5 6 8

4 2 7 3

2 4 6 8

1 3 5 7

1 5 6 8

4 2 7 3

2 4 6 8

Air Intake Housing Engine

Exhaust

Valve Cover

Fuel Pump

Air Filter

Impellers

Valve Cover Impellers

Air Filter

Air Intake Housing Engine

Exhaust

Valve Cover

Fuel Pump

Broken

Fuel Line

Air Filter

Starboard

Engine

Port

Engine

Impellers

Outboard Turbocharger

Inboard Turbochargers

Valve Cover Impellers

Air Filter

Outboard Turbocharger

Not to scale

FORWARD AFT
Factual Information 15 Marine Accident Report

According to a Ring Power Corporation representative, external temperatures on 

the Express Shuttle IIís model 3408 engines were maintained at an average of 180° F by 

cooling water that was regulated by thermostat. One section of the exhaust manifold pipe 

that connected directly to the turbocharger inlet was not water-cooled, however, and 

temperatures in that section of the pipe could reach over 1,000° F, according to the Ring 

Power representative.

Electrical power was produced by two Kubota alternating-current generators, one 

behind each engine (refer to figure 4). Each generatorís output was rated at 16 kilowatts. 

The master on the day of the fire told Safety Board investigators that normally, the vessel 

operated only one generator at a time. He was not certain which generator was operating at 

the time of the accident. None of the crewmembers reported any electrical problems on the 

vessel either before or during the fire.

Fixed Fire Suppression System

Federal regulations at 46 CFR 181.400(a) require a space that contains propulsion 

machinery (the engine compartment) in a small passenger vessel to be equipped with a 

fixed gas fire-extinguishing system.15 The gases approved for use as extinguishing agents 

are CO2, halon, and new agents such as FM200 that were developed as clean alternatives 

to halon (the United States banned the manufacture of halon in 1994 because of 

environmental concerns, but existing halon systems are still allowed).16

The fire suppression system (figure 6) in the engineroom of the Express Shuttle II

was a custom-engineered, manually operated CO2 system installed when the vessel was 

built. According to original drawings in the files of the Coast Guard Marine Safety Office 

(MSO) in Tampa, the MSO in Portland, Maine, approved the design of the Express Shuttle 

IIís fire suppression system. All components of the fire suppression system were below 

the main deck and could be accessed only through one of the hatches. A 100-pound 

cylinder of CO2 gas was located in the fuel room, forward of the fuel tanks. The system 

was equipped with a safety outlet that would release gas if excess pressure built up inside 

the cylinder at any time. Galvanized piping ran about 10 feet from the gas cylinder 

through the engineroom bulkhead to two nozzles in the engineroom. One nozzle was 

directed toward each engine.

Fixed fire-extinguishing systems are inspected as part of the annual Coast Guard 

inspection of small passenger vessels. (See ìCertification and Inspectionî section for more 

information.)

15 Exceptions are spaces so open to the atmosphere that a fixed gas fire-extinguishing system would be 

ineffective, or spaces where the amount of CO2 required in a fixed fire-extinguishing system can be supplied 

by one portable or semiportable extinguisher (46 CFR 181.400[b]).

16 Detailed information about fixed fire-extinguishing systems for small passenger vessels is found on 

the website of the Department of Homeland Security, U.S. Coast Guard, Lifesaving and Fire Safety 

Standards Division <www.uscg.mil/hq/g-m/mse4/firefixedtboat.htm>.
Figure 6. Components of Express Shuttle IIís fixed fire suppression system. CO2 gas 

could be discharged by releasing the control-head lever on the cylinder. The pressure 

of the gas would activate a pressure switch that would close the air vents in the 

engineroom and shut down the engines. The gas would then travel through a stop 

valve and on to a discharge-delay device, which would postpone the release of gas 

to the engineroom for 30 seconds. Gas could be discharged immediately by 

releasing the lever on the discharge-delay device.

BULKHEAD 

FUEL ROOM

ENGINEROOM

ENGINEROOM

STOP VALVE

SAFETY

OUTLET

PRESSURE

SWITCH

DISCHARGE DELAY

DEVICE

GALVANIZED PIPE

DISCHARGE 

NOZZLES

100-POUND CO

CYLINDER

CONTROL HEAD

2

Factual Information 16 Marine Accident Report

Fire Detection System

The Express Shuttle was required by Federal regulations to have an approved fire 

detection system.17 Because of the size, complexity, and cost of many total systems 

produced by individual manufacturers, the Coast Guard permits owners of small passenger 

vessels to install detection systems comprising components from various manufacturers so 

long as each component and the system as a whole is approved by an MSO. In the case of 

the Express Shuttle II, the vessel was equipped, according to the original drawings, with a 

custom-designed fire and smoke detection system consisting of a control panel 

manufactured by Aqualarm and components manufactured by other companies. The 

system was installed when the vessel was built and, according to letters between the vessel 

builder and the Coast Guard, was approved by the MSO in Portland.18

17 According to 46 CFR 181.400(c), engine spaces in small passenger vessels must be equipped with ìa 

fire detection system of an approved type . . . , except when a fixed gas extinguishing system that is capable 

of automatic discharge upon heat detection is installed or when the space is manned.î Because the Express 

Shuttle IIís fire suppression system (described above) was manually activated, the vessel was required to 

have an approved fire detection system.

18 The letters are on file at MSO Tampa.
Factual Information 17 Marine Accident Report

After the Express Shuttle II fire, the Coast Guard determined that the Aqualarm 

panel was approved by Underwriters Laboratory (UL) for electronic components but not 

for use in fire detection systems. As a result, the agency ceased approving Aqualarm 

devices for vessel fire detection systems.

None of the system componentsócontrol panel, detectors, wiresówas found after 

the fire, which precluded investigators from reconstructing the system that had been 

installed in the vessel. Instead, investigators developed a probable system configuration 

from control panel and wiring diagrams on file at MSO Tampa. Investigators also relied 

on interviews with the technician who repaired the system 2 weeks before the fire, and 

with the port captain who had been present at annual Coast Guard inspections of the 

Express Shuttle II.

According to the diagrams, the control panel for the fire detection system was 

located in the pilothouse, to the right of the wheel. The panel was connected to a 12-volt 

battery power supply. The connection was protected from overloading by a 10-amp fuse 

fitted onto the 12-volt power supply wire directly below the alarm panel. The control 

panel contained an indicator light for each of the six fire detection zones on the vessel: 

(1) lazarette (aftmost hull compartment), (2) engineroom, (3) fuel room, (4) forward 

storage space, (5) forepeak, and (6) galley (figure 7). The galley was a space at the rear of 

the passenger cabin on the main deck where soft drinks were served.

Figure 7. Schematic of Express Shuttle IIís fire detection system.

D

D

D D

D

D

D

Pilothouse Control Panel

Pilothouse

Alarm

123456

= Detector

Lazarette

Engineroom Fuel

Room

Forward

Storage

Space

Galley

(main deck aft)

Forepeak

Circuit

Control
Factual Information 18 Marine Accident Report

The engineroom was equipped with at least one heat detector.19 All the other zones 

had combination heat and smoke detectors. The combination detectors were ULapproved, two-wire, 12-volt devices with built-in auxiliary relays.20 The system was 

designed so that if a detector activated, the light for that zone would flash on the control 

panel and an alarm would sound in the pilothouse. The alarm was a 100-decibel, 12-volt 

horn/siren.

According to the diagrams in the vessel file, each detector was wired individually 

to the control panel (the service technician verified that design to Safety Board 

investigators). Coast Guard regulations (46 CFR 161.002-10[c]) require circuits that 

extend from a control unit to ìthe fire detectors in each zoneî to be electrically supervised 

(meaning that if a circuit is interrupted, the alarm will sound). In most designs for detector 

systems, supervision is provided by an end-of-line resistor installed at the detector. If the 

flow of electricity is disrupted (for example, by a broken power cable or a nonfunctioning 

detector), the control panel will register the change and trigger the alarm. The original 

documentation contained no indication that end-of-line resistors had been installed on the 

Express Shuttle IIís fire detection system.

Certification and Inspection

Certification. The Express Shuttle II was certificated and inspected as a small 

passenger vessel by the Coast Guard under the small passenger regulations at 46 CFR 

175-185. The vesselís COI, valid for 5 years, was issued on July 17, 2000. After the 

vesselís last drydock examination on July 8, 2003, its COI was amended to reflect the date 

of the examination. MSO Tampa was the local Coast Guard office in charge of inspecting 

the Express Shuttle II.

21

The Coast Guard COI permitted the Express Shuttle II to operate off the Florida 

coast of the Gulf of Mexico from the Fenholloway River (Apalachee Bay) in the north to 

Cape Romano in the south, not more than 20 miles from a safe refuge. The COI allowed 

the Express Shuttle IIís passengers to transfer only to and from the Royal Casino I and 

only using the shuttleís portside midship transfer station. Transfers were not allowed 

when sea conditions exceeded a 2-foot wave chop or when rolling seas or sea swells 

exceeded 2 feet.

The total number of persons allowed on the Express Shuttle II was 152, consisting 

of 149 passengers and three crewmembers. The COI permitted the vessel to carry adult 

passengers only.

19 The diagrams found in the Coast Guardís vessel file show two detectors in the engineroom, with a 

potential configuration for five detectors. However, the Paradise of Port Richey port captain told 

investigators that he recalled only one heat detector in the engineroom.

20 Auxiliary relays can be used to open or close doors or shut off electrical equipment, such as fans, 

when the system detects a fire. In the case of the Express Shuttle II, the auxiliary relays were not wired to 

any equipment.

21 MSO Tampa is responsible for inspecting over 300 small passenger vessels in its jurisdiction.
Factual Information 19 Marine Accident Report

Inspection. Two Coast Guard inspectors from MSO Tampa conducted the vesselís 

last required annual inspection 2 weeks before the accident, on October 5, 2004. One of 

the inspectors told Safety Board investigators that the inspection took about an hour and a 

half. The inspectors boarded the vessel and checked its documentation, talked to the crew, 

and inspected its lifesaving equipment. Both inspectors entered the engineroom. They did 

not ask specifically about recent engine repairs. One inspector said that only if the engine 

had been removed for an overhaul or other major work would they ask about repairs. Both 

inspectors said that their inspections did not ordinarily include inquiries about preventive 

maintenance.

The inspectors followed the Coast Guard 840 inspection book for small 

passenger vessels and identified 14 items requiring corrective action. Two problem 

areas were corrected at the time of inspection. The inspectors then submitted their report 

to MSO Tampa, which prepared a letter to Paradise of Port Richey listing the 12 

remaining items requiring correction ìto the satisfaction of the cognizant Coast Guard 

OCMI.î The fire occurred before the letter could be sent. However, a review of its 

contents revealed that none of the 12 items to be corrected related to the vesselís fuel 

lines or fuel line brackets.22

Fire Detection System. The Paradise of Port Richey port captain said that the 

Coast Guard inspections usually included the Express Shuttle IIís smoke- and heatdetection system. During the Coast Guard inspection of October 5, 2004, however, an 

outside service company (ìthird partyî) was on board repairing the fire detection 

system. Paradise of Port Richey had called for the repair because the detector in the 

galley had been damaged. During the repair work, a second detector, in the fuel room, 

was found to be nonfunctional. The service company completed the repairs and then 

tested both the alarm panel (it was equipped with a test button) and the detectors (by 

directing smoke at them from a small smoke canister). One of the Coast Guard 

inspectors stated that because of the third partyís presence, the inspectors did not test the 

fire detection system. A representative of the service company told investigators that 

Paradise of Port Richey had contracted the company only to repair the smoke and heat 

detectors, not to inspect the system.

Fire Suppression System. The required annual inspection of the Express Shuttle 

IIís fire suppression system was done by a third party, which would then submit its 

inspection report to the Coast Guard as part of the inspection record. ìA qualified servicing 

facilityî is permitted by 46 CFR 176.810(b) to inspect, maintain, and test portable fire

22 The required corrections were to install a placard near the aft ladder listing the maximum number of 

passengers allowed on the second deck, install a light cover in the engineroom, remove child lifejackets (list 

states, ìvessel representative will removeî), install strainers for the bilge lines, repair three lifefloats and 

replace their taglines, label the lifejacket storage location with size and amount, secure wires and remove 

dead-ended wires, reseal cleat backing plates, provide a support beam for (or repair) second deck overhead, 

repair and properly mount engine battery switches, and provide safety shields for the port and starboard 

power takeoffs.
Factual Information 20 Marine Accident Report

extinguishers and fixed gas extinguishing systems.23 According to the Coast Guard 

inspection record, the Express Shuttle IIís CO2 cylinder had last been weighed in May 

2004 and its last hydrostatic pressure test had been in July 2000. The May 2004 inspection 

was done by a local third-party firm, Suncoast Fire and Safety.

Wreckage

On October 21, Safety Board investigators examined the damage to the Express 

Shuttle II at a marina in Tarpon Springs. The fire had destroyed the vesselís top deck and 

main deck and severely damaged the belowdecks area (figure 8), including both engines 

and both generators. The investigators found it necessary to remove charred debris from 

the engines before they could conduct their postaccident examination.

Figure 8. Wreckage of Express Shuttle II as it appeared when Safety Board 

investigators examined it 4 days after the fire.

Structural Damage

The fire burned through most of the main deck, especially in the area of the engine 

compartment (figure 9). Wooden structural components of the main deck were heavily 

charred and fiberglass components were brittle, with most of the resin burned out of the 

23 Required tests of CO2 systems include weighing the gas cylinders (they must be recharged if their 

weight loss exceeds 10 percent of the charge); testing time delays, alarms, and ventilation shutdowns 

according to the manufacturerís instruction manual; and making sure hoses and nozzles are clean.
Factual Information 21 Marine Accident Report

fiberglass matrix. All items on the main and upper decks (chairs, tables, and other items) 

were completely destroyed. All decking over the engine space, including the stringers 

supporting the decks, was destroyed. The destroyed sections of the upper deck had 

collapsed onto the main deck and fallen into the bilge and engine compartment. The only 

remaining upright structure was a charred section of the port cabin bulkhead. The inside of 

the hull below the main deck was charred but intact.

Figure 9. Debris over the engine compartment that investigators had to remove 

before they could examine the Express Shuttle IIís engines and generators.

Engine Compartment Damage

The engine compartment was heavily damaged by the fire. Both engines and both 

generators were destroyed, and most of the aluminum engine components (such as valve 

covers) were melted.24 The starboard engine sustained more damage than the port engine 

(figure 10). The inboard sides of the engines showed intense heat damage, particularly 

near the starboard engine valve cover. Both engines were protected from impact damage 

by their overhead heat shields, which had collapsed on top of them.

The vesselís fire pump, forward of the port engine, was significantly damaged by 

fire and debris, and its drive belt had burned off. The vesselís only bilge pump and its 

drive belt off the starboard engine sustained similar damage.25

24 Most aluminum alloys start to melt at about 1,000° F.

25 As noted earlier, the bilge pump could also function as an emergency fire pump.
Figure 10. Looking aft toward the Express Shuttle IIís engine space after the fire. The 

starboard engine (left) was more severely damaged than the port engine (right).

Factual Information 22 Marine Accident Report

The electrical systems for both engines were severely damaged by the fire. 

Virtually all the electrical wiring insulation had burned off. However, investigators found 

no evidence of arcing in the remains of the wiring.

Starboard Engine. Investigators found that the fire destroyed the aluminum 

impeller26 on the compressor (air inlet) side of the engineís inboard turbocharger (figure 

11), but that the impeller on the exhaust side of the turbocharger was intact. Both 

impellers on the outboard turbocharger were also intact. The fuel filters on the inboard 

side of the engine were destroyed, and the aluminum inboard valve covers were melted.

26 An impeller is a wheel with curving internal bladesóìvanesîóradiating out from the hub. A marine 

turbocharger has two impellers (inlet and exhaust) connected by a shaft. Hot engine exhaust directed into 

one end of the turbocharger causes the impeller to spin and draw cooler ambient air from the engine 

compartment into the other end. The hot exhaust gases are kept out of the inlet chamber by a sealed bearing 

around the impeller shaft and a steel barrier between the turbochargerís two chambers. The ìVessel 

Informationî section, above, including figure 5, gives further details about turbochargers.
Figure 11. Photograph showing destruction on starboard engineís inboard 

turbocharger.

Factual Information 23 Marine Accident Report

Investigators found that the steel delivery line leading from the fuel pump to 

cylinder 5 of the starboard engine had broken at the end nearest the fuel pump, at the upper 

end of the metal sleeve, or ferrule, attaching the line to the fuel pump (figure 12). 

Investigators found no evidence, such as dents or punctures, which might indicate that the 

break was caused by falling fire debris. Investigators further discovered that the entire 

length of the cylinder 5 fuel line was without support clamps.

Investigators found one support clamp in the debris, on top of the inboard side of 

the starboard engine block between cylinders 5 and 7. The screw was loosened almost 

completely, to the extent that the end threads were flush with the outer surface of the end 

plate. No fuel lines were fastened to the clamp. Investigators found a total of seven other 

clamps supporting the fuel delivery lines on both sides of the starboard engine, but none of 

the clamps was secured to the engine block (figure 13).
Figure 12. Closeup showing where the fuel line (center) to cylinder 5 of the starboard 

engine broke away from its attachment at the fuel pump.

Figure 13. Photograph of fuel lines on the inboard side of the starboard engine block 

showing lines clamped together, and the loose clamp found between cylinders 5 and 7.

Factual Information 24 Marine Accident Report
Factual Information 25 Marine Accident Report

As noted earlier, the Caterpillar service manual for its high-performance marine 

engines (including the 3408) contains the warning: ìBe sure the fuel injection line clamps 

are installed in the correct location.î The manualís instructions for removing the fuel lines 

are: ìRemove the bolts that hold brackets to the engine. Remove the fuel injection lines as 

a unit. Put plugs and caps over all openings.î The directions for installing the fuel lines 

are: ìRemove the plugs and caps. Install the fuel injection lines as a unit.î Instructions for 

installing the fuel line brackets are: ìInstall the bolts that hold brackets to the engine.î The 

manual gives specific instructions, including torque values, for disconnecting and 

tightening the fuel line nuts and clamps. An illustration in the manual shows fuel delivery 

lines clamped to each other and to the engine block; clamping locations and numbers of 

clamps are not specified.

The fuel supply lines for the starboard engine were removed by a Safety Board 

metallurgist on scene and transported to the Boardís materials laboratory in Washington, 

D.C., for analysis. See ìTests and Researchî section for a discussion of the laboratory results.

Port Engine. The outboard side of the engine showed minimal heat damage, but 

on the inboard side, all aluminum components were melted or damaged. Though all four 

turbocharger impellers were intact, the aluminum intake housings and cowlings were 

melted. Investigators found no broken or damaged fuel lines on either side of the port 

engine. The fuel lines were clamped to each other as well as to the engine block.

Waterway Information

The Pithlachascotee (ìCoteeî) River flows for more than 20 miles through Pasco 

County, Florida, into Millerís Bayou at the town of Port Richey and then empties 

westward into the Gulf of Mexico. The river mouth is 7 miles north of the Anclote River 

and the town of Tarpon Springs, the headquarters of the sponge-fishing fleet on the west 

coast of Florida.27

An extensive shoal area lies off the mouth of the Pithlachascotee River. The Gulf 

of Mexico is shallow (1 to 5 feet deep) from the shoreline out to the 3-nautical-mile line. 

Between there and the 9-nautical-mile limit of Florida state waters, the gulf ranges from 

6 1/2 to 14 feet deep.28

A dredged navigation channel in the Pithlachascotee River runs 2.7 miles from the 

Gulf of Mexico to a turning basin just below the U.S. route 19 highway bridge, about a 

mile from the riverís mouth. The controlling depth of the channel in August 2003 was

4.9 feet (5.4 feet at midchannel).29 Two 90° turns in the channel near the riverís mouth 

27 National Oceanic and Atmospheric Administration, National Ocean Service, United States Coast 

Pilot, vol. 5 (Atlantic Coast: Gulf of Mexico, Puerto Rico, and Virgin Islands), 2004, p. 340.

28 National Oceanic and Atmospheric Administration, National Ocean Service, Coast Survey, U.S. Gulf 

Coast, Florida, Chart 11409, Anclote Keys to Crystal River, 1999.

29 United States Coast Pilot, vol. 5, p. 341.
Factual Information 26 Marine Accident Report

were known to local mariners as the S-turn. The Paradise of Port Richey marina was 

located near the highway bridge (see figure 2).

Company Operations

Paradise of Port Richey, the owner of the Express Shuttle II, began operating the 

SunCruz Port Richey Casino in 1995. At the time of the accident, Paradise of Port Richey 

had two casino boats, the Royal Casino I and the Monte Carlo (not then in service, 

however). As described earlier, shuttle boats carried passengers from the company marina 

to the casino boats, which operated in the Gulf of Mexico outside Florida waters, where 

gambling was legal. The casino owned three other shuttle boats besides the Express Shuttle 

IIóthe Express Shuttle, the Royal Express II, and the Royal Expressónot all of which 

operated at any one time. Characteristics of all the companyís boats are listed in table 2.

Table 2. Characteristics of boats owned by Paradise of Port Richey.

Vessel

Length

(ft) Gross Tons Required Crew

Maximum 

Passengers Others*

Royal Casino I 139.5 99 6 375 34

Monte Carlo 110.5 98 7 315 30

Express Shuttle II 65 43 3 149 0

Express Shuttle 64.5 82 3 144 3

Royal Express II 62.3 75 2 88 0

Royal Express 45 9 2 49 0

*Other persons in crew, or persons in addition to crew, such as casino employees.

Day-to-Day Operations

At the time of the accident, the company had two shuttle boat masters on its 

payroll and three deckhand supervisors, who worked mostly on shore. A port captain 

managed day-to-day company operations.

The casino scheduled shuttle departures from the Port Richey dock four times a day, 

7 days a weekóat 0930, 1100, 1530, and 1900. Customers could stay a few hours or until 

the last return trip, which was at 0030 (Monday through Thursday) or 0100 (Friday to 

Sunday). Other return trips were scheduled at 1500, 1730, and 2100. The masters told 

investigators that they worked either the day shift or the night shift 5 or 6 days a week, but 

that they did not have a set weekly schedule. The master on the day of the fire told 

investigators that he would play a short, recorded safety announcement when the vessel 

departed the dock.30

30 Federal regulations at 46 CFR 185.506, in part, require that, before getting under way on a voyage or as 

soon as practicable thereafter, the master will ensure that ìsuitable public announcements are made informing 

all passengersî where emergency exits and lifejackets are located and how lifejackets should be donned.
Factual Information 27 Marine Accident Report

Port Captain. The port captain told investigators that he had started with the 

company as a vessel master, serving in that capacity for about 4 years. He held a Coast 

Guard merchant marinerís license, issued in May 2001, as ìmaster of steam or motor 

vessels of not more than 500 gross registered tons (domestic tonnage) upon oceans.î After 

taking a year off, he returned to the company and was promoted to port captain. He had 

held that position for about 4 years at the time of the accident. His responsibilities 

included upkeep and maintenance of vessels and oversight of vessel safety, daily 

operations, and personnel. He told investigators that in the mornings, he transported the 

gambling boat crew offshore in one of the shuttle boats and sometimes filled in for one of 

the regular shuttle masters. He said that over the years, he had replaced the fuel lines on 

ìboth sides, both enginesî of the Express Shuttle II.

Deckhand Supervisor No. 1. Deckhand supervisor No. 1 told Safety Board 

investigators that he had about 3 years of maritime experience, including more than 1 year 

with Paradise of Port Richey. His job consisted of checking the engines in the morning, 

including oil and water levels, and he was also responsible for checking the cleanliness of 

the vessel before the first trip of the day. He said that he had worked on one of the 

companyís casino boats as an engineer. He stated that he was present for the repair 

performed by Ring Power Corporation 4 days before the fire.

Deckhand Supervisor No. 2. Deckhand supervisor No. 2 told investigators that 

he had worked for the company for about 6 months. Before that, he had been assistant 

manager of a retail store. He said that he had been hired by the company as a deckhand 

and had received all his training on the job. His responsibilities included making certain 

that the vessel engines were supplied with oil and water, that the boat appeared clean, 

and that the necessary consumables (such as food, drinks, and toilet paper) were on 

board.

Deckhand supervisor No. 2 said that he had never repaired a fuel line but had 

watched others do the work. He performed the morning maintenance checks on the 

Express Shuttle II the day of the fire and said that he ìdidnít notice anything unusualî 

when he checked the engineroom.

Slots Supervisor. This employeeís job title reflected his responsibility for 

repairing the slot machines on the casino boat. He told investigators that he had worked 

for Paradise of Port Richey about 5 years. He said that he had no other maritime 

experience and had received all his training on the job, starting as a deckhand on the 

Royal Casino I and working his way up to supervisor. At the time of the accident, his 

tasks on the companyís shuttle vessels included changing the engine oil and making 

repairs, from changing light bulbs to helping repair fuel lines. He told investigators that 

he had repaired two fuel lines on the Express Shuttle II during his employment with the 

company.

Vessel Maintenance

Paradise of Port Richey did not have a formal preventive maintenance program for 

its vessels, and Coast Guard regulations do not require small passenger vessels to have 
Factual Information 28 Marine Accident Report

such a program. Company personnel told investigators that maintenance checks were 

performed on the Express Shuttle II every morning before it began the dayís trips. 

Shoreside personnel would check such items as general vessel condition, oil and water 

levels, bilge levels, and drinking water supply. Any item requiring additional maintenance 

was noted on the checklist. The checklist was signed by the employee who performed the 

check and then by the master operating the vessel that day. At the end of the day, the 

master would complete the checklist and forward it to the port captain.

According to the master on the day of the fire, the shuttle boats maintained an 

inventory of spare fuel lines on board. The port captain said that if a fuel line failed while 

a vessel was under way, the crew would change the line and the master would note the 

repair on the daily vessel checklist. The Express Shuttle IIís checklist for October 16, 

2004, the day before the fire, stated, ìChanged fuel line starboard side,î and noted the 

Caterpillar part number.

The port captain kept a maintenance log for each company vessel in the companyís 

office. Safety Board investigators examined the Express Shuttle IIís maintenance log for 

the year before the fire, between October 15, 2003, and October 14, 2004. The logís six 

handwritten pages contained no entries for the replacement or repair of fuel lines.

All eight Paradise of Port Richey employees interviewed by Safety Board 

investigators said that they had changed or been present while someone else changed a 

failed fuel line on the Express Shuttle II.

31 One master told investigators that he did not use 

Caterpillar instructions or procedures for changing the fuel lines, but instead relied on his 

ìyears of experience of working on engines.î Deckhand supervisor No. 1 said that he had 

changed a ìcouple of fuel linesî but could not remember for which engine or which fuel 

lines. When asked by investigators whether he used a torque wrench, he said that he used 

ìjust wrenches and thingsî and did not know the torque ratings of the fuel line fittings. He 

said that he just tightened them down until they felt tight.

The port captain told investigators that a copy of the Caterpillar service manual 

was kept on board the Express Shuttle II (the copy was lost in the fire). The disassembly 

and assembly part of the manual contains a section entitled, ìRemove and Install Fuel 

Injection Lines.î The procedures describe how to remove and install fuel injection lines as 

a unit, but do not address how to remove or install a single fuel injection line. A note at the 

end of the section states, ìIf it is necessary to loosen any of the fuel injection line clamps, 

retorque the screws to 2.26 N*m (20 lb in).î32

The port captain was responsible for deciding when outside vendors should be 

called for repair work. Major engine work was done by the local Caterpillar agency (Ring 

Power Corporation). According to the port captainís maintenance log and invoices 

supplied by Paradise of Port Richey, Ring Power Corporation rebuilt the Express Shuttle 

IIís port engine in February 2004. As noted earlier, the Express Shuttle IIís fire 

31 The chief executive officer was also interviewed; he did not work on the companyís vessels.

32 N*m = Newton-meter (international system unit); lb in = pound-inch (or, inch-pound). One inchpound = 0.113 N*m. One foot-pound (measure used elsewhere in this report) = 1.356 N*m.
Factual Information 29 Marine Accident Report

suppression equipment was maintained by a local service firm. Another local firm 

repaired the fire detection system when necessary, as on the day of the vesselís last annual 

Coast Guard inspection.

Meteorological Information

Weather data recorded at Tampa International Airport, 26 miles from Port Richey, 

show that at the time of the accident, the air temperature was about 80° F, with clear skies, 

good visibility, and variable light winds. The sea temperature was also about 80° F, 

according to data recorded at Clearwater, Florida, 21 miles south of Port Richey.

Toxicological Testing

The Coast Guard requires drug and alcohol testing in the event of a serious marine 

incident.33 As stated at 46 CFR 4.06(b), ìthe marine employer shall take all practicable 

steps to have each individual engaged or employed on board the vessel who is directly 

involved in the incident chemically tested for evidence of drug and alcohol use.î

The master and both deckhands submitted urine samples for drug analysis after the 

accident. Results were negative for the five drugs of abuse (marijuana, cocaine, opiates, 

amphetamines, and phencyclidine) that Federal regulations at 46 CFR 16.113 and 

elsewhere require screening for in postaccident testing. None of the crewmembers 

underwent postaccident alcohol testing. The Paradise of Port Richey port captain told 

investigators that he was unaware that it was the companyís responsibility to conduct 

breath tests for alcohol after an accident. He stated that on-scene Coast Guard 

investigators reminded him to have the crew drug-tested but did not inform him to test for 

alcohol use.

In 1999, Coast Guard Headquarters instructed that each OCMI and each captain of 

the port (COTP), ìupon notice that a serious marine incident has occurred, should 

immediately direct the involved marine employers to ensure that drug and alcohol testing 

is conducted.î34 The directive further required that ìeach OCMI/COTP should conduct 

alcohol breath tests anytime there is concern that proper alcohol testing would not 

otherwise be accomplished.î As required by the Coast Guard Authorization Act of 1998, 

33 A serious marine incident is defined at 46 CFR 4.03-2 as (a) a marine casualty or accident that results 

in any of the following: (1) one or more deaths, (2) injury that requires medical treatment beyond first aid 

and renders the individual unfit to perform routine duties, (3) property damage exceeding $100,000, (4) 

actual or constructive total loss of an inspected vessel, or (5) actual or constructive total loss of any 

uninspected vessel that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of oil into U.S. 

waters; (c) the release of a reportable substance into the environment of the United States. Because the fire 

resulted in the total loss of the Express Shuttle II, and because the vessel was valued at over $100,000, the 

accident qualified as a serious marine incident.

34 Commandant (G-MOA) policy letter 1-99, ìPost Casualty Chemical Testing Following a Serious 

Marine Incident,î February 11, 1999.
Factual Information 30 Marine Accident Report

the Coast Guard has established procedures to ensure that alcohol testing is conducted no 

later than 2 hours after a serious marine incident. The final rule was published on 

December 22, 2005, with an effective date of June 20, 2006.35 The new regulations for 

alcohol testing appear at 46 CFR 4.06-3.

Survival Factors

Emergency Response

At 1028, according to the Coast Guard situation report on the Express Shuttle II

fire, an HH-60J ìJayhawkî helicopter on a training mission from Coast Guard Air Station 

Clearwater received a distress call on VHF-FM channel 1636 that a vessel was on fire at 

the mouth of the ìCoteeî River. On receiving the call, the helicopter diverted to the 

accident site. At 1033, the helicopter pilot reported to Coast Guard Group St. Petersburg 

that all crewmembers were off the vessel and that a ìgood Samaritanî and a tugboat were 

assisting at the scene. At 1034, Coast Guard Station Sand Key, located about 20 miles 

south of the accident site in Clearwater (refer to figure 2), notified Pasco County fire and 

rescue of the vessel fire. At 1040, the Coast Guard launched a 25-foot patrol boat to the 

scene from Station Sand Key.

At 1034, the same time the Coast Guard was notifying Pasco County of the fire, 

the Port Richey Fire Department (PRFD) received a 911 call reporting a fire on board a 

casino shuttle. Because the caller did not give an exact location, the first responding PRFD 

engine company drove to the Paradise of Port Richey dock. The PRFD captain told 

investigators that the firefighters saw a column of black smoke and a circling helicopter 

near Harborpointe, the westernmost part of Port Richey that is accessible by road. The 

PRFD captain said that while en route to the fire, he requested a fire engine from Pasco 

County.

According to its incident report, the PRFD engine company arrived on scene at 

1042 and the PRFD fire captain assumed the incident command post. The fire captain 

told investigators that the Express Shuttle IIís entire deck structure was burning and 

that the vessel appeared to be aground (figure 14). A Coast Guard Auxiliary boat 

closed the channel to traffic because the burning Express Shuttle II created a 

navigation hazard.

35 Federal Register, vol. 70, no. 245 (December 22, 2005), pp. 75954-75961.

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

calling and distress frequency.
Figure 14. When firefighters arrived at the scene, the entire deck structure of the 

Express Shuttle II was on fire and a thick plume of black smoke rose hundreds of feet 

into the air.

Photo © Mark L. Smith

Factual Information 31 Marine Accident Report

By this time, a Pasco County sheriffís office boat, the Marine 3, had arrived on 

scene and was circling the burning vessel. The PRFD captain told investigators that he 

contacted the Marine 3 via the emergency radio system established by Pasco County as 

part of a mutual aid agreement between area emergency agencies. He was advised that the 

Express Shuttle IIís crew had already been rescued from the burning vessel and that a Port 

Richey police boat was also on its way. The Express Shuttle II master told investigators 

that he called ahead for an ambulance, which was waiting at the dock of a commercial 

establishment when the company boat arrived with deckhand No. 1.

About 1050, two firefighters from the Pasco County fire and rescue station 3 miles 

away arrived with another fire engine. The firefighters from the PRFD and Pasco County 

connected a hose to the nearest hydrant and set up operations on a private citizenís lawn, 

passing hoses and equipment over a garden and a wall to the beach and setting ladders 

along the wall to access the beach. Because the burning boat was only 100 yards from 

shore and the tide was low, the firefighters waded through the mud and boarded a small 

police boat that took them to the Marine 3 (figure 15).
Figure 15. Firefighters laid hoses from shore to a Pasco County sheriffís office boat, 

then walked through mud to a police boat that took them to the sheriffís boat. The 

sheriffís boat shuttled them and their equipment close enough to the Express Shuttle 

II for them to direct water onto the fire. Later, they fought the fire with foam pumped 

from the tanks of fire engines on shore.

Photo © Mark L. Smith

Factual Information 32 Marine Accident Report

From the Marine 3, they directed water onto the burning vessel until it was cool 

enough to board, then the Marine 3 shuttled the firefighters to and from the burning vessel 

in shifts. Once on board the burning vessel (the largest number of firefighters on the vessel 

at one time was four), firefighters directed water to any fire they could see belowdecks. 

The PRFD captain told investigators that the firefighters were uncertain whether the 

vesselís fuel tanks were involved in the fire. The Pasco County fire captain said that 

because the master of the Express Shuttle II had not dropped his anchor, the burning boat 

began floating upriver on the incoming tide. The fire captain tied the vesselís anchor to a 

piling, and a towboat hooked itself to the vessel to keep the hazard away from other boat 

traffic.

At that point, two Pasco County fire battalion chiefs arrived with more fire 

apparatus and assumed control of the operation. They began fighting the fire with foam, 

discharged from the tank of one of the fire engines. The PRFD reported that firefighters 

contained the fire at 1118. At 1137, the Coast Guard helicopter reported that the fire was 

under control and returned to its base at Air Station Clearwater. At 1140, the Coast Guard 

patrol boat from Station Sand Key (Clearwater) arrived on scene.

The firefighters continued applying foam to the vessel. The Pasco County fire 

captain estimated that the foam had subdued the fire by about 1500; the PRFD captain 
Factual Information 33 Marine Accident Report

estimated that it took until 1530 or 1545. By that point, the vessel was a total loss (figure 

16). After the state fire marshal arrived on scene, the Express Shuttle II was towed out of 

the channel and to a marine repair yard in Tarpon Springs (see figure 2).

Figure 16. By the time the fire was extinguished, the Express Shuttle II was a total loss.

Photo © Mark L. Smith

Firefighting Equipment

The Coast Guard inspection record for October 5, 2004, states that the Express 

Shuttle II had four portable fire extinguishers and one 1 1/2-inch-diameter fire hose, in 

addition to the fixed fire suppression system described earlier. The inspection record states 

that the vesselís fire pumps were tested but does not indicate the number of pumps. As 

noted earlier, the vessel had one fire pump and one bilge pump that could also serve as an 

emergency fire pump.

Lifesaving Equipment

The Express Shuttle II was required by its COI to carry lifesaving equipment for 

152 persons. The equipment included 152 adult lifejackets and four lifefloats. The vessel 

was not required to carry child lifejackets because children were not allowed as 

passengers, according to the COI. According to as-planned drawings for the vessel, 

lifejackets were stowed in bins or inside benches throughout the passenger spaces. On the 

upper deck, lifejackets were stowed in a locker behind the pilothouse.37

37 Coast Guard regulations at 46 CFR 180.78 state, ìlife jackets must be stored in convenient places 

distributed throughout accommodation spaces,î and ìeach stowage container for life jackets must not be 

capable of being locked. If practicable, the container must be designed to allow the life jackets to float free.î 

Further, ìeach life jacket kept in a stowage container must be readily available.î
Factual Information 34 Marine Accident Report

The vesselís required number of lifefloats could accommodate a total of 88 people 

(22 people to each lifefloat).38 Lifefloats are buoyant apparatus that have a line attached 

around the outside. Survivors in the water can hold onto the line. The apparatus is not 

designed to support survivors out of the water.

Tests and Research

The fuel supply lines for the Express Shuttle IIís starboard engine were removed and 

sent to the Safety Boardís materials laboratory in Washington, D.C., for examination. The 

examination, which representatives of Paradise of Port Richey, Caterpillar, Inc., and Ring 

Power Corporation attended, found reddish-brown oxidation on the surfaces of the low-alloy 

steel fuel lines and clamps. The Safety Boardís materials engineerís report stated that the 

oxidation was ìconsistent with exposure to heat and fire and subsequent extinguishing media.î

The Safety Board materials engineers measured the location of each clamp on the 

fuel injection lines from the starboard engine and the material hardness of the fuel 

injection line for engine cylinder 5 (it was within the specified range). The engineers 

examined in detail the fracture area on the fuel line at the ferruleís upper edge (figure 17).

Figure 17. Closeup of the fracture area on fuel injection line 5 of the vesselís starboard 

engine. Up and forward arrows are in relation to the starboard engine.

38 According to 46 CFR 180.205(c), ìEach vessel certificated to operate on a limited coastwise route in 

warm water must be provided with life floats of an aggregate capacity that will accommodate at least 50% of 

the total number of persons permitted on board.î
Factual Information 35 Marine Accident Report

In their report, the Safety Boardís engineers characterized the fracture mechanism 

as ìmacroscopically brittleî39 and stated that the fracture area on the steel fuel line 

exhibited features ìconsistent with fatigue fracture across approximately 95 percent of the 

fracture surfaceî (figure 18). The metal fatigue originated mostly at a single area on the 

inboard surface of the fuel line. The remainder of the fatigue had multiple origins on the 

outboard surface of the line. As shown in figure 18, the outer circumference of the fracture 

surface on the fuel line showed numerous ratchet marks, indicating fatigue cracking in 

different, slightly offset planes in the metal. The materials engineers observed ìno 

evidence of crimping damage from the ferruleî on the fuel line next to the fracture.

Figure 18. Scanning electron microscope view of the fracture surface on fuel 

injection line 5 (perspective is upward through the line, which was perpendicular to 

the engine at the fracture location). Shaded area indicates the ìfinal fast fracture 

region,î that is, the last region to give way. Unlabeled arrows indicate the 

approximate direction of fatigue propagation. Fatigue originating at the inboard 

surface of the fuel injection line traveled around the center and formed a ratchet mark 

on the opposite side (arrow at center). Ratchet marks form where cracks in offset 

planes meet and generally indicate multiple fracture origins.

39 Macroscopic means visible to the naked eye. A brittle fracture mechanism such as fatigue can occur 

in ductile materials (those that can be shaped, bent, or drawn out) and will result in a fracture that does not 

permanently deform the adjacent material.
Factual Information 36 Marine Accident Report

The Safety Boardís laboratory report stated that the fuel injection line to cylinder 

5 of the starboard engine failed because of metal fatigue at the base of the ferrule on the 

fuel-pump end of the line. According to the materials engineersí analysis, the fracturing 

was typical of fatigue associated with excessive vibration. The engineersí report noted 

that ìimproper clamping can lead to excessive vibration,î and found that ìthe total lack 

of clamping led to excessive vibrations that caused the line to fatigue and fail.î

The Safety Board materials engineers also found indications of ìvibrational 

contactî between two other fuel injection lines (Nos. 1 and 3) on the starboard engine. 

The lines were worn through more than 20 percent of their diameters, ìanother 

indication of incorrect clamping or other installation problems,î according to the 

engineersí report.

Other Information

Federal Regulations Pertaining to Vessel Maintenance

Federal regulations governing small passenger vessels (46 CFR subchapter T 

[parts 175-185]) do not contain detailed instructions or requirements for vessel 

maintenance. Regarding machinery on small passengers vessels, 46 CFR 182.100 states 

the following:

This part contains requirements for the design, construction, installation, and 

operation of propulsion and auxiliary machinery, piping and pressure systems, 

steering apparatus, and associated safety systems. Machinery and equipment 

installed on each vessel must be suitable for the vessel and its operation and for 

the purpose intended. All machinery and equipment must be installed and 

maintained in such a manner as to afford adequate protection from causing fire, 

explosion, machinery failure, and personnel injury.

Passenger Vessel Association

The Passenger Vessel Association (PVA) is a voluntary organization that serves 

the interests and concerns of more than 400 vessel owners and operators, or about 65 

percent of the domestic passenger vessel industry in the United States. Association 

members operate more than 1,100 passenger vessels nationwide, carrying up to 200 

million passengers annually. PVA members offer services including dinner cruises, tour 

and excursion services, car and passenger ferries, private charters, whale-watching trips, 

overnight cruises, and gaming vessels. At the time of the Express Shuttle II fire, 

Paradise of Port Richey was a PVA member company.

The PVA has a safety and security committee dedicated to improving the safety of 

passenger vessel operations. The PVA publishes training videos and manuals to enhance 

crew training and safety among its members (among the training materials are a video and 

accompanying manual on marine firefighting that are available for a small fee) and 

maintains a website (www.passengervessel.com). In June 2005, in response to a 
Factual Information 37 Marine Accident Report

recommendation from the Safety Board,40 the PVA added to its website preventive 

maintenance documents that vessel owners and operators can download and adapt for 

their own use. The documents consist of worksheets on which to list engine specifications 

and track engine maintenance; record repair and maintenance purchases, general repairs 

and maintenance, inspection and maintenance of lifesaving equipment, and maintenance 

of heating and air conditioning systems; and track vessel painting. The documents also 

include daily and weekly checklists.

40 See ìPreventive Maintenanceî section of this reportís analysis for further information.
38 Marine Accident Report

Analysis

General

The following analysis first identifies factors that readily can be eliminated as 

causal or contributory to the fire that destroyed the Express Shuttle II. The analysis then 

discusses how and where the fire started, followed by a consideration of the major safety 

issues identified during the investigation:

ï Preventive maintenance

ï Crew response to fire emergency

ï Fire detection systems

Exclusions

At the time the fire broke out, the weather was mild and did not hamper 

detection of the fire or interfere with firefighting efforts. Crewmembers of the Express 

Shuttle II had just begun the dayís work and were well rested. All crewmembers tested 

negative for illicit drugs. The Safety Board therefore concludes that the following were 

not factors in the fire on board the Express Shuttle II: weather, operator fatigue, or illicit 

drugs. None of the crewmembers was tested for alcohol. However, investigators found 

no indication that the crewmembersí actions before or during the fire were affected by 

the use of alcohol. Therefore, although crewmembers were not given postaccident tests 

for alcohol, the Safety Board concludes that alcohol was probably not a factor in the 

accident.

The Safety Board considers improving postaccident drug and alcohol testing in the 

marine industry so important that in 2002, it placed the issue on its ìMost Wantedî list of 

transportation safety improvements. The ìMost Wantedî list is intended to increase the 

publicís awareness of, and support for, action to adopt safety steps that can help prevent 

accidents and save lives. The Safety Board is pleased that new Coast Guard regulations, 

effective June 20, 2006, make it mandatory for crewmembers to be tested for alcohol 

within 2 hours of a serious marine incident. The regulatory changes should contribute 

significantly to the timeliness of postaccident alcohol testing.

Cause and Origin of Fire

The fire damaged the Express Shuttle II so severely that before Safety Board 

investigators could examine the vesselís machinery, they had to remove layers of burned 

debris that had fallen into the engine compartment when the upper decks collapsed. Both 
Analysis 39 Marine Accident Report

engines and generators were nearly destroyed; however, evidence indicated that the fire 

originated on the inboard side of the starboard engine near the broken fuel line to cylinder 

5, as described below.

The engine parts near the broken fuel line on the starboard engine sustained the 

greatest fire and heat damage. The air filter and intake impeller on the inboard starboard 

turbocharger, facing the broken fuel line, were both destroyed (refer to figure 5 for engine 

layout). Other components on the inboard side of the starboard engine near the broken fuel 

line were damaged or destroyed as well, including all the aluminum components. In the 

engine area immediately below the broken fuel line, the aluminum valve covers were 

melted and the fuel filters were destroyed.

The damage lessened moving from the inboard side of the starboard engine 

outward to the vesselís starboard side. The outboard side of the starboard engine, while 

seriously burned, did not sustain the same amount of damage as the inboard side. For 

example, both the intake and exhaust impellers on the starboard engineís outboard 

turbocharger were found intact after the fire.

Moving outward in the other direction from the inboard side of the starboard 

engine, the inboard side of the port engine (the side closest to the starboard engine) was 

less damaged than the inboard side of the starboard engine. Further, the fire and heat 

damage to the port engine was more severe on the inboard side than on the outboard side. 

For example, all aluminum components on the inboard side of the port engine were 

destroyed, such as the aluminum pipe from the inboard turbocharger to the air intake 

housing, while the corresponding pipe from the outboard turbocharger remained largely 

intact.

Damage to the vesselís generators was also more severe near the inboard side of 

the starboard engine. The most serious damage to the starboard generator was on the 

forward end (nearest the starboard engine) and inboard sides. On the port generator, the 

aluminum components on the inboard side were melted, and the rest of the generator was 

seriously damaged but not completely destroyed. The Safety Board concludes that the 

pattern and extent of damage indicate that the fire started on the inboard side of the 

Express Shuttle IIís starboard engine.

The fuel delivery line to cylinder 5 of the starboard engine had broken off at its 

attachment to the fuel pump. After examining the fractured line, the Safety Board 

materials laboratory determined that the line failed because of metal fatigue at the base of 

the ferrule that attached the line to the fuel pump. Although the laboratory examination 

found severe contact wear in two other fuel injection lines on the starboard engine, the 

only fracture was in the line that delivered fuel to the starboard engineís No. 5 cylinder. 

The Safety Board therefore concludes that the initial source of fuel for the fire was diesel 

fuel from a fractured fuel line to cylinder 5 on the starboard engine.

Fracturing in the line was determined to be typical of fatigue associated with 

excessive vibration. The Safety Boardís materials engineers determined that excessive 

vibrations caused the line to cylinder 5 ìto fatigue and fail,î and that the vibrations 
Analysis 40 Marine Accident Report

resulted from the lineís ìlack of clamping.î The Boardís postaccident examination of the 

Express Shuttle II found that the fuel line to cylinder 5 was not clamped to the starboard 

engine block or to another fuel line, and that none of the other fuel injector lines to the 

starboard engine was clamped to the engine block (though some lines were clamped to 

each other). An unattached clamp found lying near the broken fuel line, on top of the 

engine block between cylinders 5 and 7, indicated that it had not been fastened properly. 

The Safety Board therefore concludes that the fuel line to cylinder 5 on the starboard 

engine failed as a result of metal fatigue from excessive vibrations caused by the failure to 

clamp the line.

The Caterpillar service manual contains several warnings that ìfuel leaked or 

spilled onto hot surfaces or electrical components can cause a fire.î The diesel fuel in the 

Express Shuttle IIís fuel delivery lines was under a pressure of about 1,800 psi at the 

valves. When fuel under pressure is released by an equipment failure, the result is usually 

an atomized spray of fuel over a broad area. According to a Ring Power Corporation 

representative, the engine surging reported by the master just before the starboard engine 

stopped would be consistent with raw fuel being ingested into the turbochargerís fresh air 

inlet. It is thus highly probable that the fuel from the broken fuel line was released as a 

spreading mist that contacted numerous engine parts, including the inboard starboard 

turbocharger (where it would have been ingested into the ambient air intake). Misted fuel 

mixes easily with air and ignites more readily than pooled fuel. Investigators evaluated 

whether electrical components or hot surfaces near the fractured fuel line could have 

ignited the fuel mist, leading to the ignition and propagation of the fire.

Because of the severe damage to the engineroom, investigators could not fully 

examine the engineís electrical system or electrical components and therefore could not 

eliminate them as an ignition source. Investigators, however, found no evidence of 

electrical arcing in the area of the starboard engine that suffered the heaviest damage, and 

crewmembers reported no electrical problems with the vessel either before or during the 

fire.

According to Ring Power Corporation, the Express Shuttle IIís engines, including 

the turbocharger housings, were water-cooled to an average surface temperature of 180o F. 

However, not all the vesselís external engine parts were cooled. One example, according 

to a Ring Power representative, was a section of the pipe connecting the exhaust manifold 

to the turbocharger inlet. Because the pipe carried hot exhaust from the engine, whose 

internal operating temperature was about 1,100° F, temperatures on the uncooled surface 

of the exhaust pipe could have exceeded 1,000° F. According to the material safety data 

sheet provided by the fuel supplier, the No. 2 diesel fuel used on the Express Shuttle II will 

autoignite (ignite by heat without spark or flame) at a temperature of 637° F. If the misted 

fuel from the fractured fuel line had contacted the uncooled section of the exhaust pipe, 

the hot surface could easily have raised the fuel to its autoignition point. The Safety Board 

therefore concludes that the fire on the Express Shuttle II most likely ignited when diesel 

fuel from the ruptured fuel line sprayed onto hot engine parts.
Analysis 41 Marine Accident Report

Preventive Maintenance

Express Shuttle II

From interviews with company personnel, Safety Board investigators determined 

that the fuel lines on the Express Shuttle II had failed numerous times in the months before 

the fire. Invoices from Ring Power Corporation show that since January 2004, Paradise of 

Port Richey had purchased a total of 13 replacement fuel lines on 11 different dates (refer 

to table 1). The replacement fuel lines were intended for the Express Shuttle IIís starboard 

engine, according to the evidence.

The large number of fuel line failures should have alerted company personnel 

who ordered replacements for the damaged parts that there was a problem on the 

Express Shuttle II. If company personnel had researched the fuel line failures by 

consulting the engine manufacturerís service manual, they would have seen the warning 

about improperly installed fuel line clamps and recognized that the failing fuel lines 

posed a fire hazard. The warning, which appeared in two places in the manual, read as 

follows:

Incorrectly installed clamps may allow the fuel injection lines to vibrate and 

become damaged. The damaged lines may leak and cause a fire.

Paradise of Port Richey did not have a preventive maintenance program. An 

effective preventive maintenance program contains such elements as procedures for 

reporting maintenance and repair needs, retaining and reviewing maintenance and repair 

records, conducting vessel inspections and repairs according to manufacturersí 

guidelines, verifying and testing repairs, and overseeing the maintenance and repair 

process. It also contains procedures that promote effective interaction between the 

personnel who operate vessels and the staff who perform vessel maintenance.

Employees indicated that rather than following a regular schedule for vessel 

maintenance and repair, Paradise of Port Richey waited until a fuel line fractured 

before repairing it. Safety Board investigators found that the company did not keep 

accurate records of such repairs. Although items to be repaired were noted on a daily 

checklist, the maintenance log kept by the port captain contained no entries for the 

repair or replacement of fuel lines on the Express Shuttle II. Thus, the company had 

no formal system that would have allowed it to identify an ongoing maintenance 

problem. Repair records alert vessel operators of abnormal conditions, such as a high 

failure rate of systems or components. If Paradise of Port Richey had recorded the fuel 

line failures and addressed the failures with the manufacturer, the company would 

have realized that it had a recurring serious problem and that its repair procedures 

were inadequate.

Company personnel were trained on the job and relied on their experience to 

perform maintenance tasks such as engine repairs, rather than having been trained by 

using manuals or attending training school. Not only did Paradise of Port Richey 

employees lack formal training, they also did not consult the Caterpillar service manual 
Analysis 42 Marine Accident Report

when repairing the engines. Consequently, the employees did not follow the engine 

manufacturerís recommended procedures regarding fuel line clamps, did not tighten the 

fuel lines according to the manufacturerís recommended torque, and did not use the 

appropriate tools.

If the company had kept adequate repair records, it should have known that the 

fuel lines on the Express Shuttle II were failing repeatedly during the year before the fire. 

Further, if the company had had procedures in place for dealing with engine failures, in 

particular, if its procedures had required consulting and following the manufacturerís 

recommendations, it should have recognized that improper clamping could have been 

causing the lines to fail, and that improperly clamped lines could lead to a fire. The 

company might then have been able to remedy the situation and prevent the fire. The 

Safety Board therefore concludes that the frequent need to replace fuel lines on the 

Express Shuttle II should have alerted the company that it had a problem with the fuel 

lines, which, if addressed, would have shown that the fuel lines were not being properly 

installed. The Safety Board further concludes that if Paradise of Port Richey had followed 

a formal, written preventive maintenance program, the underlying cause of the failure of 

the fuel lines could have been identified and eliminated, thereby avoiding the failure that 

led to the fire that destroyed the Express Shuttle II.

Consequently, the Safety Board believes that Paradise of Port Richey should 

develop and implement a preventive maintenance and inspection program for systems 

affecting the safe operation of its vessels, including the hull and the mechanical and 

electrical systems. Paradise of Port Richey could establish a preventive maintenance and 

inspection program with the help of materials published by the PVA. As noted earlier, the 

PVAís website contains a number of sample forms, such as worksheets, that companies 

can adapt for their own use in scheduling vessel maintenance, recording work done, and 

listing parts, paint, and other equipment purchased.

The Caterpillar service manual did not contain a specific procedure for repairing or 

replacing a single fuel line, as was done in the months and days before the fire. In the 

Safety Boardís opinion, a more detailed explanation of the procedure for replacing single 

fuel lines could reduce misunderstandings or mistakes by vessel maintenance personnel. 

The manual also did not give details of where the fuel line clamps were to be installed. 

Therefore, the Safety Board concludes that the Caterpillar engine service manual was 

deficient because it did not include the steps required to replace a single fuel line and did 

not clearly indicate the correct location of fuel line clamps. Consequently, the Safety 

Board believes that Caterpillar, Inc., should revise the service manual for its marine 

engines to give specific instructions on how to replace a single fuel line and on where fuel 

line clamps should be located.

Previous Accidents

The Safety Board has addressed the issue of preventive maintenance in a number 

of recent accidents involving small passenger vessels. Three of those accidents are 

described below.
Analysis 43 Marine Accident Report

Port Imperial Manhattan. On the evening of November 17, 2000, the U.S. small 

passenger vessel Port Imperial Manhattan, a commuter ferry operated by NY Waterway, 

was en route from Manhattan to Weehawken, New Jersey, with three crewmembers and 

eight passengers on board when a fire broke out in the engineroom. Crewmembers 

attempted to extinguish the fire with portable extinguishers, with no success. The fire 

burned out of control, causing the vessel to lose power and forcing the crew and 

passengers to abandon the interior spaces. The crew and passengers were rescued by 

another NY Waterway passenger vessel, and the burning vessel was towed to Manhattan, 

where the New York City Fire Department extinguished the fire. One passenger was 

treated for smoke inhalation. No deaths resulted from the accident. The estimated cost of 

repairing the vessel was $1.2 million.

From its investigation, the Safety Board determined that the fire on the Port 

Imperial Manhattan was caused by a loose connection in an electrical junction box in the 

engineroom, which allowed the insulation and surrounding materials to ignite, which then 

ignited the hydraulic oil tank.41 An open access door allowed the fire to spread to other 

areas of the vessel. The Safety Board concluded that if NY Waterway had had an effective 

preventive maintenance program, the loose electrical connection would have been 

detected before it caused the fire.

Seastreak New York. On September 28, 2001, the U.S. small passenger vessel 

Seastreak New York was en route from Highlands, New Jersey, to New York City with 198 

passengers and six crewmembers on board. As the vessel passed Sandy Hook Point, New 

Jersey, about 0630, a fire broke out on the No. 3 engine in the starboard engineroom. 

Flames forced the deckhand who discovered the fire to flee the engineroom. Access 

hatches, ventilation, and fuel for the main engines in the starboard engineroom were 

secured. The fixed CO2 fire suppression system was then activated. The Seastreak New 

York proceeded to a nearby Coast Guard station, using its port engines, and disembarked 

its passengers without incident. When firefighters arrived on board at 0700, they 

discovered that the vesselís CO2 suppression system had extinguished the fire. No injuries 

resulted from the fire, but damages amounted to an estimated $81,000.

The Safety Board determined that the fire was caused by a lube oil hose that had 

not been properly secured and that, as a result, contacted the hot exhaust manifold.42 The 

heat caused the hose to become brittle and break, which allowed lube oil to contact the 

exhaust manifold and ignite, resulting in the fire that damaged the Seastreak New York. 

Cited as a contributing cause of the fire was ìthe lack of inspection and maintenance 

procedures by Circle Navigation Company [the vessel operator] that might have 

discovered the improper installation.î

41 National Transportation Safety Board, Fire On Board the Small Passenger Vessel Port Imperial 

Manhattan, Hudson River, New York, November 17, 2000, Marine Accident Report NTSB/MAR-02/02 

(Washington, DC: NTSB, 2002).

42 National Transportation Safety Board, Fire on Board the Small Passenger Vessel Seastreak New 

York, Sandy Hook, New Jersey, September 28, 2001, Marine Accident Report NTSB/MAR-02/04 

(Washington, DC: NTSB, 2002).
Analysis 44 Marine Accident Report

Panther. On December 30, 2002, the U.S. small passenger vessel Panther, a 31-

foot open wood-and-fiberglass boat operated by Everglades National Park Boat Tours, 

was on its third tour of the day in the Ten Thousand Island area of Everglades National 

Park, Florida, with 33 passengers (including five children) plus a master on board. 

Midway through the tour, shortly after 1430, the vessel sank in about 12 feet of water in 

Indian Key Pass, about 3 1/2 miles from the National Park Service visitor center near 

Everglades City. Three nearby vessels responded to the accident and rescued the master 

and all passengers from the water. No fatalities resulted from the accident, but one 

passenger suffered a serious injury. Damage to the Panther was estimated at $60,000.

The Safety Boardís investigation of the Panther accident discovered serious 

deficiencies in vessel maintenance, including interior wood rot, questionable operational 

status of the starboard bilge pump and high-level bilge alarm, and serious hull damage.43

The Board determined that the probable cause of the Pantherís sinking was flooding 

through a hull breach resulting from an earlier grounding that the vesselís owner had 

neglected to address. The Board concluded that the timely arrival of other vessels to the 

scene prevented loss of life in the accident.

Previous Recommendations

Passenger Vessel Association. As a consequence of its investigation of the Port 

Imperial Manhattan fire, the Safety Board made the following safety recommendation to 

the PVA on July 3, 2002:

M-02-16

Provide your members with guidelines for developing a preventive 

maintenance program for all systems affecting the safe operation of their 

vessels, including the hull and the mechanical and electrical systems.

In its June 2005 edition of Foghorn magazine, the PVA announced that it had 

developed and made available on its website a preventive maintenance program 

(checklists, guidance documents, etc.). The announcement included a strong endorsement 

of the preventive maintenance program by the PVA president. On August 4, 2005, the 

Safety Board wrote to the PVA commending it for its efforts and classifying Safety 

Recommendation M-02-16 as ìClosedóAcceptable Action.î

Coast Guard. The Safety Boardís report on the Port Imperial Manhattan fire

discussed the lack of Federal regulations regarding preventive maintenance for small 

passenger vessels:44

The Coast Guard does not have specific regulations requiring a preventive 

maintenance program for small passenger vessels. The Federal regulators of other 

43 National Transportation Safety Board, Sinking of the U.S. Small Passenger Vessel Panther Near 

Everglades City, Florida, December 30, 2002, Marine Accident Report NTSB/MAR-04/01 (Washington, 

DC: NTSB, 2004).

44 Fire On Board the Small Passenger Vessel Port Imperial Manhattan, pp. 27-28.
Analysis 45 Marine Accident Report

transportation modes recognize the importance of preventive maintenance to the 

safety of operations and require that operators have a systematic program for 

performing inspections and maintenance. The Federal Aviation Administration 

has promulgated for all airplane operators comprehensive maintenance 

requirements, which include provisions for inspections, repairs, and preventive 

maintenance. The Federal Motor Carrier Safety Administration requires that every 

motor carrier systematically inspect, repair, and maintain, or cause to be 

systematically inspected, repaired, and maintained, all motor vehicles subject to 

its control. In addition, the Federal Railroad Administration has extensive 

inspection and maintenance requirements for locomotives, train cars, crossing 

signals, and tracks.

Because no authority other than the Coast Guard exercises oversight over 

domestic small passenger vessels, the Safety Board believes that the Coast Guard 

should require that companies operating domestic passenger vessels develop and 

implement a preventive maintenance program for all systems affecting the safe 

operation of their vessels, including the hull and the mechanical and electrical 

systems.

As a result of its investigation of the Port Imperial Manhattan fire, the Safety 

Board issued the following safety recommendation to the Coast Guard on July 3, 2002:

M-02-5

Require that companies operating domestic passenger vessels develop and 

implement a preventive maintenance program for all systems affecting the 

safe operation of their vessels, including the hull and mechanical and 

electrical systems.

On November 21, 2003, the Coast Guard Commandant responded that his agency 

disagreed with Safety Recommendation M-02-5:

We do not concur with this recommendation. Small passenger vessels are subject 

to a comprehensive set of regulations that are designed to promote vessel safety. 

The operators of these vessels are responsible for maintaining the vessel in 

compliance with all applicable regulations at all times. Additionally, the Coast 

Guard allows vessel operators to participate in the Streamlined Inspection 

Program (SIP)45 that enables the owners to more effectively manage the oversight 

of inspection requirements. We believe that the recommended requirements would 

be unnecessarily burdensome and duplicative of existing requirements. We intend 

to take no further action on this recommendation and request that it be closed.

The Safety Board generally agrees that small passenger vessel regulations are 

comprehensive in that they list the vessel components and devices that are subject to 

inspections and tests and stipulate the standards with which these devices must comply to 

allow for the safe operation of a vessel. However, regarding the upkeep of the vessel, the 

regulations state only that repairs and maintenance must be accomplished in compliance 

45 The SIP is a program set up by the Coast Guard that allows certain vessel operators to inspect their 

own vessels.
Analysis 46 Marine Accident Report

with existing standards. The regulations do not promote or require a vessel owner or 

operator to develop a systematic program for addressing repairs and maintenance. The 

continuing occurrence of small passenger vessel accidents that stem from maintenance 

failures demonstrates the need for vessel owners or operators to develop such programs. 

Preventive maintenance programs should not be considered ìburdensomeî to vessel 

operators but rather a means of improving the quality, reliability, and safety of a vessel and 

its operation. Such a program would help maintain the safety of a vessel between periodic 

Coast Guard inspections, which at present are often the only time a vesselís condition and 

its safety systems are inspected and tested.

The Commandantís reply states that participation in the Coast Guardís SIP 

ìenables the [vessel] owners to more effectively manage the oversight of inspection 

requirements.î Under the SIP, vessel owners and operators work with Coast Guard 

representatives to develop company and vessel action plans. Procedures for developing 

and approving those plans (46 CFR 8.530) specifically require a description of the 

companyís safety program, environmental protection program, and training infrastructure. 

They do not, however, specifically require a description of the companyís preventive 

maintenance program. Although participating in the SIP has good potential for improving 

overall vessel safety, it is not clear how the SIP can ensure proper preventive maintenance 

on safety-critical vessel systems. According to the Coast Guardís latest figures, only 29 

small passenger vessels had enrolled in the program as of October 2003 (representing 0.29 

percent of the 10,125 small passenger vessels the Coast Guard inspects). Those figures 

indicate that the SIP has generally been ignored by the small passenger vessel industry.

On April 7, 2005, based on the correspondence received from the Coast Guard, the 

Safety Board classified Safety Recommendation M-02-5 ìOpenóUnacceptable 

Response.î The Express Shuttle II fire further demonstrates the need for vessel owners and 

operators to develop preventive maintenance programs. The Express Shuttle IIís operating 

company did not follow a regular maintenance schedule, did not keep adequate repair 

records, did not recognize that the vessel was experiencing a large number of failed fuel 

lines, did not follow the manufacturerís guidelines for clamping and tightening the fuel 

lines, and most important, did not recognize that the failing fuel lines exposed the vessel 

and its occupants to the risk of fire. The Safety Board remains convinced that regulatory 

requirements addressing the maintenance of safety-critical equipment on small passenger 

vessels are essential. Moreover, the PVAís action in establishing readily accessible 

materials that vessel owners can use to establish preventive maintenance programs 

demonstrates industry acceptance of the importance of preventive maintenance. The 

Safety Board therefore believes that the Coast Guard should reconsider requiring 

operators of inspected small passenger vessels to develop and implement preventive 

maintenance programs for safety-critical vessel systems, including the hull and the 

mechanical and electrical systems. Consequently, the Board reiterates Safety 

Recommendation M-02-5.
Analysis 47 Marine Accident Report

Crew Response to Fire Emergency

After the engines failed, the first indication of the fire on board the Express Shuttle 

II was the white smoke the deckhands saw coming from belowdecks. The deckhands tried 

to identify the source of the smoke by lifting a small access hatch to the engine space. 

They did not first notify the master or take the precaution of having a fire extinguisher at 

the ready before opening the hatch. The deckhandsí opening the hatch served only to feed 

the fire with oxygen. From what the deckhands told investigators, it is even possible that 

they left the hatch open.

After one of the deckhands informed the master of the smoke in the engineroom, 

the crew continued to take actions that exacerbated the fire and the smoke conditions. 

First, the deckhands opened the larger hatch over the starboard engine, whereupon flames 

shot out. Then, after the master came down to the cabin, he and one of the deckhands 

again opened the larger hatch while the other deckhand stood by with the portable 

extinguisher. That action fed more oxygen to the fire and allowed smoke to fill the cabin.

Even if the deckhand had been able to discharge the portable extinguisher, he 

would not have been close enough to the fire for the extinguisher to be effective. A 

portable extinguisher has a limited range and must be directed at the base of the fire to be 

effective. The deckhandsí actions demonstrate that they were not properly trained in the 

use and limitations of the various types of fire extinguishers. Neither deckhand could tell 

investigators what kind of portable extinguisher they had used in fighting the fire on the 

Express Shuttle II.

The masterís actions demonstrate that he too lacked training in using the Express 

Shuttle IIís firefighting apparatus. On discovering the extent of the fire, he left the cabin to 

retrieve the fire hose, then realized that the fire pump could not be activated if the engines 

were not running. It is possible that the master could have used that time to discharge the 

fixed CO2 fire suppression system, whose controls were located in the fuel room. 

However, by the time the master realized that the fire hose could not be used, the cabin 

had filled with smoke, and the crew had to evacuate.

Coast Guard regulations require owners, charterers, masters, or managing 

operators to ìinstruct each crewmember, upon first being employed and prior to getting 

underway for the first time on a particular vessel and at least once every three months,î 

about their duties in an emergency (46 CFR 185.420). The regulations at 46 CFR 185.524 

require masters to ìconduct sufficient fire drills to make sure that each crew member is 

familiar with his or her duties in case of fire.î Neither deckhand on the Express Shuttle II

had undergone any emergency training, including fire drills, even though they had worked 

1 and 2 months, respectively, for Paradise of Port Richey. The master told investigators 

that he did the required fire drills ìat least once a month, and when we get new deckhands, 

I do it more often.î He said that he made sure the deckhands knew how to turn on the fire 

hose and where to direct passengers in case of fire. However, he said that he had never 

conducted a drill with either of the deckhands who were on the Express Shuttle II the day 

of the fire ìbecause they were new.î The master said the emergency drills were 
Analysis 48 Marine Accident Report

documented in a logbook that stayed with the vessel, and that the company did not keep a 

duplicate record of the drills in the office. Because the fire destroyed the logbook, the 

Safety Board could not determine when the company had last conducted the required 

emergency drills. The Safety Board therefore concludes that on the day of the fire, the 

Express Shuttle II sailed without the owner, operator, or master having previously 

instructed the deckhands as to their duties in emergencies such as fires, as required by 

Coast Guard regulations.

The Safety Board has investigated past accidents on small passenger vessels where 

crew training in fire emergency procedures was a safety issue. In its report on the Port 

Imperial Manhattan fire, for example, the Safety Board found that the crewmembers on 

the vessel

did not use proper firefighting techniques; thus, they were ineffective in 

controlling or extinguishing the fire. They did not take appropriate actions to 

prevent the heat and smoke of the fire from spreading to other parts of the vessel, 

which endangered their own safety and the safety of the passengers on board. In 

the Safety Boardís opinion, the crewmembersí inability to appropriately respond 

to this emergency was the direct result of a lack of adequate training.

As a result of its investigation of the Port Imperial Manhattan fire, the Safety 

Board issued the following Safety Recommendation to the Coast Guard on July 3, 2002:

M-02-9

Establish firefighting training requirements for crewmembers on board 

small passenger vessels in commuter and ferry service.

On November 11, 2003, the Coast Guard responded that it partially concurred with 

Safety Recommendation M-02-9, but that it believed ìthe current requirements and 

recommendations are sufficientî and that it intended ìto take no further action on this 

recommendation.î However, Federal regulations do not require masters and deckhands on 

small passenger vessels to undergo formal firefighting training. Rather, the requirements 

at 46 CFR 185.420 and 185.524 stipulate that newly hired deckhands be instructed as to 

their duties in an emergency and that masters hold ìsufficient fire drillsî to familiarize 

crewmembers with their duties in case of a fire. The format and depth of the required 

instruction for new deckhands are left to the discretion of individual companies. The 

requirement for masters to hold ìsufficient fire drillsî is also subject to discretionary 

compliance. Moreover, because masters are not required to complete training in 

firefighting techniques, they may not be prepared to train others or to evaluate the 

effectiveness of fire drills.

According to fire safety professionals and training materials such as those offered 

by the PVA, effective marine firefighting requires crewmembers to know about the 

various fire classes (A = paper and other common combustible materials, B = flammable 

liquids and gases, C = electrical, D = combustible metals such as magnesium), the basic 

chemistry of fire (fuel, heat, oxygen, chemical reaction), and the proper use of various 
Analysis 49 Marine Accident Report

extinguishing agents (water for cooling burning materials, dry chemicals or CO2 for 

extinguishing a fire). Effective marine firefighting also requires practical knowledge of 

the sequence of steps crewmembers should follow in combating a fire on board a vessel. 

The first step is to locate the fire and report it. The next step is to prevent the fire from 

spreading by closing doors, portholes, ventilators, and other openings (hatches should not 

be opened). Finally, the fire should be extinguished by using appropriate agents and 

methods. Afterward, crewmembers should monitor the area in case the fire reignites.

Because the crewmembers of the Express Shuttle II did not use proper firefighting 

techniques, they were ineffective in controlling or extinguishing the fire. Crewmembers 

delayed in notifying the master of the fire, and the master did not respond immediately to 

their warning. When the master saw smoke coming from the engine space, he should have 

realized that the fire was already beyond the first stage.46 The deckhands should have been 

instructed to secure the engineroom ventilation and close all access to the space containing 

the fire. Instead, crewmembers opened the hatches to the engineroom at least three times, 

feeding the fire with oxygen each time. The master made no attempt to activate the 

vesselís fixed CO2 fire-extinguishing system, which neither deckhand even knew about. 

The deckhands had had no formal firefighting training and had participated in no fire drills 

during their employment with Paradise of Port Richey. The Safety Board therefore 

concludes that the crewmembersí firefighting efforts were ineffective in controlling or 

extinguishing the Express Shuttle II fire because they lacked adequate firefighting training 

and because the master did not take appropriate fire suppression measures.

In light of the evidence from the Express Shuttle II and previous vessel fires that it 

has investigated, the Safety Board believes that the Coast Guard should establish 

firefighting training requirements for crewmembers on board all small passenger vessels. 

The Safety Board recognizes that rulemaking by the Coast Guard to require firefighting 

training for crewmembers on all small passenger vessels will take time. Until such time as 

the Federal regulations are revised, the Safety Board believes that Paradise of Port Richey 

should develop and implement a training program in marine firefighting for its 

crewmembers. To do so, Paradise of Port Richey could use the training videos and written 

material related to basic firefighting and marine fire safety that have been developed by 

the PVA and that the organization makes available for a small fee.

The above recommendation to the Coast Guard builds on Safety Recommendation 

M-02-9, expanding it from commuter and ferry vessels to all small passenger vessels. On 

April 7, 2005, pending further action by the Coast Guard, the Safety Board classified 

Safety Recommendation M-02-9 ìOpenóUnacceptable Response.î Because of the new 

recommendation stated above, Safety Recommendation M-02-9 is classified ìClosedó

Superseded.î

46 The first stage of a fire, known as the incipient stage, begins at the moment of ignition. During this 

stage, the flames are localized and the fire is fuel-regulated (regulated by the configuration, mass, and 

geometry of the fuel). In the incipient stage, the oxygen content is within normal range and normal ambient 

temperatures still exist. Source: National Fire Protection Association, Fire Ignition and Development, 

Catalog No. V-54 (Quincy, Massachusetts: NFPA, 1998).
Analysis 50 Marine Accident Report

Considering the time needed to promulgate new regulations regarding firefighting 

training for crewmembers on board small passenger vessels in commuter and ferry 

service, as recommended in Safety Recommendation M-02-9, on July 3, 2002, the Safety 

Board issued the following safety recommendation as an interim measure the Coast Guard 

could take:

M-02-10

Revise Navigation and Vessel Inspection Circular No. 1-91 so that it 

provides more in-depth guidance in training and drills for firefighting on 

board small passenger vessels.

The Coast Guardís response letter of November 24, 2003, stated that it did not 

concur with Safety Recommendation M-02-10 because NVIC 1-91 was intended only to 

give general guidance to marine employers and masters and that it intended to take no 

further action. On April 7, 2005, the Safety Board responded that NVIC 1-91 ìprovides 

the Coast Guardís only guidance to the small passenger vessel industry concerning fire 

training and qualifications of deckhandsî and that the list of tasks in the NVIC ìprovides 

no guidance to deckhands on what they need to know in an emergency, what their 

responsibilities are . . . or reference to further information, guidance or instruction.î 

Pending further action by the Coast Guard, the Board classified Safety Recommendation 

M-02-10 as ìOpenóUnacceptable Response.î The Board continues to believe that NVIC 

1-91 should provide detailed guidance, rather than only a list of tasks, regarding training 

and drills for firefighting on board small passenger vessels. The Board therefore reiterates 

Safety Recommendation M-02-10.

Fire Detection System

The small passenger vessel regulations at 46 CFR 181.400(c) require a space 

containing propulsion machinery to be equipped with a fire detection system of an 

approved type. The Coast Guard requires the components used in fire detection systems to 

be UL-approved for that purpose. The Express Shuttle II had a custom-designed and 

custom-built fire detection system that was installed in 1997, when the vessel was 

constructed. The system consisted of a control panel manufactured by Aqualarm and 

combination smoke/heat detectors wired directly to the panel (the engineroom had only a 

heat detector). The Aqualarm panel was UL-approved for electronic components but was 

not approved for use in fire detection systems. The Coast Guard became aware of this 

discrepancy as a result of the Express Shuttle II fire and no longer approves Aqualarm 

panels for use in fire detection systems.

Fire alarm panels are typically connected to detectors to which an end-of-line 

resistor is attached. If power is interrupted (for example, by a broken power cable or a 

nonfunctioning detector), the loss of power between the resistor and the panel activates an 

alarm. Circuits monitored in such a way are said to be electrically supervised (as required 

by 46 CFR 161.002-10[c]). No components of the Express Shuttle IIís fire detection 
Analysis 51 Marine Accident Report

system were found after the fire. From wiring diagrams in the Coast Guard files for the 

vessel, Safety Board investigators determined that each fire detector was wired separately 

to the control panel, with no evidence of an end-of-line resistor. A repair technician 

verified that configuration.

The vesselís fire detection system thus did not meet Federal requirements for 

electrical supervision, in addition to having an alarm panel that was not UL-approved for 

fire detection systems. The Safety Board therefore concludes that Express Shuttle IIís fire 

detection system did not comply with Coast Guard regulations.

The Safety Boardís investigation found that the Express Shuttle IIís fire detection 

system did not sound an alarm at any point during the fire. The master stated that he never 

heard an alarm or saw flashing lights on the alarm panel, which was located near him on 

the pilothouse console. Neither deckhand recalled hearing the alarm go off in the 

pilothouse. Because no components of the system were found after the fire, the Safety 

Board could not determine why the fire detector in the engineroom did not trigger an 

alarm. The evidence that no alarm sounded during the fire leads the Safety Board to 

conclude, however, that the vesselís fire detection system was not functioning at the time 

of the accident.

Early detection is critical to extinguishing a fire. The earlier a fire is detected and 

responded to, the better the chance of extinguishing it before it spreads out of control. If 

the deckhands had heard an alarm from the Express Shuttle IIís fire detection system, they 

would not have had to open and close the hatches to determine where the fire was and 

what was on fire (although they might have opened the hatches anyway because they had 

not been properly trained in how to react to a fire emergency). In fact, the actions of the 

deckhands exacerbated the fire by increasing the flow of oxygen into the engine space. If 

the alarm panel had given the master early notification of the fire, and if the master had 

received proper training in responding to a fire emergency, he could have activated the 

vesselís fixed CO2 fire suppression system (the CO2 system was never activated). The 

crewís efforts to fight the fire with a portable extinguisher were ineffective, and by the 

time the crew abandoned the vessel, the fire was climbing onto the upper deck. The Safety 

Board therefore concludes that the Express Shuttle IIís faulty fire detection system 

prevented early detection of the fire and precluded its early and effective suppression.

The Safety Board is concerned that other small passenger vessels might also be 

equipped with fire detection systems that do not comply with Federal regulations and that 

could put passengers and crewmembers at risk from undetected shipboard fires. The 

Board therefore believes that the Coast Guard should require that OCMIs, before issuing a 

COI to a small passenger vessel that is required to have a fire detection system, verify that 

all system components are approved for use in fire detection systems and that the circuits 

of the system are electrically supervised.
Analysis 52 Marine Accident Report

Emergency Response

The first person to reach the burning vessel was the operator of a passing 

recreational boat, who rescued all three crewmembers from the Express Shuttle II before 

anyone could be injured. Emergency responders to the fire included fire and rescue units 

from Port Richey and Pasco County, as well as the city police and county sheriffís 

department. Response was coordinated using the incident command system, with radio 

contact between responders maintained through a central dispatch system. Not only did 

the emergency responders work in a coordinated manner, they also overcame the logistical 

difficulties associated with the fireís relatively inaccessible location. The Safety Board 

therefore concludes that the emergency response to the fire was timely and appropriate.
53 Marine Accident Report

Conclusions

Findings

1. The following were not factors in the fire on board the Express Shuttle II: weather, 

operator fatigue, or illicit drugs.

2. Although crewmembers were not given postaccident tests for alcohol, alcohol was 

probably not a factor in the accident.

3. The pattern and extent of damage indicate that the fire started on the inboard side of 

the Express Shuttle IIís starboard engine.

4. The initial source of fuel for the fire was diesel fuel from a fractured fuel line to 

cylinder 5 on the starboard engine.

5. The fuel line to cylinder 5 on the starboard engine failed as a result of metal fatigue 

from excessive vibrations caused by the failure to clamp the line.

6. The fire on the Express Shuttle II most likely ignited when diesel fuel from the 

ruptured fuel line sprayed onto hot engine parts.

7. The frequent need to replace fuel lines on the Express Shuttle II should have alerted 

the company that it had a problem with the fuel lines, which, if addressed, would have 

shown that the fuel lines were not being properly installed.

8. If Paradise of Port Richey had followed a formal, written preventive maintenance 

program, the underlying cause of the failure of the fuel lines could have been 

identified and eliminated, thereby avoiding the failure that led to the fire that 

destroyed the Express Shuttle II.

9. The Caterpillar engine service manual was deficient because it did not include the 

steps required to replace a single fuel line and did not clearly indicate the correct 

location of fuel line clamps.

10. On the day of the fire, the Express Shuttle II sailed without the owner, operator, or 

master having previously instructed the deckhands as to their duties in emergencies 

such as fires, as required by Coast Guard regulations.

11. The crewmembersí firefighting efforts were ineffective in controlling or 

extinguishing the Express Shuttle II fire because they lacked adequate firefighting 

training and because the master did not take appropriate fire suppression measures.

12. The Express Shuttle IIís fire detection system did not comply with Coast Guard 

regulations.
Conclusions 54 Marine Accident Report

13. The vesselís fire detection system was not functioning at the time of the accident.

14. The Express Shuttle IIís faulty fire detection system prevented early detection of the 

fire and precluded its early and effective suppression.

15. The emergency response to the fire was timely and appropriate.

Probable Cause

The National Transportation Safety Board determines that the probable cause of 

the fire on board the Express Shuttle II was a fractured, improperly installed fuel injection 

line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the 

engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port 

Richey to have a preventive maintenance program, which could have identified the 

companyís ongoing problem with the vesselís fuel lines before a failed line led to the fire. 

Contributing to the extent of the damage were the vesselís faulty fire detection system and 

the crewís failure to employ proper marine firefighting techniques.
55 Marine Accident Report

Recommendations

New Recommendations

As a result of its investigation into the fire on board the Express Shuttle II, the 

National Transportation Safety Board makes the following new safety recommendations:

To the U.S. Coast Guard:

Establish firefighting training requirements for crewmembers on board all 

small passenger vessels. (M-06-10)

Require that Officers-in-Charge, Marine Inspection, before issuing a 

certificate of inspection to a small passenger vessel that is required to have 

a fire detection system, verify that all system components are approved for 

use in fire detection systems and that the circuits of the system are 

electrically supervised. (M-06-11)

To Paradise of Port Richey:

Develop and implement a preventive maintenance and inspection program 

for systems affecting the safe operation of your vessels, including the hull 

and the mechanical and electrical systems. (M-06-12)

Develop and implement a training program in marine firefighting for your 

crewmembers. (M-06-13)

To Caterpillar, Inc.:

Revise the service manual for your marine engines to give specific 

instructions on how to replace a single fuel line and on where fuel line 

clamps should be located. (M-06-14)

Previously Issued Recommendation Classified in This Report

To the U.S. Coast Guard:

M-02-9

Establish firefighting training requirements for crewmembers on board small 

passenger vessels in commuter and ferry service.
Recommendations 56 Marine Accident Report

Safety Recommendation M-02-9 (previously classified as ìOpenóUnacceptable 

Responseî) is classified ìClosedóSupersededî in the ìCrew Response to Fire 

Emergencyî section of this report.

Reiterated Recommendations

The National Transportation Safety Board also reiterates the following 

recommendations:

To the U.S. Coast Guard:

M-02-5

Require that companies operating domestic passenger vessels develop and 

implement a preventive maintenance program for all systems affecting the safe 

operation of their vessels, including the hull and mechanical and electrical 

systems.

M-02-10

Revise Navigation and Vessel Inspection Circular No. 1-91 so that it provides 

more in-depth guidance in training and drills for firefighting on board small 

passenger vessels.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER DEBORAH A. P. HERSMAN

Acting Chairman Member

ELLEN ENGLEMAN CONNERS KATHRYN OíLEARY HIGGINS

Member Member

Adopted: April 4, 2006
57 Marine Accident Report

Appendix A

U.S. Coast Guard Headquarters notified the Safety Board about the accident at 

1601 on October 18, 2004. The Safety Board launched a three-person investigative team 

that arrived in Port Richey, Florida, on October 19 and began the investigation. The team 

documented the damage to the Express Shuttle II and interviewed company employees, 

emergency responders, fire officials, employees of the engine manufacturerís authorized 

local representative, and Coast Guard personnel. An engineer from the Boardís materials 

laboratory joined the team in Florida on October 28. The on-scene investigation was 

completed on October 29.

The Safety Board investigated the accident under the authority of the Independent 

Safety Board Act of 1974, according to Safety Board rules. The designated parties to the 

investigation were the U.S. Coast Guard, the Florida Division of State Fire Marshal, 

Paradise of Port Richey (owner of the Express Shuttle II), Caterpillar, Inc. (engine 

manufacturer), and Ring Power Corporation (engine manufacturerís authorized local 

representative).