b'6.IftheM/VSpiritofNorfolkhadtingencyplanningformaritimethatexistingexempted Require been equipped with an engine room firefighting.SubchapterKsmallpassenger fixed gas fire extinguishing system,vessels that were in operation as of includingventilationclosures,theTheNTSBdeterminedthattheMarch10,1996,befittedwitha fire could have been extinguished.probable cause of the fire on the M/Vfixed gas fire extinguishing system Spirit of Norfolk was likely the igni- in their engine rooms. (M-23-04) 7.Theexemptionforengineroomtionofcombustiblematerialstored fixed gas fire extinguishing systemsnear the exhaust piping from the op- thecircumstancesofthis Use on small passenger vessels that wereerating port generator. ContributingcasualtyandtheNationalTrans-in operation as of March 10, 1996,to the severity of the fire was a lack ofportationSafetyBoardsreport presents an increased risk of harma fire detection system and a fixed firefindingsandrecommendationsto from an engine room fire to passen- extinguishingsystemintheengineimprove contingency plans related gers and crewmembers.room. Also contributing to the sever- to fighting fires on passenger vessels. ity were ineffective communications(M-23-05)8.Theactionsofthecrewmembersbetweentheunifiedcommandand and good Samaritan vessels resultedfirefighting teams that led to the fireWhile the first two recommendations in a timely and effective evacuationattack team opening the engine roomareself-explanatoryandexpected, with no injuries.door, allowing the fire to spread. PVA is pleased to see that the NTSB recognized the mistakes made by the 9.When the fire attack team was un- shore-based firefighters and the com-able to close the engine room door,PVA is pleased tomunicationsfailuresoftheincident it allowed the fire to spread.command in contributing to the total see that the NTSBconstructive loss of the vessel.10. The communications between therecognized the firefighting teams and the unifiedBased on fire safety presentations at command(UC)wereineffectivemistakes made bythree region meetings, PVA members because the firefighting teams didthe shore-basedwelcometheopportunityand,in not communicate to the UC thatsome cases, have already engaged to they did not find the engine roomfirefighters and theworkwithlocalCoastGuardunits emergency hatch, and the UC didcommunicationsand shore-based fire departments in not monitor the teams efforts tofailures of the developing effective firefighting con-locate the hatch. tingency plans for their vessels. Rec-incident command. ommendationscontainedinCoast 11.Had the members of the unifiedGuardSafetyAlert07-23,Critical commandandfirefightingper- Insight from Ongoing Investigations sonnelagreedtopost-casualtyIntoSmallPassengerVesselFires, interviews,theNationalTrans- RECOMMENDATIONS TOissued in response to several ongoing portationSafetyBoardwouldTHE COAST GUARD fireinvestigationshavebeensocial-have received critical informationAsaresultoftheinvestigation,theizedwithPVAvesselmembersand abouttheresponsethatlikelyNTSBmadethefollowingrecom- appropriate actions have been taken would have helped to better un- mendations to the U.S. Coast Guard: where needed.derstand the event sequence and identify additional improvementsRequirethatexistingexemptedUnderthePVA/CostGuardQuali- to pierside vessel firefighting strat- SubchapterKsmallpassengertyPartnershipafiresafetyworking egies and tactics.vessels that were in operation as ofgroup will be chartered to look at fire March10,1996,befittedwithasafety within the domestic passenger 12.Lessons learned from this casualtyfire detection system in their enginevessel industry and identify best prac-couldbeusedtoimprovecon- rooms. (M-23-03)tices and areas of improvement. 31 OCTOBER 2023'