The fire aboard the Carnival Splendor that burned on and off for more than seven hours in late 2010, cutting off power to the 3,006-passenger vessel as it sailed in the Pacific, likely could have been put out right away if a water mist fire protection system had activated immediately, authorities said.
But the "Hi-Fog" system was on a 40-second delay, and a bridge watch stander reset the fire detection systems, which caused the smoke detectors that had sounded to return to normal. According to a report released Monday by the U.S. Coast Guard, the detectors were inoperable within minutes because of the fire, making it impossible to trigger the mist automatically.
"This was a critical error which allowed the fire to spread to the overhead cables and eventually caused the loss of power," the Coast Guard report said. The mist system in the immediate vicinity of the fire was finally activated after 15 minutes.
The 51-page document also faulted crew members for immediately failing to manually activate the water mist system; firefighting teams' lack of familiarity with the engine room, which made the initial fire more difficult to find and extinguish; the use of portable dry chemicals and carbon dioxide extinguishers rather than fire hoses; the captain's decision to ventilate the engine room before the fire was fully out and carbon dioxide fire suppression systems that did not work.
"While the fire was eventually self-extinguished, the failure of the installed CO2 system and the poor execution of the firefighting plan contributed to the ineffectiveness of the crew's firefighting effort," the report said.
The report also flagged the poor condition of the air cooler -- a part that had been replaced in July of 2010 -- in the No. 5 diesel generator, which the agency said contributed to the engine failure that caused the fire.
In late December 2010, more than a month after the fire, the agency released two safety alerts detailing problems with the carbon dioxide systems. The Coast Guard said Carnival has "implemented short- and long-term solutions to rectify the problems associated with the activation of the CO2 system."
Monday's report included five recommendations, some of which Carnival has already addressed:
--Carnival should remove the 40-second time delay in activating water mist systems -- which the cruise operator has done.
--Carnival should address conditions with air cooler systems for all diesel generators as well as other features of the generators; lack of crew familiarity with procedures for fires and engine room layout; problems with CO2 systems and susceptibility of certain ships to a loss of power if a single area of electrical systems are damaged.
--Lloyd's Register, an independent inspection agency, should inspect carbon dioxide systems on all Dream class vessels.
--The Coast Guard commandant should enhance guidelines for evaluation of fire drills.
--The Coast Guard commandant should recommend better guidance for fire drills to the International Maritime Organization.
In a statement, Carnival said it had cooperated fully during the Coast Guard's inspection and already made several improvements to practices based on its own investigation.
"We agree with the U.S. Coast Guard's conclusions surrounding fire detection and firefighting processes and took numerous actions throughout our fleet as a result, including the creation of a Fire Safety Task Force," the statement said. "Those efforts resulted in the implementation and enhancements of a number of processes, training and equipment, as well as the formation of a new Marine Safety department. These actions directly contributed to the rapid detection and suppression of the fire on Carnival Triumph in February of 2013."
Like the Splendor, the Carnival Triumph lost power due to the fire and had to be towed to land -- though the Triumph took longer to reach dry ground and drew even more media attention.
After that fire, Carnival announced $300 million in upgrades to fire safety and emergency power systems on all of its 24 ships.
While not addressing specific findings, Carnival said the company looks forward to "the opportunity to review the U.S. Coast Guard report in detail to fully examine the findings and recommendations."