Carnival Splendor Fire: Troubling Revelations
Written by: David Beers
By David Beers – Editor CruiseReviews: Shortly after the Carnival Splendor fire and subsequent journey back to port under tugboat power I wrote this article which praised the crew, the actions of the ship’s Captain, and the calm and steady presence of Senior Cruise Director John Heald. However, new information indicates the actions of the crew firefighting teams aboard Carnival Splendor were totally responsible for extinguishing the fire and saving the ship from something much more ominous. In a nutshell, the automatic fire suppression system didn’t work. The crew saved the ship with fire hoses and handheld extinguishers.
What I wrote then still holds true and now in a more significant way. And, to be clear, Carnival has checked the emergency fire systems on ALL of their ships within the past few days and everything works within the design specifications. Please do not fear cruising with Carnival.
The source for the new information is the United States Coast Guard, which issued two safety alerts last week that generically discuss “critical concerns uncovered during an ongoing marine casualty investigation.” Although the Carnival Splendor is not named in either report, a reading of them shows they are obviously referring to the Carnival Splendor because of the subject matter and the timeline. Other published reports also say the safety alerts are about the Splendor.
The reports are troubling to me. When an official report uses words such as “critical concerns” it ought to make you sit up and pay attention. They don’t toss those words around lightly.
The Coast Guard safety alerts reveal many problems existed on the Carnival Splendor, ranging from incorrect system operation manuals to the operational failure of a major fire suppression system – namely the CO2 deluge system which Captain Cupisti ordered to be activated on that fateful morning. This would have flooded the affected spaces with CO2 and smothered the fire. We now know that the CO2 system didn’t work. Efforts to manually initiate it were not successful.
Here are the facts as delineated in the Coast Guard reports:
- The CO2 system test procedure used by ship builder Fincantieri has many differences with the ship’s Firefighting Instruction Manual (FIM).
- The shipyard test procedure says to select the desired CO2 discharge line prior to activating the system, yet the FIM has no such prerequisite. The FIM references a system control panel of one design but the actual control panel has an almost totally different layout.
- The FIM states that the CO2 Release station is on the starboard side but it is actually located on the port side.
- The FIM says to “pull” the valve control switches but you actually have to “turn” the switches to operate the valves remotely.
- It would be laughable if it weren’t so serious but the FIM had butchered English with “once the fire has been extinguished make sure that the temperature has decreased before investigate the area same time is needed to wait hours.” That is an exact quote from the Coast Guard report. What that is supposed to mean escapes me.
- There were some examples of incorrect signage on the CO2 stations aboard the ship and missing schematic diagrams (sometimes called mimic boards) which were referenced in the FIM as being posted at the stations but in fact were not.
- The engineering diagrams used by the shipyard differed with the physical installation of the CO2 system on the vessel. In other words the blueprint shows things are supposed to be one way, yet they were installed in a different way. This is quite significant since it could indicate that 1) system installation was not performed in accordance with the approved design, and 2) once installed, systems were not verified as being in compliance with the design specifications.
- Valve actuators are devices which are used to either automatically or manually operate valves. The actuators on the CO2 system failed to work and were held in place by small machine screws. A machine screw is appropriate for attaching the arm rest to your car doors. They are completely unsatisfactory for use on control valves for an emergency system. The actuator arm for the valve they needed to open literally fell off when the system was activated remotely and efforts to manually open it were not successful.
- CO2 system valves leaked excessively and many fittings continued to leak even after being tightened.
- System design allowed for low points where moisture accumulated and caused corrosion, which may have affected system operability.
And now the very disturbing bottom line – the CO2 system aboard the Carnival Splendor had been recently serviced and inspected by an approved vendor.
As I said in my initial blog about this event, there are many similarities to things I experienced in my career at a commercial nuclear power plant. Browns Ferry Nuclear Plant was ordered to shut down in 1985 by the Nuclear Regulatory Commission (NRC) for many reasons, chief of which was the plant systems actually didn’t match the approved design diagrams.
I suspect the reason Carnival recently canceled additional cruises for the Splendor has to do with some fairly significant design changes they are having to do on the ship. In other words they are having to make the ship look like the engineers said it was supposed to look. They are also likely having to do a complete review of all the operating procedures for the ship and ensure they match the actual layout of the ship. In nuclear power we call it procedural compliance. You follow the procedure as written, and if you can’t then you don’t wing it or use tribal knowledge to make something work. You stop and get things fixed so everything matches.
The Coast Guard has sent a signal about the tone Carnival can expect in the final incident report. I predict it will be ugly. But in the end we should all take heart in the absolute fact that the ultimate firewall – the crew of Carnival Splendor – saved the day.
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Posted: December 28th, 2010 under David Beers.