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Final Report On The Carnival Splendor Fire

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Carnival responds to the official Coast Guard report on the Splendor fire.

In November 2010 a fire aboard Carnival Splendor left the ship adrift in the Pacific Ocean. The ship suffered a complete loss of power, requiring emergency assistance from the Coast Guard, and the United States Navy by way of an aircraft carrier being diverted to assist. In the end, it took three days to tow the Splendor to San Diego. Still, most passengers praised the dedication of the crew and the considerable leadership skills of Cruise Director John Heald, who was the spokesperson to the guests throughout the event.

The investigation is now complete and the United States Coast Guard has released the final report. The report can be accessed here as a pdf download. It is quite detailed and tiresome to read, so I have sifted through it to provide the following summary.

Primary Findings

Modern cruise ships use diesel generators which produce electric power, which then is used to power electric motors that turn the propellers, either by traditional shafts with screws on the back of the ship, or by azipods which are modular electric motor/propeller pods under the ship. The Carnival Splendor has six main propulsion diesel generators, with three generators in the forward engine room, and the other three in the aft engine room. The fire originated in the aft engine room.

The #5 diesel generator engine had a catastrophic failure which caused the engine casing to rupture, causing oil, fuel, and pieces of the engine to be ejected onto the deck plating in the aft engine room. This initiated the fire, which then spread to cable trays in the overhead and ran down the cabling, destroying them and causing a loss of power from the remaining five diesel generators and affected both the forward and aft engine rooms.

The primary fire-fighting system for the engine rooms on the ship is the ‘Hi-Fog’ system. This is a hard-piped system in the engineering areas that sprays a fine mist of water upon activation. It is a lot of water and deluges the area, rapidly lowering the temperature and smothering fires. Think of it as a building sprinkler system on steroids.

The Coast Guard findings place a lot of emphasis on an action taken by an unnamed member of the bridge crew, who instead of activating the “Hi-Fog” fire suppression system after receiving indications of a fire in the aft engine room instead reset the system. Resetting the Hi-Fog system stopped it from activating. From the system’s point of view, there was no fire. This led to a crucial 15-minute delay in activating the system. The investigation concludes that the spread of the fire may have been minimized had the system been activated immediately, which could have prevented damage to critical electrical cables in the overhead that interconnected between both the forward and aft engine rooms. This possibly could have allowed the ship to recover propulsion ability instead of being left adrift.

Other issues raised by the investigation include:

– Operability of the Carbon Dioxide (CO2) fire suppression system, which is different than the Hi-Fog system. The CO2 system had several problems that kept if from being placed in operation, despite several attempts.

– Corrosion and drainage issues with the air cooler system used for all Diesel Generators. Air fed into the cylinders of a diesel engine has to be cooled and also dried so that moisture in the combustion chambers is kept to a minimum. Too much moisture can lead to a condition called ‘hydro lock’. Water cannot be compressed like air so hydro lock can cause a diesel engine to fail when the pistons cannot move against the water above them in the cylinder.

– Problems with the “slow turn” feature of the diesel engines, which were built by the Wartsila Company. In particular, the effect of increasing the slow-turn interval from 30 minutes to 2 hours, which is what had been done when the Splendor was built. “Slow Turn” is an automatic feature on Wartsila diesels, which cranks an idle engine slowly at a set time interval. This is done to detect the moisture build-up noted above so the engine isn’t started and subsequently damaged.

– The lack of crew familiarity with immediate casualty control procedures for engine room fires and crew familiarity with the engine room layout.

– The susceptibility of the Carnival Splendor and all Dream class vessels to a complete loss of power resulting from damage to a single area of electrical system components in either the forward or aft engine room. This was a design issue, which did not provide enough redundancies for key components. An analogy would be if one burner on your kitchen stove stopped working and it caused the other burners to also stop.

– A 40 second delay automatically built in to the Hi-Fog system should be removed so that the system would instantly commence operating when activated. When 2 fire/smoke detectors are activated, the Hi-Fog system was programmed with this 40-second time delay before it started operating. The delay was originally designed to avoid false positive signals.

While the report offers no conclusive reasons for the failure of the #5 diesel engine, the inclusion of the recommendations for the air cooler and slow-turn feature strongly imply they might have led to the engine failure and subsequent fire.

Subsequent to the release of the Coast Guard report, Carnival provided their responses to the recommendations:

– To address problems with the CO2 system, the cruise line modified testing and inspection of the Splendor CO2 system. They have changed the operating sequence to avoid situations that occurred during the fire. On their other ships, they have implemented a procedural change to avoid malfunctions until those ships are modified as part of the $300 million dollar upgrade program.

– Independent testing by experts and Wartsila determined that there were no problems with the air cooler system on the diesel engine that failed and caused the fire.

– Carnival and Wartsila are evaluating the slow turn questions raised by the Coast Guard.

– Perhaps the most contentious comment from Carnival involves the Coast Guard’s remarks about crew training and knowledge of the engine room layout. To quote the Carnival response, “Our crew was familiar with the engine room layout and equipment and firefighting strategy and procedures. We have reviewed all of our procedures and have reinforced our training at all levels for firefighting.”

– The susceptibility issues for the Splendor and Dream class for total loss of power is being addressed by the company’s $300 million dollar upgrade program.

– The 40 second delay has been removed from the Hi-Fog system.

This was a major incident that had the potential for a catastrophic ending. The Carnival Splendor crew responded according to their training, and eventually prevailed in the battle against the fire despite the complete failure of the CO2 firefighting system and the delayed activation of the primary line of defense, the Hi-Fog system. The failure to activate the Hi-Fog system immediately, when indications of a fire were received on the bridge, was a human performance error and perhaps the most significant problem on that unfortunate day at sea.

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Comment from Kenneth Eden
Time July 25, 2013 at 2:16 pm

yesterdays edition of the Wall Street Journal had a enlightening article about Micky Arison and the future of carnival plc

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