NTSB Report - Fire aboard Roll-on/Roll-off Passenger Vessel Caribbean Fantasy Atlantic Ocean

Coast Guard and other assets respond to the Caribbean Fantasy off the coast of Puerto Rico on Wednesday, August 17, 2016. U.S. Coast Guard Photo

gcaptainNTSB Cites Poor Safety Culture in Caribbean Fantasy Fire Investigation

Fire aboard Roll-on/Roll-off Passenger Vessel Caribbean Fantasy Atlantic Ocean, 2 Miles Northwest of San Juan, Puerto Rico - Aug 17 2016 -Full NTSB report here (pdf)

Executive Summary

​About 0725 on August 17, 2016, a fire broke out in the main engine room of the roll-on/roll-off (Ro/Ro) passenger vessel Caribbean Fantasy when fuel spraying from a leaking flange came in contact with a hot surface on the port main propulsion engine. The fire could not be contained, so the master ordered the ship to be abandoned. US Coast Guard and other first responder vessels and aircraft, along with good Samaritan vessels, helped transport all 511 passengers and crew to the port of San Juan, Puerto Rico. Several injuries, none life-threatening, occurred during firefighting and abandonment efforts. The burning vessel drifted in the wind and grounded on the sandy bottom outside the port. Three days later, the vessel was towed into the harbor, where shore-based firefighters extinguished the last of the fire. The accident resulted in an estimated $20 million in damage to the Caribbean Fantasy, which was eventually scrapped in lieu of repairs.

Probable Cause

​The National Transportation Safety Board determines that the probable cause of the fire aboard the roll-on/roll-off passenger vessel Caribbean Fantasy was Baja Ferries’ poor safety culture and ineffective implementation of their safety management system on board the vessel, where poor maintenance practices led to an uncontained fuel spray from a blank flange at the end of the port main engine fuel supply line onto the hot exhaust manifold of the engine. Contributing to the rapid spread of the fire were fuel and lube oil quick-closing valves that were intentionally blocked open, fixed firefighting systems that were ineffective, and a structural fire boundary that failed. Contributing to the fire and the prolonged abandonment effort was the failure of the Panama Maritime Authority and the recognized organization, RINA Services, to ensure Baja Ferries’ safety management system was functional.

About 0916, the crew hoisted lifeboat no. 3 back out of the water. During the hoist, the
winch tripped off line, leaving the boat suspended about 6 feet above the water. (The prime mover for the winch was designed to lift the lifeboat with a crew of six only and not a fully loaded lifeboat. 19 ) With the boat hanging at the ship’s side and unable to be lowered, none of the Coast Guard small boats were able to be effectively positioned to remove people from the lifeboat

NTSB report page 16

From the report:

During postaccident interviews, the CEO and other top managers at Baja Ferries spoke about their personal commitment to safety and the company’s safety-oriented culture; however, investigators did not find substantial evidence to validate those claims.

Nicely put.



Page 9 from the report

The master ordered a PA system announcement to inform the passengers of the fire
and to direct them to follow the instructions of the crew. At 0746, the announcement was made in English by the deck cadet, using a prewritten script, to all areas of the vessel. Immediately following this announcement, the second officer (on watch) made an announcement in Spanish. The announcement followed a different prewritten script that stated the fire was not under control and “it has been decide [sic] to abandon the vessel.” It further directed all crew to their survival craft embarkation stations. When the master was interviewed by investigators after the accident, he stated that he ordered only the announcement that was made in English and not the announcement in Spanish. He further stated that, because he did not speak Spanish, he would not have understood the second announcement.

The captain deserves a lot of credit here,none of the critical safety equipment worked, the co2, system, the water drencher system, the lifeboats, liferafts, none of it worked as designed or failed completely yet still managed to get 511 passengers off with just minor injuries.

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Im going to assume (and hope) this was not a US flagged Ferry.

It would have taken less time to look it up than to write about your hopes and assumptions.

What if I would rather hope than click a link?

It was Panamanian flagged. But the U.S. Coast Guard initially denied permission for the ship to carry passengers into a U.S. port until several deficiencies were corrected.

At the time of the incident almost none of the safety equipment on this ship worked. This incident gives an idea of what the U.S. Coast Guard standards are, it’s not too much of a stretch to say if it’s not on fire or sinking the C.G. will consider it seaworthy.

My first thought was “unless it’s an American flag ship …” then the El Faro came to mind.

When I was doing ship inspections on the Columbia river it infuriated me at the condition of many of the FoC ships while our own were nitpicked to death over the least little issue by ignorant teenagers from Kansas.

I don’t think the Captain deserves any credit if none of the critical safety systems worked.

Quote from the report
“About 0720, the motorman and the wiper noticed the smell of fuel in the main engine room. Upon investigation, the motorman saw MGO leaking from the aft end of the port main engine. He immediately notified the chief engineer, who was at the forward end of the main engine room. The chief engineer, motorman, and wiper investigated further and found fuel discharging from an end flange on the port main engine fuel supply line, located on the aft outboard side of the engine. The chief engineer proceeded to the engine control room (ECR) and, at 0723, called the bridge to inform the master of the leak. The chief engineer told the master that repairing the leak required shutting down the fuel system and isolating the fuel supply line, which would also shut down the port main engine propulsion. After receiving the call from the chief engineer, the master told the bridge watch, “Reduce the speed.” At that moment, the ship was altering course to starboard toward the pilot station at a speed of 17.3 knots.
With the permission of the master, the chief engineer took control of the main propulsion in the ECR. He reduced the load on the main engines by decreasing the pitch angle of the controllable-pitch propellers in preparation for stopping one or both engines. He then left the ECR and returned with the motorman to the location of the fuel leak. There they discovered an increased amount of fuel spraying from the fuel end flange in the direction of the engine’s exhaust manifold casing and turbocharger. Reducing the load on the engines had decreased fuel consumption and thereby increased the fuel supply line pressure, which in turn had increased the fuel spray.
The chief engineer told investigators that he was about a meter away from the flange when the fuel spray ignited. A large plume of fire, heat, and smoke forced the chief engineer, motorman, and wiper to exit the area. The chief engineer and motorman returned to the ECR. The wiper attempted to go to the ECR, but the smoke and heat prevented him from doing so. Instead, he exited the space into the auxiliary engine room. He then proceeded aft and climbed a stairway to garage B on deck 3”

The Ch Engr wasted too much precious time in going to the ECR and then back again. If he saw fuel leaking in the Engine Room, he should have brought the Engine to an Emergency Stop.