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Safety Recommendation Details

Safety Recommendation M-97-012
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 RECOMMENDS THAT THE STN ATLAS ELECTRONIK GMBH: DESIGN INTEGRATED BRIDGE SYSTEMS TO INCORPORATE MULTIPLE INDEPENDENT POSITION RECEIVERS, COMPARISON OF POSITION DATA FROM THOSE RECEIVERS, & RELATED CREW ALERTS REGARDING CHANGES IN POSITION RECEIVER ACCURACY, SELECTION, & MODE.
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: 4/10/1997
Date Closed: 6/16/1997
Addressee(s) and Addressee Status: STN Atlas Elektronik (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: STN Atlas Elektronik
Date: 6/16/1997
Response: THE BOARD UNDERSTANDS THAT ALL STN ATLAS NACOS SYSTEMS MEET THE LATEST INTERNATIONAL INTERFACING STANDARDS, CAN PRESENT SIMULTANEOUS SHIP POSITION DISPLAY FROM PRIMARY & SECONDARY POSITION SYSTEMS ON AN ELECTRONIC CHART DISPLAY, & HAVE THE CAPABILITY TO COMPARE THE PRIMARY POSITION SYSTEMS WITH A NACOS-INTERNAL DEAD-RECKONING POSITION IN SHORT-TERM & LONG-TERM INTERVALS WITH APPROPRIATE CROSS-TRACK ALARMING. THE BOARD ALSO UNDERSTANDS THAT STN ATLAS IS DEVELOPING A SYSTEM THAT WILL HAVE ALL AVAILABLE POSITION & MOTION INFO PROCESSED BY A FILTER THAT WILL PROVIDE A RELIABLE REFERENCE FOR POSITION ALARM FUNCTIONS, IN ACCORDANCE WITH THE REQUIREMENTS OF THE PENDING INTERNATIONAL ELECTROTECHNICAL COMMISSION PUBLICATION 1924. BECAUSE STN ATLAS HAS MODIFIED ITS INTEGRATED BRIDGE SYSTEMS SO THAT THEY INCLUDE THE RECOMMENDED FEATURES, M-97-12 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: STN Atlas Elektronik
To: NTSB
Date: 4/23/1997
Response: Response SINCE THE GROUNDING OF THE ROYAL MAJESTY, SEVERAL CHANGES HAVE HAPPENED REGARDING POSITION RECEIVERS & NAVIGATION SYSTEMS USING POSITI0N DATA: 1. THERE ARE INTERNATIONAL REGULATIONS, IN FORCE, WHICH DEFINE PERFORMANCE STANDARDS FOR POSITION RECEIVERS, NAMELY GPS & LORAN, INCLUDING RELIABLE INTERFACING STANDARDS, & INCLUDING THE REQUIREMENT THAT POSITION RECEIVERS MUST BE ACCORDINGLY TYPE TESTED BY GOVERNMENTAL BODIES. COMPARABLE STANDARDS FOR NAVIGATION SYSTEMS RECEIVING & PROCESSING POSITION DATA ARE IN A DRAFTING STATE. THESE STANDARDS ENSURE, THAT A NAVIGATION SYSTEM RECEIVES, DISPLAYS, & APPROPRIATELY RESPONSES TO POSITION & QUALITY STATUS INFO. OUR NAVIGATION SYSTEMS HAVE ALL SAFETY FUNCTIONS INCLUDED WHICH ARE REQUIRED BY A.M. PERFORMANCE STANDARDS, WHETHER COMPULSORY OR IN DRAFTED FORM. 2. INTEGRATED NAVIGATION & COMMAND SYSTEMS NACOS ARE THE ONLY AUTOMATED TRACK-KEEPING SYSTEMS IN THE MARKET, WHICH HAVE BEEN FULLY TYPE TESTED BY A GOVERNMENTAL TYPE APPROVAL AUTHORITY, THE GERMAN FEDERAL AUTHORITY FOR SHIPPING & HYDROGRAPHY. 3. OUR INVESTIGATIONS FOLLOWING THE GROUNDING OF R. M. DID NOT REVEAL ANY OTHER SHIP, WHICH HAD GPS-RECEIVER WITH DR-CAPABILITY CONNECTED TO A NACOS, & THERE WAS NO REPORT RECEIVED FROM A SHIP, WHERE THE NACOS DID NOT RESPOND WITH AN ALARM WHEN THE GPS ANTENNA WAS DISCONNECTED. 4. FOR SAFETY REASONS WE DO NOT COMPARE THE POSITIONS OF 2 POSITION RECEIVERS FOR THE GENERATION OF POSITION QUALITY ALARMS, BECAUSE FOR THE TYPICAL COMBINATION OF RECEIVERS (GPS + DGPS, GPS + LOARN, GPS + DECCA) THE SYSTEMATIC DIFFERENCES ARE LARGER THAN THE CROSS TRACK LIMITS TYPICALLY REQUIRED FOR SAFE NAVIGATION. PROCESSING THESE DIFFERENCES WOULD THEREFORE EITHER ALMOST CONTINUOUSLY GENERATE ALARMS OR BE OF NO USE REGARDING SAFETY. A HIGH RATE OF ALARMS WOULD ALSO DESENSIBILIZE THE CREW F FOR POSITON ALARMS. 5. THE LARGE POSITION OFFSET BETWEEN LORAN & GPS OF THE R. M. HAS TO BE CONSIDERED AS SINGULAR CASE, WHICH CANNOT HAPPEN ANYMORE WITH POSITION RECEIVERS FOLLOWING CURRENT PERFORMANCE STANDARDS. 6. IF THE AUTHORITIES WOULD REQUIRE REDUNDANT POSITION RECEIVERS OF EQUIVALENT ACCURACY TO BE CONNECTED TO AUTOMATED TRACK-KEEPING SYSTEMS, THEN THE COMPARSION OF POSITION DIFFERENCES BETWEEN SUCH RECEIVERS WOULD BE APPROPRIATE AS WELL. 7. HOWEVER, OUR NACOS SYSTEMS HAVE THE CAPABILITY TO PRESENT THE SHIP'S POSITION DERIVED BOTH FROM A PRIMARY & FROM A SECONDARY POSITION SOURCE ON AN ELECTRONIC CHART DISPLAY SIMMULTANEOUSLY. 8. OUR NACOS SYTSTEMS ALSO HAVE THE CAPABILITY TO COMPARE THE PRIMARY POSITION WITH A NACOS INTERNAL DR POSITON IN SHORT TERM & INTERVALS SEPARATELY, INCLUDING AN ALARM FUNCTION IN CASE OF DISCREPANCIES EXCEEDING THE SET LIMIT OF THE CROSS TRACK DISTANCE. 9. WHEN THE CURRENTLY DRAFTED PERFORMANCE STANDARD (IEC FUTURE PUBLICATION 1924) FOR INTERGRATED NAVIGATION SYSTEMS, INS, IS FINALIZED, WE SHALL HAVE A SYSTEM READY, WHICH PROCESSES ALL AVAILABLE POSITION & MOTION INFO BY A KALMAN-FILTER, & WHICH PROVIDES A RELIBLE REFERENCE FOR POSITION ALARM FUNCTIONS. WE HAVE A SYSTEM OF THIS TYPE IN OUR PRESENT R + D-PROGRAM.