/

PB96-916401NTSB/MAR-96/01

NATIONALTRANSPORTATIONSAFETYBOARDWASHINGTON, D.C. 20594

MARINE ACCIDENT REPORT

FIRE ON BOARD THE U.S. FISH PROCESSING VESSELALASKA SPIRIT, SEWARD, ALASKA, MAY 27, 1995

6594A

Abstract: About 0200 on May 27, 1995, the U.S. fish processing vessel ALASKA SPIRITcaught fire and burned while moored alongside a dock at the Seward Marine Industrial Center,Seward, Alaska. Firefighters extinguished the fire at 1100. The master of the vessel died, anddamage to the vessel was estimated at $3 million.

The safety issues addressed in the following report are: adequacy of noncombustibleconstruction standards for uninspected commercial fishing industry vessels; adequacy of firedetection and fire suppression equipment; drills and readiness of on-board firefighting hoses; andexisting vessel fire safety standards.

As a result of its investigation, the National Transportation Safety Board made safetyrecommendations to the U.S. Coast Guard, The Fishing Company of Alaska, Incorporated, theCommercial Fishing Industry Vessel Safety Advisory Committee, and the National FireProtection Association.

The National Transportation Safety Board is an independent Federal agency dedicated topromoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.Established in 1967, the agency is mandated by Congress through the Independent Safety BoardAct of 1974 to investigate transportation accidents, determine the probable causes of theaccidents, issue safety recommendations, study transportation safety issues, and evaluate thesafety effectiveness of government agencies involved in transportation. The Safety Board makespublic its actions and decisions through accident reports, safety studies, special investigationreports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety BoardPublic Inquiries Section, RE-51490 L’Enfant Plaza East, S.W.Washington, D.C. 20594(202) 382-6735

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(703) 487-4600

FIRE ON BOARD THE U.S. FISH PROCESSINGVESSEL ALASKA SPIRIT, SEWARD, ALASKA,

MAY 27, 1995

MARINE ACCIDENT REPORT

Adopted: June 11, 1996Notation 6594A

NationalTransportationSafety Board

Washington, DC 20594

iii

CONTENTS

ACRONYMS .................................................................................................................... vi

EXECUTIVE SUMMARY .............................................................................................vii

INVESTIGATION ............................................................................................................ 1

Accident .............................................................................................................................. 1Fire .......................................................................................................................... 5Emergency Response and Fire Extinguishing....................................................... 11

Injuries............................................................................................................................... 14Vessel Damage..................................................................................................................14Crew Information .............................................................................................................. 15

Staffing.................................................................................................................. 15Master.................................................................................................................... 15Chief Engineer....................................................................................................... 15Assistant Engineer................................................................................................. 15Cook ...................................................................................................................... 15Processor-deckhands ............................................................................................. 16Watchman.............................................................................................................. 16

Vessel Information ............................................................................................................ 16Firefighting Equipment ......................................................................................... 17Survival Equipment............................................................................................... 17The FCA................................................................................................................ 18

Waterway Information....................................................................................................... 18Meteorological Information .............................................................................................. 18Postaccident Vessel Examination...................................................................................... 19

Hull Structure and Construction............................................................................ 19Wreckage............................................................................................................... 20

Medical, Pathological, and Toxicological Information..................................................... 24Drills.................................................................................................................................. 25Tests and Research ............................................................................................................ 26

Possible Ignition Sources ...................................................................................... 26Battery Charger Examination.................................................................... 26Cook Pot Examination .............................................................................. 26

Heat Detector Testing............................................................................................ 27Other Information..............................................................................................................28

Coast Guard Regulations....................................................................................... 28Standards Applicable to Industrial Vessels ........................................................... 30Building Codes...................................................................................................... 31

iv

Life Safety Code.................................................................................................... 31U.S. Fishing Fleet.................................................................................................. 32Accident Statistics ................................................................................................. 33Coast Guard Oversight of Fish Processing Vessels .............................................. 33

Survival Factors................................................................................................................. 34Fire Control Efforts ............................................................................................... 34Notification Procedures......................................................................................... 34

Local Contingency Planning ............................................................................................. 34City of Seward....................................................................................................... 34Western Alaska Marine Firefighting Contingency Plan........................................ 35

ANALYSIS ....................................................................................................................... 38

General .............................................................................................................................. 38Source of Ignition.............................................................................................................. 38Fire Safety Standards......................................................................................................... 41

Construction .......................................................................................................... 41Fire Detection Equipment ..................................................................................... 43Fire Suppression Equipment ................................................................................. 44Existing Standards................................................................................................. 45Fire Hose ............................................................................................................... 46

Survival Factors................................................................................................................. 47Reporting of Fire ................................................................................................... 47Drills...................................................................................................................... 47

Significance of the ALASKA SPIRIT Investigation......................................................... 48Toxicological Test Results ................................................................................................ 48

Carboxyhemoglobin (COHb) ................................................................................ 49Alcohol .................................................................................................................. 49

CONCLUSIONS ............................................................................................................. 50

PROBABLE CAUSE ...................................................................................................... 51

RECOMMENDATIONS ................................................................................................ 51

v

APPENDIXES

Appendix A -- Safety Board Investigation........................................................................ 55Appendix B -- Crew Licensing Information .................................................................... 57Appendix C -- Battery Charger Examination.................................................................... 59Appendix D -- Global Fire and Safety, Inc., Heat Detector Test Report ......................... 61Appendix E -- Building Codes .......................................................................................... 69Appendix F -- Conditions Reported by the SVFD Fire Chief that Affected ALASKA

SPIRIT Firefighting................................................................................... 71Appendix G -- Toxic Effects of Carboxyhemoglobin Saturation ..................................... 73Appendix H -- Master’s Blood Alcohol Level .................................................................. 75

FIGURES AND TABLES

Figure 1 -----Port side view of the ALASKA SPIRIT while moored at Seward, Alaska... 2Figure 2 -----Accident site .................................................................................................. 3Figure 3 -----Plan of the ALASKA SPIRIT........................................................................ 6Figure 4 -----Plan of the ALASKA SPIRIT (continued) .................................................... 7Figure 5 -----Enlarged plan view of the 02 deck................................................................. 8Figure 6 -----View of the deckhouse from the trawl deck .................................................. 9Figure 7 -----Forward bulkhead of 02 deck ...................................................................... 19Figure 8 -----The ALASKA SPIRIT’s fire-damaged wheelhouse.................................... 21Figure 9 -----02 deck fire damage..................................................................................... 21Figure 10----Chase in wheelhouse.................................................................................... 22Figure 11----Fire pattern around cook pot........................................................................ 23Table 1 ------Comparison of various fire safety regulations............................................. 36

vi

ABS --------------American Bureau of Shipping

ASTM ------------American Society for Testing Materials

BAC -------------- blood alcohol concentration

BOCA ------------ Building Officials and Code Administrators International

CFR -------------- Code of Federal Regulations

CHT -------------- Center for Human Toxicology

CO ---------------- carbon monoxide

COHb ------------ carboxyhemoglobin

COTP ------------ Coast Guard Captain of the Port

DNV -------------- Det Norske Veritas

EPIRB ----------- Emergency Position Indicating Radio Beacon

FCA -------------- Fishing Company of Alaska, Inc.

ICBO ------------- International Conference of Building Officials

LSC -------------- Life Safety Code

NBC -------------- National Building Code

NFPA ------------ National Fire Prevention Association

NVIC ------------- Navigation and Vessel Inspection Circular

RPU -------------- rigid polyurethane

SBC -------------- Standard Building Code

SBCCI ----------- Southern Building Code Congress International, Inc.

SCBA------------- self-contained breathing apparatus

SECC ------------ Seward Emergency Communications Center

SMIC ------------ Seward Marine Industrial Center

SVFD ------------ Seward Volunteer Fire Department

UBC -------------- Uniform Building Code

USC -------------- United States Code

USCG ------------ United States Coast Guard

USSG ------------ United States Standard Gauge

ACRONYMS

vii

EXECUTIVE SUMMARY

About 0200 on May 27, 1995, the U.S. fish processing vessel ALASKA SPIRITcaught fire and burned while moored alongside a dock at the Seward Marine IndustrialCenter, Seward, Alaska. Firefighters extinguished the fire at 1100. The master of thevessel died, and damage to the vessel was estimated at $3 million.

The National Transportation Safety Board determined that the probable cause ofthe fire aboard the ALASKA SPIRIT was the failure of The Fishing Company of Alaska,Incorporated, to address the inadequate fire safety conditions and practices on the vessel.Contributing to the severity of the damage and the loss of life was the lack of fire safetystandards for commercial fishing industry vessels.

The safety issues discussed in this report are:

• Adequacy of noncombustible construction standards for uninspectedcommercial fishing industry vessels.

• Adequacy of fire detection and fire suppression equipment.

• Drills and readiness of on-board firefighting hoses.

• Existing vessel fire safety standards.

As a result of this accident, the National Transportation Safety Board makessafety recommendations to the U.S. Coast Guard, The Fishing Company of Alaska,Incorporated, the Commercial Fishing Industry Vessel Safety Advisory Committee, andthe National Fire Protection Association.

Accident

Following a fishing voyage, the U.S.fish processing vessel1 ALASKASPIRIT (see figure 1) arrived in DutchHarbor, Unalaska Island, Alaska, onMay 19, 1995. Prior to the vessel’sdeparture, 35 crewmembers and a U.S.National Marine Fishery Serviceobserver debarked, reducing the vesselcomplement (including the master) to 11persons. According to the engineroomlog, the vessel departed from DutchHarbor about 11002 on May 21. Itarrived at the Seward Marine IndustrialCenter (SMIC) docks (also known as theFourth of July docks), located north ofthe Fourth of July Creek and acrossResurrection Bay from downtownSeward (see figure 2), at 1130 on May24. At Seward, 3 crewmembersdebarked, reducing the crew to 8persons: the master, chief engineer,

1A fish processing vessel is defined under

Title 46 United States Code (USC) 2101 (11b) as“a vessel that commercially prepares fish or fishproducts other than by gutting, decapitating,gilling, skinning, shucking, icing, freezing, orbrine chilling.” Processing activities can includemincing, filleting, preparation of fish meal,boiling (crab), or a combination of these whichprepares the seafood for direct marketing andoften includes packaging the product. This typeof fish processing vessel also catches fish with atrawl net and is also known as a “ factory-trawler.” The term “ factory” refers to the fishprocessing operation, while “ trawler” refers tothe method of fishing it uses. A trawler catchesfish in a net (which can be compared to a funnel)towed astern.

2Al l times noted herein are given in Alaskadaylight time.

assistant engineer, cook, and 4processor-deckhands (deckhands).

The remaining crew stayed on boardto repair, maintain, and prepare thevessel for the next fishing voyage, whichwas scheduled for about July 1. No deckor engineering watches were stoodduring this period, but work in variousparts of the vessel was carried out duringthe day. Some engineroom equipmentremained operating to provide vesselhotel services.

A company-hired night watchman(watchman) testified that he maderounds about every hour from 1900 to0700 to check on the safety and securityof the ALASKA SPIRIT and theALASKA RANGER.3 The watchmansaid he would meet with the ships’master or mate and chief engineer orassistant engineer each evening. Theseofficers would advise the watchmanabout specific items to check on thatnight and tell him who he should notifyif he found something out of theordinary. He would routinely adjustmooring lines as necessary, checkoperating engines, and look forindications of flooding and any otherfactors that could adversely affect thevessels’ safety.

3The ALASKA RANGER was a trawler-fish

processing vessel operated by The FishingCompany of Alaska, Inc., that was moored at anadjacent dock, preparing for its next fishingvoyage.

INVESTIGATION

2

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0

1 4 * S W 149-20w

Figure 2 — Accident site

3

4

After completing his security checkon the ALASKA RANGER, thewatchman would board the ALASKASPIRIT to conduct a similar securitycheck of that vessel. A complete securitycheck would include a walk through theengineroom, factory deck, accessibleaccommodation spaces, and thewheelhouse. He would also checkmooring lines and the gangway. Eachround on a vessel took about 10-15minutes. The watchman reported that,after completing rounds on both vessels,he would station himself in thewheelhouse of the ALASKA RANGER.From there, he would observe thegangways of both vessels and stopunauthorized persons from boarding.

According to the ALASKA SPIRIT’scook, on May 26 he first spoke with thevessel’s master about 0800, when themaster came to the galley for coffee. Thecook next saw the master when he wentto the wheelhouse around 1100 or 1130to chat. At that time, however, themaster was on the telephone to his wife,so the cook returned below. The cooksaid that he went back upstairs about1210 to take the master his lunch. Thecook testified that the master went totown after lunch and returned about1500. The cook’s last conversation withthe master took place in the galleysometime between 1700 and 1730. Thecook told the master that he would liketo go to Anchorage that evening, towhich the master replied, “Okay, James.See you later.” The cook left the vesselabout 1810.

The chief engineer had severalconversations with the master on the day

before the accident. He stated that hespoke with the master about 1000, whenhe went to the wheelhouse to borrow atool, and again at 1100 when he returnedthe tool to the master. After completingwork sometime after 1900, the chiefengineer and the master met on thebridge deck, where they talked aboutsport fishing. The chief engineer last sawthe master about 2000, when he went tothe master’s room to borrow avideocassette. According to the chiefengineer, the master said that heintended either to read a book or watch amovie before going to bed.

The chief engineer said that afterleaving the master he watched a movie,played an electronic game, and went intothe engineroom about midnight to checkthe engineroom and operatingequipment. He found nothing out of theordinary. He checked the power board(switchboard) and found no indication ofany electrical short circuits. He thenwent to the galley for a snack, picked upan audiocassette from the factory deck,and returned to his room. He listened tosome music, played some moreelectronic games, and went to sleep.

The assistant engineer testified that,after finishing his day’s work about1700, he went to bed and read in hisroom—located forward of the galley inthe athwartships (cross) corridor. Aboutmidnight, he went to the engine controlroom and looked through some manuals.About 0130-0145, he went to his roomand read. At no time during this entireperiod did he see, hear, or smell anythingout of the ordinary.

5

About 2130 on May 26, the fourdeckhands were in the port-forwardcrewroom on the 02 deck (see figures 3,4, and 5) discussing their off-duty plansfor the evening. Three of the fourdeckhands decided to go into town. Theydeparted the vessel about 2200. Theremaining deckhand left the crewroom,stopped briefly in the galley, and went tohis room (a four-person room on theforward starboard side of the 01 deck) tosleep. About 0100 on May 27, one of thethree deckhands who had gone intoSeward returned to the vessel and signedin on a chalkboard in the galley. Heretired to his room on the 01 deck portside aft (at the foot of the inside stairwellto the 02 deck) and apparently went tosleep.

Fire -- Shortly before 0200, aftercompleting his round on the ALASKARANGER, the watchman walked to theALASKA SPIRIT, about 500 feet away.When asked by investigators about hisprevious round that evening on theALASKA SPIRIT, he stated that

It just seemed like there wasnothing unusual or anything tomake me cause any attention. Itjust seemed like everything wasOK that night.

He also testified that he did not noticeanything unusual as he made his way tothe ALASKA SPIRIT and commencedhis round in the engineroom. Afterchecking the engineroom wearing earprotection, he went up to the starboardside of the factory deck and took his earplugs out. At this time, he heard the firealarm. He went up to the net retrievalarea (trawl deck) and walked toward thechief engineer’s room on the port side afton the 01 deck accommodation area. He

saw the door to the chief engineer’sroom ajar, indicating to him that thechief engineer was awake. Thewatchman then went out to the trawldeck and saw the cook.

The cook testified that he returned bycar from Anchorage at 02044 on May 27and parked near the ALASKA SPIRIT’sgangway. He was walking towards theALASKA SPIRIT’s gangway when henoticed flames and smoke on the 02 deckaft port door and in the wheelhouse (seefigure 1). As the cook headed toward the01 deck, he met the watchman, who hadjust exited the engineroom stairwell onthe trawl deck. He climbed the outsidestairwell from the 01 deck and lookedinto the 02 deck aft doors (see figure 6).

The cook saw flames on the port sidecorridor in the overhead, and heavysmoke about a third of the way downfrom the overhead. He saw flames in thetoilet to the left and inside the port door.The flames extended along the overheadof the port corridor down to the toilet tothe right of the door. The stairwell to thewheelhouse was filled with thick smoke.On the starboard side corridor, henoticed a little smoke along the overheadbut no fire.

The watchman left the vessel and ranto the ALASKA RANGER, where hetelephoned the Seward EmergencyCommunications Center (SECC) tonotify them of the fire. The call waslogged in about 0213.

4The cook noted the time from a clock in his

car. A Seward fire investigator later checked theclock and verified that it was accurate to within30 seconds of the dispatch clock.

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Figure 5 — Enlarged plan view of the 02 deck

Figure 6 — View of the deckhouse from the trawl deck, looking forward(courtesy NFPA, Quincy, Massachusetts)

9

10

The watchman only asked if SECCknew about the fire. After receiving anaffirmative reply, the watchman hungup. He provided no further information,nor did the SECC operator request thathe provide any or identify himself.While on the ALASKA RANGER, thewatchman woke the vessel’s twoengineers, who returned with him to theALASKA SPIRIT to assist in thefirefighting activities.

The chief engineer testified that thefire alarm woke him. He dressed and lefthis room. He saw the assistant engineerand a deckhand in the corridor outsidehis room on the port side aft on the 01deck. (The assistant engineer testifiedthat he had been reading in his roomwhen he heard the alarm at 0200 and gotup to investigate.) The chief engineerattempted to go up the inside stairwellon the port side to the 02 deck where henoticed “smoke, fumes, and felt the heat,and saw the glow through the smoke offire.” He retreated and told the assistantengineer that “we were in trouble, wewere on fire.” The assistant went to theengineroom and started the fire pump.

The deckhand who had not visitedSeward that evening said he was asleepin the four-person room forward on thestarboard side of the 01 deck when thevessel’s fire alarm woke him. Hedressed, went into the corridor, andfollowed the assistant engineer aft on the01 deck. On the way, he checked thedoor to the five-person room on the portside by the stairwell to the 02 deck andfound it locked. He smelled smoke andremarked to the assistant engineer thatthe door of the room was locked, and hethought a deckhand was inside. The

assistant engineer kicked the door open,removed the sleeping deckhandandcarried him to the trawl deck.

The deckhand who had beenawakened by the alarm attempted to goup the inside stairwell to the 02 deck. Hesaid that he “wanted to have a look”because he thought that the other twodeckhands might be sleeping in theirroom on the port side forward. He wentup far enough to peer through thedoorway on the 02 deck. From there hesaw something burning on the deck tothe left of the doorway. He testified that“ I said burning floor, but now that Ithink about it, it was probably boots,‘cause I’d seen them in the hallway.” Healso saw a single row of flames in theoverhead of the 02 deck corridor.

He stated that “…there was blackstuff dripping5 out of the ceiling(overhead in the stairwell)” and “therewas a lot of heat.” The smoke was notthick or heavy. He further stated that“soon as I saw flames on top (overhead),I forgot about going up there (onto the02 deck).” He retreated down thestairwell and exited aft on the port sideof the 01 deck. He assisted the cook inputting water on the fire until theshoreside firefighters arrived. He thenassisted them as requested.

The chief engineer attempted tosurvey the fire from the exterior decks.

5Thermoplastics (such as polystyrene and

polyurethane foam insulation) will melt and dripin a fiery environment. Also, the thin coating onthe bulkhead paneling was a plastic type ofmaterial that, when heated, could have resulted ina black liquid.

11

As he was climbing the exterior stairwayand approaching the 02 deck port door,the door window blew out. He returnedto the 01 deck and attempted to surveythe fire from the trawl deck. He also hadthe crew lay out (unroll) fire hoses fromthe port and starboard midships firestations.

The ALASKA SPIRIT was equippedwith two different types of fire hose — a1 ½-inch standard hose and anonstandard Armtex hose. The hose6 thatthe cook selected for use on the port firestation hydrant was an Armtex hose,which has a nonstandard coupler,smaller in diameter than the vessel’shydrant hose connection. To attachArmtex hoses to such hydrants requiredan adapter hose coupling. Recognizingthis incompatible situation, the chiefengineer immediately returned to hisroom on the 01 deck and retrieved anadapter to mate the 1 ½-inch hydranthose connection to the smaller Armtexcoupling. The vessel carried at leastthree such adapters, which were kept inthe chief engineer’s room.

The chief engineer handed the cook afire hose and told him to spray wateronto the 02 deck outside port door. Thecook stated that the fire intensifiedwithin the first 5 minutes of thisspraying. About 5-10 minutes later, hesaw flashing lights from a police car;about 5 minutes after that, he heard a firetruck siren, signaling the arrival ofshoreside firefighters at 0220. The cookassisted the shoreside firefighters untilthe fire was extinguished.

6“Hose” refers to one or more sections of

hosing that may be connected to form a singlehose unit.

After handing the hose to the cook,the chief engineer went to theengineroom and aligned the ship’sgeneral service and seawater servicepumps to operate with the fire pump.The two engineers from the ALASKARANGER arrived and assisted in layingout hose and spraying water inside theport 01 deck inside stairwell to preventfire from “walking down” from the 02deck.

In the first 20 minutes after the fireerupted and as land-based firefightersresponded, the crew of the ALASKASPIRIT and two engineers from theALASKA RANGER conducted thefirefighting operations. Guided by theALASKA SPIRIT’s chief and assistantengineers, the crew attempted to spraywater into the interior stairwell betweenthe 01 and 02 decks using two 1 ½-inchhose lines.

The crew fought the intensifying fireat the 02 deck port side door and at the01 deck interior stairwell. The chiefengineer also had the two deckhandsmove about 30-40 cans of oil-basedpaint from the aft 01 deck corridor to thetrawl deck.

Emergency Response and FireExtinguishing -- About 0209, whilelistening to a CB scanner, a Seward taxidriver overheard persons aboard twounidentified vessels discussing a fire thatthey could see. According to them, thefire appeared to be aboard a vessel at theSMIC docks. The taxi driver phoned theinformation to the SECC.

At 0211, the Seward Volunteer FireDepartment (SVFD) dispatched a firepump truck and a medical rescue vehicle

12

from the main fire station in Seward,approximately 7-8 miles from the dock.Additionally, the deputy fire chief andfour firefighters responded to the SMICarea, where a fire pump truck and amedical rescue vehicle were already pre-positioned at a fire station within severalhundred yards of the moored ALASKASPIRIT. Fire response personnel drovethese units directly to the dock.

At 0217, the SVFD fire chief told theSECC dispatcher to request mutual aidfrom the Bear Creek7 Volunteer FireDepartment. Eventually, 30 firefightersfrom the two volunteer fire departmentswere involved in the firefighting effort.

About 0220, the deputy fire chief ofthe SVFD arrived on-scene at theALASKA SPIRIT dock. He observedbrownish-gray smoke coming from theupper deck of the vessel, but no flames.

Shortly afterwards, the SVFD firechief arrived on-scene and saw heavysmoke and flames coming from the 02deck and wheelhouse access. As theincident commander, the fire chiefboarded the vessel to assess on-boardconditions and met with the ALASKASPIRIT’s chief engineer. He establisheda command post, manned by the deputyfire chief, at the fire pump truck, whichwas positioned at the shoreside hydrant.

The chief engineer said threecrewmembers were unaccounted for (themaster and two deckhands), and hethought they were trapped on the 02deck. Additionally, the chief engineershowed the hull arrangement plan

7A community to the north of Seward and

about 9 miles from the fire.

entitled “safety plan” to the fire chief. Headvised the fire chief that the crew hadsearched all of the lower decks, but firekept them from searching theaccommodation area on the 02 deck.(Later that morning, during the shoresidefirefighting operation, the two deckhandswho had been in Seward arrived at thevessel.) The crew continued to fight thefire by spraying water onto the interiorport side 01 deck stairway and onto theexterior port side 02 deck door.

Following his survey of the accidentscene, the fire chief decided:

• To use all land-based firesuppression equipment ratherthan the equipment on theALASKA SPIRIT, because hedid not know if the firesuppression equipment on theship was reliable. In addition,the land-based firefighterswore self-contained breathingapparatus (SCBAs) and weremore familiar with their ownequipment than the shipboardapparatus. (The assistantengineer later stated that,although there were twoSCBAs on the ALASKASPIRIT, the crew had had notime to don them.)

• To attack the fire at the portside door on the 02 deck in anattempt to rescue the master.

• To continue the hose attack atthe interior stairwell to preventthe fire from walking down thestairs to the 01 deck.

While the fire chief was making hissurvey, the deputy chief pulled hosesfrom the fire engines and laid a supply

13

line between the engine and the closestfire hydrant, which was several hundredfeet away.8 The hoses were laid from theengine to the gangway area to the trawldeck. The 1 ¾-inch hose attack lineswere used rather than larger hose linesbecause they allowed firefighters greatermobility within the narrow corridors onthe vessel.

About 0230, firefighters preparing forentry into the port door on the 02 deckfound the corridor filled with a “thick,dark-black, gritty smoke” extendingfrom the overhead to the deck. As thefirefighters crawled into the port sidecorridor, they heard crackling noisescoming from all sides, but no flameswere visible due to the heavy smoke.About 2 feet from the assistant fishmaster’s room door, the firefightersadjusted their nozzle to provide a semi-fog pattern, but they could not endure theintense heat in this area and returned tothe open deck. The firefighters attemptedtwo or three more attacks using variouswater streams through the port door onthe 02 deck, but they could not reach themaster’s room (which was across thecorridor from the assistant fish master’sroom). The fire continued to burn out ofcontrol.

The fire chief later stated that,because intense heat forced thefirefighters off the 02 deck and thefirefighters on the 01 deck could not goup the inside stairwell due to heat, theycould not reach the ship’s master at that

8Engine 4 laid a 5-inch supply line from the

hydrant to the pier where the vessel was moored.The deputy chief had two 2 ½-inch hose lineslaid to the deck of the vessel and connected four1 ¾-inch hose lines.

time. He focused tactical efforts on firecontrol.

As evidenced by the heat-causedbreaking of the wheelhouse windows,the fire intensified in the wheelhouse andon the 02 deck at about this time. Thefire chief decided that he could notattack the fire in the wheelhouse becauseit was being fed by the flames comingfrom the 02 deck. Firefighters in thestarboard corridor saw that the steelbulkhead on the starboard side of theassistant fish master’s room was glowingred. They realized that there was anintense fire in the room.

Eventually, the vessel’s fire pumpfailed, as the fire consumed thewheelhouse and the circuitry for the firepump. Because responding firefightershad already charged their hose lines fromshore, fire suppression efforts were notinterrupted. Crewmembers reported that,with both the general service andseawater pumps on-line, there was nonoticeable interruption in flow rate whenthe vessel’s fire pump failed. Theydirected hose streams on the vessel’sfuel tank vents on the 02 deck near thedeckhouse to dissipate heat and dispersefuel oil vapors to prevent fuel tankignition.

At 0326, the fire chief had the SECCoperator notify the U.S. Coast Guard(USCG) Cutter MUSTANG, in port atSeward, of the ALASKA SPIRIT firesituation. He did not request CoastGuard assistance. The cutter duty officerin turn notified the USCG Marine SafetyOffice in Anchorage, in accordance withthe Western Alaska Marine FirefightingPlan. This plan was developed and

14

promulgated in 1987 by the Coast GuardCaptain of the Port (COTP)9 of WesternAlaska to coordinate firefightingactivities for marine disasters posing arisk to vessels, facilities, or harbors inthe COTP’s zone.

The fire chief felt that during the first6 hours of the effort to get the fire undercontrol, the unfamiliar and confinedconfiguration of the ALASKA SPIRIT’saccommodation area created anenvironment that taxed firefightingresources. Of the 30 firefighters at thescene, approximately 20 were involvedin suppression operations. The other 10firefighters were advisory and supportpersonnel who performed such tasks asrefilling an estimated 100 air bottles withthe cascade air resupply system.

About 0900, the fire chief establishedan arbitrary target time of 0945 for firecontrol. If the team had not gainedcontrol by that time, he planned toremove the firefighters from the fire areato a distance from which they couldwork to suppress the fire with minimumrisk to themselves. About 0930,firefighters controlled the fire. Theycontinued their suppression activities,focusing on hot spots, for another 30 to40 minutes. About 1100, the fire chiefdeclared the fire out.

At 1123, the master’s body was foundlying face-down inside the door to thehospital adjacent to his quarters. He wasdressed in his underwear. About 1330,

9The Coast Guard officer (under the

command of a District Commander) sodesignated by the Commandant to giveimmediate direction to Coast Guard lawenforcement activities within an assigned area.

the fire department completed overhaul10

of fire debris. The fire chief set a reflashwatch on the vessel, and all unitsdeparted the scene at 1356. (Seeappendix A for Safety Boardinvestigation information.)

Injuries

Injuries Vessel ComplementFatal 1Serious 0Minor 0None 7Total Crew 8

Vessel Damage

The Fishing Company of Alaska, Inc.(FCA), owner of the ALASKA SPIRIT,reported that damage to the vessel fromthis accident was estimated at $3million. Before the fire, the vessel hadbeen valued at $6 million. Replacementcost was estimated at $14 million.

In September 1995, the vessel wastowed to Japan for repair. It returned toservice on January 18, 1996. A companyspokesman told the Safety Board thatportable heaters were not reinstalled increwrooms, combustible insulation wasreplaced with fiberglass insulation, and aCoast Guard-approved marine smokedetection system was installed on thevessel.

10The process of moving and separating

burned material to locate any hot or smolderingdebris and to cool it or wet it down to preventreflash of the fire.

15

Crew Information

Staffing -- At sea, the ALASKASPIRIT carried a maximum crew of 48persons—a National Marine FisheriesService observer and about 47crewmembers. Of these crewmembers,typically about 12 were in the deckdepartment, 2 were in the engineeringdepartment, 31 were in the processingdepartment, and 2 were in the galley (thecook and cook’s assistant). Staffinginformation is approximate, as no fixedstaffing regulations are in effect for suchvessels.

Only the master, mate, chief engineer,and assistant engineer must be licensedby the Coast Guard on fishing vesselsover 200 gross tons. No licensed personswere required to be on board during thein-port period. The ALASKA SPIRIT’smaster and its two engineers were,however, properly licensed by the CoastGuard for operating this vessel (seeappendix B for crew licensinginformation). Personnel information forthe six crewmembers who made up thevessel’s complement at the time of thefire and the watchman follows.

Master -- The master, age 44, beganhis maritime career in 1972 as anunlicensed seaman. He sailed in thatcapacity aboard various fishing vesselsfor the next 9 years. In June 1981, hereceived his first license as a mate ofuninspected motor fishing vessels. Heincreased the grade and scope of hislicense over the next several years beforejoining the FCA in May 1989.

He was initially assigned as mate tothe trawler ALASKA I. He wasreassigned to the ALASKA SPIRIT inNovember 1991 and served as its master

until the accident. The National DriverRegistry has no record of suspensions orrevocations against his driver’s license.

Chief Engineer -- The chief engineer,age 33, had held that position aboard theALASKA SPIRIT since joining the FCAin March 1992. His testimony to SafetyBoard investigators described a varietyof previous engineering work that he hadperformed, dating to 1982. Thisexperience included about 1 ½ years ofserving on offshore supply vessels inconstruction diving support, over 4 yearsof operations and maintenance onvessels with multiple moorings(anchors), and another 4 years on divingsupport vessels.

Assistant Engineer -- The assistantengineer, age 46, stated that he begansailing about 1970, first on fishingvessels out of Kodiak and then ontankers operated by the Military SealiftCommand. From October 1976 toDecember 1983, he worked as anengineer aboard offshore supply vesselsoperating in domestic and foreignwaters. He then worked about 7 yearswith a towing company out of DutchHarbor, before joining the FCA in March1991. He initially worked as chiefengineer on the ALASKA RANGER forabout 2 ½ years, and then conductedshipyard maintenance work and ship-board relief work for the company.Sometime prior to the fire, he hadrelieved the regular chief engineer on theALASKA SPIRIT. At the time of theaccident, he was relieving the regularassistant engineer.

Cook -- The cook, age 46, began towork as a cook aboard FCA vessels inMay 1990. After working for 6 months

16

on the ALASKA PIONEER, hetransferred to the ALASKA SPIRIT,where he remained until the fire.

Processor-deckhands -- The twoprocessor-deckhands on board at thetime of the fire, aged 26 and 25, joinedthe FCA in January and March 1992,respectively. They worked in thatcapacity for about 200 days each yearuntil the accident. The older deckhandhad no other seagoing work experience,but the younger had in 1989 served for 5months as a processor-deckhand aboarda fish processing vessel owned byanother company.

Watchman -- The watchman, age 38,had worked for the FCA intermittentlysince 1988, mostly as a processor-deckhand. He learned to perform hisrounds through on-the-job training. Hewas taught that if he found anythingunusual, he should notify the chiefengineer, and that if he needed assistancein adjusting mooring lines, he was tonotify the mate or the master.

Vessel Information

The ALASKA SPIRIT was originallybuilt in March 1974, at Lockport,Louisiana, as a 166.4-foot-long offshoresupply vessel for the oil industry. Thevessel was named the GULF FLEETNO. 10. The American Bureau ofShipping (ABS) certified that the supplyvessel had been built in accordance withABS rules. In 1987, the vessel was takenout of service. It was sold to the PalmcoPacific Corporation on January 5, 1988,converted into a trawler-fish processingvessel (also known as a factory-trawler),at Ishinomaki, Japan, and renamed theNORTHERN HERO in February 1990.

During the conversion, the vessel waslengthened by 37.3 feet to a total lengthof 202.7 feet.

The vessel was not required to beinspected by the Coast Guard to operateas a fish processing vessel. (See sectionon Coast Guard Regulations .) It was notrequired to meet international Safety ofLife at Sea convention regulations(structural fire protection, etc.) because itwas not engaged in internationalvoyages,11 although it fished ininternational waters.

On November 25, 1991, the FCApurchased the vessel and renamed it theALASKA SPIRIT. Because the vesselwas engaged in domestic voyages by sea,it was required to have a load line.12

The Det Norske Veritas (DNV)classification society issued a certificatefor the ALASKA SPIRIT on December26, 1992, attesting that the vesselcomplied with the InternationalConvention on Load Lines of 1966. Theprincipal characteristics of the ALASKASPIRIT were:

Length Overall 202.7 feetBreadth 38.0 feetDepth 21.6 feetGross Tonnage 1,418Net Tonnage 425Horsepower 3,600

11Voyages between U.S. and foreign ports.12Lines marked on the sides of a vessel that

show the maximum depths to which the vesselmay be safely loaded, as determined by the rulesof the International Convention on Load Lines.

17

From the keel up, the ALASKASPIRIT had five decks: the hold deck(two freezer holds forward andengineroom13 area aft); the factory deck(processing area); the main or 01 deck(galley and crew accommodations (for28) were forward, and the trawl deckwas aft); the 02 deck (crewaccommodations for 20); and the bridgedeck.14 The only exterior openings in the01 and 02 decks were two weathertightdoors (one on the port and one on thestarboard side) at the aft end of eachdeck. These decks had no portholes orother hull openings.

Firefighting Equipment -- A fire pump, ageneral service pump, and a seawaterservice pump could be connected at amanifold that could distribute water tofire stations throughout the vessel. Aremote control located in the wheelhousecould start the fire pump and pressurizethe fire main.15 The fire pump and firestations were not required by regulation.Seventeen portable fire extinguishers

13It had a 20-cylinder diesel engine driving a

single propeller shaft with a controllable pitchpropeller. The vessel was also equipped with abow thruster.

14The navigation and communicationequipment in the wheelhouse included satellitecommunication equipment, direction finders, fishfinders, echo sounders and recorders, a gyro-compass, a magnetic compass, radars, radiotelephones, electronic position fixing devices,including global positioning system (satellite)equipment, other electronic equipment used forfishing or fish processing operations, and apublic address system. A console in thewheelhouse controlled the main engine, thepropeller pitch, and the bow thruster. Theconsole had audio and visual alarms.

15A seawater pipeline that provides anadequate water supply for vessel fire hydrantsand hoses.

were distributed throughout the vessel. Afixed carbon dioxide (CO2) firefightingsystem, consisting of 14 100-poundcompressed CO2 cylinders, was pipedinto the engineroom spaces.

A fire detection alarm control panel,with audio and visual alarms, was alsolocated in the wheelhouse on thestarboard side aft. The detection systemconsisted of 27 heat detectors located inthe overhead throughout the vessel (1 ineach of the 17 crewrooms, 4 in thegalley-mess room, 1 in the processingarea, 1 in the wheelhouse, and 4 in theengineering spaces), and 3 smokedetectors in the freezer holds. The firedetection system was not required byregulation.

The heat detectors activated when theheat in the vicinity exceeded 70 oC (158oF). The circuit would remain closeduntil the heat lessened to about 60 oC(140 oF), at which time the detectorwould open and reset. It would then beready for reactivation if the heat roseabove the preset temperature.

Aural fire alarm warning buzzerswere located on the bulkhead in thestarboard corridor on the 02 deck outsidethe assistant fish master’s room, on thebulkhead in the port corridor on the 01deck adjacent to the port inside stairwellacross from the galley, and in theengineroom. A fire alarm from anactivated sensor could be heard outsideas well as inside the wheelhouse.

Survival Equipment -- The ALASKASPIRIT was fully equipped with all of

18

the routinely necessary survivalequipment.16

The FCA -- The FCA formed in 1985.It purchased 1 vessel in 1986 and 10others through 1992. At the time of thisaccident, the company operated 10vessels, including the ALASKA SPIRIT.An 11th FCA vessel was not in service.The company’s main office is in Seattle,Washington, and the FCA has fieldoffices in Anchorage, Dutch Harbor, andSeward, Alaska. On an annual basis, thecompany employs about 2,000 people. Ithas 12 employees on its managementstaff and 20 in support functions.

Coast Guard records show that duringthe period from 1992 through 1994, theALASKA SPIRIT had one reportablepersonnel injury, one equipment failure,and one pollution incident. The recordsalso show that between 1986 and 1994,the 10 other vessels owned by the FCAexperienced 4 personnel injuries and 6vessel accidents. Of the 6 accidents, 1was a loss of engine propulsion fromequipment failure, 1 was a steering gearequipment failure, 1 was a collision withanother vessel, and 3 were enginereduction gear failures.

The FCA director of operationsdescribed the operation of the ALASKASPIRIT in the following manner: “Themaster is in charge of all operationaldecisions regarding the vessel at sea and

16The ALASKA SPIRIT carried flares, an

emergency position indicating radio beacon(EPIRB), 4 ring life buoys with lights, 4 otherring buoys, 2 inflatable liferafts (which couldaccommodate 50 persons each), an 18-foot-longinflatable rescue boat with a 30-horsepowerengine, 48 life preservers, and 50 immersionsuits.

in port. The fish master on the vessel isin charge of the fishing operation…”.The director further stated that the FCAhad no operating or safety manuals andthat the vessel was not routinely visitedby company managers. The companyprovided the Safety Board with a copy ofits 1995 Human Resources and ClaimsGuide.17

Waterway Information

The fire aboard the ALASKA SPIRIToccurred while the vessel was moored atSMIC, Seward, Alaska, at latitude60o05.4’ N, longitude 149o21.8’ W. Thedock is situated on Resurrection Bay,about 2.2 miles east-southeast of mid-town Seward. By road, the dock is 7-8miles from mid-town Seward. The bay isa deep waterway extending south fromSeward for about 16 miles to the Gulf ofAlaska.

Meteorological Information

From 0800 on May 26 to about 1400on May 27, skies were mostly cloudy inthe accident locale. Visibility variedfrom 5 to 20 miles and was generally 5

17The guide contained sections for a sample

emergency station bill; guidelines for reportinginjuries and illnesses; guidelines for completingCoast Guard marine accident, injury, or deathreports; guidelines for completing crew departureforms; FCA policies against harassment;guidelines for completing crew evaluation forms;guidelines for completing payroll disbursementrequests; work rules and duties; employmentcontracts for new employees; a copy of 46 CFR28; and University of Alaska marine advisoryprogram bulletin 27 on tendinitis and relatedafflictions affecting fishermen and processingworkers.

20

Sheets of polystyrene insulation(Styrofoam) appeared to have been usedin some overhead and bulkheadlocations. In other areas, the bulkheadhad fiberglass insulation in the spacesbetween the paneling and in theoverhead. The foam insulation was notcovered with noncombustible material.18

The furnishings in each roomconsisted of wood cabinetry, woodpaneling, wood bunks, and woodlockers. Rooms were not centrallyheated; instead, each room had anelectric resistance-type heater.

Investigators found the heaters insome of the rooms, but none was foundplugged into an electrical source. An airventilation ducting system providedoutside air to each room.

Wreckage -- The ALASKA SPIRIT’sentire wheelhouse, including all of itselectronic and navigation equipment,was destroyed in the fire (see figure 8).

The hull and steel deck plating in thearea of the wheelhouse and 02 deck werebuckled and distorted, and showeddiscoloration consistent with intenseheat. Masts and associated rigging in thearea of the fire sustained heat damage.

The rooms on the port, forwardcenter, and forward starboard sides ofthe 02 deck were gutted (see figure 9).The RPU foam insulation and woodworkin the 02 deck were burned and, in mostareas, completely destroyed. The fishmaster’s room in the starboard corridoraft was significantly burned, but not as

18Materials that neither burn nor produce

flammable vapor in sufficient quantity for self-ignition when heated to 1350 oF or above..

extensively as rooms on the port side.The crew shower/toilet on the starboardside sustained only heat and smokedamage. The fire damage in thestarboard side corridor decreased fromforward to the aft doorway exit.

The inside stairwell to thewheelhouse (on the port side) from the02 deck was burned extensively andpartially collapsed. A door at the top ofthis stairwell separated it from thewheelhouse. This was not a fire door,and crewmembers reported that it stoodopen most of the time. The doorappeared to have been open during thefire, although most of it was destroyedby the fire. The upper bulkheads of theinside stairwell between the 02 deck andthe 01 deck (port side) were destroyed,but the stairwell suffered only heat andsmoke damage and remained intact andusable. The 01 deck accommodationarea near the inside stairwell to the 02deck (port side) sustained limiteddamage, mainly caused by heat andsmoke. Some interior finish vinyl veneeron the paneling was melted and haddripped. The galley sustained smokedamage from the fire and some waterdamage from the firefighting operations.

The assistant fish master’s room(center aft on the 02 deck) had steelbulkheads and a wood door with alouvered vent in its bottom section. Thedoor was completely destroyed in thefire. A small ventilation fan (8- by 8-inchopening) was located about 6 feet abovethe deck aft of the door in the port aftpart of the bulkhead to the corridor (thedoor to the master’s room was across thecorr idor) . A 6- by 16- inch

24

but investigators found no evidence ofelectrical arcing. Power cords fromseveral other pieces of electricalequipment in the accommodation spacewere plugged into the multiple-plugreceptacle just inside the door.

The stairwells between the 01 and 02decks, and between the 02 deck and thewheelhouse, were constructed of woodrisers, treads, and stringers. Bothstairwells were finished on the interiorwith plywood paneling. The stairwellbetween the 02 deck and the wheelhousewas extensively burned and partiallycollapsed. The stairwell between the 01and 02 decks exhibited heat and smokedamage but was still intact and usable.The corridor that led into the stairwellbetween the 01 and 02 decks had heatand smoke damage. Some of the interiorfinish vinyl veneer that had beeninstalled over the plywood paneling wasmelted and hanging down.

Medical, Pathological, andToxicological Information

The master lost his life in the courseof the accident. The SVFD reported thatthe master’s body was located on May27 at 1123 and removed from the vesselat 1247. The body was found in thehospital room just inside the closed doorfrom the 02 deck port corridor.

The SVFD deputy fire chief said that,from the position of the body, it lookedas if the master had been headed backinto the hospital room when hecollapsed. The hospital room adjoinedthe master’s room through an interiordoor (see figure 5). Directly opposite thecorridor door to the master’s room was aventilation fan opening in the assistant

fish master’s room at a height of about 6feet above the floor. Just forward of thefan opening was the door to the assistantfish master’s room.

The deputy fire chief reported that heasked a crewmember what the master’sstandard response would have been if hehad heard the alarm. The crewmemberreplied that the master would normallygo to the wheelhouse. The deputy firechief surmised that:

Assuming that he (the master) wasin his stateroom, he would go outhis stateroom door, turn to theright and go up the stairway to thewheelhouse; where he would goahead to the alarm panel anddetermine where the alarm wascoming from.

The deputy fire chief also told SafetyBoard investigators that:

My assumption is that if he (themaster) heard the alarm or waswoken up by smoke, he opened uphis door to go see toward thewheelhouse, and it had a wholebunch of smoke. He said, ‘no,that’s not the way to go.’ (He)closed his door, because the doorwas closed. (He) went backthrough the medical area and...came up and got another blast ofair right in that passageway. (He)turned and fell down.

On May 30, 1995, the deputy chiefmedical examiner, Office of the AlaskaState Medical Examiner, autopsied themaster’s body. The autopsy report statedthat the cause of death had been smokeinhalation. The deputy chief medicalexaminer also collected a fluid blood

25

sample for toxicological analysis. Thedeputy fire marshal, who attended theautopsy, told investigators that the bloodsample had been difficult to obtain dueto coagulation. He said that neither urinenor vitreous humor was available forsampling. Analysis of the blood samplefound a blood alcohol concentration of0.353 gm/dL21 and a carboxyhemoglobin(COHb) saturation of 90.6 percent.

At the request of the Safety Board,the Office of the Alaska State MedicalExaminer sent a portion of the master’sblood sample to the Center for HumanToxicology (CHT), University of Utah,for further toxicological analysis. TheCHT findings were: blood alcoholconcentration, 0.36 gm/dL; COHb, 84percent saturation; hemoglobin, 6.8gm/dL; cyanide, negative; andphenethylamine, detected as adecomposition product. The CHTdetected no other common drugs.

The cook said that he had known themaster for 3½ years and considered hima very disciplined person who neveroverreacted. He also considered themaster physically fit. The chief engineernoted that the master would often workout on an exercise machine or jog inplace before beginning his day(frequently well before 0600) in thewheelhouse. In summary, the chiefengineer said that the master “took careof himself.” Safety Board investigatorsalso talked with the master’s wife abouthis lifestyle. She said that he wasphysically fit and that at home he onlydrank socially. She also reported that her

21Grams per deciliter.

husband did not drink on the vessel andthat he did not permit alcohol on board.

Drills

According to U.S. Coast Guardrequirements (see 46 Code of FederalRegulations (CFR) 28.270), fishingvessels must hold drills monthly. Theregulations list 10 contingencies thatmust be covered in such drills, including“abandon ship” and firefighting. Theyalso state that drills are to be conductedas if an actual emergency exists, with thebreaking out and using of emergencyequipment. Further, they state that firedrills should be held in different parts ofthe vessel.

An ALASKA SPIRIT deckhandstated that the drills on that vesselconsisted of mustering on the bridgedeck when the general alarm bellsounded. The drills were held wheneverthe vessel entered port and the crewchanged. (This took place about every 7-10 days.) Fire drills were conductedwithout laying out or charging the firehose lines from the hydrants, donningSCBAs, or putting on firefightingequipment. During abandon ship drills,the crew did not don survival suits.

According to the chief engineer, eachtime the ALASKA SPIRIT deployed fora fishing trip, the ship’s officers held ameeting, primarily to familiarize the newpersonnel (such as the fish processors)with topics such as: routine rules andpractices; general company and shiprules regarding smoking, running, ridingconveyor belts, fighting, etc.; trainingand drill procedures for fire, abandonship, man overboard, and flooding drills;and the general alarm warning sound.

26

They also used the meetings toconduct safety equipment familiarizationsessions, such as demonstrating survivalsuit-wearing procedures and liferaft use;to identify muster station locations; andto allot emergency squad assignmentsand responsibilities during firefightingand chemical responses. According tothe engineroom log, the last fire drill onthe ALASKA SPIRIT had been held onMay 5, 1995.

Tests and Research

Possible Ignition Sources -- The SafetyBoard investigated various possibleignition sources for this fire. The sourcesconsidered included portable electricspace heaters found in crewrooms, aboot warmer found outside the portforward 02 deck crewroom, (lighted)smoking materials, battery chargers, andthe cook pot found in the assistant fishmaster’s room.

The space heaters on the vessel wererated at 5,000 watts at 220 volts. Nonewas found plugged into an outlet.

Investigators examined the remains ofa boot warmer found outside the four-person crewroom on the forward portside on the 02 deck. No evidence ofelectric arcing was noted. The bottom ofthe boot warmer was found on the deckand unburned, while the top of theappliance had been burned or meltedaway.

According to crewmembers, smokinghad been permitted in the vessel’saccommodation spaces. The four-personcrewroom forward on the port side of the02 deck was considered a likely area forfire origin, because a deckhand had seenthe deck near this room on fire shortly

after the fire alarm sounded. The roomhad been occupied by smokers on thenight of the fire.

Battery Charger Examination --Investigators found that Nippon Denchiwas the manufacturer of the chargersremoved for examination from theALASKA SPIRIT’s sister vessel, theALASKA VICTORY. These chargersappeared to be identical to the heavilyfire-damaged chargers found on theALASKA SPIRIT. Electrical diagramsfor the chargers were not available. Thechief engineer testified that the chargers,which he called “converters,” had beenused to convert 105 volts AC to either 12or 24 volts DC for wheelhouse radios.According to the chief engineer, thechargers were permanently mounted.During the fire investigation, it appearedthat the chargers on the ALASKASPIRIT had been hard-wired orpermanently wired to the radios in thewheelhouse. On August 29, 1995, thefire-damaged battery chargers wereexamined (see appendix C),photographed, and disassembled. Noevidence of electrical arcing was found.

Cook Pot Examination -- Aninventory of the contents of the assistantfish master’s room provided to theSafety Board listed an object describedas a “boiler.” This appliance was a roundcylindrical object found sitting on thedeck in this room; it was essentially acook pot that had been used to heatwater. The cook pot was constructed oftwo concentric metal cans approximately9 inches tall and 7 inches in diameter.When asked if crewmembers had cookedfood in their rooms, the cook said he hadnot been aware of anyone doing so.

27

The cook pot was found next to thebuilt-in bunk bed. A darkened burnpattern around it trailed over to thecorner of the left battery charger. Apower cord extended from the bottom ofthe cook pot forward to the center of theforward bulkhead. The insulation on theexposed cord and plug had beendestroyed. Because of the damage to theroom, investigators could not determinewhether the plug had been connected toan electrical receptacle.

Investigators removed the cook pot,along with a piece of carpeting to whichit was attached. The cook pot and theremains of a small can next to it (stuckto the same piece of carpeting) were sentto the Safety Board for further analysis.Investigators found many small tube-type fuses made of glass and screwsstuck together on the can bottom. Thecan appeared to have been a receptaclefor these spare parts.

The carpeting under the cook pot wasintact and gave some evidence of heatingbut none of burning. A broken glass tuberan up the side of the cook pot betweenthe two concentric cans. The tubeappeared to have been used as a sightglass to determine the water level in thecook pot.

The power cord to the cook pot wasabout 5 feet long. Part of the power cord(about 12 inches) was coiled beneath thecook pot. This portion of the cord wasstill intact and evidenced no fire or heatdamage. The rest of the cord consisted oftwo bare wires. All the electricalinsulation on this part of the cord wasmissing. The plug that held the prongswas completely destroyed, and theprongs held the electrical leads attached

with screws. No evidence of electricalarcing was noted on the power cord.

The bottom of the cook pot wascovered by a metal plate attached withthree screws. This plate appeared to havebeen a heat reflector. About ½ inch of apowdery material that easily crumbledaway was found on top of this plate.Above this material were electricalwiring and support hardware (consistentwith Bakelite22) for attaching theelectrical leads to a heating element inthe bottom of the innermost can. Theinsulation on these wires was fiberglassand it appeared to be undamaged. Thewire attachment hardware, however, wassoft and powdery. A small switch wasfastened to a recessed hole in the centerof the inner can. This switch came apartduring the disassembly, and investigatorscould not determine whether it had beenfunctional before the fire. It appeared tohave been an over-temperature switch,but this could not be verified, since thecook pot manufacturer could not beidentified.

Heat Detector Testing -- The detectorson the ALASKA SPIRIT were automaticrestorable detectors23 and were notrequired equipment for this vessel.Following the accident, a heat detectorfrom the ALASKA SPIRIT’s galley wasremoved and tested by an independentlaboratory (see appendix D for results).

22Trademark for any group of thermosetting

plastics having high chemical and electricalresistance used in a variety of manufacturedarticles.

23A device of which the sensing element isnot ordinarily destroyed by the process ofdetecting a fire. Restoration of the device to adetection mode may be manual or automatic.

28

The detector was found in acceptableoperating order.

The detector was set to be activated atabout 70 oC (158 oF) and to reset atabout 60 oC (140 oF). Coast Guardregulations for heat detectors (see 46CFR 76.27) allow a range setting from“135 oF (57.2 oC) to 165 oF (73.8 oC)”for activating heat detectors.International regulations (Safety of Lifeat Sea, Chapter II-2, Part A, Regulation13, Paragraph 3.3) allow a range from 54oC (129.2 oF) to 78 oC (172.4 oF).

Other Information

Coast Guard Regulations -- Therequirements for uninspectedcommercial fishing industry vessels areat 46 CFR Subchapter C (UninspectedVessels), which includes Part 28,“Requirements for Commercial FishingIndustry Vessels.”24 Subpart 28.100requires that each commercial fishingindustry vessel meet the requirements ofParts 24 (General Provisions), 25(Equipment Requirements - LifePreservers, Fire Extinguishers, andEPIRBs) and 26 (Operations) ofSubchapter C, in addition to therequirements of Part 28.

Fish processing vessels “of not morethan 5,000 gross tons” are exempt fromCoast Guard inspection by law.25 TheALASKA SPIRIT was 1,418 gross tons

24The regulations went into effect on

September 15, 1991, and were the result of TheCommercial Fishing Industry Vessel Safety Actof 1988, Public Law 100-424 (Title 46 USCChapter 45).

25Title 46 USC 3302(c)(1).

and was, therefore, exempt frominspection.

Section 28.710(a) also requires that,every 2 years, fish processing vessels notsubject to inspection be examined forcompliance with Subchapter C.Compliance must be certified in writingby the ABS, a similarly qualifiedorganization such as the DNV, or asurveyor of an accepted organization.26

A DNV surveyor examined theALASKA SPIRIT on January 16, 1994,and found it to be in compliance with theappropriate regulations. The surveyorissued the vessel a Certificate ofCompliance (valid until January 16,1996) that certified that the vesselcomplied:

With the applicable requirementsof U.S. Regulations 46 CFRChapter C Uninspected VesselsPart 28 as required by 46 CFR28.710 (Lifesaving, Firefighting,Navigation, and Other SafetyEquipment).

Coast Guard regulations require thatthose vessels built or converted on orafter September 15, 1991 (the effectivedate of the regulations for commercialfishing industry vessels), “must beconstructed so as to minimize firehazards insofar as is reasonable andpractical.” Insulation must benoncombustible except when used forcertain engineering applications, in cargoholds, and in refrigerated spaces.

26An organization that meets the requirements

of 46 CFR 28.73 and is designated by the CoastGuard for the purpose of examining commercialfishing industry vessels.

29

Further, on vessels operating withmore than 49 persons, the regulations at46 CFR Part 28, Subpart D, require thatsuperstructures and deckhouses beconstructed of noncombustible materials.Because the ALASKA SPIRIT wasconverted in 1990 and carried fewer than49 persons, it was not required to meetany of these fire safety requirements.However, the vessel’s superstructure,deckhouse, and assistant fish master’sroom were constructed of steel (which isnoncombustible).

Regulations require that vesselscarrying 16 or more persons have anindependent modular smoke detector ora smoke-actuated fire detecting unit ineach accommodation space. TheALASKA SPIRIT was not required tohave smoke detectors because it wasconverted before September 15, 1991,the effective date of the regulations.

The regulations do not requirecommercial fishing industry vessels tohave sprinkler systems in theiraccommodation areas.

Regulations for existing fishingindustry vessels (those built or convertedprior to the effective date of theregulations - September 15, 1991) do notrequire a fire pump or that the pump beconnected to fixed piping (fire main).27

Only those vessels built or converted onor after September 15, 1991, that are 36feet or more in length and carry morethan 16 persons must be so equipped.The ALASKA SPIRIT, although not

27Regulations require that vessels with a

power-driven fire pump have a fire main system,including fire main, hydrants, hose, and hosenozzles.

required to have a fire pump or fire mainpiping/hydrants installed, had thisequipment.

On April 29, 1980, the Coast Guardissued Navigation and Vessel InspectionCircular (NVIC)28 8-80 (Fire Hazard ofPolyurethane and Other Organic Foams)“to alert vessel inspectors, designers,builders, and operators of the potentialfire hazard of polyurethane and otherorganic foam materials” because of“serious fires” on “several ships.” Theseguidelines are intended to apply to allvessels. The NVIC states:

When organic foams (includingthose described as self-extinguishing, non-burning, fireresistant, flame resistant, andsimilar terms) are exposed to fireor heat, they may ignite and burnwith rapid flame spread, hightemperatures, toxic gases, andvoluminous quantities of smoke.

The NVIC further states that:

Whenever polyurethane or otherorganic foam materials areinstalled in cargo holds or otherspaces, it is recommended that acovering of 22 United StatesStandard Gauge (USSG) steel(about 0.03 inches or about 1/32-inch thick) or other suitablenoncombustible material, with atleast a 15-minute fire rating, beinstalled over the foam insulation.

28Published by Coast Guard Headquarters to

disseminate recommended policy, requirements,procedures, or guidance for Coast Guard marinesafety personnel and the marine industry.

30

The ALASKA SPIRIT had RPU foaminsulation on the steel hull in the crewaccommodation areas on the 01 and 02decks. It was not covered with anoncombustible material, nor was itrequired to be. Polystyrene blocks andfiberglass insulation were also usedbetween the wooden framing andbulkhead covering, and (apparentlyrandomly) in the overheads of theaccommodation spaces.

On August 18, 1986, the Coast Guardissued NVIC 5-86 (Voluntary Standardsfor U.S. Uninspected CommercialFishing Vessels) “In response to the poorsafety record of uninspected commercialfishing vessels...”. NVIC 5-86 (page 3-9)refers to NVIC 8-80 for furtherinformation on foam insulation inrefrigerated compartments and fishholds.NVIC 5-86 (page 3-2) recommends that:(a) noncombustible materials should beused for bulkheads, decks, and otherstructures, in accommodations, serviceareas, and control spaces; (b) smoke orfire detection systems should be installedto indicate the presence and location offire or smoke in galleys, other high riskspaces, and accommodations, furtherstating that an Underwriters Laboratory-approved house-type smoke detector isusually adequate for accommodationsand galleys (page 3-5); and (c)combustible materials be limited toreduce the amount of fuel available for afire. The NVIC also states that insulatingfoams and plastics produce extremelytoxic products when burning and“should not be used or at least bereduced in quantity wherever possible”(page 3-3), and that “insulating materialsin accommodations, service areas,control spaces, and machinery spaces

should be noncombustible (Mineralwool, etc.)” (page 3-11).

Three Worcester Polytechnic Institutestudents, with the U.S. Coast GuardHeadquarters Marine Technical andHazardous Materials Division, prepareda report29 for the Coast Guard whichexamined safety factors on fishprocessing vessels. Among otherfindings, the report concluded thatpolyurethane foam “has been shown toconsistently contribute to fires aboardfish processing vessels.” The reportrecommended that a substitute be foundfor polyurethane foam insulation.

Standards Applicable to IndustrialVessels -- Coast Guard structural fireprotection regulations for Cargo andMiscellaneous Vessels are found at 46CFR 92.07 and apply to industrialvessels30 of 300 and over gross tons butless than 4,000 gross tons contracted foron or before July 1, 1968, which carry inexcess of 12 “industrial persons.”31 The

29Unclassed Fish Processing Vessel Study,

October 12, 1990.30A vessel which, by reason of its special

outfit, purpose, design, or function, engages incertain industrial ventures. Included are suchvessels as drill rigs, missile range ships, dredges,cable layers, derrick barges, pipe laying barges,and construction and wrecking barges. Excludedare vessels that carry freight for hire or areengaged in oceanography, limnology, or thefishing industry. (46 CFR 90.10-16)

31Any person carried on board an industrialvessel for the sole purpose of carrying out theindustrial business or functions of the vessel.Examples are laborers, such as wreckers andmechanics, technicians, drilling persons, anddivers. Industrial persons and fish processingpersons are similar in training and experiencewith respect to responding to emergencies aboardvessels.

31

regulations in part require that, withinaccommodation and service areas,corridor bulkheads shall be of “A”32 or“B” 33 class construction; all otherbulkheads shall be of “A,” “B,” or “C”34

class construction. Trunks35 shall be of“A” class construction; ceilings, linings,and all insulation shall benoncombustible. An approved interiorfinish may be used in corridors. Anapproved interior finish, as defined bythe Coast Guard, is one that is subjectedto American Society for TestingMaterials (ASTM) E8436 and develops aflame spread of less than 20 and hassmoke development of less than 10.

32“A” class bulkheads or decks shall be

composed of steel or equivalent metalconstruction. In a standard fire test, they would becapable of preventing the passage of flame andsmoke for 1 hour. A standard fire test is one whichdevelops in the test furnace a series of time totemperature relationships as follows: 5 minutes—1,000 oF; 10 minutes—1,300 oF; 30 minutes—1,550 oF; and 60 minutes—1,700 oF.

33“B” class bulkheads shall be constructed withapproved noncombustible materials. In a standardfire test, they would be capable of preventing thepassage of flame for ½ hour.

34“C” class bulkheads must be constructed ofapproved noncombustible materials but are notrequired to meet requirements for the passage offlame.

35A passage extending through one or moredecks to provide access or ventilation to a space.

36E84 is a standard test method developed bythe ASTM. The method exposes a 24-foot by 20-inch specimen to fire and measures the rates offlame spread and smoke development. Thematerial rating (flame spread index) and smokenumber are obtained from a comparison with theflame spread rate and smoke development of redoak. The flame spread rates for shredded woodfiberboard (treated with flame retardant), gypsumboard (with paper surface on both sides), and redoak (untreated) are -20 to 25, -10 to 25, and -100, respectively.

These requirements were in theregulations when the structural fireregulations were being developed forcommercial fishing industry vessels, butthey could not, by law, be incorporatedinto the regulations for existing fishingvessels. (See section on Coast GuardOversight of Fish Processing Vessels .) Theywere only partially incorporated forfishing vessels that operate with morethan 49 persons and were built orconverted after September 15, 1991.

Building Codes -- See appendix E forbuilding codes for shoreside structures.

Life Safety Code -- The National FirePrevention Association (NFPA)37

developed and published NFPA 101“Code for Safety to Life from Fire inBuildings and Structures,” known as theLife Safety Code (LSC).38 The purposeof the LSC, stated in Section 1.2, is:

To provide minimumrequirements, with due regard tofunction, for the design, operation,and maintenance of buildings andstructures for safety to life fromfire and similar emergencies.

37The nonprofit NFPA advances the

development and dispersion of fire safetystandards, many of which are adopted intoFederal, State, and municipal fire codes.Association volunteers are in such professions asfire service, health care, business, insurance,government, education, and industry.

38NFPA Life Safety Code, Chapter 6:“Existing Hotels and Dormitories,” Section 6-5,Interior Finishes. National Fire ProtectionAssociation, Quincy, Massachusetts, 1994.

32

The LSC mainly addresses safe egressfrom shoreside buildings. It alsoestablishes certain flammabilityrequirements for building structure andinterior design. For example, the LSCrequires that smoke detectors be placedin sleeping quarters for hotels (withmore than 16 sleeping accommodations)and dormitories (for more than 16persons). In addition, the LSC limits theflammability of the interior finishes onwalls and overheads of exit enclosures toClass A or Class B materials.39

Plywood of ¼-inch thickness has aflame spread rating of 120-196,depending on the exact type of plywoodand finish.40 The flame spread rating ofthe ¼-inch plywood used as interiorfinish on the 02 and 01 decks on theALASKA SPIRIT was not available ordetermined by testing. It is, however,likely that the rating was greater than120, based on the flame spread ratingsfor plywood of ¼-inch thickness.

If an approved automatic sprinklersystem is in place in a location, the LSCstates that Class C interior wall andoverhead finish materials shall bepermitted wherever Class B materialswould normally be required. Class Binterior wall and overhead finish

39The LSC defines three classes of finish

materials, dependent on flame spread and smokedevelopment, as follows:

Class A — Flame spread of 0-25 and smokedevelopment of 0-450,

Class B — Flame spread of 26-75 and smokedevelopment of 0-450, and

Class C — Flame spread of 76-200 andsmoke development of 0-450.40Flame Spread Performance of Wood

Products, National Forest Products Association,Washington, D.C., 1992.

materials shall be permitted anywhereClass A would normally be required.

U.S. Fishing Fleet -- The U.S. fishingfleet numbers approximately 130,000vessels, of which about 250 are fishprocessors or combination fishing-fishprocessor-type vessels. Approximately50 fish processing and 76 combinationfishing-fish processing vessels are morethan 79 feet long.41 Only one U.S. fishprocessing vessel, the 17,845-gross tonOCEAN PHOENIX (635.5 feet long), isrequired, because of its size, to beinspected by the Coast Guard.

Approximately 1,400 U.S. fishingindustry vessels are over 79 feet long.Crew size varies greatly for vessels over79 feet, “from 4 to 5 for fishing vessels,to 20 to 30 for large catcher-processors,to well over 100 for the largest floatingprocessor.”42 The Coast Guard does notmaintain records of crew size foruninspected vessels, so it does not knowhow many vessels are more than 79 feetlong and carry more than 16 (or 49)persons. Between January 1992 andDecember 1995, a total of 1,167 fishingindustry vessels were newly registeredwith the Coast Guard. Of these, 1,105were less than 79 feet long, 60 werebetween 79 and 100 feet long, 1 was112.8 feet long, and 1 was 201.2 feetlong. The last vessel is similar in size tothe ALASKA SPIRIT.

41Fishing Vessels of the United States 79'

and Over, Nautilus Publishing Co., Seattle,Washington, 1994.

42Fishing Vessel Safety, National ResearchCouncil, National Academy Press, Washington,D.C., 1991, p. 41.

33

Accident Statistics -- According toCoast Guard records, from January 1,1992, through March 15, 1994, a total of2,214 fishing vessel accidents43 werereported and investigated. Of these, 228(10.3 percent) involved fires, of which105 either were classed as uncontrollableor burned themselves out. The dollarloss of $24.8 million caused by the fireswas 29.5 percent of the total for fishingvessel accident losses ($84.2 million)during this period.

For the period March 16, 1994,through 1995, records are incompletebecause of open investigations andcomputer file loading in progress. Onefire on a fish processing vessel that wasnot included in the statistics was the fireon board the fish processing vessel ALLALASKAN in July 1994.44 The SafetyBoard investigated this fire, in which oneperson died and the 379.5-foot-longvessel sustained damage in the range of$24.3-30 million.

43Coast Guard regulations at 46 CFR 4.05

define accidents/casualty as: a grounding; loss ofmain propulsion or primary steering or anyassociated component or control system; anoccurrence that adversely affects the vessel suchas fire, flooding, failure of fixed fireextinguishing systems, life saving equipment,auxiliary generating equipment, or bilge pumpingsystems; loss of life; injury which requiresprofessional medical treatment beyond first aid,or a person is unfit to perform routine vesselduties, an occurrence not meeting the above thatresults in damage to property in excess of$25,000. (Note: Over the years, the damageamount has been gradually increased to itspresent amount.)

44Marine Accident Report -- Fire On Boardthe U.S. Fish Processing Vessel ALL ALASKAN,Near Unimak Island, Alaska, Bering Sea, July24, 1994 (NTSB/MAR-95/02).

Coast Guard Oversight of Fish ProcessingVessels -- Uninspected vessels that mustbe examined by a qualified organization(ABS, DNV, etc.) for compliance withregulations are not normally examinedby Coast Guard personnel. TheALASKA SPIRIT was in this categoryand was required to be examined by theDNV biannually. If, however, the CoastGuard had boarded the vessel at sea, anexamination could have been carried out.The Coast Guard’s at-sea program ofboarding fishing industry vesselsoperates in conjunction with search andrescue, fisheries management, and lawenforcement boarding. The Coast Guarddoes not conduct planned patrols for thesole purpose of safety equipmentenforcement.

Title 46 United States Code (USC)Chapter 45 is the codified law affectinguninspected commercial fishing industryvessels. In prescribing regulations underthis chapter, the Secretary (ofTransportation) “may not require thealteration of a vessel or associatedequipment that was constructed ormanufactured before the effective date ofthe regulation.”45 Thus, vessels areexempt from new regulations and theowner or operator cannot be required toupgrade equipment or meet constructionrequirements for vessels built orconverted before the regulation’seffective date. Fire and electricalregulations or requirements (at 46 CFRPart 28, Subpart D), and stabilityrequirements (at 46 CFR Part 28,Subpart E) are effective only for newvessels or vessels that complete a major

45Title 46 USC 4502(e)(2).

34

conversion46 on or after September 15,1991. (See table 1 on pages 36-37 forfire regulation summary and comparisoninformation.)

Survival Factors

Fire Control Efforts -- Conditionsreported by the SVFD fire chief thataffected the ALASKA SPIRITfirefighting efforts appear in appendix F.

Notification Procedures -- Seward’semergency operators normally receive 6weeks on-the-job training under asupervisor. During the program, they areinstructed in gathering basic informationfrom callers on the nature and location ofthe complaint. Seward’s emergencyoperators are also trained to questioncallers to determine if fire or hazardouschemicals are involved in the complaint.Additionally, the city of Seward hasprepared a Vessel in Distress ProcedureManual (revised March 1995) thatidentifies information that emergencyoperators should gather to address ageneral emergency involving a vessel atsea (i.e., the name of the vessel, its radiotype, coordinates, survival equipment,the number of people involved, etc.).

Among the resources available tolocal planners is the Western AlaskaMarine Firefighting Contingency Plan(see Local Contingency Planning section

46Defined at Title 46 USC 2101 (14a) as “a

conversion of a vessel that: (A) substantiallychanges the dimensions or carrying capacity ofthe vessel; (B) changes the type of the vessel; (C)substantially prolongs the life of the vessel; or(D) otherwise so changes the vessel that it isessentially a new vessel, as decided by theSecretary [of Transportation - U.S. CoastGuard].”

below). The plan provides the followingchecklist for information gathering:

• What is the name and telephonenumber of the person reporting?

• What is the nature of theemergency and extent of fire?

• What is the location of theincident?

• What is the exact location of thefire, by compartment and deck?

• Is anyone trapped or injured?

• What is burning? (Detailsregarding class of fire)

• Is any hazardous cargo in or nearthe fire?

• What, if any, firefighting effortsare in progress?

• What is the vessel’s capability tomaneuver?

• What is the amount and type of“bunker” (fuel for ship’sengines)?

While the Seward emergencyoperators were not specifically familiarwith the plan, they were trained to obtainbasic information on the nature andlocation of the fire from the initial caller.

Local Contingency Planning

City of Seward -- The Alaska Divisionof Emergency Services approved theKenai Borough Emergency Plan, whichaddresses natural disasters andhazardous materials releases. The planestablishes an emergency operationscenter and command levels foroperations and support personnel. It also

35

lists other support agencies andresources in the State.

The last training drill or “table-topexercise” conducted by the KenaiPeninsula Borough prior to the accidenttook place on December 8, 1994. Thescenario addressed was the involvementof an above-ground propane storage tankin a fire. The last previous marinefirefighting training session for theSVFD occurred on May 21, 1995.Between 1984 and June 1995, the SVFDresponded to 25 marine incidents thattook place on vessels ranging in lengthfrom 14 to 218 feet.

In summer, Seward-Anchorage is theterminus for many of the world’s largestcruise ships, which visit western Alaskafrom the West Coast of the United Statesand Canada, making approximately 185port calls (about 125 in Seward). SVFDpersonnel board all cruise ships visitingSeward to conduct a familiarization tourof each vessel. This is not part of theKenai Borough Emergency Plan. Otherthan the borough emergency plan, theSVFD does not have a local contingencyplan for dealing with shipboard fires.

Western Alaska Marine FirefightingContingency Plan -- According to theCoast Guard’s Marine Safety Manual,47

each COTP must maintain a marinefirefighting contingency plan for dealingwith shipboard and waterfront fireswithin their geographic area ofresponsibility. Marine Safety Office

47The manual presents the authority,

background, policy, and rationale for variousprograms associated with marine safety for theinformation, use, and guidance of Coast Guardpersonnel assigned to carry out marine safetyduties.

Anchorage’s area is western Alaska. TheWestern Alaska Marine FirefightingContingency Plan (dated September 18,1987) was distributed to the harbormasters and fire departments within theWestern Alaska Zone, namelyAnchorage, Homer, Whittier, Seward,Kodiak, and Dutch Harbor.

The plan recommends that local firechiefs take charge of firefightingoperations within their jurisdictions andthat vessel masters or senior officersserve as liaisons between the fire chiefand the vessel crew. It lists key steps thatshould be taken before firefightersarrive. The steps include sounding thecrew alarm, making an announcement onthe public address system, and notifyingthe local fire department with specificinformation (such as location by deckand compartment, firefighting efforts inprogress, and personnel involved).

Under a Section 20, Fire DepartmentContingency Plan recommendation:

Each fire department which isresponsible for the fighting ofshipboard fires should establish atraining program within their unit,dealing with shipboard fires. Firedepartments should establish localcontingency plans to cover suchemergencies. A copy of this plan isto be submitted to the COTP.

While Seward has not specificallydeveloped a firefighting contingencyplan to deal with shipboard fires, manyof the key steps in its firefightingstrategies and assigned individualresponsibilities are identical to those inthe Coast Guard’s Western AlaskaMarine Firefighting Contingency Plan.

Table 1 – Comparison of fire safety regulations and guidelines (all information has been revised and condensed for table inclusion)

Commercial FishingIndustry Vessels Built or

Converted BeforeSeptember 15, 1991

46 CFR Part 28, Subparts C&D

Commercial FishingIndustry Vessels Built orConverted On or After

September 15, 1991

46 CFR Part 28, Subparts C&D

Industrial Vessels 300Gross Tons (GT) andLess than 4,000 GT

46 CFR Subparts 92, 95, & 97

U.S. Coast GuardVoluntary Standards

NVIC 5-86

Chapter 3 - Fire Safety

Personson Board

16 orfewer

Morethan 16

Morethan 49

16 orfewer

Morethan 16

Morethan 49

In excess of 12 industrialpersons

Any number

Fire

Detection

Systems

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Each accommodationspace must be equippedwith an independentmodular smoke detector ora smoke-actuated firedetecting unit.

Not required, except that eachcompartment containingexplosives or enclosed spacessuited for vehicles shall beprovided with a smoke-detectingor other suitable type of fire-detecting system. However, if asmoke-detecting system isinstalled, it shall meet therequirements of 46 CFR 76.33.

An approved house-type smokedetector is usually adequate foraccommodations and galleys.Machinery spaces should have fireor smoke detectors with an audibleand visual alarm in the pilothouseand on deck. Detectors shouldindicate the presence and locationof fire or smoke in high risk areas.

Fire

Suppression

Equipment

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

A fixed gas (i.e. CO2) fireextinguishing system isrequired for all vessels 79’long or over in a spacecontaining an internalcombustion engine ofmore than 50 horsepower(HP), an oil-fired boiler,or a gasoline storage tank.

Required in cargo compartmentsand tanks for combustible cargoes,paint lockers, engine spaces onvessels of 1,000 GT and overcontaining oil-fired boilers, ortheir fuel oil units, and withengine power of 1,000 BHP orgreater. When a cargocompartment is to be working orliving quarters, a water sprinklingsystem may be required.

Machinery spaces containing oil-fired boilers, fuel oil units, orinternal combustion enginesshould have a fixed fireextinguishing system.

Fire Hose NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Hoses must be connectedto hydrants whenever thevessel is operating.

Fire hose shall be connected to the outlets at all times. However, on theopen decks where no protection is afforded to the hose in heavyweather, or where the hose may be damaged from the handling of cargo,the hose may be temporarily removed from the hydrant and stowed in anaccessible nearby location.

Fire Main NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Vessels 36’ or more inlength must have a firepump connected to fixedpiping (fire main).

One to two fire pumps, dependingon the GT of the vessel, pipingand pumping requirementsdelineated.

Fire pumps and hydrants shouldbe provided for all vessels inaccordance with 46 CFR 95.10-5to 15.

Structural

Fire

Protection

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

NOT

REQUIRED

Each vessel must beconstructed so as tominimize the fire hazardsas far as it is reasonableand practical. Insulationmust be noncombustible,except for machineryspace pipe and machinerylagging and cargo holds.In addition, for more than49 persons, the vessel’shull, structural bulkheads,columns and stanchionsmust be made of steel.Deckhouse must beconstructed ofnoncombustible material.

Ceilings, linings, and insulation,including pipe and duct coverings,shall be of incombustiblematerials. Any sheathing, furring,or holding pieces for securing anybulkhead (BH), ceiling, lining, orinsulation shall be ofincombustible materials. BHs,linings, and ceilings may have acombustible veneer within a roomnot to exceed 1/14” in thickness.Combustible veneer shall not beused in corridors. Corridors andBHs in accommodations shall beof “A” or “B” class construction.Stairtowers shall be of “A” classconstruction. The hull,superstructure, structural BHs,decks, and deckhouses shall beconstructed of steel.

Noncombustible materials shouldbe used for BHs, decks, and otherstructures and furniture inaccommodations. Combustiblematerials and insulating foamsshould not be used or should bereduced in quantity whereverpossible. For foam insulation use,consult NVIC 8-80. Insulatingmaterials in accommodationsshould be noncombustible.

Fire Drills NotrequiredunlessvesseloperatesbeyondtheBoundarylines.

Required once a month.Hold in differentlocations on the vessel.Drills to be conducted asif an actual emergencyexists. All on boardmust participate, usingemergency equipment.

Same as vessels built or convertedbefore September 15, 1991.

Drills at least once every week andconducted as if an actualemergency exists. Fire pumpsstarted and a sufficient number ofoutlets used to determine that thesystem is in proper working order.

Fire drills should be realistic anddeal with an assumed outbreak offire in some specified part of thevessel. Hoses should be laid outand tested. Drills should be held atintervals of not more than onemonth.

38

ANALYSIS

General

The weather conditions at the time ofthe accident were good and did nothamper the detection of the fire or thefirefighting efforts. The engineroomequipment functioned properly beforeand during the fire. The Safety Boardtherefore concludes that the weatherconditions and the vessel mechanicalsystems were not factors in this accident.

Source of Ignition

Early eyewitnesses reported almostsimultaneous observations of fire in thewheelhouse and on the 02 deck. If thefire had started in the wheelhouse, itwould have taken some time for it toprogress downward to the 02 deck, sowitnesses could not have seen firesimultaneously in the wheelhouse andthe 02 deck in the early stages of theaccident. In other words, had the firebegun in wheelhouse, the wheelhouseshould have been seen to have greaterfire involvement than the 02 deck, whichis not what witnesses reported. On thisbasis, investigation for an ignition sourcewas directed to the 02 deck.

On the 02 deck, the cook observedheavy smoke and fire in the port corridor2 to 3 feet down from the overhead, andhe could see only 10 to 15 feet into theport corridor. He observed only lightsmoke for the length of the starboardcorridor. If the fire had started in theforward port corridor or the forward portcrewroom, the fire spread by smoke orheat down the corridor should have

occurred in the athwartships (cross)corridor and the starboard corridor, aswell as down the port corridor. Firedamage on the 02 deck was moreextensive on the port than on thestarboard side. This pattern was mostevident in the port and starboardcorridors and living spaces along theouter perimeters of these two corridors.The final burn pattern was much deeperin the port corridor and cross corridor.

Although firefighting efforts wereinitiated at the 02 deck port aft door, theintensity of the fire forced firefighters toretreat. At this time, the port aft corridorwas already fully involved in fire.Consequently, firefighters entered thestarboard aft door to fight the fire. Earlyin the firefighting efforts, firefightersnoted that the starboard bulkhead in theassistant fish master’s room glowed redas viewed from the starboard corridor.

Since crewmembers had beensocializing in the port forward four-person crewroom on the 02 deck on theevening prior to the fire, investigatorsconsidered the possibility that discardedsmoking materials in this location mighthave ignited the fire. The duration andintensity of the fire would have ensuredthat any remaining residue fromdiscarded smoking material wasdestroyed. However, discarded smokingmaterials do not appear to have causedignition, given the ultimate burn patternand eyewitness accounts of the fire.

39

Investigation revealed numerous otherpossible ignition sources on the 02 deck.They included: a boot warmer foundoutside the port forward crewroom,space heaters in crewrooms, batterychargers found in the assistant fishmaster’s room, and a cook pot found inthe assistant fish master’s room. Thelocation of the ignition source must beconsistent with the following factors: (1)the pattern of fire damage on the 02deck, (2) the early and almostsimultaneous appearance of fire in thewheelhouse and 02 deck, and (3) theobservation of fire in the 02 deck portcorridor, but smoke only in the starboardcorridor, early in the fire progression.

The deckhand who had beenawakened by the fire alarm stated that hewent about halfway up the stairwell tothe 02 deck before the firefightersarrived and saw fire in the overhead andon the deck of the forward port corridor.He believed that he saw burning bootson the deck. Investigation of a bootwarmer found outside the port forwardcrewroom uncovered no problems withthe wiring that led over the door’s metalthreshold. Further, the boot warmerappeared to have melted or burned fromthe top down, with no indication ofignition from the lower part of thewarmer.

These observations are consistentwith radiant heat from the fire in theoverhead having caused the bootwarmer’s melting. The investigationcould not confirm what materials thedeckhand might have seen burning onthe deck.

Each accommodation space on theALASKA SPIRIT appeared to havecontained an electric space heater, since

no other heat was available in the rooms.None of the heaters located byinvestigators was powered or pluggedinto an electrical source.

A fire starting in the assistant fishmaster’s room could easily have spread(via the chase in the overhead above thebed) into the wheelhouse early in thecourse of the fire. Because the chasewould have acted as a chimney goingdirectly into the wheelhouse, fire-spreadinto the wheelhouse could have occurredbefore the smoke and hot gases escapedinto the corridor via the room’s lightwooden door and vent fan opening. RPUfoam lined the inside of the chase on theALASKA SPIRIT’s sister vessel andremnants of RPU foam were found in thechase on the ALASKA SPIRIT after thefire. Such a flammable lining wouldhave increased the rapidity with whichthe fire would have spread into thewheelhouse by this route.

A fire initiating in the assistant fishmaster’s room also could have spread tothe wheelhouse by a second route. Theburn pattern in the 02 deck corridor isconsistent with fire exiting from thisroom into the port corridor. Smoke, hotgases, and fire would have exited intothe port corridor via the fan vent openingand the light, hollow-core wooden doorof the assistant fish master’s room. Thewooden, non-fire-rated door at the top ofthe stairway to the wheelhouse wasdestroyed and, according to testimony,was probably open at the time of the fire.This testimony is consistent withdamaged conditions found after the fire.The wooden stair treads and woodenpaneling in the stairwell between the 02deck and the wheelhouse were

40

extensively damaged by the fire.Consequently, both the chase and thestairwell were major means by which theheat, smoke, and fire could have traveledfrom the 02 deck into the wheelhouse.

The assistant fish master’s room wasof fire-resistive construction, as it hadsteel bulkheads. However, the steelbulkheads were covered, interior andexterior, with light wooden constructionmaterials. The extensive destruction ofthe materials in the assistant fishmaster’s room indicates there was anintense fire in this room. The red glowthat firefighters observed in the starboardcorridor on the steel bulkhead of theassistant fish master’s room is consistentwith the burning of a high fuel load48

(bedding, clothing, wood constructionand framing material along thisbulkhead). Based on the foregoingevidence, the Safety Board concludesthat the fire originated in the assistantfish master’s room.

The burn pattern under and beside theleft battery charger found in the assistantfish master’s room indicates that thisdamage occurred early in the course ofthe fire. That is, the fire burned thewooden shelf that supported the chargersbefore the materials (debris) fell ontoand buried this charger. Further, thedifferential heat and fire damage noted inthe left battery charger, as compared tothe right charger adjacent to it, showsthat the left charger was considerablyhotter both inside and outside thecharger case. The aluminum diode(rectifier) heat sink plates of the leftcharger were melted, and some of the

48Pounds of combustibles per square foot of

deck area.

molten aluminum was found under theshelf. The insulation on the transformerwires was completely burned away, butno electrical faults or arcing could befound in this charger. In addition, thecharger contained little fuel that couldhave produced heat sufficient to meltaluminum heat sink plates.

Another possible ignition source inthe assistant fish master’s room was thecook pot found sitting on the deck nextto the bunk-type bed and just forward ofthe battery chargers. Heat damage to thewire tie-downs and the internal pottingmaterial is consistent with excessivelyhigh temperatures inside the appliancedue to overheating. Fire starting exteriorto the cook pot and then spreading to itwould have first destroyed the carpet andpower cord that was coiled beneath thecook pot before causing internal heatdamage to the cook pot. The fact that thecarpet and power cord beneath the potwere unburned supports the conclusionthat the fire did not start exterior to thecook pot.

The location of this cook pot next tothe bed also made it a prime candidate asthe ignition source. In this location,overheating of this appliance could haveignited bedding materials. The room hadnot been occupied for about 6 days. Theroom contained a heat detector but nosmoke detector. Ignition of the beddingcould have occurred sometime duringthe 6 days that the room had beenvacant, and a smoldering combustionmight have gone undetected for sometime. The presence of water in the cookpot would have delayed overheatinguntil the water evaporated.

41

From this ignition source, the firecould have spread to the wheelhouse viatwo routes. First, the cook pot was inclose proximity to the bed. Once flameserupted, the high fuel load in theassistant fish master’s room would havefacilitated rapid fire growth and spreadinto the chase directly above the bed.The fire would have spread through thechase into the wheelhouse.

Second, the combustible gases andsmoke that normally accumulate in theceiling area of a room of origin wouldhave quickly burned through the lightwooden door of the assistant fishmaster’s room, creating another path bywhich fire might have spread. Once thetop of this door was burned, the smoke,heat, and combustible gases would haverapidly spread into the corridor and upthe open stairwell to the wheelhouse.This scenario fits the report of the firsteyewitness (the cook) that he saw flamesin the wheelhouse and 02 deck port door.

Since the door to the assistant fishmaster’s room and the fan vent openingare almost opposite the door to themaster’s room and the hospital room,this fire propagation scenario isconsistent with the master being unableto escape the fire. He appears to havebeen overcome by the products ofcombustion (principally carbonmonoxide) that would have moveddirectly across the narrow corridor to thedoorways of these two rooms. Based onthe foregoing evidence, the Safety Boardconcludes that the most likely ignitionsource was the cook pot in the assistantfish master’s room.

When crewmembers leave theirvessel after a voyage, they often do notcheck their accommodation rooms to

verify that all electrical items have beenturned off and secured, and that smokingmaterials have been removed. Afteroccupants vacate a room, if it is likely tobe vacant for a period of time, the roomshould be checked for fire hazards. Goodmarine practice calls for a responsiblemeasure of “good housekeeping” onboard vessels to lessen the danger of fireor other hazards occurring unexpectedly.Regular checking of rooms for firehazards is one of the best possiblesafeguards against fire ignition. Whilesuch routine checks cannot guaranteevessel safety, they can increase thelikelihood that accidents will beprevented.

The Safety Board therefore concludesthat, had the FCA provided writtenguidance to vessel masters to check onthe fire safety condition of vacantcrewrooms and had such a reviewprocedure been implemented, the firemight have been avoided. Consequently,the Safety Board believes that the FCAshould develop written guidance for itsvessel masters to use to review the firesafety condition of all crewrooms whenthe occupants disembark from the vesseland the room will be vacant, and shouldimplement a procedure whereby theconduct of such reviews may bedocumented.

Fire Safety Standards

Construction -- The extensive use ofcombustible wood constructionmaterials, the use of unprotected, highlyflammable RPU and polystyreneinsulations, and the high concentrationof combustible bedding and furnishingson the ALASKA SPIRIT contributed to

42

a very rapidly spreading fire that wasdifficult to extinguish until much of thecombustible fuel had been consumed.The fuel load was very high on the 02deck because of the wood constructionand the volume of bedding, clothing, andwood furniture in the small rooms.

All of the partition bulkheads wereconstructed of wood with a vinyl veneerthat had a Class C flame spread rating.The assistant fish master’s room hadsteel bulkheads, but they were coveredwith highly combustible woodenstructures. Further, all of the interior hulland deck surfaces, the exteriors of whichwere exposed to the elements, werecovered with RPU foam insulation. Insome areas, sheets of polystyreneinsulation were installed behind thewooden bulkheads and overhead. Thesecombustible materials all contributed tofuel a rapidly spreading fire.

Because of the extensive use of ¼-inch plywood over light woodensupports in the escape corridors, theALASKA SPIRIT would not have metthe requirements of the Coast Guardstructural fire protection regulations forcargo and miscellaneous vessels or theNFPA shoreside LSC. The Safety Boardtherefore concludes that the rapid firegrowth and spread were due to the highfuel load and lack of noncombustibleconstruction.

The Coast Guard had establishedcargo and miscellaneous vesselstructural fire regulations and laterdeveloped the guidelines for fishingindustry vessels in the NVIC 5-86(which refer to the cargo andmiscellaneous vessel regulations (46CFR Subchapter I) for structural fireprotection). Most of these regulations

and guidelines were not incorporatedinto commercial fishing industry vesselregulations.

Had structural fire protectionguidelines been adopted into theregulations for fishing industry vessels,the FCA would still not have beenrequired to implement them. TheALASKA SPIRIT was exempted fromthe regulations because: (1) it carried 49or fewer persons, and (2) it had beenoperating as a fishing industry vesselbefore the effective date of theregulations. The previous owner of theALASKA SPIRIT apparently did not usethe information in the NVIC’s voluntaryguidelines for fire protection whenconverting it into a fishing industryvessel.

Current Coast Guard regulations fornew vessels carrying more than 16persons require that vessels “minimizefire hazards insofar as is reasonable andpracticable” and that “insulation benoncombustible.” Except for NVIC 5-86, there is no other national standard forfishing industry vessels. This accidenthighlights the need to establish structuralfire protection regulations for fishingindustry vessels that carry more than 16persons (the same figure is used in theLSC for shoreside buildings when morethan 16 sleeping accommodations areavailable in the structure). NFPA doesnot have a life safety code for vessels,but it is working with the Coast Guard todevelop such a document.

Following its 1994 investigation ofthe fire in the cargo spaces on the fish

43

processing vessel ALL ALASKAN,49 theSafety Board recommended that theCoast Guard:

M-95-16

Establish, in cooperation with theNational Fire ProtectionAssociation, a national marinesafety standard on the safe use ofrigid polyurethane foam and otherorganic combustible materialinsulations on vessels.

The Coast Guard replied to thisrecommendation that it is working withthe NFPA to develop such a standard.The Safety Board classified thisrecommendation “Open -- AcceptableResponse” on February 6, 1996. Afterthe same accident, the Boardrecommended that the NFPA:

M-95-25

Establish, in cooperation with theU.S. Coast Guard, a nationalmarine safety standard on the safeuse of rigid polyurethane foam andother organic combustible materialinsulations on vessels.

The NFPA replied that it is workingwith the Coast Guard to develop such astandard to address fire protection andlife safety aboard merchant vessels. Thenew standard will be designated NFPA301. Pending the publication of NFPA301, the Safety Board classified therecommendation “Open -- AcceptableResponse” on October 26, 1995.

49Marine Accident Report -- NTSB/MAR-

95/02.

Seeking changes to regulations takestime. In the interests of safety, the CoastGuard could, in the interim, develop anational marine fire safety standard withthe NFPA. A national marine fire safetystandard for commercial fishing industryvessels, containing structural fireprotection standards, would improve thelevel of fire safety on commercial fishingindustry vessels by reducing the amountof highly combustible materials in vesselliving spaces and corridors.

Fire Detection Equipment -- While theALASKA SPIRIT’s previous owner hadinstalled the fire protection equipmentused on the vessel, the responsibility forreviewing the adequacy of thatequipment to ensure the fire safety of thevessel and the crew lay with the currentowner, the FCA. Such a review wouldhave revealed the need for smoke ratherthan heat detectors in the vessel’s livingquarters. When the fire ignited on theALASKA SPIRIT, by the time that the(properly operating) heat detectorsactivated, the fire had advanced to apoint that the master could not escapeand shoreside firefighters could onlycontain it to the 02 deck andwheelhouse. The Safety Board thereforeconcludes that, because heat rather thansmoke detectors were used on theALASKA SPIRIT, the crew was notprovided with sufficient early warning ofthe fire, which led to the death of themaster and allowed the fire to go out ofcontrol.

An operating smoke detector in therooms, and especially in the room oforigin, would have given warning of thefire while it was still in the smolderingstage. Smoldering fires can producesmoke without significantly increasing

44

room temperature. Openings (wire chase,wooden door with ventilation opening,and the opening in the bulkhead for afan) in the room of fire origin allowedsmoke and combustible and poisonousgases to spread quickly into other spacesin the vessel.

Smoke-actuated fire-detecting unitsor independent modular smoke detectors,however, are only required in theaccommodation spaces of thosecommercial fishing industry vessels builtor converted after September 15, 1991,that carry more than 16 persons. Theminimal cost of these household-typebattery-operated smoke detectors, andtheir ease of installation, stronglysuggests the use of this safety device onexisting vessels. The Safety Boardrecognizes that the FCA has installed asmoke detection system on the repairedALASKA SPIRIT and believes that theFCA should install smoke detectors inaccommodation spaces on all its vessels,regardless of whether heat detectors areinstalled.

Fire Suppression Equipment -- By thetime the fire was discovered, it was wellestablished and beyond the crew’scapability to contain it. The crew andshoreside firefighters prevented the firefrom burning back down the port insidestairwell to the 01 deck, and shoresidefirefighters put enough water on the 02deck to prevent heat and flames frompropagating down to the 01 deck. Usingshoreside equipment, firefightersworking in narrow corridors and highheat virtually controlled the fire until itburned itself out.

The regulations for new fishingindustry vessels that are 36 feet and overin length that carry more than 16 persons

require a power-driven fire pump andfire main system, but no fire suppressionsystem in the accommodation area. TheALASKA SPIRIT had a power-drivenpump and fire main system, which werenot required by the regulations for thisexisting fishing vessel, but did not havea sprinkler system. Although automaticfire-extinguishing sprinkler systems arenot required in accommodation spaces,the management of the vessel isresponsible for ensuring that firesuppression equipment is adequate tosafeguard the crew and the vessel in caseof fire. To provide effective fireprotection to the crew and the vessel, firesuppression equipment should be part ofthe power-driven fire pump and firemain system.

The Coast Guard should considerrequiring automatic fire-extinguishingsprinkler systems on fish processingvessels with accommodations that arenot of noncombustible construction.Such vessels often carry large numbersof people not trained as firefighters.They also operate in areas remote fromprofessional firefighting assistance, inweather and sea conditions that couldprevent help from being rendered even ifavailable. Sprinklers also reduce thedependency on vessel personnel forresponding to and extinguishing a fire,which is especially important when areduced crew is staffing the vessel.

The Safety Board therefore concludesthat an installed sprinkler (suppression)system would probably haveextinguished the fire in its early stages ofdevelopment, impeded the spread of firein the accommodation spaces, andpossibly prevented the loss of life.

45

Therefore, in view of the fire dangerposed by the combustible materials usedin the construction of the ALASKASPIRIT and ALASKA VICTORY, theSafety Board believes that the FCAshould install automatic fire suppressionsystems in all its vessel accommodationspaces that are constructed ofcombustible materials.

Existing Standards -- The ALASKASPIRIT investigation has shown that firesafety standards for commercial fishingindustry vessels are inadequate. Inparticular, it highlighted deficiencies inthe areas of structural fire protection, firedetection systems, and fire suppressionsystems. The Safety Board thereforeconcludes that the development and useof a national marine fire safety standardfor commercial fishing industry vesselsthat includes structural fire protectionstandards and fire detection andsuppression systems would improve thelevel of fire safety on board thesevessels. Thus, the Safety Board believesthat the Coast Guard should develop, incooperation with the NFPA, a nationalmarine fire safety standard forcommercial fishing industry vessels,which should include structural fireprotection standards and fire detectionand suppression systems inaccommodation areas, and adopt it intothe regulations.

The Coast Guard reports that, sinceJanuary 1992, a total of 62 new fishingvessels over 79 feet long have enteredthe industry. Only two of these vesselswere over 100 feet long, and only one ofthe two was over 200 feet long.

It is probable that only these 2vessels, out of the 62 entering theindustry, will carry more than 16 persons

and so be required to meet some of thenew fire safety regulations. Even thelarger vessel will likely not carry morethan 49 persons and so will not berequired to meet the structural fireregulations at 46 CFR 28.385.

A combination of reduced fishingquotas, over-capitalization, and owners’wishes to avoid costly implementation ofthe safety features required byregulations on new vessels perpetuatesthe use of older, less fire-protectedvessels. These older vessels continue tooperate without safety improvements,such as smoke detectors and the reduceduse of combustible constructionmaterials. By exempting these oldervessels from safety regulations, twowidely differing standards of safety forthe fishing industry are effectivelysanctioned. But all fishermen and fishprocessors are exposed to the samerigors on their jobs and should beafforded the same level of workplacesafety.

As the result of Safety Boardrecommendations, passenger vesselsafety has been improved internationallyin recent years, with the phasing in ofhigher fire protection levels on vesselsbuilt before the introduction of morestringent fire safety regulations. Theolder, less fire-protected passengervessels are no longer permanentlyexcused from meeting the higher fireprevention standards for new vessels.The same procedure could be used toimprove the fire safety of fishing vessels.

Under current law, existing fishingindustry vessels built before the effectivedate of the regulations are permanently

46

exempted from meeting the newregulations. Because of the prevalence offires that occur on fishing vessels andtheir great human and economic costs,the Coast Guard should seek legislationthat would require the phasing in of firesafety regulations for all fishing vessels,regardless of age. Owners of existingfishing vessels could gradually upgradetheir vessels, in a planned costprocedure, or defer upgrading until theirvessel is no longer permitted to operateand then replace it with a new vessel thatwould meet the higher regulatorystandards. Such action would removefrom operation those vessels currentlyexempted from the safety regulationsand set a single safety standard for thefishing industry.

The Safety Board therefore concludesthat a procedure is needed to improvefire safety on existing fishing industryvessels by phasing in the fire safetyregulations currently applicable only tonew vessels to all vessels, regardless ofage. Consequently, the Safety Boardbelieves that the Coast Guard shouldpromptly seek to change the law torequire the phasing in of fire safetyregulations to apply to all existingfishing industry vessels that carry morethan 16 persons. The process of makingthe same regulations applicable to allsuch vessels should be completed by theyear 2010.

Fire Hose -- Because some Armtexhoses were used on the ALASKASPIRIT, a special adapter was requiredto connect the vessel’s hydrant outletswith the nonstandard fitting of this hose.The Safety Board therefore concludesthat because the ALASKA SPIRIT hadsome fire hoses that were incompatiblewith its hydrants, the crew was initially

delayed in its firefighting efforts. (Giventheir limited resources and the rapidity ofthe fire growth, however, it is doubtfulwhether the ALASKA SPIRIT’s crewcould have saved the master even hadthe hoses been attached to the hydrants.)

The Safety Board is deeply concernedabout the operation of a vessel with firehose equipment that was not onlyincompatible but which had criticalcomponents (i.e. adapter coupling)stowed far away from the hydrants. Itseems evident that if adapters arenecessary, they should be installed. Theresponsibility for ensuring the adequacyof vessel fire hose systems and theirpractical hookup lies with the vessel’smanagement, in this case the FCA. TheSafety Board believes, therefore, that theFCA should direct the masters of all itsvessels to check all fire stations on theirvessels to ensure that fire hose threadcouplers are compatible with vessel firehydrants and to replace incompatibleequipment as appropriate.

Coast Guard regulation 46 CFR28.315(b)(2), requires that fire hoses beconnected to each hydrant at all timesthat the vessel is operating. Thisregulation, however, applies only tocommercial fishing industry vessels thathad their keels laid or were convertedafter September 15, 1991, and thatoperate with more than 16 individuals onboard. Coast Guard regulation 46 CFR95.10-10, which applies to cargo andmiscellaneous vessels, was also notapplicable to the ALASKA SPIRIT. Thisregulation requires that all fire stationhydrants have fire hose coupling threadsof 1 ½-inch and 2 ½-inch sizes. NVIC 5-

47

86 refers to the above regulation as avoluntary standard for uninspectedcommercial fishing vessels.

As part of the regulatory efforts of theCoast Guard to ensure that fishprocessing vessels meet the regulations,every 2 years qualified organizationsmust examine and certify that vesselsmeet the requirements of 46 CFRSubchapter C. To improve the level offire safety on board uninspectedcommercial fishing industry vessels,examiners should ensure that firefightinghoses are attached to and fit fire hydrantsat fire stations.

Survival Factors

Reporting of Fire -- After the fireerupted, reports of it were quicklycommunicated to the SECC, via the 911telephone number. Despite being alone,the emergency operator performed herduties well, not only in handling theincoming calls but also in dispatchingpolice, fire, and medical units.

Nevertheless, more efficientcommunication might have beenbeneficial. Had the watchman identifiedhimself, the 911 operator could havequestioned him for additional details.The watchman might have been a sourceof specific information, such as the exactlocation of the fire on the vessel andwhether individuals might have beentrapped or injured. The FCA did nottrain night watch personnel inprocedures for notifying response centersof an emergency.

The Safety Board therefore concludesthat security night watch personnel onFCA vessels should have a checklist ofinitial notification procedures to ensure

that requisite information is provided toemergency response communicators. Ata minimum, the initial notificationprocedures should address: theemergency’s nature, location, and extent;details as to personnel trapped orinjured; and efforts in process tominimize the damage.

Drills -- The ALASKA SPIRIT’smaster last conducted a fire drill on theprevious fishing trip when the vessel wasat Dutch Harbor. However, the fire drillwas conducted without the crew’s layingout or charging the ship’s fire hose linesfrom any of the hydrants or donning theSCBAs or firefighting gear. As a result,the firefighting system was not testedand the crew was not completely familiarwith the equipment. This accidentdemonstrates the importance of holdingrealistic fire training drills, designed toimprove the crew’s familiarity with theequipment and to test the equipment’seffectiveness. The Safety Boardtherefore concludes that the lack ofrealistic fire drills compromised thevessel’s firefighting system.

Coast Guard regulation at 46 CFR28.270, applicable to the ALASKASPIRIT and all documented fishingvessels with more than 16 individuals onboard,50 requires that drills be carried outas if:

50On documented vessels with 16 or fewer

persons, the rule applies if the vessel operatesbeyond the Boundary lines as listed in 46 CFRPart 7. Generally, the lines are seaward of theshorelines and cross entrances to small bays,inlets, and rivers.

48

There were an actual emergencyand must include participation byall individuals on board, breakingout and using emergencyequipment, testing of all alarm anddetection systems, donningprotective clothing... .

Therefore, given the evidence thatdrills on board the ALASKA SPIRITwere not conducted as if an actualemergency existed, the Safety Boardbelieves that the FCA should developfire contingency plans that improve thereadiness of its vessel personnel andequipment to respond to a fireemergency, and include provisionsconcerning the duties of security watchpersonnel and the training of crew infirefighting techniques by theimplementation of realistic fire drillprocedures. To be realistic, the drillsshould require that each crewmemberknow where all fire and lifesavingequipment is stowed and how to use it.

Significance of the ALASKASPIRIT Investigation

The issues raised by the investigationof the fire on board the ALASKASPIRIT are applicable to the entirefishing industry. Thus, to ensure that allof the recommendations developed as aresult of the ALASKA SPIRITinvestigation receive wide disseminationwithin the industry, the Safety Boardbelieves that the Commercial FishingIndustry Vessel Safety AdvisoryCommittee (CFIVSAC)51 should inform

51Established under the authority of Title 46

USC 4508, the 17-member CFIVSAC advisesthe Coast Guard Commandant, the Secretary ofTransportation, and Congress on safety issuesrelated to commercial fishing industry vessels.

fishing industry vessel owners of thisaccident and advise them to: install ontheir vessels smoke detectors inaccommodation spaces; install automaticfire suppression systems inaccommodation spaces that areconstructed of combustible materials;develop written guidance for vesselmasters to review the fire safetycondition of all crewrooms when theoccupants disembark from the vessel andthe room will be vacant; direct vesselmasters to check fire stations to ensurethat fire hose couplers are compatiblewith vessel fire hydrants; and developfire contingency plans that improve thereadiness of vessel personnel andequipment, including provisionsaddressing the duties of security watchpersonnel and procedures for realisticfire drills.

Toxicological Test Results

The CHT tested the master’s bloodsample for the presence of drugs andfound phenethylamine as adecomposition product but detected noother common drugs. The Safety Boardtherefore concludes that drug use wasnot a factor in this accident. Independenttoxicological tests conducted by theAlaska State Medical Examiner’s Officeand the CHT both found high levels ofCOHb and alcohol in the sample.

Committee members include crewmembers orprocessors on uninspected fish processingvessels, naval architects or marine surveyors,manufacturers of industry equipment, industryeducators or trainers, insurance underwriters forfishing vessels, and the general public.

49

Carboxyhemoglobin (COHb) -- TheAlaska State Medical Examiner’s Officefound that the master’s death was causedby smoke inhalation. The results of theCHT test for cyanide, a toxicantsometimes found in smoke, werenegative. Another toxicant, carbonmonoxide (CO), was a component of thesmoke, as evidenced by the high levelsof COHb found in the master’s bloodsample. The Alaska Medical Examiner’sOffice and the CHT reported COHbsaturation levels of 90.6 percent and 84percent, respectively.

According to Hill,52 the master wouldhave become incapacitated and lostconsciousness at 40-50 percent COHbsaturation, before succumbing at thereported level of 84-90.6 percent COHbsaturation.

The site where the master’s body wasfound—inside the hospital room door—indicates that he had been awakened bythe fire alarm. By the time the alarmsounded, air containing CO had probablyalready circulated through the commonventilation system and the louvereddoors on the 02 deck.

Although the concentrations of CO inthe master’s room and hospital roomwhen the alarm sounded cannot be

52Hill, I.R., Aviation, Space, and

Environmental Medicine, “An Analysis ofFactors Impeding Passenger Escape fromAircraft Fires,” March 1990, pp. 261-265.

determined with certainty, at 1-2 percentconcentration of CO in the air, anexposed person would have had about120 seconds before becomingincapacitated at the level of 40-50percent COHb saturation; at 5-10 percentconcentration in the air, incapacitationwould take about 30 seconds. In eithercase, the master would have hadperilously little time for escape. (Seeappendix G for more informationconcerning the toxic effects of COHbsaturation.)

Alcohol -- The blood alcoholconcentration (BAC) of the master’sblood sample was reported as 0.353gm/dL by the Alaska MedicalExaminer’s Office and as 0.360 gm/dLby the CHT. While this is a high BAC,the Safety Board found that thepreponderance of evidence, both withregard to the master’s lifestyle and thecircumstances of his death, indicates thatthe high BAC was caused bypostmortem generation rather thaningestion. (See appendix H for additionalinformation regarding the master’sBAC.) The Safety Board thus concludesthat the high alcohol content in themaster’s blood sample was likely due topostmortem generation rather thaningestion.

50

CONCLUSIONS

1. The weather conditions and the vessel mechanical systems were not factors in thisaccident.

2. The fire originated in the assistant fish master’s room.

3. The most likely ignition source was the cook pot in the assistant fish master’sroom.

4. Had the FCA provided written guidance to vessel masters to check on the firesafety condition of vacant crewrooms and had such a review procedure beenimplemented, the fire might have been avoided.

5. The rapid fire growth and spread were due to the high fuel load and lack ofnoncombustible construction.

6. Because heat rather than smoke detectors were used on the ALASKA SPIRIT, thecrew was not provided with sufficient early warning of the fire, which led to thedeath of the master and allowed the fire to go out of control.

7. An installed sprinkler (suppression) system would probably have extinguished thefire in its early stages of development, impeded the spread of fire in theaccommodation spaces, and possibly prevented the loss of life.

8. The development and use of a national marine fire safety standard for commercialfishing industry vessels that includes structural fire protection standards and firedetection and suppression systems would improve the level of fire safety on boardthese vessels.

9. A procedure is needed to improve fire safety on existing fishing industry vesselsby phasing in the fire safety regulations currently applicable only to new vessels toall vessels, regardless of age.

10. Because the ALASKA SPIRIT had some fire hoses that were incompatible withits hydrants, the crew was initially delayed in its firefighting efforts.

51

11. Security night watch personnel on FCA vessels should have a checklist of initialnotification procedures to ensure that requisite information is provided toemergency response communicators.

12. The lack of realistic fire drills compromised the vessel’s firefighting system.

13. Drug use was not a factor in this accident.

14. The high alcohol content in the master’s blood sample was likely due topostmortem generation rather than ingestion.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of the fireaboard the ALASKA SPIRIT was the failure of The Fishing Company of Alaska,Incorporated, to address the inadequate fire safety conditions and practices on the vessel.Contributing to the severity of the damage and the loss of life was the lack of fire safetystandards for commercial fishing industry vessels.

RECOMMENDATIONS

-- to the U.S. Coast Guard:

Develop, in cooperation with the National Fire Protection Association, anational marine fire safety standard for commercial fishing industryvessels, which should include structural fire protection standards and firedetection and suppression systems in accommodation areas, and adopt itinto the regulations. (Class II, Priority Action) (M-96-1)

Promptly seek to change the law to require the phasing in of fire safetyregulations to apply to all existing fishing industry vessels that carry morethan 16 persons. (Class II, Priority Action) (M-96-2)

Publicize the circumstances of this fire to the fishing industry. (Class II,Priority Action) (M-96-3)

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-- to The Fishing Company of Alaska, Incorporated:

Develop written guidance for your vessel masters to use to review the firesafety condition of all crewrooms when the occupants disembark from thevessel and the room will be vacant, and implement a procedure wherebythe conduct of such reviews may be documented. (Class II, PriorityAction) (M-96-4)

Install smoke detectors in accommodation spaces on all your vessels,regardless of whether heat detectors are installed. (Class II, PriorityAction) (M-96-5)

Install automatic fire suppression systems in all your vesselaccommodation spaces that are constructed of combustible materials.(Class II, Priority Action) (M-96-6)

Direct the masters of all your vessels to check all fire stations on theirvessels to ensure that fire hose thread couplers are compatible with vesselfire hydrants and to replace incompatible equipment as appropriate. (ClassII, Priority Action) (M-96-7)

Develop fire contingency plans that improve the readiness of your vesselpersonnel and equipment to respond to a fire emergency, and includeprovisions concerning the duties of security watch personnel and thetraining of crew in firefighting techniques by the implementation ofrealistic fire drill procedures. (Class II, Priority Action) (M-96-8)

-- to the Commercial Fishing Industry Vessel Safety Advisory Committee:

Inform fishing industry vessel owners of this accident and advise them to:install on their vessels smoke detectors in accommodation spaces; installautomatic fire suppression systems in accommodation spaces that areconstructed of combustible materials; develop written guidance for vesselmasters to review the fire safety condition of all crewrooms when theoccupants disembark from the vessel and the room will be vacant; directvessel masters to check fire stations to ensure that fire hose couplers arecompatible with vessel fire hydrants; and develop fire contingency plansthat improve the readiness of vessel personnel and equipment, includingprovisions addressing the duties of security watch personnel andprocedures for realistic fire drills. (Class II, Priority Action) (M-96-9)

53

-- to the National Fire Protection Association:

Develop, in cooperation with the U.S. Coast Guard, a national marine firesafety standard for commercial fishing industry vessels, which shouldinclude structural fire protection standards and fire detection andsuppression systems in accommodation areas. (Class II, Priority Action)(M-96-10)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALLChairman

ROBERT T. FRANCIS IIVice Chairman

JOHN A. HAMMERSCHMIDTMember

JOHN J. GOGLIAMember

GEORGE W. BLACK, JR.Member

June 11, 1996

55

APPENDIX A

Safety Board Investigation

Investigation

The U.S. Coast Guard notified the National Transportation Safety Board of thisaccident on May 30, 1995. Four investigators from the Safety Board's Washington, D.C.,headquarters were dispatched immediately to Seward, Alaska. They began investigationof the accident on June 1, 1995. The Safety Board invited the National Fire ProtectionAssociation (NFPA) to assist in the investigation, and the NFPA sent one investigator toSeward.

The Safety Board investigated this accident independently, under the authority ofSection 304(a)(1)(F) of the Independent Safety Board Act of 1974.

The report is based on the factual information developed as a result of theinvestigation and additional analyses made by the Safety Board. The Safety Boardconsidered all facts in the investigative record that are pertinent to its statutoryresponsibility to determine the cause or probable cause of the accident and to makerecommendations.

The Fishing Company of Alaska, Inc., the U.S. Coast Guard, and the SewardVolunteer Fire Department participated as parties to the investigation.

Hearing and Deposition

Sworn testimony regarding this accident was taken on June 2, 1995, in Seward,Alaska, and on June 5, 1995, in Seattle, Washington. On August 28-29, 1995, two SafetyBoard investigators went to San Francisco, California, to witness the testing of a heatdetector that had been removed from the ALASKA SPIRIT and to examine the batterychargers removed from the ALASKA SPIRIT. On October 29, 1995, two investigatorswent to Seattle, Washington, to visit the ALASKA SPIRIT’s sister vessel, the ALASKAVICTORY, and to examine undamaged battery chargers taken from that vessel.

APPENDIXES

57

APPENDIX B

Crew Licensing Information

Master

ALASKA SPIRIT Master Todd M. Eggers received the original issue of his master'slicense on April 3, 1989, as Master of Near Coastal Uninspected Fishing Industry Vesselsof not more than 1600 gross tons; also, Master of Near Coastal Steam or Motor Vesselsof not more than 200 gross tons. On November 19, 1990, his license was amended toinclude Master of Ocean Uninspected Fishing Industry Vessels of not more than 2,000gross tons. He renewed the license on February 23, 1994. The license included anendorsement as a Radar Observer (Unlimited) and had an expiration date of January 6,1998.

Chief Engineer

Richard D. Lewis, Sr., was on his third issue of a license to serve as Chief Engineer ofLimited Oceans Motor Vessels of not more than 5,000 horsepower. The license wasissued on October 19, 1994, by the U.S. Coast Guard Officer-in-Charge of MarineInspection (OCMI), New Orleans, Louisiana.

Assistant Engineer

Frank P. Lemacks, Jr., held a license to serve as Chief Engineer of Limited Oceans MotorVessels of any horsepower, as well as Second Assistant Engineer of Motor Vessels of anyhorsepower. His license was issued for the fourth time on February 23, 1995, by theOCMI, New Orleans, Louisiana.

59

APPENDIX C

Battery Charger Examination

On August 29, 1995, the two battery chargers found on the ALASKA SPIRITwere examined, photographed, and disassembled at Fire Cause and Analysis,1 inBerkeley, California. (The charger found on the left side in the assistant fish master’sroom corresponded to model SP1-35-20B; the charger from the right side corresponded tomodel SP1-35-30B.)

The less damaged battery charger, which had been found on the right side in theassistant fish master's room, was examined first. Aside from the burned and meltedcondition of its meters, circuit breaker switches, and other plastic-type electrical devices,the battery charger did not show significant signs of damage. This charger had no meltedmetal parts. The two aluminum heat sink plates for the rectifiers (diodes) on this chargerwere intact, and the diodes were attached. The electrical insulation on the transformers inthe charger was intact, although the transformers had experienced extensive fire damage.

The investigators next examined the other (left) battery charger taken from theassistant fish master's room. The plastic-type electrical devices on this charger wereburned more extensively than the right charger's devices. The investigators separatelyremoved the two transformers of the left charger from the chassis, took them apart(removed laminated plates from the transformer coils), and examined them. All electricalinsulation had been burned from the transformers. There was no apparent arcing betweenprimary and secondary coils on either of the two transformers in this charger. Twoaluminum heat sink plates, on which the diodes had been mounted, had melted.

The exterior meter, switches, and connectors on the left charger were completelydestroyed by the fire. Interior fire damage was extensive. All electrical insulation on thetransformers in the left charger was destroyed. Investigators found no evidence ofelectrical arcing on the transformers.

1An independent company hired by the FCA to perform the analysis.

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APPENDIX E

Building Codes

The three major groups — the International Conference of Building Officials(ICBO), the Southern Building Code Congress International, Inc. (SBCCI), and theBuilding Officials and Code Administrators International (BOCA) — have developednational model building codes. The BOCA, the SBCCI, and the ICBO publish theNational Building Code (NBC), the Standard Building Code (SBC), and the UniformBuilding Code (UBC), respectively. Each code group is a consensus of building officialswith a degree of uniformity among their model codes, although different regional andgeographic needs are met by the different code groups.

Because of the high flammability of plastic foam insulation, the U.S. modelbuilding codes (shoreside) were modified in 1976 to limit the use of cellular plasticmaterials. The NBC, SBC, and UBC require that foam plastic insulation have a flamespread index of not more than 75 and a smoke development rating of not more than 450,when tested in accordance with ASTM E84. In addition, when used on room sidesurfaces, they either must be protected (covered) by a thermal barrier equal in fireresistance to ½-inch gypsum board, or they may be used only in buildings that havesprinkler systems.1 Both requirements apply to foam more than 4 inches thick. The highflame spread rate of RPU foam is attributed to its relatively low decompositiontemperature (about 325 oF) and high smoke emission rate (combustible gases).

In the 1960s and early 1970s, spray-on RPUs were advertised as self-extinguishing and nonflammable and were used extensively as thermal insulation inshoreside structures. In some instances, RPU foams were involved in fires during theconstruction phase.2 RPU foam flammability and its associated hazards are bestdemonstrated by the full-scale room studies conducted by various investigators.

In a 1973 report by W.F. Marconi,3 a room was completely lined with 1 ½-inch-thick RPU foam with a flame spread index of 200, when tested in accordance with ASTME84. The wall and overhead lining were ignited from a source in the corner. The firespread rates in this experiment exceeded the response capability of the automatic

1Model code provisions pertaining to foam plastics insulation. The Society of Plastics Industry,

Inc., 1990.2Paul, George H., Clougherty, Edward V., and Lathrop, James K., Fire Journal, “Federal Reserve

Bank - Fire in Exposed Urethane Insulation in Building Under Construction,” Boston, Massachusetts, July1977, pp. 33-55.

3Marconi, W.F., Fire Journal, “Large-Scale Fire Tests of Rigid Cellular Plastic Wall and RoofInsulation,” Boston, Massachusetts, November 1973, pp. 24-26.

APPENDIX E

70

sprinkler system. In a 1986 Swedish study,4 a room was covered with various materials,including RPU foam, and ignition was initiated in the corner. The flash over5 delay wasmeasured, and the process took 6 seconds when the room was lined with RPU foam,compared with 157 seconds when lined with wood particle board.

4Sundstrom, B., Full-Scale Fire Testing of Surface Materials, Technical Report SP-RAPP

1986:45, Swedish National Testing Institute, Boras, 1986.5Transition from a small fire to full-room involvement.

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APPENDIX F

Conditions Reported by the SVFD Fire Chief that AffectedALASKA SPIRIT Firefighting

Absence of Forward Access Doors on the 02 Deck

The absence of such doors to accommodation areas limited the firefighters’ ability toapproach one side of the fire. Deeply seated fires in the master’s room and the forwardpart of the 02 deck were not accessible during most of the incident due to intense heat.

Lack of Natural Ventilation in Accommodation Areas

In response to the high heat levels and volume of smoke, firefighters used blowers toexhaust heat and smoke from the 02 deck. Also, due to the limited firefighting access tothe 02 deck, firefighters used power saws and sledge hammers to make holes in the steelbridge deck and forward bulkhead of the 02 deck. These openings immediately beganreleasing heat and smoke, which allowed the firefighters to introduce water down ontothe fire from the bridge deck and permitted firefighter entry into the confined space.

Necessity of Frequent Firefighter Rotation

The fire chief rotated his crews to provide them respite from the intense heat and allowthem to change SCBA bottles. Due to the narrowness of the corridor, the fire chief felt itwas too hazardous to have two crews of firefighters in the accommodations areasimultaneously. During the firefighting lull while crews rotated, the fire would advancedown the corridor to the point of entry. Consequently, each crew had to rebattle the fireback to the point where the other had left it.

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APPENDIX G

Toxic Effects of Carboxyhemoglobin Saturation

The blood component hemoglobin normally carries oxygen from the lungs to thetissues. Hemoglobin, however, has a much greater affinity for carbon monoxide (CO)than for oxygen. When a person inhales air containing CO, the compoundcarboxyhemoglobin (COHb) is formed in the blood as CO occupies the positions on thehemoglobin molecule normally filled by oxygen. As indicated in table 1 (below), as thelevel of COHb saturation increases, the toxic effects become increasingly severe.

Table 1 — Toxic effects of Carboxyhemoglobin saturation

%COHb Saturation Effect

10 Psychomotor and judgment inefficiencies

10-20 Exertional dyspnoea (shortness of breath)

20-30 Headaches

30-40 Nausea, dizziness, and muscular weakness

40-50 Syncope (loss of consciousness, fainting)

50-60 Convulsions

60-70 Coma

80 Rapid death

The time required for an exposed person to reach an incapacitating level of COHbsaturation depends on the concentration of CO in the air. Fire-produced concentrations ofCO in the air can range as high as 10 percent. Lower concentrations generally occur inwell-ventilated fires. Higher concentrations occur in poorly ventilated fires, such as wasthe case during the early stages of the smoldering combustion in the assistant fishmaster’s room.

Hill’s report1 tabulated COHb levels as functions of CO concentration in the airand exposure time. The length of time it would have taken for the master to reach anincapacitating level of COHb saturation cannot be precisely calculated, but a range can bederived (see table 2).

1Hill, I.R., Aviation, Space, and Environmental Medicine, “An Analysis of Factors Impeding

Passenger Escape from Aircraft Fires,” March 1990, pp. 261-265.

APPENDIX G

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Table 2 — Carboxyhemoglobin saturation as a function of exposure time andpercentage of carbon monoxide in the air

% of CO % COHb Saturationin the air 10

SECONDS30

SECONDS60

SECONDS120

SECONDS

0.1 0.2 0.6 1.3 2.5

1 2.5 7.5 15.0 30.0

2 5.0 15.0 30.0 60.0

5 12.5 38.0 75.0 —

10 25.0 75.0 — —

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APPENDIX H

Master’s Blood Alcohol Level

The blood alcohol concentration (BAC) of the master’s blood sample wasreported as 0.353 gm/dL by the Alaska Medical Examiner’s Office and 0.360 gm/dL bythe Center for Human Toxicology (CHT). The average can be expressed equivalently as0.36 percent of alcohol by weight/volume. If the BAC was caused by ingested alcohol,the physiological effects in an individual who had not developed a tolerance for alcoholwould have been “stupor, marked incoordination, and possibly coma.”1

Upon receipt of the master’s blood sample, the CHT staff observed that it did notappear to be whole blood and that the sample had hemolyzed due to decomposition. TheCHT test found the sample’s blood hemoglobin concentration to be 6.8 gm/dL, which isabout 42 percent of that normally found in whole blood.

Literature on blood alcohol, forensic tests, and Government regulations on BAClevels all refer to concentrations in whole blood. Specimens from live individuals presentno problem, but postmortem samples may have undergone extensive clotting. When someblood solids are absent because of clotting and sedimentation, the remaining fluid bloodspecimen will have a higher-than-normal water content.

Since testing detects alcohol in proportion to water content, the amount of alcoholfound is also greater than it would be in a sample of whole blood. Such was likely thecase with the master’s blood sample, since the deputy fire marshal attending the autopsynoted difficulties in obtaining a fluid sample due to coagulation. Scientific literature2

indicates that, in these circumstances, a whole blood sample’s BAC might have been 10-20 percent lower than in the hemolyzed specimen.

Nevertheless, even if the master’s whole blood BAC had been 10-20 percentlower than the detected value, the physiological effects of that level of ingested alcoholwould still have been incapacitating. Consequently, the key question to consider is theorigin of the alcohol. Was it ingested or was it a consequence of postmortem generation?Investigators found no evidence that the master had ingested alcohol on the day orevening before the fire, although that possibility cannot be conclusively discounted.

Investigators also considered the likelihood of postmortem alcohol generation —that is, alcohol generated by microbial action within the body after death. Confirmed

1Freimuth, H.C., Medicolegal Investigation of Death, 3rd ed., W.U. Spitz (Ed.), “Forensic Aspects

of Alcohol,” Springfield, Illinois, 1993, pp. 767-775.2Garriott, J., (Ed.), Medicolegal Aspects of Alcohol Determination, PSG Publishing, Littleton,

Massachusetts, 1988.

APPENDIX H

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postmortem alcohol levels in excess of 0.30 percent have been reported3 and thecondition can best be inferred by a positive finding of alcohol in blood, coupled with theabsence of alcohol in urine and/or vitreous humor. Neither urine nor vitreous humor wasavailable from the master’s autopsy for cross-validation of the blood sample.

Postmortem generation of alcohol is likely to occur when a body has beenexposed to elevated temperatures and time elapses between death and the collection of atest specimen. Such conditions were present in this case. Before being removed from thevessel, the deceased had been exposed to heightened temperatures (because of the fire)for more than 10 hours. Further, the hemolyzed condition of the blood sample noted bythe CHT and the autopsy report’s description of the body are both indicative ofdecomposition. In summary, the conditions were highly favorable for postmortemgeneration of alcohol.

3Canfield, D.V., Kupiec, T., and Huffine, E., Journal of Forensic Sciences, 38(4),“Postmortem

Alcohol Production in Fatal Aircraft Accidents,” 1993, pp. 914-917.