NTSB cites master's actions in $1 million dock accident

[Capt_BJ]

The following is text of a news release from the National Transportation Safety Board (NTSB):

(WASHINGTON) — About 1400 on June 3, 2016, the Malta-flag cruise ship Celebrity Infinity allided with berth No. 3 in Ketchikan, Alaska. No one was injured and no pollution occurred. The vessel sustained a 9-inch-diameter hole on the forward port side, about 12 feet above the waterline. The berth suffered extensive damage to the catwalks and pilings. The cost of repairs was about $1.15 million.

Probable cause

​The National Transportation Safety Board determines that the probable cause of Celebrity Infinity’s allision with the dock was the master’s failure to plan, monitor, and execute a safe docking evolution.

Excerpt from report

The pilot told investigators that dropping the starboard anchor slowed the motion of the bow toward the pier. The master said that he then ordered chain to be paid out so the vessel could move forward and toward the dock, but the VDR recording captured the master’s order as “hold the anchor.” According to the pilot, the thrusters and anchor were able to control the bow but “whatever maneuvers they made with the pods weren’t sufficient to hold the ship and it made a hard landing on the dolphins back there.” At 1355, with the after part of the vessel pivoting toward berth No. 3, the VDR recorded someone shouting, “the stern, the stern!” and, at 1356, the vessel allided with the berth. The force of the allision opened a 9-inch-diameter hole in the vessel’s port side between frames 231 and 233, about 12 feet above the waterline. It also caused the deflection of vessel structural members. The berth suffered extensive damage to its catwalks and structural members. Damage to the berth and vessel was estimated at $1,153,738.

Click here to read the complete report.

[Mynki]

Watch what happened here.

 

[Hlitner]

Anyone remember who was the Captain (Master) on that voyage?

 

Hank

[Welland]

Anyone remember who was the Captain (Master) on that voyage?

 

Hank

 

Not trying to be rude however does it really matter? I am not sure this is the forum to name the Captain who was on the ship. I do assume that some will agree with me and others will not. Just my 2 cents worth.

[Happy Cruiser 6143]

My understanding at the time was that the captain had a choice of hitting the dock or the HAL ship which was already moored there. I think he made a good decision.

[jelayne]

DH flies planes and so reads lots of avaiation material. Many airplane accidents after investigation are deemed “pilot error”, that seems to be the cause when they can’t figure out what Mother Nature did or what equipment malfunctioned or failed.

[Clarea]

Thanks for linking this Captain, very interesting.

[grandgeezer]

DH flies planes and so reads lots of avaiation material. Many airplane accidents after investigation are deemed “pilot error”, that seems to be the cause when they can’t figure out what Mother Nature did or what equipment malfunctioned or failed.

 

Maybe it's a possibility that Mother Nature had nothing to do with the accident and none of the equipment malfunctioned or failed.

[Keith1010]

I remember when this happened just a couple of months before we arrived.

 

Keith

[chengkp75]

DH flies planes and so reads lots of avaiation material. Many airplane accidents after investigation are deemed “pilot error”, that seems to be the cause when they can’t figure out what Mother Nature did or what equipment malfunctioned or failed.

 

Having read the report, and being familiar with these investigations, and the systems and operational control plans required on ships, I can agree with the NTSB that this was the Master's fault as a root cause. Regardless of what "Mother Nature" actually did at the time of the incident, all indications show a rather slap-dash attitude towards the pre-docking planning sessions and briefs. Also, the change of conn is somewhat slipshod, and there seems to be some dissembling reported, where the Captain claims to have never heard of tugs being available, yet the ship's own powerpoint pre-docking brief mentions that they are. There doesn't seem to have been any concern given to high wind speeds in the briefs, and no contingency planning for winds as high as forecast, or as reported by the ship leaving the berth immediately before the Infinity arrived.

[rafinmd]

I'm with the NTSB on this one. Of course Mother Nature had a role in this. In my cruising history I've often heard the Captain say "We're not going to port x because the conditions there are not safe". Since Celebrity Infinity I've never questioned that decision.

 

Roy

[gerelmx]

If the conditions were adverse, why the captain did not abort the procedure?

[SmoothFlying]

The following is text of a news release from the National Transportation Safety Board (NTSB):

(WASHINGTON) — About 1400 on June 3, 2016, the Malta-flag cruise ship Celebrity Infinity allided with berth No. 3 in Ketchikan, Alaska. No one was injured and no pollution occurred. The vessel sustained a 9-inch-diameter hole on the forward port side, about 12 feet above the waterline. The berth suffered extensive damage to the catwalks and pilings. The cost of repairs was about $1.15 million.

Probable cause

​The National Transportation Safety Board determines that the probable cause of Celebrity Infinity’s allision with the dock was the master’s failure to plan, monitor, and execute a safe docking evolution.

Excerpt from report

The pilot told investigators that dropping the starboard anchor slowed the motion of the bow toward the pier. The master said that he then ordered chain to be paid out so the vessel could move forward and toward the dock, but the VDR recording captured the master’s order as “hold the anchor.” According to the pilot, the thrusters and anchor were able to control the bow but “whatever maneuvers they made with the pods weren’t sufficient to hold the ship and it made a hard landing on the dolphins back there.” At 1355, with the after part of the vessel pivoting toward berth No. 3, the VDR recorded someone shouting, “the stern, the stern!” and, at 1356, the vessel allided with the berth. The force of the allision opened a 9-inch-diameter hole in the vessel’s port side between frames 231 and 233, about 12 feet above the waterline. It also caused the deflection of vessel structural members. The berth suffered extensive damage to its catwalks and structural members. Damage to the berth and vessel was estimated at $1,153,738.

Click here to read the complete report.

 

Sooooooo, WHO is gonna 'eat' the loss on both repairs, the ship's OR the harbor master's insurance:rolleyes:. OR will each pay separately ? I can't imagine the ship's owners being none too happy having too pay for a harbor master's mistake :eek:. After all, isn't the master 'in charge' at ALL times during docking ? Or can the captain step in, and suddenly (if he deems it necessary, for the safety of HIS ship) and countermand the harbor master? Just a curious question from an 'ignorant' land lubber:o

 

Mac

[Mynki]

Sooooooo, WHO is gonna 'eat' the loss on both repairs, the ship's OR the harbor master's insurance:rolleyes:. OR will each pay separately ? I can't imagine the ship's owners being none too happy having too pay for a harbor master's mistake :eek:. After all, isn't the master 'in charge' at ALL times during docking ? Or can the captain step in, and suddenly (if he deems it necessary, for the safety of HIS ship) and countermand the harbor master? Just a curious question from an 'ignorant' land lubber:o

 

Mac

 

Wasn't it not a Celebrity Captain (Master) or Harbour Pilot in control at the time? I thought it was the former?

[Mr. Click]

Sooooooo, WHO is gonna 'eat' the loss on both repairs, the ship's OR the harbor master's insurance:rolleyes:. OR will each pay separately ? I can't imagine the ship's owners being none too happy having too pay for a harbor master's mistake :eek:. After all, isn't the master 'in charge' at ALL times during docking ? Or can the captain step in, and suddenly (if he deems it necessary, for the safety of HIS ship) and countermand the harbor master? Just a curious question from an 'ignorant' land lubber:o

 

Mac

 

The Master referred to in this report is the Master of the Ship, that is the captain. The harbor master's influence on this event ends with the port being open and ships being allowed to dock. There is a local pilot on the bridge with the captain/master of the ship. The pilot's job it to advise on the nuances of the local waters.

[chengkp75]

Sooooooo, WHO is gonna 'eat' the loss on both repairs, the ship's OR the harbor master's insurance:rolleyes:. OR will each pay separately ? I can't imagine the ship's owners being none too happy having too pay for a harbor master's mistake :eek:. After all, isn't the master 'in charge' at ALL times during docking ? Or can the captain step in, and suddenly (if he deems it necessary, for the safety of HIS ship) and countermand the harbor master? Just a curious question from an 'ignorant' land lubber:o

 

Mac

 

As noted in other posts the term "Master" means the Captain, not the harbor master, who never boards a single ship, and is only the controller of port traffic.

 

Now, insurance. The ship will pay for all damages, since this was an "allision" (a nautical term for one moving object striking a stationary object, whereas "collision" has "co" in it to mean two moving objects), and the moving vessel is always at fault.

 

So, to unconfuse things, the pilot is an advisor to the Captain, and the pilot normally is given the conn by the Captain (meaning the pilot gives orders to the helm and propulsion). However, in this instance, as with most cruise ship dockings, once the ship is close to the berth, the Captain (or in this case the Staff Captain) will take the conn and typically operate the helm and propulsion controls him/herself. The pilot, since he/she is not a company employee, is not allowed to operate any control on the vessel, he/she is to give orders to the bridge crew who then operate the controls. The Captain is always in command of the vessel, but he may delegate the conn to another officer or pilot. The Captain always has the right to intervene and relieve the pilot from the conn if he feels the pilot is endangering the vessel.

 

In this instance, it appears that the Staff Captain was conning the ship during docking, and at some point the Captain took over the conn, and this can lead to problems with communications and understanding of the ship's actual state, as the new conning officer acclimates his/her senses to the controls and the environment., and as the bridge team acclimates to taking orders from a new conning officer.

[johhnnyt]

Ultimately I think all accidents involving a ship (whether Navy or maritime) seem to use the " master’s failure to plan, monitor, and execute a ...."

Had he to do again, and the wind speed hadn't gone from 21 to 43 knots, and the Staff Captain wasn't t doing the maneuver, and..., and..... . Monday morning quarterbacking is always the easy part in post accident analysis

No one on these pages was there, or experienced what happened, other than reading the report. I would agree with Chen that it appears from the report that " it appears that the Staff point the Captain took over the conn", and that might have led to the collision, or maybe it was the fluke windCaptain was conning the ship during docking (as that I imagine is how they gain experience), and at some, or the lack of tugs, or just Murphys law.

To my mind, and from the factors mentioned in the report, it seems like the combination of 6 or 7 coincidental factors led to the collision, and just glad it was minor physical damage and no one was hurt.

[Capt_BJ]

for the record, the press release is pretty poorly written IMO. If you read the full report you get a MUCH clearer picture of the incident. It is only 9 pages and about a third of this is pictures. For example it discusses company policy wrt the pilot during actual docking ....

 

As one who has sat in the Captain's chair and oversaw/participated in many an 'entering port brief' as well as the evolutions themselves I read the report and can put red check marks to many many booboo's that led to this incident. While hindsight is always 20/20 I'd mention that at USCG "Commanding Officer School" a significant part of the curriculum is doing post incident analysis of major booboos in our fleet in the past and discussing as a group to learn from our mistakes. {A school that was created by order of Congress after a couple of serious incidents IN our fleet in the early 80's}

 

As a follow on the Chg's post ... one of my jobs as Captain / Master was to train those working their way up the ladder. One might not think of the Staff Captain as being in training in this case but if he was not MASTER that is exactly the case IMO. When I saw a 'trainee' was getting into deep trouble and decided to take over the evolution it was announced LOUDLY ... no one had any doubts when I said "Captain has the CONN" .... it didn't happen often but it did happen enuf times that my officers, at the end of my last Command tour, had a plaque made with the times I did this annotated with the comment I eventually made when I 'took over' as to WHY. Part of the reason I did 'take over' is that I did not want a 'trainee' to end up with an 'incident' on their record. Sometimes I took over with just feet to go to a big booboo ... but the booboo would happen when 'the Captain had the CONN' ..... iow on MY driving record, not theirs. I had much less to lose .... I HAD my stripes.

 

So like I said, if this interests you and you did not read the full report I encourage you to do so ... in 9 pages it paints a much clearer picture of what became a fuzzy few minutes!

[chengkp75]

To my mind, and from the factors mentioned in the report, it seems like the combination of 6 or 7 coincidental factors led to the collision, and just glad it was minor physical damage and no one was hurt.

 

You are right that there were several factors that led to the accident. This is what is known in root cause analysis as the "swiss cheese" effect. The situation is the cheese, and the causative factors are the holes in the cheese. Only when all the holes line up will the accident happen. Keeping the holes from lining up is the major reason to have "tool box meetings" (or in this case, a bridge team pre-docking meeting) to identify the holes, and methods to keep the holes from lining up. Identifying risks and the methods needed to mitigate the risks is the purpose of the ISM (International Safety Management) system that all ships operate under.

 

Three quarters of all accidents are caused by human error. Identifying the Captain's failure to have a meaningful pre-docking planning session, and apparently not even following what was presented at that meeting, is the root cause, which led to the holes lining up.

 

There is no problem with the Staff Captain conning the ship during docking, it is simply that established procedures were not followed (verbally identifying the change in conn) that could have contributed to the problem. There seem to be some statements that are contradicted by the VDR (voyage data recorder) and the bridge voice recorder.