Wednesday, November 25, 2009

Ask the MSSC—you have questions, we have answers

Many of you have already utilized the Proceedings online reader survey. We’re grateful for your input and we carefully read and consider each submission. In addition to your feedback on the magazine, you have also used this question form to pose questions of your own, such as:

“Why is celestial navigation still a test subject for merchant marine officers, and are there are any plans to discontinue it?”

“Why is the TWIC not required for public vessels sailors?”

“I would like to see an update on the Towing Safety Advisory Committee. What has been accomplished? What is the path forward? Are there going to be third-party inspectors? How would an organization become approved to be an inspector or auditor?”

Good questions—all. Better still: We have answers from the USCG Marine Safety and Security Council. We’ll post answers to these questions monthly here on the Coast Guard Marine Safety blog.

Why is celestial navigation still a test subject for merchant marine officers, and are there are any plans to discontinue it?

Answered by the USCG National Maritime Center and the Office of Operating and Environmental Standards.

Celestial navigation is still included on license exams for ocean routes for a number of reasons.

First, celestial navigation is among the required competencies in the applicable part of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended (STCW). For example, the minimum standard of competence for an officer in charge of a navigational watch includes the “[a]bility to use celestial bodies to determine the ship’s position.” The STCW is undergoing a comprehensive review and celestial navigation is among the areas receiving attention.

While it is too early to tell the outcome of this review, the position of the United States is that while the role of celestial navigation has significantly diminished, it should not be eliminated entirely. Celestial navigation performs an important function as a backup means of navigation in the event that other navigation modes fail.

Second, the use of either azimuths or amplitudes of a celestial body is the only way to determine accurately a ship’s compass error when operating outside of the visual range of terrestrial objects. The United States supports limiting the celestial navigation requirements to those necessary to perform its backup navigation role and in order to perform compass error corrections.

It is worth noting that although we have not eliminated celestial navigation from our license examinations, we have made changes that reflect its diminished use in everyday watchkeeping. In early 2002, we reduced the minimum passing grade for celestial navigation exam modules from 90 percent to 80 percent. We believe this reduction is consistent with the reduced (but not eliminated) role celestial navigation plays in modern watchkeeping.

Notwithstanding our agreement that the role of celestial navigation has diminished, its use in prudent navigation has not been entirely eliminated, and the Coast Guard does not have any immediate plans to eliminate celestial navigation from its license examinations through the amendment of our regulations found at 46 CFR §10.910.

For more information:
If you have more questions, please send an e-mail to
HQS-DG-NMCProceedings@uscg.mil, subject line “Ask the MSSC.” We’ll forward your questions to the Marine Safety and Security Council and publish the answers.

Tuesday, November 24, 2009

Boundless Brotherhood and Heroism on the Western Rivers

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. By LTJG Jesse Garrant, chief of Boat Operations, and LTJG Jodi Min, assistant chief of Prevention, both of U.S. Coast Guard Marine Safety Unit Pittsburgh.


It was a cloudy, frigid January night on the Ohio River as the motor vessel (M/V) Elizabeth M began its lock upbound through the Montgomery Locks and Dam. Despite high water conditions and swift currents in the area, operations appeared normal as the vessel executed a “knockout” lockage, a procedure that involves the towboat disconnecting from the barges due to a lack of space lengthwise within the lock chamber, then reconnecting after following the barges through the lock.

As the lock gates opened and the motor vessel exited the lock chamber with its six loaded open-hopper coal barges, an incident occurred that caused the Elizabeth M, her seven-man crew, and two of her barges to be swept over the treacherous Montgomery Dam.

As the vessel sank nearly instantly, the crew had little time to prepare for the cold, turbulent water. The powerful river current forced one crewmember overboard, which left him drifting downriver, clinging to floating debris until rescuers could arrive. Additional crewmembers clung to the small, exposed portion of the pilothouse (see picture), battling the powerful current while also trying to fight hypothermia.

All of the barges subsequently sank, posing hazards to navigation above and below the dam. Tragically, as a result of this casualty, four of the seven crewmembers perished.

Heroism
That morning, mariners along the Ohio River clearly demonstrated the true meaning of brotherhood and heroism. After hearing desperate requests for assistance from the crew, Good Samaritan responders performed actions that displayed bravery and demonstrated the underlying bond among mariners. Crewmembers from the M/Vs Lillian G, Rocket, and Sandy Drake responded, placing their lives in imminent danger.

To render assistance despite the known risk, crews maneuvered their vessels while combating high water conditions and avoiding floating debris and the threat of collision with partially submerged barges that were set adrift during the casualty. Crews from the Lillian G and Sandy Drake demonstrated commendable valor while retrieving men who had fallen overboard. As a result of their immediate response, one crewmember’s life was saved.

When faced with a decision that could cause the crew of the Rocket to suffer the same fate as the Elizabeth M, the crew unanimously decided to attempt rescue efforts for the two remaining survivors. As a result of the Rocket’s actions, both survivors, who battled frigid 34°F temperature water and 33°F air temperature, were safely rescued and successfully treated for severe hypothermia and minor injuries.

Brotherhood
These heroic actions may not have been possible without the strong bond that has been witnessed daily on the Western Rivers. In a river community such as the Pittsburgh operating region, the rivermen form a small group that is extremely protective of one another. Strong bonds like these have been in existence since people started working the rivers.

Though not always as life-or-death as the acts of the Elizabeth M survivor or Rocket’s crewmembers, it is very common to see smaller acts of help and heroism on an everyday, smaller scale. When towboats and barges go aground or have breakaways, calls of distress from any riverboat captain will be responded to by others willing to help.

River conditions warrant decisions that are based on risk management, safety, and necessity, which are juggled by all vessel captains and crewmembers. The maritime community continues to work diligently to prevent casualties, but when they inevitably do occur, the river community will continue to extend its help to its brothers.

For more information:
Full article and “Focus on Safety” edition of USCG Proceedings is available at www.uscg.mil/proceedings. Click on “archives” and then “2008 Vol. 65, Number 2” (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp.

Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.

Thursday, November 19, 2009

McAlpine Lock Allision—a misaligned approach sets off a chain reaction

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. By LCDR Phillip Ison, chief, Prevention Department, U.S. Coast Guard Sector Ohio Valley.


On January 26, 2006, while southbound on the Ohio River near Louisville, Ky., a towboat pushing three loaded asphalt barges during a period of high water attempted to enter the approach to the McAlpine lockway. It was a clear day with excellent visibility, but the pilot did not line up his approach correctly. The tow allided with the vane dike at the head of Portland Canal and the force of the blow snapped the barges’ connecting wires.

The tow broke apart, with each barge drifting downstream individually. Tugs attempted to recover all the barges before they drifted down to the dam, but two barges escaped this recovery effort and went over the dam. The first over was recovered. The second struck a railroad bridge sideways. Within a few minutes, the current forced the upstream edge of the barge down and flipped the barge onto its port side.

There it sat, 300 feet long, 54 feet wide, with 900,000 gallons of asphalt, heating oil, and diesel aboard, bottom pressed firmly against two bridge supports, its port side on the bottom of the river.

Over the next four months, the incident command worked as a cooperative group to address all aspects of the incident, from oil recovery to salvage, from site safety to cargo recovery. Conflicting concerns, needs, and recommendations were invariably resolved to the satisfaction of all parties.

Cargo offload was finally complete in late May 2006. The asphalt required re-heating before pumping could proceed, which involved cutting into the barge at each cargo tank and inserting heating coils. This was river-level dependent, and operations were suspended numerous times due to rising water levels. Once ready for removal, the barge was salvaged over a two-day period, using an A-frame crane to lift the barge while it was pulled away from the railroad bridge.

For more information:
Full article and “Focus on Safety” edition of USCG Proceedings is available at www.uscg.mil/proceedings. Click on “archives” and then “2008 Vol. 65, Number 2” (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp.

Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.

Tuesday, November 17, 2009

Barge Break-aways—an ever-present risk

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. By LT Matthew Meskun, chief, Prevention Department, U.S. Coast Guard Marine Safety Unit Pittsburgh, and CWO William Perkins, marine inspector/investigator, U.S. Coast Guard Sector Upper Mississippi River.

Because of their efficiency, barges are the primary commercial cargo transportation mode. Unfortunately, from time to time, barges can break free from their mooring or towing arrangements and are swept down the river, potentially wreaking havoc to the river system until they are either corralled by assisting towing vessels or salvaged (if the barges have sunk).

For example, this picture shows what’s left of a hopper barge after an allision with the Eads Bridge in 2005. The vessel was traveling southbound on the upper Mississippi River as part of a 15-barge tow when it hit a bridge and broke away from the tow.

Barge Break-away Locations
There are two primary locations where barge break-aways occur: either at a fleeting area facility, or from a towing vessel underway.

Many factors can contribute to a barge break-away that originates from a fleeting area, such as impact from large items floating downriver, high winds and current, rapid changes in water levels, or human error. Break-aways may also occur when other barges hit the fleeting area.

Normally when a barge breaks from a towing vessel underway, the tow hits some drift or other obstruction. This collision then breaks the wire gear holding the barges together as a unit. This event can also cause a chain reaction, as the break-away barges can hit other barges further down the river.

Barge Break-away Prevention
Federal regulatory bodies, river industry associations, working groups, and companies have all taken active roles to promote methods that reduce barge break-aways. For example, the U.S. Army Corps of Engineers (USACE) oversees the location and placement of each fleeting area facility. Each fleeting area operator is required to submit a fleeting area operations manual that provides detailed information and procedures for a river’s different stages and conditions.

Coast Guard Marine Safety Unit (MSU) Pittsburgh has created additional preventive measures that have been adopted by other Coast Guard units on the Western Rivers. One very successful outreach effort is an annual barge break-away seminar that highlights the importance of properly maintaining the fleet in order to prevent barge break-aways.

Another initiative that MSU Pittsburgh spearheaded is random fleeting area facility inspections, conducted with USACE partners. The joint inspection teams visit fleeting facilities to:
  • check the condition of the materials used to secure the barges,
  • ascertain overall worker safety efforts,
  • verify training practices,
  • affirm the use and currency of the approved fleeting area operations manual.

Barge Break-away Response
Coast Guard response to a barge break-away notification typically seeks to mitigate any hazard to navigation. The operations specialist standing radio watch in the sector command center receives the notification and issues an urgent marine information broadcast to alert all vessels in the area of the barge break-away and to request assistance from any available vessels in the area.

Once the situation is under control and all hazards have been removed, the Coast Guard will stop all operations at the source of the break-away. The operator of the responsible fleeting area will be required to investigate and determine the cause of the break-away, and submit a proposal on how to rectify the discrepancy to prevent a similar reoccurrence.

The Western Rivers system is a vital part of America’s economy, and preventing barge break-aways on it is critical. The industry, USACE, and the Coast Guard are working to ensure that the inland river transportation system remains open and free-flowing for the efficient trade and movement of commerce.

For more information:

Full article and “Focus on Safety” edition of USCG Proceedings is available at www.uscg.mil/proceedings. Click on “archives” and then “2008 Vol. 65, Number 2” (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp.Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.

Thursday, November 12, 2009

Measuring the Economic Impact of Marine Casualties

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. By CAPT Denise L. Matthews, former commanding officer, U.S. Coast Guard Marine Safety Unit Paducah; LTC Steven J. Roemhildt, Nashville District engineer, U.S. Army Corps of Engineers; and LCDR Thomas J. Kaminski, former supervisor, U.S. Coast Guard Marine Safety Detachment Nashville.


On August 3, 2006, a tank barge carrying 20,000 barrels of mixed xylene was damaged while locking upbound through Wilson Lock and Dam (L/D) in Florence, Ala. The towing vessel M/V Potomac was pushing the jumbo barge (297 feet by 54 feet), HTCO-3016, at the time of the incident. As the lock chamber filled, the barge came into contact with the upper lock gate, dislocating it from its track. As this upper gate fell back into place, the barge became wedged beneath it, as seen in the picture.

For more than four months, local, state, and federal agencies worked closely to safely remove the damaged tank barge and repair and reinstall the damaged lock gate. They also had to manage constantly changing vessel queues to minimize economic impact to the marine transportation system, its suppliers, and customers.

The Response
The actions taken following this major marine casualty exemplify the interagency coordination and teamwork required for effective and efficient marine transportation system recovery on the inland waterways. During the emergency response and prolonged post-emergency phases of this incident, key stakeholder issues included:
  • potential pollution,
  • possible toxicity and explosion hazards,
  • resumption of safe navigation and normal locking operations,
  • repair of the main lock chamber,
  • waterways safety/security,
  • economic impact due to lock delays.

By late afternoon on August 3, a unified command was established that included senior representatives from Coast Guard Marine Safety Unit Paducah, TVA, the U.S. Army Corps of Engineers (USACE is the operator of the lock and dam), the Florence Fire Department, and Maryland Marine Inc. (owner of barge HTCO-3016). The initial objectives of the unified command were protecting the community, responders, and maritime industry; safely securing and removing HTCO-3016 from under the lock gate; and beginning operation of the Wilson auxiliary lock to keep barges moving through the area.

Barge Removal
USACE also began construction of a temporary dam and a support structure for the damaged lock gate. Since the dislocated and damaged lock gate was sitting atop—and therefore supported by—the damaged barge, the plan was to pump out water to lower the barge, thereby transferring the lock gate’s weight to the newly constructed support. On August 5, the U.S. Army Corps of Engineers completed the removal of HTCO-3016.

Restoring Traffic
On the morning of August 6, USACE reopened the auxiliary lock to commercial vessel traffic, which had grown to seven towing vessels and 90 barges awaiting lockage. By the afternoon of August 9, the vessel queue had increased to 15 towing vessels and 139 barges loaded with a variety of cargoes.

Economic Impact
The significant decrease in Wilson L/D’s ability to lock commercial vessel traffic resulted in significant economic impact to the towboat industry and the Tennessee River marine transportation system—approximately $29 million. Additional costs were prevented due to outstanding stakeholder cooperation.

Stakeholder Communication and Cooperation
On August 8, the MSD Nashville supervisor attended a U.S. Army Corps of Engineers briefing where USACE expressed its understanding and concern for the economic impact this incident would have on the river industry.

In general, USACE used “first-in, first-out” prioritization to lock barges but also requested representatives to serve on an industry-led queue management board to help make decisions on priority lockage requests. Priority lockage decisions were made based on type/amount of cargo and impact on industry.

On August 17, USACE removed the damaged lock gate, and on August 18 commenced use of the temporary caisson configured for main gate lockage. USACE then began weekly teleconferences to communicate lock repair, vessel queue status, and caisson-use schedules to the Coast Guard, TVA, and industry stakeholders. This process continued until the damaged main chamber lock gate was repaired and reinstalled. Wilson L/D resumed normal operations on December 5.

For more information:

Full article and “Focus on Safety” edition of USCG Proceedings is available at www.uscg.mil/proceedings. Click on “archives” and then “2008 Vol. 65, Number 2” (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp. Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.

Tuesday, November 10, 2009

Safety is at Our Core

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. By ADM Thad Allen, Commandant, U.S. Coast Guard.


One of the Coast Guard’s greatest strengths is our multi-mission character. It allows us to conduct a wide range of functions in the maritime domain, from marine safety, to law enforcement and national defense, to environmental protection and humanitarian response. The Coast Guard has accrued these roles and missions over two centuries of service because these duties serve a collective good and are most efficiently and effectively accomplished by a single federal maritime force.

Our marine safety mission remains the bedrock of the Coast Guard’s value to the nation, and it underpins our security and environmental stewardship programs. This focus on safety pervades all of our mission areas; it is woven into the very fabric of our service, and is the ultimate focus of all we do.

We secure our ports and waterways to keep America safe from terrorist attack, safe from the ravages of illegal drugs, and safe from unlawful entry of any kind. We protect the world’s oceans and our living marine resources. In the event of any natural or man-made disaster, we act to ensure the safety of our citizens and to remove them from harm’s way.

The U.S. Coast Guard Marine Safety & Security Council supports these missions, and its members direct and drive these efforts. Our operational model is flexible, adaptive, efficient, and capable of succeeding with innumerable maritime scenarios. This positions the Coast Guard to meet a broad range of national interests.

As we seek to continually improve maritime safety, we will also strive to balance each of our essential mission requirements. Coast Guard men and women serve across the nation and around the world keeping people safe, ports secure, and our waters protected. For hundreds of years, we’ve been there when the nation needed us most. While we live in a changing world, one thing is certain: Marine safety will forever be at our core.

We will be sharing examples of this sentiment in action in the next series of blogs, excerpted from the “Focus on Safety” issue of Proceedings of the Marine Safety & Security Council magazine.

For more information:
Full article and “Focus on Safety” edition of USCG Proceedings is available at www.uscg.mil/proceedings. Click on “archives” and then “2008 Vol. 65, Number 2” (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp.Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.

Thursday, November 5, 2009

Lessons Learned – Fire Aboard a Cruise Ship, Part II





Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. To read Part I, please see our Nov. 3 post.


Lessons learned from marine casualty reports are regularly featured in Proceedings of the Marine Safety & Security Council magazine. These articles explore marine incidents and the causal factors, outline the subsequent casualty investigation, and describe the lessons learned as a result.

As the fire raged aboard the cruise ship, four couples struggled for survival:

Rooms A344 and A320: The two married couples in these rooms encountered a closed fire screen as they attempted to escape, and became separated. One wife assumed her husband had made it to safety when she heard a door slam shut ahead of her. Both wives escaped.

Between 3:44 and 4:02 a.m., the engine fire party recovered the male passenger of room A320 in that alleyway. They pulled the semi-conscious man to safety, and he survived.

Just 30 feet away, the party found the male of room A344. Though he, too, was quickly transported to safety, where a medical party quickly came to assist, they found he had stopped breathing, had no pulse, and could not be revived.

Room A402: This married couple was able to escape their stateroom, but the elderly man suffered a respiratory arrest and collapsed on his way to their muster station. He was later recovered and taken to safety.

Room A340: This couple was trapped in their room, unable to get through when calling 911. The fire party evacuated them.

Of 2,690 passengers and the 1,123 crewmembers, there was one casualty. The autopsy of the man in room A344 reported his immediate cause of death was asphyxia, secondary to inhalation of smoke and irrespirable gases. Another 13 passengers and four crewmembers were treated for smoke inhalation.

The Aftermath
The cruise ship in this casualty seemed to be doing everything it should be. The ship was up to code and following the required regulations. Additionally, the crew’s quick and decisive actions prevented the situation from becoming worse.

There was no evidence that accelerants were used to intentionally set the fire, and the only electrical fittings on the balcony were the enclosed light fittings above the balcony doors. The damage to the light fittings was consistent with exposure to an external heat source; there was no evidence of arcing or failure.

The most likely source of ignition was a discarded cigarette. It was determined that the fire probably smoldered for about 20 minutes before flames developed.

Although passengers aboard the cruise ship were instructed to properly extinguish cigarettes in ash trays during a safety video shown throughout the day on embarkation, as well as in stateroom safety literature, rules such as these are not always followed.

Updated Regulations
After the fire, the International Council of Cruise Lines published a safety notice with recommended practices for balcony fire safety. IMO’s Maritime Safety Committee also initiated urgent measures to address cruise ship balcony fire safety, which were adopted just nine months after the fire.

Under the new amendments, partitions separating balconies must be constructed of non-combustible materials. Furniture on cabin balconies must be of restricted fire risk unless fixed fire extinguishing systems, fixed fire detection, and fire alarm systems are fitted to the balconies.

The photo shows polycarbonate balcony partitions, plastic furniture, and polyurethane deck tiles after the fire. These materials were highly combustible and produced very thick black smoke.

Lessons Learned
In this case, not even the most experienced maritime organizations thought of every possible scenario, as evidenced by the lack of regulations regarding balcony materials.

Perhaps this example will provide food for thought by prompting all vessel owners to evaluate whether all areas of their vessels are safe, what potential problems may arise, and whether the persons aboard are ready to respond to emergencies at all times.

Full article is available at www.uscg.mil/proceedings. Click on “archives” and “2008 Volume 65, Number 2” (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp. Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.

Tuesday, November 3, 2009

Lessons Learned – Fire Aboard a Cruise Ship, Part I

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine by Ms. Diana Forbes, managing editor, Proceedings.

Lessons learned from marine casualty reports are regularly featured in Proceedings of the Marine Safety & Security Council magazine. These articles explore marine incidents and the causal factors, outline the subsequent casualty investigations, and describe the lessons learned as a result. We will post a "Lessons Learned" feature on this blog once every two months.

It is important to note that lives were lost in some of the marine casualties we present. Out of respect for the deceased, their families, and surviving crewmembers, we do not mention the name of any person involved.


On March 23, 2006, the passenger ship Star Princess suffered a serious external fire. Even though the ship met the necessary fire protection requirements, a fire broke out on a balcony then spread rapidly from balcony to balcony. As a result, 13 passengers and four crewmembers suffered smoke inhalation, and one passenger died.

The Incident
On the morning of the incident, the sea was calm and visibility was good. At 2:50 a.m., a security patrol smelled something burning. This was reported to the officer of the watch and the area was checked. Nothing was found, but the officer instructed the security patrol to include the area during overnight rounds.

Nineteen minutes later the fire turned from smoldering to fully blown. At that time (3:09 a.m.), the officer of the watch received a call from a passenger. The bridge lookout reported the same fire almost simultaneously. The photo is a still from a video taken two minutes after the first alarm.

Quick Reaction
Amidst a steady stream of smoke detectors, heat detectors, and alarms going off on multiple decks, the crew’s response also occurred in rapid succession.

The officer of the watch made a broadcast over the public address system and sent the assessment party to the area (3:10 a.m.). The senior first officer saw the scale of the fire and immediately requested the bridge to broadcast the crew alert (3:13 a.m.).

The fire’s location was pinpointed and at 3:14 a.m. the fire screen doors were closed. In the next few minutes, the ventilation was also stopped, and the captain reduced speed to lessen the wind over the deck. During this maneuver, the relative wind shifted and the flames became more vertical.

At 3:20 a.m., the passengers were instructed to go to their muster stations. Lifeboats were prepared, but the port boats waited for protection from fire hoses because the fire was on the ship’s port side.

Firefighting Efforts
The fire started on a port side balcony and spread rapidly to adjacent balconies and up several decks. It also spread into staterooms as heat shattered the balcony doors, but was contained by each stateroom’s fire-smothering system.

As the fire progressed, the balcony partitions and other combustible materials generated dense black smoke which entered staterooms and alleyways and hampered evacuation.

Passenger Rescue Complications
Section leaders attempted to clear every stateroom by using keys to enter and evacuate passengers. However, one section leader didn’t have keys to dozens of staterooms, and had to bang on doors.

Because telephone lines were busy, the section leader couldn’t call his zone commander to request additional master keys, nor could he inform the commander that he was unable to check those locked rooms.

There was much confusion trying to piece together who was safe, especially when passengers went to incorrect muster stations. Initial headcounts and roll calls took hours because they had to be repeated several times, especially in one muster station that did not have a megaphone.

The Cause
The fire was likely started by a discarded cigarette that ignited combustible materials on a balcony, then spread rapidly from balcony to balcony.

But why did the fire burn so quickly and densely? Aren’t regulations in place to fireproof passenger ships?

The material used for the partitions and deck covering was determined by several factors, such as durability in a marine environment, weight, aesthetics, cost, and availability. Combustibility and toxicity when burning, however, were not evaluated.

Previous to this incident, such concerns were only defined in regulations that were applicable to internal spaces, not outdoor balconies. This incident brought to light that the regulation’s purpose to contain a fire in its space of origin was by no means achieved.

In Part II we will detail rescue efforts and lessons learned in the aftermath.

Full article is available at www.uscg.mil/proceedings. Click on “archives” and "2008 Volume 65, Number 2" (Summer 2008).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp. Online survey available at: http://www.uscg.mil/proceedings/survey.asp.

Direct requests for print copies of this edition to: HQS-DG-NMCProceedings@uscg.mil.