T&T: Cruise Ship Rudder Control

[Dale Moses]

A real scary story - but lessons here for us all even tho from a large ship!
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Issue Date: April 2008

A sudden list to starboard, then chaos
Douglas A. Campbell

Passengers describe a day of terror in report on the Crown Princess cruise
ship


The 46-year-old executive assistant was enjoying an afternoon massage on an
upper deck of the Crown Princess. It was 3:25 p.m. on July 18, 2006 - the
final day of her cruise. The sea just outside Port Canaveral, Fla., was
calm, the sun was shining, and, in the shade of a privacy canopy, she was
drifting into a comfortable sleep.

Then, she told the National Transportation Safety Board, "I felt [the] ship
turning as if it were turning back southward and then sharp turn." The
woman, whose name the NTSB wouldn't release, continued. "All of a sudden,
the table I was on started to tip over, and I went flying off it as I heard
people screaming and the man in the next canopy came crashing through mine
onto me, as well as tables, canopies, etc."

At the same instant, up and down the 15 passenger decks of the 947-foot
cruise ship, tables, chairs, dinnerware, planters and many of the 4,545
passengers and crew became projectiles. As the ship heeled to 24 degrees,
the water emptied out of the swimming pool, washing children and adults
across the deck. Elderly passengers playing bingo in wheelchairs slammed
into walls; others clung to the railings from which they had been enjoying
the seascape an instant before.

A series of mistakes

Nearly 300 passengers and crewmembers were injured, 14 seriously, in the
incident, which the NTSB says happened when the second officer, left by
senior officers to oversee the bridge, made a series of mistakes. But the
agency also blames the ship's captain and staff captain for "contributing to
the accident." The board also faulted the training provided to the crew of
the Crown Princess, a new ship operated by Princess Cruises and on its first
cruise.

"Had the crew been better trained in the equipment they were using, this
accident may not have occurred," says NTSB chairman Mark V. Rosenker.

Where a passenger happened to be that afternoon directly affected his or her
exposure to injury. An example is Tom Daus. The 32-year-old resident of
Brooklyn, N.Y., was on the top deck, above a pool, talking with his parents
and some friends as he lounged on a deck chair, backed up against the
Plexiglas bulwark along the starboard edge of the deck.

"All of a sudden, the ship started to list [to starboard]," Daus recalls.
Held by the 4-foot-high bulwark, his chair remained in place, giving him a
stable view of the mayhem. "Everything started flying. I recall people being
thrown into plastic lounge chairs. They [the chairs] cracked. Everything was
thrown into a pile, including people.

"There were about eight people in the pool," he continues. "They got washed
out," he says, and thrown into pool-side chairs. Daus says he saw at least
two people in wheelchairs get injured. "People were cut and bruised," he
says.


What they experienced

The passenger descriptions of the day of terror aboard the Crown Princess
came in the form of answers to a questionnaire NTSB had sent out. Among the
responses were these accounts. (All were among the injured who were later
shipped to Florida hospitals.)

. A retired 68-year-old woman and her 35-year-old daughter were in the
casino on the sixth deck, seated on stools and playing slot machines, when
they were thrown to the floor and, with shattered glass flying, slammed into
a wall.

. A 50-year-old woman and her husband were on Deck 15 near the pool. She and
her deck chair were washed across the deck by the flood of pool water, and
she found herself against the clear plastic bulwark under a pile of about 10
deck chairs. Her husband was flung head-first into the ceramic tiles of a
pizza bar.

. A 54-year-old teacher and her mother were on Deck 7, setting up for the
bingo game. There was a rumbling, and the floor shook. As the ship began to
list, passengers around them assured them there were no problems. Then
mother and daughter slid across the floor as glasses fell from a bar and
shattered. The daughter got in front of her 84-year-old mother to protect
her from sliding furniture.

. An 80-year-old woman was in a lounge on the starboard side when she felt
herself being thrown about 20 feet. Tables and chairs and upended people
began to pile up on top of her.

. Another teacher, 55, and her mother were in an elevator when the ship
tilted, the elevator doors opened and the two women were thrown across a
hallway into a wall.


Physician lends a hand

Among those caring for the injured was a passenger, Dr. Gerald B. Brock, a
urologist from Ontario. He and his wife had been at their midships cabin on
the ninth deck when the ship heeled. "It was dramatic enough that inside our
room, we had a marble coffee table that went flying across the room and
smashed into doors that went out onto a balcony," he recalls. "My wife was
out on the balcony, and it was enough of a list that . she couldn't really
walk up into the room. She had to pull herself up on the railings to get
back into the room."

Neither Brock nor his wife was injured, so while she remained in the room,
he went to the ship's infirmary on the fourth deck to offer medical
assistance. "It was really quite impressive, the equipment they had," Brock
says. He was impressed as well by the number of injured.

"It was clear that there were lots of people and there was going to be lots
of work," Brock says. He was sent to the buffet several floors above the
infirmary, and there he saw food scattered across the floor and water from
the pool soaking the carpets. He also found "lots of people crying and
upset." Among the injured, he found broken bones and cuts and elderly
passengers complaining of chest pains, he says.

According to the NTSB, the damage was done on a day with relatively calm
seas and the Crown Princess traveling at 20 knots, close to full speed,
across relatively shallow water. Soon after it left port, the Crown Princess
began experiencing difficulty with its steering. The NTSB says, according to
voice recordings from the bridge, that the captain and staff captain talked
about the problem before they left the bridge and tried several measures to
correct it.

The ship was running on autopilot when the senior officers left the controls
in the hands of the second officer, according to the NTSB report. All of the
navigational equipment was combined in one control on the bridge - an
integrated navigation system - joining the radar, autopilot, electronic
charts and Automatic Identification System (AIS). The senior officers had
made adjustments to the system to limit the amount of rudder movement that
could take place, but the steering problem persisted, according to the
report. At one point, the captain told the staff captain the heading was
"wandering all over the place."


'Shallow water effect'

NTSB investigators later determined that the problem was a combination of
shallow water and the speed of the ship, which created turbulence called a
"shallow water effect."

"The ship moving through the water carries along a lot of water with it,"
explains the NTSB lead investigator, Tom Roth-Roffy. "Operating in shallow
water, you start to get some interplay between the water being dragged along
and the bottom water. Essentially, the response of the ship to rudder
commands would be different than in deep water. The turning diameter of the
ship would be greater. If you put 20 degrees rudder on in deep water," he
says, the ship would turn more quickly than in shallow water. Outside Port
Canaveral, the Crown Princess, with a draft of around 28 feet, was traveling
in water slightly less than twice that deep, which Roth-Roffy says qualifies
as shallow.

Left in command of the bridge, the second officer was "under a lot of
stress, and he perhaps lost his situational awareness," says Roth-Roffy.
With an even-more-junior officer at his side, apparently questioning his
moves, the second officer turned off the autopilot and took the wheel,
turning first to port 10 degrees, then to starboard 15 degrees, then again
to port 30 degrees, then starboard 30 degrees and finally port, 45 degrees,
the NTSB says.

It was about 35 seconds after the second officer began steering manually
that the captain and staff captain hurried back to the bridge and gave the
command to center the rudder and slow the ship's engines, the NTSB says. By
that time, the decks were littered with the terrified and injured.


A call for training

In its final report, the NTSB recommends the International Maritime
Organization, an international shipping safety group, make training in
integrated navigation systems mandatory for all watchkeepers on vessels with
those systems. Until that happens, the NTSB recommends that cruise operators
voluntarily provide that training and a requirement that crewmembers prove
they are proficient in using the systems. It also recommends that the
operators teach crews about the effects of high speeds in shallow water.

Roth-Roffy says the Crown Princess crew had training in the ship's
integrated navigation system, but he says that a "number of factors may have
contributed to less than optimum training."



Dale Moses
Camano 41 - Port Hadlock, WA
dalemoses at aol.com <mailto:dalemoses at aol.com>