- The Washington Times - Thursday, January 10, 2008

A wrong turn is chiefly to blame for causing a Caribbean cruise ship bound for New York to suddenly tilt, injuring hundreds of terrified passengers who were sent crashing about the ship 10 miles off the Florida coast in 2006, federal safety officials said today.

National Transportation Safety Board officials said the second officer aboard the Crown Princess cruise ship on July 18 turned too sharply in the wrong direction, while trying to correct an unexplained high turn rate when the ship was on autopilot.

The ship, one of the largest cruise liners in the industry, was making its fourth-ever voyage, leaving Port Canaveral, Fla., for New York on the last leg of a Caribbean cruise.

As the ship turned north toward the open waters of the Atlantic Ocean, the crew’s second officer turned off the autopilot system and took over manual control, according to the NTSB.

The move, meant to stabilize the ship, actually made things far worse. By turning too sharp to port, the ship tilted 24 degrees, causing 298 passengers to be tossed about and struck by chairs, tables, trash cans and any other unsecured objects.

A tilt of more than 10 degrees is considered severe, though the Crown Princess wasnt ever in danger of toppling, NTSB officials said. Still, the turn caused a “catastrophic effect,” said NTSB chairman Mark V. Rosenker at the board’s meeting in the District. An unidentified 54-year-old attorney told the NTSB that he was on the 15th floor of the ship at the buffet when it began to list. Glasses and plates slipped off of tables and smashed, transcripts show. “I saw my sister-in-law fly off her chair. I fell off my chair, tried (to) grab my wife and slid across the room,” he recalled. But NTSB officials also faulted the ship’s captain and staff captain for turning the ship’s controls over the second officer too soon, after they had noticed problems with fluctuations in the ship’s heading, NTSB officials found. In NTSB transcripts, the second officer said he was sweeping the horizon with binoculars shortly after the captain turned the ship over to him. When he came back around to the control console, he saw a sensor screen showing the ship was turning too much to port. “Man on the wheel,” he shouted. He turned off the autopilot and manually steered the ship to correct the problem, a decision the NTSB said was likely correct. However, he then turned in the wrong direction. Later, the second officer told investigators he regretted the mistake, but couldn’t say why he made it. “I went to port. I turned the wheel to port, which was my mistake. I meant to go to starboard with the ship sheering off to port I need to go to starboard, but I went to port,” he said. NTSB board member Deborah A. P. Hersman theorized that “stress of the moment” played a role. Before the sharp turn, the ship’s captain and staff captain also misunderstood the real reason for why the cruise liner was experiencing heading fluctuations while on autopilot, the NTSB found. Investigators said the ships was traveling quickly in shallow waters. The faster a ship in shallow water, the less responsive its rudder, officials said. But the ship’s officers thought the heading problem instead had something to do with its automation system, according to investigators. What’s more, officials also discovered a problem with the ship’s rudder economy setting. Set according to a five-point system, with one for calm seas and five for rough seas, the economy setting was set to the maximum of five, even though the seas were relatively calm, officials said. The NTSB said Princess Cruises, which operates the ship, made changes to fix several of the concerns that they found during the 18-month investigation. Among the moves by the company was increased mandatory training and the hiring of a former NTSB official to run its investigations department, officials said. Today, the company issued a statement saying the “isolated incident was the unfortunate result of human error, and we again apologize to all our passengers and crew who were injured or frightened by the unexpected listing of the ship.” “During the past year and a half since the incident, we have introduced many measures designed to keep a similar situation from occurring,” the company said. The measures included enhanced training for deck officers “with an emphasis on Integrated Navigation Systems, strengthened professional standards and oversight for our deck officers,” the company said. In addition, the company said it now has enhanced emergency response and training, including new procedures to quickly account for passengers and crew. Reviews were mixed among passengers about the crew’s immediate response to the accident, though the NTSB said the captain “acted appropriately” and the crew “responded effectively.” The ship turned back to port after the accident. The ship was never in danger of toppling into the water, but the tilt was enough to send passengers and any loose objects tumbling. One woman told an NTSB investigator that she was on an open deck sitting on a lawn chair when the cruise ship tilted 28-degrees. Holding onto a railing, she considered jumping because she thought the ship might keep going over. Though the NTSB said the ship tilted 24 degrees, Princess officials said they thought it was closer to 18 degrees, according to the NTSB, which said it had confidence in its own calculations. A ship doctor told an NTSB investigator he was resting when he felt the ship tilt and saw water above his window. He went to the ship’s medical center, where he saw the first of the injured passengers. The treatment room was dark, the examination table on its side and water was pouring onto the floor. For the first 15 minutes, he and two nurses had to attend to more than 50 patients before more medical personnel, including several passengers, helped treat the injured. Later, he said the ship’s medical center isn’t meant to handle 300 patients, which he said would overrun a small-town hospital. The doctor also said he immediately thought there would be injuries because he experienced a similar situation on another cruise liner months earlier. NTSB officials said “keeling” events are rare and that the cruise industry is safe, though some board members questioned how frequently tilt because of a lack of reporting on such incidents. Among the recommendations of the board were mandatory training on integrated navigation system and greater awareness about the dangers of keeling when traveling fast in shallow water.

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