MARINE SAFETY INVESTIGATION

REPORT 165

Independent investigation into the fire andmuster of the passengers aboard the

Australian flag passenger ferry

in Bass Straiton 24 February 2001

Spirit of Tasmania

Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation Act 1912

Navigation (Marine Casualty) Regulations

investigation into the fire and muster

of the passengers aboard the Australian flag passenger ferry

Spirit of Tasmania

in Bass Strait

on 24 February 2001

Report No 165

August 2002

ISSN 1447-087XISBN 1 877071 07 2

Investigations into marine casualties occurring within the Commonwealth's jurisdiction are conductedunder the provisions of the Navigation (Marine Casualty) Regulations, made pursuant to subsections425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations provide discretionarypowers to the Inspector to investigate incidents as defined by the Regulations. Where an investigationis undertaken, the Inspector must submit a report to the Executive Director of the Australian TransportSafety Bureau (ATSB).

It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incidents so as to improve safety at sea and enhance the protection of the marineenviroment.

To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website or obtained from:

Australian Transport Safety BureauPO Box 967Civic Square ACT 2608

Phone: 02 6274 64781800 621372

Fax: 02 6274 6699Email: marine@atsb.gov.auInternet address: www.atsb.gov.au

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Contents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Spirit of Tasmania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Emergency equipment and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Evacuation procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

The Ship’s Photographer shop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Passengers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

The fire scene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

ATSB technical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

The electrical system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Short circuit and earth leakage protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Inspections of electrical equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Shipboard risk management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Licencees’ staff training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Fire protection and detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

The response to the emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Fire fighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Cabin evacuation and mustering the passengers . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Passenger survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Safety information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Effectiveness of alerting/alarm system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Reaction to the alarm/emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Barriers to effective movement under alarm conditions . . . . . . . . . . . . . . . . . . . . . .21

The passenger and crew mustering system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Passenger survey conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Spirit of Tasmania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

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Figures

1. Spirit of Tasmania at Station Pier in Melbourne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

2. General arrangement of Spirit of Tasmania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

3. Plan of the Ship’s Photographer’s shop on E Deck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

4. Doorway to store area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

5. Heat damage to deckhead panelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

6. Fire debris in the forward section of the store . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

7. Fire damage to computer workstation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

8. Fire damage under computer workstation showing ‘V’ pattern in corner . . . . . . . . . . . . . .13

9. The features of the recovered section of the electrical lead and drain hose . . . . . . . . . . . .15

10. A remnant of a copper conductor wire (arrowed) exposed by cutting the

remaining intact insulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

11. Fire: Spirit of Tasmania events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . .24

v

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vi

SummaryAt 1800 on 23 February 2001, the Australianflag roll on-roll off passenger ferry Spirit ofTasmania departed Station Pier in Melbournebound for Devonport in Tasmania. On board theship were 967 passengers, 112 crew and 10 stafffrom licensed businesses. The weather was goodwith wind from the south-south-west at 17-21 knots and a low swell. The ship wasaveraging a speed of approximately 17 knots.

At 0114 the second mate on the bridge receiveda fire ‘pre-warning’ from a detector heidentified as being in ‘The Ship’s Photographer’shop on ‘E’ deck. Approximately one minutelater the detector initiated a fire alarm followedshortly after by the second detector located inthe shop. He immediately contacted the twonight security stewards and asked them toinvestigate the alarms. The stewards called backa short time later confirming that there was afire, which appeared to be in the store at therear of the photography shop. The two mencould see into the shop through the locked glassfront door but could not enter as they did nothave the key. The second mate then called themaster and started the muster signal in the crewaccommodation.

The master arrived quickly on the bridge and,after assessing the situation including furtherconfirmation that the fire was serious, initiatedthe muster signal throughout the passengeraccommodation. The time was 0120.

By this time members of the attack and back-upemergency parties had started to arrive outsidethe photography shop with fire fightingequipment. The mate who was leading the attackparty, nominated two integrated ratings to donbreathing apparatus to enter the shop andextinguish the fire.

As smoke was spreading from the shopthroughout the ship’s accommodation, the matecalled the bridge and requested that the firedoors throughout the ship be closed remotely.The time was 0125.

The shop door key was obtained from the shopmanager and the two nominated IRs entered thephotography shop, initially with hand heldextinguishers. Although the smoke was verythick, they located the fire in the store area atthe rear. They attempted to extinguish the firewith the hand held extinguishers but found thatthe fire kept re-igniting. The lead IR realisedthat the only option was to cool the area with afire hose. Both men retreated from the shop. Afire hose was quickly charged, both men re-entered the shop and, after five minutes, the firewas extinguished using salt water. After theshop area was thoroughly checked, the fire wasdeclared out at 0144.

While the fire was being extinguished, thepassenger muster was proceeding relativelysmoothly. By 0152 all passengers had beenmustered at their designated muster areas by theship s crew. The crew dealt with a number ofproblems during the muster including the needto move one group away from a smoke filledmuster area, one passenger with a suspectedheart attack and two others who hadexperienced asthma attacks. All passengers werekept at their muster areas for the next hourwhile the smoke in the accommodation wascleared and the area of the fire monitored forany signs of re-ignition.

At 0255 it was decided that the smoke in theaccommodation had cleared sufficiently for thepassengers to be escorted back to their cabins.The rest of the voyage was completed withoutincident with Spirit of Tasmania arriving atDevonport on schedule on the morning of 24 February.

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Sources ofInformationMaster and crew of Spirit of Tasmania

The passengers aboard Spirit of Tasmania

TT-Line Company Pty Ltd

ASP Ship Management Pty Ltd

Tasmanian Fire Service

Australian Maritime Safety Authority

Mr Adam Brumley, AMOG Consulting Pty Ltd

ReferencesConsolidated edition of the InternationalConvention for the Safety of Life at Sea(SOLAS), 1997.

Australian/New Zealand Standard AS/NZS3760:1996, ‘In-service safety inspection andtesting of electrical equipment’.

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Narrative

Spirit of TasmaniaSpirit of Tasmania (figure 1) was an Australianflag roll on-roll off passenger ferry operated byTT-Line Company Pty Ltd (TT-Line), ofDevonport. ASP Ship Management, based inMelbourne, was responsible for the technical,and some of the personnel management, of theship.

TT-Line is wholly owned by the state ofTasmania and has terminals in Devonport inNorthern Tasmania and Port Melbourne inVictoria. For most of the year, Spirit ofTasmania was the only vessel operated by TT-Line, with the ship carrying freight, passengersand vehicles across Bass Strait on a schedule ofsix crossing per week. Higher demand for theservice during the summer period meant thatSpirit of Tasmania completed eight crossings perweek.

Spirit of Tasmania was built in 1986 atSeebeckwerft AF, Bremerhaven, Germany, andfor seven years operated as Peter Pan on theBaltic Sea between Germany and Sweden. Thevessel was purchased in 1993 by the Tasmaniangovernment and entered service on Bass Straitin November 1993 after completing extensivemodifications. In July 1995 Spirit of Tasmaniaunderwent further modifications andrefurbishment during a dry docking inNewcastle, New South Wales.

The ship was constructed under GermanischerLloyd (GL) survey with a hull class of �100A5 M(Restricted International Service) E2, Ro-Ro-Ship, Ferry, Passenger Ship, IW andmachinery class of � MC E2 AUT-14h. Theship has been maintained continuously in classwith GL since the time of building.

Spirit of Tasmania is 161.52 m in length overall,has a moulded depth of 18.52 m and amaximum breadth of 28.20 m. It has a grosstonnage of 31 356 and a maximum draught of6.217 m. The ship has 10 decks above the tanktop level alphabetically labelled from A deck atthe top, to K the deck above the tank tops(figure 2). Machinery spaces containingaccommodation ventilation fans and theemergency generator are located on an 11thdeck above A deck. There are 1324 berths forpassengers and crew in 468 cabins and hostelstyle accommodation.

Crew cabins are located on A deck aft of thebridge and on B deck forward of the crew messareas. Passenger cabins are located forward ofrestaurant, shopping and entertainment areas onC, D and E decks. The reception area andpurser’s office is located on E deck with walk-on passengers accessing the area via gangwayslocated midships, port and starboard, on F deck.Further passenger cabins are located outboard ofthe two upper vehicle decks on F and G deckswith more passenger cabins at the forward endof J deck and the hostels located at the forwardend of K deck. The engine room is located aft ofthe passenger accommodation on J and K decks.

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A DeckB Deck

J Deck

K Deck

H Deck

F Deck

C DeckD DeckE Deck

G Deck

FIGURE 2:General arrangement of Spirit of Tasmania

‘A’ Class bulkheadsforming fire zones The Ship’s Photographer shop

The ship has the capacity to carry 35 semi-trailers and 360 standard sized cars on its threevehicle decks. The main vehicle deck isdesignated H deck and is a continuous deckrunning the full length of the ship. H deck isdivided along its fore-aft centre line by a casingwhich contains the engine room exhaustuptakes, ventilation and other service trunking,five lift shafts, and stairways for accessing theengine room and lower accommodation spaces.Vehicle access to H deck is via the bow andstern doors and ramps. Semi-trailer cargo isusually loaded on the outboard sides of H deckwith smaller vehicles being loaded along thecentre line of H deck and via hydraulicallyactuated ramps onto the upper vehicle deckslocated either side of the centre casing on F andG decks. The main vehicle deck is divided bythree sets of flood control doors, which protectthe ship’s stability in the event of H deckbecoming flooded.

Spirit of Tasmania has watertight subdivisionbelow H deck in accordance with therequirements of the International Convention forthe Safety of Life at Sea. On Spirit of Tasmaniathis means that the ship has sufficient damagestability and subdivision to survive two adjacentwatertight compartments being flooded.Hydraulically operated watertight doors, whichare usually left open, seal the watertightbulkheads in the J and K deck passenger areas.The engine room is similarly divided into fourcompartments by watertight bulkheads fittedwith watertight doors, which allow these spacesto be sealed in an emergency.

Spirit of Tasmania’s propulsive power isprovided by four, 8-cylinder, MAK 8M552AK,medium speed diesel engines, which provide atotal of 19,600 kW. The four main engines areclutched into two reduction gearboxes, which inturn drive a pair of contra-rotating controllablepitch propellers to give the ship a service speedof 20 knots. Auxiliary power is provided by four1795 kW diesel generator sets, which supply themain switchboard with 660 V, 60 Hz, 3-phasealternating current. Transformers are used tostep the voltage down to 440 V 3-phase and

220 V single phase power for use throughout theship.

On the night of the incident, Spirit of Tasmania’screw complement was 112. The crew consistedof:

• the master;

• four mates (including the ship’s securityofficer who is designated 1st mate);

• the chief engineer and eight engineers(including a chief electrician and a hotelservices electrician);

• two shipwrights;

• chief and 12 integrated ratings (IRs); and

• two pursers, the hotel manager, fourexecutive and 62 other stewards, theexecutive chef, 12 other cooks and onesupernumerary.

The master on board Spirit of Tasmania at thetime of the incident held a Master Class 1certificate of competency issued by theAustralian Maritime Safety Authority and hadbeen at sea for 30 years. He had been appointedmaster nine years previously and had spent thelast two years as one of the three permanentmasters on Spirit of Tasmania. All other shipsstaff were appropriately qualified.

Emergency equipment andprocedures Spirit of Tasmania held current certificates forall ship’s safety equipment, including the firefighting equipment. The ship was subject to aweekly inspection by the master and seniorofficers to ensure that the vessel was wellmaintained and the principles of good shiphusbandry were observed.

Spirit of Tasmania has a sophisticated firedetection system with every space in the vessel,where required, fitted with a detector. The firedetection panel is located on the bridge andmonitors the fire zones within the ship,identifying any space in which a smoke detectoris activated. A fire plan is also displayed on thebridge showing the layout of the ship and the

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fire detection and fire fighting resources. Thereare 1256 detectors located in three zonesthroughout the ship. The majority of thedetectors fitted in the system are of ionisationtype. Optical and heat detectors are fitted inareas such as galleys and engine room. Eachdetector has an individual address. Whenactivated the system will indicate on theconsoles, both on the bridge and in the engineroom, which detector has activated.

Structurally, the passenger areas above F deckon Spirit of Tasmania are divided into threemain vertical zones. The bulkheads dividingthese zones are ‘A’ class, constructed of steel oran equivalent material and are insulated to resistthe passage of heat and smoke for a minimumof one hour. Each vertical zone has a number offire-protected escape routes from the accommo-dation areas to the muster areas and the boatdeck. Passages which cross from one verticalzone to another are equipped with automaticfire doors. These fire doors may be operatedfrom the bridge, or locally, in the event of a fire.

Evacuation proceduresSpirit of Tasmania had a planned passengerevacuation procedure. There were sevendesignated areas located on B, C, and D decksfor mustering passengers. Each passenger wasallocated a specific muster area depending onhis/her berth. Passengers were provided with anumber of sources of information detailing theevacuation procedures. A safety pamphlet wasprovided when boarding the ship and there wasfurther written information located on the insideof each cabin or hostel dormitory door. A safetybriefing, including information on how thepassengers would be notified of an emergencyand what action they should take, was playedover the ship’s public address system shortlyafter leaving port.

During an evacuation, individual crew memberswere detailed to clear a specific section ofcabins and escort the occupants to theirallocated muster area. In the event of

abandonment of the ship, passengers were to beissued with life jackets at the muster areas andthen led to lifeboats or life rafts by ship’s staff.

The evacuation system was reliant on crewtraining and participation, passenger awarenessand the safe design and construction of the ship.New crew members underwent safety training inaddition to a mentoring process. Theirindividual responsibilities in the event of anemergency were clearly defined and practiced.Fire and abandon ship drills for the crew wereconducted each week.

The Ship’s Photographer shopFive licensed enterprises operated on Spirit ofTasmania: Admirals Casino; Galacticaamusement arcade; Allder’s on Board gift shop;Kingford Promotions travel agency and TheShip’s Photographer shop. These businesseswere owned by private companies and operatedon Spirit of Tasmania under a license agreementwith TT-Line. The Ship’s Photographer shop wasowned and operated by Sundisk Pty Ltd. Thestaff who operated the license areas wereemployed directly by the owners of thebusinesses. They were accommodated inpassenger cabins on the ship but participated aspart of the ship’s crew in safety drills and wereincluded on the crew muster lists.

The Ship’s Photographer shop (photographyshop) was located on the port side of E deck(figure 3). The Promenade restaurant wasadjacent to the after end of the photographyshop and a lavatory block was located forwardof it. The photography shop fronted onto theport side promenade, which was a passage thatconnected the ship’s reception area to thePromenade restaurant. The inboard bulkhead ofthe shop was bounded by an internal stairwelland the engine room casing. Access to the shopwas from the promenade via a plate glass door.The space was originally used as a children’splayroom when the ship operated in Europe.

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Both the forward and inboard bulkheads of theshop space, together with the deck anddeckhead are rated as ‘A.60’ divisions.1

Prior to the ship entering service on Bass Strait,the licensed business areas, passenger amenitiesand entertainment areas on C, D, and E deckswere extensively modified. The photographyshop on E deck was constructed in 1993 with

some further modifications performed while theship was in dry dock in 1995.

During the 1995 dry-docking the Promenaderestaurant was constructed in place of anexisting cafeteria. Part of the refurbishinginvolved sealing an access door and shortpassage from the after end of the store area of

the photography shop into the restaurant. Asmall locker for the new restaurant wasconstructed in its place.

At the time of the fire the photography shopconsisted of a display space with a floor areaapproximately 4.2 m athwartships and 6.4 mfore and aft. The forward area of the shop wasoccupied by display racks and the after endcontained the sales desk, a film developing

machine and a print processing machine. Therewere two smoke detectors fitted to the deckheadof the shop display space, as part of the ship’sfire detection system.

Inboard of the shop display area were storageand office areas which were accessed via a doorleading from the display area. The office and

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Silver recovery unit

Developing machine

Counter

Access door sealed in 1995

Hose for chemical o’flow

Power boardComputer

StairwellEngine casing

SinkFridge under

Store/Office area

Shower

PromenadeFire doors

Promenade restaurant

Lavatory Shop/Display

Forward Aft

Restaurant cupboard

Printing machine

Battery charger

A. 60 Bulkhead

A. 0 Bulkhead

B. 30 Bulkhead

Unrated division

Fire detectors

FIGURE 3:Plan of The Ship’s Photographer shop on E deck

1 'A' class bulkheads are of steel construction, 'B' Class bulkheads are of alternative non-combustible material, able to prevent the passage of flame. The qualifying number indicates the insulation property in minutes in terms of standards required under the Safety of Life at Sea Convention 1974, Ch.II-2 Regulation 3.

storage area was approximately 1.2 m wide by5.5 m fore and aft. The most forward section ofthe store area (about 1.2 m x 1m), originally abathroom including a shower recess, was used tostore spare film processing chemicals.

At the time of the fire the photography shop hada stock of photographic chemicals as well as alarge stock of paper products. The chemicalswere of either Dangerous Goods Class-8(Corrosives) or were of unspecified class. Mostof the chemicals were noted to cause possibleeye or skin irritation but were not combustible.However one of the chemicals was liable todecompose and give off hazardous fumes in theevent of a severe fire. The ship’s staffmaintained a register of material safety datasheets for all the chemicals.

Immediately aft of the chemical storage areawas an office space approximately 2.2 m inlength. A bench was fitted along the inboardbulkhead with an in-built sink at its forward endand a computer work-station at the after end. Aseries of shelves above the desk were used tohouse a printer and compact disk writer and,above these, documents and some smaller itemsof stock were stored. A small fridge was locatedunder part of the bench forward of the computerwork-station, with the space immediately underthe work-station used to store of boxes full ofphotograph envelopes. There were also anumber of boxes of picture frames storedagainst the bulkhead opposite the bench.

Aft of the office space in the shop store was asmall area with equipment lockers adjacent tothe inboard bulkhead and a small dark room atits after end. Two battery chargers were locatedon a shelf adjacent to, and just aft of, the doorfrom the shop space.

Power for the fridge, printer, compact diskwriter, and the two camera battery chargers inthe after store area was supplied from a powerboard fixed to the bulkhead adjacent to thecomputer work-station. Power to the batterychargers was provided by a flexible electricalcable run through the door frame into the officearea and over the door from the shop, to the

shelf where the chargers were located. A shortextension lead had been used to connect thefridge power lead to the power board. Thisextension lead was run along the deck under thecomputer work-station with the connectionbetween the fridge plug and the extension leadsocket located on the deck in the corner underthe bench.

A reinforced plastic hose was led from themachines in the sales/display area to the sink inthe store area. The hose was run through thebulkhead dividing the display and store areas tothe inboard bulkhead, then forward through thebulkhead between the forward and after storeareas. The hose ran along the deck beneath theoffice desk before rising to terminate at thesink. The hose was rigged to drain any overflowof a chemical used in the film developing andprinting processes.

No automatic ship fire detection or suppressionsystem was fitted within the store/office area.

The incidentAt 1800 on 23 February 2001, Spirit ofTasmania sailed from Station Pier in PortMelbourne with 967 passengers, 112 crew and10 staff employed by the licensed businesses onboard. The ship’s destination was the northernTasmanian port of Devonport some 232 miles tothe south-south-east. Shortly after leaving theberth, the standard safety briefing was playedover the ship’s public address system in all thepassenger areas.

By 2042, Spirit of Tasmania had cleared pointLonsdale, at the entrance of Port Phillip Bay, tobe running clear en route to Devonport. Theweather was good, with wind from the south-south-west at 17-21 knots and a moderate sea ona low swell.

At 2145 the manager closed the photographyshop for the evening. Prior to closing the shopthe manager propped open the door into thestore area at the rear of the shop to help dispelsome chemical fumes resulting from a spill ofchemical the previous evening. The spill had

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emanated from the drain hose for the silverrecovery unit. Usually the manager ensured thatthe door into the store area was locked when theshop was closed.

At 0100 the ship’s two night security stewardsconducted rounds of the ship’s accommodation.They passed the photography shop at approxi-mately 0103 and did not notice anythingunusual.

At 0114 the second mate on watch on thebridge, received a fire ‘prewarning’, on the firedetection panel on the bridge, from detector0460 ‘Child.Pl.Room Deck-E’. He identified thedetector on the ship’s fire plan as one of twodetectors in the photography shop on E deck.Approximately one minute after the prewarning,detector 0460 initiated a fire alarm on thedetection panel, followed shortly after by aprewarning from detector 0459, the otherdetector in the shop. At 0116 detector 0459 alsoinitiated a fire alarm. The second mateimmediately contacted the night securitystewards by 2-way radio and instructed them toinvestigate the alarms.

Initially, one night security steward walkedaround the corner from the catering office in thereception area on E deck to The Ship’sPhotographer shop. He looked through the plateglass entrance door into the shop to see smokecoming out of the store area at the back of theshop. He could also see some light at the backof the shop and, while he was looking, he saw apiece of paper float out of the store area on fire.He immediately called the bridge to confirm theexistence of the fire. The first night securitysteward was quickly joined by the second nightsecurity steward who had been on a coffeebreak. Both men tried their keys in the lockeddoor of the shop to find that none would fit.They stayed at the front of the shop andgathered the portable fire extinguishers locatedaround the area. They also ran out the fire hoselocated at the closest fire point2 at the forwardend of the Promenade restaurant. The shop

filled quickly with smoke as the two men wereassembling the fire fighting equipment.

After being notified by the night securitysteward that the fire alarm in the photographyshop was not a false alarm, the second matecalled the master and started the muster signalin the crew accommodation on A and B decks.The master arrived very quickly on the bridgeand took the watch from the second mate andinstructed him to go down to the photographyshop and report on the situation. The masteralso instructed the 12-4 IR to go through thecrew accommodation and rouse the crew.

The second mate proceeded quickly to the shoprousing the mate and security officer on his way.Once he arrived at the shop, he found that it wasfull of smoke and that smoke was starting to fillthe promenade outside the shop. He contactedthe master, reported the situation and made hisway back to the E deck reception area.

On the bridge, the master was joined by thethird mate, the chief purser and an IR. Once thesecond mate had reported the situation in thephotography shop, the master instructed thechief purser to initiate the muster signalthroughout the whole of the ship's accommo-dation. The mustering of the passengerscommenced and the chief purser started arunning log to record the timing of events. Thetime was 0120.

The mate had dressed quickly after being rousedby the second mate, and proceeded directly tothe photography shop. There he met the secondmate and the night security stewards who leftshortly afterwards to perform their respectivemuster duties.

By this time the IRs in the attack and back-upfire teams had started to arrive at thephotography shop. After leaving their cabins onA deck on hearing the muster signal and beinginformed of the situation by the 12-4 IR, theyhad proceeded to their muster area on the portside of B deck. Once there, the word was passedon the location of the fire. They had movedquickly down and opened the equipment locker

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2 Cupboard containing a portable extinguisher, a fire main connection, with a fire hose and nozzle.

at the fire station, adjacent to the port gangwayon F deck, where they collected breathingapparatus (BA), torches, extinguishers an axeand a lifeline. Three of the IRs who had donnedBA then proceeded to the photography shop onE deck via the promenade.

The security officer also arrived outside thephotography shop during this time and, seeingthat the shop doors were locked, he wentimmediately to the shop manager’s cabin in thepassenger accommodation on G deck andobtained the key from the shop manager. Hemoved quickly back to the shop and unlockedthe doors.

The chief steward and two other stewards hadbeen closing the ‘Tiger’ bar on C deck whenthey heard the muster signal over the ship’spublic address system. The chief steward rangthe bridge and was informed that there was afire in the photography shop and that thepassengers were to be mustered. The threestewards went immediately to the crewaccommodation and started knocking on doorsto ensure that all the crew were awake andmoving and had been informed that there was tobe a full evacuation of the passenger accommo-dation.

At approximately 0125, the master made thedecision to slow the ship to five knots. This wasa precaution in case the situation became rapidlyworse and the ship had to be abandoned.

At this time, the mate saw that there was smokeissuing from cracks around the closed front doorof the photography shop. He was concernedabout the spread of the smoke into the rest ofthe accommodation and so he used the localtripping switch to close the fire doors forwardof the shop on the promenade. He alsocontacted the bridge to request that all firedoors throughout the accommodation beremotely closed to slow the spread of thesmoke. The time recorded on the bridge forclosing the fire doors was 0125. Later, at 0135,the watertight doors were remotely closed fromthe bridge and the ventilation to the shop areawas shutdown by the engineers.

Once the attack party had assembled outside theshop, the mate nominated two of the IRs to gointo the shop to extinguish the fire. A lifelinewas attached to the leading IR, their BA waschecked, and they moved to enter the shop, eachman equipped with a dry powder extinguisher.One of the shipwrights kept a time board tomonitor the two men in BA.

As the door was opened and the two menentered the photography shop, smoke billowedout to fill the corridor outside, forcing most ofthe crew to move back to the reception area. Themate and the chief IR, who was handling thelifeline, lay on the deck outside the shop. Asmore smoke filled the corridor, the mate andchief IR were forced to move back behind thefire doors forward of the shop, with one of thedoors open just enough to feed the lifeline.

The smoke inside the shop was very thick andeven with torches the IRs could not see morethan a metre ahead. The two men initially madetheir way to the developing machine at the afterend of the shop. Finding nothing, they movedtowards the rear of the shop and then sawflames in the store area. As they got closer, themen saw two areas burning in the forward partof the store, one on the left adjacent to thebulkhead dividing the store from the displayarea, and another to the right around thecomputer work-station. They used the drypowder extinguishers on both areas toextinguish the fires momentarily but, as the areawas extremely hot, flames flared up againalmost immediately. The lead IR realised thatthe only option was to use water to cool the areaand so the men withdrew from the shop. A firehose was charged. The two men re-entered theshop with the hose and within five minutes hadextinguished the fire.

While the fire was being extinguished, areasadjacent to the photography shop were beingchecked for hot spots by members of the backupparty led by the security officer and the secondmate. No hot spots were found in any of theadjacent spaces although the second mate notedthat there was water dripping through to the

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vehicle deck below. The backup party also notedthat smoke was leaking into an adjacent lockerat the forward end of the Promenade restaurantand the deck above.

After ensuring that the fire was out, the twointegrated ratings came out of the photographyshop to report to the mate. They changed the airbottles on their BA sets and then went back intothe shop with the fire hose to cool the area ofthe fire by spraying water on the bulkheads anddeckhead in the store area. At 0144 the chief IRnotified the bridge that the fire was out.

The engine room was also notified that the firehad been extinguished and engine room staffwere sent to check the funnel casing adjoiningthe shop.

At 0150, the hotel services electrician wasinstructed to isolate the power to thephotography shop at the local electrical distri-bution board. When he inspected thedistribution board he found that one of thecircuit breakers supplying the power outlets inthe shop was in a tripped condition.

Evacuation of the passengers by the hotel staffwas proceeding smoothly while the fire wasbeing fought. By 0130 all muster areas had beenmanned. At 0151 the chief purser announcedover the ship’s public address system that thefire had been extinguished but that passengerswere to continue to muster and remain at theirmuster stations until the smoke had been clearedfrom the accommodation. At 0152 the secondmate reported to the bridge that everyone was attheir muster stations. The chief purser recordedthat final reports were received on the bridgefrom all muster stations by 0211.

The crew had been presented with a number ofproblems during the evacuation, includingexcessive smoke in muster area six, in theNauticals restaurant on D deck, whichnecessitated moving the passengers into musterarea seven in the Huon Room restaurant also on

D deck. One passenger suffered a suspectedheart attack and two other passengersexperienced asthma attacks. These passengerswere eventually stabilised after being moved tothe ship’s hospital and attended by the ship’snurse and two doctors, who were travelling aspassengers.

During the next hour or so the photographyshop was continuously monitored for any signof the fire reigniting. A deckhead panel withinthe shop was taken down to see if there was anyfire as a result of the heat transmitted into theceiling cavity, but no signs of damage due toheat or smoke were found. Both fire detectorheads were also isolated in the shop so that thedetection system could be reset.

At 0205 fire doors on C, D, and E deck wereopened to help clear the smoke from theaccommodation.

At 0212, the engineering staff started to re-establish the accommodation ventilation byopening the fan dampers and restarting theventilation fans. Passengers were made ascomfortable as possible at the muster areas bythe hotel services staff and kept informed of thesituation regularly by the chief purser over thepublic address system.

The master was concerned about the passengerwith a heart problem and so, at 0235, he rangthe engine room to indicate that he would beworking the ship up to full speed to get toDevonport as quickly as possible. By 0255 thesmoke had cleared sufficiently for thepassengers to be escorted back to their cabins bythe hotel services staff.

After the passengers had returned to their cabinsand the ship was on passage at full speed, themaster inspected the photography shop and thencontacted AusSAR to report the fire. Acontinuous watch was maintained on the shopand the surrounding areas for the remainder ofthe voyage.

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Comment andanalysis

EvidenceTwo investigators from the Australian TransportSafety Bureau (ATSB) attended Spirit ofTasmania in Devonport on the afternoon of 24 February 2001 and continued the investi-gation on board until the vessel arrived inMelbourne on the morning of 25 February2001. The primary aim of the investigation wasto establish the cause and circumstances of thefire, its initiation, detection, and extinction. Inaddition, given the current internationalregulatory focus on the safe evacuation ofpassenger vessels, measuring the effectivenessof the ‘real’ passenger evacuation, whichoccurred on board Spirit of Tasmania as a resultof the fire, was seen to be a high priority of theinvestigation.

Evidence relating to the cause of the fire wasgathered at the fire scene in the photographyshop.

Evidence regarding the circumstances of theincident and the sequence of events wasobtained by interviewing various members ofthe crew in addition to various documentaryevidence in the form of logs etc. Thoseinterviewed included: the master, mate, securityofficer, second mate, electrician, hotel manager,chief steward, night security stewards, chief IR,the photography shop manager and the IRs inthe attack party who fought the fire.

Various other documentary evidence relating tothe investigation was obtained from the ship andfrom TT-Line including: official log books,vessel certification, fire plans, crew trainingplans, procedures relating to emergency andevacuation, crew and passenger manifests andinformation relating to chemicals used in the

photography shop. TT-Line also provided someinformation on the history of the modificationsmade to the photography shop in 1993 and1995.

An extract from the events and causal factorschart for the incident is reproduced in figure 11.

PassengersTo establish the effectiveness of the emergencyevacuation procedures and the effectiveness ofthe crew, a survey in the form of a questionnairecomprising 28 questions relating to the fire andevacuation was developed jointly by ATSB andTT- Line.

The questionnaire was designed to elicitinformation on:

• the effectiveness of safety information;

• the effectiveness of the alerting/alarmsystem;

• reaction to the emergency alarm;

• barriers to effective movement under alarmconditions; and

• the effectiveness of the passenger and crewmustering system.

Of the 967 passengers on board Spirit ofTasmania on the night of 24 February, TT-Linehad contact details for 291 who had madebookings directly through their reservationsystem. These passengers were posted a copy ofthe questionnaire, which ultimately resulted in123 completed questionnaires returned. Theinformation contained in the completedquestionnaires was collated and analysed by theATSB to produce the report contained inappendix 1.

The fire sceneThe fire scene in the photographic shop wasexamined by the two investigators from theATSB in the company of a fire scene examinerfrom the Tasmanian Fire Service. The primaryaim of the examination was to determine thesource of ignition of the fire.

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The retail/display area of the shop showedextensive smoke and water damage throughoutwith some heat damage in the upper part of theshop, particularly the deckhead adjacent to thedoor into the store area where some mountedplastic fittings had melted. There was noevidence of flame damage within the displayarea apart from in the doorway leading into thestore area at the rear (figure 4).

Inside the store area, all the bulkheads anddeckhead panels showed extensive fire andsmoke damage. The examination revealed thatthe fire had started in the forward end of thestore/office area and had been mainly confinedto this area. In many areas plastic laminatefacing of the bulkhead and deckhead panels hadeither been burnt away or delaminated from thebacking particle board. In all of these areas thefire resistant particle board had remained whollyintact (figure 5).

In the forward section of the store, the deck wascovered in fire debris (figure 6). The debrisconsisted mainly of charred paper, broken glassand melted plastic. Most of the debris was lyingin the area of the computer desk and adjacent to

the opposite bulkhead. Among the debris werethe remnants of the electrical power-board,which had been fixed to the bulkhead adjacentto the computer work-station. Examination ofthe remnants of the power board showed that theplastic components of the board and of theplugs to the extension lead supplying the fridge,CD writer, printer and battery chargers had beendestroyed, to leave only the conductors withinthe board relatively intact. Of the electrical leadsplugged into the power board only the copperconductors remained. The position andcondition of the power board presented onepossible source of ignition for the fire.

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FIGURE 4:Doorway to store area

FIGURE 5:Heat damage to deckhead panelling

FIGURE 6:Fire debris in the forward section of the store

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FIGURE 7:Fire damage to computer workstation

FIGURE 8:Fire damage under computer workstation showing ‘V’ pattern in corner

On closer inspection, the seat of the fireappeared to be centred low in the area aroundthe bench where the computer was located. Thecomputer monitor and keyboard both showedextensive fire damage (figure 7). The compactdisc writer and printer on the shelf above thecomputer, and a stock of manuals on the shelfabove that, had been destroyed. Systematicclearance of the debris from the deck under thecomputer work-station (mostly partially burnedcardboard boxes containing photographenvelopes), revealed a characteristic fire ‘V’pattern low in the corner between the enginecasing bulkhead and the part bulkhead betweenthe forward and after sections of the store(figure 8). The pattern of the burn damage inthe surrounding boxes of photograph envelopesindicated that the flame had travelled from apoint close to the deck in an upwards direction,partially consuming the boxes of envelopes inits path.

Adjacent to the burn pattern under the computerwork-station lay a section of a short extensionlead, which had connected the power board tothe power lead from the fridge (figure 9). Theplastic hose used to drain chemical from thesilver recovery unit in the shop to the sink in thestore lay alongside the connection between theextension lead and the fridge lead. This hosehad been partially damaged by the fire and hada charred hole in it adjacent to the extensionlead connection.

It was concluded from the fire sceneexamination that the likely sources of ignitionfor the fire were the electrical power board orthe short extension lead supplying power to thefridge. To positively establish the source ofignition, the remnants of the power board, shortextension lead, fridge power lead and a shortsection of the chemical drain hose, which hadfused to the extension lead, were taken forfurther examination by the technical analysisunit of the ATSB.

ATSB technical analysisThe technical analysis unit of the ATSBexamined the remnants of the power board andfound that there was no evidence ofshorting/fusing between any of the conductorswithin the power board or on the pins of theplugs, which had been plugged into it. It wasconcluded that the damage to the board wasmost likely to be the result of the fire, not thecause.

After examining the section of extension lead,fridge power lead and chemical hose, theATSB’s technical analysis unit provided thefollowing report:

A section of electrical extension lead located atthe seat of the fire was recovered for detailedexamination. The extension lead supplied powerto a fridge. It was apparent that the section of thelead had been looped and trapped between thelead connection plug and a reinforced plasticdrain hose (waste photographic processingchemicals). The plastic material on the side of theplug in contact with the lead and drain hose hadbeen affected by melting and charring (see fig 9).

The trapped section of lead (plastic insulation andcopper conductor strands) had been destroyed.The features of the ends of the conductor strandsprotruding from the intact section of the leadwere consistent with melting and resolidification(see fig 10).

The plastic drain hose had also been affected bylocalised melting and charring to a degree thatcreated leaks. The blue coloured compounds onthe plug pins are consistent with a reactionbetween the copper alloy of the pins and wastephotographic processing chemicals.

ANALYSISIt is likely that the complete destruction of thecopper conductor wires in the section of theelectrical lead trapped between the plug fittingand drain hose was caused by electrical arcingbetween the conductor wires.

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In normal use, electrical arcing betweenconductor wires is prevented by the dielectricproperties of the polymeric materials used inelectrical lead construction. Dielectric strengthdepends on material properties and the distancebetween the conductors. A significant factor inthe electrical breakdown of polymeric (plastic)dielectric materials is the loss of dielectricthickness by deformation. Because plastics arevisco-elastic materials they will deform if amechanical load is imposed on the material for aperiod of time. Electrical heating effects willexacerbate the process of deformation.

CONCLUSIONSIt is evident that electrical arcing occurredbetween the copper conductor wires of thesection of lead trapped between the plug anddrain hose. There was no evidence of arcingbetween the pins of the plug fitting.

It is likely that the significant factor in the

development of arcing between the lead wires

was the imposition of a mechanical load on the

trapped section of the lead.

Based on the technical analysis unit’s findings,it is probable that the fire in the photographyshop was caused by arcing/heating as a result ofthe breakdown of the insulation between theconductors in the section of extension leadtrapped between the chemical drain hose and theplug. It is likely that the poly vinyl chlorideinsulation in the lead had ‘flowed’ until thinenough to allow heating/arcing (a short circuit)between the conductors after being subjected tothe weight of the boxes of photographenvelopes. These boxes had been stored underthe computer work-station, resting on theplug/lead/hose, for a considerable period of time(approximately three months according to theshop manager).

Neither moisture, from a spill of water/chemicalfrom the sink or the fridge, nor a leak from thechemical drain hose contributed to the fire. It isprobable that the hole in the chemical drain hoseadjacent to the plug was the result of the fire.There was no evidence of any accelerant at thefire scene which may have increased the speedof flame propagation.

The electrical system Short circuit and earth leakage protection

Analysis of the remains of the electricalextension lead indicated that the initial shortcircuit may have occurred between the activeconductor and either the neutral or earthconductor in the lead. It was not possible toidentify which of these two leads was the first tocomplete the short circuit. In either case, if theshort circuit protection within the electricalsystem had isolated the power to the lead at anearly stage, the fire may have been prevented.In the case of a current flow to the earthconductor in the lead, the ship’s earth leakage

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FIGURE 9:The features of the recovered section of the electricallead and drain hose (two views)

FIGURE 10:A remnant of a copper conductor wire (arrowed) exposed by cutting the remaining intact insulation

detection system may also have alertedengineering personnel to the short circuit. Therewas no evidence to indicate that there was suchan earth fault detected prior to the fire.

Like all ships, Spirit of Tasmania was protectedat multiple levels against short circuits in itselectrical distribution system. In the case of theshort circuit in the extension lead in thephotography shop, the first level of protectionwas the circuit breaker within the power boarditself, rated at 10 amps. The next level of shortcircuit protection was provided by a circuitbreaker in the local distribution board for thewhole power circuit, into which the power boardwas plugged, this was rated at 16 amps. Thereare further circuit breakers in the distributionsystem, progressively higher rated, which aredesigned to protect against short circuits atprogressively higher levels. The fire in thephotographic shop occurred despite thesemultiple levels of short circuit protection.

The circuit breaker in the power board wasfound after the fire in a tripped condition.Similarly when the hotel services electricianopened the local distribution board at approxi-mately 0150 after the fire had beenextinguished, he found that the circuit breakersupplying the power board in the photographyshop had tripped. The tripped condition of thesecircuit breakers requires explanation.

Considering the sequence of events, it is likelythat the initial rate of insulation breakdownbetween the conductors in the extension leadwas slow. Eventually the insulation thinned tothe point where a current was established fromthe 220 volt active to the, nominally zero volt,neutral or earth conductors. Once the currentwas established, the resultant heating wouldhave been rapid even for a relatively smallcurrent (but less than required to trip the circuitbreaker) flowing across the high resistance ofthe remaining insulation. With the rapid heating,the remaining insulation would have brokendown quickly with a progressively higher shortcircuit current flowing between the conductors

until the 10 amp circuit breaker tripped on thepower board. By this time the insulation on theextension lead must have started to burn with aready source of fuel for the fire in the cardboardboxes sitting on top of it.

The distribution board circuit breaker may havetripped at the same time as the power boardcircuit breaker, (depending on the amount ofcurrent at that instant). The other possibility isthat this breaker tripped sometime later due to asecond short circuit, perhaps when the fire hadconsumed the insulation on the power board orwhen water had been sprayed into the store tofight the fire.

Inspections of electrical equipment

As a vessel managed by ASP Ship Management,Spirit of Tasmania was subject to the technicalprocedures and policies applicable to all vesselsmanaged by the company. These included apolicy and associated procedure (QPRO-8.17,‘Testing of Portable Electrical Equipment')relating to the periodic testing and inspection ofportable electrical equipment.

Procedure QPRO-8.17, contains instructions forship’s personnel regarding the type of portableelectrical equipment to be tested and thefrequency and method by which such equipmentshould be tested. The procedure does not referspecifically to the testing of extension leads butstates: ‘This procedure must be read inconjunction with AS/NZS 3760:1996 “in-service safety inspection and testing of electricalequipment”.’

AS/NZS 3760:1996 states under section 1.1‘Scope’:

This standard specifies procedures for the in-service safety inspection and testing of single andpolyphase electrical equipment, other than fixedequipment, which is designed for connection by aflexible power supply cord and plug to a lowvoltage supply. It applies also to cord extensionsets, (author’s emphasis), electrical portableoutlet devices, cord-connected residual currentdevices and portable isolation transformers.

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The standard stipulates that all equipment mustbe inspected prior to initial introduction toservice. QPRO-8.17 states:

It is the responsibility of the chief engineer ofeach vessel to ensure that portable electricalequipment which has not been tested by aqualified electrician, shall be tested according tothis procedure.

QPRO-8.17 also stipulates that portableelectrical equipment used in areas like cabinsand offices must be re-tested every 12 months.Neither the extension lead, nor the power board,in the store of the photography shop had everbeen tested or inspected by a suitably qualifiedmember of the ship’s engineering staff. Had thelead been tested and its conditions of servicebeen inspected at some time in the three monthsbefore the incident, the failure of the lead andresultant fire may have been prevented.

The hotel services electrician on board Spirit ofTasmania stated that standard AS/NZS3760:1996 was, indeed, used for guidance whentesting of the portable appliances on the vessel,however he indicated that it was not usualpractice to test either extension leads or powerboards. In this regard there appears to be somediscrepancy between the intent of QPRO-8.17and its application on board Spirit of Tasmania.In submission TT-Line’s Chief Executive Officerstated:

As you have correctly noted the inspection andtagging standard set out in Procedure QPRO-8.17as read in conjunction with AS/NZS 3760:1996covers electrical extension leads and powerboards. I am advised that extension leads were, infact, inspected and tagged in accordance with thedesignated procedure at the time of the incident.Further, I am also advised within the last 2 yearsTT-Line supplied the entire ship’s complimentwith power boards that incorporated the correctlyrated circuit breaker. Accordingly, it is mostlikely that the extension lead and power box wasbrought on board by Sundisk’s personnel withoutthe knowledge or approval of the Chief Engineerand/or ship’s engineering and electrical staff.

Shipboard risk managementThe ASP Ship Management qualitymanagement system in use aboard Spirit ofTasmania included a number of procedures forensuring the occupational health and safety ofthe crew and for preventing accidents on thevessel. These procedures included theformulation of a ‘Health, Safety andEnvironment Committee’ (QPRO-8.24), the useof ‘Hazard Logs’ for identifying workplacehazards, periodic ‘Shipboard Safety Surveys’(QPRO-8.27) and ‘Shipboard RiskManagement’ (QPRO-8.28). The stated purposeof these interlinked procedures was to pro-actively identify hazards in the form of ‘unsafeacts and conditions associated with the crew andvessel’ and ‘to assist in the assessment ofidentified hazards in terms of their risk and thenmanage that risk.’

All regular crew members received training inidentifying hazards and were encouraged toenter any hazards they may identify in one ofthe ‘Hazard Logs’ located in various placesaround the ship.

In addition to the ‘Hazard Log’ system, QPRO-8.27 stipulates that areas including store roomsmust be regularly surveyed by designatedmembers of the ship’s crew to identify hazardssuch as hazardous materials, storage andelectrical equipment. Like the entries in the‘Hazard Logs’, safety survey results werepresented at the monthly meetings of the Health,Safety and Environment Committee. Thiscommittee, which was made up of seniormembers of the crew, assessed the risks of anyhazards identified, (guided by QPRO-8.28), andthen made a decision about any requiredremedial action.

The photography shop store contained stocks ofchemicals as well as an extensive range of paperproducts. It is not possible, after the fire, toassess how tidily and safely the paper andchemicals were kept. However such stores are a

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potential, if low-level hazard, and should bestowed properly and inspected regularly. Thestowage of the boxes of photograph envelopeson top of the electrical extension lead under thecomputer work-station was an identifiable firehazard. A regular inspection of the photographyshop by ship’s crew or a safety survey may haveidentified such a hazard and thus prevented thefire. There were no records of any safety surveyor inspection of this area at any time prior to thefire.

Access for regular ship’s crew to the licensedbusiness areas on Spirit of Tasmania waslimited, even for normal ship’s routines andprocedures, including the weekly inspections bythe master and senior officers. These inspectionsnormally occured when the ship is in port whenthe licensed business areas are closed andsecure and their staff are off duty. The purposeof such inspections, however, is to ensurecleanliness and safety and hence no area in theship should be restricted.

Indeed at the time of the fire, neither the matenor the security officer had a key to thephotography shop and had to obtain the keydirectly from the shop manager, although aspare key for the shop was located in themaster’s key locker. Valuable minutes may havebeen lost if the shop manager had not beenreadily available while the spare key was foundor if another method of access to the shop hadto be used.

Licensees’ staff trainingThe staff working in the licensed businesses onSpirit of Tasmania sometimes worked on thevessel continuously for lengthy periods of timewithout leave as they did not work under theprovisions of a maritime award. In many casesthe staff in these areas spent considerably moretime on the vessel than regular members of thecrew.

Although the licensee’s staff used the crewmessing and other facilities on board and partic-ipated in the weekly fire and emergency drills,they did not receive the training that the regular

crew were required to undertake beforecommencing sea-going duties. The crew trainingincluded such things as the operation of thesurvival craft, firefighting, evacuation, andoccupational health and safety including hazardidentification. None of the photography shopstaff had received training in these basic aspectsof shipboard safety, the issue of hazard identifi-cation being of particular relevance. There wasno requirement for such training under thearrangements existing between TT-Line and thebusiness operator.

It is a matter for some conjecture whether thephotography shop staff may have found a saferway of stowing the boxes of photographenvelopes, rather than on top of the extensionlead, if they had received the training providedto the crew. Nevertheless, as staff regularlyworking on the ship, they should be trained in,and fully conversant with, the ship’s fire andemergency evacuation plans and safetymanagement strategy.

Fire protection and detectionThe International Convention for the Safety ofLife at Sea (SOLAS) contains specificrequirements for structural fire protection, andfire detection and extinction on all ships. Therequirements for passenger ships like Spirit ofTasmania are particularly rigorous.

In 1993 when many areas of the ship weremodified, the Australian Maritime SafetyAuthority worked with TT-Line to ensure that allthe materials used in the modificationscomplied with SOLAS requirements tominimise the spread of fire and the generationof smoke and toxic fumes. The store in thephotography shop was subject to intense heat at,and just below, the deckhead level. Both thedeckhead and the bulkhead material showedonly superficial damage but remainedstructurally intact and thus effectively preventedthe spread of the fire into adjacent spaces.

The photography shop was protected by twosmoke detectors located approximately three

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metres apart on the deckhead in the displayarea. The partitioning of the space to create thestore at the rear of the shop meant that there wasno detector in the area where the fire started.Regulation 41-2 of SOLAS (consolidatededition, 1997), ‘Requirements for passengerships carrying more than 36 passengersconstructed before 1 October 1994’ wasapplicable to Spirit of Tasmania and states insection 2:

All accommodation and service spaces, stairwayenclosures and corridors shall be equipped with asmoke detection and alarm system of anapproved type and complying with therequirements of regulation 13.

On the basis of regulation 41-2, it could beargued that the shop store should have beenfitted with a smoke detector. Several originalstore/office areas of a similar size throughoutthe ship and used for similar purposes werefitted with a smoke detector.

The door into the shop store area was normallyclosed and locked, fortunately on this occasionthe door had been left open to vent somechemical fumes. It is likely that the outcome ofthe fire would have been more serious if thedetection and extinction of the fire had beendelayed by a locked store door. A smokedetector fitted in the shop store would haveallowed significantly faster detection and thusfaster extinction of a fire in normal circum-stances.

The response to the emergencyFire fighting

The response to the fire, from the time of itsfirst detection to the time it was extinguished,was effective and well executed. A matter ofslight concern is the time taken to isolate theelectrical power in the photography shop, whichoccurred at 0150, after the fire had beenextinguished. The officers and crew involved infighting the fire were familiar with the ship and,notwithstanding the delay in isolating the power,proper precautions were adopted with the fire

team’s responses being proportionate andconsistent with their training.

There were, however, two areas of concern thatcould have led to delays or an inappropriateresponse had any of the key staff been new tothe ship or had outside support, such as shorefirefighters, been involved.

The ‘prewarning’ provided by smoke detector0460 was the first detection of the possibility offire. The fire panel on the bridge indicated thatthere was smoke in ‘Child.Pl.Room Deck-E’and the detector number. Since 1993 thedetection system had not been modified toreflect the ship’s Australian configuration andthe conversion of the space from what was oncea playroom for children to the photographyshop. This may have been a source of confusionif the second mate had been new to the vesselalthough this issue has been partially addressedby a system of reference cards, kept adjacent tothe fire detector panel, which indicated thelocation of individual detectors and theirnumber.

All ships carry a fire plan approved by the flagState marine regulatory authority, in this casethe Australian Maritime Safety Authority. Thefire plan, which shows the location of firefighting and detection equipment and means ofaccess to spaces, may be used to plan an attackon a fire. A current copy of the fire plan mustbe kept at the gangway to provide shore serviceswith a plan of the ship and its fire fightingresources.

With respect to the photography shop, the fireplan on board Spirit of Tasmania at the time ofthe fire, was not accurate. Despite beingapproved by AMSA in February 1996, the plandid not show the alterations to the shop that hadbeen completed in July 1995. The plan showedan entrance to the store area of the photographyshop from the forward end of the Promenaderestaurant although this entrance had beenblocked off and turned into a store for therestaurant in 1995. During the fire, some of the

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crew had opened the cupboard, not aware of themodification, to try to gain alternative access tothe area of the fire.

Neither the out-of-date space indicator on thefire detection system, nor the inaccurate fireplan were critical in this incident, but underdifferent circumstances such deficiencies maylead to unnecessary delays in response or createcritical situations.

Cabin evacuation and mustering thepassengers

The master did not hesitate to order a muster ofpassengers. He knew there was a fire but couldnot predict what course the fire would take. Indeciding to muster the passengers he ensuredthat the passengers had the maximum timeavailable to evacuate their cabins and thusminimised the potential for the evacuation to becomplicated by the spread of smoke or fire. Hisdecision, although the fire was quickly broughtunder control, was, in the Inspector’s opinion,totally appropriate. He received full support ofTT-Line management for his actions.

Passenger surveyGeneral

Of the questionnaires sent out, 123 individualsresponded, of whom three were under the age of12, 100 were between 19 and 60 years of ageand 20 were over 61 years of age. Of all thepassengers surveyed, only one specified a firstlanguage which was not English. Sixteen percent of the passengers were embarked for theirfirst crossing, 57 per cent had crossed betweenone and five times and 27 per cent had crossedon more than five occasions. At the time the firealarm was raised, 91 per cent of the respondentswere in their cabins, just under half of whomwere asleep.

Safety Information

Three questions sought information on theeffectiveness of safety information provided byTT-Line through announcements, notices oncabin/dormitory doors and in material providedwith the passenger’s ticket.

Eighty two per cent of respondents recalled theroutine safety announcement made shortly afterthe ship sailed, however 13 per cent of thoserespondents stated that they did not understandthe instructions given in the announcement. Tworespondents commented that the announcementwas hard to hear above the noise of otherpassengers. Sixty three per cent of passengersstated that they read the safety notice on theircabin door, of which 76 per cent stated thathaving read the instructions helped them duringthe emergency. Almost the same number 77,stated that they read the safety information withtheir ticket documentation.

Effectiveness of alerting/alarm system

The questionnaire asked the question, ‘Howwere you first alerted to the emergency?’ It is ofconcern that only seven per cent stated that thefire alarm by itself alerted them. A further eightper cent were alerted by the fire alarmscombined with either the public address systemor the warnings by crew or other passengers. Itwas also established that, even when alerted tothe emergency, people within the dormitory didnot hear the fire alarm. Thirty per cent ofpassengers were initially alerted by the publicaddress system. Again a proportion reported thatit was a combination of the public address andother warnings that first alerted them. Eithercrew (36 per cent), or other passengers (four percent), or a combination of the two alerted a totalof 43 per cent of the respondents.

Comments from respondents stated that thepublic address system was too muffled tounderstand inside the cabin. Other commentsrelated to the fire alarm, public address systemand crew instructions being given simulta-neously, leading to some confusion.

Reaction to the alarm/emergency

About 45 per cent of respondents did notinitially believe that the emergency was real.The majority of these were persuaded that therewas indeed a fire when instructed by the crew orhearing other passengers. Sixty four per centwere convinced that the emergency was real intwo minutes or less. Of concern was the fact

that nine per cent of respondents took over tenminutes to accept that the emergency was real.

The great majority of passengers (86 per cent)of respondents recalled that a crew membergave them instructions as they evacuated theircabins and 69 per cent recalled being guided totheir muster station by a crew member orfollowing other passengers under instructionfrom a crew member. Sixty per cent ofrespondents were evacuated leaving theirpersonal belongings in their cabin/dormitory,while 36 per cent took small bags or items ofluggage. Some ensured they took warmclothing.

Barriers to effective movement underalarm conditions

Some difficulty or delay in evacuating to themuster areas was reported by 23 per cent ofrespondents. These varied from the difficulty inwaking passengers to their slowness in gettingdressed and to the level of mobility of somepassengers (generally older passengers) inclimbing the stairs. One wheel chair had to becarried up stairs, while other passengers found itdifficult to find doors and exit points. Sixpassengers reported that some passengersattempted to go down the stairs against the flowof the evacuation.

In commenting on the behaviour of otherpassengers, 17 per cent commented on fellowpassengers being intoxicated, while a number ofrespondents noted other passengers beingdifficult, or displaying signs of panic, and somecomplained of jokes in ‘poor taste’, particularly‘Titanic’ jokes. Yet other passengers remarkedon how calm people were in general. Somepassengers commented on the cold and the lackof warm clothing, while others were frustratedat not knowing the nature of the incident.

The passenger and crew musteringsystem

Respondents were asked to estimate how long ittook them to reach their muster station. Seventyone per cent estimated that they took fiveminutes or less, while 15 per cent estimated

some time between five and ten minutes. Fiveper cent estimated that it took between 13 and20 minutes, while six per cent did not supply anestimate.

Half the respondents recall, once at the musterstation, being told of the nature of theemergency, the vast majority by the crew. Themajority of the respondents 71 per cent recalledbeing kept informed of what was going onthrough the public address system or acombination of the address system and crewbriefing.

The majority, 70 per cent, of the respondentswere unaware of a head count by the crew at themuster station, while the vast majority, 89 percent, were aware that there was a crew memberwith them at all times. Eighty six per cent of therespondents understood the announcementsmade while at the muster station.

The respondents were asked to rate the crewperformance on a scale of five (excellent) to one(poor). Eighty three percent rated the crewperformance as four or five, while 10 per centrated the crew as average (three). Four per centof respondents did not respond and three percent rated the crew as scale one or two.

Passenger survey conclusions

The passenger survey results indicate that theevacuation procedures in use on board Spirit ofTasmania are generally effective. The vastmajority of passengers surveyed had receivedand understood the emergency and evacuationinformation provided by TT-Line in the safetybriefing, the safety information pamphletprovided when boarding and/or the informationlocated on each cabin door. Response andevacuation times were satisfactory, with themajority of survey respondents reaching theirdesignated muster point in less than 10 minutes.The vast majority of passengers also expressed avery high level of satisfaction with theperformance of the crew. Of the 99 passengerswho made written comments in the survey, 58specifically commended the actions of the crew.

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The passenger survey, however, did raiseconcerns about some aspects of the evacuation.The inaudibility of the alarms and publicaddress system in some areas of the ship, twopassengers not mustered and passenger ‘backflow’ are the predominant issues highlighted bythe survey which need to be addressed.

A number of respondents commented that theyhad difficulty hearing and understanding theannouncements made over the ship’s publicaddress system. In addition, a very highproportion of respondents indicated that theywere first alerted to the emergency by meansother that the fire alarm (only seven per centwere first alerted by the fire alarm). Based onthe evidence provided by the passengerssurveyed, the audibility and clarity of the alarmand public address systems throughout the shipneeds to be reviewed.

More concerning is the report that twopassengers had slept through the emergency inone of the hostel areas. The ship’s evacuationplan requires the crew to systematically clearand check each berth to ensure that allpassengers have been mustered. In this case itappears that the crew may have failed to clear,and then check, the area properly.

Spirit of Tasmania is required to carry acomplete passenger manifest on each voyage. In

the event of an emergency, the manifest mayallow a final check of the number of musteredpassengers by conducting a systematic headcount. The evacuation plan in use at the time ofthe fire did not include a final check ofpassenger numbers at the muster stations,although 30 of the passengers surveyedindicated that they were aware of a head countat their muster station. A final head count andreconciliation of the passenger numbers basedon the manifest would have identified that therewere passengers missing from the muster.

Passenger ‘back flow’ or unescorted passengersmoving back down to their cabins during theevacuation was noted by several of thepassengers surveyed. ‘Back flow’ during anevacuation must be strictly controlled by thecrew. By returning to their cabins, thepassengers may be placing themselves at risk byentering unsafe areas, or they may slow the flowof others moving in the opposite direction to themuster points. Three of the respondents whonoted the passengers going back to their cabinsindicated that their evacuation was slowed as aresult. When dealing with passengers in anevacuation, the importance of staying in a singlegroup while moving in one direction to themuster points, must be emphasised by theaccompanying crew members. Passengers mustnever be allowed to return to their cabinsunescorted.

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ConclusionsThese conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.

Based on the evidence available, the followingfactors are considered to have contributed to theincident:

1. The fire in The Ship’s Photographer shopwas caused by a short circuit in theextension lead under the sink in the storearea supplying power to the fridge.

2. The short circuit in the extension lead wascaused by the breakdown of the insulationbetween the conductors in the lead. Thebreakdown of insulation was the result ofthe imposition of a mechanical load on thelead, ie. the stowage for several monthspreviously of boxed photograph envelopeson top of the lead.

3. Neither the short circuit protection nor theearth leakage detection in the electricaldistribution system was effective in eitherdetecting or limiting the damage caused bythe short circuit in the extension lead.

4. The extension lead and its conditions of usehad not been inspected by qualified ship’sstaff at any time prior to the fire.

5. The poor stowage of the boxes on top of theextension lead was a fire hazard which hadnot been identified by any crew inspectionin the three months prior to the fire.

6. The photography shop staff were not awareof the dangers of stowing the boxes ofphotograph envelopes on top of theextension lead, nor had they received anytraining in recognising such a danger.

7. The limited access for ship’s staff to thelicensed business areas aboard Spirit ofTasmania for normal ship’s routines andprocedures impeded the inspection of thephotography shop store area.

It is further considered:

8. The fire plan in use at the time of the firedid not accurately depict the photographyshop store space by not showing theblocked access door from the Promenaderestaurant.

9. The fire detection panels were misleadingas they did not accurately describe thelocation of the detectors which trippedinitially in the photography shop displayarea.

10. The crew’s response to the fire from thetime that it was detected to the time it wasextinguished was effective and wellexecuted.

With regard to the passenger evacuation it isconcluded:

11. The master’s actions in ordering anevacuation of the passengers, immediatelyafter the existence of the fire wasconfirmed, was totally appropriate.

12. The crew are to be commended on the passenger evacuation which was generallyvery effective.

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FIGURE 10:Fire: Spirit of Tasmania events and causal factors chart

Events Factors Assumed factors

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26

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1. The licensed business areas on board Spiritof Tasmania should be subject to the samesafety management policy, procedures androutine inspections as any other part of thevessel.

2. Consideration should be given to providingthe staff of the licensed businesses on thevessel with the same safety training asreceived by regular crew members.

3. A smoke detector fitted in the store wouldimprove the speed of detection and extinctionof a fire in the photography shop store.

4. The audibility of the alarm and publicaddress systems in some areas of the shipneeds to be reviewed.

5. Consideration should be given to theinclusion of a final head count of passengersin the evacuation plan.

6. Passenger evacuation ‘back flow’ issues needto be addressed in crew evacuation training.

Recommendations

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SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report. Sub-regulation 16(4) provides that such a personmay provide written comments or informationrelating to the report.

Copies of the draft report were sent to themanager and owner of The Ship’s Photographershop, the master and managers of Spirit ofTasmania, the Chief Executive Officer of TT-Line and the Australian Maritime SafetyAuthority.

Submissions were received from the ChiefExecutive Officer of TT-Line and the AustralianMaritime Safety Authority. The report wasamended and submissions included whereappropriate. The following is an extract from theTT-Line Chief Executive Officer’s submissionwhich details the company’s safety actions inresponse to the incident and investigation:

1. All fire detector addresses have been re-written toprecisely identify the spaces in the ship’s currentconfiguration.

2. Safety drills include a weekly search procedurefor a randomly "lost" person.

3. Masters have been instructed to notify AUSSARas soon as passengers are mustered and placerelevant authorities on standby.

4. Fire alarms and public address systems areconstantly checked and rectified immediatelywhen noted to be faulty (regrettably, theintentional rendering of this equipment as inoperable makes this a full time task).

5. Back flow issues of passengers during mustershave been highlighted to all crew.

6. Steps are being taken to require the compulsoryattendance of all Licensees’ personnel atModified Sea Safety Training to ensure, amongstother things, that they can assist passengers in thesame manner as any of the crew in times ofemergency.

7. In order to avoid any access difficulties arisingfrom availability of keys to Licensee’s premises,break glass boxes are to be fitted adjacent toLicensee’s premises.

8. The fire plan that was being updated at the timeof the incident has now been completed and thenew plan approved.

9. A fire detector has been fitted and included in theship’s system to the photography shop Licensee’sstoreroom. All other spaces have also beenchecked on board to ensure compliance.

30

Spirit of TasmaniaIMO Number 8502391

Flag Australian

Classification Society Germanischer Lloyd

Ship Type Ro-Ro passenger ferry

Builder Seebeckwerft AG, Bremerhaven

Year Built 1986

Owner TT-Line Company Pty Ltd

Ship Managers Technical management and officers supplied byASP Ship Management

Gross Tonnage 31 356

Net Tonnage 14 129

Maximum draught 6.217 m

Length overall 161.53 m

Breadth 28.20 m

Moulded depth 18.52 m

Engine 4 x MAK 8M552AK 4 stroke, single acting

Total power 19 600 kW

Crew 112

APPENDIX 1: Passenger Survey Results

At 1800 on 23 February 2001, Spirit of Tasmania departed from Port Melbourne with 967passengers, 112 crew and 10 other staff on board en route to Devonport, Tasmania. At approxi-mately 0110 in the morning of 24 January, with the ship in Bass Strait, a fire broke out in the Ship’sPhotographer shop which led to a full evacuation and muster of the passengers.

To gain some insight into the effectiveness of the passenger evacuation system used on the ship andthe responses of the passengers to the emergency, a passenger questionnaire comprised of 28targeted questions was developed by the Australian Transport Safety Bureau in conjunction with theferry operators TT-Line. TT-Line posted the questionnaire to 291 of the passengers who hadprovided contact details when booking their travel. Of the 291 passengers surveyed, 123 respondedwith completed questionnaires. The following is a summary of those responses.

Summary of Responses

Q.1 Age and gender of those who responded, as at 23 February 2001.

The majority of respondents (51%) were aged between 46 and 60 yearsOne child was aged less than sixTwo children were aged 6-1112 respondents were aged 19-3025 respondents were aged 31-4517 respondents were aged 61-753 respondents were aged over 76No respondents were aged between 12-18

Total of Male respondents 69Total of Female respondents 54

Q. 2 Is English your first language?

Out of the 123 respondents only one passenger answered ‘No’. This person specifiedHungarian was their first language.

Q. 3 How many times have you crossed Bass Strait by ferry?

0 16% of respondents1-2 39%3-5 18%5-10 15%10-20 7%>20 5%

Q. 4 On 23/4 February did you read the safety information on the back of the cabin door? Part 2: If yes, did it help you?

Of the 123 respondents, 78 answered ‘Yes’, while 45 answered ‘No’.Of the 78 respondents who answered ‘Yes’, 60 stated that it did help.

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Q.5 Did you read the safety information pamphlet provided with your boarding pass? Part 2: If yes, did it help you?

Of the 123 respondents, 77 answered ‘Yes’, while 44 answered ‘No’.One respondent could not recall and another did not answer.Of the 77 who answered ‘Yes’, 59 stated that it did help.

Q. 6 Do you recall a safety announcement demonstrating the ship’s emergency alarm system just after the ship left from Melbourne? If yes, did you understand the instructions?

Of the 123 respondents, 101 answered ‘Yes’, 20 answered ‘No’ and 2 did not answer.82 of the respondents understood the instructions.13 respondents did not understand the instructions.18 respondents did not necessarily tick the box but have answered ‘Yes’ to part one of thequestion.One respondent wrote: ‘Don’t know’.

Some passengers commented:

‘…too much noise could not hear’ (respondent 66).

‘It was very hard to hear because of the level of noise in the dining room’ (respondent 77).

Q. 7 Where were you when you became aware of the emergency?

Of the 123 respondents, 54 stated that they were asleep in their cabins at the time.A further 59 respondents stated that they were in their cabins,8 respondents did not answer this question.Two respondents said they were at the muster station.

Q. 8 How were you first alerted to the emergency?PA, Fire Alarm, Smelled/saw smoke,Warning from other passenger,Warning from ship’s crew: Other, please describe?

Of the 123 respondents, 35% said that they were first alerted to the emergency by warningsfrom the ship’s crew and a further 30% by the ship’s PA announcement.

PA,Fire Alarm, Warning from Crew 1%

PA,Warning from Passenger, Warning from Crew 2%

Voices/Noises in corridor 2%

Warning from Pass 4%.

Warning from Passenger, Warning from Crew 1%

Ship's Warning Signal 1%

Fire Alarm,Warning from Ships Crew 1%Fire Alarm 7%

Warning from Crew 36%

PA 30%

PA,Warning from Crew 7%

Not answered 2%Fire Alarm,Warning from other Pass 2%.

PA,Fire Alarm, Warning from Crew 4%

Some respondents commented on the clarity of the PA announcements:

‘Too muffled to understand’ (respondent 6).‘PA not functioning in cabin’ (respondent 29).‘My husband and I filled out a passenger feedback form on the morning following the fire –because no fire alarm sounded in the dorm room’ (respondent 40).‘Had to open our door to hear the announcement clearly’ (respondent 83).‘PA announcement very difficult to hear inside cabin with door shut’ (respondent 107).

Another passenger who had selected PA announcement, Fire alarm and the warning fromship’s crew, stated in the comments section:

‘Heard all at once!’ (respondent 96).

Q. 9 Did you believe that there was a real emergency when first alerted? If no, describe what clues were required to convince you that there was a real emergency:

Of the 123 respondents, 65 replied ‘Yes’, 55 replied ‘No’ while 3 did not answer.Of the 55 respondents that answered ‘No’, the table below identifies clues which convincedrespondents that there was a real emergency:

Instructions from crew 19Further PA announcements 9Hearing noise/voices from other passengers outside cabin 5Knocking on cabin door (by crew) 3Smelled/saw smoke 3When alarm was sounded 1Convinced by travelling companion 1Hearing noise/voices from other passengers and knocking on cabin door 1Not until got outside cabin 1Further PA announcements/Hearing noises/voices outside cabin 1Further PA announcements/Smelled/saw smoke 1Second calls 1Smelled saw smoke/Hearing noises/voices outside cabin/Instruction from crew 1Not answered 11No comment 2

Some of the passengers added comments:

‘A crew member came and assured us it was for real’ (respondent 22).

‘I thought it was just some sort of fire drill till we got outside’ (respondent 21).

‘Because I couldn’t hear the alarm & PA, I wasn’t sure that there was a problem, it wasn’t untilI heard other passengers jumping out of their bunks and a general sense of agitation did I bother to wake my wife…I lost what could have been valuable time if it had been more serious’(respondent 105).

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34

Q. 10 Estimate how long it took for you to be convinced that there was a real emergency? (mins/secs)

The following table summarises the time it took for the respondents to be convinced theemergency was ‘real’ with 47% indicating that they were convinced in one minute or less.

10 seconds 13Less than a minute 281 minute 191.5 minutes 32 minutes 163 minutes 85 minutes 115.5 minutes 110 minutes 620 minutes 115 minutes 230 minutes 150 minutes 1Not answered 13

Q. 11 Describe your very first actions when you realised that the emergency was real.

Of the 123 respondents, 42% answered that they dressed, with 20% stating that theydressing in warm clothing.

Respondent’s answers were wide-ranging from real actions undertaken to identifyingemotional feelings such as annoyance, fear or confusion.

Annoyance 1 Grabbed blanked & dressed warmly 1Concerned 2Concerned & followed instructions from crew 1Calmed others & got wallet 1Fearful 1Fearful & followed instructions from crew 1Thought it was a fire drill 3Thought it was a fire drill & remained calm 1Followed others 3Dressed 27Dressed & followed instructions from crew 2Dressed & left cabin 2Dressed & proceeded to muster station 7Dressed, went to toilet, read instructions on back of cabin door & proceeded to muster station 1Dressed, got wallet 2Dressed, got wallet and followed instructions 1Dressed & waited at the door 1Dressed and wondered where to go 1Dressed and waited in hallway with others 4

35

Dressed and woke others in cabin (kids) 1Dressed in warm clothing 14Dressed in warm clothing & proceeded to muster station 8Dressed in warm clothing & got wallet 1Got out of bed 1Left cabin 1No answer given 5Wondered what to do 1Wondered what to do & felt annoyed 1Offered assistance & proceeded to muster station 1Panicked 1Felt panic & annoyance 1Proceeded to muster station 4Remained calm 6Remained calm & concern 1Remained calm & followed instructions from crew 1Worried about the kids 1Woke others in cabin 1Woke others in cabin & dressed 6Woke others in cabin and dressed in warm clothing 1Woke others in cabin and left cabin 1Wondered what to do 1

Q. 12 Estimate how long it took you to start evacuating after first being alerted to the emergency. (mins/secs)

10 secsonds 1%Less than a minute 10%1minute 11%1.5 minutes 5%2 minutes 18%2.5 minutes 2%3 minutes 16%4 minutes 3%4.5 minutes 1%5 minutes 16%6 minutes 2%7 minutes 2%8 minutes 4%10 minutes 2%20 minutes 1%30 minutes 2%Don’t know 2%Not answered 2%

Q. 13 Was your muster station the first place you decided to go when evacuating? Yes/No,Other, please describe

Of the 123 respondents, 103 answered ‘Yes’, 16 answered ‘No’, while 4 did not answer thequestion. Some of the respondents who answered ‘No’, commented:

‘Waited for advice from ship’s crew member who directed us to muster station’ (respondent 6).

‘To wait with other passengers in the passage-way’ (respondent 4).

‘We were asked to wait 5 minutes in a corridor which was closed off from stairs’ (respondent 15).

Q. 14 Did a ship’s crew member instruct you on what to do when evacuating your cabin? Yes/No

Of the 123 respondents, 106 answered ‘Yes’, 13 answered ‘No’, while 4 did not answer.

Q. 15 Did you take any personal effects or luggage with you when evacuating your cabin? Yes/No If yes, please describe

Of the 123 respondents, 60% answered ‘No’, 36% ‘Yes’ and 4% did not answer.

Of those passengers who did take personal effects or luggage when evacuating their cabin,the descriptions included; bags/wallets/backpacks (32 respondents), warm clothes (6 respondents). Other items included; cameras, mobile phones, cabin keys, car keys,medication, jewellery, knives, cigarettes.

Q. 16 How did you get to your muster station? – ship’s crew guided you, followed other passengers or made own way.

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Crew Guidance, Made Own Way, 5%

Followed Passengers 12%

Made Own Way, Crew Guidance 1%

Crew Guidance,Followed Passengers 13%

Followed Passengers, Made Own Way 1%

Made Own Way 15%

Not Answered 3%

Crew Guidance 50%

How passengers reached their muster stations

37

Q.17 Did you experience any difficulty or delays in reaching your muster station? No/Yes. Ifyes, please describe why

Of the 123 respondents, 74% of answered ‘No’, 23% answered ‘Yes’, with 4 respondentsnot answering.

For those that answered that they did experience difficulty or delays in reaching musterstations some of the reasons were stated as:

Unsure of correct muster station (2).Commented they went to the wrong muster station (1).Became tired climbing stairs (4).Commented they were confused as to which way to go (2).Passenger movement being too slow (1).Passengers suffering medical conditions & concerns over the elderly (5).Door not open (2).Unable to locate exit door from hostel (1).Crowding on stairs (4).Waiting in passage (3).Difficulty waking passengers (1).Delays in evacuating passengers from cabins (1).

Some passengers commented:

‘…it took rather long to get all passengers out of cabins’ (respondent 8).

‘…waited in passageway with other passengers until crew told us to move’ (respondent 10).

‘…waiting in corridor for crew to alert elderly couple’ (respondent 15).‘My wife’s fitness level is very poor and she had trouble getting up stairs – I thought she wasgoing to collapse’ (respondent 21).

‘Couldn’t find exit out of dorm passage to muster station stairway (respondent 28).

‘…delay due to passenger on oxygen’ (respondent 68).

‘Bunch of older women panicking. They took a long time to get ready-Ship’s crew made usstay together’ (respondent 69).

‘…we were behind a distressed woman in a wheel chair being carried up stairs – only shortdelay’ (respondent 92).

Q. 18 On your way to the muster station did you see any passengers going back down to thecabins? No/Yes, If yes, did this cause congestion or slow the evacuation?

Of the 123 respondents, 89% answered ‘No’, 5% answered ‘Yes’, 2% did not know while4% did not answer this question.

Three respondents who had answered ‘Yes’, stated that passengers going back down tothe cabins did cause congestion or slowed the evacuation.

One commented:

‘Passengers who didn’t know their muster station were confused and slowed the process offinding their correct deck’ (respondent 49).

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Q. 19 Were there any specific examples of passenger behaviour you would like to comment on?Describe:

Of the 123 respondents, 48 did not answer this question, 21 people commented thatintoxicated passenger(s) were annoying and frustrating to both crew and fellow passengers.

Examples of those comments were:

‘A gentleman who had too much to drink, was making jokes and being silly about the situation’(respondent 33).

‘One gentleman had to much to drink, giving the crew a hard time’ (respondent 2).

Other comments included:

Passengers displaying behaviour of panic or anxiety (9).Respondents stated some passengers were being difficult/annoying (7).Respondents stated that passengers remained calm and in control (13).Respondents stated that passengers were not adequately dressed for the cold conditions atmuster station (7).Confusion - as to which way to go to muster station (3).Concerns expressed that children did not give up seats for the elderly (2).Distressed woman in wheel chair (2).Crew kept together in tight bunch (1).Concerns that life jackets were not handed out (1).Respondents felt things went well (1).Frustration – in not knowing the nature of the incident (3).Passengers suffering medical conditions (3).Respondents felt that passengers obeyed instructions (6).Respondent felt that reference to ‘Titanic’ not funny (2).Respondent noted that children were upset (1).

Q. 20 How long did it take to reach your muster station once you started from the place you were first alerted to the emergency?

Not answered 5%

Time taken to reach muster station

< 1 minute 1%

1 minute 7%

2 minutes 25%

2.5 minutes 1%

3 minutes 16%

3.5 minutes 2%4.5 minutes 1% 4 minutes 2%

5 minutes 15%

7 minutes 1%6 minutes 2%

9 minutes 1%8 minutes 2%

10 minutes 11%

13 minutes 1%15 minutes 1%

Don't know 2%20 minutes 2%

10 secs 1%

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Q. 21 At the muster station, were you told what the emergency was? Yes/No: If yes, by whom?Crew/other passenger

Of the 123 respondents, 60 answered ‘Yes’, 58 answered ‘No’, 4 respondents did not answer,and 1 respondent could not remember.

Of the respondents that answered ‘Yes’, 50 respondents answered Crew, 1 respondent saidcrew and other passengers, 5 said other passengers while 4 respondents did not specify.

Q. 22 While at the muster station were you kept informed of what was going on? By the crew (yes/no) or Public address system (yes/no)

Q. 23 Were you aware if a head count was conducted by the ship’s crew at your musterstation? (yes/no)

Of the 123 respondents, 87 answered ‘No’, 30 answered ‘Yes’, 5 did not answer this questionwhile 1 respondent did not know.

Q. 24 Did you understand the announcements made over the ship’s public address system? (yes/no)

Of the 123 respondents, 106 answered ‘Yes’, 11 answered ‘No’, while 6 did not answer.

Q. 25 Was there a member of the crew with you at the muster station at all times? (yes/no).Comments

Of the 123 respondents, 110 answered ‘Yes’, 5 answered ‘No’, 6 did not answer and 2 did notknow.

Comments included:

The crew were excellent, helpful, professional (39).There was insufficient information given by the crew (2).The crew were reassuring (3).

70

60

50

40

30

20

10

0Crew Crew, public

addresssystem

Not answered Not applicable Public addresssystem

7

16

5

31

64

How were you kept informed

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The crew were wearing life-jackets (1).The crew were there most of the time (1).Several crew were at the station (1).The crew were inexperienced (2).

Q. 26 How long were you at the muster station?

Comments:

‘At the muster station for 40 minutes – we were moved to the Tiger Bar for a further 65 minutes’ (respondent 36).

‘At the muster station for 60 minutes approximately – then we went to a public room foranother 90 minutes’ (respondent 49).

Q. 27 When the emergency was over did you return to your cabin? (yes/no)If no, please specify where you went

Of the 123 respondents, 113 answered ‘Yes’, 5 answered ‘No’ and 5 did not answer thisquestion.

Those respondents who did not return to their cabin specified that they went to:

Bar (1)Dance floor area (1)Moved to the public room (2)‘No' but did not specify where they went (9)

Length of time at muster station

Not applicable 1%

30 minutes 5%

40 minutes 2%50 minutes 1%

Not answered 3%

4 minutes 1%

25 minutes 2%10 minutes 2%

No comment 1%

90 minutes 28%100 minutes 3%

120 minutes 32%

60 minutes 11%

70 minutes 2%75minutes 1%80 minutes 2%

Don't know 2%

150 minutes 2%

135 minutes 1%

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Q. 28 How do you rate the overall performance of the crew during the evacuation? 5,4,3,2,1

Other Comments:

Of the 123 respondents 92 provided comments.

Felt anxious 3No oxygen masks available 1Valium obtained too late by passengers 1Thermal blankets were required 1Alarms not heard in Hostel 6Muster station should be better organised (eg water/seating) 3Crew were professional 19Insufficient care given to elderly/children 1Exposure to cold conditions 8Not hearing alarm 2Compensation sought 4Warm clothing was locked in car 1Unsuitable comments from Captain 1Difficult passengers 1Intoxicated passengers 3Passenger unaware of incident 1Insufficient details of emergency 19Still enjoyed the trip 1Concerns that life jackets not handed out 4Smokey muster station 2Crew efficient and helpful 20Unaware passengers left in cabin 4Frightening experience 1Passengers equipped to help were not asked 1Debrief to passengers should have been offered 1Passengers were slow in climbing stairs 1Safety instructions not clear 1Concerns over the elderly 1Reservations about using ‘Spirit’ again 2PA, FA and Crews warnings heard all at once 1

60

50

40

30

20

10

01 2 3 4 5 N/A

Rating

No. o

f res

pond

ents

Overall performance of crew (1-5)

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Muster station should have been re-located (away from smoke) 1Muffled PA announcements 7Incident exaggerated by media 2Safety announcement dept. Melbourne hard to hear 7Staff poorly trained 2Crew should have better ID 1Will not travel on ‘Spirit’ again 1Confused as to what was happening 1Insufficient life boats 1Crew Professional –No panic 19Muster station confusion 1Would not stay in hostel again 1Discount on trip sought 1Not frightened 2Distressed woman in wheelchair 1Will travel on ‘Spirit’ again 4No comments 24

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Spirit of Tas. 08.02