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RELATED COVERAGE

PORT RICHEY, Fla. (WFLA) - The National Transportation Safety Board released the results of its investigation into the Tropical Breeze Casino shuttle boat fire that killed a woman on Jan. 13. 

The fire forced 50 people to jump for their lives off the coast of New Port Richey. Carrie Dempsey, 42, died after inhaling "products of combustion," according to an autopsy report.

"This person who died was a single mother. She left behind a pair of twins, a boy and a girl who were 12-years-old, who now do not have parents," said NTSB chairman Robert Sumwalt during a board meeting on Tuesday.

"And here is a company that had the opportunity to learn from a tragedy in 2004. And they did absolutely nothing. And after it happened twice, what have they done? This is absolutely absurd."

In the NTSB's findings released Tuesday, the following safety issues were identified:

• Lack of company guidance regarding engine high-temperature alarms: The captain did not shut down the engine after receiving the alarm, but kept it idling, which aided in starting the fire.
• Lack of fire-detection in unmanned spaces with exhaust tubing
• Insufficient preventive maintenance
• Insufficient crew training and documentation: The investigation revealed crew members lacked sufficient understanding of firefighting principles and training drills were infrequent or not completed. 
• Inappropriate material and design of fuel tank level-indicator system: Fuel tanks were equipped with plastic hoses and the system did not have automatic shutoff values, so during the fire, this plastic material melted and the release of diesel fuel exacerbated the fire.

The NTSB found that the captain's decision to return the vessel to the dock after seeing the engine's high-temperature alarm and his decision to beach the vessel when the smoke became overwhelming were prudent and increased the likelihood of survival for the passengers. 

"They went out to gamble but they did not expect to gamble with their lives. And that's what happened," said Sumwalt.

Click here to read the NTSB's full report

The NTSB ruled the probable cause of the fire was Tropical Breeze Casino Cruz's "ineffective
preventive maintenance program and insufficient guidance regarding the response to engine
high-temperature conditions, which resulted in the captain’s continued operation of an engine that
was overheating due to a cooling water pump failure, leading to ignition of the exhaust tubing and
surrounding structure."