Lessons Learned—The Grounding of a Cruise Ship—Part II

Part II—A Lesson in Maritime Management


Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. Read Part I here.


Just before the turn that immediately led to the grounding, the officer of the watch (OOW) was distracted by a phone call on the bridge regarding a disturbance related to a loud party in a stateroom. He was also required to silence a smoke alarm that had sounded on the bridge.

As soon as he felt the ship vibrate from contact with the reef, the master returned to the bridge and assumed the watch of the ship. At about 1:35 a.m. all of the watertight doors were ordered closed to prevent further flooding throughout the ship. The photo depicts the water level in an interior stairway.

At 1:47 a.m., the general emergency signal was sounded, and all passengers and crew were told to report to their emergency/abandon ship stations. By 2:20 a.m. all of the passenger cabins had been evacuated.

At 2:35 a.m. the master intentionally grounded the ship on a sandbar. Since this was accomplished successfully, the decision was made to evacuate the passengers by tenders rather than via the lifeboats. The evacuation was carried out by the shore-based tenders in about an hour and a half.

What Went Wrong?
As with many incidents, no single error caused it. There were organizational errors, navigational errors, and individual human errors.

One of the most critical organizational errors was the master’s not following the standards and procedures as laid out in the ship’s safety management system. Specifically, the officers on the bridge:

• did not set down a written passage plan for this particular deviation;
• did not follow the departure checklist;
• did not take a navigational fix;
• relied on only one navigational instrument, the automatic radar plotting aid (ARPA);
• relied on only one navigational aid, the Proselyte Reef lighted buoy;
• had not updated the charts to reflect the information in the latest Notice to Mariners.

This last item was critical, as the latest notice let mariners know that the Proselyte Reef lighted buoy the OOW was using to navigate had moved 125 meters west of the position on the ship’s chart.

The navigational errors were numerous as well. The officer of the watch did not take an initial fix on the ship’s position and did not account for the current and wind in his calculations. He also relied solely on the automatic radar plotting aid and did not take a terrestrial fix or utilize the global positioning system.

Not surprisingly, the human factors were also many. The master decided to sail to the east side of Proselyte Reef, which is the most dangerous side to transit, as the current moves in a westerly direction, the wind is normally easterly, and the lighted buoy they were navigating by is positioned on the west side of the reef. The master also had a managerial style that did not encourage communication of suggestions or questions by his bridge officers.

Additionally, the other officers of the bridge took no initiative to prepare a passage plan, record the passage of the vessel on the navigation charts, or even take readings from any of the other navigational aids to ensure that the ship was where they thought it was.

What’s the Bottom Line?
Of the multitude of mistakes made that led up to the grounding, many might have not occurred if the master had embraced and encouraged his crew to follow the procedures laid out in the ship’s safety management system.

Part III outlines the human errors and lessons learned from this incident.

For more information:
Full article is available at www.uscg.mil/proceedings. Click on “archives” and “2006 Volume 63, Number 2” (Summer 2006).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp.