Marine Accident Report - Grounding of the Liberian Passenger Ship Star Princess on Poundstone Rock

Lynn Canal, Alaska
June 23, 1995

NTSB Number: MAR-97-02
NTIS Number: PB96-916403
Adopted June 20, 1997
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Executive Summary

On the evening of June 22, 1995, the Liberian-registered passenger vessel Star Princess, carrying 1,568 passengers and 639 crewmembers, 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 northwest of Juneau. The vessel's bottom sustained significant damage on the starboard side, including the rupture of oil tanks, which 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.

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.

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 recommendations to the U.S. Coast Guard, the State pilot commissions, the Alaska Board of Marine Pilots, the Southeastern Alaska Pilots Association, the Alaska Coastwise Pilot Association, the San Diego Bay Pilots Association, Inc., Princess Cruise Lines, the American Pilots' Association, and the International Council of Cruise Lines.

Recommendations

To the U.S. Coast Guard:

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea. (M-97-41)

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. (M-97-42)

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. (M-97-43)

To the State pilot commissions:

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea. (M-97-44)

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. (M-97-45)

To the Alaska Board of Marine Pilots:

Develop and implement a mechanism for monitoring the performance of pilots on a routine basis. (M-97-46)

Encourage or require pilots of passenger vessels operating in southeast Alaska to take bridge resource management training with bridge watch officers. (M-97-47)

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. (M-97-48)

To the Alaska Coastwise Pilot Association:

Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea. (M-97-49)

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. (M-97-50)

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. (M-97-51)

To Princess Cruise Lines:

Coordinate with the Alaska pilot associations to arrange bridge resource management training between your bridge watch officers and Alaska pilots. (M-97-52)

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. (M-97-53)

To the American Pilots' Association:

Advise your members about the effect of fatigue on performance and about sleeping disorders such as sleep apnea. (M-97-54)

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. (M-97-55)

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. (M-97-56)

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. (M-97-57)