NTSB to Academies: Up Cadet's Game

 accident reporting, maritime accidents  Comments Off on NTSB to Academies: Up Cadet's Game
Feb 092009
 

Empress of the North

grounding site

Location of the grounding

Maritime academies in the US have been told to ensure that their cadets understood their responsibilities as licensed officers when they assume their first navigational watch as professional mariners. The advice followed the publication of the US National Transportation Safety Board’s report on the grounding at night of the 300-foot passenger vessel Empress of the North in May, 2007, while under the command of a third mate who had graduated from the California Maritime Academy less than three weeks before.

The officer was not familiar with the bridge equipment or procedures. Neither the Master nor Chief Mate had reviewed the route with him, discussed the steering modes, or critical equipment such as radar. One particular hazard, Rocky Island, required the Officer Of the Watch to make a critical decision.

He was initially assigned to the midnight to 0400 watch, his first navigational watch, with the senior third mate. The day before the accident the senior third mate fell ill. The master decide to maintain the planned watch but to add the vessel’s most experienced helmsman in an attempt to mitigate the junior third officer’s inexperience.

During the passage, the third officer gave effective command to the helmsman. He later told investigators” My understanding was he (the helmsman) would be in control of the boat, and I would be there because I have a license.”

The road to the rock

An inexperience officer left navigation to the helmsman

About 0130 on Monday, May 14, 2007, the Empress of the North, grounded on Rocky Island, which was illuminated by a flashing green navigation light. The US Coast Guard and several Good Samaritan vessels assisted in evacuating the passengers and nonessential crewmembers and safely transporting them back to Juneau. No injuries or pollution resulted from the accident, but the vessel sustained significant damage to its starboard underside and propulsion system.

Say the NTSB: “the junior third mate failed to understand and fulfill his responsibilities as a licensed officer… Newly licensed third officers will often find themselves on a ship they have never sailed on, in an unfamiliar waterway they have never transited before, and in the company of a master and crew they have never served with before. These circumstances do not, however, absolve them of their responsibility to take charge as the officer of the watch when so assigned .. His (the junior third officer’s) expressed confidence… suggests that he did not fully appreciate his duties and responsibilities and what was required to fulfill them.”

In a letter, the NTSB urges maritime academies: “teach your students the circumstances of this accident, including their responsibilities as newly licensed officers to prepare themselves for assigned duties and to express their concerns if placed in situations for which they are unprepared.

NTSB Empress of the North report

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New Third Mate Grounded Empress, Master's Decision 'Poor'

 accident reporting, Ferry, grounding, NTSB  Comments Off on New Third Mate Grounded Empress, Master's Decision 'Poor'
Jul 242008
 

MASTER’S POOR DECISION LED TO GROUNDING OF PASSENGER VESSEL EMPRESS OF THE NORTH, NTSB DETERMINES


Washington, DC – The National Transportation Safety Board has determined that the probable cause of the grounding of the Empress of the North was the failure of the officer of the watch and the helmsman to navigate the turn at Rocky Island, which resulted from the master’s decision to assign an inexperienced, newly licensed junior third mate to the bridge watch from midnight to 4:00 a.m. The third mate was not familiar with the route, the vessel’s handling characteristics, or the equipment on the vessel’s bridge.

“The flawed decision making in this accident created the potential for a catastrophic disaster,” said NTSB Chairman Mark V. Rosenker. “Those in leadership positions need to make sure they consider every option possible when making critical decisions that could put lives at risk.”

On May 14, 2007, the 300-foot passenger vessel Empress of the North, operated by Majestic America Line, grounded on a charted rock at the intersection of Lynn Canal and Icy Strait in southeastern Alaska, about 20 miles southwest of Juneau. The vessel was negotiating a turn west out of Lynn Canal into Icy Strait on its way to Glacier Bay, the next stop on a 7-day cruise, carrying 206 passengers and 75 crewmembers. The vessel struck the rock, known as Rocky Island, which was illuminated by a flashing green navigation light.

Passengers and crewmembers were evacuated safely without injuries. The vessel sustained damage to its starboard underside and propulsion system.

In the report adopted yesterday, the Board noted that because of the senior third mate’s illness, the master replaced him with the new junior third mate for the midnight-to-4:00 a.m. watch. The third mate held an unlimited, any-ocean third officer’s license but had never before stood watch on the vessel or traveled the waters of Lynn Canal.

The master had ample time to consider the watchkeeping assignment, the Board stated. However, the Safety Board investigators found no evidence that the master considered other options and did little to prepare the junior third mate for his first underway watch.

The third mate lacked any knowledge of the route and should not have been left to make this critical maneuver on his own, the Board said. The Safety Board concluded that the master jeopardized the vessel’s safety by allowing the third mate to stand a bridge watch before he was familiar with the route and the bridge equipment.

As a result of its investigation of this accident, the Safety Board recommended that state and U. S. maritime academies use the circumstances of the accident to teach students about their responsibilities as newly licensed officers. The Safety Board also recommended that the Passenger Vessel Association inform its members about the circumstances of the accident.

A synopsis of the Board’s report, including the probable cause and recommendations, is available on the NTSB’s website, www.ntsb.gov, under “Board Meetings.” The Board’s full report will be available on the website in several weeks.

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Fear Of Ferry Royals

 accident reporting  Comments Off on Fear Of Ferry Royals
Jul 222008
 

By coincidence, this week could be dubbed ‘Ferry Cropper Week”. In the Philippines the Board of Marine Inquiry is to release its report on the sinking of the Sulpicio Line’s ferry Princess Of The Stars, which cost more than 700 lives, while the US National Transportation Safety Board is to release its report of the grounding of the sternwheeler Empress of the North.

Since we’re talking of ferries let’s add the Queen of the North report released by Canada’s Transport Safety Board earlier this year.

The Queen of the North grounding and sinking took two years of investigations which included recovery of physical evidence such as computer hard drives from the ship’s bridge and recording of radio traffic, and video from ROV examination of the sunken vessel. The report is backed up by a video simulation of the vessel’s voyage and sinking.

Investigating the Empress of the North grounding has taken a little over a year. It, too, will involve the examination of physical evidence.

The Philippines BMI has taken around one month, has taken statements from some 28 persons, including two seafarers who were travelling on the ferry as passengers, but neither asked for nor secured physical evidence as to how the vessel capsized, took on water and capsized.

There was certainly the opportunity to gather physical and photographic evidence from the Princess of the Stars. Divers went aboard her to photograph the faces of the dead in a misguided attempt to have them identified by relatives seeking their lost. The project was stopped following advice that the photographs would not be useful in identification and would have been disturbing those those trying to discover whether their loved ones were alive or dead.

That photographic equipment could have been put to good use in the cargo hold, where cargo is said to have shifted in the storm and caused the ship to list. They might have been useful in the area of the rear ro-ro ramp.

Divers were taken off the vessel following the discovery of a highly toxic cargo of endosulfan in a container but an examination could have been done using ROVs, which certainly are available in the Philippines.

Much might have been learned by simulating the last voyage of the Princess of the Stars in a bridge simulator, of which there are several in Manila, another in Cebu, and three in Subic Bay. It woiuld have provided a fairly accurate representation of conditions at the time, far more accurate that witness testimony – only witness in the BMI inquiry, for instance, correctly identified the ship’s list as to port, everyone else recalled it as starboard.

An engineering simulation of the forces acting upon the ship, something which might have been done at University of the Philippines, would, too, have told us much about the mechanics of the capsize and sinking.

Given the time the BMI has taken, and the lack of substantive investigation and forensic techniques, sadly it can be little more than a superficial exercise, no matter how well meaning the intent of those comprising the board.

There are very meaningful differences between the BMI and those agencies which investigated the Empress of the North and the Queen of the North incidents. These last incidents were investigated by full time agencies of relative independence, manned by professional, trained, qualified maritime casualty investigators. The Philippines has no such agency.

Determining the underlying, root, cause of an incident and addressing it will save more lives than determining who is at fault.

What is needed is a professionalised agency whose investigation is solely concerned with the safety aspects of an incident, who can interview witnesses without them having the sword of liability hanging over them, and with the capability to gather forensic evidence, and whose reports are publicly available on the internet.

While such an agency’s investigations must, as a matter of safety, take precedence over other investigations its recommendations do not need the force of law, they have the force of public embarrassment – a ferry company that doesn’t implement recommendations made to it will certainly be grist for the media mill.

Liability should be determined solely by the courts with the force of law behind them. Boards of Marine Inquiry, or their equivalent, have largely been abandoned around the world and the Philippines should follow suit.

The BMI’s function of establishing liability would be better replaced by an Admiralty court under the Supreme Court, with specialist judges and attorneys trained in maritime law.

Given the strategic economic and social importance of the domestic shipping industry in the Philippines, it’s difficult to argue against such changes.

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