NTSB report reveals insufficient maintenance and lack of guidance led to fatal ferry fire

The US National Transportation Safety Board (NTSB) determined during a public meeting held on Tuesday, December 11, that an insufficient preventive maintenance program and lack of guidance for responding to high-temperature conditions led to the January 14, 2018, fire aboard the small passenger vessel Island Lady in the waters of the Pithlachascotee River near Port Ritchey, Florida.

Island Lady was a 21-metre-long passenger vessel operated by Tropical Breeze Casino. It was used to shuttle passengers and company employees to and from the casino boat Tropical Breeze I.

On the day of the fire, Island Lady was carrying 36 passengers, a crew of four, two “pre-hires,” and 11 other employees.

Of the 53 people aboard that day, 15 were injured and transported to local hospitals. One female passenger died several hours after the fire.

No pollution was reported in connection with the accident, and damage to Island Lady resulted in the vessel, valued at US$450,000, being declared a constructive total loss.

While the accident was not declared a major marine casualty, the NTSB has investigated this accident as an accident of recurring character because of a similar fire in 2004 on board Express Shuttle II, another of the operating company’s vessels.

On the day of the fire, Island Lady was en route to Tropical Breeze I, located about 14 kilometres offshore in the Gulf of Mexico. Just before 16:00, the captain received a high-temperature alarm for the port engine’s jacket-water system.

The captain turned the vessel around to return to the dock and notified the operating company. Smoke began filling the lazarette, main deck spaces, and engine room.

The captain then deliberately beached the vessel close to shore in shallow water. All passengers, crew, and company employees evacuated by jumping from the vessel into the water and wading ashore.

The NTSB’s investigation determined:

• Tropical Breeze Casino’s lack of guidance regarding engine high-temperature alarms led to the captain leaving the port engine idling, rather than shutting it down, leading to the fire.
• The lack of a requirement for a fire detection and suppression system in an unmanned space containing engine exhaust tubing prevented early detection of, and a swifter response to, the fire in the lazarette.
• The captain’s decisions to return to the dock and to subsequently beach Island Lady were prudent and increased the likelihood of survival for those on board.
• The failure of the port engine’s raw-water pump led to overheating of the engine and exhaust tubing. The raw-water pump’s failure resulted from Tropical Breeze Casino’s failure to follow Caterpillar’s recommended maintenance schedule.
• Neither weather, fatigue, nor impairment were factors in the accident.
• Island Lady’s crew had insufficient firefighting training.
• The use of plastic tubing on local tank level indicators and lack of automatic shutoff valves on the fuel tanks resulted in the release of diesel fuel, which contributed to the severity of the fire.
• The US Coast Guard did not correctly assess the compliance of Island Lady’s fuel system with applicable regulations during an inspection of the vessel.

As a result of its investigation, the NTSB issued four safety recommendations with two issued to Tropical Breeze Casino and two to the US Coast Guard. The safety recommendations issued to Tropical Breeze Casino seek the development and application of an oversight system to ensure their maintenance program complies with the manufacturer’s recommended preventive maintenance program and revision to the company’s marine firefighting training program.

Safety recommendations issued to the US Coast Guard seek a requirement for fire detection systems in unmanned spaces with machinery or other potential heat sources on board small passenger vessels and the issuance of a Marine Safety Information Bulletin addressing the need to use only approved material and components in fuel tank level-indicator systems.

The NTSB also reiterated two safety recommendations issued to the US Coast Guard. Safety recommendation M-12-3, issued in 2012, seeks a requirement for operators of US-flagged passenger vessels to implement safety management systems. Safety recommendation M-02-5, issued in 2002, seeks a requirement for the development and implementation of a preventive maintenance program, by companies operating domestic passenger vessels, for all systems affecting the safe operation of their vessels, including hull, mechanical, and electrical systems.