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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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Comments

Comment from Rob
Time December 28, 2010 at 7:21 pm

This article is dead on, nice work. Carnival will get the message that there is no compromise of safety on the high seas.

Comment from Dave Beers
Time December 28, 2010 at 8:14 pm

I appreciate your comments, Rob. Frankly I was aghast as I read the Coast Guard reports. Procedures not matching up to actual system layout; Systems not installed in accordance with the approved design prints; Systems apparently not verified to be installed in accordance with the approved design prints; etc. It really makes me wonder about anything Fincantieri has built. Are there any other problems out there?

Comment from Kenneth Eden
Time December 29, 2010 at 9:09 am

One rule of thumb that I have held strong and fast to over the years, is that I never sail on any ship that does not call at a port of call in the USA. PERIOD. It certainly is not a fail-safe measure, nor is it fool proof,but, the ship or ships will have a US Coast Guard boarding, and inspections will be made. A once in a blue moon visit is not any guarantee, but, it helps.

It also makes sense to NEVER take ANY ship from ANY non-US port of embarkation on any ship that NEVER calls in the USA or Canada, as these ships are not inspected. I will not name names, however, there are some popular ships and cruise lines that do not make this grade. Sailing out of Barbados, say, on a ship that does not call in the US or Canada does not an inspected ship be.

In the case of the Splendor, presumably all proper inspections were done, or so it would have been believed. something was awry, and as david points out, so very CLEARLY, a disater of epic propotions could have taken place. Thank god the crew was so attentive and well trained.

Don’t ever poo-poo the crew and their drills while you are on a cruise. They are training for LIFE AND DEATH. I can not believe some of the things I hear passengers say as the crew is drilling, or the interferences they try to subject the crew to during these important safety drills.

When you are out to sea, the crew, a well trained one, is the fine line between safety or disaster.

There are plenty of sites to browse for USCG Health Inspections, but where are the ones for what really matters, SAFETY> Maybe hounding CLIA (Cruise Line International Association) for which cruise lines pay big bucks to belong to, could form a lobbying effort to let pasenghers know the critical safety measures and failures of ships that sail to/from North America.

It is important, the safety issue, far more important than finding a radish on the floor of the galley, or a paper towel on the floor of a lavatory.

If you care for safety at sea, hound CLIA

Comment from gharkness
Time December 29, 2010 at 6:53 pm

Yes, I know we should not be afraid to sail on Carnival lines….and I am not. I have a cruise booked on Carnival and I will certainly take it.

However, if these issues were found on the Splendor, then is it out of line to ask “how far does this extend to the rest of the fleet?”

Comment from Dave Beers
Time December 29, 2010 at 7:44 pm

gharkness,

It isn’t out of line to ask about the extent of the problem.

Carnival says that since the Splendor fire happened they have tested the fire systems on all of their ships, and that everything is working as expected.

I will take Carnival’s word that all is well. But this incident does show that intrusiveness by whatever inspecting authority needs to be rigorous, and obviously it has not been so.

Comment from Barry
Time January 7, 2011 at 12:36 am

David Beers comments above represents one of the best articles I have read about the Splendor event. I also have worked in the commercial nuclear power industry for almost 40 years now (and still do). If a commercial nuclear plant in the US discovered a safety or quality related system in the condition of the Splendor CO2 system, we would be instantly subject to an Enhanced Inspection Team and driven into an audit (95002 or 95003) that would have the potential of costing between 20 and 200 hundred million dollars to successfully deal with. It is likely the subject plant would be forced to shut down. I think there are strong parallels between nuclear power and cruise ships because both industries have an accountability for protecting the health and safety of many people. In the case of the Splendor there were almost 5000 soles aboard.

I agree with Mr. Beers optimism but only to a limit. In spite of some very vocal opinions to the contrary, the commercial nuclear industry truly does an outstanding job running safe facilities. Even plants rated in the bottom quartile are very good at what they do. In my opinion we do such a good job, not for altruistic reasons, but because we are so highly regulated. Each plant has at least two permanent NRC inspectors (residents) permanently assigned to the plant. We are constantly audited and inspected by an industry group (INPO) that, in many respects, is much tougher than the NRC. There is also a strong presence by the insurance companies, OSHA, and others. In other words, we operate in a huge fish bowl and any misstep or violation is immediately either self reported or noticed by a regulating body. It would be unthinkable to have an operable safety related system in the condition reported by the Coast Guard of the CO2 system on the Splendor. My point is, realistically, without the ever present overwhelming regulation we would not do such a good job. After all, we are a business and human nature, without other strong influence, will always have the bottom line trumping safety. It is naïve to think differently. For the same reason, I do not believe marine facilities, the petroleum industry, or any other industry for that matter, will ever consistently and comprehensively achieve the standards reasonably expected by the public simply because they will never be regulated on a day to day real time basis (as is nuclear power). For example, there are no Coast Guard inspectors permanently assigned to a cruise ships assuring day to day ops are in accordance with established laws and procedures. This is just the way humans behave and there is no reason to expect things will change.

Comment from Dave Beers
Time January 7, 2011 at 9:31 am

Barry,

Thank you for your kind comments. I agree. Prior to the enhanced NRC oversight and creation of INPO by the nuclear industry, nuclear plants were often run with a gunslinger mentality.

As a minimum I’d hope the Coast Guard would increase the rigor of their current inspections. I don’t know what they do for their initial safety inspections when a new ship arrives in U.S. waters. Obviously a need existed on the Splendor for someone not connected with the builder or operator to perform system walk-downs. I think anyone who works in nuclear power would, given the choice, prefer an NRC inspection to an INPO evaluation. Of course, as you and I know it isn’t that NRC is lax but they are bound by their statutory authority, whereas INPO has been made a defacto regulatory agency by the nuclear industry which funds it, and INPO has pretty much a blank check on what they can “suggest” which really means “require”.

It may be time for the cruise line industry to have a meaningful in-house watchdog such as INPO. I’d also like to know more about what, if any, type of formal Corrective Actions Program cruise lines have. I suspect there are no such programs.

Comment from Barry
Time January 7, 2011 at 11:19 pm

INPO, is indeed a very positive and very popwerful force in the nuclear industry. As you stated, whereas the NRC enforces the written law, INPO promotes and audits for “good practices”. I believe we do a better job by orders of magnitude because of INPO’s influence. What I find fascinating is that the industry INPO so very effectively regulates is also their source of funds. Isn’t this like the fox guarding the hen house and doing a really excellent job guarding it?

Comment from CBPete
Time February 23, 2011 at 7:57 pm

I’m left wondering how the unconformities were missed by the initial Lloyds, USCG, and other regulatory authorities. What else did they miss???? I doubt that the engineers on board the ship altered the delivered ship to that extent…
Perhaps someone noticed that it was odd, but thought that if it was installed that way, that must be the way it is supposed to be.
Also, in the airline industry, the flight manuals and maintenance manuals are updated frequently with the knowledge that the FAA just might require something to be done in accordance with the latest revision. Did no one review or practice with the FIM to gain familiarity with it???

The fact that Lloyds missed all this stuff, and so did the USCG, and other maritime authorities makes me wonder how good are they at inspecting for nonconformities? How much do they study the drawings and the actual installation to see that the manufacturing process conforms? How much training do the ship-board engineers receive in making sure their ship conforms to design?

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