Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation M-97-005
Details
Synopsis: ON 6/10/95, THE PANAMANIAN PASSENGER SHIP ROYAL MAJESTY GROUNDED ON ROSE CROWN SHOAL ABOUT 10 MILES EAST OF NANTUCKET ISLAND, MASSACHUSETTS, & ABOUT 17 MILES FROM WHERE THE WATCH OFFICERS THOUGHT THE VESSEL WAS. THE VESSEL, WITH 1,509 PERSONS ON BOARD, WAS EN ROUTE FROM ST. GEORGE'S, BERMUDA, TO BOSTON, MASSACHUSETTS. THERE WERE NO DEATHS OR INJURIES AS A RESULT OF THIS ACCIDENT. DAMAGE TO THE VESSEL & LOST REVENUE, HOWEVER, WERE ESTIMATED AT ABOUT $7 MILLION.
Recommendation: THE NTSB REITERATES RECOMMENDATIONS M-93-18 & -19 & RECOMMENDS THAT THE USCG: PROPOSE TO THE INTERNATIONAL MARITIME ORGANIZATION THAT IT DEVELOP APPROPRIATE PERFORMANCE STANDARDS FOR THE TRAINING OF WATCH OFFICERS ASSIGNED TO VESSELS EQUIPPED WITH INTEGRATED BRIDGE SYSTEMS & REQUIRE THIS TRAINING.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 4/10/1997
Date Closed: 4/20/1999
Addressee(s) and Addressee Status: USCG (Closed - Unacceptable Action)
Keyword(s): Training and Education

Safety Recommendation History
From: NTSB
To: USCG
Date: 5/2/2008
Response: This information derived for the greensheet issuesd on 5/2/08 M-08-1 and 2:The Coast Guard disagreed with the recommendation and notified the Safety Board that it planned to take no action on it. Consequently, the Board classified Safety Recommendation M-97-5 as Closed Unacceptable Action on April 20, 1999. Since the Safety Board issued its recommendation in 1997, errors in integrated navigation system use have continued. Although in recent years the International Maritime Organization has recognized the need for additional attention to integrated navigation system training for bridge watch officers, the training is still not mandatory. The record of passenger vessel incidents and accidents related to deficiencies in integrated navigation system training since the Royal Majesty accident contradicts the outcome foreseen by the Coast Guard when it responded to Safety Recommendation M-97-5 that there is no indication that the existing international standards of qualification are inadequate and that the 1995 amendments to the international convention on standards of training, certification, and watchkeeping for seafarers, 1978, (STCW) provide ample international standards and regulations governing integrated navigation system training. The International Maritime Organization has developed a model training curriculum for integrated navigation system and integrated bridge system equipment. The curriculum, which is advisory only, addresses many of the shortcomings in integrated navigation system training requirements that the Safety Board noted in its investigation of the Crown Princess accident. However, because there is no international requirement for integrated navigation system training, the proposed model curriculum may not be effective in addressing the shortcomings in integrated navigation system training noted in this investigation. Until crewmembers are required to demonstrate mastery of integrated navigation systems and integrated bridge systems through formal, well-designed training programs, there can be no assurance that watchkeepers are proficient in the use of these sophisticated systems. The model International Maritime Organization curriculum, or other training endeavors that meet similar instructional objectives, if implemented and made mandatory with mariner participation in the training, would increase the likelihood that crewmembers will use integrated navigation system or integrated bridge system equipment effectively in all operating conditions. Therefore, the Safety Board believes that the Coast Guard should propose to the International Maritime Organization that, in conjunction with the upcoming revisions to the Standards of Training, Certification, and Watchkeeping for Seafarers, it make training in integrated navigation systems and integrated bridge systems mandatory for watchkeepers on vessels equipped with such systems. The Crown Princess accident demonstrated the need for obtaining and archiving data on vessel angles of heel. Investigators had to determine the Crown Princess’s maximum angle of heel from images taken by cameras installed on the vessel for purposes other than accident investigation. The vessel’s voyage data recorder (VDR), designed to collect data for use in accident investigations, did not record heel angles, and there is no requirement that VDRs do so. Data that accurately record a vessel’s angle of heel can onsiderably assist those attempting to understand the nature of a heeling event. Therefore, the Safety Board believes that the Coast Guard should propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values.

From: NTSB
To: USCG
Date: 4/20/1999
Response: THE SAFETY BOARD IS DISAPPOINTED THAT THE COAST GUARD BELIEVES THAT EXISTING INTERNATIONAL STANDARDS OF QUALIFICATION ARE ADEQUATE, AND WHEN COMBINED WITH THE REQUIREMENTS OF THE INTERNATIONAL SAFETY MANAGEMENT (ISM) CODE, WILL PROVE SUFFICIENT TO ADDRESS THE INTENT OF THIS RECOMMENDATION. THE BOARD BELIEVES THAT TODAY'S SOPHISTICATED ELECTRONIC WHEELHOUSES REQUIRE WATCHSTANDERS TO HAVE SPECIALIZED TRAINING AND, THUS, APPROPRIATE PERFORMANCE STANDARDS NEED TO BE DEVELOPED TO MEASURE AN OFFICER'S COMPETENCY FOR THESE COMPLICATED INSTALLATIONS. BECAUSE THE COAST GUARD PLANS NO ACTION AND REQUESTS THAT THIS RECOMMENDATION BE CLOSED, M-97-5 HAS BEEN CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

From: USCG
To: NTSB
Date: 11/6/1998
Response: WE DO NOT CONCUR WITH THIS RECOMMENDATION. THE FACT THAT THE WATCH OFFICERS IN THIS INCIDENT DID NOT PERFORM THEIR WATCHKEEPING DUTIES PROPERTY DOES NOT ESTABLISH A NEED FOR SPECIAL INTERNATIONAL STANDARDS OF TRAINING FOR WATCH OFFICERS ON VESSELS EQUIPPED WITH INTEGRATED BRIDGE SYSTEMS. THERE IS NO INDICATION THAT THE EXISTING INTERNATIONAL STANDARDS OF QUALIFICATION ARE INADEQUATE. THE 1995 AMENDMENTS TO THE INTERNATIONAL CONVENTION ON STANDARDS OF TRAINING, CERTIFICATION, AND WATCHKEEPING FOR SEAFARERS, 1978, (STCW) PROVIDE AMPLE INTERNATIONAL STANDARDS AND REGULATIONS WHICH, IF FOLLOWED, WOULD PREVENT INCIDENTS SUCH AS THE GROUNDING OF THE ROYAL MAJESTY. FOR EXAMPLE, REGULATION 1/14, STCW REQUIRES A COMPANY THAT OWNS OR OPERATES A SHIP TO ENSURE THAT "SEAFARERS, ON BEING ASSIGNED TO ANY OF ITS SHIPS, ARE FAMILIARIZED WITH THEIR SPECIFIC DUTIES AND WITH ALL SHIP ARRANGEMENTS, INSTALLATIONS, EQUIPMENT, PROCEDURES, AND SHIP CHARACTERISTICS THAT ARE RELEVANT TO THEIR ROUTINE OR EMERGENCY DUTIES." OFFICERS IN CHARGE OF A NAVIGATIONAL WATCH ARE REQUIRED TO HAVE THE "ABILITY TO DETERMINE THE SHIP'S POSITION BY USE OF ELECTRONIC NAVIGATIONAL AIDS," AND ONE CRITERION TO EVALUATE THE OFFICER'S COMPETENCE IN NAVIGATION IS THAT "THE RELIABILITY OF THE INFORMATION OBTAINED FROM THE PRIMARY METHOD OF POSITION FIXING IS CHECKED AT APPROPRIATE INTERVALS." WATCHKEEPING REQUIREMENTS SPECIFY THAT "DURING THE WATCH, THE COURSE STEERED, POSITION AND SPEED SHALL BE CHECKED AT SUFFICIENTLY FREQUENT INTERVALS, USING ANY AVAILABLE NAVIGATIONAL AIDS NECESSARY, TO ENSURE THAT THE SHIP FOLLOWS THE PLANNED ROUTE." STCW ALSO REQUIRES THAT MASTERS AND CHIEF MATES BE PROFICIENT IN EFFECTIVE BRIDGE TEAMWORK PROCEDURES. WE ANTICIPATE THAT THE 1995 STCW AMENDMENTS, COMBINED WITH THE REQUIREMENTS OF THE INTERNATIONAL SAFETY MANAGEMENT CODE (ISM CODE), WILL IMPROVE WATCHKEEPING PRACTICES. THE COAST GUARD PLANS NO FURTHER ACTION ON THIS RECOMMENDATION, AND REQUESTS THAT IT BE CLOSED.

From: NTSB
To: USCG
Date: 7/14/1998
Response: NTSB REQUESTED A FOLLOWUP.