ANCHORAGE - When a crewman's hot water kettle set fire to a cabin on board the Holland America Line cruise ship Nieuw Amsterdam 16 months ago in Glacier Bay, officers and crew members rushed to take action.
According to the National Transportation Safety Board, much of it was the wrong action.
In a report released last week, the NTSB said officers ignored their own shipboard firefighting plan. As a result, fire spread beyond the cabin, smoke reached upper decks and contact with the Coast Guard was not made for nearly an hour.
"Had several officers handled the emergency differently, the fire might never have escaped from the confines of the cabin," the board concluded. "Additionally, the spread of smoke might have been curtailed, which would have reduced the risk of injuries to passengers and crew members."
No names were attached to the report.
"Our function is to assess safety issues, not to assign blame," said Lauren Peduzzi, an NTSB public affairs officer in Washington, D.C.
Holland America spokesman Erik Elvejord said company officials are reviewing the NTSB report, which recommended revisions in firefighting training procedures. He said the company will respond to the recommendations this week.
Holland America sold the Nieuw Amsterdam after the 2000 season to American Classic Voyages. The ship was not equipped with sprinklers and was grandfathered out of a regulation that requires such equipment until 2005.
The 704-foot, Netherlands-registered ship carried 1,169 passengers and 542 crew members May 23, 2000, on a cruise from Vancouver, British Columbia, to Seward.
The fire resulted in one injury. A passenger suffered smoke inhalation and was evacuated to Juneau's Bartlett Regional Hospital. Damages exceeded $360,000, but after a Coast Guard inspection, the ship continued the cruise.
The NTSB concluded that crew members had properly attended firefighting training, conducted periodic drills and established responsibilities. They just didn't follow them.
The Bureau of Alcohol, Tobacco and Firearms traced the fire to an electric hot water kettle left on a table in a cabin shared by four crew members on the D deck, the lowest deck on the ship.
NTSB conclusions included:
At 9:11 a.m. the ship was five miles north of Russell Island in Tarr Inlet, 110 miles northwest of Juneau, when a fire alarm sounded.
On the bridge, the on-duty third officer ordered a quartermaster to investigate to make sure it was not a false alarm. The quartermaster carried a full-face smoke mask and a radio down to D deck.
The quartermaster found cabin D98's door locked with smoke pouring out of the ventilation louvers in the lower section. He radioed his observations to the third officer, who informed the captain.
The firefighting plan called for the chief officer to report to the bridge to assume command of a confirmed fire. Instead, the captain ordered the chief officer down to D deck to investigate the fire.
The quartermaster met a crewman who had retrieved a dry chemical extinguisher and a room steward who had a cabin pass key. The quartermaster opened the cabin and the crewman discharged the extinguisher. Smoke poured out of the cabin and the quartermaster closed the door to contain the fire.
Other officers arrived on D deck and crew members began retrieving a fire hose when the ship's safety officer arrived on D deck. He ordered that the fire be reported to the bridge. At 9:19 a.m., eight minutes after the first alarm, and upon hearing the fire had not been extinguished, the captain ordered the general alarm sounded, alerting passengers to get to their assigned staging areas.
The captain did not order the chief officer to return to his emergency station on the bridge but instead assumed command of firefighting operations.
As the chief officer approached D deck, he met the quartermaster in a stairwell. He donned the quartermaster's smoke mask and entered the main passageway. He saw thick, white smoke from cabin D98 and found an uncharged fire hose in the passageway.
When the chief engineer appeared, the chief officer ordered him to stand by a fire hydrant valve. The chief officer then picked up the uncharged hose and headed for the burning cabin.
Neither man had a fire suit, gloves, helmet or breathing apparatus other than the chief officer's smoke mask taken from the quartermaster.
The chief officer positioned himself near the closed door of the burning cabin, ordered his hose pressurized, pushed open the door and directed a stream of water inside for 30 to 40 seconds. Intense heat, white smoke and steam rushed out of the cabin door, forcing him back, and he dropped the charged hose. Both he and the chief engineer fled. But the fire hose was left on the floor in the doorway, keeping the cabin's door propped open.
When the general alarm sounded, the ship's firefighters mobilized. At 9:30 a.m. a four-person team entered the passageway on their knees and attacked the fire, which had spread from cabin D98. With backup from another team, they extinguished the fire.
The NTSB concluded a number of officers acted improperly, starting with the captain.
Under the ship's firefighting protocol, the chief officer should have been on the bridge managing the firefighting effort, not the captain.
"While the master was trying to juggle his own responsibilities and those of the first officer, additional crucial actions were not executed in a timely manner," the report concluded.
Once the quartermaster confirmed the fire, the captain did not immediately sound the general alarm, signaling fire teams to assemble, or broadcast a message alerting crew members on D deck to evacuate their rooms.
The report said the captain did not make sure the Coast Guard was contacted in a timely manner. About an hour elapsed before the Coast Guard received a relayed distress message from another Holland America vessel.
"If the fire on the ship had been beyond the capabilities of the shipboard firefighters, the delay in contacting the Coast Guard and arranging for additional resources could have had tragic consequences," the board concluded.
The board said the captain secured decks after they were filled with smoke and did not order crew teams to assist passengers in evacuating decks until after smoke had reached the main deck more than 20 minutes after the alarm.
The board also faulted the chief officer and the chief engineer for stepping in as firefighters.
"Their actions were ill advised and actually made the situation worse," the board concluded. "Had either of these two officers been injured in their firefighting effort, the ship would have lost the benefit of his knowledge and expertise during the emergency."
The board recommended Holland America revise its shipboard training and drills. The board recommended that officers emphasize their management responsibilities during a fire.
All but two of Holland America's 10 cruise ships now are equipped with sprinklers in crew and passenger cabins, company spokesman Elvejord said. The Westerdam is partially equipped with sprinklers but is due to be sold in March. The Noordam has no sprinklers but is required by law to have them by 2005.
The crew member who owned the hot water kettle was fired, Elvejord said. He was not aware of any punitive action taken by the company against officers.
Details of the National Transportation Safety Board's investigation are available through http://www.ntsb.gov./Surface/marine/marine.htm