Some of the rather frightening items that were drawn out:

USCG Report (PDF)

Neither the bridge team nor the fire fighting teams had a meaningful grasp of the fire-fighting tactics needed fight this fire

The fire fighting teams had never actually drilled in the engine room

The OOD on the bridge at the time of the fire "reset" the alarm system which resulted in the "Hi Fog" suppression system not being activated until a full 14 minutes after the fire erupted.

It was not until 2 1/2 hours the fire erupted that the Captain ordered the use of CO2 and dry powder.

The engine room was ventilated far too soon afterwards which resulted in the fire flashing up again.

The emergency generator failed several times.

The severity of the fire caused cable-runs to burn through which eliminated any hope of restoring power from the forward engine room. It's worth noting that the "Hi Fog" system was located beneath these crucial cables and could have prevented this.

The fire was caused by a catastrophic fault in Diesel Generator 5 (DG5) in which it ejected a 780 lb crankshaft from the casing. It's worth noting that DG5 had been experiencing torsional vibration since July of that year.

The air cooler on DG5 was corroded to an almost degenerative state.

CO2 valves were installed backwards.

CO2 Valves were packed with inferior hemp packing which the USCG and surveyors had previously issued recommendations against. The hemp caused leaks and clogging which affected the system's ability to perform as required.

Carnival could not supply complete, or in some cases, ANY data on engine performance and faults.

I imagine both Carnival Corp and Fincantieri have a lot of work ahead of them to address and rectify the faults outlined which run the gamut from shoddy workmanship, incomplete documentation or lack of any at all, to faulty systems and only the most perfunctory of training.

I also imagine that the USCG along with the various flag-states and survey groups will be instituting stricter oversight of newbuilds and certification of class.

I've been in this industry a long time and that report shocked the heck out of me.

Tim

[ 07-16-2013: Message edited by: Tim in Fort Lauderdale ]

[ 07-16-2013: Message edited by: Tim in Fort Lauderdale ]

[ 07-16-2013: Message edited by: Tim in Fort Lauderdale ]

[ 07-16-2013: Message edited by: Tim in Fort Lauderdale ]

[ 07-16-2013: Message edited by: Tim in Fort Lauderdale ]

http://www.cruiseindustrynews.com/cruise-news/9577-carnival-responds-to-coast-guard-report.html

It will be interesting to see what further responses or specific proof of actions taken are provided going forward. Some of the responses were so vague and general as to be worrisome:

In response to crew training familiarity:

c. Our crew was familiar with the procedures for engine room fires. We have reviewed all of our procedures and have reinforced our training at
all levels for firefighting. We have modified our approach to deploying the CO2 system.

d. Our crew was familiar with the engine room layout and equipment and firefighting strategy and procedures. We have reviewed all of our
procedures and have reinforced our training at all levels for firefighting.

When the USCG detailed out in their report that the crew had never actually trained or drilled in the engine room(s) but only on the mooring deck or in marshaling areas, responses like the above raise my antennae.

Is Carnival turning into General Motors of the 1980s?

quote:

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Originally posted by desirod7:
Splendor, Miracle, Concordia; no innovative ships since Queen Mary 2.[...]

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For example, given the importance of the Hi-Fog, why was the alarm panel reset, and reset twice, on the bridge? What flaws in knowledge, training and procedures prompted those actions? I would have expected this to have been investigated thoroughly, but the report gives no indication of any conclusions about that.

So how thorough a job of investigating this accident did the Coast Guard actually do?

And although there's a lot of good mood music about lessons learned, just when were they learned (if at all)? What will we find out about Carnival Triumph's superficially similar accident? Will "lessons learned" turn out to have been merely hollow words?

quote:

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Originally posted by desirod7:
Splendor, Miracle, Concordia; no innovative ships since Queen Mary 2.

Is Carnival turning into General Motors of the 1980s?

Lack of direction, too big, run by bean counters cashing in on the brand equity?

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quote:

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Originally posted by Globaliser:
[QB
For example, given the importance of the Hi-Fog, why was the alarm panel reset, and reset twice, on the bridge? [/QB]

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quote:

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Originally posted by timb:
To have an officer reset this panel on the surface would seem to suggest there had been prior false alarms and the expected outcome was to reset it

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But the report doesn't say whether they looked at this question and whether this was in fact the answer, or whether it was something else that required rectification.

And even if this was the answer, the report doesn't say whether the investigation looked deeper into questions about why there had been false alarms and whether anything had been done to reduce the incidence of them.

And perhaps most pertinently, whether anything had been done in the safety management system to reduce the risk of the "boy crying wolf" syndrome - which, after all, is exactly the syndrome that would cause someone to reset the panel twice and thus disable the Hi-Fog system, even though on both occasions the alarm was genuine and demanded immediate action.

To my mind, this also raises questions about the 40 second delay which has now been eliminated. Was this a knee-jerk reaction that will in the long term do more harm than good? What was the purpose of the 40 second delay? Was it to allow for an attempt to report that a particular alarm is a false alarm so that the Hi-Fog can safely be disabled? If the cause of the false alarms has not been diagnosed and remedied, will this now result in the Hi-Fog being repeatedly triggered? Will it tempt people to do something else to circumvent this, possibly disabling some other protective system in the process?

All of these seem to me to be obvious questions to ask and obvious topics to investigate. Yet the report doesn't go into any of them. Which leads me to the question of just how good was this investigation, anyway?

quote:

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Originally posted by Globaliser:
...Which leads me to the question of just how good was this investigation, anyway?

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I made the same remark to someone the other day. The report comments on the drill logs and states there was no detail with some entries other than that a drill was held. So how can they come to the conclusion that no drills were held in the engine room over a six month period prior to the fire and that the fire crew were unfamiliar with the engine room.

Carnival say the crews were familiar with the engine room, in which case if true, it is Carnival's fault having this stated as they should have logged the details properly. But such an investigation should get to the bottom of these things and not a your word against mine scenario.

The report itself is airy fairy, with 'it appears' and not fact. Certainly not as detailed and comprehensive as previous reports I have read; but then I am a layman in these things and not qualified to comment Perhaps fuller reports are produced for the people that matter.