Norway’s Hurtigruten has installed a water mist fire fighting system in the engine rooms of its ships and beefed up the fire training of all of its crew, following the Sept. 2011 fire on the Nordlys where three crew died.

The official accident report released by Statens Havarikommisjon today did not add much to the information about the causes of the fire previously available, but stated that incomplete maintenance instructions and lack of training beyond the officers may have contributed to the fire.

In addition, following the outbreak of the fire, the water-based firefighting system did not release as it was in a manual mode, and the CO2 was not released because the Captain did not know if the engine room had been evacuated.

Furthermore, when the Nordlys was brought alongside, her starboard stabilizer had not been retracted, and caused a hole in the side of the ship, which nearly caused her to capsize. The ship was constructed to survive sideways damage between compartments, but as a watertight door leaked or was left open, the situation became critical.

Hurtigruten has since not only installed the water mist system, but also made design changes in its engine rooms, including insulation of hot surfaces, and introduced more thorough crew fire safety training, as well as initiated a study in cooperation with the University of Bergen to identify and raise the safety culture aboard the ships.