A fire aboard a massive cruise ship caused by leaking fuel could be a “dress rehearsal for a future tragedy” if the cruise industry and the company that operated the ship doesn't make changes.

That dire warning from National Transportation Safety Board (NTSB) Chairman Robert L. Sumwalt came during the board’s Tuesday meeting about the Aug. 17, 2016 aboard the Caribbean Fantasy – an incident that resulted in injuries to dozens of passengers.

(Pictured above: The Caribbean Fantasy’s starboard side during the final stage of abandonment, with its starboard anchor down. Gray smoke is coming out of the two blue funnels, and an orange Coast Guard helicopter is hovering over the blue upper deck of the ship. Photo by U.S. Coast Guard)

How it happened

The fire began in the main engine room of the 614-foot long, Panamanian-flagged vessel, when fuel spraying from a leaking flange contacted the hot surface of the port main engine. The fire could not be contained, and the master ordered abandon ship. The fire burned for three days while the vessel, used for ferry service between Santo Domingo, Dominican Republic, and San Juan and Mayaguez, Puerto Rico, drifted and subsequently grounded near the port of San Juan. The fire was extinguished by shore-based firefighters after the Caribbean Fantasy was towed into the harbor.

More than 45 of the 511 passengers and crew aboard were treated for non-life-threatening injuries including knee, ankle and leg injuries, fainting, breathing difficulties and other issues. Only six injuries – ankle injuries incurred while sliding down the marine evacuation system – were considered serious. The accident resulted in an estimated $20 million in damage and the Caribbean Fantasy was eventually scrapped in lieu of repairs.

Leaking fuel not the only factor

While the NTSB determined that the immediate cause of the fire was the leaking fuel, quick-closing valves for fuel and lube oil that were intentionally blocked open contributed to its rapid spread.

The NTSB also found that fixed firefighting systems and a structural fire boundary failed.

Also contributing to the fire and subsequent prolonged abandonment effort was Baja Ferries’ poor safety culture and ineffective implementation of its safety management system on board the Caribbean Fantasy, the NTSB found. Adding to the severity of the fire was the failure of the Panama Maritime Authority and the recognized organization, RINA Services, to ensure the safety management system was functional.

What should be fixed

As a result of the investigation the NTSB issued safety recommendations to the U.S.Coast Guard, Baja Ferries S.A. de C.V., RINA Services S.p.A, the International Association of Classification Societies, and the Panama Maritime Authority.

The recommendations address machinery maintenance practices, fuel and lube oil quick-closing valves, fire protection, crew training on and familiarity with emergency systems and procedures, implementation of the company’s safety management system, and oversight by Panama.

“The recommendations that we issued today, if acted upon, will improve marine safety,” said NTSB Chairman Robert L. Sumwalt. “I urge the recipients to act on these recommendations, so that this fortunately non-fatal fire is not remembered as the dress rehearsal for a future tragedy.’’

The synopsis, findings and all recommendations related to the accident are available online athttps://goo.gl/4azkER. The full report will be available in a few weeks at ntsb.gov.