CREW MISTAKES CAUSED HEELING OF CROWN PRINCESS CRUISE SHIP

[NTSB Press Releases <NTSBPressReleases@xxxxxxxx>]

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                      NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: January 10, 2008
SB-08-01

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CREW MISTAKES CAUSED HEELING OF CROWN PRINCESS CRUISE SHIP



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        The National Transportation Safety Board today 
determined that the probable cause of an accident involving 
the cruise ship Crown Princess was the second officer's 
incorrect wheel commands, executed first to counter an 
unanticipated high rate of turn and then to counter the 
vessel's heeling. 

        Contributing to the cause of the accident were the 
captain's and staff captain's inappropriate inputs to the 
vessel's integrated navigation system while it was traveling 
at high speed in relatively shallow water, their failure to 
stabilize the vessel's heading fluctuations before leaving 
the bridge, and the inadequate training of crewmembers in 
the use of integrated navigation systems.

        "We see from this accident the importance of having 
adequate training," said NTSB Mark V. Rosenker. "Had the 
crew been better trained in the equipment they were using, 
this accident may not have occurred, and implementing our 
recommendations is one way to help ensure this." 

        On July 18, 2006, the cruise ship Crown Princess, 
which had been in service about a month, departed Port 
Canaveral, Florida, for Brooklyn, New York, its last port on 
a 10-day round trip voyage to the Caribbean. About an hour 
after departing, the vessel's automatic navigation system 
caused the ship's heading to fluctuate around its intended 
course. Alarmed by a perceived high rate of turn, the second 
officer attempted to take corrective action that resulted in 
the ship heeling to a maximum angle of about 24 degrees to 
starboard. This caused people to be thrown about or struck 
by unsecured objects, resulting in 14 serious and 284 minor 
injuries to passengers and crewmembers. The vessel incurred 
no damage to its structure but sustained considerable damage 
to unsecured interior components, cabinets, and their 
contents. 

        The report adopted by the Board today states that the 
Crown Princess was operating at nearly full speed when the 
second officer took the controls. Because of instabilities 
in the automatic steering system, the officer faced the 
problem of navigating a vessel that exhibited both 
increasing course deviations and high rates of turn. The 
second officer took manual control of the steering and 
steered back and forth between port and starboard in 
increasingly wider turns. Rather than remedying the problem, 
the second officer's actions aggravated the situation, 
resulting in a very large angle of heel. The captain quickly 
returned to the bridge and brought the vessel under control 
by centering the rudder and reducing speed. The Safety Board 
concluded that the incident occurred because the second 
officer initially turned the wheel to port, when he should 
have turned it to starboard to counteract the turn.  

        The Safety Board also stated that the captain and 
staff captain made errors with regard to the ship's 
integrated navigation system. These errors included:
 
*               Failure to recognize that the integrated navigation 
system could be unpredictable at high speed in shallow 
water.

*               Failure to recognize that the rudder economy and 
rudder limit settings on the integrated navigation 
system were inappropriate for the vessel's speed and 
operating conditions.

The Board concluded that these errors stemmed from 
inadequate training and lack of familiarity with the 
integrated navigation system. 

        As a result of its investigation, the Safety Board 
made recommendations regarding integrated navigation system 
training to the U.S. Coast Guard, the Cruise Lines 
International Association, and to SAM Electronics and Sperry 
Marine, manufacturers of integrated navigation systems.

        A synopsis of the Board's report, including the 
probable cause and recommendations, is available on the 
NTSB's website, www.ntsb.gov, under "Board Meetings." The 
Board's full report will be available on the website in 
several weeks.

Media Contact: Keith Holloway (202) 314-6100 
hollowk@xxxxxxxx






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