Monarch of The Sea Grounding 15dec98
Monarch of The Sea Grounding 15dec98
Monarch of The Sea Grounding 15dec98
JOINT
MARITIME INVESTIGATOR, OSLO, NORWAY
UNITED STATES COAST GUARD
REPORT OF INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE GROUNDING OF THE
This marine casualty report is a joint Norwegian/U.S. Coast Guard report prepared by the
Maritime Investigator in Oslo and the United States Coast Guard, Office of Investigations
and Analysis, Washington, D.C.
MONARCH OF THE SEAS has a Passenger Ship Safety Certificate for International Voyages
issued by the Norwegian Ship Control in Oslo on 9 November 1998 and valid until 31
October 1999. The ship is permitted to carry a total of 2,766 passengers and provided with
life-saving appliances for a total of 3,600 persons.
The main propulsion machinery of MONARCH OF THE SEAS consists of four Wrtsila Pielstick engines of 7,425 horsepower each. There are two KaMeWa propellers and two
KaMeWa bow thrusters. Full speed is approximately 19.5 knots. At full speed the crash stop
distance is 1,050 m. At half speed the crash stop distance is 930 m.
MONARCH OF THE SEAS is equipped with; inter alia, the following primary navigation
equipment:
- Two radars, Sperry Marine Rascar 3,400 m, one of
10 cm and one of 3 cm, all with ARPA equipment.
- One gyrocompass, Sperry Marine.
- One magnet compass, Marine Data Ltd.
- One course plotter, ToKimec.
- One echo sounder, Skipper ED 162.
- Two GPS units, Navigator Mx 200 Professional and
Trimble Navigator NT 200.
Chart room navigational
equipment
- One Loran, North Star GPS Loran 800.
: Grounding
: East side of Proselyte Reef (south of Philipsburg,
St. Maarten, the Netherlands Antilles)
Time of accident
Vessel's draught
Extent of damage
Measures taken to
stop water ingress
Evacuation
Lives lost
Pollution
2.1
A maritime inquiry was held by consular court on board the ship MONARCH OF THE SEAS
and at the Great Bay Hotel, St. Maarten on 18 and 19 December 1998. The president of the
court was Consul General Aage Os. Expert court Investigators were Mr. Valter Berg and
Mr. Nils A. Hgseter.
The following representatives were present at the maritime inquiry and had the opportunity to
ask the witnesses questions:
Andrew W. Anderson, RCCL/Keller & Houck
David Zawadzki, RCCL
Finn Paulsrud, Maritime Investigator, Oslo
Ole R. Lindbck, Norwegian Maritime Directorate
Marlon Granviel, Nautical Expert, Neth. Antilles
Jan R. Scheele, St. Maarten Port Authority NV
Edmond D. Johnson, St. Maarten Port Authority NV
Lt. Mark Hammond, U.S. Coast Guard MSD, Miami, Florida
Lt. Blake E. Welborn, U.S. Coast Guard MSD, St. Thomas, USVI
Timothy J. Farley, U.S. Coast Guard, Office of Investigations & Analysis, Washington DC
The above representatives were in agreement on using the recommended IMO Code for the
Investigation of Marine Casualties and Incidents (A849(20)) as a guideline for the
investigation.
Chronology
At about 0030 hours on the night of
15 December 1998, the MONARCH OF
THE SEAS arrived outside Great Bay,
St. Maarten. The ship, which was initially
enroute from St. Thomas, U.S. Virgin
Islands to Martinique, had deviated from its
intended course in order to sail into St.
Maarten to disembark a sick passenger who
needed immediate shore side medical
treatment. After the MONARCH OF THE
SEAS arrived at the prearranged meeting
point the passenger, together with the ship's
doctor and nurse, was transported ashore via
a shore side launch. While the vessel
awaited the return of the vessels crew, the
ship drifted freely on an easterly heading in
a position about four cable lengths (0.4 nm)
south of Fort Amsterdam.
At about 0125 hours the doctor and nurse returned to the vessel. The ships master himself
then piloted the ship to starboard from an easterly course heading, steadied the vessel up and
set a departure course of 160 degrees true to pass east of the Proselyte reef. This course was
based largely on the masters mariner eye as well as on the Officer of the Watchs (hereinafter
the OOW) feedback that the Automatic Radar Plotting Aids (ARPAs) calculated Closest
Point of Approach (CPA) to the Proselyte reef lighted buoy on the 160 degree course was
three (3) cables off (0.3 nm). The master felt that
this course provided the vessel a safe passage to
the east of Proselyte reef as well as would allow
a safe passage astern of an outbound sailboat that
was just to the south and ahead of the
MONARCH OF THE SEAS in the vicinity of the
Proselyte Reef lighted buoy. The course of 160
degrees was established without first sufficiently
determining the initial position of the vessel.
Further, no track line for the 160 degree course
was laid down or marked on the navigational
chart in use at the time nor was the 160 degree
course part of the voyage plan from St. Maarten
to Martinique. Additionally, the ship's chart used
at the time of the grounding, U.S. no. 25613, was
not updated in accordance with Notices to
Mariners no. 32/98 with respect to an updated
position of the lighted buoy on Proselyte Reef.
Chart of Great Bay
At the time of the vessels departure from St. Maarten, the persons present on the bridge were
the master, the staff captain, the OOW who was the ships second officer, the helmsman (an
experienced off-duty helmsmen asked to stand in for the less duty helmsman), and the duty
helmsman who served as the lookout. At
about 0128 hours and, after steadying the
vessel on a course of 160 degrees true, the
master handed over the navigational watch
to the OOW but not before asking the
question, How are we doing with clearance
to buoy? To this the OOW replied,
Closest point would be three cables off and
safe. This verbal exchange was
accomplished while visually observing the
Proselyte Reef lighted buoy 60-70 degrees
on the starboard bow but without first
checking the vessels actual position on the
navigational chart.
MONARCHs bridge, view from centerline
forward to starboard. Hooded equipment on
middle-left of photo is the ARPA in use by the
OOW at the time of casualty.
to input, either manually or automatically, set/drift calculations into the ARPA nor did he
ground lock the ARPA.
The OOW planned to change course to 190 degrees
true when the vessel was abeam of the Proselyte Reef
lighted buoy. Immediately before the intended course
change and while he was monitoring the vessels
progress on the ARPA, the OOW received a telephone
call from the purser's desk concerning a passenger who
had complained of noise near his cabin. The OOW
promised to dispatch someone to look into the matter.
At about the same time, an automatic smoke detector
alarm also sounded on the bridge. The lookout
responded to this alarm, found all was well and then
silenced the alarm
3.2
DATE:
TIME:
0000
0000
0010
0030
0040
0049
0125
0127
0128
0128
0221
0226
0233
0300
0316
0135
0136
0140
10
0145
0147
0148
0155
0157
0159
0159
0201
0207
0210
0213
0215
0218
0220
0221
0222
0226
0231
0233
11
0235
0236
0237
0239
0240
0241
0242
0243
0245
0249
0300
0302
0305
0307
0309
0326
0330
12
0334
0338
0348
0354
0400
0402
0404
0407
0412
0415
0428
0441
0510
0514
0515
0519
0530
13
3.3
14
The OOW determined the ship's position visually by use of radar ranges and bearings. The
OOW on the 0000-0400 watch was a navigator the master trusted and he had approved of the
officer's assignment to the 1200-1600, 0000-0400 navigational watch rotation.
According to the deck log, the ship's position, recorded in the logbook by the OOW at 0100
hours on 15 December 1998, was, Fort Amsterdam bearing 000 degrees, 4.0 cable lengths
off.
At 0125 hours when the doctor and nurse returned to the vessel, the master was still in
command. As the ship was drifting on an easterly course the master decided to depart
St. Maarten to the east side of Proselyte Reef. He ordered an increase in ships speed, turned
the ship to starboard and steadied up on a true course of 160 degrees.
The master's intention was to steer 160 degrees true until the Proselyte Reef lighted buoy was
abeam to starboard. Once the lighted buoy was abeam then he planned to alter course to
starboard to 190 degrees true. There was no approved departure voyage plan from
St. Maarten to Martinique. The revised voyage plan that had been verbally agreed to by the
master but not formally signed off or approved, listed the desired course for the first leg of the
voyage from St. Maarten to Martinique as 180 degrees (notation being 1 leg, 180 degrees, 30
nm). The master did not consult the navigational chart prior to departure and based the 160
degree departure course on his mariners eye and the CPA feedback by the OOW computed
for the Proselyte reef light-buoy. Further, he failed to ensure that a departure position and the
intended 160-degree departure track line was plotted on the navigational chart in use.
The master asked the OOW, How are we doing with clearance to buoy? The OOW
reported back that, The closest point will be three (3) cables off and safe. The master
himself nor any other member of the navigational watch did not verify if the clearance to the
Proselyte Reef lighted buoy was indeed safe, nor did the master ask anyone else to verify the
maneuver. In hindsight the master remarked that he would have preferred five (5) cables
clearance from any know hazard.
At 0128 hours the master handed over the command of the vessel to the OOW and ordered
him to, Go fast but safe. At 0128 hours the ship was steady on a true course of 160 degrees
and the speed was approximately 5-6 knots.
When the master left the bridge he visually observed the Proselyte Reef lighted buoy bearing
60-70 degrees on the starboard bow. On his way out from the bridge he said to the staff
captain and the OOW that they should, Keep safe well off buoy, go fast and safe. The
master left the bridge, but returned shortly thereafter and asked, It's so quiet here, have we
forgotten anything? Both the OOW and the staff captain reassured him by replying, No,
everything under control.
The master recalled that the staff captain was in the forward part of the wheelhouse when he
left and he expected him to remain on the bridge for five to ten minutes more as was
customary. The OOW was at the starboard radar, a helmsman was at the wheel, and there
was also a lookout on the bridge. The wind was easterly 6-8 knots, sea less than a half meter,
no swell and normal current.
15
When the master left the bridge he went straight to the toilet, as he desperately needed to use
the facilities. He had been suffering from a strong cold and diarrhea for two-three days. The
ships doctor had given him over the counter medicine for both the cold and the diarrhea
symptoms and he had been taking the medications for two-three days.
Monday evenings are normally busy due to a cocktail party with the ships passengers and the
master felt slightly fatigued on the evening of 14 December. He stated that he did not feel
tired from the medicines he took. The master had a valid health certificate for employees on
board ship.
After the visit to the toilet, the master went to the pantry for a sandwich and, at 0130 hours, he
suddenly heard and felt that the ship had struck something on what he felt was the starboard
side. Just before he departed the bridge the master had observed a sailboat just ahead of and
on the MONARCHs port side so he initially thought the ship had hit it.
The master immediately returned to the bridge and took over command of the navigational
watch. He steadied the ship on a southwesterly course and ordered the engines stopped. He
asked the navigational watch, Where are we and what has happened? He saw the lighted
buoy on starboard side and determined the vessels position. Everyone on the bridge was in a
state of shock and could not immediately speak.
The safety officer, chief engineer and junior chief engineer informed the master by radio that
the ship was taking on water and the situation was quickly worsening. The safety officer
reported that the watertight doors had to be closed and this was done at 0135 hours.
The master informed the company in Miami, the port authorities and the St. Maarten agent of
the vessels grounding and notified them that the ship was taking on water.
At 0147 hours the general emergency signal, seven short blasts and one long blast, was given
on board and all passenger were informed over the public address system about the
emergency. The announcement was subsequently made in Spanish, French and German
languages.
The master decided to take the ship to shallow water in Great Bay, Phillipsburg harbor and
ordered full speed ahead. The ship was difficult to handle because it was down by the head
and he realized how serious the situation had become. All lifeboats were lowered to the
promenade deck and were ready for embarkation at 0215 hours.
At approximately 0235 hours, the master, with the assistance and consultation of the local
port authorities, grounded the ship on a sandbar in Great Bay, St. Maarten. The grounding
was a smooth landing at a reduced speed of 6-7 knots.
From approximately 0245 hours to approximately 0515 hours on 15 December 1998 all 2,557
passengers were evacuated using tenderboats from the shore. The passengers were taken
ashore at Philipsburg, St. Maarten.
16
During the questioning of the witness in Oslo on 5 March 1999, the master explained
himself to the Maritime Investigator by making, inter alia, the following statement:
The witness explained that at no time during the planning of the voyage from St. Maarten to
Martinique did he consider sailing on the west side of Proselyte Reef. The ship steered an
easterly course outside Great Bay, St. Maarten when it went in to disembark a sick passenger
and he therefore considered it natural to sail out on the east side of Proselyte Reef. The
witness therefore put the ship on true course 160 degrees. The helmsman confirmed before
the witness that the ship was steering true course 160 degrees. The witness explained that the
160- degree course was a maneuvering course out of Great Bay towards the first waypoint
east of Proselyte Reef. Neither the first waypoint nor the 160-degree course was written in
any voyage plan. The witness acknowledges that the voyage plan for the passage St.
Maarten-Martinique had not been signed by himself or any other officer.
The witness explained that he did not check the distance to the Proselyte Reef lighted buoy at
any point during the navigation out of St. Maarten. He gave the following order to the
watchkeeping mate (OOW): How are we doing with clearance to buoy?. The OOW's reply
was, Closest point would be three cables off and safe. The witness therefore considered
the navigation to be completely under control. He handed over the command to the OOW
after giving him all information about the navigation and left the bridge shortly after. Before
leaving he bridge he gave the following order to the OOW: Keep safe well off buoy, go fast
and safe. The witness did not check the ship's position before going down from the bridge,
but he checked the course - 160 degrees - and he visually observed Proselyte Reef buoy,
whose position was bearing 50-60 degrees on starboard bow. The reason why the witness left
the bridge before the ship's passing Proselyte Reef was that he desperately needed to go to the
toilet.
Before the witness went down from the bridge he also asked the following question to the
OOW and the staff captain: It's so quiet here, have we forgotten anything?. Both officers
replied: No, everything under control. In the evening of 14 December, the witness wrote,
among other things, the following in the night orders book, which the OOW read and signed:
If any doubt and irregularities, call me right away. The witness did not specifically order
the OOW or the staff captain to check the ship's position, as he took their action in this
respect for granted.
3.3.2 Second officers statement/documentation
The second officer (OOW), a 30-year-old Norwegian citizen, started his seagoing career in
1988 as a radio operator in the Norwegian navy. He began working for Royal Caribbean
International in September 1994 and worked his way up, starting as a deck cadet, later serving
as ordinary seaman, quartermaster and second officer trainee until he was promoted to second
officer. He received his Deck Officer Class 4 certificate from the Norwegian Maritime
Directorate in June 1996. On 15 December 1998 he had altogether 27 weeks of experience as
a second officer. He had attended a course in the use of automatic radar plotting aid (ARPA)
in 1994. His health certificate for employees on board ship was valid. He was familiar with
the companys procedures and instructions for officers in charge of a navigational watch.
The second officer arrived in San Juan, Puerto Rico from Norway on the evening of
12 December 1998 after an eight (8) week holiday. He had had approximately seven and a
half hours (7 ) of sleep that night at a hotel and embarked the MONARCH OF THE SEAS at
17
approximately 1130 hours on 13 December, starting his 1200-1600, 0000-0400 watch rotation
shortly after arriving on board.
On the evening of 14 December 1998 he had been resting from 2000 hours to 2300 hours and
felt fit for watch when he came on the bridge at approximately 2330 hours. He had been
asked to come on the bridge at 2330 hours in order to get a better picture of the situation as
the ship had deviated from its course to evacuate a sick passenger at Philipsburg, St. Maarten.
When he arrived on duty the ship was on an easterly course approaching St. Maarten at full
speed, 19.5 knots. He relieved the officer in charge of the 2000-2400 watch at midnight after
checking the charts and getting information from the officer in charge about the new courses
from Philipsburg, St. Maarten to Martinique, which had been entered into the GPS by the
latter.
On 15 December 1998 the master took over the command of the navigational watch at 0010
hours and the vessels speed was reduced for the approach to Philipsburg. The OOW was
taking distances and bearings as well as monitoring the radar for the approach to the bay. He
was also watching for other traffic. At 0024 hours the said OOW recorded the following in
the deck log: The Corner, bearing 000 degrees, 1.2 nautical miles off.
At 0040 the ship was drifting on an easterly heading in position 0.4 nautical miles south of
Fort Amsterdam. The OOW recorded the following in the deck log at 0100 hours: Fort
Amsterdam, bearing 000 degrees, 0.4 nautical miles off. The tenderboat came alongside for
the sick passenger, doctor and nurse. The ship maintained a true course 070-075 degrees to
make a lee for the tenderboat. The OOW monitored the position, which was basically the
same all the time from when the tenderboat departed until it returned to the ship at 0125 hours
with the doctor and the nurse.
The master was in command of the navigational watch on the bridge during this evolution and
as soon as the tenderboat departed the ships side he gave orders to turn the ship to starboard.
He then steadied the ship on a true course of 160 degrees to pass east of the Proselyte Reef,
the speed then having been increased to approximately 7-8 knots. The pitch on the variable
pitch propellers was set at ten on the controls but a computer program in the engine control
room ensured that the pitch, and thus the speed, increased slowly. The course of 160 degrees
surprised the OOW as he expected the vessel to depart port on a more customary, westerly
course, passing to the west of the Proselyte Reef and leaving the lighted buoy to port.
At 0128 hours, as the ship was on true course 160 degrees and outbound from the drifting
position south of Fort Amsterdam, the master handed over the navigation of the ship to the
OOW with the following order: We are going fast and we are going safe and we have good
clearance off the buoy. Good watch. The OOW took over the navigation of the ship and the
master left the bridge very quickly. The OOW was operating the starboard radar, its scale
fixed at 1.5 nautical miles. The radar is equipped with an ARPA computer getting its input
automatically from the speed log. The Proselyte Reef lighted buoy had been designated as a
target on the ARPA when the ship was inbound to St. Maarten. As the ship proceeded
outbound from the drifting position off of Fort Amsterdam, on a true course 160 degrees, the
OOW watched the ARPA and observed that the closest point of approach (CPA) to the
Proselyte Reef lighted buoy was calculated to be 0.3 nautical miles, which he had reported to
the master. He did not provide the ARPA computer with input for set and drift nor did he
ground lock the ARPA. All the time the OOW visually observed the flashings from the
18
Proselyte Reef lighted buoy and he felt safe with a 0.3 nautical mile CPA clearance to the
lighted buoy.
During the departure he received a phone call from the pursers desk concerning some noise
near cabin 1549. While he was still on the phone and at the same time monitoring the radar,
he saw the lighted buoy come abeam on the starboard side. Then the lighted buoy
disappeared from view and he could not visually observe it from his position by the radar. He
put away the phone and ordered the helmsman to alter course to 190 degrees. At 0130 hours,
just as the ship had started a slow turn to starboard and had reached a course of about 163-164
degrees, the grounding on Proselyte Reef occurred. When the ship hit bottom it was traveling
at an approximate speed of 12-13 knots and there was a sound similar to that produced by a
really hard maneuvering. The ship came off the reef on the south side. Weather conditions
were: wind easterly force 3, gentle breeze, partly cloudy, sea approximately 1.25 meters, bar.
1015, air temperature 28 degrees C.
The master immediately returned to the bridge, conferred with the senior officers on board
and initiated emergency evacuation procedures informing all passengers that the ship had
grounded. He told the passengers to get dressed, don their lifejackets and proceed to their
lifeboat stations.
Reports came in to the bridge that the ship was taking on water on deck zero, at the photo lab
and the laundry area, and that the watertight doors were closed.
The ship was turned around and navigated on the west side of Proselyte Reef towards
Philipsburg, St. Maarten with the intention of deliberately grounding the vessel. The port
authorities had been informed and a boat was sent out to guide the ship into Great Bay to
ensure the best approach to the sandbank off of Philipsburg harbor.
At 0235 the ship was grounded at Great Bay, St. Maarten.
According to the OOW, the main factor contributing to the grounding is that the ship sailed on
the east side of Proselyte Reef. The chart used on board had not been corrected in accordance
with Notices to Mariners no. 32/98 in respect of the relocation of the Proselyte Reef lighted
buoy. After the grounding the OOW observed by GPS that the position of the said lighted
buoy was even further west than the position given in Notices to Mariners no. 32/98.
3.3.3 Staff captains statement/documentation
The staff captain, a 54-year-old Norwegian citizen, has approximately 20 years of seagoing
experience and has been with the company for about 16 years. He received his Deck Officer
Class 1 certificate (Master Mariner) from the Norwegian maritime agency in 1985. He has
been sailing as a staff captain for approximately 30 months, including 31 weeks on board the
MONARCH OF THE SEAS. His health certificate for employees on board ship was valid.
As staff captain he is next in command to the master and is the masters assistant. Among his
duties and responsibilities are safety, security and the discipline of the crew. He has regular
meetings with the deck officers and other officers. He is not considered to be in command on
the bridge until the master hands over the command to him.
19
He has ARPA training from the time he finished his master mariner education but he has no
training in ship handling (maneuvering).
On 14 December 1998 the staff captain went up to the bridge at approximately 2330 hours
and remained on the bridge until arrival at St. Maarten.
At 0010 hours on 15 December 1998 the master took over the command of the vessel. One
bow thruster was started at 0030 hours as the master navigated the ship into a position five
cable lengths south of Fort Amsterdam. The ship was maneuvered and kept in the
aforementioned position on an easterly heading. The tenderboat came alongside at 0040
hours and departed with the patient, doctor and nurse at 0049 hours.
At 0125 hours the tenderboat was back alongside the ship with the doctor and the nurse. The
tender departed the ships side at 0127 hours and the side shell gate was closed.
While the tenderboat was leaving, the master was in the process of maneuvering the vessel
out from the harbor. The staff captain was standing by the pitch controllers as was his
customary duty when entering or departing port. There was no twisting on the pitch
controllers. The speed was slow, with pitch on the controls set at 2 or 3. The speed was then
increased as soon as a sailboat located ahead of the ship was past and clear.
The staff captain noticed that the master turned the ship to starboard and steadied it on true
course of 160 degrees. He was not aware that the master intended to stop the starboard turn
and steady up on the 160 degree course. The staff captain was surprise at the course chosen
by the master as he had expected him to continue the turn the vessel to put the Proselyte Reef
lighted buoy on the ships port side and depart to the west of the reef as was customary. Had
the staff captain chosen a departure course for St. Maarten he would have chosen to go to the
west of Proselyte Reef to allow for the prevailing easterly wind and westerly set of the
current. At no time did the staff captain check the vessels position nor the progress of the
vessel as it departed St. Maarten. He also indicated that he did not see the OOW consult or
plot a position on the navigational chart in use at the time and that was located on the chart
table.
The master inquired with the OOW about what would be the distance off when passing the
lighted buoy. The OOW answered: 0.3 nautical miles off, safe distance. As the staff
captain heard this statement he trusted the masters and the OOWs judgment where the
planned navigation was concerned. The staff captain had so much respect for the master that
he would trust his decisions. The staff captain remarked that he would have advised the
master of any situation he felt was dangerous although, when he had previously done this in
the past, the master had not received the information in a positive manner.
At 0128 hours the master handed over command of the navigational watch to the OOW and
ordered full speed. The master also added: Drive fast but safe, safe distance to the lighted
buoy. Before the master left the bridge he informed the OOW, You are in charge, the
course is 160 degrees, controllers are about to increase the speed. The staff captain felt that
the OOW had the navigation of the vessel under control at that time.
At this stage the staff captain did not feel worried about anything and was in the process of
calling the engine-room asking for a load program. The pitch controllers were set at six. The
chief engineer confirmed that the load program was running and the pitch controllers were put
20
on the full speed setting by the staff captain. He was there monitoring the speed, the pitch
controllers and the instruments in front of him to see that everything was normal. He had felt
a pressure from the master to depart St. Maarten as fast as possible so that the ship would
reach Martinique around 1400 that afternoon.
The master exited the bridge but returned shortly to ask if something had been forgotten. The
time was still 0128 hours. Both the staff captain and the OOW replied that all was normal,
and so the master left the bridge again.
From the staff captains point of view, the reason for the masters return was related to the
general procedures at departure, in respect to such things as stabilizers, thrusters, etc, and not
based on the navigation layout. The master often asked a question like that during arrivals
and departures.
At 0130 hours, as the staff captain was still monitoring the instruments; he also visually
observed that the lighted buoy was abeam on the ships starboard side.
The OOW, who was standing by the starboard radar, gave orders to change course to
starboard and steady on a true course of 180 degrees. The ship had reached approximately
163 degrees when the grounding occurred. The speed at that time was approximately 12-13
knots and there was an enormous shaking at the time of the impact. The staff captain realized
that the ship had hit the bank and he took the pitch controllers back to 7 or 8, just by reflex
action. He also realized then that the ship had come over the bank (reef). The msater
immediately returned to the bridge and assumed command of the vessel commencing at 0131
hours. The staff captain gave him as much information as he could following the grounding.
The staff captain remarked that he did not always get positive feedback from the master when
he gave the master advice. The staff captain felt that the communication between himself and
the master could have been better.
3.3.4 Helmsmans statement/documentation
The quartermaster, a 24-year-old Norwegian citizen, was helmsman after midnight on
15 December 1998. He had started his seagoing career in 1993 and was the holder of a Deck
Officer Class 4 certificate from the Norwegian maritime agency. He had been on board
MONARCH OF THE SEA for approximately 14 weeks. Although he was originally on the
20-24 navigational watch he was asked to stay on the helm during the vessels departure from
St. Maarten as he was more experienced than the normal 00-04 helmsman.
As helmsman on the aforementioned night he executed the orders given by the master and the
OOW. He had worked with the latter for 4 weeks.
After the patient had been taken ashore and the tenderboat had returned, the master ordered
him to steer 160 degrees on the gyrocompass. The order was loud and clear. While he was
steering 160 degrees he visually observed the buoy but does not recall the angle on the bow.
He heard the master leave the bridge saying, Good watch, and he heard the sound of the
door being closed. After the master left the bridge the remaining personnel on the bridge
were the staff captain, the OOW, the lookout and himself.
21
At a later time he received an order from the OOW to steer 190 degrees. He turned the rudder
five degrees to starboard, equivalent to a turn rate of eight degrees per minute. The staff
captain gave him no orders.
After the ship had turned 3-4 degrees, the ship began shaking violently. He turned the rudder
amidships and straightened out. No order was given to do this. He looked out to starboard
and could see the buoy at an angle of about 90 degrees, but he did not know how far off the
buoy was.
Immediately after the vessel shook the master returned to the bridge and ordered a turn to
starboard.
3.3.5 Lookouts statement/documentation
The lookout, a 23-year-old Norwegian citizen, was originally posted on the bridge for the
00-04 navigational watch on 15 December 1998 as the helmsman but was asked if he had
steered the vessel before. After answering that he had not steered the vessel before he was
relieved at the helm by the more experienced 20-24 helmsman who remained on the bridge
for the departure of St. Maarten. He then served as a lookout more or less. He received his
Deck Officer Class 4 certificate from the Norwegian maritime agency in February 1997.
When the tenderboat left the ships side, the lookout believed that the ship turned to starboard.
He was standing/walking by the port radar. The OOW was mainly operating the starboard
radar, which is located close to the starboard bridge wing.
He visually observed the flashing light from the buoy. He also saw the buoy on the radar,
with CPA 0.3 nautical miles. It was a clear night. It was very difficult to judge the distance
to the buoy visually.
He believes the order to change from 160 to 190 degrees came at the point where the buoy
was approximately 90 degrees on starboard. When he heard that order, he believes the master
may have been gone for maybe three minutes. At about the same time he heard and
responded to an automatic smoke detector alarm, finding everything was okay.
The staff captain was standing at the pitch controllers before the grounding and he was also
moving around. The lookout did not hear the staff captain give any commands.
After the grounding the lookout was ordered to help with the anchors.
3.3.6 Safety officers statement/documentation
The safety officer, born 21 June 1954, closed and locked the shell gates after the tenderboat
left the ships side on the night of 15 December 1998.
At 0130 hours he felt the ship vibrate differently. He ran to the engine control room, where
the chief engineer, junior chief engineer, and second engineer were dealing with many
different alarms.
The safety officer went forward, only to find that there was water up to the deck plates in
pump room number 1. He also found water coming into pump room number 2. The safety
22
officer closed watertight doors numbered one (1) and two (2). Afterwards he contacted the
bridge and suggested that all watertight doors be closed. Together with the third engineer he
closed the escape hatches to pump rooms numbered one (1) and two (2). The laundry room
filled up very quickly with water and water also came into the lobby by the central store area
in the vicinity of watertight door number ten (10), which he found in the opened position.
This was in violation of standard operating procedures that required watertight door number
ten (10) to be closed and secured at 2300 every evening. He felt that the ship would have
been lost without blanking off watertight door number ten (10) as the vessel was a twocompartment ship.
The safety officer judged that the ship would have been lost if the master had not deliberately
grounded it on the sandbank. Where the safety of the ship is concerned, his opinion is that the
ships personnel were exemplary on the day in question. During the evacuation of the vessel
there were no language problems. Regarding why the lifeboats were not used, the safety
officer remarked that using lifeboats would have taken key personnel away from their
functions. The training program on board is in accordance with the STCW Convention. The
ship is in compliance with SOLAS requirements for passengers with special needs.
23
24
The Master may decide to alternate the command on the bridge with the Staff Captain under
special circumstances, such as dense fog, even in close waters, provided that the Staff Captain
can take control and maneuver the vessel under these conditions.
All deck officers shall read and understand the contents of this manual. The Standard
Operational Procedures in chapter 5 are of special importance. The Master shall, at least
once every contract period ensure that the officers are familiar with the Standard Operational
Procedures and review these procedures annually.
4.1.3 Concerning the ships ISM manual: text of instruction 1.2
(The Human Factor in the Navigational Operation)
The most common cause of accidents is human error. The risk of human error can be
reduced by proper operating procedures on the bridge, combined with training and
teamwork. For example, the Staff Captains lack of training in maneuvering and piloting can
impair his ability to advise the Master to a sudden change of conditions.
It is the Masters responsibility to train the Staff Captain in pilotage and maneuvering. The
aim of the training is that the Staff Captain reaches the same level of skill as the Masters. A
log indicating this training should be retained by each Staff Captain as part of his personal
file. Sample of this log is provided in the appendices.
Safety is potentially jeopardized in poor visibility, if the team lacks a vital member, if there is
an untrained member in the team, if operators are unfamiliar with new equipment, if there are
technical malfunctions, a change of the ships route or if an unfamiliar port has to be entered.
The Officer of the Watch often observes the radar when the vessel enters or leaves a port, if
so, he shall be instructed to follow the progress of piloting by comparing radar observations
with the passage plan.
Proficient, effective communication is utmost important to keep all involved always informed
of decisions made. Lack of information is a common cause of human error.
Human error is accepted because it is not intentional, but negligence is not. Mistakes must
never be hidden. They must be reported, discussed and corrected so we can learn from them.
Errors must be detected quickly, and the bridge team must then agree methods that will avoid
these errors in the future.
The print out from the maneuvering recorder (where applicable) and the course recorder
shall be stored on the bridge for three years and then destroyed, unless if a case is pending.
25
BASIC FUNCTION:
The Staff Captain shall be the Masters deputy. The Master shall keep the Staff Captain
acquainted with all aspects of his command, and he shall keep all other officers advised as
required by their duties and responsibilities. In this respect, the Master shall ensure that the
Staff Captain receive practice in maneuvering the ship, in particular approaching and leaving
port, as well as docking and undocking. He shall hold meetings with all department heads,
his marine officers and other members of the crew as described in Chapter 7 in this manual.
QUALIFICATIONS:
The Masters qualifications and licenses shall conform to all International and National
conventions and regulations and he shall have an unlimited Masters License.
RESPONSIBILITIES:
The Masters primary responsibility is the safety and care of all persons on board, the ships
seaworthiness, navigation and operation, and the prevention of pollution. In the event the
ship becomes endangered, the Master, shall use all resources available to minimize the effects
of an incident to persons, property and the environment and to successfully guide an
evacuation and rescue should the situation so require. He shall do his utmost to protect and
preserve the ships documents and valuables.
4.1.5 Concerning the ships ISM manual: text of instruction 4.2
(Position descriptions, Staff Captain)
REPORTS TO:
Master
BASIC FUNCTION:
QUALIFICATIONS:
The Staff Captains qualifications and licenses shall conform to all International and
National conventions and regulations and he shall have an unlimited Masters License.
RESPONSIBILITIES:
The Staff Captain shall have a full understanding of the Safety and Quality Management
Program including his responsibilities in the Safety Organization according to the Emergency
Plan and Station Bill.
26
The Staff Captain shall be familiar with the Masters duties, responsibilities and authorities
and shall be prepared to take command without notice. The Staff Captain shall assist the
Master in all service matters and keep him informed of significant events and trends
pertaining to the welfare of the ship, passengers and crew.
He is in charge of the Deck Department.
4.1.6 Concerning the ships ISM manual: text of instruction 4.5
(Position description watchkeeping officers)
REPORTS TO:
Master
BASIC FUNCTION:
QUALIFICATIONS:
The Watchkeeping Officers qualifications shall conform with all international and national
conventions and regulations.
RESPONSIBILITIES:
All Watchkeeping Officers shall have an understanding of the Safety and Quality
Management Program including their responsibilities in the Safety Organization according to
the Emergency Plan and Station Bill.
The Watchkeeping Officer shall perform in accordance with the Masters standing
instructions and the specific orders for the watch. Under no circumstances shall the
Watchkeeping Officer occupy himself with anything that will distract his attention during the
watch.
Navigation
The Watchkeeping Officer to whom this task is delegated shall assist the Master with the
navigation of the ship acting directly subordinate to the Master. His duties shall include
operating the ships navigational instruments, plotting gear, charts and nautical publications
and entries in the ships log on behalf of the Master.
4.1.7 Concerning the ships ISM manual: text of instruction 5.1
(Standard Operational Procedures)
All nautical deck officers shall keep themselves familiar with these instructions. These are
part of the Nautical Officers Familiarization.
The Watchkeeping Officers are the Masters representative and responsible to him for the
safe navigation of the vessel, the strict compliance of navigational rules, the applicable laws
and regulations as well as the Masters orders.
27
THERE MUST ALWAYS BE A LOOKOUT ON THE BRIDGE WHEN THE SHIP IS AT SEA
When automatic pilot is in use, the helmsman may be released to attend other duties, subject
to the provisions of Regulation 19, Chapter V of the SOLAS Convention.
The Watchkeeping Officer to whom the navigation equipment is assigned, shall ensure that all
charts and documents for the voyage are updated and corrected. All corrections shall be
signed and dated. An updated library of publications and charts for the sailing area shall
always be maintained.
1. FAMILIARIZATION OF STCW
It is the responsibility of all nautical deck officers to familiarize themselves with the
STCW 95 Convention. They shall also be familiar with the PRACTICAL GUIDE
TO BRIDGE WATCH KEEPING.
2. RESPONSIBILITIES
All deck officers and crew shall carefully read and understand their specific
responsibilities as described in the individual position descriptions, in chapter 4 of
this manual.
3. FAMILIARIZATION OF BRIDGE EQUIPMENT
All nautical officers shall familiarize themselves with all bridge equipment and
instruments. If an Officer has the slightest doubt about any equipment, he is
responsible for consulting a colleague, the Staff Captain or the Master.
4. MASTER ON THE BRIDGE
The Watchkeeping Officer is in charge of the watch even if the Master is on the bridge.
The Master will clearly state when he takes over or gives back the bridge
responsibility to the Watchkeeping Officer. This procedure shall be logged in the
Deck Log Book.
5. OFFICER IN DOUBT
If the Watchkeeping Officer has the slightest doubt about orders being given, he shall
ask the Master to clarify the orders.
Consequently, the Master or any officer of the bridge team, should be alert to the
anticipated helm or engine control orders. This applies to all controlling factors, not
pertinent to who is in control.
6. THE MASTER TO BE CALLED
The Master should be called under the following circumstances:
in poor visibility according to the Masters instructions
if the traffic or the movement of other vessels causes concern
if difficulty is experienced in maintainin course
on failure to sight land, a navigational mark, or to obtain soundings by the
expected time
if a sight of land or navigational mark or a change in soundings occurs
unexpectedly
on the breakdown of engines, loss of electrical power, steering gear, or
navigational equipment
28
29
30
4.4
What the ships course recorder shows
The ships course recorder for 15 December 1998 shows that the MONARCH OF THE SEAS
steered a course of about 090 degrees at around 0114 hours Local Time (LT). In the period
from about 0114 hours to about 0125 hours LT the ship changed course from approximately
090 degrees to approximately 160 degrees. The ship steered the latter course from about 0125
hours to about 0130 hours LT. At 0130/0131 hours LT the ships course was changed to
approximately 166-167 degrees. In the period between approximately 0131 hours and 0140
hours LT the ship steered courses varying between 174 and 160 degrees.
4.5
Notices to Mariners no. 32 of 8 August 1998
According to Notices to Mariners no. 32/98 of 8 August 1998, the buoy 25613 (the Proselyte
Reef lighted buoy) had been moved from position 17 degrees 5923 N / 063 degrees 0331
W to a position of 17 degrees 5918.6 N / 063 degrees 0336.0 W. Reference is made
therein to chart U.S. no. 25613 and Notices to Mariners no. 31/98. (The aforementioned
moving of the Proselyte Reef lighted buoy changed the buoys position to a position indicated
to be approximately 125 meters further west.)
4.6
Failure to correct the ships chart U.S. no. 25613 in accordance with Notices to
Mariners
The ships chart U.S. no. 25613, which was used at the time of the grounding, had not been
corrected in accordance with Notices to Mariners no. 32/98 of 8 August 1998 before
15 December 1998 in respect of the new position of the Proselyte Reef lighted buoy,
17 degrees 5918.6 N and 063 degrees 0336.0 W. The latest correction made on the said
chart was consequent on information found in Notices to Mariners no. 31/98.
4.7
Warning in the ships chart U.S. no. 25613
In the margin of the above chart, the following warning is printed:
WARNING. The prudent mariner will not rely solely on any single aid to navigation,
particularly on floating aids.
4.8
Currents at Proselyte Reef
According to the pilot chart for the waters of the Caribbean Sea, the current at Proselyte Reef
moves in a westerly direction at a daily average speed of 0.6-0.7 knots. Those familiar with
the port entrance confirmed a customary westerly current near Proselyte Reef for that time of
year.
4.9
Alcohol and drug tests of the crew after the grounding
On 15 December 1998, in the period between 0330 hours and 0400 hours, blood samples
were taken of the following: the master, the staff captain, the second officer who was OOW
on the 0000-0400 hours watch, the helmsman, the lookout, the second officer who was OOW
on the 2000-2400 hours watch, and the navigation officer.
The blood samples taken of the above crews were analyzed by Toxicology Testing Service,
Inc., Miami and all samples were found to be negative.
31
Alcohol use was permitted on board the vessel provided crewmembers only consumed
alcoholic beverages with a maximum alcohol content of two and a half (2 ) percent by
volume. Crewmembers are prohibited from consuming alcoholic beverages within eight (8)
hours of watch duty.
4.10 Information from the master on the cause of the grounding
On 18 December 1998, the master wrote the following in the Marine Casualty Report 97 in
the space below line no. 86 (conditions which contributed to the casualty): Navigated too
close to Proselyte Reef.
4.11
The companys own investigation of the casualty contained the following conclusions and
recommendations:
1. The primary cause of this grounding was human error by the Master and his Bridge
Resource Management Team in that they failed to:
a. Accurately determine the position of their ship in relation to a known reef area, and;
b. To navigate their ship in a manner which would give wide berth to such a hazard.
2. Contributing causes are:
a. The Master, Staff Captain and Bridge Watchkeeping Officers failure to comply with SQM
Deck Procedures, Section 5.1 Standard Operating Procedures, which requires that a Port
Departure Plan be developed and shall include courses and parallel index distances to
dangerous areas (in this case, Proselyte Reef);
b. The failure of the Master to verify the track line prepared by his Bridge Watchkeeping
Officer;
c. Total reliance by the Master and Bridge Watchkeeping Officer on Proselyte Reef Lighted
Buoy as the sole source to determine the ships position when departing Philipsburg when
terrestrial fixes were readily available. This action failed to comply with SQM Deck
Procedures, Section 5.1 Standard Operating Procedures, Item 14, regarding fixing the
ships position;
d. Failure to correctly update the position of Proselyte Reef Lighted Buoy on the navigation
chart;
e. Failure of the Master, Staff Captain and Bridge Watchkeeping Officer to perform as a
coordinated, cohesive Bridge Resource Management Team in all aspects regarding the
safe navigation of the ship, especially the planning and actual transit of a known,
submerged hazard to navigation;
f. The actual position of Proselyte Reef Lighted Buoy being approximately 150 yards northnorthwest of its position published in Notice to Mariners 32/98; and
g. The Master setting full speed prior to the ship safely passing known navigational hazards.
3. The Master failed to take adequate measures to safely navigate his ship.
32
4. The Bridge Watchkeeping Officer failed to properly and accurately determine the position
of the ship when departing St. Maarten.
5. The Staff Captains failure to interject himself as an active participant of the Bridge
Resource Management Team during the planning and execution of a transit near a known
hazard may have contributed to this casualty.
6. Notice to Mariners 31/98 and 32/98 corrections were not properly made on Chart 25613.
7. There is no evidence which would indicate culpability on the part of the remaining
personnel on the Bridge (the Helmsman and the Lookout) or the two off-Watch Bridge
Watchkeeping Officers regarding their part in this accident.
8. Based on the negative findings of all Blood Chemistry specimens tested by the Toxicology
Testing Service of Miami, FL, it is concluded that there is no evidence to indicate that
either bensodiazepines, opiates, marijuana, amphetamines or ethyl alcohol contributed to
this casualty.
9. The availability of additional automatically recorded data (e.g., operational Voyage
Management System; more user friendly KIM Voyage Recorder; Bridge Voice Recorder)
would have made reconstruction of the events resulting in this casualty more definitive.
10. Had a Port Departure Plan been developed which:
a.
b.
Identified navigational hazards (Proselyte Reef) and a safe course to steer to clear it,
and/or;
Had danger bearing information set to warn of encroachment on Proselyte Reef;
Officers must first meet the requirements established by the Norwegian Maritime Directorate
certifying, under both Norwegian and international requirements (including STCW), that the
individual is competent and able to perform the duties for which he or she is certified.
33
Training for these duties is an integral part of the certification process. On each ship, the
master is responsible for the manning including the specific watches to which officers are
assigned. In particular, it is the masters responsibility to assess the competence of the
officers on the bridge and take corrective action if he or she has any doubts regarding the
officers competence.
In the case of the watchkeeping second officer on duty at the time of the grounding, the
relevant facts are:
4.13
The classification society found water ingress in the following tanks/spaces after
the grounding:
Compartment
SW tank No. 1
Dry Tank No. 2
Dry Tank No. 3
Dry Tank No. 4
Dry Tank No. 5
Dry Tank No. 7
No. 1 Pump Room
No. 2 Pump Room
Laundry
Forward Staircase
(flooded to below
No. 1 Deck)
Dark Room, Stores
FO Overflow Tank
DO Tank No. 1
Laundry Tank,
Port
34
4.14
U.S. Coast Guard Marine Safety Centers Stability Analysis of the MONARCH
OF THE SEAS (information, graphics and photos in this section courtesy of the
U.S. Coast Guard Marine Safety Center, Hull Division)
35
Conclusions:
The Coast Guards stability analysis concluded that MONARCH OF THE SEAS would
have stayed afloat in open water provided that there was no progressive flooding due
to additional structural failures such as watertight subdivision boundaries.
The vessel would have remained afloat at least 12 hours during which the vessel
would have remained stable enough to launch its lifeboats and liferafts.
The presence of double bottoms greatly contributed to the vessels ability to survive.
SOLAS damage requirements ensured adequate reserve buoyancy.
Note: The stepped bulkheads forward of pump room no. 1 were a primary reason why the
ship stayed afloat.
36
Progressive Flooding
37
Facts established
That the master holds a Deck Officer Class 1 certificate (Master Mariner) from the
Norwegian Maritime Authority, has received ARPA training, and has served for two
(2) years and eight (8) months as a master;
The master deviated from the vessels intended voyage to Martinique in order to
disembark a critically ill passenger.
That the master took over the navigation of the vessel at about 0010 hours on
15 December 1998, when the ship was approaching Philipsburg, St. Maarten on an
easterly course
That all navigational instruments on board the vessel at the time were in good working
order, including the two radars (Sperry Marine Rascar 3400M 3 cm and 10 cm
complete with ARPA) and the GPS equipment (one Navigator MX200 Professional
and one Timble Navigator NT 200) that were in use;
That the ship had a chart and nautical publications for the waters in which it sailed, but
that U.S. chart No. 25613, Approaches to St. Maarten, had not been corrected in
accordance with Notices to Mariners No. 32/98 concerning the new position of the
Proselyte Reef lighted buoy;
That the master, at about 0040 hours, stopped the ship approximately four (4) cable
lengths south of Fort Amsterdam, as planned;
That the master thereafter maintained the ships position on an easterly course by
using the engines, during which time a tenderboat from St. Maarten arrived/departed
from the ships side (with patient, doctor and nurse on board);
That the ships position at 0100 hours was south of Fort Amsterdam, bearing 000
degrees, 0.4 cable lengths off, and that this position was entered in the deck log by the
watchkeeping second officer;
That the master decided to sail out of St. Maarten on the east side of Proselyte Reef;
That the master, at about 0125 hours, after the tenderboat had arrived and departed
from the ships side, gave speed ahead by using pitch 2-3, and turned the ship to
starboard from an easterly course towards a course passing east of Proselyte Reef;
That the master then maintained a true course of 160 degrees;
That the true course 160 degrees was not mentioned in any voyage plan for the
passage St. Maarten to Martinique;
That the first course referred to in the voyage plan St. Maarten - Martinique was 180
degrees (1 leg 180 degrees 30 nm);
That the voyage plan St. Maarten to Martinique was not signed or approved by the
master or any other person;
That at the time of departure from St. Maarten no departure checklist had been
completed;
That the master asked the watchkeeping second officer: How are we doing with
clearance to the buoy? (the Proselyte Reef lighted buoy), whereupon the latter
replied: Closest point will be three cables off and safe;
38
That the master did not ask the watchkeeping second officer if he had ever sailed on
the east side of Proselyte Reef;
That the master did not himself check the ships closest point of approach to the
Proselyte Reef lighted buoy;
That the master, at 0128 hours, handed over the navigation to the watchkeeping
second officer with all information about the navigation, and also ordered full speed;
That the master did not write any orders in the night order book upon departure from
St. Maarten;
That the master, on 14 December 1998 for the voyage St. Thomas to Martinique had
written, inter alia, the following night order: If any doubt or irregularities call me
right away;
That the master gave the following order to the watchkeeping second officer before
leaving the bridge: Keep safe well off buoy, go fast and safe;
That the master not check the ships position before leaving the bridge;
That the master, before leaving the bridge, checked that the ship steered true course
160 degrees, and that he visually observed the Proselyte Reef lighted buoy in bearing
50-60 degrees on starboard bow;
That the master, before leaving the bridge, asked the following question to the
watchkeeping second officer and the staff captain: It is so quiet here, have we
forgotten anything?, whereupon both officers replied: No, everything under
control;
That after the master had left, the following remained on the bridge: the watchkeeping
second officer, who among other things operated the starboard ARPA, the staff
captain, who among other things monitored the pitch controller panels and speed, a
helmsman steering manually, and a lookout who, among other things, was monitoring
the port radar;
That the reason why the master left the bridge before the ship had sailed past Proselyte
Reef was that he desperately needed to go to the toilet;
That the master, before leaving the bridge, did not give the watchkeeping second
officer or the staff captain any order to check the ships position, as he took for
granted that they would do so;
That at the time of the masters leaving the bridge visibility was good, wind was
easterly, 3-5 meters, slight sea, dark, variable cloud, barometer 1015, and air
temperature 28 degrees C;
That the master, after leaving the bridge, went to the toilet and later to a pantry;
That the master, after having heard and felt the grounding at 0130 hours, immediately
returned to the bridge and took over the command of the vessel;
That the master informed the passengers that the ship had grounded and that they were
requested to get dressed, put on their lifejackets and go to their muster stations;
That the master navigated the ship back to St. Maarten where he deliberately grounded
the vessel in Great Bay at about 0235 hours;
That the master ensured that all passengers were evacuated from the ship in the period
from about 0245 hours to about 0515 hours on 15 December 1998, by means of the St.
Maarten tenderboats;
That the master at the time of departure from St. Maarten had a strong cold and a
diarrhea, a condition that had lasted for 2 to 3 days duration.
39
That the watchkeeping second officer (hereinafter OOW) holds a Deck Officer
Class 4 certificate from the Norwegian Maritime Authority, has received ARPA
training, and that he has served for 27 weeks as a second officer and is familiar with
the companys procedures and instructions for mates who are assigned watchkeeping
duties;
That the OOW, who had been assigned the 0000-0400 and 1200-1600 watches, came
on the bridge at about 2330 hours on 14 December 1998 after having rested from 2000
hours to 2300 hours;
That the OOW relieved the watchkeeping mate on the 2000-2400 watch after having
obtained navigational information, at a time when the ship was approaching
Philipsburg, St. Maarten on an easterly course at a speed of 19.5 knots (to disembark a
sick passenger);
That the OOW was relieved by the master at 0010 hours;
That the OOW thereafter, inter alia, monitored the radar, fixed bearings and distances,
and looked out for other traffic as the ship was approaching Philipsburg;
That the OOW entered the following position in the deck log at 0024 hours: The
Corner, bearing 000 degrees, 1.2 nautical miles off;
That the OOW observed the ships drifting position at 0040 hours as being: 0.4
nautical miles due south of Fort Amsterdam;
That the OOW entered the following position in the deck log at 0100 hours: Fort
Amsterdam, bearing 000 degrees, 0.4 nautical miles off;
That the OOW was monitoring the position, which was basically the same all the
time until the tenderboat returned to the ship at 0125 hours;
That the OOW, at 0128 hours, at a time when the ship steered true course 160 degrees
at a speed of 6-7 knots and pitch 10 navigating out of drifting position south of Fort
Amsterdam, was handed over the command of the vessel from the master with the
following order: We are going fast and we are going safe and we have good clearance
off the buoy (the Proselyte Reef lighted buoy);
That the OOW, inter alia, was operating the starboard radar with ARPA, its scale set
at 1.5 nautical miles, where the Proselyte Reef lighted buoy had been plotted when the
ship sailed into St. Maarten;
That the OOW observed on the radar that the ship steering true course 160 degrees
would get a CPA (closest point of approach) to the Proselyte Reef lighted buoy of 0.3
nautical miles, which he reported to the master;
That the OOW entered no information as input into the ARPA in respect of the
easterly wind and current moving the ship westwards;
That the OOW was visually observing the flashes from the Proselyte Reef lighted
buoy all the time and felt safe with the clearance of 0.3 nautical miles to the lighted
buoy (0.3 nm CPA);
That the OOW, as he was monitoring the radar and visually observing the Proselyte
Reef lighted buoy abeam on starboard, received a telephone call from the pursers
desk concerning noise near cabin number 1549;
That the OOW, from his position at the radar, lost sight of the Proselyte Reef lighted
buoy;
40
That the OOW put down the telephone and ordered the helmsman to change course to
a true course of 190 degrees (from true course 160 degrees);
That at 0130 hours, as the ship had slowly begun to change its course to starboard and
had reached approximately 163-164 degrees, the MONARCH OF THE SEAS ran
aground on Proselyte Reef by raking the reef and did not become permanently
stranded;
That the ship was sailing at a speed at approximately 12-13 knots when it ran aground,
and that it came off the reef on the south side;
That the master immediately returned to the bridge and took over the command of the
vessel.
That the staff captain holds a Deck Officer Class 1 certificate (Master Mariner) from
the Norwegian Maritime Authority, has received ARPA training, has served for two
(2) years and six (6) months as a staff captain and has been with the company for
about 16 years;
That the staff captain shall be familiar with the masters duties, responsibilities and
authorities and shall be prepared to take command without notice;
That the staff captain knew that the master took over the navigation at 0010 hours on
15 December 1998 and that a bow thruster was started at 0030 hours;
That the staff captain knew that the ship was navigated to a position 5 cable lengths
south of Fort Amsterdam and that the ship was held in position there, on an easterly
course, when the patient, doctor and nurse were disembarked by the tenderboat;
That the staff captain knew that the master navigated the ship to starboard from the
position south of Fort Amsterdam immediately after the tenderboat left the ships side
(when the doctor and nurse had returned);
That the staff captain operated the pitch controllers on the masters orders while the
ship was navigating out of St. Maarten;
That the pitch controllers first were set steady at 2-3, with no twisting, and that the
speed was then gradually increased (after a sailboat had passed safely ahead of the
ship);
That the staff captain noticed that the master steadied the ship on true course 160
degrees;
That the staff captain did not know that the master had planned to steady the ship on
true course 160 degrees;
That the staff captain was surprised at the course chosen by the master (steering a
course east of the Proselyte Reef lighted buoy) as he had expected that the ship would
steer a course to the west of that buoy as was customary;
That the staff captain heard the master ask the watchkeeping OOW a question about
the closest point of approach to the lighted buoy, to which the OOW replied: 0.3
nautical miles off, safe distance;
That when the staff captain heard this reply, he trusted the judgment of the master and
the watchkeeping second officer with regard to the planned navigation;
That the staff captain had such respect for the master that he trusted his decision (with
regard to the navigation);
41
That the staff captain knew that the master had handed over the navigation to the
watchkeeping second officer (OOW) at about 0128 hours saying, Drive fast, but safe,
safe distance to the lighted buoy, and that the master ordered full speed;
That the staff captain heard the master tell the OOW that, You are in charge, the
course is 160 degrees, controllers are about to increase the speed;
That the staff captain felt that the OOW had the navigation of the vessel under control;
That the staff captain set the pitch controllers at full speed and that he afterwards
monitored the speed, pitch controllers and the instruments in front of him to see if all
was normal;
That the staff captain felt some pressure from the master to get out of St. Maarten as
soon as possible to arrive at Martinique at about 1400 hours;
That the staff captain and the OOW both answered the master that, All is normal
when the latter, leaving the bridge, asked if something had been forgotten;
That at 0130 hours the staff captain, while monitoring the instruments (pitch
controllers and speed), also visually observed the Proselyte Reef lighted buoy abeam
on the starboard side;
That the staff captain knew that the OOW was at the starboard radar and that the latter
gave orders to change course to a true course of 180 degrees;
That the staff captain noticed a violent vibration of the ship when the grounding
occurred and that he therefore, as a reflex action, moved the pitch controllers back to
7-8;
That the staff captain noticed that the ship was steering a course of approximtely 163
degrees and sailing at a speed of 12-13 knots at the time of the grounding;
That the staff captain noticed that the master was back on the bridge at 0131 hours and
that he then gave the master as much information as he could;
That the staff captain felt that the communication between him and the master could
have been better.
That the helmsman holds a Deck Officer Class 4 certificate from the Norwegian
Maritime Authority and that he had been on board the vessel for about 14 weeks;
That the helmsman, at the masters orders, was steering 160 degrees on the gyrocompass when the ship sailed out of St. Maarten and that he then visually observed the
Proselyte Reef lighted buoy;
That the helmsman heard the master say, Good watch before leaving the bridge
(the sound of the door being closed);
That the helmsman then received orders from the watchkeeping second officer to steer
190 degrees, whereupon he turned 5 degrees to starboard, Which gave a turn rate of 8
degrees per minute;
That the helmsman did not receive any order from the staff captain;
That the helmsman, after turning 3 to 4 degrees, felt a big shaking;
That the helmsman immediately changed the rudders position to amidships on his
own direction and that he then saw the lighted buoy approximately 90 degrees to
starboard;
That the helmsman shortly thereafter was ordered by the master to turn to starboard.
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That the lookout holds a Deck Officer Class 4 certificate from the Norwegian
Maritime Authority;
That the lookout, among other things, was standing by the port radar and that he
noticed that the watchkeeping second officer was operating the starboard radar;
That the lookout visually observed the flashes from the Proselyte Reef lighted buoy;
That the lookout saw the Proselyte Reef lighted buoy on the radar, with a CPA of 0.3
nautical miles;
That the lookout believes the order to change course from true course 160 degrees to
190 degrees was given at the moment when the Proselyte Reef lighted buoy was
approximately 90 degrees on starboard and that the master had then been away from
the bridge for maybe three minutes;
That the lookout responded to and silenced an automatic smoke detector alarm that
sounded on the bridge at about the same time as the course change was ordered;
That the lookout noticed that the staff captain was operating the pitch controllers at the
time of the grounding and that he did not hear the staff captain give any orders.
That the safety officer secured the side shell opening following the return of the ships
doctor and nurse
That the safety officer felt vibrations of the ship at 0130 hours;
That the safety officer ran forward and discovered that the ship was taking water in
pump rooms number 1 and 2 and other spaces;
That the safety officer closed watertight door number ten which was discovered to be
in the opened position in violation of standard operating procedure.
That the safety officer judged the situation to be of such seriousness that he felt that
the ship would have been lost if the master had not grounded it;
That the safety officer believes the ships personnel were exemplary with regard to
their emergency response on the day in question.
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That the master did not ensure that U.S. chart no. 25613, used for the navigation out of
St. Maarten, was updated in accordance with Notices to Mariners no. 32/98 of
8 August 1998, in violation of the 1974 SOLAS Convention, Chapter V,
Regulation 20.
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160-164 degrees for about two minutes, a distance of approximately 0.392 nautical
miles (approximately 725 meters);
That the chart used by the ship, U.S. no. 25613, shows depths of 6.7 to 6.9 meters on
the east side of Proselyte Reef;
That the Proselyte Reef lighted buoy on 15 December 1998 was located in a position
approximately 125 meters west of the position indicated on the ships chart U.S. no
25613;
That the ships draught on 15 December 1998 was 7.65 meters forward and 7.5 meters
aft.
5.2
Investigator Analysis
The U.S Coast Guard and the Marine Investigators analysis and comments are as follows:
Instructions and procedures prescribed by the ISM Code
At the time of the grounding the company Royal Caribbean Cruises Ltd. had developed
instructions and procedures for a Safety Management System in accordance with the
International Safety Management (ISM) Code including, inter alia, Standard Operational
Instructions and The Human Factor in the Navigational Operation.
The grounding would not have occurred if the master and the watchkeeping OOW had
followed the above instructions and procedures.
Planning phase of the navigation out of St. Maarten
During the planning phase of the vessels navigation, before maneuvering out of St. Maarten,
the master decided to sail to the east side of Proselyte Reef as was contrary to the customary
southwesterly departure passage. The east side of the reef is the most dangerous side to sail
close to for the following reasons:
The lighted buoy that shows the location of the Proselyte Reef is located on the west
side of the reef, which extends approximately 0.2 nautical miles in an east-west
direction;
The current moves in a westerly direction;
The wind is normally easterly (which was also the case on the night the casualty
occurred);
The lighted buoy may be out of the indicated position due to bad weather, current,
damage, etc.
There was no officially approved voyage plan from St. Maarten to Martinique.
The 160 degree departure course from St. Maarten was not part of the unofficial voyage
plan from St. Maarten to Martinique.
The 160 degree course track-line was not laid down or plotted on the navigational chart in use
at the time of transit.
Initial phase of the navigation out of St. Maarten
In the initial phase of the vessels departure, the master established the 160 degree true course
to pass east of the Proselyte Reef based largely on his mariner eye as well as on the OOWs
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feedback that the ARPAs calculated CPA to the Proselyte Reef buoy on the 160 degree
course was three (3) cables off (0.3 nm). The master did not ask the OOW about the distance
to Proselyte Reef itself. Nor did he orally, or in writing, give any order about a specific CPA
to be observed when sailing past the reef hazard. The master failed to give consideration to
the following warning, printed in the ships chart U.S. no. 25613: The prudent mariner will
not rely solely on any single aid to navigation, particularly on floating aids.
The OOW used the starboard radar with ARPA equipment soley to determine the CPA to the
Proselyte Reef lighted buoy and reported back to the master that, The closest point will be
three cables off and safe. The OOW thus considered, based on his experience as a navigator,
that the CPA to the reef would be safe. The master did not express any doubt in his
communication with the OOW as to the quality of the latters judgement. Nor did the master
check on the chart or otherwise to verify if a CPA of three cable lengths (0.3 nm) to the
lighted buoy was a safe distance from the reef. The master did not give the staff captain or
any other member of the navigational watch any order to verify the safety of the intended
passage, plot the vessels position or plot out the 160 degree track line on the navigational
chart.
During the initial phase of the navigation out of St. Maarten, the master chose, in spite of the
above warning printed in the ships chart and his maritime training and experience, to use the
Proselyte Reef lighted buoy as the primary navigational aid on which to base all of his
navigational decisions while piloting the vessel out of St. Maarten. The Proselyte Reef lightbuoy was the most uncertain navigational aid in the area. On the ships port side when
navigating out of St. Maarten lies Point Blanche, an excellent point for taking good and safe
bearings by means of radar. No bearing and distance from Point Blanche was taken.
The course of 160 degrees was established without first sufficiently determining the initial
position of the vessel. Further, no dead reaconing track-line for the 160 degree course was
laid down or marked on the navigational chart in use at the time.
The navigation out of St. Maarten and checking the ships position
After the OOW had taken over the navigational watch, he continued to check the ships
position by means of ARPA bearings and distances to the Proselyte Reef lighted buoy, relying
solely on the ARPA radar. He did not provide any input information into the ARPA
concerning the easterly wind and current moving the ship westwards or ground lock the
ARPA. Nor did he give consideration to the following warning, printed in the ships chart
U.S. no. 25613: The prudent mariner will not rely solely on any single aid to navigation,
particularly on floating aids.
The master did not check or fix the ships position on the navigational chart himself before
leaving the bridge.
During the navigation out of St. Maarten, the navigational watch failed to use any terrestrial
navigation for fixing positions and GPS for continuous follow-ups, as prescribed by the
companys own ISM manual instructions (Fix Positions).
The staff captain, who was on the bridge when the ship sailed out of St. Maarten, did not
receive any order from the master relating to position checks. Nor did the staff captain check
the ships position on his own initiative.
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6. CONCLUSIONS
The conclusion of the U.S. Coast Guard and the Maritime Investigator is that the
6.1
grounding of MONARCH OF THE SEAS on Proselyte Reef on 15 December 1998 was due to
a myriad of human performance deficiencies.
6.2
In the opinion of the U.S Coast Guard and the Maritime Investigator, the grounding is
primarily due to the following causal factors:
6.2.1 Violations of the ISM Code Safety Management System
The master and crew violated the prescribed ISM Code Safety Management System (SMS)
guidance regarding the following Standard Operational Procedures:
Paragraph 10, Voyage Plan and Port Passage Plan, requiring voyage and port
passage plans.
Paragraph 11, Checklists, requiring checklist be completed to ensure voyage and
port passage plans were complete and thorough.
Paragraph 14, Fix Positions, requiring terrestrial navigational fixes as well as
continuous GPS follow-up position checks.
The investigation revealed the primary reason for the master and crews decision not to
adhere to SMS procedures centered on the masters disregard for and lack of by-in to the
formalized requirements of the ISM Code SMS. He voiced his displeasure for the sort of
company oversight, bureaucracy and micromanagement that the SMS procedures represented.
Without the masters expressed support of the ISM procedures the crew unsurprisingly failed
to embrace the newly established SMS and disregarded the established procedures, guidelines
and job aids made easily accessible to them on the vessels bridge.
This violation significantly contributed to the casualty because the intended benefits of the
ISM Code SMS went unrealized and the defenses established by the guidelines to prevent this
sort of casualty, voyage passage planning, port entry and exit procedure checklists and vessel
position fixing and navigation requirements, were not employed by the master and crew.
RECOMMENDED SAFETY ACTIONS
RCCL should establish a check and balance system whereby a designated officer, such
as the safety officer or staff captain, shall independently verify and document
compliance with ISM SMS guidelines, procedures and job aids.
RCCL should require ISM training for all ships officers in their fleet.
RCCL should market and promote the benefits of the SMS to all vessel crewmembers.
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50
51
The ARPA unit was located on the forward, starboard side of the bridge, which provides a
navigator the optimal location to view radar information as well as any vessel traffic on the
starboard or burdened side of the vessel. Further, the ARPA display provides the navigator
with a myriad of critical radar information. For these reasons it is reasonable that a watch
officer would take up station near or at the starboard
ARPA. However, the layout of navigational
equipment on the bridge failed to allow easy
access to the chart table or the output information of
other electronic navigational instruments such as the
GPS receiver and thus would serve to hamper a
navigators efforts to verify and plot the vessels
position by other navigational means. All
navigational charts and navigational instruments
were located to the rear of the bridge and required a
navigational watch officer to physically step around
Chart table with electronic navigation
the vast chart table and move to the aft end or rear of
instruments.
the bridge away from the ARPA; a valuable and easy
to use navigation aid.
The investigation revealed an over
reliance by the navigational watch officers
on electronic navigation instruments and a
reluctance on their part to take manual
terrestrial navigation fixes. Taking a
terrestrial navigation fix involves
physically breaking out the azimuth
bearing circles, placing them on the gyro
repeaters, taking several bearings and then
plotting them on the chart. This is a time
consuming evolution but, onboard the
MONARCH OF THE SEAS, it is further
complicated by the physical layout of the exterior bridge wings. Each bridge wing has large
equipment cowlings that block accessibility to the gyro repeaters and only allows minimal
physical clearance. This makes taking a bearing difficult or, at least, more difficult than
normal. Aside from the effort involved with taking terrestrial navigation fixes in general, the
inaccessibility of the bridge wing gyro repeaters would further deter a watch officer from
taking terrestrial fixes.
The OOW also failed to recognize the limitations of the ARPA in this particular pilotage
situation. He also failed to either manually input the set and drift calculation to allow for the
current and wind or ground lock the ARPA radar, either of which would have allowed the
ARPAs computer to correctly calculate critical navigational data considering the vessels set
and drift. The OOW was also not fully familiar with all of the ARPA functions although he
had undergone ARPA training in 1994.
RECOMMENDED SAFETY ACTION
RCCL should require all navigational watch officers attend ARPA certification and
periodic refresher training.
RCCL should develop a brief, in-house ARPA training refresher course or training
aids that navigational watch officers must successfully complete on an annual basis or
when first assigned to a particular vessel.
For each vessel owned and operated by RCCL, they should examine the physical
bridge layout and work with the vessels navigational watch officers to modify the
design to permit the most effective, efficient and safe navigation of the vessel. This
should consider locating navigation charts and plotting tools as well as electronic
navigational instrument readout in close proximity to the primary navigating station.
6.2.7.b
Masters early departure from the bridge
The masters decision to depart the bridge prior to the vessel passing a known navigational
hazard was primarily physiological, as he urgently needed to use the toilet. Because of his
confidence in the abilities of the navigational watch he felt comfortable leaving the bridge and
attending to his needs in his own stateroom although he could have easily used the toilet
facilities on the bridge.
Further, the master had been suffering slightly from a head cold and diarrhea for several days
and was taking over the counter medications as directed by the ships doctor. He also testified
that he was somewhat tired from his required social engagements with the passengers that
commenced on the first night of the voyage.
Although the master testified that the medications did not affect his judgment, he passed all
post casualty drug and alcohol testing and all evidence suggests that he was alert and capable
of commanding the vessel, the combined deleterious effects of not feeling well, being tired
and having to urgently relieve himself would all serve to negatively influence his performance
and hinder his decision making process.
RECOMMENDED SAFETY ACTION
RCCL should implement a two-man pilot/co-pilot arrangement during vessel
navigation in critical pilotage waters. A co-pilot arrangement - the term borrowed
from aviation where this type of arrangement is a common means of enhancing safety
- can be used on most ships to substantially improve control of the ship navigation.
54
Under this type of arrangement, the navigation bridge is manned by two navigators,
the pilot (charged with the navigation and control of the ship) and the co-pilot
(assisting in the pilots tasks and often actively controlling proposed actions to be able
to take over command of the vessels control at all times). The master decides if and
when a co-pilot arrangement is to be used, e.g. when approaching or navigating out of
a port, in narrow waters, at times of reduced visibility, and in congested waters. The
pilot is the navigator in charge of the actual navigation of the ship and responsible for
keeping the co-pilot well informed about actions to be taken. The pilot should be the
one who communicates by VHF with approaching vessels and for other reasons of
navigational safety. The co-pilot should assist the pilot only and have no other tasks
to attend to but be ready to assume vessel control in cases the pilot becomes
debilitated or needs to be relieved for some unexpected reason.
6.2.7.c.
Vessel departure route
The investigation failed to find a clear indication of why the master chose the departure route
he did, passing just 0.3 nm east of the Proselyte Reef lighted buoy with the prevailing easterly
wind and current setting the vessel to the west, when his past experience and the rules of good
seamanship dictated otherwise. In hindsight, he remarked that he would have more likely
preferred to be at least 0.5 nm off the reef hazard. That comment provides insight into the
masters comfort with maneuvers and clearances to hazards that other experienced mariners
would consider otherwise hazardous. There was ample sea room to both the east and west of
the Proselyte Reef that provided a much greater margin of error and presented a relatively
insignificant delay in reaching the vessels ultimate goal of safely arriving in Martinique as
safe and quickly as possible.
While the master testified that there was no pressure to arrive in Martinique at any particular
time, the crew understood the implications of being late or missing the Martinique port call.
It was stated that one of the primary reasons St. Maarten was chosen for disembarking the
sick passenger was that it was situated along the vessels route to Martinique and presented
the least likely disruption to the voyage.
RECOMMENDED SAFETY ACTION
RCCL should widely disseminate this report to all vessels in its fleet and make it
required reading for all officers.
6.2.7.d.
Chart Corrections
The investigation failed to reveal why the ship's chart used at the time of the grounding, U.S.
no. 25613, was not updated in accordance with Notices to Mariners no. 32/98 (the most recent
Notice) with respect to the new position of the Proselyte Reef lighted buoy which placed the
buoy 125 meters west of the position indicated on the navigational chart in use during the
transit. This is of particularly concern to the investigators as this was a routine port call for
the vessel and the buoy in question marked a major hazard to navigation that was routinely
passed in close proximity. This is further evidence of the navigational watch officers lax
attitude and propensity for taking shortcuts.
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Chart usage
The crew failed to adequately explain why the vessels departure track line was not plotted on
the navigational chart in use as well as why no predeparture position fix was made on the
chart as per the ISM manual, Standard Operating Procedures. This shortcoming is also
indicative of the navigational watch officers lax attitude and disregard of the vessels SMS.
RECOMMENDED SAFETY ACTION
RCCL should disseminate this report to all vessels in its fleet and make it required
reading for all navigational watch standers.
RCCL should explore ways to better incorporate SMS guidance into a mariners
routine job function.
6.2.8
The staff captains function on the Bridge Team was of little value and failed to enhance to
the safety of the vessel. The staff captains contribution to the navigational watch appeared to
be limited solely to operating the engine controls during the vessel maneuvers. He did not
participate in any other phase of the vessels navigation such as ensuring the vessels position
was plotted or verifying that the planned course past a know navigational hazard was safe.
RECOMMENDED SAFETY ACTION
RCCL should clearly define and indicate what a staff captains function is when
attending the vessels bridge. The staff captain should be regarded as the vessels copilot and be ready to assume vessel control in the event that the master may become
incapacitated for some unexpected reason.
6.2.9
OOWs function
The OOW had arrived in San Juan, Puerto Rico after traveling from Norway on the evening
of December 12th following an eight-week holiday. He reported to the vessel on
December 13th at 1130 hours and immediately assumed the 12/4 navigational watch.
He had transited the approaches to St. Maarten on many occasions but the night of the
casualty was his first nighttime transit of the area and the very first time he had witnessed a
departure from St. Maarten to the east of Proselyte Reef. Every other time he had transited
the area it had been during the daylight hours and the vessel had always arrived and departed
St. Maarten to the west of Proselyte Reef as was the routine.
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Although the OOW testified he was fit for work, licensed and qualified to assume the
navigational watch on the night of the casualty, its questionable that the OOW was operating
at optimal performance due to the following reasons:
Expected jet lag from his airplane trip from Norway to Puerto Rico.
He had only three navigational watches to reacquaint himself with the 12/4
navigational watch procedures and associated navigational equipment after an eightweek vacation.
He was unaccustomed to a nighttime transit of St. Maarten.
RECOMMENDED SAFETY ACTION
RCCL should require all navigational watch officers to transit critical navigation areas
such as a port approach or confined shipping channel a predetermined number of times
with appropriate supervision in both daylight and nighttime conditions prior to
allowing the watch officers to assume full operational control of a vessel in those
areas.
RCCL should consider establishing an overlap period between watch officers that are
newly hired, newly assigned to the vessel or those returning from extended periods
away from the vessel with those mariners currently standing the navigational watch.
This will permit the oncoming watch officers to become familiar with SMS
procedures as well as with all navigational equipment before they assume full
navigational watch responsibilities.
6.2.10 Interruption of the OOW
The OOWs attention was interrupted during a critical vessel navigation and maneuvering
evolution by a telephone call from the vessels hotel staff regarding a disturbance in a
passengers stateroom. The policy of allowing calls to the bridge regarding hotel type
services in unacceptable and may have contributed to this casualty by distracting the OOW
from his navigational duties.
RECOMMENDED SAFETY ACTION
RCCL should completely segregate hotel type responsibilities from the safe navigation
of the vessel. All hotel complaints should be dealt with entirely by the hotel staff or
by the designated ship safety or security personnel and never interfere with the safe
navigation of the vessel.
6.2.11 Watertight doors
After the vessel grounded all watertight doors (WTDs) were immediately closed remotely
from the vessels bridge. However, during a check of the resultant flooding, the vessels
safety officer found WTD number 10 in an opened position allowing water to leak into the
lobby by the central store area. This was in violation of RCCL policy as WTD number 10
should have been closed and secured at 2300 hours every night. The vessel safety officer felt
that the ship would have been lost without blanking off WTD number 10 as the vessel was a
two-compartment ship.
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58
7. LESSONS TO BE LEARNED
7.1
To prevent similar groundings (due to human error) in the future, the following lessons
are to be learned:
1. The importance of adequate voyage planning, cf., inter alia, the standards prescribed by the
1995 STCW Convention (revised edition 1998), Chapter VIII, section A-VIII/2, Part 2,
Voyage Planning;
2. The importance of adequate control of the ships position, cf., inter alia, the standards
prescribed by the 1995 STCW Convention (revised edition 1998), Chapter VIII, section AVIII/2, Part 3, Performing the navigational watch, prghs 23 to 51; and
3. The importance of implementing the principles of effective Bridge Resource Management
such as voyage planning, open and effective communication, and teamwork.
4. Instructions and procedures for adequate voyage planning and control of the ships position
must be implemented in the ships ISM manuals, and such manuals must be used daily by
the ships personnel, like any other tool.
5. The value of the recommended co-pilot arrangement during vessel navigation. A
co-pilot arrangement - the term borrowed from aviation where this type of arrangement is a
common means of enhancing safety - can be used to substantially improve control of ship
navigation.
6. The value of establishing an overlap period between watch officers that are newly hired,
newly assigned to the vessel or those returning from extended periods away from the
vessel with those mariners currently standing the navigational watch. This will permit the
oncoming watch officers to become familiar with SMS procedures as well as with all
navigational equipment before they assume full navigational watch responsibilities.
7. The importance of a well designed bridge layout.
8. The dangers of over reliance on electronic navigational aids.
9. The value of using prescribed port entry/exit checkoff job aids.
10. The value of updating charts.
11. The importance of not interrupting the navigational watch for non vessel operational
issues during critical vessel maneuvering evolutions.
12. The value of laying down intended track lines on the navigation chart.
13. The value of plotting out no-go danger areas on the navigation chart.
14. The dangers of being overconfident and complacent with regard to navigation.
59
15. The danger of relying on a single source of navigational information and/or not cross
checking position by other navigational means.
16. The value of giving known hazards a wide berth.
17. The danger of passing a known navigational hazard up-wind and up-current.
18. The danger of not allowing for set and drift when navigating near a known navigational
hazard.
19. The value of using parallel indexing when piloting a vessel near shore.
20. The value of clearly communicating the intended course of action among the navigation
team when making emergency or not-routine port calls.
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61
12. RCCL should develop a brief, in-house ARPA training refresher course or training
aids that navigational watch officers must successfully complete on an annual
basis, when first assigned to a particular vessel, or when the vessel changes to a
new route.
13. RCCL should examine the physical bridge layout of each vessel that it owns and
operates and work with the vessels navigational watch officers to modify the
design to permit the most effective, efficient and safe navigation of the vessel.
This should consider locating navigation charts and plotting tools as well as
electronic navigational instrument readout in close proximity to the primary
navigating station.
14. RCCL should implement a two-man pilot/co-pilot arrangement during vessel
navigation in critical pilotage waters. A co-pilot arrangement - the term borrowed
from aviation where this type of arrangement is a common means of enhancing
safety - can be used on most ships to substantially improve control of ship
navigation.
15. RCCL should establish a check and balance system whereby a designated officer,
such as the safety officer or staff captain, shall independently verify and document
all chart corrections.
16. RCCL should establish an overlap period between watch officers that are newly
hired, newly assigned to the vessel or those returning from extended periods away
from the vessel with those mariners currently standing the navigational watch.
This will permit the oncoming watch officers to become familiar with SMS
procedures as well as with all navigational equipment before they assume full
navigational watch responsibilities.
17. RCCL should develop vessel evacuation contingency plans for non-routine vessel
evacuations such as experienced in this casualty.
18. RCCL and other cruise ship companies should develop contingency plans for
large-scale vessel evacuations and other emergency situations with the officials
and response authorities of each port of call.
19. The port of Philipsburg and port authorities of St. Maarten should consider
replacing the Proselyte Reef lighted buoy with a more permanent navigational aid.
20. Recommend a copy of the report be provided to the International Maritime
Organization, Royal Caribbean International, St. Maarten Port Authority,
International Council of Cruise Lines and the International Association of
Classification Societies.
Finn Paulsrud
Maritime Investigator in Oslo
Timothy J. Farley
U.S. Coast Guard, Office of
Investigations and Analysis
10 APRIL 2003
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