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Safety Recommendation Details

Safety Recommendation M-95-029
Details
Synopsis: ABOUT 2225, ON 6/10/95, THE PANAMANIAN PASSENGER SHIP ROYAL MAJESTY GROUNDED IN ABOUT 11 FEET OF WATER ON ROSE & CROWN SHOALS ABOUT 10 MILES EAST OF NANTUCKET ISLAND, MASSACHUSETTS. THE VESSEL, WITH 1,509 PERSONS ON BOARD, WAS EN ROUTE FROM ST. GEORGES, BERMUDA, TO BOSTON, MASSACHUSETTS, WHEN THE ACCIDENT OCCURRED. THE GROUNDING OCCURRED IN AN AREA OF HARD SAND THAT CAUSED THE VESSEL TO BE TRIMMED ABOUT 10 FEET BY THE STERN & TO ASSUME A 3.5 DEGREES STARBOARD LIST. THE VESSEL'S ENGINEERING & HABITABILITY SYSTEMS, HOWEVER, REMAINED FULL OPERATIONAL.
Recommendation: THE NTSB RECOMMENDS THAT THE STN ATLAS ELECTRONIK GMBH: IMMEDIATELY INFORM CUSTOMERS WITH THE NACOS 25 INTEGRATED BRIDGE SYSTEM OR SIMILAR SYSTEMS OF THE CIRCUMSTANCES OF THE ROYAL MAJESTY GROUNDING & REVIEW THE DESIGN & IMPLEMENTATION OF THEIR SYSTEMS TO IDENTIFY POTENTIAL SYSTEM & OPERATIONAL FAILURE MODES THAT MIGHT RESULT IN UNDETECTED CHANGES TO THE AUTOPILOT FUNCTION. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Atlantic Ocean, AO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA95MM042
Accident Reports:
Grounding of the Panamanian Passenger Ship Royal Majesty on Rose and Crown Shoal
Report #: MAR-97-01
Accident Date: 6/10/1995
Issue Date: 8/9/1995
Date Closed: 12/21/1995
Addressee(s) and Addressee Status: STN Atlas Elektronik (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: STN Atlas Elektronik
Date: 12/21/1995
Response: THE BOARD IS PLEASED THAT STN ATLAS ACATED PROMPTLY TO DISSEMINATE APPROPRIATE INFO TO ALL OF ITS CUSTOMERS USING NACOS INTEGRATED BRIDGE SYSTEMS. WE ALSO WELCOME STN ATLAS'S COMMITMENT TO ADDRESS THE MARINE INDUSTRY'S LACK OF INTEGRATED BRIDGE SYSTEM STANDARDS. CONSEQUENTLY, M-96-29 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: STN Atlas Elektronik
To: NTSB
Date: 8/25/1995
Response: Response STN ATLAS HAS PROVIDED A COMPREHENSIVE 10 PAGE RESPONSE. STN ATLAS HAS COMPLETED THE REQUESTED ACTION..."INFORM ITS CUSTOMERS OF THE CIRCUMSTANCES OF THE ROYAL MAJESTY ACCIDENT & DEVELOP CORRECTIVE MODIFICATIONS AS REQUESTED." STN ATLAS VOICED CONCERN THAT THE NACOS 25 SYSTEM FAILURE IDENTIFIED IN THE ROYAL MAJESTY ALONE WAS NOT THE CAUSE OF THE ACCIDENT...NAVIGATION CREW FAILINGS ALSO. STN ATLAS EXPLAINS THE INSTALLATION OF THE SYSTEM ON THIS VESSEL...THE ORIGINAL PURCHASER HAD INTENDED TO VESSEL FOR A CERTAIN RUN, THEY DEFAULTED & THE VESSEL WAS ULTIMATELY PURCHASED BY ANOTHER COMPANY & IS NOW OPERATED ON A TOTALLY DIFFERENT RUN (OCEAN SERVICE VICE BALTIC SEA FERRY FJORDS). FURTHER, STN ATLAS DID NOT INSTALL THE SYSTEM, IT WAS INSTALLED BY THE SHIPYARD & WAS HOOKED UP WITH OTHER MANUFACTURERS EQUIPMENT. STN ATLAS EXPLAINS THEY CAN NOT BE HELD ACCOUNTABLE FOR THIS, & IN ADDDITION BE JUDGED IN 1995 FOR 5 YEAR OLD TECHNOLOGY. STN ATLAS WOULD LIKE TO MEET WITH THE BOARD ON THIS ISSUE.