Not all that often does the NTSB get to investigate a cruise ship incident

Not to pick Celebrity as their bridge crews are just as good or better than average. However, this NTSB report is very interesting. It is not very often that the public has a chance to read a comprehensive safety analysis of a marine incident as most episodes take place in jurisdictions outside of the US waters where safety evaluations are not all that good. In my opinion they are often treated as closely guarded secrets.     This report gives an excellent breakdown of the command system on the bridge as well as detail regarding the ships propulsion, anchoring and thruster layout.     "The National Transportation Safety Board determines that the probable cause of the Celebrity Infinity’s collision with the dock was the master’s failure to plan, monitor, and execute a safe docking evolution."   https://www.ntsb.gov/investigations/AccidentReports/Reports/MAB1736.pdf  

Tags: Celebrity Cruises Celebrity Infinity

9 Answers

Thanks for posting this interesting article.  I always thought the pilot docked the ships.  I learned something.

What a very detailed report.  I found it very interesting to read.  Thanks for posting it.

Very interesting report. Thanks for sharing it.

Yes, the NTSB reports are usually written so to be very clear for the laymen. They do use industry jargon and acronyms but usually provide an immediate explanation. I've been in the airplane game most of my professional life and have limited experience in the commercial salmon gill net fishery and seine fishery as well as paying attention to the detail regarding large vessels, particularly cruise ships but I continue to learn a lot. For instance. I never heard of "allide" I thought they misspelled collide: 

 

"allide   (verb)

(nautical) To impact a stationary object."

 

Then it came as a surprise to learn the anchor chains were over 1100 feet long and that a "shot" is 90 feet long. I also thought that the "port pilot" had a lot more to do with docking, although I knew the "Master" had ultimate command and could over rule the pilot at any time. I'm also surprised that the port itself didn't have more jurisdiction over whether or not the vessel should be compelled to have tugs, at least require them to be in standby. My hunch is that the Alaska ports are pretty lenient compared to major ports around the world.   

 

Just slightly over a year ago we almost got our 32 day cruise canceled when about three weeks before embarkation the vessel impacted the side of a breakwater during entrance to a port due to wind gusts which slammed the stern into the rocks. Some lower compartments were flooded due to a hole in the side. The cruise line had to cancel the next two cruises in order put the ship in "wet dock" and patch it. On another cruise we almost ran aground due to one pod taking a un-commanded turn action resulting in the Captain having to release the anchor to keep us off the beach. I didn't understand how he could have gotten the anchor down so fast. Now I know, from this NTSB report, is that they unlock the anchor when close to shore allowing the bridge to electronically release it.

Interesting read.  Thanks for posting the link.  One thing that comes to mind with this accident are what we call in commercial aviation maintenance, "Human Factors", or the "Dirty Dozen".

 

For the sake of something different to read (for those interested) here they are.  And also I'll write how I think they apply here:

 

-Lack of communication - I think there was good communication here.

-Complacency - Perhaps, easy to slip into the mentality of we've done it before, we can do it again, so no worries.

-Lack of knowledge - Not in this case

-Distraction - Not in this case

-Lack of teamwork - Not in this case

-Fatigue - Not in this case

-Lack of resources - Not in this case

-Pressure - Perhaps pressure to be part of the flow and not stand out.  Also the pressures of time constraints and getting people off the ship to enjoy their shore excursions.  

-Stress - Perhaps since they have time limits to abide to, could face extra charges, or heat from management if not on time.

-Lack of assertiveness - Perhaps, maybe someone thought to speak up and say, "We really should call for a tug and wait for it's arrival".  But for what ever reason decided to say nothing.

-Lack of awareness - Not in this case

-Norms - I think so.  Mentality seems to be, "We've never used tug boats, why should we use it now?"  

Very informative. Thank you for posting.

Here is one portion of the report that gives me the most concern. Reminds me of the El Faro, this was a vessel that served Anchorage for over a decade as the "Northern Lights". Its disaster, which took the lives of every single crew member (33), was in part directly attributed to the Master's casual attitude toward weather reports and forecasts:

 

Celebrity Infinity------"Both the master and the staff captain believed the vessel could be safely docked in 30–35-knot beam winds.

 

Celebrity Infinity received weather forecasts for the docking area from the NWS and from WRI. The NOAA marine forecast issued at 1943 local time on June 2 included a gale warning with 35-knot southerly winds for the Ketchikan area through June 3. The NOAA/NWS Ketchikan weather forecast issued at 1042 on June 3 predicted southeast winds of 30 mph with gusts to about 45 mph. The 0714 WRI forecast for the Ketchikan area predicted gale-force to strong gale-force winds from the south-southeast of between 40 and 45 knots with brief gusts to 50 knots.

 

At 1302, the pilot on the Celebrity Infinity radioed the pilot on a vessel that was leaving berth 3 and learned the wind was a steady 25 knots with gusts to 35 knots.

 

The master told investigators that the weather conditions were discussed at the pre-arrival brief; however, investigators reviewed the VDR and CCTV and noted that the master and the pilot did not participate in the brief.

 

Further, the VDR did not record the four people who did attend the pre-arrival brief―staff captain, first officer, safety officer, and third officer―discussing the weather conditions.

 

The Celebrity Infinity VDR recorded a 40-knot wind gust. At the Ketchikan airport, an anemometer recorded a rooftop wind speed (a measurement taken from a height close to the same height as the Celebrity Infinity’s anemometer) of 50 knots shortly after the Celebrity Infinity docked, and it is likely that the vessel also experienced wind gusts of 50 knots at the time of the docking."

 

El Faro---

https://www.washingtonpost.com/business/ntsb-to-issue-probable-cause-of-el-faros-sinking/2017/12/12/a06e9eb6-df32-11e7-b2e9-8c636f076c76_story.html?utm_term=.772e864a60ac   "The NTSB board also has examined poor decisions by the captain, problems with weather forecasting, management of the freighter, the suitability of the ship’s lifeboats and the oversight of the vessel by its owner, TOTE Maritime, Inc."

 

If the dock AND the ship were moving, it would have been a COLLISION. As it was only the ship moving, it was an ALLISION.    If the ship and the dock had somehow planned this incident, it would have been, Big SmileBig SmileBig Smile  COLLUSION !  bwahahahahahahaha !

 

 

sorry. Couldn’t resist.

And if it were all in your head, ILLUSION.

 

That has to be one of the most well-written government reports I have ever read. I actually understood most of it.

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