Press Release [DATE] - NTSB - National Transportation Safety Board

NTSB Press Release

National Transportation Safety Board
Office of Public Affairs

BOARD MEETING OF JUNE 10, 1997 GROUNDING OF THE LIBERIAN PASSENGER SHIP STAR PRINCESS ON POUNDSTONE ROCK, LYNN CANAL, ALASKA, JUNE 23, 1995

JUNE 10, 1997

EXECUTIVE SUMMARY

On the evening of June 22, 1995, the Liberian-registered passenger vessel Star Princess, carrying 1,568 passengers and 639 crew, was en route from Skagway to Juneau, Alaska, via the Lynn Canal under the direction of a southeast Alaska pilot. At 0142 on June 23, the Star Princess grounded on the submerged Poundstone Rock in Lynn Canal, about 21 miles north of Juneau. The vessel's bottom sustained significant damage on the starboard side, including the rupture of oil tanks that resulted in the loss of at least 5 gallons of oil. The vessel was piloted to safe anchorage at Auke Bay, Alaska, (about 10 miles north of Juneau) to assess damage and debark passengers. No injuries or deaths resulted from this accident. The total cost resulting from required repairs and the delay before the vessel could return to service was estimated at $27.16 million.

The major safety issues discussed in this report are -

The adequacy of the pilot's physical fitness for duty,

The importance of bridge resource management,

The pilotage practices in the Alaskan cruise industry, and

The need for search and rescue planning.

As a result of this accident, the National Transportation Safety Board makes 3 recommendations to the U.S. Coast Guard, 2 recommendations to the State pilot commissions, 2 recommendations to the Alaska Board of Marine Pilots, 1 recommendation to the Southeastern Alaska Pilots Association, 2 recommendations to the Alaska Coastwise Pilots Association, 1 recommendation to the San Diego Bay Pilots Association, Inc., 2 recommendations to Princess Cruise Lines, 2 recommendations to the American Pilots Association, and 2 recommendations to the International Council of Cruise Lines.

CONCLUSIONS

Findings

Neither weather nor equipment failure caused the grounding of the Star Princess, neither the pilot nor the navigating crewmembers were impaired by alcohol or illegal drugs, and the helmsman steered courses as ordered by the pilot.

The pilot's decision to stay essentially on his existing course ultimately resulted in the grounding of the vessel.

The 2-degree course change ordered by the pilot 7 minutes before the accident was not sufficient to allow the Star Princess to clear Poundstone Rock or to indicate his intentions to the pilot of the Fair Princess.

The pilot should have been alert to the current and taken appropriate actions in response to it.

The pilot's limited use of the radar hampered his ability to evaluate the navigation situation accurately.

Although it was not totally dark in the period before the accident, the pilot's sense of distance to the Poundstone Rock buoy would have been inaccurate due to the level of illumination.

By relying on visual reference to a floating aid, the pilot did not follow sound navigation practices.

Before the pilot of the Star Princess tried to pass Poundstone Rock buoy, he should have established communication with the pilot of the Fair Princess.

The pilot was chronically fatigued as a result of obstructive sleep apnea.

Fatigue may have reduced the pilot's ability to appropriately assess and respond to the developing situation.

The pilot's use of an antidepressant (Effexor) probably did not affect his performance

Pilot performance would be improved if the Alaska Board of Marine Pilots had a mechanism for obtaining feedback on pilot performance.

The pilot's use of an antidepressant (Effexor) probably did not affect his performance.

Pilot performance would be improved if the Alaska Board of Marine Pilots had a mechanism for obtaining feedback on pilot performance.

Considering the accident history and medical condition of the Star Princess pilot, the Alaska Board of Marine Pilots did not oversee his performance adequately.

Had the watch officers monitored the pilot's navigation, projected the course ahead from their fixes, and communicated this information to the pilot, he would have had time to take action to avoid grounding.

Effective management of resources and coordination of duties were not practiced on the Star Princess at the time of, or immediately before, the accident.

To learn how to work effectively as teams, pilots and watch officers in Alaska should take bridge resource management training together.

The master did not give the passengers timely notification about the situation; had the passengers needed to evacuate, they would not have been prepared to do so.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the grounding of the Star Princess was the pilot's poor performance, which may have been exacerbated by chronic fatigue caused by sleep apnea. Contributing to the accident was the fact that the pilot and the watch officers did not practice bridge resource management.

RECOMMENDATIONS

-- to the U.S. Coast Guard:

Review, in consultation with experts in occupational health, your medical standards, guidelines, and examination forms to ensure that they require the disclosure and appropriate evaluation of the history or presence of any medical conditions, symptoms, or medication use that would affect an individual's fitness to pilot a vessel.

Advise passenger vessel operators of the need for masters to provide immediate notification to passengers and crew of emergency situations that have been assessed as having the potential to require evacuation of the vessel.

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea.

-- to the State pilot commissions:

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea.

-- to the Alaska Board of Marine Pilots:

Develop and implement a mechanism for monitoring the performance of pilots on a routine basis.

Encourage or require pilots of passenger vessels operating in southeast Alaska to take bridge resource management training with bridge watch officers. (M-97-XX)

-- to the Southeastern Alaska Pilots Association:

Advise your members about the Star Princess accident and encourage those members that navigate on vessels in the Alaska cruise trade to participate in bridge resource management training including such training with bridge watch officers.

-- to the Alaska Coastwise Pilots Association:

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea.

-- to the San Diego Bay Pilots Association, Inc.:

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea.

-- to Princess Cruise Lines:

Coordinate with the Alaska pilot associations to arrange bridge resource management training between your bridge watch officers and Alaska pilots.

Require your masters to notify passengers and crew immediately of emergency situations that have been assessed as having the potential to require evacuation of the vessel.

-- to the American Pilots Association:

Advise your members about the effect of fatigue on performance and about sleeping disorders such as sleep apnea.

-- to the International Council of Cruise Lines:

Advise your members about the Star Princess accident and encourage those members that operate vessels in the Alaska cruise trade to participate in bridge resource management training including such training that involves both bridge watch officers and pilots.

Encourage your members to ensure that masters provide immediate notification to passengers and crew of emergency situations that have been assessed as having the potential to require evacuation of the vessel.

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The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.