Fire Investigation NTSB

This recently-released NTSB report is only 9 pages but makes for very interesting reading, with some very valuable lessons; chief among these being the importance of an operational fire detection systems.

Summary: A simple chain of events, malfunctioning cabin lighting led to the use of candles, placed on a timber table top, adjacent to curtains, which started a fire, which went undetected because the smoke/heat alarms system was malfunctioning, which in turn led to this significant loss. Of course there are a slew of other related and important details. From lighting candles to smoke driving crew to abandon the vessel... about 10 minutes.

https://www.ntsb.gov/investigations/AccidentReports/Reports/MAB2117.pdf

CANDLES. The OPEN FLAME kind, used on a boat?! Jeebus that's stupid.

If you want the look there's some really nice battery-operated ones, even have a wax shell to the cylinder and flickering lighting effects.

Amazing how poorly the paid, professional, crew responded to the unmaintained fire alarm system, loss of lighting in the cabins. Unbelievable aboard a mega yacht that they didn’t have battery powered lights to place in the cabin rather than candles. Also for 2 months there was no record of the captain getting qualified people out to repair the nonfunctional fire alarm system fixed. Lost a 6 million dollar yacht because they lighted candles and left them unattended.

Comodave said:

Amazing how poorly the paid, professional, crew responded to the unmaintained fire alarm system, loss of lighting in the cabins. Unbelievable aboard a mega yacht that they didn’t have battery powered lights to place in the cabin rather than candles. Also for 2 months there was no record of the captain getting qualified people out to repair the nonfunctional fire alarm system fixed. Lost a 6 million dollar yacht because they lighted candles and left them unattended.

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I would have to add the question of where the owner was in all this. He knew they had the problems, knew they failed the Class survey.

As to candles, an outdated technology in my view. We only have flameless candles in our home, much less on a boat.

Alarm system isn't working, don't allow guests to board. Lights not on, don't take guests aboard.

Sure takes a lot of failures to create such a disaster but avoiding any one of the errors could have prevented it. I'd like to say "sad", but the word that comes to mind is "disgusting."

Aside from the stupidity involved, it's a good reminder to install and/or test your smoke alarms. In this case, had an alarm sounded they would have had a good chance of putting out the fire before it spread. Instead, in the 10 minutes that elapsed after lighting the candles, the boat was completely overtaken by smoke and flames. It's amazing how fast it happens.

twistedtree said:

Aside from the stupidity involved, it's a good reminder to install and/or test your smoke alarms. In this case, had an alarm sounded they would have had a good chance of putting out the fire before it spread. Instead, in the 10 minutes that elapsed after lighting the candles, the boat was completely overtaken by smoke and flames. It's amazing how fast it happens.

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And also anywhere else at a marina, the damage done might have destroyed many boats and even the marina. Just look at how fast others had fire hoses in place and multiple fire departments arrived.

I love it....how many have propane stoves?

Kero or oil heaters with open flames?

It's not the open flame (candle) that's dangerous....it's where and in/on what it is placed that is important.

I do not own a propane or electric fire place because I don't like the lack of wood smell. I do prefer a wood stove over a fireplace...but I would never sit around anything else besides a wood camp fire when outdoors.

So I might prefer real candles over led ones.....if led are preferred, I would just have backup lighting in critical areas.

There are many ways to burn or sink a boat, but hazard mitigation and alarm systems can make even candle "safe" for those willing to use their heads.

psneeld said:

I love it....how many have propane stoves?

Kero or oil heaters with open flames?

It's not the open flame (candle) that's dangerous....it's where and in/on what it is placed that is important.

I do not own a propane or electric fire place because I don't like the lack of wood smell. I do prefer a wood stove over a fireplace...but I would never sit around anything else besides a wood camp fire when outdoors.

So I might prefer real candles over led ones.....if led are preferred, I would just have backup lighting in critical areas.

There are many ways to burn or sink a boat, but hazard mitigation and alarm systems can make even candle "safe" for those willing to use their heads.

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For cooking without a genset propane remains the least costly and simplest approach. However, virtually no yachts of this size, at least none I've inspected, and fewer and fewer new smaller yachts, use propane or any open flame devices, induction cooktops have put yet another nail in the propane coffin. I'm not opposed to propane per se, provided the installation is ABYC compliant, and most aren't, it's just that easier and safer alternatives now exist. IMO, candles, and unattended candles at that, have no place aboard a yacht. An oil lamp perhaps, those remain fairly common on traditional sailing vessels, but they are designed to go to sea and are much safer than a candle.

At very low coast, the crew could have installed household smoke alarms until the onboard system was repaired.

Not saying things couldn't have been better handled on that vessel.

Or saying propane on a vessel that size is in question.

Just boaters who say open flames on a boat are stupid when many here are smart, responsible boaters who have open flame cooking and heating aboard....so are we all stupid?

Like many things considered dangerous on a boat that are mishandled or safety suggestions not followed.....doesn't mean that with proper care they are still "dumb".

There are candle lanterns that resemble oil lamps, are enclosed, securely hold the candle and may in my mind be safer than oil lamps to a degree. No, just a candle that has flame access to surroundings or can slide or tip over is a menace anywhere where someone isn't present.

Small points.... but this forum is ripe with comments that say OK for something in one thread and then virtually disapprove it in another. Kinda drives me nuts....

I can’t even imagine that they thought lighting candles was an acceptable solution, particularly on a boat of that size, what were they going to go camping? They didn’t have any flashlights on board?

Comodave said:

I can’t even imagine that they thought lighting candles was an acceptable solution, particularly on a boat of that size, what were they going to go camping? They didn’t have any flashlights on board?

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They thought failure to have their survey and renew Class was acceptable.

They thought months without alarms was acceptable.

They thought lights not working in various areas of salon and then of lower deck was acceptable.

They thought having guests on a boat with all the above was acceptable.

They thought candles were acceptable.

They thought setting candles on a dresser near curtains was acceptable.

They thought leaving the candles unattended was acceptable.

Nothing the owners or crew thought acceptable was, so I think their actions and conduct were entirely unacceptable. There are responsibilities that come with both boat ownership and being crew. All involved in this failed. Far more a deeper investigation would uncover but not for the NTSB. However, was the boat underfunded or was the captain and engineer lousy? Was the owner blind and unaware or complicit? Were the stews untrained? ABS seems to be the only one doing their job as they'd withdrawn Classification, failed the boat and required the alarm systems be addressed and even returned as recently as the day before to note nothing had been fixed. Classification isn't required by law unless chartering so boat still free to be used, although if I was investigating I would check the guests out to be sure they were not paying anything and another illegal charter.

Actions like those of the owner and crew (and why the heck is engineer taking vacation when he hasn't had the issues fixed) infuriate me as a boat owner who might have to share marinas with such boats. Fortunately lives were not lost, but they could have been and other boats could have been destroyed and even lives lost there.

Yes, this was an accident, but one caused by a litany of acts and failures to act and total irresponsibility and an accident that was easily foreseen.

Was insurance voided?

Not the same sort of issue, but so glad I finally sorted out the auto-stop feature for my main engine upon fire fighting agent release the other day.

rgano said:

Was insurance voided?

Not the same sort of issue, but so glad I finally sorted out the auto-stop feature for my main engine upon fire fighting agent release the other day.

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Doubt it.

Also when I refer above to owner, I'm thinking likely are owner's representatives involved as I doubt the owner, Marc Anthony, is hands on. Likely too busy with music and models.

I might add, he sold his Coral Gables home this year for $27 million.

BandB said:

They thought failure to have their survey and renew Class was acceptable.

They thought months without alarms was acceptable.

They thought lights not working in various areas of salon and then of lower deck was acceptable.

They thought having guests on a boat with all the above was acceptable.

They thought candles were acceptable.

They thought setting candles on a dresser near curtains was acceptable.

They thought leaving the candles unattended was acceptable.

Nothing the owners or crew thought acceptable was, so I think their actions and conduct were entirely unacceptable. There are responsibilities that come with both boat ownership and being crew. All involved in this failed. Far more a deeper investigation would uncover but not for the NTSB. However, was the boat underfunded or was the captain and engineer lousy? Was the owner blind and unaware or complicit? Were the stews untrained? ABS seems to be the only one doing their job as they'd withdrawn Classification, failed the boat and required the alarm systems be addressed and even returned as recently as the day before to note nothing had been fixed. Classification isn't required by law unless chartering so boat still free to be used, although if I was investigating I would check the guests out to be sure they were not paying anything and another illegal charter.

Actions like those of the owner and crew (and why the heck is engineer taking vacation when he hasn't had the issues fixed) infuriate me as a boat owner who might have to share marinas with such boats. Fortunately lives were not lost, but they could have been and other boats could have been destroyed and even lives lost there.

Yes, this was an accident, but one caused by a litany of acts and failures to act and total irresponsibility and an accident that was easily foreseen.

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To be fair, based on the report it sounds as if the non working cabin lights were a new issue, and the crew had gone to another nearby vessel belonging to the same owner, to accommodate the guest as plan B, while the stewardess set the candles. Candles and months' long non-functioning smoke alarms remain major blunders.

Steve DAntonio said:

To be fair, based on the report it sounds as if the non working cabin lights were a new issue, and the crew had gone to another nearby vessel belonging to the same owner, to accommodate the guest as plan B, while the stewardess set the candles. Candles and months' long non-functioning smoke alarms remain major blunders.

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The Captain knew the moment he stepped on the boat at 3:00 PM that none of the lights were working. They had the guests on that boat because the Azimut they owned and originally wanted had A/C not working. Stew still took guests down, and, with candles. I wonder if the guests realize how close they came to losing their lives in a horrible fire?

The interviews of the crew are very revealing and I will share more later after finishing all. However, for a start, the captain was basically chosen by a previous captain, had never captained a boat that size, got 2 hours turnover, no procedures, and was managed by the owner's sister by phone from NY. Oh, and the owner spent 296 days aboard the previous year according to the captain. Captain had actually let his USCG license lapse at one point but then got a 200 Ton MCA Yachtmaster.

I don't understand all the discussion. The fire occurred because of the use of candles placed where they should not have been. There of course is the issue of the delayed maintenance and repairs that led to the use of the candles. If the owner knew of the maintenance issues... well shame on them. Safety systems are paramount.



Part of boat ownership, whether is is a 10 foot wooden row boat or 60 meter yacht is upkeep. My opinion is that is if you can't keep up with the issues that arise, consider selling to to someone who can. The sad and sobering thing is that every marina has at least one boat that is an accident waiting to happen.

HTurner said:

I don't understand all the discussion. The fire occurred because of the use of candles placed where they should not have been. There of course is the issue of the delayed maintenance and repairs that led to the use of the candles. If the owner knew of the maintenance issues... well shame on them. Safety systems are paramount.



Part of boat ownership, whether is is a 10 foot wooden row boat or 60 meter yacht is upkeep. My opinion is that is if you can't keep up with the issues that arise, consider selling to to someone who can. The sad and sobering thing is that every marina has at least one boat that is an accident waiting to happen.

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And more than one captain with poor judgement on top of just poor maintenance.

I know lots of people who won't live in multi family dwellings for that reason....if they owned a boat,, I wonder how they would feel about marinas.

When I travelled with the USCG a lot, I started carrying my own smoke alarm....debated on the portable ladder too because of maintenance I had no idea about. And I am not close to being a paranoid type.

psneeld said:

And more than one captain with poor judgement on top of just poor maintenance.

I know lots of people who won't live in multi family dwellings for that reason....if they owned a boat,, I wonder how they would feel about marinas.

When I travelled with the USCG a lot, I started carrying my own smoke alarm....debated on the portable ladder too because of maintenance I had no idea about. And I am not close to being a paranoid type.

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Thank you for mentioning judgement! No matter the qualifications, certifications and licenses, without a level head and good judgement, it means nothing.

I lived aboard a boat for years that had kerosene interior lights and an alcohol stove. The only electricity was for the starter and running lights. The ability to avoid open flames now because of the improvements in lights and appliances is something that I value (and can now afford).

Even ignoring the fire danger, any open flame can produce carbon monoxide and other toxic substances under certain situations. I had a kerosene lamp that ran out of fuel one night and I thought that it saved me from getting up and turning it down/off. Apparently it smoldered for hours. The next morning I had a horrible headache and sore throat. Sore to the point that I could cough up blood.

Wife has some battery powered candles at home. So far, I've avoided having them on board. What would be next, potpourri? No candles or bananas on board.

This can be a wake up call just to double check our fire extinguishers and safety items..... AND our procedures.



Totally agree on keeping open flames off a boat.



I do have a propane grill, and will probably keep it. Using the little canisters seems pretty safe. Last boat was all electric and worked great.


As for living in a marina (or an apartment or condo), not for me.... for the most part. Ok for occasional travel, but there certainly ARE risks with unknown boats and people that don't have the same safety standards that you do.

Seevee said:

I do have a propane grill, and will probably keep it. Using the little canisters seems pretty safe. Last boat was all electric and worked great.

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Just be sure to store the little canisters as you would a larger tank. A seal failure on one little cannister stored below is probably just the right amount of propane to make a flying bridge actually fly.

Last Saturday a neighbor had a grill out that used the 1 pound canisters. New canister and when he took it off the grill propane spewed out of the canister. The seal failed on thr first usage. Definitely store the canister where if it leaks the propane will go overboard not into the interior. And don’t refill them, they aren’t designed to do that.

The cause....

NTSB only determines direct cause, and in this case that was obvious. Candles, curtains, flammables, burn. However, there's much more to the story and you get it in the depositions of the crew.

This was a boat meant for a disaster like this and the fact no lives were lost is amazing.

Captain wasn't interviewed by anyone but just handed the job in a two hour handover by the prior captain who knew him. Similar with the Chief Engineer. Captain wasn't even told it was a Class vessel and had no experience with one. Had let his USCG license lapse through neglect years earlier but now had an MCA license. Chief Engineer had no Engineering License as he'd been licensed as a mate. Had just taken the introductory engineering course. He wasn't informed when hired that the boat's Class was suspended.

Management was by owner's sister in NY but she didn't interview anyone. No alcohol or drug testing. No program in place for such. No procedures or policies. No logs.

All crew had turned over in a few months as was normal for the boat. Captain hired crew by doing what he called a speed lunch date, sitting in a restaurant and spending 20 minutes or so with each candidate. Then choosing. No other approvals or reference checks or anything.

Captain thought it was an electrical fire at first because all the electrical was a mess, in his words. He said he knew there was no point in making a check list of work to be done as it could never all get done, that the entire boat was a disaster when he joined.

As to candles, they were regularly used especially in the owner's suite and in the sky lounge, as the owner liked them. Also, the smoke alarm in the owner's suite was disconnected because the owner liked to smoke in there and was afraid of setting it off.

As to lights, the salon lights were out on the Monday before, so lighting issues didn't just suddenly appear on the day of.

Captain wasn't there for ABS because he needed to do work on his vehicle. Engineer was getting married on day of fire. Captain didn't keep on top of engineer's work as he said he never tried to manage a chef or engineer as they were very temperamental.

Owner spent 296 days aboard the previous year. When owner not aboard, work day was 9 to 5, but when he was aboard there might be guests in the evening and crowds would grow and would often party until 5 am.

So much more, but like many disasters, the problem goes all the way to the top, the CEO or Owner in this case. This was a boat in bad condition, mismanaged. No hiring plan just let the one leaving choose his replacement. No organizations. People far over their head in responsibilities with no help. They knew the fire alarms didn't work. Can't blame the second stew for using candles as they were used all the time on this boat. The owner made that decision. The Florida Fire, Arson, and Explosives investigators final sentence of their report read, "In addition to the above, the majority of the crew was admittedly new to the industry, not properly trained, or even very familiar with the vessel they were serving on and it's safety procedures."

This was, in every way possible, a disaster waiting to happen and just fortunate the main loss was this boat. No loss to the owner as he wanted to sell it.

The liveaboards some marinas fear aren't confined to clearly derelict vessels, but they can be wealthy in a neglected very expensive yacht.

Anyone who wants to read more detail, here is the resource.

https://data.ntsb.gov/Docket?ProjectID=100711

WARNING: WILD UNFOUNDED SPECULATION AHEAD

A boat that the owner is selling, that needs a lot of work and can't pass inspection......with less crew than normal and one guest on a top outside deck, and the owner out of town, and very little effort to contain the fire......

Does that seem suspicious to anyone else ?

Benthic2 said:

WARNING: WILD UNFOUNDED SPECULATION AHEAD

A boat that the owner is selling, that needs a lot of work and can't pass inspection......with less crew than normal and one guest on a top outside deck, and the owner out of town, and very little effort to contain the fire......

Does that seem suspicious to anyone else ?

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If it seems suspicious to us, my guess those that really care will too and take this further.

psneeld said:

If it seems suspicious to us, my guess those that really care will too and take this further.

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It didn't look suspicious to the Florida Fire, Arson and Explosives Investigators. Whether it did or not to the insurers, I can't say. You could add to it the owner selling his home so lots of selling taking place. I personally don't think it was intentional though, just a lot of neglect.

BandB said:

It didn't look suspicious to the Florida Fire, Arson and Explosives Investigators. Whether it did or not to the insurers, I can't say. You could add to it the owner selling his home so lots of selling taking place. I personally don't think it was intentional though, just a lot of neglect.

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My point I don't give a flying F....and most of these cases I will never know 1/100 of the story. So how can I care or comment other than to say it is in others hands.

As many have noted, lots of blame to go around. In my work with vessels of this size and complexity I see far too much of the crew unfamiliarity issue. Every one of these vessels are different, even with similar systems it takes weeks if not months for a captain, engineer and crew to fully learn a vessel's systems. A 2 hour "familiarization"?! Good grief.

Simply put, had the lights been working this would not have happened, and there are many vessels out there like this, classed and unclassed, and based on my inspections frankly I'm surprised this does not happen more often.

A relative of mine was involved in a megayacht loss in the Bahamas in 2006. The vessel was lost because the engines ran out of fuel, even though it had thousands of gallons aboard, the engineer, who was new to the vessel, didn't know how to transfer it. Once again, remarkably, no one perished.