An arsonist's fire killed 159 people aboard the Scandinavian
Star en route from Norway to Denmark. An international panel
concluded in 1991 that the ship, which had just been sold
by the Miami-based SeaEscape cruise line to VR DaNo Lines
of Denmark for use in a ferry service, had rotted life boats
and missing or insufficient fire alarms. The ship had been
certified safe by the U.S. Coast Guard and the London-based
Lloyd's Register of Shipping.
1. The Ship and Her History
The Scandinavian Star was built in France in 1971 as a combined
passenger ship and ferry for cars and trailers. It had nine
Deck 1 Engine room and tanks
Deck 2 Engine room, other machinery spaces refrigerated
stores and crew cabins
Decks 3&4 Car deck with passenger cabins outboard
Deck 5 Passenger cabins
Deck 6 Lounge, restaurant and shops
Deck 7 Shops, officers cabins, embarkation deck for the
Deck 8 Wheel house, officers cabins and disco
Deck 9 Open air deck
The ship was built to SOLAS 1960 requirements and Method
I was used with respect to fire protection. This means that
fire resistant materials were used for internal bulkheads.
For the accommodation decks, the bulkheads were constructed
of 30mm asbestos silicate covered generally with a 1.5mm
layer of laminated plastic, although in some areas there
were 2 layers of plastic covering. The ceilings were formed
of 10mm asbestos silicate, again generally covered with
1.5 mm layer of laminated plastic but for 90 cabins amidship
on deck 5 the asbestos silicate ceiling was covered with
4mm PVC. The "A" class bulkheads and deck insulation
consisted of 25mm rockwool and the cabins were fitted with
B-15 fire doors.
The ship was divided into three main vertical fire zones
which were numbered 1 to 3 from aft to forward. On Decks
3-5, there were four stairways to port and four to starboard.
They were numbered from aft and stairways 3P&S and 4P&S
extended down to Deck 2 and 3P&S also to deck 1. There
were some internal stairways, also on the upper decks, but
they were generally not in the same positions as those on
the lower decks. The doors to stairways were usually fitted
with A-60 self closing fire doors.
As Method I was used, the ship generally was not fitted
with either an automatic fire detection system or an automatic
fire fighting system, although some spaces, such as the
engine room, were fitted with this type of equipment. In
the event of a fire, the alarm was sounded manually by pressing
activation buttons on the Bridge.
2. Events Prior to Disaster Voyage
Until 1987 the ship had been classed with Bureau Veritas
but thereafter it was classed with Lloyds Register and carried
the Bahamian flag.
The ship had previously been operating out of Miami on
short cruises but was purchased in March 1990 by the V R
Dano Group to replace the Holger Danske on the run between
Frederikshaven in Denmark and Oslo, Norway. The ship was
quickly brought into service by the new owners, making its
first run on the new service on 1 April. Only nine original
members of the crew remained with the ship and they comprised
mainly engineering crew including the chief engineer. The
rest of the crew were either previous members of the crew
of Holger Danske, consisting of deck officers and catering
officers, or they were recruited new to the ship. This latter
group were mainly "hotel staff' of Portuguese nationality.
3. The Disaster Voyage
The Scandinavian Star came into service on the new run on
1 April. It appears to have operated without incident until
the tragic voyage on 6 April. The ship left Oslo at 21.45
hours that day under the command of Captain Hugo Larsen
and with a crew of 99 and 383 passengers.
Between 01.45 hours and 02.00 hours on 7 April, a small
fire was discovered in a pile of bed clothes outside Cabin
No.416 on the port side of Deck 4. This fire was quickly
extinguished. However, a little after 02.00 hours, a second
fire started in the aft section of the starboard corridor
of Deck 3 near to staircase 2S. The accommodation on this
deck was not in use. The fire was not extinguished quickly
and at 02.24 hours the ship sent a mayday message giving
its position. Subsequently at 03.20 hours, the captain decided
that it was not possible to extinguish the fire and the
decision was taken to abandon ship.
I first became aware of the incident at about 08.00 hours
on the morning of 7 April when I heard about the fire on
the BBC news. The report said at that time that four people
were believed to have died in the incident. Shortly afterwards
I received instructions to investigate the cause of the
fire on behalf of one of the parties and I left later that
morning for Sweden.
At 11.55 hours the ship was taken under tow to the small
town of Lysekil in Sweden where she arrived at 21.17 hours.
I also arrived there shortly afterwards. At this time there
was a small amount of smoke coming from the ship and externally
there appeared little evidence of a major fire. However,
during the night whilst the fire brigade was trying to extinguish
the fire, the fire developed and spread significantly causing
extensive damage to most decks.
The fire was eventually extinguished at 16.00 hours on
Sunday 8 April. During the next week, the emergency services
were employed in removing the bodies from the ship. It was
eventually found that 158 people had died in the tragedy;
156 were passengers and two were crew. Four bodies had been
carried out onto the after part of Deck 5 prior to the ship
being abandoned. All except one of the bodies that were
recovered from inside the ship in Lysekil were found in
the passenger accommodation Decks 4 and 5. The one exception
was recovered from the restaurant on Deck 6. The bodies
found on Decks 4 and 5 were recovered from the following
4. Investigations into the Reasons for the Tragedy
Following the tragedy, Sweden, Denmark and Norway agreed
to set up a committee to investigate the reasons for the
tragedy. As well as taking evidence from survivors, the
ship was also inspected fully. In addition, calculations
and fire tests were later carried out at the National Institute
for Testing and Verification (Dantest) in Denmark and at
SINTEF NBL, the Norwegian Fire Research Laboratory. Much
of the rest of this paper describes the findings and recommendations
of the Committee of Inquiry.
4.1 The cause of the fire
Both the earlier fire that was extinguished and the one
that led to the tragedy were almost certainly started deliberately
by the application of a naked flame to bedclothes in the
first instance and probably paper and bedding that had been
placed at the site on the second occasion. No one has been
charged with starting the fires.
4.2 The development of the fire
The development of the second fire can be summarised as
The fire was ignited shortly after 02.00 hours. Between
2 - 8 minutes later, the heat release from the fire reached
200 kW which was enough to start the corridor wall burning
Fire spread rapidly to staircase 2S and then upwards
Smoke reached Deck 4 about 1 minute after ignition and was
drawn into the corridors fore and aft of the staircase.
The fire door forward of the staircase remained open.
Smoke reached Deck 5 after 2-3 minutes and began seeping
into adjoining corridors.
The fire spread to the port side along the transverse corridor
on Deck 5.
On the port side the fire was drawn down through the 2P
Smoke was drawn into the port corridors on Deck 4 and to
a lesser extent on Deck 5
The fire spread down to deck 3 where the fire door onto
the car deck remained open.
The fire spread into the restaurant on Deck 6 through an
open fire door at the top of the 2S staircase.
Thus within 8 to 12 minutes of the fire starting, most of
the corridors where the people died were filled with smoke.
While the ventilation was running, this maintained a positive
pressure in the cabins keeping the smoke out, but when the
ventilation was switched off possibly as late as 02.30 hours,
smoke seeped into the cabins. It is considered that all
158 people who lost their lives in the tragedy had probably
died by 02.45 hours.
4.3 The reasons for the very large loss of life
a). SOLAS Requirements
The Committee found that in principle the Scandinavian Star
complied with those requirements in SOLAS 1960 and SOLAS
1974 that a ship built in 1971 was supposed to comply with.
However they did find the following deficiencies in the
ship and its equipment:
workshops and stores had been set up on the car deck
some of the sprinkler heads on the car deck were blocked
pressure bottles were stored incorrectly
there was a defective fire door on the port side of the
the motorised lifeboats were generally in poor repair
a fire door was missing from the aft starboard part of Deck
6 and the door opening had been fitted with a glazed door
three alarm bells were missing from the fire alarm system
These deficiencies were generally not significant, apart
from the missing alarm bells which I shall discuss in the
b). The fire alarm system
The fire occurred while many of the passengers were asleep
in their cabins. Consequently the fire alarm system was
important in arousing people from their sleep.
As a result of the missing alarm bells it was found that
only in about 37% of the cabins was the sound level of the
alarm over 68 dB, which was considered to be "probably
sufficient". In addition, as buttons had to be held
down on the Bridge to maintain the sounding of the alarm,
the alarm was not sounded for long enough periods
c). Composition of materials used in the construction of
the accommodation decks
The carpets and cabin furniture were not considered to
have been particularly significant in the development of
the fire. However the laminated plastic coating on the walls
and ceilings of corridors, although only about 1.5mm thick,
was significant. Subsequent tests showed that the coating
had a calorific value of 48 MJ/m2. SOLAS 1960 did not specify
a maximum calorific value for such coating and the material
was therefore acceptable. Indeed it is only 3 MJ over the
maximum acceptable amount under SOLAS 1974. Nevertheless
the material provided an uninterrupted surface in corridors
and stairways that greatly assisted the spread of fire.
In addition it was also found that the material, when it
burned, produced large quantities of carbon monoxide and
hydrogen cyanide, both of which were found to have been
responsible for causing many of the deaths.
d). Fire doors
The fire doors in general were fitted with magnetic catches
and could be closed either locally or from the Bridge. Although
most of the doors were eventually closed some in the areas
affected by fire, remained open. In particular, as no alarm
was ever given from the zone on Deck 3 where the fire started,
because no one was there to press the alarm button, the
fire door from the zone to stairway 2S was never closed.
This allowed the fire to spread to the staircase and hence
to other decks. Other doors were also left open. The fact
that some doors remained open while others were closed also
created draughts which assisted the rapid spread of fire.
e). The ventilation system
The ventilation system aboard the Scandinavian Star may
not have been stopped until 02.30 hours. While it was operating
it did prevent the spread of smoke into cabins. However
during the initial stages of the fire it also played a part
in determining the route by which the fire spread, although,
as the heat output from the fire increased, the buoyance
of the hot combustion gases became the more dominant factor.
f). The escape routes
Many of the escape routes soon filled with smoke and this
affected the evacuation of the accommodation. In addition,
the routes involved changes of direction, corridors with
dead ends and staircases that were not continuous. An example
of the problem that this caused was the aft escape from
the starboard corridor on Deck 5. The escape was not at
the end of this corridor but about three metres forward
set in the outboard bulkhead. In fact there was a door at
the end of the corridor but this led only to a small storage
cupboard. Some 13 bodies were found at the end of the corridor.
The layout of some of the escape routes meant that passengers
unfamiliar with the ship needed the assistance of crew and
signposts to find their way quickly. Following the change
of ownership, the ship had been put into service without
posting emergency notices in a Scandinavian language even
though the ship was operating between two Scandinavian ports.
In addition as passengers were not issued with boarding
cards, they were unable to follow the colour coding system
used to direct them to their allocated muster station. This
led to an uneven distribution between the different muster
stations. The assistance offered by the crew is considered
in the next section.
g). The manning of the ship and the action of the crew
The ship was not under-manned and the officers possessed
the necessary qualifications and certificates but the Committee
found that the navigation officers should have had better
training in safety matters. It also found that there was
a language problem in that many of the Portuguese had little
or no knowledge of English. However the most serious criticism
made of the crew is that they never acted as an organised
unit and that no real attempt was made to fight the fire.
Furthermore it was found that the alarm was only sounded
for a short period of time and that there was no organised
waking of sleepers.
5. Overall Conclusion and Committee Recommendations
As a result of the previous factors the overall conclusion
of the committee was that the ship was not ready to sail
with passengers when it was brought into service and that
it had been brought into service far too rapidly. The committee
also made the following recommendations that all ships in
passenger traffic to Scandinavian ports:
should be fitted with sprinkler systems
should be fitted with smoke detectors in corridors, stairways,
saloons and cabins. The smoke detectors should be connected
to indicators on the Bridge and be installed in sufficient
numbers and arranged in such a way as to detect smoke as
soon as possible and provide adequate indication of the
spread of smoke.
should be manned with a crew which has attended courses
in safety procedures approved by the maritime administrations.
should be inspected before coming in to service and then
they should be subjected to further periodic scheduled and
The Committee also recommended that regulations were laid
down governing the duty of ship owners to establish systems
for the safe operation of ships.
The tragedy of the Scandinavian Star again illustrates just
how important it is to detect a fire quickly, to start fighting
it immediately and implement properly organised evacuation
procedures supervised by properly trained people.