Holland America Line - Nieuw Amsterdam Cruise Ship Fire
Holland America Line - Nieuw Amsterdam Cruise Ship Fire
On May 23, 2000, the Netherlands-registered passenger ship Nieuw Amsterdam, operated by Holland America Line Westours, Inc. (Holland America), was carrying 1,169 passengers and 542 crew members while en route to Glacier National Park as part of a 7-day cruise between Vancouver, British Columbia, and Seward, Alaska. At 0911 hours, when the ship was about 5 miles north of Russell Island, in the Tarr Inlet, an alarm sounded on the bridge's fire detection system console, indicating that a smoke detector in a crew cabin on D deck had activated.
At the time of the fire alarm, senior officers with emergency command and control responsibilities, as listed in Holland America's Safety Management System (SMS), were in various areas of the ship. The master, who had responsibility for the safety of the ship, was on the bridge. The chief officer, who had responsibility for directing firefighting command and control operations, was in his cabin, aft of the pilothouse. The safety officer, who had responsibility for the firefighting drills and training and the command of one of the two fire squads, was doing routine maintenance on D deck. The chief engineer, who had responsibility for ensuring the safe operation of the propulsion, steering, and other engineering systems, was in the engine control room. The second engineer, who was the commander of the second fire squad, as well as the operational backup for the chief engineer, was also in the engine room.
In addition to the master, the on-duty bridge crew included two deck officers, two quartermasters, a lookout, and an Alaska State-licensed pilot. The on-duty third officer stated that when the alarm sounded, he followed company procedures and informed the master of a possible fire on D deck and ordered one of the quartermasters to investigate to ensure that it was not a false alarm. He advised the quartermaster to carry a full-face cartridge respirator (smoke mask), as well as a UHF radio so he could report his findings.
The quartermaster descended to D deck, eight decks below the navigation deck, and proceeded aft about 250 feet to the area where the smoke detector had activated. After passing fire screen door (FSD) D1, he observed smoke overhead and donned his smoke mask. Upon arriving at cabin D98, he saw smoke coming through the ventilation louvers in the lower section of the cabin door. He tried the door, but it was locked. He said that he immediately radioed a report of his observations to the third officer on the bridge, who, in turn, informed the master that smoke was coming from cabin D98.
Based on the third officer's description of the quartermaster's account, the master called the chief officer, who was in his cabin on the navigation deck, and directed him to investigate the fire on D deck. The chief officer later stated that he knew that Holland America's SMS procedures stipulated that, in the event of a fire, he was to command firefighting operations from the bridge. However, at the direction of the master, he went to D deck to investigate the fire.
He was still responsible for performing his regular duties as master, as well as his own emergency command duties, which, in this case, included making announcements to the passengers, identifying and navigating to a safe area to anchor, and handling the external communications with the U.S. Coast Guard (Coast Guard), shoreside emergency response agencies and Holland America's shoreside offices.
As the chief officer was descending from the navigation deck to the area of the fire, he said, he heard the general alarm and smelled smoke on C deck. He did not contact the bridge to confirm whether he should report to his emergency station or to tell the master that smoke had spread beyond D deck. When he reached D deck, he met the quartermaster in the stairwell, standing by FSD D1, which was slightly open. The chief officer grabbed and donned the quartermaster's smoke mask and instructed him to keep the door closed.
The chief officer said that when he entered the main passageway, he observed “a small amount of smoke.” He then walked through the passageway and adjacent corridors, pounding on doors and yelling for people to evacuate. He said that while he walked along the passageway toward cabin D98, he could feel heat radiating from the cabin's inboard bulkhead. He then saw “thick, white smoke” streaming through the louvers of the D98 door and observed that a layer of smoke about 1 meter thick had filled the upper area of the passageway. He stated that he crouched beneath the layer of smoke and continued his sweep of the area, checking to ensure that no crew members were in their cabins. He said that as he approached WD15,5 the WTD at the main vertical zone bulkhead, he found the door partially open and an uncharged fire hose on the deck.
The chief engineer was in the engine control room when the first 0911 hours alarm sounded indicating a smoke detector had activated in D98. When the general alarm sounded at 0919 hours, he checked the operation of the fire pump and mustered engineering personnel. He said that he then left his emergency station to check the area of the activated smoke detector because he had noted on the fire detection system's repeater in the engine room that the detector was not far from the engine room. Once on D deck, he saw the chief officer near the partially open WD15. The chief engineer said that the chief officer told him to stand by a fire hydrant valve. The chief officer then picked up the uncharged hose and, crouching under the thickening layer of smoke, proceeded forward toward cabin D98. Neither of the men had fire protection gear, such as a self-contained breathing apparatus (SCBA), fire suit, gloves, or helmets. The only gear that the chief officer wore was the smoke mask that he had taken from the quartermaster.
After positioning himself near the closed door of D98, the chief officer shouted at the chief engineer to pressurize the hose line. The chief officer said that, while he stood in front of cabin D98, he could feel intense heat radiating from it, an indication that the fire was now fully developed. He partially opened the cabin door and could hear the fire, but could not see any flames. He bent down low to the deck and sprayed a straight stream of water into the cabin for about 30-40 seconds. He said that intense heat, white smoke, and steam came rushing out of the cabin door, forcing him back, whereupon he dropped the charged hose and retreated to WD15. He and the chief engineer then exited the area, closing the WTD behind them. Although the chief officer could not remember whether he had closed the door to cabin D98, subsequent events showed that he had not.
When the general alarm sounded, the ship's firefighting assets mobilized, which involved donning full fire protection gear at their assigned muster area. Holland America's emergency procedures for the Nieuw Amsterdam establish two onboard firefighting organizations, Alpha squad and Bravo squad.
Each squad was to be composed of two attack teams. The Alpha squad was responsible for vessel spaces outside engineering, which included the crew accommodations areas, and the Bravo squad was responsible for the engineering spaces.
The bridge ordered the Alpha squad to position itself forward of WD16 in preparation for the assault on the fire. Only one of the two Alpha attack teams proceeded to the area of the fire. This unit, the Alpha 1 attack team, had three, rather than four, members and consisted of the fourth officer and two crewmen on the hose line. While the Alpha 1 attack unit proceeded to D deck, it was joined by the Alpha squad commander and assistant commander. On C deck, the group encountered smoke and donned SCBAs before continuing. Once the group members reached D deck, they rigged a hose line. The Alpha squad assistant commander then returned to C deck to turn off the electrical power to WD15 and WD16 so that the fire teams could open them. The Alpha squad commander and assistant commander both had UHF radios with which they could communicate with the bridge and with the Bravo squad.
In the meantime, the master ordered the Bravo squad to position an attack unit at WD15 and to backup the Alpha 1 team. The Bravo squad commander (the second engineer) chose to have the Bravo 1 attack team consist of himself, the assistant squad commander (the third engineer), and a day engineer. The third engineer had a UHF radio with which to communicate with the master and with the Alpha squad. The Bravo 1 attack team rigged a fire hose to extend from the boiler room toward WD15. While the team members were proceeding down from C deck, they met the chief officer and the chief engineer. The chief officer told the second engineer where the fire was and that a charged hose line was unrolled on the deck, forward of WD15.
The chief engineer returned to his emergency station in the engine control room and the chief officer returned to the bridge to assume the command of the firefighting efforts from the master. The chief officer said that while he was en route to the navigation deck, he observed smoke on both C and B decks.
About 0929 hours, the Alpha 1 attack team and the Bravo 1 attack team both radioed the master that they were in position, forward of WD16 and aft of WD15, respectively. The master ordered the Alpha 1 team to attack the fire. The Alpha squad commander said that he opened WD16 and a lot of black smoke rushed out, reducing visibility to almost zero. The hose team advanced through FSD D1 into the passageway, giving shorts blasts of water to the overhead and bulkhead panels. The team leader (the fourth officer) followed the hose team. The squad commander indicated that because the team leader was new to the ship, he followed her to monitor her actions. When the attack team members were a few feet into the passageway, the team leader collapsed, and the squad commander picked her up and carried her back through WD16. The rest of the Alpha team followed, and they closed WD16 behind them. The squad commander then directed the squad assistant commander to take command of the hose team and stand by while he took the team leader to B deck. When the team leader appeared to be all right, the Alpha squad commander later returned to D deck.
At 0930 hours, upon overhearing radio communications between the Alpha squad and the bridge, the Bravo 1 attack team radioed the bridge that it was entering the area through WD15. The second engineer said that he took the fire hose nozzle and led the attack. He had the day engineer serve as backup on the hose and the third engineer follow with a flashlight and a UHF radio.
The Bravo 1 attack team members entered the passageway on their knees. The second engineer said that the main passageway was filled with thick black smoke but had a light draft of air moving through it. He said that when he sprayed the overhead, he saw burned paint hanging down but no flames. He did not see any flames in the passageway; however, he heard a noise in the area of the overhead, which he thought was the bubbling sound of paint burning.
As the Bravo 1 attack team approached cabin D98, the second engineer realized that the fire had progressed outside the cabin of origin. He said that he felt an increase in temperature and could see flames on the deck in the main passageway and in a portside corridor. He found the door to D98 open and saw flames inside the cabin. He said that, while approaching cabin D98, he was spraying water in the main and other passageways when he discovered that the hose line from the boiler room would reach no farther. He retrieved the charged hose line that the chief officer had abandoned and resumed spraying the decks and overheads. He then attacked the fire inside cabin D98. He said that after he sprayed water into the cabin for several minutes, the flames were no longer visible.
While the Bravo 1 attack team was fighting the cabin fire, the Bravo 2 attack team,carrying a second hose line from the boiler room, arrived at WD15 and began working its way forward toward FSD D1, spraying water on the fires in the passageways. A member of the Bravo 2 team relieved the day engineer, who then returned to the engine room to start the ventilation fans. When the low-pressure alarm sounded on the second engineer's air bottle, the third engineer relieved him. The hose teams continued spraying water until all flames were extinguished on D deck. Shortly before 1000 hours, all ventilation was restored to evacuate the smoke and improve visibility, and the Alpha squad commander reported to the bridge that the fire was under control. The teams continued with overhaul operations and stood by for re-flash until about 1022 hours, when the fire was declared out.
On the bridge, about the time when the quartermaster made his first report, the fire control panel began indicating that multiple smoke alarms had activated. Between 0911 hours, when the first smoke detector activated, and 0919 hours, when the master ordered the general alarm sounded, 15 smoke detectors activated on D deck. Of these, two detectors were in the crew staircase by FSD D1.
Upon receiving the report of a fire from the officer on D deck, the master made the following announcements7 to the passengers and the crew, at 0920 hours and 0921 hours, respectively: Ladies and gentlemen, may I have your attention. This is your captain with an important announcement for all guests and crew. We just received a fire alarm on the D deck. We just received a fire alarm on D deck. Our fire squads are currently checking out the situation. Please cooperate closely with the officers and crew in following their instructions. There is no cause for alarm. We will keep you closely informed.
This is an announcement for crew. There has been a fire reported on the D deck aft; please evacuate the D deck; please evacuate the D deck. Fire squads report to your fire stations, medical teams report to the infirmary, lowering squads report to the bridge wings, passenger-assist team report to housekeeping office, traffic directors report to dining room forward.
At 0928 hours, a smoke detector activated in a crew stairwell on B deck. Shortly after 0930, the master began receiving reports from crew members that smoke was spreading upward to decks C, B, and A. He conferred briefly with the Alaska State pilot on an appropriate location to anchor the vessel in the event that the fire adversely affected propulsion or steering. During this discussion, the pilot offered to call the Coast Guard while en route to the anchorage, and the master accepted his offer. The pilot, however, had problems contacting the Coast Guard because high mountains in the area interfered with the VHF radio transmissions. A staff officer offered to help the pilot and attempted to send a message via the ship's satellite communication system; however, the staff officer was not familiar with the equipment because operating it was not one of his duties. He inadvertently sent a message with a distress priority without the master's knowledge or approval. Another Holland America vessel in the area received the message and radioed both the company's shoreside office and the Coast Guard with news of the fire. At 1015 hours, the Coast Guard radioed the Nieuw Amsterdam to determine the status of the fire.
According to shipboard personnel, when the general alarm sounded at 0919, most passengers were either on the promenade deck (deck No. 7) or the sun deck (deck No. 10), where they were observing the glaciers and listening to a commentary being given by a ranger from the National Park Service. Some passengers were in their cabins, and “a small number of passengers” were eating breakfast in the restaurant on the lido deck.
Shipboard personnel said that, at the sounding of the general alarm, most passengers listening to the commentary on the upper decks proceeded to their muster stations, as directed in the practice drill held when the ship departed Vancouver. Also, most passengers who were in their cabins retrieved their lifejackets and proceeded directly to their stations. Some passengers returned to their cabins to retrieve their lifejackets. One couple in the lido deck restaurant first finished their breakfast and then went to their cabin, which was on B deck, to retrieve their lifejackets, medicine, and valuables. They said that they also wanted to obtain warm clothing for the outside air. The couple said that when they reached B deck, they observed the passageway was “a little smoky.” They estimated that they stayed in their cabin about 6-7 minutes.
Meanwhile, at the muster stations, crew members took roll of the assembled passengers, as required by Holland America's SMS, and informed the master that passengers from a cabin on B deck and a cabin on main deck could not be accounted for. The master then ordered evacuation teams with SCBAs to check the two cabins and decks for the missing people.
About this time, the two passengers who had returned to their cabin on B deck exited their room and encountered thick smoke that severely reduced visibility. The woman put her jacket over her face and moved aft along the passageway. She said that her husband told her to get down near the deck. He followed her and shouted for help. She said that as she neared a doorway and stairs, a crew member grabbed her and led her to the crew mess hall and then to the promenade deck. She then advised the crew members that her husband was still on B deck.
According to the husband, when he crouched to move along the deck, he became disoriented. He thought that he might have passed some exit doors (FSDs that were closed) and that he might have blacked out at one point. He said that a crew member grabbed him and helped him up the stairs first to the crew mess hall and then to the promenade deck to rejoin his wife. A shipboard medical team examined the couple to determine the scope of their injuries. They were later evacuated by medical helicopter to a hospital in Juneau, where the husband was admitted for treatment of injuries.
About 1100 hours, after the fire had been declared out, the passengers were moved inside to the lounges and public spaces, which had been ventilated and cleared of smoke. About an hour later, after all cabins on the lower decks had been checked, the passengers were allowed to return to their rooms. The Nieuw Amsterdam weighed anchor and continued with the cruise. However, when the bridge requested medical evacuation for the injured couple who had been stranded on B deck, the Coast Guard asked the Nieuw Amsterdam to proceed south. The ship subsequently received a Coast Guard Captain of the Port (COTP) order to anchor in Bartlett Cove for a Coast Guard inspection. After officials from the Alaska State Fire Marshal's Office and the Coast Guard inspected the ship, Marine Safety Office-Juneau issued a COTP order granting permission for the ship to resume its voyage.
On May 25, when the Nieuw Amsterdam arrived in Seward, investigators from the Safety Board and the U.S. Treasury Department's Bureau of Alcohol, Tobacco, and Firearms (ATF) boarded the vessel. Investigators interviewed the four crew members who had occupied cabin D98. One crew member stated that he had returned to his cabin to have a cup of tea and had plugged in a coffee maker to heat the water when he was called back to work. He said that he had switched off the coffee maker but had not unplugged it. He recalled that all other electrical appliances were turned off.
The ATF conducted a systematic examination of cabin D98 to determine the origin and cause of the fire. Investigators observed burn patterns on the cabin bulkheads and furnishings, indicating that the greatest heat and flame damage came from a point near a small round table in the middle of the room, near the starboard bulkhead. In examining the debris in this area, investigators found the remains of a coffeemaker and a hot water kettle (electric). The ATF's examination of the coffeemaker showed damage indicative of heating and melting from the exterior to the interior of the appliance. The coffeemaker's internal heating element and associated electrical components were undamaged. The remnants of the hot water kettle heating element showed metal distortion indicative of internal heat damage that extended from the inside to the outside of the appliance. Investigators eliminated other possible sources of ignition, including any other electrical source and smoking materials, in this cabin area and concluded that the hot water kettle was the source of the fire.
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