Marine Accident Report - Grounding of Panamanian Passenger Ship Royal Majesty

Nantucket Island, MA
June 10, 1995

NTSB Number: MAR-97-0l
NTIS Number: PB97-916401
Adopted April 2, 1997
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Executive Summary

About 2225 on June 10, 1995, the Panamanian passenger ship Royal Majesty grounded on Rose and Crown Shoal about 10 miles east of Nantucket Island, Massachusetts. The vessel, with 1,509 persons on board, was en route from St. George's, Bermuda, to Boston, Massachusetts. Initial attempts to free the vessel were unsuccessful. Deteriorating weather and sea conditions prevented the evacuation of passengers and crewmembers from the vessel.

On June 11, the Royal Majesty, with the aid of five tugboats, was freed from its strand. Initial damage surveys revealed deformation of the vessel's double bottom hull. However, no penetration or cracking of the hull was detected, and no fuel oil had been spilled. The U.S. Coast Guard gave the vessel permission to proceed to Boston. On June 12, the vessel arrived in Boston and disembarked its passengers.

There were no deaths or injuries as a result of this accident. Damage to the vessel and lost revenue, however, were estimated at about $7 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the grounding of the Royal Majesty was the watch officers' overreliance on the automated features of the integrated bridge system, Majesty Cruise Line's failure to ensure that its officers were adequately trained in the automated features of the integrated bridge system and in the implications of this automation for bridge resource management, the deficiencies in the design and implementation of the integrated bridge system and in the procedures for its operation, and the second officer's failure to take corrective action after several cues indicated the vessel was off course.

Contributing factors were the inadequacy of international training standards for watchstanders aboard vessels equipped with electronic navigation systems and integrated bridge systems and the inadequacy of international standards for the design, installation, and testing of integrated bridge systems aboard vessels.

This report examines the following major safety issues:

  • Performance of the Royal Majesty's integrated bridge system and the global positioning system.
  • Performance of the Royal Majesty's watch officers.
  • Effects of automation on watch officers' performance.
  • Training standards for watch officers aboard vessels equipped with electronic navigation systems and integrated bridge systems.
  • Design, installation, and testing standards for integrated bridge systems.

As a result of its investigation of this accident, the Safety Board issued safety recommendations to Majesty Cruise Line, the U.S. Coast Guard, STN Atlas Elektronik GmbH, Raytheon Marine, the National Marine Electronics Association, the International Electrotechnical Commission, the International Council of Cruise Lines, the International Chamber of Shipping, and the International Association of Independent Tanker Owners.

Recommendations

As a result of its investigation of this accident, the National Transportation Safety Board reiterates the following recommendations:

To the U.S. Coast Guard:

Propose to the International Maritime Organization that standards and curricula be developed for bridge resource management training for the masters, deck officers, and pilots of ocean-going ships. (M-93-18)

Propose to the International Maritime Organization that the masters, deck officers, and pilots of ocean-going ships be required to successfully complete initial and recurrent training in bridge resource management. (M-93-19)

Also as a result of the investigation, the National Transportation Safety Board makes the following recommendations:

To Majesty Cruise Line:

Provide initial and recurrent formal training on essential technical information, equipment functions, and system operating procedures to all bridge watchstanding personnel on all its ships that are equipped with integrated bridge systems. (M-97-1)

Review the bridge watchstanding practices on all its vessels, and revise, as necessary, to ensure that all watch officers adhere to sound watchstanding practices and procedures, including using landmarks, soundings, and navigational aids to verify a vessel's position, relying on more than one source for position information, and reporting to the master any failure to detect important navigational aids. (M-97-2)

Periodically review the performance of all officers on board its vessels. (M-97-3)

Eliminate the practice of openly routing navigation equipment cable to decrease the risk of damage. (M-97-4)

To the U.S. Coast Guard:

Propose to the International Maritime Organization that it develop appropriate performance standards for the training of watch officers assigned to vessels equipped with sophisticated electronic navigation equipment and integrated bridge systems and then require this training. (M-97-5)

Propose to the International Maritime Organization that it develop standards for integrated bridge system design that will require

  • multiple independent positionreceiver inputs;
  • monitoring position-receiver data for failures/invalid data and subsequent positive annunciation to the crew;
  • comparing position-receiver data for significant discrepancies between position receivers, and subsequent positive annunciation to the crew; and
  • failure modes and effects analyses (FMEAs) during the design process and once again when all peripheral devices and equipment details have been "frozen" if the FMEA during the design process does not account for all peripheral device/equipment variations. (M-97-6)

Propose to the International Maritime Organization that it apply existing human-factors engineering standards in the design of integrated bridge systems on vessels. (M-97-7)

Propose to the International Maritime Organization that a provision be included in the performance standard for integrated bridge systems that would require that a competent independent authority inspect and certify the navigation bridge of each commercial vessel equipped with an integrated bridge system when the system is installed and throughout its life. (M-97-8)

Continue its research on shipboard automation, focusing on watch officers' monitoring and decisionmaking aboard ships with automated integrated bridge systems. (M-97-9)

As part of the foreign flag passenger ship control verification examination program, assess the adequacy of installed integrated bridge systems and verify that the ships' officers are properly trained in their operation and possible failure modes. (M-97-10)

As part of the foreign flag passenger ship control verification examination program, verify that the watchstanding procedures of ships' officers include the use of multiple independent means of position verification. (M-97-11)

To STN Atlas Elektronik GmbH:

Design its integrated bridge systems to incorporate multiple independent position receivers, comparison of position data from those receivers, and related crew alerts regarding changes in position- receiver accuracy, selection, and mode. (M-97-12)

Recommend that all its customers have final failure modes and effects analyses for their integrated bridge system installations. (M-97-13)

To Raytheon Marine:

Design its hybrid positioning systems to identify themselves as integrated instruments (II) with an appropriate system mode identifier (SYS) in coordination with the National Marine Electronics Association. (M-97-14)

Design its position receivers to provide continuous aural alarms that require the user to take action to silence them. (M-97-15)

To the National Marine Electronics Association:

Revise the 0183 electronic interface standard to provide an explicit means of indicating when hybrid position receivers are transmitting dead reckoningderived position data. (M-97-16)

Advise its members to (1) immediately inform the National Marine Electronics Association and the International Electrotechnical Commission of perceived inadequacies in electronic interface standards and (2), if applicable, design their hybrid positioning systems to identify themselves ("talk") as integrated instruments (II) with an appropriate system mode identifier (SYS). (M-97-17)

Recommend to its members that they design and install critical aural alarms that are continuous and require the user to take action to silence them. (M-97-18)

To the International Electrotechnical Commission:

Advise its members to (1) immediately inform the National Marine Electronics Association and the International Electrotechnical Commission of perceived inadequacies in electronic interface standards and (2) if applicable, design their hybrid positioning systems to identify themselves ("talk") as integrated instruments (II) with an appropriate system mode identifier (SYS). (M-97-19)

Revise the 1162 electronic interface standard to provide an explicit means of indicating when hybrid position receivers are transmitting dead reckoningderived position data. (M-97-20)

To the International Council of Cruise Lines:

Recommend that its members provide initial and recurrent formal training on essential technical information, equipment functions, and system operating procedures to all bridge watchstanding personnel on their ships that are equipped with integrated bridge systems. (M-97-21)

Recommend that its members review the bridge watchstanding practices on all their vessels, and revise as necessary to ensure that all watch officers adhere to sound watchstanding practices and procedures, including using landmarks, soundings, and navigational aids to verify a vessel's position, relying on more than one source for position information, and reporting to the master any failure to detect important navigational aids. (M-97-22)

Recommend that its members periodically review the performance of all officers on board their vessels. (M-97-23)

Recommend that its members eliminate the practice of openly routing navigation equipment cable to decrease the risk of damage. (M-97-24)

Recommend to its members that they ensure that integrated bridge systems installed on their vessels provide critical aural alarms that are continuous and require the user to take action to silence them. (M-97-25)

Recommend that its members ensure that their existing and new integrated bridge systems incorporate the following:

  • multiple independent positionreceiver inputs;
  • monitoring position-receiver data for failures/invalid data and subsequent positive annunciation to the crew;
  • comparing position-receiver data for significant discrepancies between position receivers, and subsequent positive annunciation to the crew; and
  • failure modes and effects analyses on existing systems, during the design process for new systems and whenever peripheral devices or equipment details change. (M-97-26)

To the International Chamber of Shipping and to the International Association of Independent Tanker Owners:

Recommend to its members that they ensure that integrated bridge systems installed on their vessels provide critical aural alarms that are continuous and require the user to take action to silence them. (M-97-27)

Recommend that its members ensure that their existing and new integrated bridge systems incorporate the following:

  • multiple independent positionreceiver inputs;
  • monitoring position-receiver data for failures/invalid data and subsequent positive annunciation to the crew;
  • comparing position-receiver data for significant discrepancies between position receivers, and subsequent positive annunciation to the crew; and
  • failure modes and effects analyses on existing systems, during the design process for new systems and whenever peripheral devices or equipment details change. (M-97-28)