Atlantic Ocean Off Port Canaveral, Florida
July 18, 2006
NTSB Number MAR-08-01
NTIS Number PB2008-916401
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Executive Summary:On July 18, 2006, the cruise ship Crown Princess, which had been in service about a month, departed Port Canaveral, Florida, for Brooklyn, New York, its last port on a 10-day round-trip voyage to the Caribbean. Slightly more than an hour after departing, while on a heading to intersect its track to Brooklyn, the vessel's automatic steering system began a turn to port. In an effort to counter the effects of a perceived high rate of turn, the second officer, the senior watch officer on the bridge, disengaged the automatic steering mode of the vessel's integrated navigation system and took manual control of the steering. The second officer turned the wheel first to port and then from port to starboard several times, eventually causing the vessel to heel at a maximum angle of about 24° to starboard. The heeling caused people to be thrown about or struck by unsecured objects, resulting in 14 serious and 284 minor injuries to passengers and crewmembers. The vessel incurred no damage to its structure but sustained considerable damage to unsecured interior components and to cabinets and their contents.
The National Transportation Safety Board determines that the probable cause of the Crown Princess accident was the second officer's incorrect wheel commands, executed first to counter an unanticipated high rate of turn and then to counter the vessel's heeling. Contributing to the cause of the accident were the captain's and staff captain's inappropriate inputs to the vessel's integrated navigation system while the vessel was traveling at high speed in relatively shallow water, their failure to stabilize the vessel's heading fluctuations before leaving the bridge, and the inadequate training of crewmembers in the use of integrated navigation systems.
The Safety Board's investigation of the accident identified the following safety issues:
As a result of its investigation, the Safety Board makes recommendations to the U.S. Coast Guard, to the Cruise Lines International Association, and to SAM Electronics and Sperry Marine (manufacturers of integrated navigation systems).
As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations.
To the U.S. Coast Guard:
Propose to the International Maritime Organization that, in conjunction with the upcoming revisions to the Standards of Training, Certification, and Watchkeeping for Seafarers, it make training in integrated navigation systems and integrated bridge systems mandatory for watchkeepers on vessels equipped with such systems. (M-08-1)
Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. (M-08-2)
To the Cruise Lines International Association:
Until the International Maritime Organization makes training in integrated navigation systems mandatory, recommend to your members that they voluntarily provide initial and recurrent training in integrated navigation system operation to crewmembers having watchkeeping responsibilities on vessels equipped with such systems, and include in that training a requirement for a demonstrated level of proficiency. (M-08-3)
Through your website, publications, and conferences, inform your members about the circumstances of this accident and urge them to incorporate into their safety management systems and training programs for officers in charge of the navigational watch (1) information about the effects on vessel performance of high-speed vessel operations in shallow water, and (2) initial and recurrent training for emergency ship-handling scenarios based on the lessons learned from serious marine incidents and accidents. (M-08-4)
To SAM Electronics and Sperry Marine:
Work with cruise lines and other vessel operators to develop a system that provides you with critical information regarding errors or potential problems in the use of integrated navigation systems or integrated bridge systems and apply the lessons learned to system design and crew training. (M-08-5)
