MCRM Case Studies

Maritime Crew Resource Management
Case Studies
Originally developed by Oxford Aviation Academy (SAS Flight Academy)
Version 12, December 2010
Oxford Aviation Academy Woodford Aerodrome, Chester Road, Woodford, Cheshire, SK7 1AG
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For Training Purposes Only 2010
Case Studies
Contents
2010 Oxford Aviation Academy UK Limited. All Rights Reserved.
Contents
Case Study Introduction
Case Study Guidelines
MCRM Case STUDY 1: Cosco Busan
MCRM Case STUDY 2: Maersk Kithira
MCRM Case STUDY 3: Moondance
MCRM Case STUDY 4: Mv balduin
MCRM Case STUDY 5: Figaro/camargue
MCRM Case STUDY 6: tor scandinavia
MCRM Case STUDY 7: Torrey Canyon
MCRM Case STUDY 8: Thuntank 5
MCRM Case STUDY 9: malinska
MCRM Case STUDY 10: Royal Majesty
MCRM Case STUDY 11: Arahura
MCRM Case STUDY 12: Viking Wanderer
MCRM Case STUDY 13: crown princess
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Case Studies
Introduction
Case Study Introduction

We have now reached the stage when we are going to look at a number of case studies. In the case
studies we inevitably focus on things that went wrong. We dont look at the 99% of cases in which
mariners did a good job, day out and day in. These success stories are sadly not news.
The case studies chosen have been selected for their suitability in that respect and because the
documentation concerning them has been easily available.
We believe that there are many advantages to be gained by examining specific cases and viewing them
from the MCRM point of view only.
Before you start we would like you to read a few preliminary comments:

We are attempting to view the accident purely from the point of MCRM.
We shall use the material presented in the MCRM course as the base line of proper resource
management methods. We do this with full realisation that the mariners involved in the cases
had probably never heard of the methods we suggest. Accordingly, we are not attempting to
second guess or criticise their performance in any way, as this would be totally unfair. Rather,
we are attempting to learn from their experience and to see if our methods would protect us
from similar situations in the future. We seek ONLY a learning experience.
Because we are only engaging in a learning experience, we feel that it is not unreasonable
to engage in some speculation. When we do this, we may at times be unfairly treating the
mariners involved, as our information may be either inaccurate or incomplete, but if we, as
professional mariners, can learn from this we feel it is justified.
With these thoughts in mind, please continue with the case studies.
Case Studies
Guidelines
Case Study Guidelines

1. Use MCRM terms to find the root causes and to build the error chain that caused the
accident. Try to focus on the management issues and ignore the technical ones. The following
questions might help:
2. Do you think that any of the people involved had any Hazardous Thoughts? If so, who and
what thoughts?
3. How was the teams situational awareness?
4. What can be said about the communication?
5. What can be said about briefings in this scenario?
6. Do you think that a proper challenge and response would have made any difference?
7. Were Checklists an / or SOPS used or violated?
8. Was there a good balance between Authority and Assertiveness?
9. Were any of the persons involved exposed to an unbalanced workload?
10. What was the team state? How was monitoring?
11. What management methods do you feel would have been most helpful in preventing an
incident from happening?
The research by the NTSB stated the most common management errors in aviation as below. Do you
find any similarities between the management errors in this case and the ones in aviation? Tick off if
any.
Preoccupation with minor technical problems?
Failure to delegate tasks and assign responsibilities?
Failure to set priorities?
Inadequate monitoring?
Failure to utilize available data?
Failure to communicate intent and plans?
Failure to detect or challenge deviations from SOPs?
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Case Studies
MCRM Case Study 1: Cosco Busan
MCRM Case STUDY 1: Cosco Busan

Allision of Hong Kong Registered Containership M/V Cosco Busan with
the Delta Tower of the San FranciscoOakland Bay Bridge San Francisco,
California November 7th, 2007
On Wednesday, November 7th, 2007, about 08:30 Pacific standard time, the Hong Kong-registered,
901-foot-long containership M/V Cosco Busan allided with the fendering system at the base of the
Delta tower of the San FranciscoOakland Bay Bridge. The ship was outbound from berth 56 in the Port
of Oakland, California, and was destined for Busan, South Korea. Contact with the bridge tower created
a 212-foot-long by 10-foot-high by 8-foot-deep gash in the forward port side of the ship and breached
the No. 3 and 4 port fuel tanks and the No. 2 port ballast tank. As a result of the breached fuel tanks,
about 53,500 gallons of fuel oil were released into San Francisco Bay. No injuries or fatalities resulted
from the accident, but the fuel spill contaminated about 26 miles of shoreline, killed more than 2,500
birds of about 50 species, temporarily closed a fishery on the bay, and delayed the start of the crabfishing season. Total monetary damages were estimated to be $2.1 million for the ship, $1.5 million for
the bridge, and more than $70 million for environmental cleanup.
The Cosco Busan was scheduled to depart its berth at pier 56 in the Port of Oakland at 07:00 on
November 7th, 2007, with an all-Chinese Crew. Cargo operations had begun the previous evening, and
about 06:00 on November 7th the Longshoremen had loaded the last container on the vessel. The ship
was carrying 2,529 containers and was destined for Busan, South Korea. A Pilot from the San Francisco
Bar Pilots Association was assigned to navigate the vessel from the time it left the berth until it exited
the bay.
Dense fog was restricting visibility in the bay when the Pilot boarded the Cosco Busan about 0620. When
he arrived on the bridge, he introduced himself to the ships Master and handed him a San Francisco Bar
Pilots Pilot card. The Master asked the Pilot, can go? to which the Pilot replied that they would take
a look at things and see how the visibility developed. The bridge Watch Officer provided the Pilot with
the vessels Pilot card, which contained ship characteristics and ship maneuvering performance data.
The Pilot acknowledged receipt of this information by signing the document, noting recd only next
to his signature and citing the name of the assist tug to be used, revolution, just below his signature.
This same Pilot card had a checklist for the Crew to use before departing to verify that the ships vital
navigation, steering, and mooring gear had been tested and was operational.
According to the notations on the form, at 06:30, the Third Officer completed another required
navigational safety form titled Bridge Checklist 4 Master/Pilot Exchange. Checkmarks on the form
indicated that the Pilot had been provided with the vessels Pilot card and that the Pilot and the Master
had discussed and agreed on the proposed passage plan, weather conditions, un-berthing procedures,
and use of the assist tug. The checklist also indicated that the progress of the ship and the execution
of orders would be monitored by the Master and the officer of the watch. This checklist was signed
by the Third Officer and the Master. The onboard voyage data recorder (VDR) did not capture any
conversations with regard to the issues noted on the various checklists.
About 06:37, the Pilot, as required, contacted vessel traffic service (VTS) and informed the VTS operator
that he planned to depart berth 56 and pass through the DeltaEcho span (the 2,200-foot-long span
between bridge towers/piers D and E) of the Bay Bridge, and then to the deep water traffic lane. He
inquired about visibility around Alcatraz and the Golden Gate Bridge and was told that visibility was
1/8 to 1/4 nautical mile all the way to the Golden Gate Bridge.
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By this time, the Pilot had begun working with the Master and the Third Officer to adjust (tune) the
ships two radars with regard to picture display. The men tested the target acquisition of the automatic
radar plotting aid (ARPA) until the Pilot was satisfied that the radars were performing acceptably. The
discussions that took place between the Pilot and Crewmembers while these adjustments were being
made were recorded by the VDR. The ship was also equipped with an automatic identification system
(AIS) and an electronic chart system.
According to the VDR transcript, about 0650, the Pilot said to the Master:
So, Captain, theres a . . . tug and a barge coming in. We let them come in first and then - cause you can
see the other side now, and theres no more traffic - this looks good. The currents not very strong. Its
coming this way, so I think well be able to go as soon as [the tug and the barge go] past us.
The Master responded, yeah, yeah, yeah.
About 1 minute later, the Pilot told the Master, As [soon as the] tug gets by, you can single up. About
1 minute after that, the Pilot called VTS and said, Were going to wait until the [barge] William R gets
past us, and were still finishing up a little paperwork.
About 07:21, the Pilot said to the Master, You can single up, Captain, if you want. The Master
responded, OK, single up.
About 07:30, the Pilot estimated that visibility was about 1/4 mile. The Pilot later told Safety Board
investigators that he consulted with the Master about whether it was safe to depart, and the two
agreed to commence the voyage. If such a discussion took place, it was not recorded by the VDR.
About 07:45, the Pilot and the Master went outside onto the bridge wing where the Pilot said they
would stay for now, until we get a ways out, then well go in [to the wheelhouse].
The bridge wing audio channel of the VDR recorded the Pilot giving instructions to the tug revolution
and informing the tug Master that he planned to shift the tug to the centre stern chock when they
reached the middle of the channel just for insurance. The Pilot also told the Cosco Busan Master of
his plans to shift the tug to the stern. The Pilot commented to the Master that the loaded vessel had
a deep draft that was unusual for ships leaving Oakland because most ships left the port all empty.
About 08:00, the vessel moved away from berth 56 with the aid of the tractor tug revolution on the
port quarter pulling with one line while the ship used its 2,700-horsepower bow thruster. About this
time, the VDR recorded the voice of a Crewmember saying, in Mandarin, . . . American ships under
such conditions, they would not be under way.
About 08:05, the Pilot and the Master came in from the bridge wing. At that time, the bridge navigation
Crew consisted of the Master, the Third Officer, a Helmsman, and the Pilot. The ships bosun was on the
bow, and the Second Officer was on the stern. After the vessel eased off the dock, the Pilot had the tug
shift to the stern as had been planned. The Pilot told investigators that the ship handled reasonably
well except for perhaps being a little sluggish because of its deep draft. The Pilot card for the ship
indicated a forward draft of 39 feet 9 inches and an aft draft of 40 feet 1 inch.
Case Studies
About 08:10, with the tug trailing behind on about 100 feet of slack line, the Cosco Busan started
making headway out of the Inner Harbor Entrance Channel on a heading of about 288. The trip would
take the vessel northwest out of the entrance channel directly toward the southeast tip of Yerba
Buena Island and into the Bar Channel. Once in the Bar Channel, the vessel would turn left toward
the southwest to clear Yerba Buena Island, and then turn right to the northwest to cross under the
Bay Bridge using the DeltaEcho span . According to the chart, the approximate course out of the
entrance channel was 286 true followed by a left turn to an approximate course of 272 through
the Bar Channel, then a right turn to line up for a course of approximately 310 true to pass under the
DeltaEcho span of the bridge.
About 08:08, the Pilot called the Master of the tug revolution by VHF radio and informed him of his
intention to keep the tug trailing behind the Cosco Busan until the containership had got through the
Bar Channel. The Pilot asked the tugs Master about his work schedule and was told that the tugs next
assignment was at 08:30. The vessel proceeded outbound on a slow bell until 08:20 when the Pilot
ordered half ahead, which would increase the ships speed. The Pilot stated that as the Cosco Busan
continued to make its way out of the Inner Harbor Entrance Channel, he could see the No. 6 and 4
buoys pass by on the port side and noted that their flashing lights were visible. He kept the vessel to the
high side (north side) of the channel as he departed the entrance channel in anticipation of the flood
current (water flowing into the harbor with the rising tide) that he would encounter. He stated that the
visibility again diminished and that he did not see the No. 1 buoy marking the northern boundary of
the entrance to the Bar Channel as the ship passed it. As the Pilot later told investigators was his usual
practice, he set the radars variable range marker (VRM)14 at 0.33 nautical mile as a reference for his
approach to the Bay Bridge.
He stated . . . I usually . . . put the ring on there, and it just keeps the ring on the island as you go
through the bridge, and that brings you to the centre of the bridge.
According to the VDR, about 08:22, the Pilot, referring to the electronic chart, said (to the Master),
What are these ah red [unintelligible]? The Master responded, This is on bridge. The Pilot then
said to the Master, I couldnt figure out what the red light red red triangle was.
About 08:23, the Pilot began a left turn to the southwest by ordering 10 port rudder. Radar data
indicate that the ship at this time was on a heading of 282 and was travelling about 10 knots. A
radar image from about 08:25 showed that the VRM ring, which the Pilot indicated he would normally
attempt to keep positioned along the southern edge of Yerba Buena Island, had overlapped the edge
of the island.
Although the Pilot would later tell investigators that the radars were not performing properly, the VDR
did not record the Pilot making any comment to this effect during the voyage. The Pilot stated that
when he made the turn to port, he was where he wanted to be, but because of a deterioration in the
radar display, he decided to use the electronic chart and aim for the location (identified on the chart
by the red triangles) that the Master had pointed [out as] the centre of the bridge. At this point, the
vessel was about 1 mile from the Bay Bridge.
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About 08:25, the vessel had reached a heading of 253, and the Pilot ordered rudder to mid-ships
(centreed) before then asking for a heading of 250, followed by 245. Less than 1 minute later, the
Pilot ordered 10 starboard rudder, then starboard 20 and the engine to full ahead. According to the
VDR capture of the ships radar display, at that time, the ships heading was 241 (almost parallel with
the bridge) and its course over ground was 255. When starboard rudder was applied and the ships
heading began to move toward the northwest, the ships course over ground continued southwest.
About 08:27, the ships heading was 247 while its course over ground was 236. A few seconds later,
the heading had increased to 261, but the course over ground was 235. The speed had remained
constant at about 10 knots.
About this time, when the Cosco Busan was about 1/3 nautical mile from the bridge, a VTS operator
who was monitoring traffic in the Central Bay Sector, including the progress of the Cosco Busan,
noticed that the vessel appeared to be deviating from its intended route and was out of position to
make an approach to the bridges DeltaEcho span. The VTS operator radioed the Pilot addressing him
by his Pilot designator name, Romeo. The VTS operator and the Pilot referred to VTS as traffic.
The following exchange occurred, as recorded by the vessels VDR and captured on audio recordings
provided by VTS:
Speaker Time Transcript of communication
VTS 08:27:24 Unit Romeo, Traffic.
Unit Romeo 08:27:29 Traffic, Romeo.
Unit Romeo 08:27:45 Traffic, Romeo, did you call?
VTS 08:27:48 Unit Romeo, Traffic. AIS shows you on a 235 heading.
What are your intentions? Over.
Unit Romeo 08:27:57
Well, Im coming around; Im steering 280 right now.
VTS 08:28:04 Roger, understand you still intend the DeltaEcho span.
Over.
Unit Romeo 08:28:15 Yeah, were still DeltaEcho.
VTS 08:28:21 Uh, roger, Captain.
The VDR showed that when the Pilot reported to VTS that he was steering 280, the ships actual
heading was 262. The VTS operator did not further communicate with the Pilot.
VDR voice recordings indicate that during his conversation with the VTS operator, about 08:28:08, the
Pilot asked, This [apparently referring to a point on the electronic chart] is the centre of the bridge,
right? The Master answered, Yeah.
Over the next 2 minutes, the Pilot gave rudder orders of hard starboard, mid-ships, starboard 20, and
hard starboard. At 08:29, the bosun used his radio to report, in Mandarin, The bridge column. The
bridge column. The Master replied (in Mandarin), Oh, I see it. I see it.
The Pilot then said, Yeah, I see it. About 10 seconds later, the Pilot ordered the rudder (which had
been at hard starboard) to mid-ships. After another 5 seconds, the Pilot ordered hard port rudder.
The forward port side of the vessel struck the corner of the fendering system at the base of the Delta
tower at 0830. (It would later be determined that contact with the bridge had breached the ships No.
2 water ballast tank and the No. 3 and 4 port fuel tanks. About 30 seconds later, after being reminded
by the Crew that the rudder was still hard to port, the Pilot ordered the rudder to mid-ships and the
engine to dead slow ahead. At that point, the vessel was past the bridge tower.
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The Pilot contacted the VTS operators by VHF radio and informed them that his ship had touched
the Delta span and that he was proceeding to anchorage (just west of Treasure Island, about 2 miles
away) where he planned to anchor the vessel. At that point, the Cosco Busan Chief Officer reported
to the Master, in Mandarin, that the ship was leaking. The Pilot asked if the ship was all right, and the
Master answered, No, no, no, its leaking. The Pilot then said, OK, dead slow ahead. Were going to
anchor.
As the ship proceeded toward the anchorage, the Pilot had the following exchange with the Master
(from the VDR transcript, intervening helm commands deleted):
Pilot:
[unintelligible] you said this was the centre of the bridge.
Master: Yes.
Pilot: No, this is the centre. Thats the tower. This is the tower. Thats why we hit it. I thought

that was the centre.
Master:
Its a buoy. [unintelligible] the chart.
Pilot: Yeah, see. No, this is the tower. I asked you if that was [unintelligible]. . . . Captain, you

said it was the centre.
Master:
Cen cen cen centre.
Pilot: Yeah, thats the bridge pier [expletive]. I thought it was the centre.
Shortly after this conversation, the Master can be heard saying, in Mandarin, He should have knownthis is the centre of the bridge, not the centre of the channel.
In his post accident interview with Safety Board investigators, the Pilot stated that when he was tuning
the vessels radars and testing the ARPA before departure, he also examined the electronic chart and
noticed that the symbols on the . . . electronic chart didnt look similar to me to the symbols that are
on paper charts. He stated:
So I asked the Captain, Wheres the centre of DeltaEcho span [of the Bay Bridge] on this electronic
chart? So he pointed to a position on the chart, and it had two red triangles on either side of the bridge.
So I said, Well, what are these? And he said, Oh, those are to mark the lengths for the centre of the
span.
The Pilot told investigators, I see probably 10 different ECDIS during a week but I have never seen
a red triangle on any piece of navigation information, electronic, paper or otherwise. . . . Thats why I
asked him, I said, What does this mean? The conversation that the Pilot described was not recorded
by the onboard VDR.
The Pilot further told investigators that about 08:25, when the Cosco Busan was making the turn to
port in its approach to the Bay Bridge, the onboard radars became distorted:
As I made the turn . . . the radar picture of the bridge got distorted. It got wider. The bridge got wider.
The RACON never appeared. And I couldnt see the bridge piers or the buoys south of the span. I
couldnt pick it up on the radar. So at that point, I figured that the electronic chart would be more
accurate because . . . I wasnt comfortable with the [radar] display[s].
The Pilot further stated that he was confused by the VTS communication at 08:27 in which VTS stated
that it showed the vessel on a heading of 235:
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And Im standing at the radar, and the radar and the electronic chart are right next to each other, and .
. . I said my heading flasher is on 280. . . . I was nowhere near 235. I mean its not even a course you use
to get to the bridge. I never go left of 250. When I leave the Bar Channel generally, I steer towards the
tower or somewhere between 250 and 260, depending on the current. So I mean that really stunned
me. I was really confused by that. I couldnt understand how they could have me at 235 and I had me at
280. . . . the heading flasher showed that I had already cleared what the Captain had indicated was the
centre of the bridge. The heading flasher was to the right of it, and we were still coming right . . . from
the electronic chart, it looked to me like I was already past the centre and I was . . . a little concerned
about going too far to the starboard.
(Just over a year after the accident, Safety Board investigators collected sworn testimony from the
Master and the second and Third Officers after they had been given immunity from prosecution by
Federal law enforcement officials.)
The Master told investigators that, in his view, the fact that the port was not closed and that the Pilot
was willing to sail in the existing visibility conditions left the Master with limited reason to object to
departing. He said that he understood that the responsibility for the vessels safe operation ultimately
rested with him as the Master. He noted:
It is not [for] me to decide whether to set sail or not under such condition. Basically, I have to follow
his [the Pilots] direction.
The Master also stated that the fact that the port was not closed indicated to him that vessels were
expected to sail. As he testified, the decision [to sail came] from the Port Authority.
The Master stated that the Pilot did not tell him of his intention to proceed through the DeltaEcho
span of the Bay Bridge, nor did the Master ask the Pilot about his intentions. The Master stated that
he did not have any conversation with any of the ships deck officers concerning the planning for the
transit from the berth in Oakland to the San Francisco Pilot station or a discussion of any potential
hazards along the route, such as the Bay Bridge. The Master said that during the accident voyage he
was monitoring the ships radar. He said that he observed the radar signature of the RACON marking
the centre of the DeltaEcho span, but the ships VDR recorded no comment by the Master or other
Crewmember about the RACON display.
Before the vessel got under way, neither the Master nor the Second Officer briefed the bridge team
members on the outbound voyage. The Master stated that he did not want to make the Pilot feel
uncomfortable or unwelcome, so he chose not to engage the Pilot in a discussion of his plans with
regard to the outbound voyage.
The Master told investigators that he thought that the Pilot asked about the red triangles on the
electronic chart because he was curious and want[ed] to know what that was. The Master said he felt
that the Pilot should have known what the symbols meant. The Master told investigators that when he
responded to the Pilots question about the centre, he meant the centre of the entire bridge and not
necessarily the centre of the DeltaEcho span.
The Master later stated in a deposition that when he answered the Pilots question about the buoys, he
was just guessing, and he did not realise it was a serious question.
According to the Master, the VTS San Francisco practice of using the name or designator name of the
Pilot rather than the name of the vessel made it difficult initially to monitor VTS communications with
the vessel. As the Master told investigators:
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[VTS at] another port normally would call the ships name. If the VTS called the Pilots or the persons
name, maybe private conversation. If for working, I think its best way to call ships name, because you
call the ships name, not only Pilot would understand that, even the Captain understands.
The Chief Officer and the Third Officer both stated that, before the accident voyage, they had not
received any training from Fleet Management on the Masters standing orders, on passage planning,
or on bridge team management. The Chief Officer also stated that he had never before worked on a
ship with an electronic chart system. The Second Officer stated that, before the voyage, neither the
ships Master nor Fleet Management superintendents had provided him with any training, instruction,
or guidance on the Masters standing orders or on Fleet Managements Bridge Procedures Manual.
He said he had not prepared a berth-to-berth passage plan when the vessel departed Busan, Long
Beach, or Oakland. The Third Mate stated that, in contrast to his experience sailing with other technical
management companies, he and fellow Crewmembers were given limited opportunity to meet with
the off-going Cosco Busan Crewmembers and had little time to become acquainted with the ship and
to review Fleet Managements policies and procedures before they undertook their first voyage on the
vessel.
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Cosco Busan Case
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MCRM Case Study 2: Maersk Kithira
MCRM Case STUDY 2: Maersk Kithira

BACKGROUND
Maersk Kithira was originally built as P&O Nedlloyd Cook, but was renamed on her transfer to the A.P.
Mller Maersk Group in 2007. She was built with a totally enclosed bridge, situated in the after third
of the ships length, and approximately 200m from the forecastle.
At the time of the accident, Maersk Kithira was manned with a crew of 24, consisting of UK officers,
with the exception of a Ukrainian Second Engineer and Filipino ratings. The ship had just started a
new voyage loop, and was on the first rotation. The loop started at Yokohama, visited Chinese ports
southbound, Singapore, Jebel Ali, the Chinese ports northbound, Taiwan, Los Angeles, and returned to
Yokohama.
Operating a traditional three watch system, it was the routine for the Master to stand a watch
between 16:00 and 17:00, and between 07:00 and 08:00 to allow the Chief Officer to leave the bridge
to complete paperwork, or carry out upper deck rounds as required.
Maersk Kithira sailed from Yantian (Mirs Bay, Hong Kong) at 14:30 on September 23rd 2008, for
Xiamen, where she was due to berth at 10:00 the following morning. Weather reports about the
approaching typhoon Hagupit had been received on board, and the heavy weather checklist from the
company SMS had been completed by 15:30. This included a requirement to check the anchor securing
arrangements, ventilator closures on the forecastle and hatch cover locking devices. The Chief Officer
was relieved by the Second Officer as officer of the watch (OOW) when full away on passage was rung
at 1518. At 15:30, the Chief Officer commenced rounds of the upper deck to visually confirm that the
ship was secured for heavy weather, and at the same time the crew checked the cargo lashings.
At 17:00 the Chief Officer relieved the Master as OOW, and a weather report was sent, indicating
force 9 winds and 6m swell. At 17:25 and for a few minutes after that, a series of alarms sounded
on the ships voyage management and monitoring system. This indicated that both the main and
emergency starboard navigation lights had failed and that there was an earth on the circuit. This was
correctly diagnosed as indicating that the sidelight unit had been hit by a wave, a fact substantiated
during discharge the following day when a number of containers were noted to have been damaged
in the vicinity of the starboard sidelights. However, no impact had been felt on the bridge, and speed
was maintained. The Master was informed, and he decided that no further action would be taken to
remedy the situation due to the exposed position of the lights and the poor weather. It was agreed that
approaching ships would be alerted to Maersk Kithiras presence by illuminating the deck if necessary.
By 19:00 it was fully dark, and it was no longer possible to see the sea ahead of the ship. The wind
direction remained steady at about 30 degrees on the port bow, causing a 2-3m sea. A large swell of
about 6m was also evident coming from 20-30 degrees on the starboard bow. Under these influences,
the ship was rolling to about 10, but not pitching heavily. Engine speed was set for 20 knots, and the
ship was making a good speed of 12 knots. This speed was considered to be sufficient for Maersk Kithira
to make her scheduled arrival time at Xiamen the next morning as the Master expected the overall
voyage speed to increase as the vessel passed to the north of the typhoons centre and proceeded
further east into calmer waters.
At 19:45, the bosuns store bilge alarm sounded indicating to the Chief Officer the possibility that a
forecastle watertight closure had failed. Once he was relieved by the Third Officer at 19:50, he went
to discuss the problem with the Master. Finding the Master with the Chief Engineer, he informed the
Master of the alarm, and it was agreed that the Chief Officer would go forward to investigate the cause
of it. The Chief Engineer volunteered to accompany the Chief Officer, so both men changed into
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working gear and prepared to make their way forward via the under-deck passageway on the starboard
side. The Master went to the bridge to oversee the operation, and took the con from the Third Officer.
The Master reduced the speed of Maersk Kithira to 10 knots and altered her course to starboard to
reduce the rolling by placing the swell directly ahead of the vessel.
On arrival at the bosuns store the Chief Officer and Chief Engineer found that the deck was wet, and
that water was entering through the forecastle deck stores hatch cover seal. Shortly afterwards, at
2007, they reported to the bridge by telephone what had been found.
The Master, Chief Engineer and Chief Officer jointly agreed that it would be necessary to tighten the
dogs securing the forecastle stores hatch cover to prevent further water from entering the space. The
Third Officer switched on the foredeck floodlights, and the Chief Officer and Chief Engineer waited
briefly at the top of the access to the upper deck for the Master to give permission for them to proceed.
At 20:10, permission was given, and the two men went onto the upper deck. Ship movement was
such that neither found it difficult to stand. They made their way initially to the access port in the
breakwater, and stood in the shelter of the breakwater to assess the motion of the ship, and gauge
the amount of water being shipped on the deck. Noting that the only water coming onto the deck was
spray coming up through the hawse pipe, they decided that it was safe to go onto the forecastle, and
at 20:11, informed the Master by UHF radio of what they were doing.
Communication between the forecastle and the bridge continued by UHF radio, with the Chief Officer
commenting that both men were getting wet due to the spray coming on board. At 20:18, having
received no response from the forecastle team to repeated calls by UHF radio, the Master ordered the
Third Officer to go forward and investigate. The Master reduced the speed of Maersk Kithira further
to 5 knots.
At 20:23, as the Third Officer was getting changed to go on deck, the Master received a telephone call
from the Chief Engineer, in the bosuns store, telling him that a large amount of spray had come on
board and soaked the radios, rendering them inoperable. The Chief Engineer also confirmed that the
stores hatch cover securing dogs had been tightened. However, the starboard anchor cable securing
chain was noted to be slack, and he reported that he and the Chief Officer would take a couple of
minutes to tighten it. The Master then called the Third Officer back to the bridge, explaining that
contact had been re-established.
The Chief Officer and Chief Engineer returned to the forecastle and set about tightening the anchor
cable securing chain. This required one man to mount the windlass platform to release the securing
chain locking screw, while the other remained at deck level to adjust the securing chain through a
link of the anchor cable. The Chief Engineer mounted the platform, and released the locking screw,
allowing the Chief Officer to adjust the chain. As the Chief Engineer then re-tightened the locking
screw, a wave broke over the forecastle and washed him off the platform. The wave also knocked the
Chief Officer off his feet and propelled him into the windlass, rendering him unconscious. No wave
impact was seen or felt by either the Master or Third Officer on the bridge.
The Chief Officer woke up seconds later in about 30cm of water. Looking around, he saw the Chief
Engineer forward of the windlass, lying stationary on the deck. The Chief Officer dragged the Chief
Engineer behind the breakwater and put him into the recovery position. He then went to the bosuns
store and telephoned the bridge.
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At 20:37 the general alarm was sounded, and the Master made an announcement on the ships public
address system stating that there had been an accident and for personnel to muster in the ships office.
The ships emergency organisation was such that the Chief Officer was the medical officer, with the Third
Officer acting as his deputy. On mustering in the ships office the Third Officer and the fourth engineer
were sent by the Master to find the casualties and make an initial assessment of their condition. Taking
a first-aid kit, they made their way forward and found the Chief Officer holding the Chief Engineer in
the recovery position aft of the breakwater. The Third Officers initial assessment was that the Chief
Engineer required a stretcher, while the Chief Officer could walk if assisted. The Third Officer then used
the telephone in the bosuns store to discuss his findings with the Master on the bridge and request
that a stretcher party be sent forward. The stretcher party arrived shortly afterwards, and the Chief
Engineer was carried aft to the ships hospital. The fourth engineer escorted the Chief Officer aft to the
ships accommodation.
The Third Officer took charge of the attempt to provide the Chief Engineer with first-aid. It was readily
apparent that the Chief Engineers injuries were very serious, so the Master sought advice by telephone
from the companys medical officer.
Following reassurance from the company medical officer that the actions being taken were
appropriate,the Master began to assess options for evacuating the Chief Engineer to hospital ashore.
At 08:30, he stopped breathing, and Cardiopulmonary Resuscitation (CPR) was started by the Third
Officer, assisted by the electrician and other crew members. The ship arrived alongside her berth at
Xiamen at 10:00, when paramedics boarded, and assessed the situation. CPR was stopped at 10:42,
and Mr Ross was pronounced dead.
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Maersk Kithira Case
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MCRM Case Study 3: Moondance
MCRM Case STUDY 3: Moondance

General
The Bahamas registered and Det Norske Veritas classified ro-ro cargo ship Moondance had been
owned by Seatruck Navigation Limited since 1997. The vessel was one of six managed by Seatruck
Ferries Shipholding Limited (referred to throughout this report as Seatruck Ferries) based at Heysham
in Lancashire.
Operation
Moondance operated on the Heysham to Warrenpoint route and was certified to carry up to 12
passengers. Trade was predominantly centred on transporting self drive trucks and freight trailers. The
cargo was loaded from the stern ramp and carried on numbers 1 and 2 decks. Although the lower hold
deck was designed for carrying cars, it was no longer used for cargo-carrying purposes.
The trading pattern typically involved sailing from Heysham at 08:00 and arriving at Warrenpoint
between 16:00 and 17:00. Following off-loading and re-loading cargo, the vessel sailed at about 20:00,
arriving at Heysham at 05:00 to continue the pattern. The company operated a three-ship schedule on
the route, which allowed all vessels periods of lay-over, both in Heysham and in Warrenpoint.
Three of the eighteen crew on board were British: the Master, Chief Officer and Chief Engineer. The
remainder were Polish nationals. The working language on board Moondance was English. Moondance
was not fitted with either a voyage data recorder or a machinery data logging system.
Accident Summary
At approximately 18:11 on June 29th 2008, the ro-ro cargo ship Moondance was shifting from a layby berth to the ferry linkspan in Warrenpoint Harbour, Northern Ireland. At 18:13 she grounded on the
south-western bank of Carlingford Lough following an electrical blackout. There were no injuries, but
the vessel suffered severe distortion of the port and starboard rudder stocks.
At 18:08, just before Moondance left the quay, the port generator high fresh water temperature alarm
sounded. The Second Engineer was working under pressure and unsupervised during the critical time
of preparing to leave the berth. He was unable to determine the cause of the alarm and did not alert
the Chief Engineer or Master to the problem. Soon after leaving the quay, with the vessel proceeding
astern, the starboard generator also alarmed, and at 18:11 a total blackout occurred. The controllable
pitch propellers (CPP) defaulted to the full astern position and Moondance continued her sternway
until she grounded.
The Chief Engineer and his team arrived at the Engine Control Room (ECR), and the main engines were
immediately shut down without approval from the bridge and without knowledge of the navigational
situation. The situation in the ECR was chaotic. The Chief Engineer had difficulty establishing his
authority because the Polish engineers discussed fault finding options, in Polish, without consulting
him.
The problems were exacerbated because there was no lighting; the emergency generator had failed to
start automatically because it had been left in hand control. This was due to a long-standing defect
that the Chief Engineer was unaware of. It was not until 15 minutes later that the emergency generator
was started and the generators were cooled down sufficiently to enable them to be re-started.
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Communications between the bridge and engine room were poor, which resulted in the main engines
being started without approval from the bridge. However, they were shut down soon afterwards on the
orders of the Master, which were relayed, in person, by the Chief Officer. At 19:45 the Master ordered
the starboard engine to be started and, with tug assistance, Moondance berthed alongside at 20:22.
The investigation concluded that the generator high freshwater temperature was due to the isolating
valve for the sea water cooling system, supplying the generators, being left shut or being only partially
opened during the system reconfiguration for departure.
Many of the routines on board were lax. The move from the lay-by berth to the linkspan was considered
by senior staff on board Moondance to be a routine operation.
There were insufficient manning levels on the bridge and in the engine room, which contributed to the
accident.
Engine room events leading up to, and immediately after the blackout
At approximately 18:08, just before Moondance slipped from the berth, the Second Engineer was in
the engine room when he heard an alarm. He returned to the ECR and saw that the port generator
high fresh water temperature alarm was sounding and the red alarm light was illuminated on the ECR
alarm panel. The Second Engineer cancelled the alarm and went into the engine room to investigate
the cause. As he approached the port generator another alarm sounded, but he did not, at this point,
return to the ECR to check what the fault was, nor did he alert the Chief Engineer or the Master to the
overheating problem.
The Second Engineer felt the port generator fresh water cooler outlet pipe and found it to be hot. He
also noted that the fresh water cooling thermometer was reading above 90C. Unable to determine
the cause of the overheating, the Second Engineer returned to the ECR, where he was confronted with
numerous red lights and audible alarms, including those for the starboard generator. He cancelled the
alarms, but once again he did not alert the Chief Engineer to the problems. Believing there must have
been an interruption in the sea water cooling of the generator fresh water system, the Second Engineer
re-started the harbour service pump to supply the necessary cooling water to the generators. As he
was about to leave the ECR to check the positions of the generator sea water system valves, the Third
Engineer contacted him by dial telephone to find out the cause of the alarms he had heard from his
cabin alarm panel.
(When the main engine fresh water cooling jacket temperatures reached 60C the procedure on board
Moondance was for one of the main sea water service pumps to be started to cool down the main
engine fresh water system).
Almost immediately afterwards, at about 18:11, a total blackout occurred as the port and starboard
generators tripped on high fresh water temperature.
It was not until the cabin lights went out, and the ventilation fans stopped, that the Chief Engineer
was aware of problems in the engine room. He picked up his torch and ran from his cabin towards the
engine room. He was followed by the Third Engineer ,and slightly later by the electrician, motorman
and fitter.
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On arrival at the ECR they found that both main engines were still running and that the Second Engineer
was trying to connect the starboard shaft generator to the switchboard to restore electrical supplies.
This was unsuccessful because of difficulties in controlling the generators voltage. The Second Engineer
was extremely nervous and told the Third Engineer, in Polish, that the vessel had suffered a blackout
but that he was not sure of the cause. There were no discussions at this point with the Chief Engineer.
The Third Engineer went into the engine room to investigate the cause of the generator high temperature,
but he was hampered, as there was no lighting because the emergency generator had failed to start
automatically. On his way he put both of the main engine fuel racks to the no fuel position to stop the
engines. At the same time, the Chief Engineer operated both main engine emergency stops from the
ECR. As the main shafts slowed down, the port shaft generator supply breaker opened, disconnecting
it from the switchboard and with it power was lost to the bow thruster. Notably, the Third Engineer did
not inform the Chief Engineer what he had done in deciding, unilaterally, to stop the engines; neither
did the Chief Engineer inform the Master of his intention to stop the main engines.
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MCRM Case Study 4: MV Balduin
MCRM Case STUDY 4: Mv balduin

Grounding of MV Balduin October 30th 1984
On October 30th 1984 the MV BALDUIN left Oslo for Fredikstad, a short voyage of approximately five
hours down the Oslo fiord.
After departure the Master left the bridge leaving the Pilot and the Second Officer to navigate. He told
the Second Officer to call him 20 minutes before the Videgrunnen light bouy.
The voyage was normal apart from that the Second Officer and the Pilot did not communicate verbally.
This was probably the result of a small personality clash, when the Pilot and the Second Officer met on
the bridge before departure.
When passing the Struten lighthouse at 19:28 the Second Officer made a note in the logbook. The
vessel proceeded at full ahead, 17 knots. At 19:55 the Second Officer called the Master as instructed
earlier.
The vessel was steered by autopilot; the Pilot himself executed course changes, without informing the
Officer on watch. For some reason the Pilot did not notice that the vessel was passing the Tresteinerne
lighthouse where they were due to change course to 090 degrees towards Fredrikstad. They proceeded
without any alteration of course.
At 20:05 the Master arrived at the bridge. He did not speak to the Second Officer and did not acquaint
himself with the vessels position. He disconnected the autopilot and placed the Lookout at the helm.
The Klvingarna lighthouse was now seen on the port bow.
The Second Officer did not involve himself in the navigation of the vessel after the Master had arrived
on the bridge but concentrated totally on other duties. Afterwards the Pilot claimed that he felt
insecure about the vessels position at the time, but did not inform anybody. The Master now asked the
Pilot about the vessels position and was told that the Tresteinerne lighthouse was on the port bow,
which in fact was the Klvingarna lighthouse.
At 20:18 the course was changed to 090 degrees as the Balduin rounded the Klvingarna lighthouse.
The Helmsman, who lived in the city of Strmstad now 15 nm ahead of the vessel, had a strange feeling
of familiarity, so he asked the two men in front of him, Arent the red lights far ahead the masts in
Strmstad????. Nobody replied.
At 20:23 the Balduin struck bottom with full speed ahead on the Svartskren rocks, causing severe
damage to the fore part of the vessel.
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On October 30th 1984 the MV BALDUIN left Oslo for Fredikstad, a short voyage of approximately five
hours down the Oslo fiord.
After departure the Master left the bridge leaving the Pilot and the Second Officer to navigate. He told
the Second Officer to call him 20 minutes before the Videgrunnen light bouy.
The voyage was normal apart from that the Second Officer and the Pilot did not communicate verbally.
This was probably the result of a small personality clash, when the Pilot and the Second Officer met on
the bridge before departure.
When passing the Struten lighthouse at 19:28 the Second Officer made a note in the logbook. The
vessel proceeded at full ahead, 17 knots. At 19:55 the Second Officer called the Master as instructed
earlier.
The vessel was steered by autopilot; the Pilot himself executed course changes, without informing the
Officer on watch. For some reason the Pilot did not notice that the vessel was passing the Tresteinerne
lighthouse where they were due to change course to 090 degrees towards Fredrikstad. They proceeded
without any alteration of course.
At 20:05 the Master arrived at the bridge. He did not speak to the Second Officer and did not acquaint
himself with the vessels position. He disconnected the autopilot and placed the Lookout at the helm.
The Klvingarna lighthouse was now seen on the port bow.
The Second Officer did not involve himself in the navigation of the vessel after the Master had arrived
on the bridge but concentrated totally on other duties. Afterwards the Pilot claimed that he felt
insecure about the vessels position at the time, but did not inform anybody. The Master now asked the
Pilot about the vessels position and was told that the Tresteinerne lighthouse was on the port bow,
which in fact was the Klvingarna lighthouse.
At 20:18 the course was changed to 090 degrees as the Balduin rounded the Klvingarna lighthouse.
The Helmsman, who lived in the city of Strmstad now 15 nm ahead of the vessel, had a strange feeling
of familiarity, so he asked the two men in front of him, Arent the red lights far ahead the masts in
Strmstad????. Nobody replied.
At 20:23 the Balduin struck bottom with full speed ahead on the Svartskren rocks, causing severe
damage to the fore part of the vessel.
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MV Balduin Case
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MCRM Case Study 5: Figaro/Camargue
MCRM Case STUDY 5: Figaro/camargue

Collision between the Swedish Auto Carrier Figaro and the French
Tankship Camargue, Galveston Bay Entrance, Texas November 10th, 1988.
Extract from NTSB Marine Accident Report
On the Figaro
On November 10th 1988 at approximately 06:45 the 650 foot Swedish auto carrier Figaro arrived off
the Galveston sea buoy en route to the Barbours Cut Terminal at the head of Galveston Bay. There was
good visibility and an eight to ten knot breeze blowing from the south-southwest when the Houston
Pilot boarded at 07:00. The vessels draft was 9.1m, and her deadweight tonnage was 28,210.
The Pilot introduced himself to the Master and immediately ordered full ahead on a course of 300
degrees. Shortly after the Master informed him of the vessels draft and the engine speeds used for
manoeuvring, but did not discuss stopping distances or other manoeuvring data. The Pilot stated that
he was familiar with this type of vessel and had in fact piloted the Figaro several months before (but
records did not confirm this). There was also a discussion about the inbound vessel about 1/2 a mile
ahead, which was later found to be the French tankship Camargue. It became obvious to the Master
that the Pilot intended to overtake and pass the Camargue and at 07:02 the Figaros Pilot radioed the
tankship requesting a pass to starboard of her and said that he would ....cut inside no. 4 buoy (1.1 nm
northwest of the sea buoy). The Camargue agreed to this.
The Pilot estimated that the transit time to the terminal was about 3 and 1/2 hours. According to a
statement by the Master after the accident, labour to work the Figaro at the terminal was not scheduled
until 13:00, so he wondered why the pilot was in such a hurry. The Pilot later stated that he did not
know when the Figaro was expected. He also knew that the Camargue was bound for Texas City and
would soon exit the Houston channel.
The Pilot stood at a forward window close to the centreline of the vessel. According to the Master he
was not a particularly friendly person and did not engage in idle conversation, he looked busy, and
mumbled his orders unclearly.
After observing the relative speed of the two vessels for several minutes the Master realised that the
Figaro was slow in overtaking and increased the speed from eight (full ahead manoeuvring) to nine (an
increase of about one knot). The Pilot agreed that the increase in speed was necessary since he wanted
to overtake the Camargue before reaching buoy number four. The vessels were now on a parallel course
with the Camargue right of centre of the channel.
The sea buoy was abeam at 07:08 and by then the Figaros speed had increased to about 15 knots. The
Master recalled that at this time the tankship was between 10 and 20 degrees on his port bow and
four cables ahead. About the same time the Pilot altered the Figaros course to port in two degree
increments to 294 to enter the channel with the no. four buoy to starboard. He stated that he wanted
to pass the tankship before reaching the no. four buoy, although he could have gone outside the buoy
if needed, but he felt this was unnecessary. The Helmsman recalled that as soon as the vessel steadied
on 294 the Pilot ordered a change to starboard to 296, followed by 298.
The Master was concerned that the Pilot on board the Camargue could have been unaware of the
Figaro and asked the Pilot if he had contacted the Camargue by radio, to which the Pilot replied yes.
The Pilot however made a second call to the Camargue so the Master could hear it and not get jumpy
about it. At 07:12 the Pilot again radioed the tankship and asked its Pilot to reduce speed so the
Figaro could ...get by you. (A review of the tape recording of the VHF traffic indicated that although
the Figaro Pilot had attempted to contact the Camargue at 07:10, he did not get through until 07:12).
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The Master overheard the Camargue apparently agreeing to the reduced speed, although there was
no exchange of information between the two vessels about the overtaking, the speeds or the exact
positions. The Figaro Pilot did not discuss with the Master his plan to overtake the Camargue before
entering the buoyed channel except that he had done this manoeuvre many times and that the
faster ships always go ahead. Neither man talked about bank effect, how the Figaro would react as it
entered the channel, of the forces of hydrodynamic interaction, or how the Figaro would react if it got
close to the Camargue.
The Figaros Master walked out on the port bridge wing to better observe the tankship and look at his
own vessels wake. He could see that the wake was fairly straight and concluded that the vessel was
steering good. However he noticed that the rudder angle indicator showed the rudder to be hard to
starboard. He immediately called the Helmsman and asked if he could turn the vessel to starboard. The
Helmsman replied No. By this time the Figaro had some overlap on the Camargue. The Helmsman
said that he did not inform the Pilot that the rudder was hard to starboard because at the time, he had
seen the Pilot look at the rudder angle indicator. But he did tell the Pilot that the vessel would not
answer the helm. The Pilot stated that he was unaware that the Figaro was swinging slowly left until
the Helmsman informed him. The Helmsman thought he heard the Pilot say keep......hard starboard.
The Master immediately ordered the Helmsman to bring the rudder amidships and the Chief Mate to
stop the engine. With the engine order on stop, the Master quickly activated the main engine control
on the port bridge wing and moved the control lever to full astern. He noticed the speed log indicated
13 knots and estimated that the vessels were about 20 metres apart.
The Master stated that the Pilot agreed with the order to stop the engine saying oh yes, stop the
engine or words to that effect. The Master also stated that soon after he ordered the helm amidships
and stopped the engine, the Pilot appeared to ignore the situation, turned away and looked aft.
The vessels continued to close until at approximately 07:15 the Figaro struck the Camargue on the
starboard side forward of the bridge in the no. 3 starboard wing tank.
On the Camargue
The Camargue was a 135,500 deadweight tons tanker and a draft of 11.1 metres, with French Officers.
Two Galveston Pilots boarded the Camargue at the north western end of the Galveston Bay Traffic
Separation Zone. The Master recognised the lead pilot from a previous voyage. The conning Pilot had
been on the vessel about six weeks before and was familiar with the ships handling characteristics.
The Master relayed the conning Pilots orders in French to the Helmsman and was constantly aware
of what the Pilot was doing. According to both Pilots the Master was kept appraised of the intended
manoeuvres of the vessel as it proceeded towards Texas City, agreed with the Pilots decisions and
never interfered.
At 07:02 the first radio communication was made with the Figaro over VHF Channel 13. The conning
Pilot on the Camargue recalled that he received a request from the Figaro Pilot for a passing while she
was about 1/2 a mile off his starboard quarter and outside the channel. He agreed to the request and
told the Pilot that as soon as an outbound vessel was clear he would move over to the green side (or
left side) of the channel. The Camargues Master had no objection to the pending manoeuvre.
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At 07:12 as the Camargue approached the Galveston Bay Entrance Buoys number 3 and 4, the Pilot on
the Figaro made his request for the Camargue to slow down. The Camargues main engine was slowed
to half ahead. The Master said that at the time he had no objection to the reduction in speed but later
stated that it would have taken about five minutes for the headway to come off the vessel. Both Pilots
on the Camargue recalled that the Figaro appeared to be angled towards buoys 3 and 4 and that it
looked as though it would enter the channel before reaching them.
As the Figaro approached the Camargues starboard quarter the Master of the Camargue walked out
on the starboard bridge wing to observe the manoeuvre. As he saw the Figaro approach he became
concerned and gestured to the Pilot to get his attention. The Master stated that in his opinion the
situation had become dangerous. The Pilot went out onto the starboard bridge wing, immediately saw
that the vessels were not on parallel courses and that a collision was imminent. He also noticed that
the stern of the Camargue had already passed inside of buoys 3 and 4.
As the distance between the two vessels narrowed the conning Pilot ordered the helm hard a port.
The Master gave some orders in French to the mate to prepare for a collision and an alarm sounded
throughout the ship. He did not attempt to countermand the conning Pilots orders. In less than a
minute the vessels collided. The conning Pilot was unsure whether the Camargue responded to his last
helm order before the collision.
Figaro-Camargue Case
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MCRM Case Study 6: Tor Scandinavia
MCRM Case STUDY 6: tor scandinavia

The grounding of MV Tor Scandinavia in the archipelago of Gothenburg,
December 23rd 1979
The MV Tor Scandinavia, at the time a Swedish flagged passenger ferry, LOA 182.2 m, GRT 7846,
maximum draught 6.30 m, was on a regular voyage to Felixstowe. The departure from the berth in
Gothenburg went according to plan at 18:00 (all times local), with 363 passengers onboard.
The weather on the occasion was southerly winds, force six, and visibility was about two miles.
After departure, the bridge was manned by the Master-solely responsible for the navigation, the
Helmsman - an able seaman, and the Chief Officer. A Lookout was posted on the forecastle. The Chief
Officer was not taking part in the navigation, instead he was working on routine tasks at the chart
table. The Master navigated by optical means, checking with the radar, which was set on 1.5 miles,
relative motion, head up.
The first part of the voyage through the archipelago was normal in respect of navigation and
manoeuvring. However there was a very loud and animated discussion between the Chief Officer
and the Second Officer, who now had come to the bridge to take over the watch. The discussion was
about a rumour that the Tor Scandinavia and her sister ship were to be sold, which would endanger
the employments of the crew. The Master took part in some of the discussion, but he claims that it
ended before passing Gveskr. The discussions were so loud that the Helmsman was forced to ask for
silence to be able to concentrate on his task.
After passing Gveskr at 18:18, the Second Officer relieved the Chief Officer. The Second Officer did
not take part in the navigation. He turned his attention to the navigation computer, which was to be
used after leaving the archipelago.
They continued to pass north of Btt, on a course varying between 250 and 254 degrees. The speed
was 17-18 knots. The visibility had deteriorated and was now down to approximately half a mile.
At 18:21, when the Master thought that they had passed Btt West Light buoy, the speed was
increased to 21 knots, and the rudder was put ten degrees to port and a heading of 218 degrees was
ordered.
What they in fact had passed was Brandnsbrotten.
Less than one minute later, when the vessel had come to a heading of 228 degrees, the Master
suddenly discovered land 45 degrees to port. He immediately put both propellers full astern and
ordered the Helmsman to put the rudder hard a starboard. At 18:29 the vessel had stopped. There was
land close on the port side, approximately 200 m away. The Master was uncertain of his position and
wanted to remain stationary. Therefore he put slow ahead on the starboard propeller, slow astern on
the port propeller and set both bow thrusters to starboard.
After only a short while, in fear of damaging the propellers, the Master stopped the bow thrusters and
put both propellers on slow ahead. Neither the Master nor the Helmsman can state the rudder angle
when this manoeuvre was carried out. The rudder angle recorder was inoperative.
At 18:32 the Tor Scandinavia ran aground on a heading of 150 degrees, with the bow raised 0.9 m.
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MCRM Case Study 6: Tor Scandinavia
Source: Investigation report by the Swedish Nautical Commission of Inquiry, Nov 1980.
Tor Scandinavia Case
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MCRM Case Study 7: Torrey Canyon
MCRM Case STUDY 7: Torrey Canyon

Torrey Canyon grounding March 18th 1966
Shortly before 02:30 Captain Rugiati wrote his night instructions for First Officer Bonfiglio who would
relieve Second Officer Fontana at 04:00. Bonfiglio was to call him as soon as the Scilly Isles appeared
on radar. In any event Bonfiglio was to call with a report at 06:00 whether he had radar contact with
the Scillies or not. Captain Rugiati went to bed at 02:40. The Torrey Canyon was at 16 knots on a course
of 018 degrees on autopilot.
At 04:00 Bonfiglio relieved Fontana. Visibility was good - 10 miles. He expected to see the Scillies on
the starboard side after dawn. At 05:00 there was no sign of them on the radar. At 06:00 still no sign.
Bonfiglio called the Captain. It is 6 o clock, Captain. I have not yet seen the Scillies on radar. Captain:
Uh, thanks. When do you estimate them to come within radar range?
About 7
Call me when you make contact. Bye.
At 06:30 Bonfiglio observed the Scillies on radar at a distance of 40 miles. But the position came as a
shock. Instead of lying to starboard they were off to port. The set of the current had forced the vessel
off course by about 8 miles. Bonfiglio changed course without notifying the Captain. First he called
the Helmsman to the wheel. Then he moved the steering control lever from automatic to manual
before giving the order Come left to zero zero six degrees. The vessel was then heading directly for
the Bishop Rock Lighthouse but was 24 miles away. He expected Captain Rugiati to confirm the course
change and order another change to port to bypass the lighthouse and return to the original track.
Once the Torrey Canyon had settled on zero zero six degrees he called the Captain.
Captain, I have tracked the Scilly Isles on radar. We have moved over to the right of the course. I have
headed the bow for the Scilly Isles. I am heading for the Scilly Isles.
Rugiati was angry, which surprised Bonfiglio. What? You changed course without consulting me?
But we were off track.
Thats not your decision. With our original heading of 18 degrees, would we be free of the Scillies?
Yes.
Then continue on course zero one eight degrees. I intend to pass to the starboard of the Scilly Isles.
If you really think so Captain.
Pay attention. In a few minutes I will be on the bridge.
Captain Rugiatis first action on the bridge was to confirm that First Officer Bonfiglio had carried out
his instructions and placed the vessel on the original 18 degrees heading. He then checked that the
vessel was free of the Scilly Isles. She was headed for the narrow channel between the Scillies and the
Seven Stones. But he felt no concern for the ships safety. Fixes were taken at 07:09, 07:45 and 08:00.
Relations were back to normal with First Officer Bonfiglio who left the bridge shortly after 08:00.
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Rugati and Bonfiglio then concerned themselves with the transfer of cargo problem that had to be
solved before the Torrey Canyon could enter Milford Haven on the high tide at 23:00 that night. Rugati
had been warned that his maximum draft must be 52 feet and two inches. His draft at the bow and
stern was 51 feet seven inches. But there was a sagging amidships, by careful distribution they had now
reduced to nine inches. This meant that the draft amidships was only 52 feet and four inches. So this
would have to be reduced even more to get into Milford Haven.
Making the problem worse was the fact that the cargo transfer could only be done in calm seas since
the tanks were nearly full and this would take five hours. ETA at Milford Haven was 16:30. So if transfer
could not be done at sea then there was just enough time (an hour and a half) to delay the transfer
until the Torrey Canyon entered the Milford Haven Roads, but there was no time for a delay.
By 08:00 when Officer Bonfiglio left the bridge it was not clear whether a transfer at sea was possible
and whether they did in fact have a time problem.
Between 08:00 and 09:00 on the bridge with Captain Rugiati were Scotto, an experienced Helmsman
and Alfonso Coccio, an inexperienced Third Officer. Both were on their maiden voyage with the
Torrey Canyon. When Scotto first joined the bridge at 08:00 Captain Rugiati sent him down to get
two ashtrays, then a second time to get some sandpaper. He was not informed of the vessels course.
Coccio had spent hours the previous day checking the charts and course in the expectation that they
would be going west of the Scillies. Now he was informed that were going east. After the briefing
Coccio Bonfiglio left the bridge.
Fixes were taken at 08:10 and at 08:18. The speed was 15.75 knots. They were now abeam of the
Peninnis Head Lighthouse on the Scillies and 30 minutes from the shoals of the Seven Stones reef.
Coccio checked the radar. Captain, there are two fishing vessels ahead.
Yes, Captain Rugiati replied. I have seen them already.
It had always been his intention to come to port once clear of the Scillies. Captain Rugiati changed the
ships heading to 015 degrees. With the automatic steering system being used this could still be done
in auto without moving to the manual position.
However the set of the current, drift and wind were counteracting the three degree turn to port and the
vessel was still heading on 018 degrees.
At 08:30 the Torrey Canyon was still in a slow sweeping turn to port. The heading was then 010 degrees
and Captain Rugiati was intending to turn further to port. But the presence of more fishing vessels to
port meant that he ordered put the ship back on a course of 013 degrees for about 10 minutes.
Alfonso Coccio was uncertain of the ships exact position at that time and made three attempts to plot
the position. At 08:38 Captain Rugiati looking over Coccios shoulders could see that the fix was grossly
inaccurate. He could see that the last position was in error by at least a mile. Captain Rugiati could now
see that he was in trouble. He didnt know where he was. He would have to take over himself.
Stop using the Scillies for bearings. he told Coccio, Use the lightship.
Coccio ran out to the starboard wing to take a bearing on the lightship. It was 033 degrees. The Captain
took the radar distance - 4.8 miles. When the position was plotted Rugiati saw that the ship was only
2.8 miles from Seven Stone. The time was 08:40.
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The ship was still on automatic Pilot. Rugiati decided to change to manual and change course to 000
degrees. He put her on course then changed back to automatic steering. In the meantime Coccio took
another bearing - the Torrey Canyon was 2.78 miles from the lightship, within less than a mile of the
nearest rock.
At that point Captain Rugiati fully realised the danger. He sprinted from the chart room yelling to
Helmsman Scotto: Come to the wheel. Come to the wheel. Take it hard to port!
Rugiati was already at the wheel, repeating his orders. Hard to port. Go to 350. Take her to 340. Take
her to 320. Then he returned to the chart room.
Scotto put the wheel hard over. For a few seconds he watched in growing amazement as the rudder
indicator didnt move. He shouted to the Captain: Captain, the ship is not turning. But Rugiati was
too engrossed in the chart and didnt hear in all the excitement.
It took Captain Rugiati close to a minute to sense that something was seriously wrong and it took him a
few seconds longer to realise what it was. The gyro compass was not clicking. He went cold and turned
towards Scotto. Shes not turning, Captain the Helmsman repeated.
Even then there was time, if only Rugiati could find out what was wrong quickly. His first fear was that
it was a fuse. This had happened before. Rugiati tested each in turn. They were all OK. Still the rudder
did not respond. His second thoughts were that the oil pumps controlling the rudder had broken down.
That too had broken down before.
In desperation Rugiati leaped for the telegraph and dialled the engine room. In his haste however he
dialled 14 instead of 6, and got the Officers dining room instead.
Julio, here. Captain, are you ready for breakfast?
Rugiati slammed the phone down. He was redialling when his fingers stopped. He had a clear view of
the steering control panel. Porco Dio he swore. The steering lever was not in manual but in the
control position. The Torrey Canyon could not turn. In effect the wheel was disengaged.
He then rushed to the control panel, switched it to manual and helped the Helmsman turn the wheel
hard to port.
The bow started to move to port. The ship reached a heading of 350 degrees, but it was too late. She
was slamming into Pollard Rock at a speed of 15.75 knots. Coccio felt the rocks touch at 08:50.
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(Extracts taken from The Black Tide in the wake of the Torrey Canyon by Richard Petrow, published
by Hoddard and Stoughton SBN 340 02990 0).
Torrey Canyon Case
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MCRM Case Study 8: Thuntank 5
MCRM Case STUDY 8: Thuntank 5

The grounding of the MT Thuntank 5, in the approach to Gvle, Sweden,
on December 21st 1986
The MT Thuntank 5, LOA 102 m, maximum draught 6.8 m, carrying 5024 tonnes of heavy fuel oil, was
on voyage from Slagen, Norway, to Gvle, Sweden.
The prevailing weather, at the time of the grounding, was North-north-easterly winds, force nine to
ten, visibility varying between 1 and 1.5 miles - due to heavy snowfall, mean height of waves - 4 to 5
metres.
During the voyage, Thuntank 5 was in an intense and wide low pressure, moving from the southern
part of the Baltic Sea towards Latvia. On the way down through Kattegatt, on the 19th of December,
the forward toplight went out. Consequently the spare light was switched on. There was no attempt
to repair the main light. It was considered too dangerous since the forecastle was washed away by the
heavy seas.
The voyage went according to plan, in respect of navigation. The Thuntank 5 passed through both
Kalmarsund and the archipelago of Stockholm, with Pilot assistance, for the benefit of sheltered waters.
On the day of the 21st of December the forward spare top light went out as well. With the forward
mast covered with ice, and north-north-easterly winds, force five to six, it was decided to continue
without a forward top light. The ETA to the Pilot station at Gvle was at 18:00 the same day.
At 15:10 (all times local), with 32 miles to the Pilot station, a Pilot was ordered for 18:30. However the
wind increased to force ten, and the speed dropped, indicating an ETA at 20:00. The Pilot station was
informed.
The visibility had deteriorated, due to heavy snowfall, to approximately 1.5 miles.
At 19:25, six miles from the pilot boarding area, the last position fixing was done by means of Decca,
and plotted on the chart. From thereon in the vessel was navigated from the radar picture, and with
occasional optical sights of marks and land.
The Master had passed through the specific area some 30 times. This means that all following positions
are approximate.
When passing 0.4 miles north of the light buoy Vktaren, at 19:36, it was observed both visually and
on the radar.
The Pilot station was contacted on VHF, and it was agreed that the Pilot would embark 0.5 miles
south of the low profiled island Grsjlsbdan. The Pilot station was informed that they were without
forward top light.
Also approaching Gvle, close on the port quarter of Thuntank 5, was the Nord Transporter, a 499 GRT
bulk carrier, not required to carry a Pilot. At anchor, south-west of Grsjlsbdan, was the Russian
vessel Sibirskye 21-31.
The Thuntank 5 was on autopilot, and at full sea speed, which in the prevailing circumstances would
mean nine to ten knots. The master was in command, with the Chief Officer assisting him. There were
two different radar sets in operation; one used by the Master, and the second used by the Chief Officer.
Both radars were on automatic sea clutter.
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The Lookout was at that time giving notice to the rest of the crew about their approach to Gvle, and
trying to clear the pilot ladder from ice.
A westerly course was set, but with the strong north-north-easterly wind, and the accommodation
placed aft, the Thuntank 5 probably made a course of 275-277 degrees over ground.
Halfway between the Pilot station and the Pilot boarding area, the radar of the Pilot boat broke down,
due to an electrical malfunction. This also affected the heating, resulting in icing of the windows and a
visibility close to zero. The Pilot boat decided to continue, and it was agreed with the Pilot station that
they would await the Thuntank 5 close to the vessel at anchor.
Just before passing Eggegrund, the master of the Thuntank 5 observed an echo ahead, which he believed
to be Grsjlsbdan. What it probably was, was the vessel at anchor. The Eggegrund light house was
passed at approximately 19:44, at a distance of 0.8 miles.
From time to time the Chief Officer observed some white lights ahead. He believed them to be the
leading lights of Lim.
At 19:50, halfway between Eggegrund and Sjlstenarna, the Thuntank 5 contacted the Nord Transporter,
0.5 miles on the port quarter. They were informed of Thuntank 5s intention to alter course to port, and
were suggested to pass on the starboard side of Thuntank 5.
Shortly after the communication between the two vessels, the Thuntank 5 was called by the Pilot
station, and was informed of the presence of the vessel at anchor. The position was stated to be
approximately 1 mile south-west of Grsjlsbdan.
The Master now realised that what he has thought to be Grsjlsbdan, in fact was the vessel at anchor.
What the Chief Officer had thought to be the leading lights, was the anchor lights from the Russian
vessel.
The vessel at anchor was visually observed at 19:54. The Thuntank 5 was now so close to Grsjlsbdan
that, due to the low profile of the island and both radars were on automatic sea clutter, it was only
presented as a very small echo.
The Master believed this echo to be the Pilot boat. In the trying situation, he believed the echo of
Lvgrund, one mile further to the north, to be Grsjlsbdan.
The Master called the Pilot boat, and asked if it was possible to pass north of the vessel at anchor. The
response from the Pilot boat was yes.
The Master called the Nord Transporter and told them that they intended to alter course to starboard.
The response from the Nord Transporter was that they would reduce speed.
Alteration of the course to starboard was done, and the speed was reduced to four to five knots. The
master, now believing he was heading for the pilot boat, was looking for the lights. He could not see
any... Due to the weather, the windows were partly covered with ice, so the Master went to the bridge
wing to search for the Pilot boat. The bridge wings were not fitted with wind breakers, which made it
impossible to see anything. When the Master returned inside the bridge at 20:05, the Thuntank 5 ran
aground on a heading of 350-355 degrees.
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Source: Investigation report by the Swedish National Maritime Administration, 1987 TK93.
Thuntank 5 Case
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MCRM Case Study 9: Malinska
MCRM Case STUDY 9: malinska

Canadian Transportation Safety Board
Factual Information
Particulars of the Vessel:
Name
MALINSKA YTEQ.
Official Number
8505848.
Port of Registry Rijeka, Yugoslavia.
Flag Yugoslavian.
Type
Bulk carrier.
Gross Tons
23,306.
Length
222 m (overall).
Breadth
23 m.
Depth
14.76 m.
Draught (At time
7.91 m (F), 7.94 m (A).
of occurrence)
Built
1987, R.O. Brodogradiliste Rijeka, Yugoslavia

Strengthened for heavy cargos.
Propulsion
Sulzer 6 cylinder, 9.9961 kw, controllable-pitch.
Propeller
Owners Jugolinija Rijeka, Yugoslavia.
History of the Voyage

At 12:15, May 12th 1991, the Yugoslavian-registered bulk carrier Malinska departed Hamilton, Ontario,
with 23.929 tonnes of steel coils, bound for sea via Sorel, Quebec. On board were 25 persons: the
Master, the Pilot and 23 crew members.
Under the conduct of the Pilot, the Malinska left Hamilton harbour and was full away on passage
at 13:45, on autopilot, making an average speed of 13 knots over the ground. This voyage, between
Hamilton and Cape Vincent, is generally considered simple and straightforward in terms of navigation.
At 14:00, the Pilot left the bridge, but remained on board and returned to the bridge from time to time.
The weather was fair, the visibility good, and this part of the voyage, up to Main Duck, was uneventful.
The midnight watch was assumed by the Mate, who came on the bridge approximately ten minutes
early. He was satisfied with the ships 2400 position, which he had obtained by satellite and radar,
plotted on chart LC 2000, and then transferred to US Chart No. 14802. The ships 2400 position
showed the vessel to be 0.5 mile north of the down bound track and about 7.6 miles South West of
Main Duck Island light. This information was not relayed to the Pilot when he came onto the bridge a
few minutes later.
In the meantime, the Pilot was called into his cabin as he had previously instructed, and came onto the
bridge at about 00:05 to assume the conduct of the vessel. He checked the position of the vessel using
Parallel Index Plotting (PIP) and believed that the vessel was on the down bound track.
About five minutes before the course alteration, the Master joined the Pilot on the bridge. There was no
effective exchange of navigational and operational information between the different crew members
and the Pilot when they came onto the bridge around midnight.
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The wind was from the west at about 10 knots, the sea was calm, and the visibility, which was variable
in fog patches, was approximately four miles at the time.
When the Pilot noticed that Main Duck Island light was abeam, at about 00:28, he ordered the course
altered to 039 true (T) and gyro (G), as depicted on the chart. While the Mate was altering course, the
Pilot went to the port wing of the bridge to look for the Ducks light buoy MM2. As he could not find
it, he went back inside to check the buoys position on the chart. To his surprise, he suddenly saw the
red light buoy on the starboard bow. He immediately ordered hard to starboard which was executed
by the Second Mate, who switched the autopilot to manual and turned the wheel to starboard. At the
same time, the Master ordered midship rudder and engine full astern.
It was too late; the vessel hit the rocky bottom and ran aground at 0.3 mile north west of buoy MM2
at about 00:33, May 13th 1991. Attempts to free the vessel were to no avail.
A general alarm was sounded and Officers were sent to make soundings of all the tanks and holds of
the vessel. Initial reports indicated that the vessel was not in immediate danger, that there was no
pollution, but that the vessel was taking on water.
Composition of the Bridge Watch

During the lake passage, the bridge watch consisted of the Officer of the Watch (OOW), a Helmsman
and a Deckhand.
Assessment of the Position of the Vessel

When the Pilot came onto the bridge, the wind was from the west at about 10 knots and the sea was
calm. The vessel was on automatic steering on a course of 0700 (G) with a stated gyro error of zero,
making an average speed of 13.25 knots over the ground.
The Pilot then proceeded to determine if the vessel was on the down bound track using the radar and
the technique of PIP on the stabilized relative-motion radar display.
The Pilot used Main Duck Island light as the echo of the fixed object. An electronic bearing line parallel
to the course of 0700 (G) drawn from the echo of the fixed object was set parallel to the course of
0700 (G). The Pilot then moved the variable range marker circle to be tangential to the electronic
bearing line. He believed the distance between the ships position and the tangential line to be 3.2
miles (the desired passing distance) and therefore concluded that the ship was following the down
bound track. No position fix was obtained.
According to the OOW, when he looked at the ARPA he saw an electronic bearing line set parallel to
course 0700 at a distance of two miles rather than the intended 3.2 miles. He did not know what the
intention of the Pilot was, and so did not raise any question.
Distance Estimation
At the time of the occurrence, visibility was about four miles in low fog patches. The presence of fog
can have a deleterious effect on the judgement of distances. Gradient cues and light intensity are
reduced and, especially at night, the extent of fog conditions is difficult to estimate. The diminished
perceptual cues combined with a failure to fully appreciate the extent of the fog at night may result in
a false perception or an illusion of increased distance.
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Course Change
The course recorder graph showed the course change versus time, and the course plotted was
synchronized with the gyrocompass. The course recorder graph indicated that the vessel:

Altered course from 070 (G) to 039 (G) in about four minutes.
Steadied on 030 (G) for nearly one minute; and
Turned to starboard from 039 (G) it 066 (G) in three minutes and remained on the heading
of 066 (G) at the grounding position.
The Grounding
The Pilot discontinues the PIP at 00:15 and did not effectively re-check the track of the vessel. There
was no other vessel in the general vicinity.
When the vessel was abeam by visual bearing of the Main Duck Island light (List of Lights no. 424),
at about 00:28, the Pilot ordered the course to be altered to 039 (G) and (T), the desired course. At
that time, as well as during the preceding 13 minutes, the Pilot did not effectively observe either radar
presentation to confirm the vessels position or the distance from the Main Duck Island light. He did
not see the Ducks light buoy MM2 before altering course, reportedly due to some low fog patches.
Under the direction of the Pilot, the course was altered by the Second Mate who altered the autopilot
by increments of five degrees. Witnesses on the bridge all agreed that the vessel was turning very
slowly. The Ducks light buoy MM2 was still not observed either visually or by radar by the bridge watch
before altering course.
In the meantime, the Pilot went to the port wing of the bridge to look for The Ducks light buoy MM2
but he could not find it. After returning to the wheelhouse, he suddenly saw the red light buoy on
the starboard bow at approximately two ship-lengths away. When he spotted the buoy, he did not
know whether the vessel or the buoy was out of position. Nonetheless, he ordered hard to starboard.
Immediately afterwards, he looked at the radar and noticed that the ships heading marker was on
Yorkshire Island, suggesting the vessel was out of position. The Second Mate switched the autopilot to
manual and turned the wheel to starboard. At the same time, the Master saw the red light buoy MM2
on the starboard bow and ordered midship rudder and engine full astern, but it was too late.
Everyone on the bridge felt the impact when the vessel hit the rocky bottom and ran aground at 0.3
miles North West of buoy MM2. The time was approximately 00:33 on May 13th.
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Malinska Case
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MCRM Case Study 10: Royal Majesty
MCRM Case STUDY 10: Royal Majesty

Grounding of the Panamanian vessel Royal Majesty, following a
navigational error
Approximately 22:25 on June 10th, 1995, the Panamanian passenger ship, Royal Majesty, grounded on
Rose Crown Shoal near Nantucket Island, Massachusetts.
The Royal Majesty, carrying 1,509 passengers and crew members, was on route from St. Georges,
Bermuda, to Boston, Massachusetts. No injuries or deaths resulted from the grounding.
On the night of the accident, the Royal Majesty was on the last day of a seven day voyage. The ship had
left Boston from Bermuda on June 5th.
The vessel had arrived in St. Georges on June 7th, where it was berthed until it departed Bermuda on
June 9th for the return trip to Boston. The vessel was scheduled to arrive in Boston around 05:30 on
June 11th.
The return trip to Boston was divided into two legs. The first leg normally extended from St. Georges
to the entrance of the approaches to the port of the Boston traffic separation scheme (Boston traffic
lanes) - a distance of more than 500 miles over open ocean.
The second leg normally took the vessel in a northerly direction through the traffic lanes along the
eastern edge of Nantucket shoals and around the eastern shores of Cape Cod.
The entire voyage to Boston (a distance of about 77 miles) normally took approximately 41 hours.
The Navigator testified that on June 9th, he went on duty about an hour before scheduled departure
time of 12:00. He said that he customarily tested the vessels navigational equipment before getting
underway. He stated that when he tested the navigation equipment, including compasses, repeaters,
radars, NACOS, GPS, Loran-C, and the communications systems during the half hour before the vessel
departed St. Georges, he found the equipment to be in perfect operating condition.
When set on the nav. mode, the NACOS 25 autopilot automatically corrected for the effect of set and
drift caused by the winds, sea and current, to keep the vessel in a preset distance of its programmed
track.
He said that shortly after departure, he set the navigation and command system (NACOS 25) autopilot
on the navigation mode. He further stated that later, when the vessel dropped off the harbour Pilot
about 12:30, he compared the position data displayed by the GPS and by the Loran-C, and found that
the two sets of position data indicated positions within approximately a nautical mile of each other.
According to the Watch Officers on duty, the northbound trip was uneventful during the first 24 hours.
The Watch Officers stated that the Royal Majesty followed its programmed track, as indicated on the
display of the automatic radar plotting aid (ARPA), maintaining a course of about 336 degrees (true).
At 12:00 on June 10th, the Navigator was again on watch, assisted by a Quartermaster. According to
the Navigator, the Royal Majesty maintained its course of 336 degrees and its speed was 14.1 knots
(over ground).
Entries in the vessels bridge log indicated cloudy skies, winds out of the East-North-East at eight knots,
and seas between one and three feet. Meteorological visibility was reportedly as at least 10 miles.
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The Navigator stated that during his watch, he was using the port ARPA on the 12-mile range scale. He
also stated that he was plotting hourly fixes on the chart of the area using position data from the GPS.
He stated that although he frequently checked the position data displayed by the Loran-C, all of the
fixes that he had plotted during the voyage from Bermuda were derived from position data taken from
the GPS and not the Loran-C.
The Navigator further stated that in open sea near Bermuda, the position indicated by the GPS and
Loran-C would have been expected to be within half to one mile of each other. As the vessel approached
closer to the United States the positions would have been expected to be within 500 metres of each
other.
At 16:00, the watch changed, and the vessels Chief Officer relieved the Navigator. The Chief Officer
was assisted by a Quarter Master, who acted as either Helmsman or a Lookout on an as-needed basis.
The Chief officer stated that he used the port radar set on the 12-mile range. He further stated that no
procedures specified the number of radars to use, but that usually two were used in bad weather. He
stated that because the weather was good and visibility was clear, he used one radar.
The Chief Officer also indicated that he relied on the position data from the GPS to plot hourly fixes
during his watches, and that the Loran-C was used as a back up system, in case of GPS malfunction. He
stated however, that for the 17:00 and 18:00 hourly fixes he compared the data from the GPS with the
data from the Loran-C, and that in both instances the Loran-C indicated a position about one mile to
the South-East of the GPS position.
The Chief Officer testified that prior to the 17:00 hourly fix, at about 16:45, the Master telephoned the
bridge and asked when he expected to see the BA buoy, the buoy that marked the southern entrance
to the Boston traffic lanes.
The Chief Officer responded that the vessel was about two and a half hours away from the buoy. The
Master testified that he asked the Chief Officer to call him when he saw that buoy.
According to the Chief Officer, approximately 45 minutes later (17:30), the Master visited the bridge,
checked the vessels progress by looking at the positions plotting on the chart and at the mapped
overlay exhibited on the ARPA display and asked a second time whether the Chief Officer had seen the
BA buoy. The Chief Officer responded that he had not. Shortly thereafter the Master left the bridge.
According to the Chief Officer, at approximately 18:45, he detected on radar a target off his port bow
at a range of about seven miles and concluded that the target was the BA buoy. He stated that his
conclusion had been based on the GPS position data, which indicated that the Royal Majesty was
following its intended track and on the fact that the target had been detected about the time, baring,
and distance, that he had anticipated detecting the BA buoy. He further testified that on radar the
location of the target coincided with the plotting position of the buoy on the ARPA display.
According to the Chief Officer, at approximately 19:20, the radar target that he believed to be the BA
buoy, passed down the Royal Majestys port side at a distance of 1.5 miles. He stated that he could not
visually confirm the targets identity because of the glare on the ocean surface, caused by the light of
the setting sun.
The Chief Officer testified that at approximately 19:30, the Master telephoned to the bridge and asked
him for a third time whether he had seen the BA buoy. According to the Chief Officer he responded that
the ship had passed the BA buoy approximately ten minutes earlier (about 19:20).
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The Master then asked whether the Chief Officer had detected the buoy on radar; the Chief Officer
replied that he had.
According to the testimony of the Chief Officer and the Master, the Chief Officer did not tell the Master
that he had been unable to visually confirm the identity of the BA buoy, and the Master did not ask
whether the buoy had been visually confirmed.
The Safety Officer (Second Officer) testified that he arrived on the bridge at approximately 19:55 and
prepared to assume the watch from the Chief Officer. According to the testimony of both Officers,
during the subsequent change of watch briefing (20:00), they discussed traffic conditions and the
vessels course, speed, and position. According to the testimony the Chief Officer did not discuss with
his relief the circumstances surrounding his identification of the BA buoy.
The Second Officer testified that at 20:00, he assumed the watch, assisted by two Quarter Masters, and
that the Chief Officer left the bridge. The two Quarter Masters served as port and starboard Lookouts.
The Second Officer stated that shortly after assuming the watch, he reduced the range setting on the
port radar from the 12 mile range to the six mile range. He testified that he relied on the position data
from the GPS in plotting hourly fixes during his watches and that he considered the Loran-C to be a
back-up system. He also stated that it was not his practice to use the Loran-C to verify the accuracy
of the GPS.
The Quarter Master standing Lookout on the port bridge wing (port Lookout) stated that about 20:30
he saw a yellow light off the vessels port side and reported the sighting to the Second Officer. According
to the Quarter Master, the Second Officer acknowledged the report, but took no further action. At the
time of the sighting, the NACOS 25 was showing the Royal Majesties position to be about halfway
between BA and BB buoys.
The BB buoy is the second buoy encountered when travelling northbound in the Boston traffic lanes.
Shortly after the sighting of the yellow light, both the starboard and port Lookouts reported the
sighting of several high red lights off the vessels port side (a series of radio towers with flashing red
lights are on the eastern end of Nantucket).
Because the towers are about 30 miles from the traffic lanes, the lights are not generally visible to
vessels transiting the traffic lanes. According to the Lookouts, the Second Officer acknowledged the
report, but took no further action.
The port Lookout stated that shortly after the sightings of the yellow and red lights, the Master came
to the bridge. The Master testified that he spent several minutes talking to the Second Officer and
checking the vessels progress by looking at the chart and the map overlaid on the ARPA display.
According to the Master, the GPS and ARPA display was showing that the vessel was within 200 metres
of its intended track. The Master then left the bridge. According to the testimony of both the Master
and the Second Officer, no one told the Master about the yellow and red lights that the Lookouts had
sighted.
The Master testified that at approximately 21:45, he telephoned the bridge and asked the Second
Officer whether he had seen the BB buoy. The Master stated that the Second Officer told him that he
had seen it.
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According to the Master, about 22:00 he arrived on the bridge for the second time during that watch.
He testified that after talking with the Second Officer for several minutes, he checked the vessels
progress by looking at the positions plotted on the chart and at the map overlay on the ARPA display.
He stated that he again asked the Second Officer whether he had seen the BB buoy and the Second
Officer replied that he had. Satisfied that the positions plotted on the chart and that the map display
on the radar continued to show the vessel to be following its intended track, the Master left the bridge
at approximately 22:10.
He stated that he did not verify the vessels position using either the GPS or the Loran-C for two reasons:
1. His Officers had reported that the BA and the BB buoys had been sighted.
2. He had observed that the map overlay on the ARPA display showed that the vessel was
following its intended track.
The Second Officer testified that he had not seen the BB buoy but had informed the Master otherwise
because he had checked the GPS and was on track and because perhaps the radar did not reflect
the buoy. He also testified that on the previous two transits of the traffic lanes, he had sighted buoys
both visually and by radar.
According to the testimony of the Lookouts, a few minutes after the Master left the bridge, the port
Lookout reported to the Second Officer the sighting of blue and white water dead ahead. According
to this Lookout, the Second Officer acknowledged receiving the information, but did not discuss it or
take any action.
The port Lookout stated that the vessel later passed through the area where the blue and white water
had been sighted.
The Second Officer testified that at approximately 22:20, the Royal Majesty unexpectedly veered to
port and then sharply to starboard and healed to port.
The Second Officer stated that because he was alarmed and did not know why the vessel was veering
off course, he immediately switched from autopilot to manual steering. The Master, who was working
at his desk in his office, felt the vessel heal to port and ran to the bridge.
He stated that when he arrived on the bridge, he saw the Second Officer steering the ship manually
and instructed one of the Lookouts to take over the helm.
The Master then turned on the starboard radar, set it on the 12 mile range, and observed that Nuntucket
was less than 10 miles away.
According to the Master he immediately went into the chart room to verify the position. He stated
that he then immediately ordered the Helmsman to apply hard right rudder. However, before the
Helmsman could respond, the vessel grounded at 22:25.
The Master stated that he then had the vessels GPS and Loran-C checked and realised for the first time
that the GPS position data was in error by at least 15 miles. The Loran-C position data showed that
the vessel had grounded at approximately one mile south of Rose and Crown Shoal. Charts of the area
indicate that the shoal, which is approximately 10 miles east of Nantuckets Sankaty head light, has a
hard sandy bottom.
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Royal Majesty Case
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MCRM Case Study 11: Arahura
MCRM Case STUDY 11: Arahura

Engine room case: December 14th 2004: M/S Arahura experiences limited manoeuvrability due to
sensor malfunctions.
On the afternoon of December 14th 2004, RoRo passenger ship Arahura departed Picton for Wellington,
via the Tory Channel.
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Arahura Case
Arahura had experienced technical earth faults on the CSI1 alarm and monitoring system over a period
of six months. One of the functions of this system was to monitor the sensor information outputs from
the PEs, which supplied electrical power to the four PMs.
The sensors supplied the following information to the alarm and monitoring panel: (see above):

Engine temperatures - exhaust, lube oil, fuel oil, turbo and fresh water cooling.
Engine revolutions.
Engine pressures - lube oil, turbo, fuel and cooling water.
The sensor information was compared with the manufacturers preset alarm values to ensure the
vessels running machinery remained within the manufacturers specifications. If a breach of these preset values occurred, the system was designed to alarm and alert the duty Watch Keeper.
On previous voyages, a number of earth faults were identified in the alarm systems, which included the
main engine RPM2 signal.
On instructions from the Owner, a shore based Electrical Contractor was instructed to trace and isolate
the earth faults. The Contractor was experienced, fully trained, and qualified for the electrical system
on Arahura.
On December 14th, a shore based Electrical Contractor boarded Arahura at Wellington. After reporting
to the Chief Engineer, he completed a permit to work, as per the Company Safety Manual.
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Case Studies
The Contractor commenced work on the CSI3 alarm system in the engine control room, which was
situated in the forward engine room. He traced an earth fault leading to PM 2 RPM signal. There were
no technical or mechanical problems with the running machinery during this time. The Contractor
ceased work shortly before the vessel arrived at Picton.
When Arahura left Picton, three of the four PEs were operating namely numbers 1, 3 and 4. Of the four
propulsion motors, PMs 1, 2 and 3 were running and No. 4 was shut down.
The Contractor, who was in the engine control room, started to isolate what he believed to be the part
of the alarm system to PM 2 RPM sensor. At approximately 14:20 hours, whilst the Contractor was still
working on the CSI alarm systems, the Engine Room Watch Keeping Officer (EO) in the engine control
room, was alerted by the PE 4 over speed shut down alarm sounding. The EO was aware the Contractor
was working on the alarm panel and verbally reported the alarm to him.
The Contractor realised the two wires he had just removed from the alarm system must have been
monitoring PE 4 and not PE 2. He reconnected the wires.
However, the over-speed alarm indicator for PE 4 continued to sound whilst the engine remained
running still on load. However, PEs 1 and 3 came off load and shut down leaving PE 4 on load by
itself. The reason for this was unknown. PMs 2 and 3 then stopped, leaving only PM 1 running on the
port shaft. At about 14:23 hours, the EO contacted the bridge by telephone and told them that all
propulsion drive had been lost. When he realised, after looking at the power distribution board, that
PM 1 was still running, he immediately told the bridge.
The Master activated the bridge emergency procedures checklist as follows:

14:24 Hours - Emergency contingency plans activated.

14:27 Hours - Anchors cleared.
14:29 Hours - Navigational warning sent to all vessels.
The Master considered the following in consultation with the Bridge Team:

Taking all way off the vessel and anchoring or,

Continuing on voyage through the eastern entrance of Tory Channel.
The Master decided to continue on the voyage, having taken account of the following:

Prevailing weather conditions.

Tidal influence.
Other traffic.
Previous experience of manoeuvring when operating on only one shaft.
The Chief Engineer (CE) proceeded to the engine control room after being told what had happened. At
this stage, only PE 4 and PM1 were running.
At approximately 14:30 hours, the CE, EO, and Electrical Officer re-started PE 2 and put it on load. At
the Masters request, power was supplied to the bow thrusters to assist in manoeuvring the vessel, if
required. At approximately 14:35 hours, PM 3 was started, which supplied power to the port shaft and
was put on load. Subsequently, the engine room informed the bridge that they had two motors on the
port shaft. PEs 1 and 3 were then started and put on load. Attempts to start PM 2 failed.
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At approximately 14:43 hours, Arahura cleared the Tory Channel. She was still operating on only the
port shaft but with both PMs in operation.
At approximately 15:05 hours, PM2 was started. The bridge was told they now had one motor on
the starboard shaft. Power to the bow thrusters was switched off at this time. Arahura continued to
Wellington without further incident.
At approximately 15:10 hours, the Master told the Duty Manager about the incident. The owner
company then notified Maritime New Zealand.
Other Information
Technical
The Electrical Contractor was working on the CSI alarm system to PE 2. When the EO
informed the contractor that an over speed alarm had sounded for PE 4 the Contractor
realised he had mistakenly removed the RPM monitoring wires for PE 4.
PEs 1 and 3 shut down after the wires were removed from PE 4. As the Contractor had
ascertained that earth faults existed in the RPM sensors, it is probable that the removal of
these wires caused an electrical spike. This then caused the voltage to rise high enough to
trigger an over speed shut down of the three operating propulsion engines. This was the
conclusion reached by the Contractor.
When in port, the engine room team tried to replicate the fault using the same engine
configuration at the time of the incident. The same two wires were removed from the RPM
sensor to PE 4. The alarm activated as expected on the CSI alarm panel. However, engine shut
down did not occur. The only factor that was different was that the engines were not running
on load.
Schedule
Arahura has limited lay over periods due to her operating schedule. Onboard Senior Engineering
Officers felt that they had inadequate time during lay over periods for planned, advanced maintenance.
Work was therefore being done during a passage in enclosed waters, which affected or could affect the
propulsion of the ship, no matter how remote.
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Case Studies
MCRM Case Study 12: Viking Wanderer
MCRM Case STUDY 12: Viking Wanderer

Accident onboard Offshore Supply Vessel Viking Wanderer in 2003
This accident happened in a large compartment on the Viking Wanderer, an Offshore Supply Vessel
(OSV). (Note; An OSV is a vessel that carries supplies to offshore platforms and rigs drilling for oil and
gas in the oceans, such as the waters of the Gulf of Mexico).
The Viking usually carries most of the supplies as deck cargo, but drilling mud and other chemicals are
carried below the cargo deck in a compartment designated as the Bulk Mud Room, which is some 60
feet long.
In the Vikings Bulk Mud Room compartment some 20 large pressurized cylindrical tanks measuring 15
to 18 ft. in diameter and 10 to 12 ft. in height were permanently installed to carry the chemicals. This
meant that although the compartment was large, it was pretty well occupied by the tanks, piping and
structures.
On the Viking the Bulk Mud Room was normally accessed through watertight doors located at the
forward end, where the Crew quarters were located, and at the after end where the engine compartment
was located. The watertight doors were normally kept closed for safety reasons in case of hull damage
and flooding.
Viking had two narrow walkways constructed inside the Bulk Mud Room, one port and one starboard,
to reach the engine compartment from the Crew quarters, since the Bulk Mud compartment normally
did not have a toxic, or explosive, or asphyxiating atmosphere.
But, because the watertight doors were normally closed, two small blowers (one port and one
starboard) had been installed so the compartment received some outside air creating positive pressure
ventilation.
The Chief Mate decided to order a Crewmember to spray paint the overhead area of the Bulk Mud
Room, while the vessel was tied to the dock.
Since it was known that toxic fumes would be generated by the spray paint, in an effort to remove
the paint fumes, the rotation of the two small blowers was reversed creating a negative pressure
ventilation rather than a positive pressure ventilation, which is the preferred method of ventilation.
The Crewman assigned to perform the spray paint job was provided with a respirator, but didnt
perform any fit testing procedure for tight-fitting respirators. In order to reach the overhead areas to
be spray painted, a 6-ft. aluminum type III stepladder was also provided to fit in the narrow walkway.
The ladder had several permanent deformations on the rails and the spreader, and was rated light duty,
200 lbs. working load.
After some 10 minutes of spray painting the Seaman collapsed from the ladder due to the toxic fumes
and fell in the bilges and sustained major injuries. There were no witnesses to the fall.
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MCRM Case Study 13: Crown Princess
MCRM Case STUDY 13: crown princess

Accident Narrative
At 14:06 on July 18th, 2006, the Bermuda-registered cruise ship M/V Crown Princess, operated by
Princess Cruises, departed Port Canaveral, Florida, for Brooklyn, New York, on the last leg of a 10-day
round-trip voyage to the Caribbean. It was the vessels fourth voyage after being christened in Brooklyn
on June 14th. A total of 4,545 persons were on board - 3,285 passengers and 1,260 Crewmembers. A
Florida state harbour Pilot had the conn - that is, was in control of the ships movement. The ships
Captain, Staff Captain (second in command on Princess Cruises vessels), Relief Captain, Second
Officer, two Fourth Officers, and two Helmsmen were also on the bridge. According to the Captain,
the wind was light, the sky was clearing, visibility was good, and the sea state was slight as they left
Port Canaveral.
At 14:37, according to the ships log, the Pilot left the bridge, disembarking soon afterwards, and the
Captain assumed the conn. The Captain then began increasing the ships speed in increments of 10
propeller revolutions per minute.
At 14:56, as recorded on the vessels VDR, the Captain told the Chief Engineer, We want to go as fast
as we can for the time being, for the weather. The Staff Captain told investigators that the Captain
was hoping to get ahead of a developing storm along the vessels route. Around the same time, the
Captain shifted control of the engines to the engine-room. The Chief Engineer, now in direct control of
the vessels propulsion system, continued to increase the ships speed. From the dock to a point beyond
where the Pilot disembarked, the bridge Crew controlled the vessels steering manually.
At 15:01, on orders from the Captain, the Crew engaged the trackpilot, the autopilot function of the
vessels integrated navigation system (INS). The INS on the Crown Princess was a NACOS (Navigation
and Command System) manufactured by SAM Electronics of Hamburg, Germany. The Crew set the
course to 100 in heading mode, one of three available steering modes in the trackpilot. According to
the ships log, the seas were calm and there was a gentle breeze from the northeast. Shortly after the
course was set, the Captain noticed that the vessels heading was fluctuating, and he reviewed the
trackpilot settings (table 1). According to the Second Officer, the course fluctuations were causing
quite an excessive rate of turn. The Second Officer said that he asked the Captain, Would you like to
go back into hand steering? and the Captain said, No, Ive got the conn.
At 15:05:06, during the second heading fluctuation, when the rate of turn reached 9 per minute, the
trackpilots rudder limit alarm sounded. According to the operating instructions for the NACOS, the
rudder limit alarm indicates the following:
The set rudder limit value has been reached; with this rudder limit, the manoeuvre cannot be performed
without a deviation, or, the present rudder angle lies outside the rudder limit. Remedy:

Increase the rudder limit,

Wait until the rudder angle becomes less than the rudder limit, or
Switch over to manual steering.
After the alarm sounded, the Captain called the Staff Captain over and said,
Were wandering all over the place . . . we put her into NACOS-1. 12 At 15:06:09, the Captain said, At
the moment she is not responding other than 10 degrees at a time. At 15:06:27, the rudder limit alarm
sounded again. The staff Captain checked the INS settings. He told investigators that the rudder limit
was set at 5. VDR data show that the vessels speed was about 19 knots at the time. At approximately
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15:07, the Staff Captain increased the rudder limit from 5 to 10. The Staff Captain later explained to
investigators:
. . . you exceed this alarm of too much [rudder] and with basically 5 degrees [of rudder limit] set, the
ship cannot go back on track within a certain time . . . so I intervened with the Captain still having the
conn and increased the rudder limit up to 10 and . . . we regained the intended heading that he wanted.
The Staff Captain further explained:
To increase the rudder limit, it doesnt really mean . . . that the system will apply 10 degrees of rudder.
Normally, that gives us more allowance and a little bit of a faster response but, of course, it doesnt
mean that by setting the [rudder] limit that the limit is used constantly. The limit is only there if there
is a need for using it by the system. Since you are in heading mode, it doesnt really make a difference
because this applies only when you move from heading or course mode down to track mode.
The Staff Captain added that he was not aware of guidance from the cruise line or the manufacturer on
when to change the rudder limit.
At 15:08, the rudder limit alarm sounded again. At 15:13, the vessel began a turn to port to intersect
the first plotted track to New York. The course change, from a heading of 100 to a heading of 040,
was executed through several small adjustments to the autopilots set heading. The vessels speed had
now reached 20 knots. The Captain directed the Second Officer: Stay in that turn . . . OK, well run like
that. The Captain then asked the Second Officer for the heading of the next navigation track.
At 15:18:14, the Captain turned the conn over to the Second Officer. At approximately 15:19, the
vessels heading again began to fluctuate around the set heading. The Captain, Relief Captain and Staff
Captain left the bridge at 15:22.
At approximately 15:23, the vessel reached a turn rate of about 10 per minute to starboard. The turn
then shifted to port, and the rate of turn reached nearly 20 per minute. The rate-of-turn indicator
displayed red for turns to port and green for turns to starboard. The indicator did not show turn rates
beyond 30 per minute in either direction, although a turn rate of any size was displayed digitally next
to the indicator. The Second Officer told investigators that shortly after he took the conn, the rate-ofturn indicator was a bright red colour and my eyes were instantly drawn to it.
At 15:24, the Second Officer disengaged the trackpilot and, because he was closer to the wheel than
either of the Helmsmen, he took manual control of the steering.
The Second Officer told investigators, I just saw the rate of turn and instinct took over, I thought
. . . were going to be swinging to port really fast here and Ive got to get hand steering . . . [to] try
to stop the swinging. VDR data show that for about a minute after disengaging the trackpilot, the
Second Officer repeatedly turned the wheel back and forth between port and starboard (table 2). VDR
data also shows that after the Second Officer disengaged the trackpilot, the speed at which he moved
the wheel exceeded the rudders ability to respond to his commands. Thus, the rudders lagged the
wheel inputs. The vessels response lagged the steering inputs even farther. The Second Officer first
turned the wheel to port 10. He told investigators that he had meant to turn to starboard, but instead
went to port. He was unable to explain his action. Eight seconds after turning to port, he turned the
wheel to starboard 10. The Fourth Officer on watch immediately alerted the Second Officer that the
rudders were at port 10. (Although the Second Officer had already turned the wheel to starboard, the
rudders required several seconds to respond.) The Second Officer acknowledged the Fourth Officers
statement, saying, Yeah, I am coming over to starboard, but he then turned the wheel to port 30.
Several seconds after being reminded, You are at port 10, and after again telling the Fourth Officer
that he was coming over, the Second Officer turned the wheel to starboard 10. The VDR recorded
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numerous audio alerts around this time, along with the sound of objects falling to the bridge deck. The
Second Officer told investigators, Ive never seen a ship lean over that far before.
He further stated,
I dont remember just moving the wheel around and I cant say which way I was doing it and how
much I was doing it because by then, the ship was leaning over so much that I was just basically trying
to do anything that I thought was going to assist in getting the ship upright.
The Captain, Staff Captain, and Relief Captain ran to the bridge, arriving over a period of several
seconds. The Relief Captain, who arrived first, ordered, Reduce the speed, reduce the speed. Two
seconds later, the Second Officer turned the wheel to starboard 30, followed four seconds later by
a turn to port 35. The Second Officer then pulled back on the throttle, ordered zero revolutions per
minute, and turned the wheel to port 45. 10 seconds later the Captain ordered, Stop the engines,
stop the engines, stop the engines. By that time, the wheel had been turned to midships and the Staff
Captain had arrived.
At approximately 15:25, the vessel reached a maximum angle of heel of about 24 to starboard. At
the same time, the vessels rate of turn reached a maximum of 80 per minute. Immediately after the
vessel reached its maximum heel, the Staff Captain turned the wheel hard to starboard.
All audible warnings ceased at 15:26:20, and the vessel returned to even keel at approximately 15:27.
By then, its speed had slowed to 12 knots.
Princess Cruises, like other cruise lines, employed dedicated observers on both bridge wings to monitor
the balconies for fire. After the accident, the Captain asked the observers whether they had noticed
any passengers or crewmembers fall overboard. They told him that they had not. The Captain decided
against mustering the passengers because of the information from the observers and his sense that the
passengers were in shock as a result of the accident.
Responses to a Safety Board questionnaire, which was sent to most passengers who were evacuated
to hospitals and 200 other passengers selected at random, describe the passengers reactions to the
ships sudden heeling. Passengers in cabins saw televisions fall from their bases and tables and chairs
move rapidly about the cabins, while those in public areas observed similar occurrences for both light
and heavy objects. A 54-year-old man who was entering the buffet on the fifteenth deck wrote:
They had reset the tables for dinner with wineglasses and china. The ship began to list to the starboard.
The glasses and plates began to slide off the tables and I saw my sister-in-law fly off her chair. I fell off
my chair, [I] tried [to] grab my wife and slid across the room. My sister-in-law seriously injured her hand
and was taken off by ambulance. My son jumped off his bunk bed and hurt his knee. I was scraped and
hurt my hamstring.
During the accident, water, people, and objects spilled out of the ships swimming pools. A 44-year-old
woman, who was near one of the pools at the time of the accident, reported:
I first realised something was wrong when I felt the boat tilt and it was uncomfortable to stand upright.
We (my husband and I) noticed the water slowly coming out of the pool and drinks on tables falling. A
second tilt occurred and we moved quickly towards the railing for support, and watched [as] a small
wave of water, people, and belongings moved out towards the starboard side. The tilting stopped for
a few seconds and then a much greater tilt occurred with a large wave [spilling] out knocking over
people, chairs, tables, and miscellaneous belongings.
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The Captain made several announcements over the vessels public address system after the event.
Following the first announcement, he asked the senior physician on the vessel about the condition
of any injured passengers. She recommended, and he agreed, to return to port to enable those who
needed more extensive medical treatment than available on the ship to be taken to hospitals.
The Crown Princess returned to Port Canaveral and docked with gangways down at 18:36.
The Crown Princess was returning to New York from a Caribbean cruise with ports of call at Grand Turk
Island, Ocho Rios, Jamaica, and Grand Cayman Island when it heeled about 10 nautical miles east of Port
Canaveral, Florida. Inset shows the ships track from Port Canaveral to the accident site. Water in the area
was relatively shallow, about 26 feet below the vessels keel.
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Table 1: Sequence of events while the trackpilot was engaged:

Time Event
15:01
Crew shifts steering from manual to track pilot.
15:03
Captain notices heading fluctuations.
15:05:06 Track pilot rudder limit alarm sounds.
15:05:38
Captain: Were wandering all over the place.
15:06:09
Captain: At the moment she is not responding other than 10 degrees at a time.
15:06:27 Rudder limit alarm sounds.
15:07:07
Staff Captain increases rudder limit to 10.
15:08:00 Rudder limit alarm sounds.
15:12
Staff Captain: Is it okay now? Captain: No.
15:13
Staff Captain discusses track pilot settings with the Captain.
15:13 New course input to trackpilot, vessel begins turn to port
15:14:33
Captain: Stay in that turn . . . OK, well run like that.
15:18:14
Captain to the Second Officer: Okay, you got the conn.
15:22 Heading approaches ordered course of 040, again begins to fluctuate.
15:22
Captain and Staff Captain leave the bridge.
15:23 Relief Captain leaves the bridge.
Trackpilot display on the Crown Princess. The rate-of-turn indicator is at the top, abbreviated ROT. The
highest rate of turn displayed in either direction on that indicator was 30 per minute.
55

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Maritime Crew Resource Management

For Training Purposes Only 2010

Case Study Introduction

Case Study Guidelines

MCRM Case STUDY 1: Cosco Busan

Cosco Busan Case

MCRM Case STUDY 2: Maersk Kithira

Maersk Kithira Case

MCRM Case STUDY 3: Moondance

MCRM Case STUDY 4: Mv balduin

MCRM Case STUDY 5: Figaro/camargue

MCRM Case STUDY 6: tor scandinavia

Tor Scandinavia Case

MCRM Case STUDY 7: Torrey Canyon

Torrey Canyon Case

MCRM Case STUDY 8: Thuntank 5

MCRM Case STUDY 9: malinska

History of the Voyage

Composition of the Bridge Watch

Assessment of the Position of the Vessel

MCRM Case STUDY 10: Royal Majesty

Royal Majesty Case

MCRM Case STUDY 11: Arahura

14:24 Hours - Emergency contingency plans activated.

Taking all way off the vessel and anchoring or,

Prevailing weather conditions.

MCRM Case STUDY 12: Viking Wanderer

MCRM Case STUDY 13: crown princess

Increase the rudder limit,

Table 1: Sequence of events while the trackpilot was engaged:

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