NTSB Accident Review: Cause & Recommendation

National Transportation Safety Board Determines Cause of engineroom fire on board passenger vessel in Oregon.

Washington, DC (November 17, 2009): The National Transportation Safety Board today determined that the probable cause of the fire on board the Queen of the West was the failure of a pressurized component on the port main propulsion hydraulic system, resulting in hydraulic oil spraying onto the port engine's exhaust piping and catching fire.

On April 8, 2008, a fire broke out in the engineroom of the 221-foot U.S. small passenger vessel Queen of the West. The vintage-style paddlewheel vessel was traveling east on the Columbia River near Rufus, Oregon, with 124 passengers and 53 crewmembers on board, as part of a 7-day cruise. The vessel had both an automatic fire detection and fixed fire suppression system on board, which functioned properly by alerting the bridge team and suppressing the fire. The crew was able to confine the fire to the engineroom, and the vessel did not need to be evacuated.

After a thorough examination of the portside engine, NTSB investigators concluded that one of the hydraulic oil hoses that serviced portside pumps 3 and 4 had failed. Because of
the fire damage, the hoses could not be pressure-tested for preexisting holes or leaks. Consequently, the NTSB could not determine the specific hose that failed.

However, because of the proximity of the hydraulic oil hoses to the hot exhaust piping, and the lack of alternative ignition and fuel sources in the immediate area, investigators
determined that the fire was caused by hot surface ignition of hydraulic oil. The hydraulic oil leak was in the form of atomized spray; therefore, it created a fuel-air mixture that ignited when it came in contact with the near-800 F exhaust piping.

Because the vessel did not carry survival craft, there would have been no means to readily evacuate those onboard the vessel had the fire not been controlled. The risk of serious or fatal injuries would have been considerable. There are no U.S. Coast Guard requirements for this vessel to be equipped with survival craft.

Contributing to the survivability of the vessel, and to the absence of injury or loss of life, was Majestic America Line's voluntary installation of an automatic fire detection system and a fixed fire suppression system. The Board concluded that this action by Majestic America Line, which was not required by Coast Guard regulations, limited the fire damage to the vessel and enhanced the survivability of passengers and crew.

As a result of this accident investigation, the Safety Board issued a new recommendation and reiterated a previous recommendation to the U.S. Coast Guard regarding requirements to equip small passenger vessels with out-of-water survival craft as well as automatic fire detection and fixed fire suppression system.

A synopsis of the Board's report, including the probable cause and recommendations, is available on the NTSB's website by clicking HERE. The Board's full report will be available on the website in several weeks. NTSB Reference: SB-09-62

Media Contact: Keith Holloway / telephone: (202) 314-6100 / E-mail: [email protected]