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Safety Recommendation Details

Safety Recommendation M-16-003
Details
Synopsis: On March 9, 2015, at 1230 central daylight time, the inbound bulk carrier Conti Peridot collided with the outbound tanker Carla Maersk in the Houston Ship Channel near Morgan’s Point, Texas. The collision occurred in restricted visibility after the pilot on the Conti Peridot was unable to control the heading fluctuations that the bulk carrier was experiencing during the transit. As a result, the Conti Peridot crossed the channel into the path of the Carla Maersk. No one on board either ship was injured in the collision, but an estimated 2,100 barrels (88,200 gallons) of methyl tert-butyl ether spilled from the Carla Maersk, and the two vessels sustained about $8.2 million in total damage. The National Transportation Safety Board determines that the probable cause of the collision between bulk carrier Conti Peridot and tanker Carla Maersk in the Houston Ship Channel was the inability of the pilot on the Conti Peridot to respond appropriately to hydrodynamic forces after meeting another vessel during restricted visibility, and his lack of communication with other vessels about this handling difficulty. Contributing to the circumstances that resulted in the collision was the inadequate bridge resource management between the master and the pilot on the Conti Peridot.
Recommendation: TO THE LONE STAR HARBOR SAFETY COMMITTEE: Develop predetermined ship movement strategies (considering options such as increased vessel separation, one-way traffic, and/or anchoring) to be implemented before or at the onset of hazardous weather conditions to enhance safety for vessels under way in the Houston Ship Channel.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Marine
Location: Morgan's Point, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA15MM017
Accident Reports: ​Preliminary Marine Accident Summary - Houston Ship Channel, Buoy 89-90, Upper Galveston Bay, TXCollision between Bulk Carrier Conti Peridot and Tanker Carla Maersk Houston Ship Channel near Morgan’s Point, Texas
Report #: MAR-16-01
Accident Date: 3/9/2015
Issue Date: 6/22/2016
Date Closed:
Addressee(s) and Addressee Status: Lone Star Harbor Safety Committee (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Lone Star Harbor Safety Committee
Date: 5/2/2019
Response: We previously pointed out that the improvements that you were planning to implement would not satisfy the intent of this recommendation, which is to develop predetermined ship movement strategies. Pending receipt of detailed actions beyond outreach and installing weather sensors along the HSC, Safety Recommendation M-16-3 was classified “Open—Unacceptable Response.” It has now been almost 3 years since this recommendation was issued and we have not received any additional information from you regarding any actions that you have completed or planned in response to this recommendation. Pending our receipt of an update, Safety Recommendation M-16-3 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: Lone Star Harbor Safety Committee
Date: 1/24/2017
Response: We note that you have a number of ongoing projects underway and have identified improvements that you will consider implementing, including working with waterway users to improve scheduling efficiency to reduce congestion and lessen risk along the HSC; installing visibility and weather sensors at strategic locations along the entire waterway that are incorporated into the existing National Oceanic and Atmospheric Administration’s (NOAA’s) PORTS system, so the data will be available to all HSC users; continuing outreach to the maritime community to improve safety along the HSC; and forwarding an overview of HSC protocols to NOAA to be included in volume 5 of the United States Coast Pilot. Although the above measures are a good start, they do not satisfy the intent of this recommendation, which is to “develop predetermined ship movement strategies.” Pending receipt of detailed actions beyond outreach and installing weather sensors along the HSC, Safety Recommendation M-16-3 is classified OPEN--UNACCEPTABLE RESPONSE. We note that your Pilot Board Investigation and Recommendation Committee disagrees with our findings in this accident, and we have forwarded that opinion to our marine division for their information.

From: Lone Star Harbor Safety Committee
To: NTSB
Date: 11/4/2016
Response: -From James E. Prazak, Chair, Lone Star Harbor Safety Committee, Captain George Pontikos, Co-Chair, NTSB Recommendations Working Group, Lone Star Habor Safety Committee, and Paul A. Caruselle, Co-Chair, NTSB Recommendation Working Group, Lone Star Harbor Safety Committee: As you are aware from our earlier letter, the primary focus of the Lone Star Harbor Safety Committee (LSHSC) is on navigation safety-related matters involving the ports of Houston, Galveston, Texas City and Freeport, as well as the associated waterways of the Gulf Intracoastal Waterway and the offshore lightering zones. Our membership is comprised of public and private stakeholders who represent maritime interests throughout the industry, including the port authorities, pilots and vessel owners/operators. It is clear that maintaining a safe and efficient ship channel is critical to all of the stakeholders, as well as to our nation's economy. The LSHSC has now completed its review of recommendation M-16-3, which came from your investigation into the collision of the Conti Peridot with the Carla Maersk. At our meeting on August 5, 2016, the Committee assigned the review of this recommendation, as well as a review of the overall incident, to our Causality Working Group, which falls under our Navigation Operations (NAV OPS) Subcommittee. The Causality Working Group tasked a special focus group to concentrate on the above. This special focus workgroup was comprised of bluewater mariners, brown water mariners, Pilots, harbor tug operators, vessel owners/operators, the USCG and other key stakeholders. Tapping into the many years of expertise these members bring to the table, the workgroup provided their findings to the full LSHSC. This letter summarizes those findings, and after considerations by the full LSHSC Committee, has been unanimously accepted and approved for submission to the NTSB as our response to the recommendation forwarded to our committee, M-16-3. Background/Basis of Review: Prior to commencing the review, it was important to set a proper framework as to how the focus group would review the information that was available. It was decided that any recommendation developed must be both reasonable and viable, while remaining flexible enough to allow for adaptation as conditions change in the future. All considerations must align with the longstanding protocol of "ordinary practices of seamen", the Navigational Rules (in particular Rule 6), and in no cases can they impinge on the state-licensed Pilot and/or Masters/ Captain's authority and responsibilities with respect to the safe navigation of the vessel. Hazardous weather conditions can be difficult to predict, particularly fog, which can be localized and patchy at times, forming and moving in an unpredictable manner, and not always aligning with forecasts. Further limiting options is the fact that the Houston Ship Channel has limited availability of layberths and turning basins, and no mid-bay or upper channel anchorages. Any stoppage of a vessel in the navigable waterway has further effect on other bluewater and brownwater traffic that might be moving toward the area of the stoppage, which could create more risk than continuing t he voyage. Review of the Findings by Other Entities: The workgroup discussed the findings that were developed by both the NTSB and the Pilot Board Investigation and Recommendation Committee (PBIRC) . The PBIRC was created through the Rules and Regulations Governing Pilots and Pilotage on the Houston Ship Channel Between the Galveston Bar and Turning Basin, which were adopted to carry out the Houston Pilots Licensing and Regulatory Act, Chapter 66 of the Texas Transportation Code (Vernon 2008). Findings from the PBIRC included the fact that the Pilot on the Conti Peridot had ordered hard over rudder and full ahead shortly before the collision, but the engine and rudder did not fully respond to the commands. The reason for the lack of propulsion responsiveness remains unknown. The Pilots have asserted that it may be due to complications of using ultra low sulfur fuel oil in the main engine. This lack of responsiveness, whatever the cause, appears to have further degraded the handling of the vessel. Therefore, the working group does not fully support the NTSB finding 3.1.1, as vessel propulsion systems could very well have been a factor in this accident. The Coast Guard Vessel Traffic Service (VTS) provides an invaluable service to mariners and serves to mitigate navigation safety risk, especially during periods of restricted visibility. The professional watchstanders at VTS provide traffic information to the personnel in control of t he vessel relevant to situational awareness along the waterway, providing another tool in support of the bridge management team and Masters of the vessels transiting the area. Due to the limited width of the channel, along with the limitations of AIS and radar system displays, and with the necessity for vessels to pass within close proximity, the ultimate responsibility for safe navigation remains with the mariners in command of their respective vessel. Therefore, the working group does not support the NTSB finding 3.1.5 that VTS Houston/Galveston did not effectively monitor vessel traffic or identify the developing risk of collision due to restricted visibility, as this is the responsibility of the person in command of the vessel. Existing Traffic Management Strategies: The focus group found that there are existing predetermined ship movement strategies for the Houston Ship Channel that are implemented daily. During periods of hazardous weather and/or restricted visibility, additional measures are implemented. As such, the working group supports finding 3.1.6 regarding the recommendation for predetermined ship movement strategies. As the risk of hazardous weather conditions or restricted visibility increases, various strategies are implemented based on the assessment of that risk. Existing protocols include: • The Number 1 Pilot, who is the Pilot to board the next inbound bluewater vessel from the bar, assesses all available information and determines if it is safe to proceed with the boarding or close the bar. The Pilot is receiving information from weather forecasts, other mariners on the waterway (including other Pilots), and VTS. The operator of an inland towing vessel uses similar information to make his or her decision. • For piloted bluewater vessels already underway, the Pilot and Master/Captain are in the best position, given their authority and responsibilities under applicable rules and regulations, along with their professional assessment on scene, to make the decision on how to proceed when encountering or anticipating the onset of restricted visibility. A vessel, faced with the prospect of decreasing visibility and increasing navigation safety risk, has the option to proceed to his/ her destination, seek a nearby available layberth, or anchor in the channel. In these situations, early and effective communication with VTS is the key to managing the situation. If a vessel does go to anchor in the channel, VTS will then coordinate with the other vessels in transit to safely close the affected portion of the waterway. Moving the right vessel at the right time is a key to effective movements along the ship channel. During times of hazardous weather conditions and/or restricted visibility, it becomes even more important. The local Port Coordination Team (PCT) is used to assess the waterways and prioritize stakeholder needs and waterway movements. The work product of the PCT conference informs VTS traffic organization schemes. The severity or impact of a particular hazardous weather event, and in particular restricted visibility, is difficult to predict with any certainty. Whether the cause is a passing thunderstorm or patchy fog, the forecasting in place does not provide sufficient accuracy to confidently apply predetermined ship movement strategies. The most accurate assessments of visibility come from the mariners operating along the waterway, and combining that information with other data sources (i.e. forecasts, VTS, etc.) provides the information that is used by mariners to make their decisions from the bridge/wheelhouse. Besides having a significant impact to both the local and national economy, taking preconceived steps solely based on forecasts would lead to unnecessary restrictions and/or closures that would lead to further delays and bottlenecks with in the area waterways, only further increasing congestion and shifting risk to a later point in time. Predetermined strategies are in place, but the strategies that are implemented will vary based on circumstances and conditions that are being reported and forecasted. Detecting and predicting restricted visibility along individual portions of the waterway and how significant those restrictions will be remains a significant challenge, and is an area that must be further investigated to help mitigate risk on all of our nation's waterways. Sensors, in particular those that would aid in predicting fog, would be invaluable to mariners sailing on our waterways, if placed in strategic locations along the ship channel. Way Forward: The Houston port community has a proven t rack record of successfully working together to solve safetyrelated issues, and the LSHSC takes the lead in bringing all of the waterway stakeholders together to further this objective. It is incumbent on the waterway users to continue working to minimize risk on some of the busiest waterways in the USA. The LSHSC has a number of ongoing projects underway, and also has identified other improvements that will be investigated for possible implementation: 1. LSHSC subcommittees and its working groups continue working with the bluewater and brownwater communities and those that use their vessels (i.e. terminals and cha rterers) to improve scheduling efficiency, thus reducing congestion and lessening risk along the waterways. 2. LSHSC strongly supports initiatives to install visibility and weather sensors at strategic locations throughout the entirety of the waterway. These sensors should be incorporated into the existing NOAA PORTS® system, thus making the data available to all waterway users. LSHSC will continue working with local stakeholders to seek installation and maintenance of this equipment, and we look to the NTSB to provide any support possible. 3. LSHSC continues its outreach to the maritime community to improve safety along the waterways. These include Brownwater University, Bluewater/Brownwater Interface meetings and updates to various reference materials, such as "Navigating the Houston Ship Channel" (targeting commercial traffic) and "Sharing our Bay" (targeting recreational boaters). 4. An overview of Houston Ship Channel protocols is being forwarded to NOAA for inclusion in Volume 5 of the United States Coast Pilot. We thank the NTSB for their interest in the safety of our port area and for their partnership in our ongoing efforts to improve waterway safety on the Houston Ship Channel with both recreational and commercial users.

From: NTSB
To: Lone Star Harbor Safety Committee
Date: 9/16/2016
Response: We note that you assigned review of this recommendation, as well as of the overall incident, to your navigation operations subcommittee’s casualty working group, which will include a variety of members within the maritime industry who can use their expertise to address this issue. We further note that the working group will provide a response or follow-up for approval to the full committee during the next committee meeting in early November. Subsequently, the committee will update us on action planned or taken prior to the height of the next fog season. Pending this further update, Safety Recommendation M 16 003 is classified OPEN--ACCEPTABLE RESPONSE.

From: Lone Star Harbor Safety Committee
To: NTSB
Date: 8/18/2016
Response: -From James E. Prazak, Chair, Lone Star Harbor Committee: I am writing to you regarding the recommendation issued to the Lone Star Harbor Safety Committee (Lone Star) related to M-16-3, which came from your investigation into the collision of the Conti Peridot with the Carla Maersk. Lone Star's primary focus is on navigation safety-related matters involving the ports of Houston, Galveston, Texas City and Freeport, as well as the associated waterways of the Gulf Intracoastal Waterway and the offshore lightering zones. Our membership is comprised of public and private stakeholders who represent maritime interests throughout the industry, including the port authorities, pilots and vessel owners/operators. At our meeting on August 5, 2016, the Committee agreed to assign the review of this recommendation, as well as a review of the overall incident, to our Causality Working Group, which falls under our Navigation Operations (NAV OPS) Subcommittee. A special focus group will be conducting the main part of the review, tapping into expertise from a variety of members within the maritime industry who can provide their expertise to the work effort. Our goal is to have a further response and/or follow-up for approval by the full committee at our next meeting in early November, which would allow us to reply back to the NTSB before we reach the height of the next fog season. We thank the NTSB for their interest in the safety of our port area, and will work closely with our partner agencies and stakeholders to thoroughly evaluate the recommendation.