Marine Safety Investigation Unit

SAFETY INVESTIGATION REPORT

201212/023 REPORT NO.: 22/2013 December 2013

The Merchant Shipping MV CARNIVAL SPIRIT (Accident and Incident Safety Investigation) Regulations, Fire in the sauna 2011 prescribe that the sole in position 20° 19.2’S 169° 55.8’E objective of marine safety investigations carried out in 30 December 2012 accordance with the regulations, including analysis, conclusions, and recommendations, which either SUMMARY result from them or are part of the process thereof, shall be the prevention of future marine At 1818 (LT) on 30 December work surrounding the sauna’s accidents and incidents through the ascertainment of 2012, a fire broke out in the heating element/hot stones. causes, contributing factors women sauna room of the and circumstances. passenger vessel Carnival Spirit, An examination of the dry Moreover, it is not the purpose whilst en route from Mystery sprinkler pipe and check valve of marine safety investigations carried out in accordance with Island, to revealed that the latter was these regulations to apportion . blocked in the closed position blame or determine civil and criminal liabilities. and did not open due to

Automatic fire/heat detection corrosion/oxidation of the valve NOTE devices activated and alerted the seat. This report is not written with litigation in mind and pursuant crew. Although the fire was to Regulation 13(7) of the Merchant Shipping (Accident contained inside the sauna room, The safety investigation has also and Incident Safety the fixed water dry sprinkler found that there were no Investigation) Regulations, 2011, shall be inadmissible in system did not activate and the specific maintenance records for any judicial proceedings whose purpose or one of whose fire was extinguished manually. the fixed dry sprinkler system in purposes is to attribute or the sauna. apportion liability or blame, unless, under prescribed The safety investigation has conditions, a Court determines otherwise. concluded that the fire was In view of the safety actions The report may therefore be caused by the placement of the taken by the ship managers, no misleading if used for purposes other than the promulgation of women’s sauna wooden cedar recommendations have been safety lessons. floor grate on top of the frame made. © Copyright TM, 2013 This document/publication (excluding the logos) may be re-used free of charge in any format or medium for education purposes. It may be only re- used accurately and not in a misleading context. The material must be acknowledged as TM copyright.

The document/publication shall be cited and properly referenced. Where the MSIU would have identified any third party copyright, permission must be obtained from the copyright holders concerned. MV Carnival Spirit

MV Carnival Spirit 1 201212/023

FACTUAL INFORMATION Also contained within the sauna is a wooden cedar floor/foot grate (Figure 2). During Vessel normal operation, the floor grate is positioned Carnival Spirit is a 12 deck passenger class on the floor for comfort. The floor grate is built in 2001 by Kvaerner Masa- approximately 1.5 m in length, 0.65 m in Yards Helsinki Finland and registered in breadth and 0.025 m thick. Malta. The vessel is owned by Carnival Corporation, operated by Carnival Cruise Lines and is classed by Lloyd’s Register. The vessel’s length is 292.50 m and has a beam of 38.80 m. Her summer draught is 7.80 m.

The vessel’s cruise programme from Sydney, Australia primarily consists of round voyages throughout the South Figure 2: Wooden floor grate (shown on the bench Pacific, , Vanuatu, and New Zealand. seating inside the men’s sauna)

The sauna facility The heating element can be activated by a The women’s sauna is situated on deck no. circuit breaker fitted inside the Beauty Parlour 9, forward of the Beauty Parlour Treatment Treatment and Spa Reception area. There is and Spa Reception Area on the starboard no circuit breaker inside the sauna. side of the vessel adjacent to the solarium and beauty treatment rooms. Both the men’s and women’s saunas are identical in Environment configuration and consist of a tiled floor, The wind was South-Easterly, force 5, and the glass and wooden cedar deck head and sea state was moderate. Air temperature was bulkhead panelling. recorded at 26°C and sea temperature was 27°C. Inside each sauna is a single heating element containing hot stones (Figure 1) situated opposite two wooden cedar bench Narrative seats. The heating element is surrounded On 29 December 2012, maintenance works by a wooden cedar framework, which had been assigned to the vessel’s senior joiner serves as a physical barrier to protect in both the men’s and women’s saunas. The passengers from coming in contact with the work consisted of sanding the wooden cedar heating element. benches and the wooden cedar floor grates.

At approximately 0745 on the following day (30 December 2012), the senior joiner attended the spa area and requested that the heating elements be switched off.

Works commenced at approximately 0815 in one of the saunas and during this time, the senior joiner sanded the wooden cedar floor grate whilst it remained on the tiled floor Figure 1: Sauna heating element within the sauna. After completion, he placed it horizontally on the tiled floor. Sanding of

MV Carnival Spirit 2 201212/023

the wooden benches and floor grate were A fire eventually broke out, spreading from the completed at approximately 0915. heating element within the women’s sauna to the wooden cedar bulkheads and deck head of Following the completion of the sanding the sauna. works at approximately 1000, the hotel steward was instructed to clean the ladies’ sauna. Alarm and fire fighting procedures At approximately 1820, the fire detection The hotel steward had not cleaned this area devices inside the women’s sauna activated before; however, instructions were received and alerted the crew members on the bridge of from one of the hotel stewardess. The hotel a fire within the area of the vessel’s Beauty steward was then left alone to clean the Parlour and Spa on deck no. 9. tiled floor and wash the area. Immediately afterwards, the safety officer In order to facilitate the cleaning, he lifted together with the assigned fire crews, made the wooden cedar floor grate from its their way towards the Beauty Parlour and Spa. horizontal position and placed it on the They were immediately met with extensive framework surrounding the heating smoke coming from within the women’s element, thereby gaining access to the sauna. surrounding areas (Figure 3). A visual inspection confirmed that no persons were inside the women’s sauna. Moreover, it was also evident that the fixed dry sprinkler system installed within the sauna had not activated.

Fire crews successfully extinguished the fire with both CO2 and other fire fighting appliances including fire hoses. No injuries were reported and the fire was contained Figure 3: The wooden floor grate as positioned on inside the women’s sauna. the framework surrounding heating element (reconstruction) Reported damage After the fire was extinguished and smoke had At approximately 1430, the assistant cleared up, a visual inspection of the women’s stateroom stewardess made her way sauna was carried out. It was observed that the towards the Beauty Parlour Spa Reception wooden cedar floor grate had been left on the with a passenger. The assistant stateroom top of the heating element and consequently stewardess instructed one of the had suffered extensive fire damage. hairdressers to turn on the heating element within the steam room. The fire had also spread to the wooden cedar deck head and bulkhead panelling, and the Evidence suggested that the heating bench seating (Figures 4 to 6). element was turned on for both the sauna and the steam room. No visual inspection of the women’s sauna was conducted, neither before nor after the heating elements were turned on.

MV Carnival Spirit 3 201212/023

ANALYSIS

Aim The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, and to prevent further marine casualties or incidents from occurring in the future.

Fixed water dry sprinkler system

Figure 4: Fire damage to the wooden cedar foot Water supply reaches the sprinkler head grate in the women’s sauna (Figure 7) through a downward pipe.

Figure 7: Smoke detection and dry sprinkler system Figure 5: Fire damage to the wooden cedar bench head and thermal bulb. and bulkhead panel

The pipe, which is about 20 cm in length, is fitted with a top check valve located outside the sauna space but fitted between the deck head and the wooden panelling (Figure 8).

The system was a dry sprinkler system of the conventional type. First, the smoke detector senses the smoke. Once the smoke is detected, the water flow into the pipe is activated by the opening of the check valve. When the pre- determined temperature is reached, the bulb breaks and water is released under pressure Figure 6: Fire damage to the deck head panelling inside the women’s sauna (Figure 9).

MV Carnival Spirit 4 201212/023

Figure 8: Fire detection and dry sprinkler head

Top Check Valve 20cm Dry Pipe

Dry Sprinkler head and broken thermal bulb

Figure 9: Sprinkler head, dry pipe and check valve

An inspection of the accident site revealed It is therefore concluded that the blocked that the thermal bulb sprinkler head had check valve had remained in the closed burst as designed. However, an position, preventing the water flow from examination of the top check valve seal entering the dry sprinkler pipe and the (Figure 10) and the internal lining of the dry sprinkler head after the thermal breakage of pipe revealed corrosion and oxidation. the bulb had occurred.

MV Carnival Spirit 5 201212/023

Integrity management of equipment and (preventive) maintenance are related. Actually, while integrity management is a process which starts from the design to the discarding of the equipment after its lifespan would have expired, preventive maintenance is one important step within the integrity management process.

Therefore, lack of preventive maintenance (which may also encompass regular testing) has the potential to stall the maintenance regime adopted on board, endanger the ship and persons on board, and necessitate the Figure 10: Check valve in the closed/blocked switch from preventive maintenance to position breakdown maintenance, which is not necessarily an optimal situation on board a ship. An inspection of the dry sprinkler system installed in the men’s sauna and all the Nonetheless, whilst Carnival Cruise Lines did steam rooms (four in total) was carried out. not have a specific preventive maintenance It was found that three dry sprinkler valves procedure for the dry sprinkler system were also blocked and did not operate as installed in the sauna areas, the Company does designed. have a robust preventive maintenance system for the entire conventional sprinkler system.

Equipment reliability and maintenance Evidence suggested that at the time of the accident, there were no specific CONCLUSIONS management procedures pertaining to the saunas’ heating element, wooden cedar 1. The safety investigation revealed that the floor grate and inspection of the saunas fire was caused by the ignition of a prior to bringing them back into service. wooden cedar foot grate when it was However, Carnival Cruise Lines did have in positioned over the heating element/hot place general procedures requiring the stones inside the women’s sauna. Housekeeping Department to inspect and control the cleanliness of all public areas 2. No visual checks were conducted by the after such procedures as occurred in the crew members to ensure that it was safe sauna. to switch on the heating element. 3. There were no specific management The intrinsic safety of a piece of equipment procedures with respect to inspections of may be related to its design and quality of heating elements before the switching on material. However, its safety after it has of the saunas’ heating element, although been installed is mostly attributed to, inter a Company’s general procedure for the alia, maintenance. Therefore, inadequate Housekeeping Department to check all maintenance or inability to predict failures public areas after the completion of which may occur throughout its lifespan, is cleaning and /or maintenance jobs was correlated to lack of reliability. In fact, available. reliability is considered to be a key indicator of maintenance efficiency. 4. The fixed water dry sprinkler system fitted inside the women’s sauna did not

MV Carnival Spirit 6 201212/023

activate during the fire due to a e) annual test of the sprinkler manual blocked top check valve. valves; 5. There were neither periodic tests nor f) five-year inspections for control valves; preventative maintenance measures in and place with respect to the dry sprinkler g) adopting other various preventive system inside the saunas. maintenance requirements of the system as developed and approved by the classification society, the flag State Administration and the manufacturer. SAFETY ACTIONS TAKEN DURING THE COURSE OF THE SAFETY INVESTIGATION1

In light of this accident, Carnival Cruise Lines has made two significant changes to the sprinkler systems on board and specifically as used in the saunas.

The type of sprinkler used in the sauna has been changed to a conventional wet sprinkler system. The sprinkler head is set to open at 141°C. Check valves have now been removed from the sprinkler systems in all saunas and steam rooms. This change has been made across Carnival Cruise Lines’ fleet.

Moreover, all Housekeeping Department personnel, including managers and supervisors have been retrained in the requirements to check and clean affected areas following the completion of maintenance work.

The second change, which has been made across the fleet, is the frequency and type of preventive maintenance required on the sprinkler system. The revised preventive maintenance procedures now require: a) weekly visual inspection of the sprinkler stations; b) monthly test of the sprinkler pump; c) monthly test of the sprinkler stations; d) annual test of the sprinkler automatic valve;

1 Safety actions should not create a presumption of blame and / or liability.

MV Carnival Spirit 7 201212/023

SHIP PARTICULARS Vessel Name: Carnival Spirit Flag: Malta Classification Society: Lloyd’s Register IMO Number: 9188647 Type: Passenger Registered Owner: Carnival Corporation Managers: Carnival Cruise Lines Construction: Steel Length Overall: 292.50 m Registered Length: 260.65 m Gross Tonnage: 85920 Minimum Safe Manning: 21 Authorised Cargo: NA

VOYAGE PARTICULARS Port of Departure: Mystery Island Port of Arrival: Sydney Type of Voyage: International Cargo Information: NA Manning: 942

MARINE OCCURRENCE INFORMATION Date and Time: 30 December 2012 at 1818 Classification of Occurrence: Less Serious Marine Casualty Location of Occurrence: 20° 19.2’S 169° 55.8’E Place on Board Accommodation - Other Injuries / Fatalities: None Damage / Environmental Impact: Fire damage inside the sauna Ship Operation: Normal Service – in passage Voyage Segment: Mid-water External & Internal Environment: The wind was South-Easterly, force 5, and the sea state was moderate. Air temperature was recorded at 26°C and sea temperature was 27°C. Persons on board: 3524

MV Carnival Spirit 8 201212/023