ACCIDENT REPORT

NTSB/mAR-08/02

Nationa PB2008-916402 l

Transportation

Safety Board

marine

Grounding of U.S. Passenger Vessel 

Empress of the North

Intersection of Lynn Canal and Icy Strait

Southeast Alaska

May 14, 2007

National

Transportation

Safety Board

Marine Accident Report

Grounding of U.S. Passenger Vessel 

Empress of the North

Intersection of Lynn Canal and Icy Strait

Southeast Alaska

May 14, 2007

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

NTSB/MAR-08/02

PB2008-916402

Notation 7907D 

Adopted November 4, 2008
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Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

National Transportation Safety Board. 2008. Grounding of U.S. Passenger Vessel Empress of the North,

Intersection of Lynn Canal and Icy Strait, Southeast Alaska, May 14, 2007. Marine Accident Report 

NTSB/MAR-08/02. Washington, DC.

Abstract: This report discusses the May 14, 2007, accident in which the passenger vessel Empress of 

the North grounded on Rocky Island, about 20 miles southwest of Juneau. The vessel was carrying 206 

passengers and 75 crewmembers on a cruise through Alaska’s Inland Passage. The junior third mate, a 

newly licensed officer, was on his first navigation watch at the time of the accident. The U.S. Coast Guard 

and good Samaritan vessels evacuated passengers and crewmembers and transported them back to 

Juneau. No injuries or pollution resulted from the accident. The cost of repairing the vessel and returning 

it to service was estimated at $4.8 million. 

The National Transportation Safety Board identified the following safety issues as a result of its accident 

investigation: the master’s decision to put an inexperienced third mate on watch without supervision 

or guidance; the junior third mate’s actions; watchkeeping procedures; documentation deficiencies; and 

malfunctioning lifesaving devices.

As a result of its investigation, the Safety Board made recommendations to the U.S. state and Federal 

maritime academies and to the Passenger Vessel Association. Earlier recommendations were made to 

the Coast Guard.
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Contents

Acronyms and Abbreviations....................................................................................... v

Executive Summary ....................................................................................................... vi

Factual Information .........................................................................................................1

Accident Narrative..................................................................................................................1

Injuries.....................................................................................................................................11

Damages .................................................................................................................................11

Personnel Information..........................................................................................................11

Regulatory Requirements................................................................................................11

Master.................................................................................................................................12

Chief Mate..........................................................................................................................13

Second Mate ......................................................................................................................13

Senior Third Mate.............................................................................................................14

Junior Third Mate .............................................................................................................15

Able-Bodied Seaman .......................................................................................................16

Chief Engineer...................................................................................................................17

Vessel Information ................................................................................................................17

Construction and Equipment .........................................................................................17

Propulsion and Associated Engineering Equipment..................................................18

Bridge Equipment.............................................................................................................19

Certification and Inspection............................................................................................21

Emergency Equipment ....................................................................................................24

Wreckage ................................................................................................................................27

Damage Assessment ........................................................................................................27

Vessel Stability .................................................................................................................31

Waterway Information .........................................................................................................32

Meteorological Information.................................................................................................33

Toxicological Testing ............................................................................................................33

Survival Aspects ....................................................................................................................34

On-Scene Emergency Response .....................................................................................34

Coast Guard Response.....................................................................................................36

Shoreside Emergency Response.....................................................................................38

Tests and Research ................................................................................................................38

Voyage Data Recorder.....................................................................................................38

Lifesaving Equipment .....................................................................................................39

Operational and Management Information .....................................................................42

Corporate Organization...................................................................................................42

Safety Management System............................................................................................43

Previous Accidents...........................................................................................................44

Additional Information ........................................................................................................46

Majestic America Line Actions Since the Accident .....................................................46
Contents

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Safety Board Actions Since the Accident ......................................................................49

Coast Guard Actions Since the Accident ......................................................................50

Other Actions Since the Accident...................................................................................51

U.S. Maritime Academies................................................................................................52

Analysis............................................................................................................................53

General....................................................................................................................................53

Exclusions ...............................................................................................................................53

Accident..................................................................................................................................54

Master’s Decision to Put Inexperienced Third Mate on Watch......................................54

Junior Third Mate’s Actions.................................................................................................58

Watchkeeping Procedures ...................................................................................................60

Documentation Deficiencies ................................................................................................63

Crew Certification ............................................................................................................64

Vessel Certification...........................................................................................................64

Survival Factors .....................................................................................................................65

Emergency Response ......................................................................................................65

Lifesaving Equipment......................................................................................................67

Conclusions.....................................................................................................................70

Findings ..................................................................................................................................70

Probable Cause ......................................................................................................................71

Recommendations..........................................................................................................72

New Recommendations .......................................................................................................72

Previously Issued Recommendation Resulting From This Accident Investigation....72

Previously Issued Recommendation Classified in This Report......................................73

Appendixes

A: Investigation ....................................................................................................................77

B: Voyage Plan..........................................................................................................78

C: Standing Orders ..............................................................................................................79

D: Excerpt from Bridge Audio Recording........................................................................81

E: Vessel Data Recorded Immediately Before Accident...............................................92

F: Contents Pages from Company’s New Safety Management Manual ...................93

Contents
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Acronyms and Abbreviations

AB able-bodied seaman

ACG Ambassadors Cruise Group

AIS automatic identification system 

ARPA automatic radar plotting aid

CFR Code of Federal Regulations

COI certificate of inspection

ECDIS electronic chart display and information system

GPS global positioning system

IBA inflatable buoyant apparatus

ICR inspection criteria reference

IEC International Electrotechnical Commission

ISM International Safety Management 

NMEA National Marine Electronics Association

NVIC navigation and vessel inspection circular

OCMI officer in charge, marine inspection

SOLAS International Convention for the Safety of Life at Sea

STCW Seafarer’s Training, Certification, and Watchkeeping 

VDR voyage data recorder

VHF very high frequency
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Executive Summary

About 0130 on Monday, May 14, 2007, the 300-foot passenger vessel Empress 

of the North, operated by Majestic America Line, grounded on a charted rock at the 

intersection of Lynn Canal and Icy Strait in southeastern Alaska, about 20 miles 

southwest of Juneau. The vessel was negotiating a turn west out of Lynn Canal into 

Icy Strait on its way to Glacier Bay, the next stop on a 7-day cruise, carrying 206 

passengers and 75 crewmembers. The junior third mate, a newly licensed officer, 

was on his first navigation watch when the vessel struck the rock, known as Rocky 

Island, which was illuminated by a flashing green navigation light. The U.S. Coast 

Guard and several good Samaritan vessels assisted in evacuating the passengers 

and nonessential crewmembers and safely transporting them back to Juneau. No 

injuries or pollution resulted from the accident, but the vessel sustained significant 

damage to its starboard underside and propulsion system. 

The National Transportation Safety Board determines that the probable 

cause of the grounding of the Empress of the North was the failure of the officer 

of the watch and the helmsman to navigate the turn at Rocky Island, which 

resulted from the master’s decision to assign to the midnight-to-0400 watch an 

inexperienced, newly licensed deck officer who was not familiar with the route, 

the vessel’s handling characteristics, or the equipment on the vessel’s bridge. 

The Safety Board’s investigation of the accident identified the following 

safety issues:

• Master’s decision to put an inexperienced third mate on watch without 

supervision or guidance.

• Junior third mate’s actions.

• Watchkeeping procedures. 

• Documentation deficiencies.

• Malfunctioning lifesaving devices.

As a result of its investigation, the Safety Board makes recommendations 

to the U.S. state and Federal maritime academies and to the Passenger Vessel 

Association. Earlier recommendations were made to the Coast Guard.
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Factual Information

Accident Narrative

At 07101 on Sunday, May 13, 2007, the passenger vessel Empress of the North 

(figure 1), operated by Majestic America Line, arrived at Skagway, Alaska, on a 

7-day cruise of southeast Alaska that began in Juneau on May 12 and called at 

Skagway, Glacier Bay, and Sitka before returning to Juneau (figure 2). The cruise 

was the vessel’s first round-trip through Alaska’s Inland Passage of the 2007 season. 

The Empress of the North began the season with cruises on the Columbia, Willamette, 

and Snake rivers of Oregon and Washington, then was repositioned from Oregon to 

Juneau between April 28 and May 12. Passengers joined the “repositioning cruise” 

in Seattle on April 30 and disembarked in Juneau on May 12.

The Empress of the North was inspected and certificated by the U.S. Coast 

Guard under Title 46 Code of Federal Regulations (CFR) parts 70-89 (subchapter 

H). As a passenger vessel that traveled in international (Canadian) waters, it was 

also required to comply with certain standards of the International Maritime 

Organization,2

 including the 1974 International Convention for the Safety of Life at 

Sea (SOLAS), the International Safety Management (ISM) code,3

 and the Seafarer’s 

Training, Certification, and Watchkeeping (STCW) code.4

In Skagway, the crew tested gear5

 in preparation for the trip south toward 

Glacier Bay. No problems were found. At 1720 on May 13, the vessel departed 

Skagway under the command of a licensed master, carrying 206 passengers and 

a crew of 75. As listed on the crew manifest, the ship’s officers, in addition to the 

master, consisted of a chief mate, a second mate, two third mates, a chief engineer, 

a first engineer, a second engineer, and a third engineer. Among the unlicensed 

crew were five able-bodied seamen (ABs) and three deckhands.

One of the third mates had joined the crew the day before, the start of his 

first maritime job after graduating from the California Maritime Academy. The 

1 All times are Alaska daylight saving time according to the 24-hour clock.

2 The International Maritime Organization is a specialized agency of the United Nations.

3 The full name of the code is International Management Code for the Safe Operation of Ships and for 

Pollution Prevention. For more information, see “Safety Management System” subsection of “Operational 

Management Information” section, later in this report.

4 The STCW code is attached to the International Convention on Standards of Training, Certification, 

and Watchkeeping for Seafarers, as amended in 1995; it is incorporated in the Coast Guard regulations at 

46 CFR 10.205.

5 A marine term used to describe the required testing of propulsion, communications, steering, and other 

critical systems before a vessel’s departure from port.
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new, or junior, third mate’s employment-related activities between graduating 

and joining the crew of the Empress of the North were as follows: 

April 28 .........................Graduate from California Maritime Academy; 

receive Coast Guard third mate’s license

May 11............................Report for work at Majestic America Line offices in 

Portland, Oregon; sign employment papers

May 11............................Fly to Seattle, Washington

May 12............................Fly to Juneau, Alaska, to join Empress of the North

The company had arranged for the junior third mate to spend 7 days on 

the vessel before beginning a regular 4-week duty on May 19. The master told 

investigators that his plan for the junior third mate was to have him observe 

operations during his first 7 days, when his duty schedule would overlap that of the 

senior third mate. After that, the junior third mate would serve as a watchstander 

and the senior third mate would go off duty.

According to interviews, when the junior third mate came on board, he 

introduced himself, observed deck operations, and talked to the mates and other 

deck crewmembers. The junior third mate stood a port watch when the vessel was 

docked in Skagway, while the second mate conducted bridge tours for passengers. 

Figure 1. The Empress of the North under way in Auke Bay, Alaska. The newly constructed 

ship had four passenger decks and was designed to mimic Mississippi River paddle wheelers 

(the red paddle wheel is barely visible at the vessel’s stern). Passengers embarked and 

disembarked using the gangway at the bow, shown here in the raised position.
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Figure 2. Empress of the North accident site and other southeast Alaska locations 

referenced in the report. Inset shows the vessel’s path to its grounding on Rocky Island.
Factual Information

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On May 13, the senior third mate had the watch from midnight to 0400. During 

his watch, he experienced gastrointestinal distress and could not complete the duty. 

The chief mate relieved him. Later that morning, the vessel docked in Skagway, 

where a local physician examined the senior third mate and recommended that he 

remain isolated on the vessel and off duty until his condition improved. 

The chief mate told investigators that he informed the master later on the 

morning of May 13 about the senior third mate’s illness. He said that he did not 

discuss with the master replacing the ill third mate with the junior third mate. The 

master told investigators, however, that he briefly talked to the chief mate about 

replacing the ill third mate with the junior third mate, and that “the chief mate 

was in agreement.” According to the master, replacing the ill third mate on the 

midnight-to-0400 watch “wasn’t really a decision per se.” But he said, “I felt that it 

was an easy watch, so it was a good place to start.” He added that he considered 

the junior third mate “qualified for the assignment I gave him, for sure . . . by virtue 

of his training and by virtue of what he saw on the bridge.” The second mate told 

investigators that when he discussed with the master assigning the junior third 

mate to the watch, “We had agreed that it was an easy watch, much easier than 

[the] Snake River or the Columbia River, even, and one, two, three—three course 

changes, fairly easy.” The chief mate said that there was no discussion with the 

master about familiarizing the junior third mate with the route or the vessel before 

he was to take the watch. 

The junior third mate told investigators that the master told him that “due 

to the circumstance of the [other] mate being sick, that I would need to do that 

[stand watch].” The junior mate said, “ My understanding was he [the helmsman] 

would be in control of the boat, and I would be there because I have a license.” 

When asked whether he had felt ready to assume the watch, the junior third mate 

told investigators, 

I felt comfortable enough to be up there, and I knew that if . . . there was 

anything that . . . was out of the ordinary, I’d just give him [the master] a 

call, and that he would be there, but I never, did not attempt to do that.

The master switched the schedule of one of the ABs to allow him to serve 

as helmsman during the junior third mate’s first watch. The master described that 

AB as experienced in the local waterways and knowledgeable about the bridge 

equipment.6

 The master said that he assigned the most experienced AB to serve 

as helmsman with the junior third mate because he knew that the AB “would not 

withhold anything [and] would try to help him [the junior third mate] as best he 

can.” He described the AB as “a well-spoken, soft-spoken guy that . . . would be very 

unintimidating.” He also said that he knew the AB was familiar with the alarms on 

the bridge and could explain them to the junior third mate. The master said that he 

told the junior third mate that he, the master, would be available throughout the 

watch and that the junior third mate should not hesitate to call him with questions. 

6 The AB told investigators that he had traveled on the accident route only once before, and that was as 

ordinary seaman, not helmsman. His AB experience had been on the Empress of the North’s river routes.
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At 2323 on May 13, the junior third mate entered the bridge and met with the 

second mate, whom he was relieving as officer on watch, the AB on watch, and the 

relieving AB. The junior third mate and the second mate discussed the route, the 

vessel’s equipment, and other information relevant to watchkeeping. The bridge 

was equipped with a printed navigation chart for the area7

 and two electronic 

navigational charting systems—ECDIS (electronic chart display and information 

system) and Nobeltec.8 Also available to the watchstanders were a general voyage 

plan (appendix B) and the vessel’s standing orders (appendix C).9 The first entry 

on the voyage plan for the day of the accident states: “Security call for rounding 

Rocky Is, west bound,” at Point Couverden.10 The master left no night orders for 

the trip (orders to the night watchstanders including course changes, weather, 

speed, warnings of hazards, and so forth).11

The navigation charts showed two tracklines, one between Rocky Island 

and Point Couverden and the other south of Rocky Island (see “Bridge Equipment” 

section for details). According to both the master and the chief mate, the decision 

about which trackline to take was left to the officer of the watch. The waterway 

between Rocky Island and Point Couverden was about 0.5 mile wide. The second 

mate told investigators:

I showed him [the junior third mate] that if he followed the tracklines, 

he’d have no problem. He could either go south of Rocky Island, or in the 

Nobeltec and on the ECDIS, it has us actually going between—a half-mile 

between land [and the island]. On the Snake River, we have plenty of times 

where we’re [in passages] less than half a mile [wide]. Not a big deal, so I 

didn’t really think it was an issue. I told him that he needed to go south of 

the island if he didn’t feel comfortable, or he could go right down through 

the channel there. He didn’t tell me what he was going to do either way. 

He just nodded his head.

7 Lynn Canal: Icy Strait to Point Sherman, chart 17316, Coast Survey, United States, Alaska—Southeast 

Coast (Washington, DC: U.S. Department of Commerce, National Oceanic and Atmospheric Administration, 

2002; corrected through Notice to Mariners 35/05 and 44/06).

8 ECDIS and Nobeltec are electronic versions of navigation charts. They provide navigation information 

but do not direct a vessel along a particular route.

9 Standing orders are written instructions to the watch officer concerning responsibilities, duties to be 

performed, and precautions to be observed for safe vessel operation while on watch. As an ISM-compliant 

vessel, the Empress of the North was required to have a safety management system. The safety management 

system required masters to issue standing orders (Majestic America Line, Fleet Instructions: Empress of the 

North, subsection 1.9.1, “Standing Orders”) and gave a compilation of standing orders from various company 

vessels that masters were allowed to modify as necessary. The safety management system is described 

further in the “Operational and Management Information” section.

10 A security call is an informational message of a safety nature issued to all area vessels.

11 The company’s safety management system treated night orders as optional: “Night orders may be 

used to supplement Standing Orders” (Fleet Instructions, section 7.0, “Operations at Sea—Navigation,” 7.9, 

“Bridge Resource Management,” subsection 7.9.1, “Standing Orders”). Night orders came about because 

vessel masters cannot stay up 24 hours a day. The orders are generally kept in a night order book that 

watchstanders must sign before they go on watch. Investigators found that a total of seven night orders had 

been issued for the Empress of the North between the nights of February 18-19 and May 9-10. 
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The recordings from the bridge made by the vessel’s voyage data recorder 

(VDR)12 show that during the 20 minutes in which the second mate and the junior 

third mate were changing the watch, seven other crewmembers were either coming 

on the bridge or going off, including two crewmembers who had no duties on the 

bridge. At 2334, the two nonwatchstanding crewmembers entered the bridge and 

for about 10 minutes, according to the VDR record, engaged the mates and the AB 

in conversation not related to vessel navigation. The bridge watch standing orders 

for the Empress of the North stated, “While underway no visitors are to be allowed 

on the bridge that are not involved with the navigational watch,” in accordance 

with 46 CFR 78.10-1.13

While the nonwatchstanding crewmembers were on the bridge, the second 

mate and the junior third mate attempted to continue their discussion of navigation 

issues. The only navigation information they exchanged, as recorded by the VDR, 

was vessel position and track, when to take fixes, and vessel speed. The second mate 

also gave the junior third mate his room number and told him that he should feel free 

to call him during the watch and that he would be happy to answer any questions. 

The two nonwatchstanding crewmembers left the bridge at 2342. The 

second mate left the bridge at 2343, around the time the relief AB came on watch. 

The junior third mate began his watch with the relief AB serving as helmsman. 

Two other crewmembers, an AB and a deckhand, were serving as lookouts on the 

bridge but left about midnight for a scheduled hourly security round that lasted 

30 to 40 minutes. 

The vessel was traveling south at about 12 knots when the watch 

changed. The weather was cloudy and drizzly, and the helmsman was steering 

by autopilot (he stated that he used the autopilot throughout the voyage). Radar 

images captured by the vessel’s VDR show that the high-resolution X‐band radar 

(3-centimeter wavelength) was tuned to the 6-mile scale throughout the entire 

accident sequence.14

The standing orders for the Empress of the North stated, “All bridge watch 

officers shall have a thorough understanding of bridge equipment and electronics 

and their use.” During the voyage, the helmsman attempted to explain the autopilot 

and other bridge equipment to the junior third mate. After the accident, the junior 

third mate told investigators that he was unfamiliar with the bridge equipment 

and bridge procedures. 

12 VDRs, which are similar to the flight data and cockpit voice recorders carried on aircraft, continuously 

record audio data from the bridge in addition to maintaining continuous, sequential records of data items 

relating to a ship’s equipment.

13 Title 46 CFR 78.10-1 states: “Masters and pilots shall exclude from the pilothouse and navigation 

bridge while underway, all persons not connected with the navigation of the vessel.” The regulations allow 

others on the bridge, such as licensed officers of vessels, pilot trainees, and Coast Guard or Safety Board 

officials, “upon the responsibility of the master or pilot.” 

14 The vessel was also equipped with a long-range S-band radar (10-centimeter wavelength). The VDR 

did not capture images from that radar.
Factual Information

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In accordance with Coast Guard regulations, the company’s fleet 

instructions required watch officers to assure “an alert all-round visual and aural 

lookout.”15 At 0100, the AB and deckhand left the bridge on their second scheduled 

hourly security check, leaving the helmsman to serve as lookout while the vessel 

approached Rocky Island.16 According to the STCW code,17

The duties of the lookout and helmsperson are separate and the helmsperson 

shall not be considered to be the lookout while steering, except in small 

ships where an unobstructed all-around view is provided at the steering 

position and there is no impairment of night vision or other impediment to 

the keeping of a proper lookout.

About 0126, according to the VDR audio recording from the bridge, both 

the helmsman and the junior third mate saw the flashing green navigation light 

on Rocky Island.18 VDR radar data show that Rocky Island was about 0.9 mile 

away at that point. The navigation chart for the area indicates that the light, placed 

43 feet high on the island, flashes at 4-second intervals and is visible for 4 miles in 

clear weather. The VDR data indicate that although the vessel’s automatic radar 

plotting aid (ARPA) was turned on, the watchstanders did not use it to acquire the 

island as a radar contact (that is, to display its range and bearing).19

About 0127, according to VDR data, the helmsman began an 80° turn to 

the west that would take the vessel north of Rocky Island, between the island 

and Point Couverden. The junior third mate told investigators, “There wasn’t any 

conversation between him and I when he was going to turn. I relied on his expertise 

when to initiate it and how much [to] turn.” Sailing between Point Couverden and 

Rocky Island, rather than south of Rocky Island, would have saved an estimated 

6 minutes of travel time, according to the master. Both the junior third mate and the 

helmsman told investigators that the Empress of the North was not behind schedule 

and that neither had felt compelled to save time.

15 Majestic America Line, Fleet Instructions, section 7.0, “Operations at Sea—Navigation,” subsection 7.1, 

“Watchstanding Requirements and Duties of Watch Officers,” paragraph 1. The Coast Guard’s international 

and inland navigation rules state: “Every vessel shall at all times maintain a proper look-out by sight and 

hearing as well as by all available means appropriate to the prevailing circumstances and conditions so as to 

make a full appraisal of the situation and of the risk of collision” (U.S. Department of Transportation, United 

States Coast Guard, Navigation Rules: International—Inland, part B, “Steering and Sailing Rules,” section 1, 

“Conduct of Vessels in Any Condition of Visibility,” rule 5).

16 Coast Guard regulations at 46 CFR 78.30-5 state: “In addition to the licensed deck officer or pilot, there 

shall be at least one member of the crew also on watch in or near the pilothouse at all times while the vessel 

is being navigated.”

17 Section A-VIII/2, part 3-1, “Principles to be observed in keeping a navigational watch.” 

18 Appendix D contains a transcript of conversations recorded on the bridge from a few minutes before 

the accident until about 1/2 hour afterward. Appendix E shows plots of data recorded by the vessel’s VDR 

immediately before the accident, with conversations between the junior third mate and the helmsman 

superimposed. 

19 Fleet instructions for the Empress of the North (section 7.2, “Navigating and Maneuvering,” paragraph 

5) state: “When using radar, select an appropriate range scale and ensure that plotting or systematic analysis is 

commenced in ample time.” As noted earlier, the waterway was about 0.5 mile wide between Point Couverden 

and Rocky Island.
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After beginning the turn, the helmsman told the junior third mate that he 

did not think the vessel was turning fast enough. The master told investigators 

that the crew typically turned the vessel at 10° per minute, increasing a turn in 

increments of 10° per minute as needed. He said that if the vessel turned faster 

than 20° per minute, wineglasses would spill and, when it approached a turn rate 

of 30° per minute, the vessel would begin to heel unless the speed was very slow 

(“under about 5 kilometers” per hour). 

After the helmsman’s remark about the vessel not turning fast enough, the 

junior third mate said that he walked over and saw the helmsman increase the 

rate of turn. “At that point,” said the junior third mate, “I lost visual contact with 

the light,” that is, the flashing green light on Rocky Island he had seen earlier. The 

lookouts (the AB and the deckhand) were not on the bridge, and the bridge layout 

did not obstruct the light. After the accident, the Coast Guard surveyed the aids to 

navigation in the area, including the flashing light on Rocky Island, and reported 

that all were “watching properly.” 

About half a minute before the vessel grounded, VDR data show that the 

helmsman, without receiving a steering command from the junior third mate or 

announcing his intentions, altered the course to the left. The junior third mate 

walked to the starboard side to continue looking for the flashing light, saw rocks, 

and immediately gave the helmsman his first steering command, “Hard left.” 

About 0130, the vessel struck submerged rocks on its starboard side, then floated 

free. 

Within 15 seconds, the master arrived on the bridge from his quarters, 

where he had been sleeping, and began emergency action. He notified the Coast 

Guard in Juneau of the grounding20 and arranged to evacuate all passengers and 

nonessential crewmembers. Some of the vessel’s lifesaving equipment (evacuation 

slides and liferaft releases) failed to deploy properly, but the passengers and 

nonessential crewmembers, all wearing lifejackets, were safely transferred to 

other vessels in the vicinity (see “Survival Aspects” section for details). The master 

described weather conditions in a call to the Coast Guard as “zero wind . . . drizzle 

. . . it’s calm outside . . . seas and swell are slight, calm and a slight chop.”

The master learned that the hull had been breached because the vessel began 

listing to starboard during the first hour after the grounding. He ordered the chief 

engineer and other crew to check the belowdeck spaces for flooding. Because there 

was no flooding in the interior of the vessel, the master said he that thought he had 

holed an underdeck void that stretched across the beam of the ship, and that as it 

filled with water, the vessel would level out. The engineers continued to monitor 

belowdeck spaces for signs of flooding throughout the evacuation of passengers 

and nonessential crewmembers, which was completed at 0521. 

20 As recorded on the VDR, the master first stated the accident location to the Coast Guard as Couverden 

Rock, then he gave the location as “just south of Hanus Rock” [Hanus Reef], which is about 3 miles southeast 

of Rocky Island. See appendix D.
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Both the chief engineer and the first engineer, who was standing watch 

with an oiler21 in the engineroom at the time of the accident, stated in interviews 

with investigators that the Empress of the North had experienced no propulsion, 

steering, or any other engineering plant problems before the grounding. The oiler 

stated that he had been on watch since 1800, which was 7 1/2 hours before the 

grounding, and that the engineering plant had been operating with all conditions 

normal—it was a “normal watch up to the grounding.” The master also stated in 

his interview that the vessel’s machinery was operating “correctly” at the time of 

the grounding.

At 2345, the first engineer had reported to the engineering operating station 

(the area of the engineroom containing the propulsion controls, monitoring 

equipment for the power and auxiliary systems, and communications equipment) 

to assume the midnight-to-1200 watch from the second engineer. Normally, 

the first engineer had the watch from 0800 to 1600, but he said that he took the 

midnight watch because a new third engineer had reported on board only the 

day before (along with the junior third mate). The first engineer stated, “The new 

third engineer was fresh out of school, and I didn’t want him standing watch by 

himself.”

The first engineer said that when the vessel grounded, he heard a “strange 

grounding, growling, nasty, vibration, like we just ran over an island.” The noise 

persisted for what he estimated to be about 5 seconds and the vibration continued 

along the vessel’s entire length. Immediately, the first engineer saw that the 

propulsion drives “went slack,” meaning that the propellers had stopped. It was 

later determined that the bridge had brought the throttle controls to the stopped 

position.

The first engineer saw and heard the bilge level sensors on the engineroom 

alarm panel go into alarm status. According to the datalogger, five belowdeck spaces 

began to flood through breaches in the hull within 5 minutes of the grounding. 

The engineering crew was unaware that the starboard fuel tank, which had been 

emptied of fuel about a week before the accident, had also been breached. An alarm 

that sounded for the starboard propulsion unit indicated to the first engineer that 

the unit had been struck during the grounding.

Immediately after the vessel grounded, the first engineer woke the chief 

engineer to inform him of the accident. He then sounded the “engineers’ assistance 

needed” alarm, waking all engineroom crewmembers and alerting them to report 

immediately to the engineering operating station. While waiting for the crew, the 

first engineer directed the oiler to go forward and check for water in the internal 

spaces. He also started the ship’s bow thruster and passed control of it to the 

bridge, in case it should be needed to control the vessel. 

21 The oiler was an unlicensed crewmember responsible for assisting the engineering watch officer by 

making rounds, checking pressures and temperatures of the engineering plant’s equipment, and reporting any 

anomalies to the watch engineer.
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The chief engineer arrived in the engineroom operating station shortly after 

being called and took command of the engineering space, the damage control 

efforts, and his crew. He sent the three unlicensed crewmembers to find leaks and 

shut tank vents, to prevent breached tanks from discharging water into the vessel. 

He assigned the engineers to pump out the void spaces. They used all available 

engineroom pumps, including two bilge-and-ballast pumps, two bilge pumps, 

and the fire pump, which could also be used as a bilge pump. Portable pumps 

were used in crew accommodation spaces that had taken on water around the 

deck manhole seals because of pressure from the seawater in the breached voids 

underneath. 

The chief engineer informed the bridge about which tanks had taken on 

water and the status of the engineering crew’s actions and called periodically 

afterward with updates.22 The chief engineer also kept the bridge informed about 

the degree of starboard list, which he estimated had increased to a maximum of 8° 

about 1 hour after the accident. As the crew controlled the flooding over the next 

few hours, the vessel eased back toward even keel. No fuel oil was released to the 

environment as a result of the grounding.

About 2 hours after the grounding, the first engineer shut down one of 

the generators because the vessel was no longer under way. The chief engineer 

told investigators that throughout the accident period, the vessel never lost power 

from the main generators. He stated that the damage to the starboard propulsion 

unit did not interfere with the vessel’s power generation or auxiliary systems. At 

no time did the engineers operate the emergency generator to provide power to 

the vessel’s emergency lighting and control circuits. 

The crew’s pumping of the breached spaces decreased the flooding to a 

manageable rate by the time the passengers had evacuated. The master decided 

that because the flooding rate was under control, he would try to return the vessel 

to port under its own power. Once the vessel received the Coast Guard’s clearance 

to transit back to Auke Bay, Juneau, the crew prepared for getting under way. 

The vessel got under way for the transit to Auke Bay at 0600, according 

to bridge log entries. On leaving the accident site, the vessel used both port and 

starboard propulsion drives, but about 0715, the engineering staff shut down the 

starboard propulsion drive after observing that it was drawing less current than 

the port drive, indicating that the starboard propellers had been damaged. The 

Empress of the North arrived dockside in Auke Bay at 1030 on May 14. 

22 Communication between the engineroom and the bridge was carried out primarily by phone instead of 

by radio, to avoid interfering with the deck officers’ emergency communications.
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Injuries

No passengers or crewmembers were injured in the accident. According to 

an incident report from the Capital City (Juneau) Fire and Rescue duty officer who 

was on watch at the time of the accident, two passengers were transported to a 

hospital by ambulance because of medical complaints not related to the accident. 

One other passenger requested medical evaluation but refused any treatment or 

transport.

Damages

Majestic America Line officials estimated that the total cost of repairing 

damage to the hull and machinery of the Empress of the North and of returning the 

vessel to service was $4.8 million. The ship returned to service on July 7, 2007.

Personnel Information

Regulatory Requirements

Under 46 CFR subchapter H, large passenger vessels (those measuring 100 

gross tons or more23) that carry more than 12 passengers for hire24 may not operate 

without a valid Coast Guard certificate of inspection (COI), which is issued by 

the Coast Guard officer in charge, marine inspection (OCMI), for a particular 

inspection zone. The COI stipulates a number of operating requirements, including 

minimum staffing needs. When determining the number and competencies of the 

crewmembers, the OCMI considers, among other things, the size of the vessel, 

its route, the type and horsepower of the vessel’s propulsion machinery, the 

number of passengers the vessel will carry, the type and location of lifesaving 

equipment installed on the vessel, and the hazards peculiar to the route and 

service. According to its COI, the Empress of the North was required to carry the 

following crew complement: one master, three licensed mates, four able-bodied 

seamen, two ordinary seamen, one chief engineer, two licensed engineers, two 

oilers, one wiper, and one patrolman.

23 Gross tonnage is a measure of vessel volume, or overall size. The Empress of the North measured 

296 gross domestic tons. See “Vessel Information” section. 

24 As defined in Title 46 United States Code, section 2101(21)(21a), passenger for hire means “a 

passenger for whom consideration is contributed as a condition of carriage on the vessel, whether directly or 

indirectly flowing to the owner, charterer, operator, agent, or any other person having an interest in the vessel.” 

SOLAS regulation 2(f) defines a passenger ship as “a ship which carries more than twelve passengers.”
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Master

The 44-year-old master had been employed as a master by Majestic America 

Line for over 3 years at the time of the accident. He held Coast Guard licenses as 

master of steam or motor vessels of any gross tons on oceans, master of auxiliary 

sail vessels of not more than 200 gross registered tons (domestic) or 500 gross tons 

(international) on oceans, and master of towing vessels on oceans and western 

rivers. His license included the endorsements of first-class pilot of any-gross-ton 

vessel on Washington main ship channels, Lake Washington ship canal, Hood 

Canal, Saratoga Passage, and several Washington State Ferry routes. He also held 

Coast Guard ratings for any unlicensed deck rating including AB, tank person in 

charge, storage department food handler, wiper, and person in charge of medical 

care. He held an STCW certificate, meaning that he met the minimum safety and 

competence standards of the STCW code. 

The master obtained his Coast Guard license after completing high school 

and attending a maritime training school in Florida. He then joined the Coast Guard 

and served for 4 years. After his Coast Guard service, he worked in commercial 

shipping for 22 years on research vessels, break-bulk (noncontainer cargo) vessels, 

tankers, towing vessels, and, for 7 years, on passenger vessels.

He served for 1 1/2 years as master on the Columbia Queen, a passenger 

vessel operated by Delta Queen Steamboat Company (which became part of 

Majestic America Line) on Pacific Northwest rivers. The company encountered 

financial difficulties and he left the company, thereafter serving as master of a 

passenger ship in Hawaii. After that he served as master of a research vessel, also 

based in Hawaii, and then joined Majestic America Line.

The master estimated that he woke at 0600 on Friday, May 11. That 

afternoon, a passenger experienced a medical emergency, and the master oversaw 

the passenger’s evacuation from the vessel. Later that night, the master learned 

that the passenger had died. The master, the purser, and the AB on watch at the 

time of the accident25 informed the passenger’s wife of her husband’s death. The 

master then went to bed, at what he estimated to be 0030 to 0100 that night. He 

rose the next morning about 0630 and oversaw the vessel’s return to Juneau, the 

disembarkation of passengers, and the embarkation of the passengers joining the 

next 7-day cruise. He estimated that he went to sleep just before midnight on 

May 12. He rose on May 13 at 0600 in advance of the vessel’s planned 0630 arrival 

in Skagway. He entered the bridge that night at 2200 and left about 2230, went to 

his cabin, and fell asleep. He was awakened by the sounds of the grounding.

Majestic America Line discharged the master after this accident, and the 

Coast Guard suspended his license for 5 months.26 The master had been involved in 

another grounding of the Empress of the North about a year before, on the Columbia 

25 The AB had been trained as a medical technician and performed an onboard assessment of the 

passenger who fell ill.

26 The suspension began the week of June 9, 2008.
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River. (See “Previous Accidents” section for more information.) The Coast Guard 

investigated that incident and took no action against the master. 

Chief Mate

The 41-year-old chief mate had been employed by Majestic America Line 

and its predecessor, American West Steamboat Company, for 5 years. He held a 

Coast Guard license as master of steam or motor vessels of not more than 1,600 

gross registered tons (domestic) or 3,000 gross tons (international) on oceans, master 

of uninspected fishing industry vessels of not more than 2,000 gross registered 

tons (domestic) or 3,000 gross tons (international), second mate of steam or motor 

vessels of not more than 2,000 gross registered tons (domestic) or 3,000 gross tons 

(international) on oceans, third mate of steam or motor vessels of any gross tons on 

oceans, and also unlimited radar observer. He held an STCW certificate as master 

and as officer in charge of a navigational watch (second or third mate). 

After graduating from the California Maritime Academy in 1989, the chief 

mate worked as a third mate on vessels based in Fort Lauderdale, Florida, including 

a passenger vessel. He then worked as a deck officer on the Washington State 

Ferries, on tankers, and as a master of small passenger vessels. He then served as 

a chief mate on fishing vessels and after that, on passenger vessels along the U.S. 

west coast. He joined Glacier Bay Cruise Lines, became a port captain, and assisted 

as a crewmember on vessels in the Juneau area. He then served as a chief mate on 

a cable vessel traveling between Oregon and Alaska. He joined American West 

Steamboat Company about 3 years before the accident as a third mate and became 

a chief mate 2 years later.

Because of a death in his family around the time of the accident, the chief 

mate was not available during the on-scene investigation. He was interviewed 

by telephone 6 weeks after the accident. He told investigators that, after his 

involvement with the evacuation of the ill passenger, he went to sleep about 2200 

on May 11 and rose about 0315 on May 12. He went to bed about 2300 on May 12 

but was awakened just after midnight on May 13 because of the ill third mate. He 

went to the bridge about 0030 and completed the remainder of the senior third 

mate’s watch and then his own 0400-to-0800 watch. After completing the watches, 

he returned to his cabin, where he slept from 0830 until he was needed for the 

master’s safety meeting, about 1000. After the meeting, he returned to his cabin and 

slept from around noon to about 1515 before rising for the start of his scheduled 

1600-to-2000 watch. He went to sleep about 2200 on May 13 and was awakened by 

the accident.

Second Mate

The 34-year-old second mate had worked for Majestic America Line since 

February 2007. The repositioning cruise was his first voyage on the accident route. 
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He held a Coast Guard license as master of steam or motor vessels of not more 

than 1,600 gross tons (domestic) or 3,000 gross tons (international) on oceans, 

unlimited radar observer, and second mate of steam or motor vessels of any gross 

tons on oceans. He held an STCW certificate as master and as officer in charge of a 

navigational watch (second mate). 

The second mate graduated from the U.S. Merchant Marine Academy at 

Kings Point in 1995 and joined the U.S. Navy. In 1998, he left the Navy and joined 

Maritime Limited as a third mate, sailing on large medium-speed roll-on/roll-off 

vessels that carried military supplies. In 2001 he rejoined the Navy, then left in 

2004. He worked in Iraq until October 2006.

The second mate came on watch at 0800 the day before the accident. After 

his watch, which he spent correcting charts, he went to sleep about 1630 and woke 

about 1900. He showered and ate before assuming the 2000-to-midnight watch. 

He turned over the watch to the junior third mate at midnight and returned to his 

quarters, where he fell asleep about 0100. He was awakened by the accident and 

went to the bridge, his duty station during emergencies. He told investigators that 

before his watch he “had had plenty of sleep” and would have stayed with the 

junior third mate on watch if asked.

Senior Third Mate

The 53-year-old senior third mate began working for Majestic America Line 

in April 2007 and joined the crew of the Empress of the North at the end of the 

month, after riding the vessel for 4 days on the Columbia River as an observer. 

The repositioning cruise was his first voyage on the accident route. He held a 

Coast Guard license as master of steam or motor vessels on inland waters and was 

authorized for near-coastal service on the sheltered waters of British Columbia 

south of Moresby Island; he also held an STCW certificate as master on those British 

Columbia waters. He held a first-class pilot’s license for vessels of any gross tons 

on ferry routes in Puget Sound and the San Juan Islands of Washington, as well as 

an unlimited radar observer’s license. 

The senior third mate joined the Navy after graduating from high school. 

After leaving the Navy, he worked in the construction industry, then joined the 

Washington State Ferries in 1977 as an AB. He worked as master on the Washington 

State Ferries from 1991 until he retired in 2006, then did not work until he joined 

Majestic America Line a year later. He said that he had familiarized himself with 

the Empress of the North for 3 or 4 days after coming on board. He told investigators 

that the midnight-to-0400 watch was “traditionally” the third mate’s. As noted 

earlier, he fell ill before his midnight watch on May 14 and was told to remain 

apart from passengers and crew by his examining physician. He said that after the 

accident, he dressed, left his cabin, and helped launch the liferafts (experiencing 

the difficulties in deploying the rafts noted earlier) and made sure the passengers 

wore their lifejackets. 
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Junior Third Mate

The 22-year-old junior third mate began his employment with Majestic 

America Line on May 11, 2007, after graduating from the California Maritime 

Academy on April 28 with a BS degree in marine transportation. The day of his 

graduation, he received a Coast Guard license as third mate of steam and motor 

vessels of any gross tons on oceans and as unlimited radar observer. He also 

received an STCW certificate as officer in charge of a navigational watch (third 

mate) and a Coast Guard Merchant Mariner’s Document with the following 

ratings: wiper, steward’s department (food handler), person in charge of medical 

care, life boatman, fast rescue boat, tank assistant, and any unlicensed deck rating, 

including AB.

The junior third mate had served as a student deck officer at sea on the 

California Maritime Academy vessel Golden Bear for 4 months—2 months in the 

summer of 2004, after his freshman year, and 2 months in the summer of 2006, 

after his junior year. The junior third mate passed both courses, worth eight credits 

each. He also passed two 2-credit courses that involved navigation on a bridge 

simulator, one in the spring of 2006, his junior year, and one in the fall of 2006, his 

senior year. 

Safety Board investigators interviewed six of the junior third mate’s 

instructors at the California Maritime Academy whose classes addressed deck 

officer skills.27 Each instructor characterized the junior third mate’s performance in 

class as “average” and “in the middle,” except for an instructor in ship handling, 

who described his skills as excellent. Instructors who oversaw his navigation 

in either the bridge simulator or on the bridge of the school’s training vessel 

expressed confidence that he could successfully determine a vessel’s position, 

execute a turn, and perform the basic navigational duties of a recent graduate of 

a maritime college. The instructors stated that the junior third mate was qualified 

to serve as a watch officer. They also stated that, in general, it was imprudent to 

place a recent graduate of the school, with no watch experience outside a training 

environment, on watch, at night, in pilotage waters, in an unfamiliar vessel, and 

without additional preparation or supervision.

The junior third mate had met the Empress of the North master in January 

2007, when the master visited the California Maritime Academy campus for a job 

fair. The junior third mate, one of several students who had expressed an interest 

in employment with Majestic America Line, had impressed the master because 

of his enthusiasm for the company, whose operations he had researched. Before 

he graduated, the junior third mate was offered a job as a deck officer by Majestic 

America Line and by another company, not a passenger carrier. He accepted 

Majestic America Line’s offer because he wanted to work on a passenger vessel.

27 Other instructors taught courses that were required for a degree but did not offer opportunities to 

observe the junior third mate’s navigation or ship-handling skills—for example, introduction to sociology, 

English literature, and rules of the road.
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The junior third mate told investigators that on May 11, a company human 

resources representative in Portland told him that he would most likely go through 

a training program on the Empress of the North. The company arranged for him to 

fly to Juneau, by way of Seattle, to join the vessel on May 12. In Juneau he met the 

master and other crewmembers, was given a passenger stateroom, and met the 

purser in order to get a crew identity card. He went to the bridge about the time 

the senior third mate was relieving the second mate, introduced himself to both 

mates and to the ABs, and walked around the vessel. He went back to the bridge 

and between 1600 and 1800 observed the departure from Juneau while the chief 

mate was on watch. The chief mate introduced him to additional deckhands, and 

he started to “ask the chief mate about operations.” The chief mate also informed 

the junior third mate that the master was to hold a weekly all-crew meeting the 

next morning to review safety and operational items but that he did not have to 

attend. The junior third mate had dinner about 1800.

The junior third mate estimated that he went to sleep between 2100 and 2200 

on May 12 and woke at 0500 on May 13. He went to the bridge at 0530, observed the 

arrival and mooring at Skagway at 0645, and assisted in passenger disembarkation. 

He then attended the master’s safety meeting with the crew. Afterward he went 

ashore. When he returned, he learned about the ill third mate, who was given 

the junior third mate’s cabin. The junior third mate moved into and shared the 

cabin of the second mate. The junior third mate then reported to the bridge and 

took the 1200-to-1600 watch while the vessel was docked in Skagway. During that 

watch, the master informed him that he would need to stand the midnight-to-0400 

underway watch. The junior third mate remained on the bridge with the chief 

mate and observed him test gear. He had dinner at 1700, then slept from 1800 to 

2300. He arrived on the bridge about 2320. 

After the accident, Majestic America Line discharged the junior third mate.

Able-Bodied Seaman 

The 36-year-old AB who was at the helm at the time of the accident had 

been employed by Majestic America Line for 17 months. Before that, he worked 

for U.S. Army intelligence. After leaving the Army, he trained in and practiced 

nursing, and later joined a National Park Service concessionaire managing a hotel. 

He then worked for Glacier Bay Cruise Lines as a hotel manager for 2 years. In that 

time, he said, he “fell in love with the ocean” and decided to become a deck officer. 

He stayed with Glacier Bay Cruise Lines in management for the rest of the season, 

then worked periodically on deck to build up his sea time. His transition to the 

bridge started with that cruise line. Glacier Bay Cruise Lines went bankrupt, and 

he joined Majestic America Line as an ordinary seaman about 17 months before 

the accident. He served as an ordinary seaman in 2006, then became an AB for 

the 2007 season. He told investigators, “I had been in the area [the accident route] 

before, but not as an AB.” 
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On May 11, the AB went to sleep about 1900 and rose at 0600 on May 12. 

He went to sleep about 1900 on May 12 and rose at 0600 on the day of the accident. 

Later that day, he went to sleep about 1500 and rose at 2300.

Chief Engineer

The chief engineer, 26 years old, began working for Majestic America Line in 

January 2006, initially as a third engineer. He held a Coast Guard second assistant 

engineer’s license with unlimited horsepower endorsements for steam, motor, 

and gas turbine powerplants. After graduating from the U.S. Merchant Marine 

Academy in 2003, he worked for 2 years on various merchant vessels, employed 

through a union, from the port of Houston. He was promoted to chief engineer 

on the Empress of the North in October 2006. His typical daily work schedule was 

from 0600 to 1800. His work/vacation schedule was 30 days on duty, followed 

by 30 days off the vessel. He had been on duty nearly 1 month at the time of the 

grounding. 

During their routine postaccident review of officer licenses, Safety Board 

investigators noted that the chief engineer’s license did not contain a chief 

engineer’s endorsement and sought to clarify whether his license was compliant 

for his position. Company officials said that they had assumed that the Coast 

Guard regulations implied that a second assistant engineer’s license qualified the 

holder to serve as chief engineer. The Division of License Credentialing Program 

Policy at Coast Guard headquarters stated that a second engineer’s unlimited 

license would not authorize a crewmember to serve as chief engineer. A Sector 

Juneau representative confirmed that the chief engineer should have had an 

additional endorsement to be properly certificated to sail as chief engineer on 

the Empress of the North. On August 31, 2007, the chief engineer’s license was 

amended to include an additional endorsement as “designated duty engineer 

of steam, motor, or gas vessels of any horsepower limited to vessels of not more 

than 500 gross registered tons (domestic tonnage) when operating beyond the 

boundary line.” 

Vessel Information

Construction and Equipment

The Empress of the North was built in 2003 by Nichols Brothers Boat Builders 

in Freeland, Washington. Constructed of welded steel, the vessel had four decks 

with passenger accommodations, a gangway on the bow that could be lowered 

to allow passengers to embark and disembark, and a paddle wheel at the stern 

(figure 3). 
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The vessel was 299.3 feet long and had a beam of 58.3 feet. Its gross tonnage 

was 296 domestic tons and 5,975 international tons. The vessel was delivered to 

American West Steamboat Company (which later became Majestic America Line) 

on August 7, 2003.

Propulsion and Associated Engineering Equipment

The Empress of the North’s main and propulsion power was supplied by 

four 16‐cylinder, 2,450-horsepower model 3516B diesel engines manufactured by 

Caterpillar, Inc. Three engines were generally sufficient to run the vessel at normal 

sea speed and supply its other power needs. The engines were coupled to 1,825-

kilowatt generator sets that could run independently or in parallel, depending on 

the vessel’s power requirements. The generators supplied power to a common 

switchboard that distributed power for consumption throughout the ship, as well 

as to the motors that drove the propulsion thrusters. 

The vessel was propelled by two Schottel-manufactured thrusters at the 

stern, one on each side of the vessel. Each thruster had two three-bladed propellers, 

an arrangement that minimized noise. The thrusters were each driven by a 2,000-

horsepower General Electric direct-current motor located in the engineroom. The 

thrusters were capable of 360° directional thrust, affording the Empress of the North

Figure 3. Paddle wheel at the stern of the Empress of the North. To save fuel, the paddle 

wheel was usually allowed to freewheel during vessel transits, as during the accident 

voyage, rather than being powered by its driving motor.
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a high degree of maneuverability and allowing its speed to be controlled from 

stations in the engineroom and on the bridge.28

The bow thruster at the vessel’s forward end was manufactured by Schottel 

and powered by a 1,000-horsepower General Electric motor. The bow thruster was 

of the waterjet type, using a pump to discharge water at high speed, and could 

provide 360° thrust. The paddle wheel at the vessel’s stern was driven by a 1,000-

horsepower General Electric motor.

Bridge Equipment

The electronic and communications equipment on the bridge of the Empress 

of the North included the following:

• Furono model FAR-2127 radar (high-resolution X-band (3-centimeter 

wavelength) and long-range S‐band (10‐centimeter wavelength) with 

ARPA.

• ECDIS, Raytheon model Pathfinder/ST MK-2.

• Electronic chart, Nobeltec Admiral model.

• Global maritime distress and safety system, Skanti model Skanbridge 

A3 series.

• Gyrocompass, Anschütz Standard 20. 

• Autopilot, Anschütz Pilotstar D type AP02-S0.1.

• Global positioning system (GPS), Northstar model 941X.

• Very-high-frequency (VHF) radios (2), Skanti model 1000 DSC (digital 

selective calling function).

• Automatic identification system (AIS) unit,29 Japan Radio Company 

model JHS-182.

• Echosounders (2), L-3 Communications ELAC Nautik model LAZ 

5000.

• Speed log, Consilium model SAL-R1. 

• Portable two-way radios (30), Motorola Radius CP 200.

• Fire detection annunciator, Notifier model AM2020/AFP 1010. 

28 Because the propellers could be rotated in any direction, a rudder was unnecessary. 

29 All ships of 300 gross tons or more engaged on international voyages are required by SOLAS chapter 

V, regulation 19.2, to be fitted with an AIS—a shipboard broadcast system, operating in the VHF maritime 

band, that can send and receive ship information such as identity, position, course, and speed. In U.S. waters 

governed by vessel traffic service or vessel movement reporting systems, certain commercial and towing 

vessels and all passenger vessels carrying 150 or more passengers are required to carry AIS equipment.
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The monitors for the two electronic navigation charts were next to the 

helmsman’s station (figure 4). The Nobeltec showed a trackline going between 

Rocky Island and Point Couverden, the ECDIS showed a trackline going south 

of Rocky Island, and the paper chart showed tracklines both north and south of 

Rocky Island. The paper chart was used to mark navigation fixes (vessel positions), 

but the Nobeltec was used for navigation purposes, according to Majestic America 

Line.

The vessel was also equipped with a model MER VDR manufactured by 

AVECS Corporation AG (head office Fichtenwalde, Germany). The VDR recorded 

inputs from two audio channels, 12 data channels, and a video source (ARPA radar). 

The audio data were recorded by six microphones on or near the ship’s bridge 

(four on the bridge itself and two on the bridge wings) and from transmissions 

and receptions on channel 16 of the ship’s VHF radio.

Figure 4a. View of bridge showing location of 

monitors for Nobeltec (front) and ECDIS (rear) 

at helmsman’s post.

Figure 4b. Tracklines marked on paper 

navigation chart.

Figure 4c. Trackline marked on Nobeltec. Figure 4d. Trackline marked on ECDIS

Figure 4. Figure 4a.
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Certification and Inspection

Sector Portland (Oregon) was the local Coast Guard office in charge of 

inspecting the Empress of the North and issuing its COI. The Empress of the North

was inspected by Sector Portland because Portland was the vessel’s home port, 

although its Alaskan route took it into the area of responsibility of Sector Juneau. 

Personnel from Sector Juneau examined the damaged vessel after the accident. 

The COI issued after the Empress of the North’s last annual inspection on 

February 17, 2007, permitted the vessel to operate in sheltered waters off the west 

coast of North America. The total number of persons permitted on board was 327, 

including 237 passengers and 90 crewmembers. The vessel was drydocked for a 

complete hull examination during the 2007 annual inspection. 

Pilotage. The Empress of the North’s COI contained the following endorsement 

regarding pilotage:

When not sailing on register30 and operating upon the navigable waters of 

the United States, all deck officers shall meet the requirements as first class 

pilot of inspected vessels of at least 1600 gross registered tons31 . . . on both 

designated and non-designated pilotage waters in accordance with 46 CFR 

15.812(b) and (c); and Table 15.812(e)(1).32

The Empress of the North’s COI required its deck officers to be qualified pilots 

when operating on the navigable waters of the United States,33 whether or not 

those waters were designated pilotage waters.34 The vessel’s pilotage requirement 

thus applied both to the waters of southeast Alaska (all of which are designated 

pilotage waters) where the accident occurred and to the waters of the Columbia, 

Willamette, and Snake rivers (some of which are designated pilotage waters and 

some of which are not) where the vessel also operated.

Coast Guard navigation and vessel inspection circular (NVIC) 8‐94 explains 

that according to Federal regulations, two categories of mariners may serve as 

pilot. One is a mariner holding a Federal first-class pilot’s license with endorsement 

30 “On register” means employed in foreign trade.

31 In March 2008, Sector Portland corrected this portion of the vessel’s COI to read “inspected vessels of 

not more than 1600 gross registered tons.” The Empress of the North was 296 gross tons.

32 Title 46 CFR 15.812 contains the Coast Guard pilotage requirements. Table 15.812(e)(1) is a quickreference tool within that regulation.

33 Navigable waters are defined at 33 CFR 2.36 as follows: “(1) Territorial seas of the United States; 

(2) Internal waters of the United States that are subject to tidal influence; and (3) Internal waters of the 

United States not subject to tidal influence that: (i) Are or have been used, or are or have been susceptible 

for use, by themselves or in connection with other waters, as highways for substantial interstate or foreign 

commerce, notwithstanding natural or man-made obstructions that require portage, or (ii) A governmental or 

non-governmental body, having expertise in waterway improvement, determines to be capable of improvement 

at a reasonable cost (a favorable balance between cost and need) to provide, by themselves or in connection 

with other waters, as highways for substantial interstate or foreign commerce.”

34 The Coast Guard designates pilotage waters. According to information from the OCMI for Sector 

Juneau, all southeast Alaska waters are designated for pilotage purposes (OCMI Southeast Alaska, “Letter of 

Promulgation for Southeast Alaska Pilot License Requirements,” April 4, 2007). 
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for the route, in accordance with 46 CFR 15.812(b)(1). The other is what the NVIC 

terms an “acting as” pilot, that is, a licensed member of the crew who also meets 

the requirements of 46 CFR 15.812(b)(2), as follows: 

• Must be at least 21 years old.

• Must maintain a current knowledge of the waters to be navigated (one 

round-trip within the past 60 months).

• Must have four round-trips on the route. If the route is to be traversed 

during darkness, at least one of the round-trips must be made during 

darkness.

“Acting as” pilots self-certify as to their qualifications for a route, that is, 

they are not issued a pilot’s license or an endorsement on their license that specifies 

the waters on which they are authorized to serve as pilot.35 Title 46 CFR 15.812(d) 

requires pilots, when asked, to furnish documentation to the Coast Guard proving 

that they have complied with the pilotage regulations. They must produce either 

a first-class pilot’s license or documents showing that they have met the selfcertification requirements, including having made the required number and type 

of round-trips. NVIC 8-94 states that if the Coast Guard “has reason to doubt an 

individual’s qualifications to ‘act as’ a pilot . . . the vessel’s departure could be 

delayed pending receipt of satisfactory evidence [that] the required round trips 

have been made.”

According to the company’s safety management system, the master was 

responsible for ensuring that his vessel was manned in accordance with its COI.36

None of the Empress of the North’s deck officers held a first-class pilot’s license 

valid for the accident route (the master and senior third mate held first-class pilot’s 

licenses valid on the waters of Washington state). The junior third mate, the officer 

of the watch on the accident voyage, did not have current knowledge of the waters 

and had not been on any round-trips on the route in daylight or darkness. The 

senior third mate and the second mate had both joined the company recently and 

had not made four round-trips on the route before the accident. The master and 

chief mate had worked for the company for 3 and 5 years respectively and met the 

experience requirements of 46 CFR 15.812(b)(2).

35 NVIC 8-94 states: “A description of the route requirements for a licensed first class pilot and an ‘acting 

as’ pilot may be obtained from the OCMI concerned. It is incumbent upon the mariner who will ‘act as’ a pilot to 

determine in advance whether he/she meets the local pilotage requirements. . . . For purposes of establishing 

the requisite number of round trips in a given pilotage route segment, the local knowledge requirements 

may be satisfied when the licensed individual has transited the length of the segment or, if the local pilotage 

requirements permit, has made trips to one or more facilities within the segment.”

36 Majestic America Line, Office Safety Management Manual, section 7.1, “Manning Levels.” See 

“Operational and Management Information” section for information on the company’s safety management 

system at the time of the accident.
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Document of Compliance. The Coast Guard report on the vessel’s February 

17, 2007, inspection noted that its documents had been “inspected satisfactory.” 

However, 2 weeks after the accident, company management discovered that its 

document of compliance, which verifies that the company complies with the ISM 

code, was not valid. A document of compliance is issued for 5 years but requires 

annual verification. Majestic America Line’s document of compliance had not 

been verified since the company’s ISM auditor, the classification society American 

Bureau of Shipping,37 issued the document on July 5, 2005. An ISM-compliant 

vessel such as the Empress of the North is not allowed to sail if the company does 

not possess a valid document of compliance. The Coast Guard can levy a civil 

penalty of $6,500 against vessel owners whose documents of compliance are not 

valid. Majestic America Line was not fined.

Safety Management Certificate. The ISM code also requires vessels operating 

in international waters to hold and display a safety management certificate, 

signifying that the vessel’s operating company and shipboard management 

operate in accordance with an approved safety management system. According to 

the Majestic America Line safety management system at the time of the accident, 

a manager (the ISM “designated person ashore”) was responsible for system 

documentation.38

The Empress of the North carried a safety management certificate issued by the 

American Bureau of Shipping on January 12, 2004, that was valid until December 

10, 2008. However, the validity of the safety management certificate depended 

on the validity of the company’s document of compliance. Therefore, because the 

company’s document of compliance was invalid, the safety management certificate 

for the Empress of the North was also invalid. 

The annual Coast Guard inspection in 2007 did not identify that either the 

company’s document of compliance or the vessel’s safety management certificate 

was out of compliance. On May 30, 2007, the American Bureau of Shipping issued 

the company a valid interim document of compliance and on June 30, 2007, a 

valid interim safety management certificate for the Empress of the North. On March 

10, 2008, the American Bureau of Shipping issued another interim document of 

compliance to the company, valid until March 9, 2009, and on March 15, 2008, 

another interim safety management certificate for the Empress of the North, valid 

until September 14, 2008. 

VDR Certification. SOLAS chapter V, regulation 18.8, requires VDRs to 

undergo annual performance tests. The VDR carried on the Empress of the North

was inspected by a certified manufacturer’s representative on February 17, 2007—

37 Classification societies are private, independent organizations that establish and apply technical 

standards for the design, construction, and survey (inspection) of ships. Many countries delegate responsibility 

for some regulatory functions to classification societies, such as inspection for compliance with certain national 

and international regulations and issuance of some safety certificates, and may also adopt class society rules 

as their own national standards.

38 Office Safety Management System, section 6.6.3, “Marine Safety Manager/Designated Person Ashore.”
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the same day as the annual Coast Guard inspection. Although the manufacturer’s 

representative noted deficiencies in the VDR’s engine, rudder, and main alarm 

recording systems in his report, he issued a certificate of compliance on February 

18, 2007, which the master signed. The safety management system did not discuss 

VDRs, but the fleet instructions stated that the master was responsible for “reporting 

defects” and for “ensuring that all documentation that is designated as ‘controlled’ 

is up to date.”39 The Coast Guard did not note the VDR deficiencies in its inspection. 

If it had done so, it would have issued a notice of inspection requirements but 

allowed the vessel to sail. The company had the VDR repaired, inspected, and as 

of the date of this report was awaiting a new certificate of compliance.

Emergency Equipment

Lifesaving. The COI for the Empress of the North required the vessel to carry 

approved lifesaving equipment for 327 people, as follows:

Adult lifejackets 348

Child lifejackets 24

Rescue boats/platforms 2

Inflatable liferafts40 20

Ring buoys 12

Immersion suits 10

Portable lifeboat radios 3

The Empress of the North carried two types of inflatable survival craft for 

use if the vessel had to be abandoned, plus inflatable slides for escaping from 

the vessel into the survival craft. Twenty inflatable liferafts, which held 50 people 

each, were kept in overhead cradles along the main outer deck, 10 on either side 

of the vessel (figure 5). 

Each liferaft had two remote-release units, model H20 manufactured by 

Hammar, that would free the raft from its cradle. If the vessel sank, the liferafts would 

be launched automatically by a unit that, when submerged to a predetermined 

depth, would sever the line securing the raft. Manually releasing a liferaft required 

the use of a hydrostatic hand pump located on the vessel bulkhead, next to the 

rafts (figure 6). 

39 Fleet Instructions, section 2.0, “Personnel Resources and Responsibilities,” subsection 2.6.1, 

“Captain.” 

40 The vessel had a SOLAS exemption issued by the Coast Guard that allowed it to substitute inflatable 

liferafts for required lifeboats. A typical passenger vessel of the Empress of the North’s size would be required 

to have lifeboats on each side of the vessel capable of carrying 37.5 percent of the total number of persons on 

board in addition to liferafts (46 CFR part 199.201 [b][i]).
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Figure 5. Liferafts mounted in overhead cradles above the main deck of the Empress of 

the North.

Figure 6. Liferaft remote-release unit mounted on a bulkhead near one of the liferafts.
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Activating the pump would sever the line, freeing the liferaft from its cradle 

and allowing it to drop into the water alongside the vessel. A placard posted below 

each pump directed, “Pump plunger two to six times until the raft releases.” The 

release units were disposable, to be replaced after 2 years of use. All release units 

on the vessel had expiration dates of February 2009.

Although not required by the vessel’s CIO, one inflatable buoyant apparatus 

(IBA),41 holding 50 people, was stowed on each side among the liferafts. Regulations 

at 46 CFR 199.190 (g)(i),(ii) require liferafts and IBAs to be serviced annually. Pacific 

Marine Distributors in Portland, Oregon, serviced all the liferafts and IBAs on the 

Empress of the North between January 5 and January 18, 2007.

Also not part of its required lifesaving apparatus, the Empress of the North

carried two Coast Guard–approved model SL32 inflatable marine evacuation 

slides manufactured in December 2002 by DBC Marine Safety Systems, Ltd., of 

Richmond (Vancouver), British Columbia. When inflated, the evacuation slides 

would create an escape route from the vessel into an IBA (figure 7), from which 

evacuees could easily enter the liferafts. 

The evaluation slides were packed in fabric valises and stored separately in 

a locker on the main deck. Arrows were stenciled on the outside of the valises to 

indicate whether an end should face inboard or outboard and also where to find 

the pull-cord that would inflate the slide. The chief mate told investigators that the 

valises were brought out during drills and installed in their launching position for 

practice; the crew did not inflate or repack the slides during the drills. 

Evacuation slides require annual servicing by an authorized facility to 

maintain Coast Guard approval. Annual servicing involves inflating, inspecting, 

and repacking the slides. Marine Safety Services in Seattle, which the Coast Guard 

41 Buoyant apparatus are similar in size and construction to liferafts but do not offer the protection of a 

canopy, as do liferafts. 

Figure 7. Drawing showing inflatable evacuation slide leading from ship’s deck into an 

IBA.
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had approved to do the work, last serviced both slides before the accident on 

February 5, 2007. Coast Guard regulations require that a gas inflation test must be 

done every 5 years (46 CFR 160.151-57[g]). Marine Safety Services last gas-inflated 

the slides on the Empress of the North in August 2003 and March 2004. 

The person servicing the slides had to be certified by the manufacturer, and 

the training had to comply with Coast Guard regulations regarding the training 

of servicing technicians (46 CFR 160.151-39). The slides were inspected by a DBCcertified servicing technician at Marine Safety Services. The technician had most 

recently completed a training course May 1, 2007. The technician’s last previous 

certification course was on September 17, 2004. 

Firefighting. According to its COI, the Empress of the North was required to 

carry the following firefighting equipment:

• Three fire pumps.

• Thirty-three firehoses, each 75 feet long.

• Seventy portable fire extinguishers (29 class A-II, 27 class B-II, 14 class 

C‐II).42

• Four fixed carbon dioxide fire-extinguishing systems (a 3,100-poundcapacity system in the engineroom, 35-pound-capacity systems for the 

bow thruster motor and paint locker, and a 50-pound system for the 

paddle wheel motor).

The vessel was also equipped with water mist fire-extinguishing systems 

in the accommodation and public spaces and a potassium-based fire suppression 

system in the galley. A fire-detection annunciator was located on the vessel’s 

bridge.

Wreckage

Damage Assessment

On May 15, the day after the grounding, divers in Juneau conducted a 

preliminary dockside hull survey of the Empress of the North and made emergency 

repairs to seal the vessel’s breached spaces. On May 20, the vessel left Juneau for 

Ketchikan to undergo initial repairs at Alaska Ship and Drydock and a further 

damage assessment on May 24. 

42 Class A extinguishers are for fires involving ordinary combustibles, such as wood, cloth, and paper. 

Class B extinguishers are for fires involving flammable liquid, grease, or gas. Class C extinguishers are for 

fires involving energized electrical equipment, such as appliances, switches, panel boxes, and power tools 

(these extinguishers are also rated for class A and class B fires). According to the Coast Guard classification 

system, type A-II portable extinguishers hold 5 pounds of dry chemical; class B-II, 10 pounds; class B-V, 50 

pounds; and class C-II, 10 pounds.
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The description of the wreckage that follows is based on those surveys, as 

well as on the company’s temporary repair plan for the Empress of the North before 

it was moved to Oregon for permanent repairs. The plan outlined repairs to the 

vessel’s stem (bow), the No. 2 starboard fuel tank, and void spaces 1 through 4. 

All the underwater damage was to the vessel’s starboard side. Both 

propellers on the starboard propulsion thruster were damaged to such a degree 

that they had to be replaced (figure 8). The grounding also extensively damaged 

the steel plating on the underwater hull’s starboard side (figure 9). 

The underwater damage is described below, going from bow to stern and 

referencing the transverse frames, which were numbered from 0 to 150, starting at 

the bow (figure 10). The vessel’s stem below the waterline, just forward and above 

the point where the keel transitioned upward toward the bow, sustained damage 

that bent this section of the hull to the port side. The stem was also cracked open 

for several feet in the same area. The empty starboard fuel tank between frames 37 

and 53 was breached during the grounding and was split at the chine.43 The split 

was intermittent from frames 40 to 53 and about 0.5 inch wide for approximately 

30 feet.

Void 1, aft of the starboard fuel tank between frames 53 and 73, was breached 

along its flat centerline keel plate, as well as at the chine at frame 73. Some vertical 

internal framing members were also bent back by the force of the grounding. Void 

2, on the vessel’s bottom from frames 73 to 89, was holed at the chine at frame 73. 

The 0.5-inch-wide split ran approximately 3 feet along the length of the hull. The 

damage at frame 73 also buckled the internal bulkhead between voids 1 and 2, 

causing a loss of watertight integrity between the two spaces. Void 2 also had bent 

internal frames.

Void 3, which ran along the hull’s underside from frames 89 to 109, was 

breached at the keel at frame 99. The crack was approximately 1.5 feet long and 0.5 

inch wide. Frames in void 3 were also bent. Void 4, from frames 109 to 113, took 

on water after the grounding. The space had lost its watertight integrity when the 

bulkhead between it and void 3 buckled at frame 109.

Once the initial repairs in Ketchikan were complete, the Empress of the North 

sailed to Cascade General Shipyard in Portland for final repair work, arriving 

there on June 9. About 52.5 tons of steel were replaced in repairing the vessel. 

The repairs were completed on June 27, 2007, and the vessel returned to service in 

Alaska on July 7. 

43 The chine is the transitional section from the relatively flat underside of the vessel’s hull to the upward 

vertical side plating along its exterior.
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Figure 8. Damage to propeller blades of starboard propulsion thruster (foreground). Port 

thruster (rear) was not damaged in the grounding.

Figure 9. Damage to steel plating on starboard side of the Empress of the North hull.
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Figure 10. Damage to underwater hull and starboard propeller. Dark-shaded sections 

were breached. Bow thruster was not damaged but is shown for reference. 
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Vessel Stability 

The stability book44 for the Empress of the North demonstrated, in accordance 

with 46 CFR 170-11045 and stability testing carried out at Coastal Transport, Inc., 

Seattle, on July 17 and August 1, 2003, and witnessed by the American Bureau of 

Shipping, that the Empress of the North had sufficient intact and damaged stability46

to comply with Coast Guard and SOLAS rules for passenger vessels in operation 

on restricted coastal service. 

According to the stability book, the Empress of the North was restricted to 

operating 25 miles from shore from May to September and between Portland and 

Juneau. The stability book was approved by the American Bureau of Shipping on 

behalf of the Coast Guard on August 6, 2003.

Subdivision. Calculations indicated that, when operated in accordance 

with the approved stability book, the Empress of the North would remain afloat and 

upright with any one major compartment flooded (one-compartment subdivision). 

A major compartment is the total space between any two adjacent main transverse 

watertight bulkheads. The watertight bulkheads were located at frames 9, 21, 37, 

53, 73, 89, 109, and 129. There was one class 3 watertight door47 in frames 21, 37, 

53, 73, 89, and 109. 

Damage Survival. Calculations indicated that the Empress of the North would 

stay upright (no more than 7° of list under ideal conditions—minimal wind, wave, 

and passenger movement) after side damage when the side damage was limited 

to any one major compartment and more than 11.40 feet inboard from the side of 

the hull.

Hull damage was found to extend from frame 37 through frame 113, an 

area that contained five main watertight zones. However, flooding was restricted 

to the starboard side voids and tanks and did not extend throughout each main 

watertight zone. The greatest angle of list at any time during the accident was 

about 8°.

44 A stability book describes a vessel’s stability characteristics (such as the angle to which it can heel 

before capsizing or the amount of reserve energy available to right it) and is a tool for the master and crew to 

use in controlling the vessel under different conditions. 

45 Because of its gross tonnage and passenger load, the vessel was required to comply with 46 CFR 

parts 70-89 (subchapter H). Title 46 CFR 170.080 directs stability and subdivision considerations to 46 CFR 

parts 170-174 (subchapter S).

46 Intact stability is a naval architecture term referring to how an intact, or undamaged, vessel will respond 

when heeled over. Damaged stability is the “worst intact condition,” assessed by analytically opening various 

combinations of watertight compartments to the sea.

47 As defined by 46 CFR 170.250, a class 3 watertight door is a “sliding door, operated by power and by 

hand gear.”
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The vessel was stability-limited to a maximum allowable vertical center of 

gravity,48 as specified in the stability book, and the maximum draft was not to 

exceed the Plimsoll mark.49

Waterway Information

The grounding occurred in the Inland Passage of southeast Alaska off Point 

Couverden, which is at the southernmost end of an isthmus that extends into the 

junction of the east end of Icy Strait (running northwest to southeast) and Lynn 

Canal (running roughly north and south). The ship grounded on the southeastern 

shoals of Rocky Island (58° 10.6′ N and 135° 03.1′ W). (Refer to figure 2.)

According to the United States Coast Pilot, Icy Strait is part of a 61-milelong waterway that connects the northern part of the Inland Passage to the sea. 

The waterway averages 4 to 8 miles wide. Lynn Canal is described as 5 miles 

wide at Rocky Island, “nearly free of dangers,” and “generally very deep.”50

The navigation chart for the area shows a stretch of navigable water between 

Rocky Island and Point Couverden about 0.5 mile wide. The rocks advance to 

the south of Point Couverden by about 0.3 mile and form the right boundary of 

the navigable water between the island and the point. The Coast Pilot describes 

Rocky Island as

grass covered and marked by a light, . . . 3.2 miles NW of Hanus Reef. The 

water is deep to within 250 yards of the island. As currents are erratic in 

the channel between Rocky Island and Point Couverden, the slight saving 

in distance this channel offers does not warrant its use; however, if used, 

vessels should favor Rocky Island, as shoal water extends from Point 

Couverden.51

The Coast Pilot characterizes currents in the southern part of the canal as 0.3 

to 1 knots, with “strong tide rips” at the entrance to Swanson Harbor (just west of 

Point Couverden and Rocky Island). Tidal data for Juneau (the closest data station) 

show that at the time of the accident, the tide had just begun to ebb.52 The Coast 

Guard reported a 0.5-knot westerly current at the time of the accident and calm 

48 Distance from hull bottom to center of total weight present.

49 The Empress of the North complied with the requirements of regulation 10(2), annex I of the International 

Convention on Load Lines, 1966. A load line is a symbol, also called a Plimsoll mark, painted amidships on 

each side of a ship to show whether the ship is overloaded. The purpose of a load line is to ensure that a ship 

has sufficient freeboard (distance between the waterline and the main deck) to allow it to remain buoyant if the 

ship sinks deeper into the water. The load line indicates the maximum safe draft (vertical distance between 

the waterline and the bottom of the hull) and therefore the minimum freeboard for the vessel under various 

operating conditions. 

50 National Oceanic and Atmospheric Administration, National Ocean Service, United States Coast Pilot, 

vol. 8 (Alaska: Dixon Entrance to Cape Spencer), 2004, pp. 313, 365. 

51 Coast Pilot, vol. 8, p. 315.

52 National Oceanic and Atmospheric Administration data were obtained from the National Climatic Data 

Center website <www.ncdc.noaa.gov>.
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seas. The day after the accident, the Coast Guard recorded the sea temperature at 

Auke Bay (Juneau) as 37° F.

Meteorological Information

According to National Climatic Data Center observations for Hoonah 

Seaplane Base, about 14 miles west of the accident site, skies were overcast at the 

time of the accident, visibility was 7 miles, the air temperature was 43° F, and 

winds were from the southeast at 8 to 10 miles per hour. Light rain was recorded 

at 0056. 

The forecast for the coastal waters of Icy Strait issued by the National 

Weather Service for the night of May 13 and the day and night of May 14 was for 

east winds varying from northeast to southeast at 20 knots, seas 3 to 4 feet, and 

rain. Data from the U.S. Naval Observatory in Juneau indicate that for the date and 

time of the accident, the moon was below the horizon.

Toxicological Testing

Drug and alcohol testing was conducted on board the Empress of the North

for eight crewmembers, including the master and all watchstanding personnel, 

between 0550 and 0717 on May 14. The alcohol tests employed a breathalyzer. Drug 

tests for the five illicit drugs for which Federal regulations require screening53 were 

conducted using urine specimens. All the alcohol and drug tests were negative.

Coast Guard regulations at 46 CFR 4.06 require alcohol tests to be completed 

within 2 hours and drug tests to be conducted within 32 hours of a serious marine 

incident “unless precluded by safety concerns directly related to the incident.”54

Alcohol testing can be conducted up to 8 hours following an accident if a crew 

is actively engaged in responding to an emergency or ensuring the safety of the 

vessel. Personnel on the Empress of the North were occupied for several hours in 

responding to the emergency. Alcohol tests were conducted on crewmembers 

within 8 hours. Drug tests were conducted less than 6 hours after the accident.

53 Regulations at 46 CFR 16.113 specify testing for marijuana, cocaine, opiates, phencyclidine, and 

amphetamines.

54 A serious marine incident is defined at 46 CFR 4.03-2 as (a) a marine casualty or accident that results 

in any of the following: (1) one or more deaths, (2) injury that requires medical treatment beyond first aid and 

renders the individual unfit to perform routine duties, (3) property damage exceeding $100,000, (4) actual or 

constructive total loss of an inspected vessel, or (5) actual or constructive total loss of any uninspected vessel 

that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of oil into U.S. waters; or (c) the release 

of a reportable substance into the environment of the United States.
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Survival Aspects

On-Scene Emergency Response

The master arrived on the bridge seconds after the grounding and at 0132 

instructed crewmembers to go to the main deck. He then made several emergency 

calls on VHF radio channel 16. At 0135, he radioed the Coast Guard in Juneau to 

inform it of the emergency and the vessel’s location. At 0140, the Coast Guard 

issued an urgent marine information broadcast. 

At 0142, the master announced the emergency to passengers and shortly 

afterward, instructed them to dress and report to their muster stations with 

their lifejackets. (As required by SOLAS, an abandon-ship drill had been held 

the afternoon of May 12 in Juneau after the passengers had boarded.) He told 

passengers to remain calm, assured them that the vessel was stable, and kept 

them informed about evacuation plans. Passengers were accounted for when they 

reached their muster stations. After the passengers mustered, crewmembers went 

through all the cabins to ensure that they were clear, marking the doors of those 

that had been searched and found empty. 

The master used two emergency procedures checklists in responding to the 

grounding. Written emergency procedures are required by the ISM code to be part 

of any safety management system. The emergency response checklists were kept 

on the vessel’s bridge and were readily accessible. 

The master told investigators that he decided to launch liferafts as a 

precaution, although he considered the liferafts a “last resort” that he did not 

want to use because of the large number of elderly passengers on board.55 He said 

his plan was to launch liferafts on the port side because the vessel was listing to 

starboard. The purser on the bridge noted that liferafts were launched at 0224. 

Postaccident examination of the lifesaving equipment showed that eight 

liferafts were launched from the port side, along with the IBA for that side, and 

that four liferafts were launched from the starboard side. The chief mate told 

investigators that the hand pumps failed to activate about half the mechanisms 

in the 12 liferafts that were launched. He said that the plungers were pumped 

“upwards of a dozen to two dozen times” but did not activate the hydrostatic 

release units. Crewmembers cut the lines with their knives to launch the liferafts. 

It was later discovered that the pumps connected to the hydrostatic release units 

had not been lubricated as directed by the manufacturer (see “Safety Board Actions 

Since the Accident” section). 

The vessel’s two inflatable evacuation slides were deployed on the port side. 

The first slide inflated upside-down and as a result, blocked the embarkation area. 

55 The senior vice president of operations told investigators that Majestic America Line catered to 

passengers over 60.
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The crew could not flip the slide into the correct position because the tethering 

lines were too taut, so they cut it loose. The second slide also inflated upside-down 

and blocked the exit. It too was cut loose, and crewmembers manually turned both 

slides over and secured one at the embarkation area. According to the chief mate, 

the crew spent about 15 minutes trying to deploy each slide. 

The chief mate said that all personnel in the vicinity verified that the 

arrows stenciled on the valises were pointing in the correct direction and that 

they all believed the slides were installed properly on the deck: “I confirmed with 

everyone so that everyone could see that it was indeed put in the proper direction.” 

Investigators observed and photographed a valise after the accident showing the 

correct labeling. 

Within minutes of the accident, the Empress of the North was in contact with 

other vessels in the area, including two commercial fishing vessels, the 56-foot 

Evening Star and the 32-foot Willow, the small passenger vessel Spirit of Columbia, 

and the towing vessel Tiger. The vessel masters all agreed to help evacuate 

passengers from the cruise ship. The two fishing vessels were the closest. At 0223, 

the Evening Star came alongside the Empress of the North, allowing 30 passengers 

and 3 crewmembers to step onto it from the cruise ship. The Evening Star departed 

at 0239. The Willow came alongside at 0251; 13 passengers and 1 crewmember from 

the Empress of the North stepped aboard, and the Willow was away at 0308.

At 0329, the Spirit of Columbia tied up on the port side of the Empress of the 

North, and 52 persons (including 4 in wheelchairs and 5 needing help to walk) 

transferred to the Spirit of Columbia using the cruise vessel’s gangway. Meanwhile, 

the towing vessel Tiger arrived and tied up alongside the fuel barge it was towing. 

The Evening Star and Willow then transferred to the Tiger the 47 passengers and 

crewmembers they had rescued. About 0415, the Tiger tied up on the starboard 

side of the Empress of the North and took on 22 additional passengers. The Tiger

now had 65 passengers and 8 crewmembers on board. 

The Spirit of Columbia got back under way at 0424. At 0438, the Coast Guard 

cutter Liberty, which had arrived at 0405 and assumed on-scene command, tied 

up on the port side of the Empress of the North and took on 89 passengers and 38 

nonessential crewmembers (127 persons total). The Tiger remained alongside the 

Empress of the North until 0519. A minute or so after the Tiger untied, a Coast Guard 

47-foot motor lifeboat that had been dispatched to the scene transferred the last 

four nonessential crewmembers from the Empress of the North to the Tiger.

While still alongside the Empress of the North, the Liberty’s commanding 

officer visited the cruise ship’s bridge. When he returned to the Liberty, he told his 

executive officer that the Empress of the North master seemed to be sober, aware of 

his surroundings, and handling the stress well. At 0521, the Liberty got back under 

way, leaving 29 essential crewmembers on board the Empress of the North. All 206 

passengers and 46 nonessential crewmembers (252 persons) were now on board 

the Tiger, the Spirit of Columbia, or the Liberty. 
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About 0554, the 418-foot-long ferry Columbia arrived. The vessel, part of the 

Alaska Marine Highway System,56 had been on a scheduled run to Juneau when it 

received the Coast Guard’s urgent marine information broadcast and diverted to 

the scene to assist. The Coast Guard decided to transfer all evacuated passengers 

and crew to the Columbia because, according to the Coast Guard chief of response, 

“It was a much better platform that could house everybody. . . . We didn’t like 

having people all spread out all over the place. So we moved them.” 

At 0625, after the Empress of the North had departed for Auke Bay, the Liberty

tied up to the Columbia, making fast alongside an access to the ferry’s car deck that 

aligned well with the Liberty’s main deck. The 127 passengers and crewmembers 

on the Liberty transferred to the Columbia. Over the next 2 1/2 hours, the Coast 

Guard 47-foot motor lifeboat ferried passengers and crewmembers from the Tiger

and the Spirit of Columbia to the Columbia by way of the Liberty. The transfer was 

complete by 0840. 

After all passengers were safely on board the Columbia, the Liberty departed 

at 0855. The Coast Guard conducted a final accountability check before allowing 

the Columbia to depart for Juneau shortly after 0900. The Columbia arrived at Auke 

Bay around 1100 and docked at the Alaska Marine Highway System pier.

Coast Guard Response

The Coast Guard response was structured according to the incident command 

system, an integrated organizational structure, originally developed to manage 

wildfires, that allows multiple agencies to respond to an emergency without 

jurisdictional conflicts. The Coast Guard, the city of Juneau, and the state of Alaska 

together formed a unified command, with the Coast Guard captain of the port serving 

as incident commander. State and local government representatives, as well as 

personnel representing the cruise ship operator, also served on the command staff. 

The search-and-rescue operations plan of Coast Guard District 17, which 

was in charge of search-and-rescue operations for the area where the Empress of the 

North grounded, contained a threat assessment for the area and risk assessments 

for different vessels operating there. The worst-case scenario was described as “a 

grounding or fire on board a high capacity passenger vessel or large fish-processing 

vessel in a remote location that lacks a quick response infrastructure.” According 

to the risk assessment: 

A major concern with high capacity passenger vessels is with the disposition 

of the passengers, many of whom may be elderly, handicapped, injured or 

requiring special medical care. Local medical facilities will be quickly over 

whelmed. Accountability for all passengers and crew will be a priority.

56 The Alaska Marine Highway System operates ferries along 8,000 miles of coastline that are not linked 

by roads.
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The plan contained an execution checklist, procedures for evacuee accountability, 

and a multiagency, quick-start guide for cruise ship emergencies. 

Immediately after the Coast Guard communications center at District 17 

headquarters received the first emergency radio transmission from the Empress 

of the North at 0135, the command center took charge of coordinating the searchand-rescue effort. At 0138, Air Station Sitka was briefed on the grounding, and the 

station’s two available helicopters were prepared to launch. The communications 

center then issued the urgent marine information broadcast over VHF radio channel 

16 that alerted good Samaritan vessels to the emergency. At 0145, the Coast Guard 

cutter Liberty, a 110-foot patrol boat on standby status, was tasked by District 17 

with responding to the accident. The District 17 chief of response was called to the 

command center and began overseeing the search-and-rescue operation. 

The chief of response told investigators that one of his first acts was to 

contact the Marine Exchange of Alaska57 for information about vessels operating 

near the accident site. The Marine Exchange ran a secure system that used satellite 

and AIS transponders to track vessels in Alaska. The Marine Exchange provided 

the Coast Guard with the names of AIS-equipped vessels that were nearby, as well 

as a copy of the AIS playback of the grounding. The chief of response instructed the 

communications center to call specific vessels identified by the Marine Exchange 

as being in the vicinity of the Empress of the North and request their assistance. 

Air Station Sitka launched its first HH-60 Jayhawk helicopter at 0230 and 

the second at 0245. Station Juneau launched a 47-foot motor lifeboat at 0233. Before 

those assets arrived on scene, the communications center was kept apprised of 

the emergency situation by radio updates from the Empress of the North as well as 

by status reports from good Samaritan vessels as they responded to the urgent 

marine information broadcast.

At 0315, the first helicopter arrived at Icy Strait and assumed on-scene 

command. According to the chief of response, the helicopter crew’s job was to 

make sure that everyone was evacuated safely and to keep track of the ships 

that passengers were being evacuated onto. As passengers transferred from the 

Empress of the North to other vessels, the helicopter crew received their names by 

radio and passed them to the command center. This helicopter crew oversaw the 

response until 0405, when the cutter Liberty arrived. The second helicopter from 

Sitka arrived on scene at 0318. 

Two other aircraft, a Jayhawk helicopter from Cordova and a C-130 from 

Kodiak, were launched but then called back when it was established that the 

two Jayhawk helicopters from Sitka were sufficient. A third helicopter was later 

launched from Air Station Sitka to relieve those on scene. At least one Coast Guard 

57 Marine Exchange of Alaska is a nonprofit organization, established in 2000, to bring the diverse Alaska 

maritime community together “by providing information, communications, and services to help ensure safe, 

secure, efficient and environmentally responsible maritime operations” <www.mxak.org/> (accessed June 24, 

2008).
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air asset was present throughout the entire evacuation. Station Juneau launched a 

25-foot response boat at 0722 to provide a relief crew for the 47-foot motor lifeboat 

on scene. The 25‐foot boat eventually escorted the Empress of the North back to 

Juneau.

The command center monitored the transfer of passengers onto other 

vessels, ensured 100-percent accountability, and provided response assets. The 

center’s active role continued until the passengers returned safely to Juneau.

Shoreside Emergency Response

The Coast Guard coordinated closely with the city of Juneau during the 

rescue operation. On being notified of the accident, the city put into action its 

plan for a cruise ship disaster. The plan assigned the responsibilities and tasks 

for emergency and disaster response operations to various departments and 

agencies operating under the incident command/unified command system. The 

city practiced its response plan in annual drills. The last drill before the accident 

was held in Anchorage in January 2007.

An emergency operations center was set up at the Juneau police station, 

staffed by designated personnel, including the port manager for Juneau and 

representatives of the fire department and Coast Guard. The duty officer for Capital 

City (Juneau) Fire and Rescue was the first to arrive at the operations center. He 

was followed by the city emergency coordinator, a Coast Guard representative, 

and a representative from the Alaska Marine Highway System. The operations 

center helped obtain an accurate passenger manifest and prepared to receive the 

passengers from the Empress of the North. Ambulances were waiting for the ferry 

Columbia when it arrived with rescued passengers, and buses were waiting to 

transport passengers to a reception facility 12 miles away in downtown Juneau. 

Passengers were accounted for a final time when they arrived at the facility. Food, 

blankets, cots, and shelter were provided until transportation home could be 

arranged for all passengers.

Tests and Research

Voyage Data Recorder

As required by SOLAS, the Empress of the North was equipped with a 

VDR that stored the last 12 hours of bridge, audio, radar, and parametric data 

in crash-protected memory units.58 The VDR was not damaged in the grounding 

and remained on board the vessel. After the accident, Safety Board investigators 

58 SOLAS chapter V, regulation 20, requires passenger ships constructed on or after July 1, 2002, to carry 

VDRs. Data items to be recorded are established in International Maritime Organization resolution A.861(20) 

and International Electrotechnical Commission (IEC) standard 61996. 
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downloaded the VDR data onto a portable hard drive that they delivered to the 

Board’s surface recorder laboratory in Washington, DC.

The laboratory transcribed relevant data from the bridge audio and radar 

records and from the parametric data specified by National Marine Electronics 

Association (NMEA) standard 0183.59 The quality of the audio recording was 

described as “fair to good.”60 The laboratory identified the following valid NMEA 

fields as having been recorded: wind speed and angle, water speed and heading, 

water depth, time and date, true heading, rate of turn, geographic position, datum 

reference, recommended minimum specific GPS data, commanded port and 

starboard thruster position, course and speed over the ground, and watertight 

and fire door status. 

SOLAS chapter V, annex 10 (appendix), requires VDRs to record 15 data 

items, among them engine order, engine response, and actual thruster position. 

The laboratory determined that the VDR carried on the Empress of the North did not 

record that required information. 

Lifesaving Equipment 

As noted earlier, the evacuation slides on the Empress of the North did 

not deploy correctly after the accident. On November 6, 2007, Safety Board and 

Coast Guard investigators visited Marine Safety Services in Seattle, which had 

serviced the evacuation slides. The company had two employees, one of whom 

did all servicing, packing, and maintenance. The company had an approved 

service manual, last updated in 2006, that contained packing instructions for the 

model SL40 slide, similar to the model SL32 carried on the Empress of the North. 

Investigators interviewed the employees about the packing procedures and 

reviewed the service manual. One employee said that he would usually refer to 

the manual only if he encountered a problem with the packing or maintenance, 

especially for that type of slide, whose packing he regarded as straightforward. The 

two slides from the Empress of the North were the only slides of that type serviced 

by Marine Safety Services. 

On November 7, 2007, the same investigators visited the manufacturer of 

the evacuation slides, DBC Marine Safety Systems of Vancouver, British Columbia, 

Canada, to observe and test the procedures used to pack and inflate the slides. 

No examples of the model SL32 were available, so a model SL25 slide, about 5 

feet shorter than the model SL32 but otherwise nearly identical, was used for 

demonstration purposes. The model SL25 slide was packed into a model SL32 

59 IEC standard 61162 cites NMEA standard 0183 as an approved method of storing data. The NMEA 

standard is also used for passing information between pieces of equipment, for example, sending position 

data from GPS to ECDIS.

60 According to the Safety Board’s VDR audio data report: “Portions of the audio were unintelliglble due 

to the close proximity of commercial satellite and VHF radio speakers to the VDR microphones. Nonpertinent 

conversation close to one or more microphones also masked relevant bridge conversation.” 
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valise, resulting in a slightly loose fit. DBC Marine Safety Systems engineers told 

investigators that the loose fit should not affect slide inflation.

Investigators first observed the approved method of packing a slide into 

its valise. A valise, with the inflation cylinder already packed in the bottom, was 

placed open on the floor of the company’s warehouse. A deflated slide was laid out 

next to the valise (figure 11). On 

one side of the slide was a pullcord (to be attached to a firing 

pin for the inflation cylinder 

inside the valise) and on either 

side were two securing lines (to 

be attached to D-rings on the 

vessel deck before deploying 

the slide). The securing lines 

were 6 inches long with a 

carabiner (a metal ring with one 

spring-loaded side) attached to 

one end. 

In the demonstration, 

the handle of the inflation pullcord was placed through its 

designated hole in the valise 

and into position under the 

outside flap. The slide was then 

placed on the bottom half of the 

valise and folded back on itself 

several times into a stack. The 

top half of the valise was folded 

over the slide and secured to 

the bottom by a Velcro strap 

along the edges of the valise. 

The last step was to connect the 

line from the inflation handle 

to the cylinder’s firing pin. 

Once packed in the valise, the 

slide could be carried by its two 

handles, similarly to a duffel 

bag.

Three possible configurations in which a slide might 

deploy upside-down were 

identified and tested. The tests 

Figure 11. Evacuation slide laid next to a valise 

in preparation for packing. Photo was taken during 

tests at the DBC Marine Safety Systems warehouse 

in November 2007, after the company had labeled 

its valises This Side Up (see “Other Actions Since the 

Accident” section).
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were conducted on a platform approximately 10 feet high to simulate the deck of 

a ship:

•	 Valise upside-down. In this configuration, the stenciled instructions and 

the flap with the inflation pull-cord could not be seen. The chief mate 

told investigators that he could see the stenciled instructions when 

crewmembers positioned the valises on the deck of the Empress of the 

North. Investigators found that to reach the pull-cord required lifting 

the side of the valise that contained the 66-pound inflation bottle. 

Investigators did not try to inflate the slide with the valise in this 

position. 

•	 Slide packed in wrong side of valise. When the valise was open on the 

floor, investigators observed no marks or other identifiers to indicate 

into which side the slide should be packed. The slide was then folded 

according to the servicing manual but placed in the top of the valise 

instead of the bottom. The slide fit easily into the valise, and the 

securing lines and pull-cord were accessible. The valise looked as if it 

were correctly packed, but with the stenciled instructions facing up, 

the slide was actually upside-down. 

To test how the slide would inflate in this condition, the valise was placed 

on the testing platform according to the stenciled arrows, that is, with 

the outboard arrow on the valise pointing toward the platform edge. 

The valise was secured to eyebolts on the platform rather than using 

the carabiners. Because DBC Marine Safety Systems employees were 

unsure how the slide would inflate in this configuration, they requested 

that one of the securing lines not be tied off. One line was put through 

an eyebolt and held by a Marine Safety Systems employee, who allowed 

the line to pull free to avoid damaging the slide. When the inflation cord 

was pulled, the slide inflated outboard in an inverted position.

•	 Valise positioned backward. The slide was then deflated using a 

vacuum and repacked into the valise according to the manufacturer’s 

instructions. The valise was secured to the testing platform backward, 

so that the inboard arrow pointed toward the edge. To avoid excessive 

wear on the slide, the second inflation was conducted using compressed 

air, which resulted in a longer inflation time. The slide’s securing lines 

were tied on both sides to the eyebolts. When the inflation began, 

the slide popped out of the valise and fell off the test platform. The 

securing lines held it in position so that it inflated upward and folded 

back against the platform, or what would have been the outside of the 

ship. The slide ended in an inverted position, with the bottom facing 

inboard.

To confirm that this result was not due to the slower rate of inflation 

with compressed air, DBC Marine Safety Systems agreed to allow a second gas 

inflation test. The slide was deflated and packed back into the valise with a new 
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carbon dioxide charge. The valise was again secured on the testing platform with 

the inboard arrow pointing toward the edge. The slide was gas-inflated in this 

position, with the same result as for air inflation. As the slide began to inflate, it 

was forced off the test platform. The slide was inverted, and because of its position 

off the platform, it inflated upward and back toward the platform.

DBC Marine Safety Systems created two diagrams showing different 

postinflation positions for the evacuation slide. The diagrams were sent to the 

chief mate of the Empress of the North, who was asked to identify which position 

best matched the position of the slides on the vessel. The chief mate identified the 

position in which the slide was inverted and folded back against the outside of the 

ship, thereby blocking the embarkation area. 

Operational and Management Information 

Corporate Organization

According to the company’s website,61 Majestic America Line was formed 

in 2006 with the combined assets of American West Steamboat Company and 

Delta Queen Steamboat Company. Based in Seattle, the company was part of 

Ambassadors Cruise Group (ACG), a division of Ambassadors International, 

Inc., a cruise, marine, insurance, and travel and event company.62 In January 2006, 

ACG acquired American West Steamboat Company and its two paddle wheelers, 

the Empress of the North and the Queen of the West. In April 2006, ACG acquired 

Delta Queen Steamboat Company, which included three companies and three 

ships (American Queen, Delta Queen, and Mississippi Queen). Later that year, ACG 

acquired two more ships, the Columbia Queen and the Executive Explorer, which it 

renamed the Contessa. In April 2007, ACG acquired Windstar Cruises, a subsidiary 

of Holland America Line, and its three ships. 

The senior vice president of marine operations oversaw deck and engine 

operations for Majestic America Line. He had been in the position about 2 months 

when the accident occurred. Before that, he was a maritime consultant and before 

that, he worked for Holland America Line, first as a passenger vessel master and 

then as director of environmental compliance. At the time of the accident, he was 

integrating Windstar operations with those of Majestic America Line. He reported 

to the president of Majestic America Line and oversaw, among others, the vice 

president of marine operations. Vessel masters reported to the vice president of 

marine operations.

On April 29, 2008, Ambassadors International, Inc., announced that it 

planned to sell Majestic America Line.

61 <www.majesticamericaline.com>.

62 <http://stocks.us.reuters.com.stocks/fullDescription.asp?symbol=AMIE.O> (accessed May 19, 2008).
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Safety Management System

As a passenger ship traveling on international waters, the Empress of the 

North was required to meet mandatory international certification requirements for 

safety management systems under the ISM code. The ISM code was incorporated 

by the International Maritime Organization in SOLAS chapter IX and by the Coast 

Guard in U.S. regulations at 33 CFR 96, “Rules for the Safe Operation of Vessels 

and Safety Management Systems.” 

The objectives of a safety management system are to create a “culture of 

safety” by documenting a vessel owner’s operational policy, chain of authority, 

and operational and emergency procedures; specifying the responsibilities 

of the owner or operator, managers, and masters; and outlining procedures 

for management review, internal audits, and correction of nonconformities 

(failure to adhere to procedures or regulations). Procedures are compiled in a 

safety management manual and a copy is kept on board the vessel. A person 

or persons are designated in writing to monitor the safety management system, 

and managers conduct regular audits to ensure that employees follow the 

procedures. Checklists are supplied for critical procedures. A complete list of 

documents required for a safety management system under Federal regulations 

is found at 33 CFR 96.250. 

Safety management systems are monitored through internal and 

external audits. Companies establish their own internal audit schedules. When 

deficiencies are noted or an accident or a noncomformity occurs, corrective 

action is taken until the problem is resolved. External audits are performed at the 

company’s request by an approved independent third party, usually a marine 

classification society. A document of compliance, valid for 60 months, is issued 

after completion of a satisfactory safety management audit. The Coast Guard 

or another organization authorized to act on behalf of the United States must 

annually verify that a company’s safety management system has complied with 

the ISM code. The signature of the authorized official must be affixed to the 

document of compliance after each of the required annual verifications. 

At the time of the accident, the safety management system for the 

Empress of the North was documented in two manuals. The 76-page Office Safety

Management Manual, issued in February 2006, introduced the company’s safety 

management system and stated policies and procedures regarding management, 

document control, reporting, audits, operation of ships, shipboard maintenance, 

and emergency situation with respect to the ISM code. The 117-page manual of

Fleet Instructions, first issued in 2003 and revised in 2004, covered preparations for 

sea, such as bridge equipment tests, voyage plans, and predeparture checklists; 

operations at sea, such as watchstanding requirements and duties of watch officers, 

watch changes, steering and lookout, and bridge resource management; and duties 

and responsibilities of the engineering department. The instructions also dealt with 

personnel, administration, emergency preparedness, and preventive maintenance 

and inspection.
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On January 12, 2004, the American Bureau of Shipping issued a safety 

management certificate for the Empress of the North certifying that the ship’s safety 

management system had been audited and that it complied with the ISM code. 

The document was valid until December 10, 2008, but as noted earlier, was invalid 

at the time of the accident because the company’s document of compliance had not 

received its required annual verification. 

About 2 weeks before the accident, Majestic America Line hired a former 

vessel master to serve as director of marine compliance and as the “designated 

person ashore,” a position required by ISM-compliant vessels, but that employee 

had not yet joined the company. A senior manager was serving as the designated 

person in the interim but had numerous other responsibilities and duties. As the 

senior vice president explained to investigators, the position of director of marine 

compliance was part of the company’s efforts to upgrade its safety management 

system. Of the Majestic America Line vessels, only the Empress of the North

was required to have a safety management system because the ship traveled 

in international waters between the United States and Canada. However, the 

company intended to upgrade the safety management system and apply it to all 

vessels in its fleet. 

The company was also in the process of restructuring its marine operations 

department, with the vice president of marine operations becoming the vice 

president of technical operations. Other positions were to be modified into vice 

president of nautical operations and technical superintendents based in Portland, 

Oregon, and St. Louis, Missouri. Senior management, including the company 

president, went onto each vessel in the spring, met with the crew, and showed a 

video about the company’s safety policies. 

Previous Accidents

The Empress of the North had been involved in three earlier accidents, two 

while under previous management. The first accident occurred on October 22, 

2003, on the Snake River in Washington state. The Empress of the North, bound 

upriver, entered Ice Harbor Lock and Dam (figure 12). When the lock was 

filled, the upstream gate was lowered and the lock master radioed the Empress 

of the North that it was clear to exit. The crew cast off lines and began to exit 

the lock. However, the vessel struck the gate over which it had been cleared to 

pass, sustaining damage to the forward ballast tank. No injuries or pollution 

resulted. 

A month later, on November 22, 2003, the Empress of the North was bound 

down the Columbia River, carrying 68 passengers and 56 crewmembers. After 

leaving the lock at The Dalles, Oregon, the master turned the watch over to the 

second mate, and the helmsman requested permission to shift from autopilot to 

hand steering. During the shift, the vessel lost propulsion control and grounded 

on the Washington side of the river. The hull was damaged and required shipyard 
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repair. Seven passengers and five crewmembers were injured, three of whom 

required medical attention beyond first aid.

On March 24, 2006, the Empress of the North grounded in the Columbia River 

near Washougal, Washington, while trying to avoid a towing vessel that was 

having difficulty maneuvering in the channel. On board were 178 passengers and 

79 crewmembers. According to the senior vice president of operations at Majestic 

America Line,

. . . the vessel took avoidance action and strayed out of the channel because 

of a barge . . . that had lost control. . . . In order to avoid a worse situation, 

they went outside of the buoy markers and struck ground.

The Empress of the North sustained significant damage, but no pollution or 

injuries were reported. The Coast Guard investigated the incident and issued letters 

of warning to the Empress of the North second mate and to the towboat operator 

because they had failed to communicate clearly. The master at the time was also 

in command during the May 2007 grounding that is the subject of this report. As 

noted earlier, the Coast Guard did not fault the master in the 2006 grounding.

Figure 12. Sites of previous accidents (Ice Harbor Lock and Dam on the Snake River; 

The Dalles, Oregon; Washougal, Washington) involving the Empress of the North. Also 

shown are locations mentioned in the report but not indicated on the accident location map 

(figure 2).
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As a result of the 2006 grounding, Majestic America Line issued new 

policies for the Empress of the North in the form of supplementary bridge watch 

standing orders. In addition to policies specifically related to the grounding, such 

as establishing no-passing zones on the vessel’s river routes, the supplementary 

orders included requirements for bridge watch officers to “have a thorough 

understanding of bridge equipment and electronics and their use” and to fully 

understand the route being followed before relieving the watch. Before the 2007 

accident, the master and all watchstanders were required to sign a form attesting 

that they had read and understood the standing orders The junior third mate 

had not signed the form when he assumed the watch during which the accident 

occurred.

Additional Information

Majestic America Line Actions Since the Accident

After the accident, Majestic America Line voluntarily redesigned its safety 

management system and completely rewrote its safety management manual. The 

new document, which sets out the definitions and procedures for implementing 

the company’s safety management system, covers 834 pages, divided into five 

volumes: 

Vol. I Safety Management Manual (25 pages).

Vol. II Operations Manual (319 pages, including company and vessel 

organization charts and job descriptions). 

Vol. III Operational Checklists and Forms (109 pages).

Vol. IV Preventive Maintenance Program (183 pages).

Vol. V Emergency Contingency Plan (198 pages).

Listed in the margin of the text are relevant Coast Guard or International 

Maritime Organization regulations (such as parts of the ISM code) and crossreferences to other sections of the safety manual. The contents pages of all five 

volumes are reproduced in appendix F.

Volume I gives general definitions related to the safety management system 

and defines company responsibilities and authority. Section 4.0, for example, 

defines the designated person ashore as responsible for maintaining the system, 

including matters related to the company’s document of compliance and each 

vessel’s safety management certificate. 

Deck operations and technical operations (engineering) are covered in 

volume II, supplemented by an appendix giving detailed job descriptions for 

vessel officers, deckhands, engineers, and hotel employees. Section 4.2, “Deck 
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Watchkeeping,” subsection 4.2.1, lists vessel features that “each licensed, 

registered, or certificated individual must become familiar with . . . prior to 

assuming his or her duties,” such as maneuvering characteristics and operation of 

navigation equipment. Further, before they are “allowed to stand a navigational 

watch alone,” new deck officers are required to complete a bridge equipment 

checklist, and masters must “consider for a navigational officer” seven items 

related to pilotage, taken from the Coast Guard’s qualifying requirements for 

first-class pilots at 46 CFR 10.705. 

Subsection 4.2.1 reminds employees: “[I]f a first-class pilot has not served 

over a particular route within the past 60 months, the pilot’s license or endorsement 

is invalid for that route.” An overlap period of between 1 and 4 days, or longer 

in special cases, is established for ensuring that an officer is qualified to stand 

watch alone. Further, “If deemed necessary by the Master or Chief Engineer, 

an experienced Officer will join the new Officer during the first watch or for a 

period of time, regardless of the overlap period with the off-signing Officer.” Two 

pages of the manual are devoted to discussing the responsibilities of the officer of 

the watch (section 4.2.6) and three pages to “Keeping Watch While Underway” 

(section 4.2.7). 

Standing orders and night orders are dealt with in section 4.2.5 of the manual, 

which states, “The Master is to use a ‘Night Order Book’ for giving information 

and instructions to the [officer of the watch] regarding the navigation of the ship.” 

Standing orders are to be permanently attached to the night order book, which 

deck officers are required to sign and date. 

Deck standard operating procedures are laid out in section 4.3 of the Operations 

Manual. The manual states, “A detailed voyage or passage plan should be prepared” 

and is to “be available at all times on the bridge.” The manual devotes 4 1/2 pages 

to analyzing the process of voyage planning and passage appraisal. The first 

step in developing a voyage plan is to be an appraisal of information relevant to 

the voyage, such as vessel condition, crew availability, certificates, weather, and 

pilotage. The manual lists 11 factors that should be included in the plan itself, such 

as plotting of intended route, safe speed, course alteration points, and position 

fixing. Decisions involved in executing the plan are also discussed, such as tide, 

weather, and traffic. The manual also contains over four pages of instructions for 

navigating in inland waters, including details about the effect of shallow water on 

a ship’s draft (“squat” effects) and specific examples and considerations for pilots 

to keep in mind. 

Section 4.4 of the Operations Manual deals with documentation. The manual 

states, “The Master is responsible for tracking the expiration of all certificates 

issued to the vessel or maintained on the vessel.” They include the COI and SOLAS 

certificates. Other contents of the Operations Manual are listed in appendix F.

Operational checklists and forms are gathered in volume III of the safety 

management system documents. The operational checklist for passage appraisal 
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(OP 3.3) includes the task, “Make up trip voyage plan,” noting that an Excel 

template is located in the computer for that purpose. The master is required to 

prepare and review the passage appraisal checklist. The three-page checklist for 

bridge watch changes (OP 4.4) includes specific watch handover information that 

the officer on watch and his relief are responsible for (Operations Manual, section 

4.1.10, “Change of Watch”). 

Volume IV, the preventive maintenance program for the Empress of the 

North, gives inspection criteria references (ICRs) for 17 categories of shipboard 

items, including emergency equipment.63 The appendix contains 30 detailed test 

procedures and checklists. The ICRs give authorization information (inspector, 

references, frequency) and list requirements for monthly, quarterly, and annual 

required checks. The criteria for inspecting the vessel’s inflatable liferafts (ICR B.05) 

give the following specific instructions for maintaining the remote-release units: 

“Hammar Manual Remote Release System Pneumatic Pump Units to be lubricated 

per instructions at least every two years. See USCG [Coast Guard] Marine Safety 

Alert 4-07” (the alert is described in the “Coast Guard Actions Since the Accident” 

section, below).64 For the contents of volume V, the Emergency Contingency Plan, 

see appendix F.

Although the Empress of the North was the only ship in the Majestic America 

Line fleet that was required by international regulations to have a safety management 

system, the company informed the Safety Board that since the accident, it had 

voluntarily implemented the system fleetwide. Further, an implementation team 

was visiting all vessels to ensure that the safety management system was properly 

implemented, and the American Bureau of Shipping had approved the system. 

The company informed the Safety Board of numerous steps it had taken as of 

March 2008 to improve the safety of its operations, among them the following:

• Had all newly hired bridge watch officers evaluated at Pacific Maritime 

Institute (a vocational training center in Seattle for mariners) on a full 

bridge simulator. 

• Contracted with Pacific Maritime Institute for a 2-year mates training 

program to provide trained officers to the company’s fleet. 

• Contracted with a maritime risk consulting firm to examine company 

operations for risk and recommend changes to policies and procedures; 

implemented all recommendations.

63 The other categories are documents and paperwork; lifesaving equipment; fire protection equipment; 

structural fire protection; ventilation; navigation equipment; ground tackle; hull, decks; fittings, watertight 

integrity; accommodation/related spaces; emergency drills; forms, notices, publications, crew requirements; 

propulsion systems; diesel power systems, unfired pressure vessels; auxiliary machinery and equipment; 

electrical systems.

64 Section 3.4.1 of the Operations Manual states that critical equipment, which includes lifesaving 

equipment, is to be inspected every year when the manufacturer has not defined the inspection interval.
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The company stated that it had also become an active member of the Cruise 

Line Industry Association and the Passenger Vessel Association. The Cruise Line 

Industry Association is the official trade organization of the North American cruise 

industry, composed of 24 major cruise lines. The Passenger Vessel Association 

represents the interests of more than 350 vessel owners and operators in the U.S. 

passenger vessel industry. 

Safety Board Actions Since the Accident

On July 5, 2007, after finding that the approved lifesaving equipment 

carried on the Empress of the North malfunctioned during the emergency response 

to the accident, the Safety Board issued two urgent safety recommendations to 

the Coast Guard. The first recommendation concerned the failure of half of the 

manual release mechanisms for the vessel’s liferafts:

M-07-9

Verify the functionality of Hammar model H20 remote-release units for 

liferafts by inspecting or delegating the inspection of a sample of the 

models, requiring authorized facilities to demonstrate functionality, or 

other equally effective method. (Urgent)

On August 21, 2007, the Coast Guard responded that it concurred with the 

recommendation. The Coast Guard’s letter stated that according to the company’s 

port engineer, 20 of the 22 remote-release units had been on the Empress of the North

for over 2 years and had not been properly lubricated since they were installed. 

The letter stated further that Majestic America Line had replaced those 20 units 

and was “taking steps to ensure” that the units would be lubricated as required (as 

described in the previous section, the company’s revised preventive maintenance 

program contains specific requirements for the Hammar remote-release units). 

The response letter continued that inspectors from Coast Guard Sector 

Portland had inspected more than half of the new units on June 30, 2007, and had 

“found them functioning satisfactorily.” The letter stated that Coast Guard action 

on the recommendation was complete and requested that the recommendation 

be closed. On April 23, 2008, the Safety Board classified Safety Recommendation 

M-07-9 as “Closed—Acceptable Alternate Action.”

The other urgent safety recommendation to the Coast Guard concerned 

the incorrect deployment of the inflatable evacuation slides on the Empress of the 

North:

M-07-10

Conduct a one-time inspection and correction of all deficiencies of 

evacuation slides last serviced by Marine Safety Services of Seattle, 

Washington. (Urgent)
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On August 21, 2007, the Coast Guard responded that it concurred with 

Safety Recommendation M-07-10 and that inspectors from Coast Guard Sector 

Seattle who visited Marine Safety Services on July 6, 2007, had determined that

it would be extremely difficult to pack the slides incorrectly without 

making significant modifications to the valise. The pull cord especially 

must be oriented correctly inside the valise in order for it to be accessible at 

the flap. Any incorrect folding or orientation would likely make the slide 

impossible to deploy in any direction. 

The Coast Guard concluded that 

there were no deficiencies in the evacuation slide servicing by Marine 

Safety Services. It is likely that crewmembers, dealing with the stressful 

circumstances associated with the grounding, placed the valises upside 

down on the deck, leading to the slides deploying incorrectly. 

The Coast Guard stated that its action on Safety Recommendation M-07-10 

was complete and requested that the recommendation be closed, noting that 

at the time of the casualty, the valises were marked only with “inboard” and 

“outboard” markings to indicate the correct orientation. The manufacturer 

has since added additional markings to ensure that the “up” and “down” 

sides are clearly indicated.

The actions of the manufacturer, DBC Marine Safety Systems, are discussed 

below in “Other Actions Since the Accident.” After the Safety Board received the 

Coast Guard’s response, a Safety Board investigator and a Coast Guard investigator 

visited both Marine Safety Services and DBC Marine Safety Systems to test the 

evacuation slides, as described earlier in the “Tests and Research” section. On 

April 23, 2008, the Safety Board classified Safety Recommendation M‐07‐10 as 

“Open—Acceptable Response.”

Coast Guard Actions Since the Accident

Liferaft Release Units.On September 26, 2007, the Coast Guard issued Marine 

Safety Alert 4-07 regarding the Hammar remote-release units, noting, without 

naming the Empress of the North, that “a recent passenger ship grounding revealed 

difficulties the crew had in manually deploying the vessel’s liferafts from their 

mounting cradles.” The safety alert “strongly” recommended that the Hammar 

pump units “be maintained in accordance with the manufacturer’s recommended 

maintenance schedules.” The alert featured a photo of a Hammar remote-release 

pump unit and stated that the units were clearly marked, “Lubricate piston every 

second year.”

Document Inspection. According to the Coast Guard chief of prevention for 

Sector Portland, after learning that the last annual inspection of the Empress of the 
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North had failed to identify problems with Majestic America Line’s document of 

compliance, Sector Portland senior officers met with the inspector of the Empress 

of the North and then held a training session for all the Sector Portland vessel 

inspectors. The chief of prevention also listed other measures that Sector Portland 

had taken to prevent future oversights regarding vessel documentation:

• Inspection staff meets periodically to review shortcomings and identify 

ways to correct problems.

• Senior officers reevaluate inspection checklists.

• Inspection staff members review vessel certificates coming up for 

inspection in their sector.

• Inspectors participate in weekly training.

Coast Guard headquarters recently informed the Safety Board that the 

American Bureau of Shipping had agreed to notify the Coast Guard when an ISM 

document becomes invalid; headquarters staff will then notify the local OCMI for 

action. The Coast Guard also stated that it would seek similar agreements with the 

other two classification societies (Det Norske Veritas and Germanischer Lloyd) 

that issue ISM documents on U.S.-registered vessels.

Pilotage. The chief of vessel inspections for Coast Guard Sector Juneau 

informed the Safety Board that after the accident, Sector Juneau had checked 

13 U.S. passengers vessels (subchapter T and subchapter K) for which pilotage 

requirements applied and was taking action to verify compliance. The chief 

estimated that it could take 30 to 60 days for a mariner to satisfy the “acting as” 

pilot requirements if he or she had no previous experience in southeast Alaskan 

waters. 

The chief of vessel inspections said that Sector Juneau had explained the selfcertification pilotage requirement to the managers of the companies that operate 

vessels in southeast Alaska. At the end of the 2007 season, Sector Juneau surveyed 

self-certified pilotage on 13 domestic cruise vessels that operate in southeast 

Alaskan waters. All masters and mates were found to be in compliance with the 

regulations, according to the assistant chief for inspections in Sector Juneau. At 

the beginning of the 2008 season, Sector Juneau again checked pilotage and found 

all vessels in compliance, though some had had to hire extra mates, adjust watch 

schedules, or temporarily hire Federal pilots.

Other Actions Since the Accident

On July 12, 2007, DBC Marine Safety Systems issued two service bulletins 

concerning the model SL32 slide carried on the Empress of the North. Bulletin 

DBC‐07‐04 instructed that at the next servicing, all slide valises should be marked 

with the labels This Side Up on the top and Turn Over on the bottom. Bulletin 
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DBC-07-06 gave new instructions on the packing of the model SL32 slide, as 

follows:

This service bulletin outlines how the SL32 shall be packed. It differs slightly 

from the SL40 instructions because the cylinder is in a different position[;] 

this method allows for the cylinder to be packed at the back of the valise so 

that when it is carried the cylinder does not shift. The SL25 shall be packed 

similar to the SL40 because its cylinder is in a similar position to the SL40.

The company informed the Safety Board in May 2008 that it had prepared 

stencils for labeling the insides of the valises so that service technicians could 

readily determine into which side of the valises they should pack the slides.

U.S. Maritime Academies

Six state maritime academies and the U.S. Merchant Marine Academy offer 

training to prospective merchant marine officers (table). Students are organized as 

military academy cadets and take examinations for Coast Guard licenses before 

their graduation date. The state academies operate with Federal aid. The U.S. 

Merchant Marine Academy is funded by the U.S. Department of Transportation’s 

Maritime Administration and administered by the U.S. Maritime Service.

Table 1. Maritime academies in the United States.

Academy Location Founded Enrollment Degrees Awarded

California 

Maritime 

Academy

Vallejo, 

California

1929 650 BS marine transportation; BS marine 

engineering; Coast Guard license 

offered, deck and engine studies

Great Lakes 

Maritime 

Academy

Traverse City, 

Michigan

1969 80 BS business; associates degree, applied 

science, marine technology; Coast 

Guard license offered, deck and engine 

studies

Maine Maritime 

Academy

Castine, Maine 1941 720 BS marine transportation; BS marine 

engineering; Coast Guard license 

offered, deck and engine studies

Massachusetts 

Maritime 

Academy

Taylor Point, 

Buzzards Bay, 

Massachusetts

1891 900 BS marine transportation, marine 

engineering;

Coast Guard license offered, deck and 

engine studies

State University 

of New York 

Maritime 

College

Throggs Neck, 

New York

1874 900 BS marine transportation; BS marine 

engineering; master’s program, 

international transportation management; 

Coast Guard license offered, deck and 

engine studies

Texas Maritime 

Academy

Galveston, 

Texas

1962 260 BS marine transportation; BS marine 

engineering; Coast Guard license 

offered, deck and engine studies

U.S. Merchant 

Marine Academy

Kings Point, 

New York

1943 950 BS marine transportation; BS marine 

engineering; commissioned ensign, U.S. 

Naval Reserve; Coast Guard license 

offered, deck and engine studies

Table. Maritime academies in the United States.
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Analysis

General

The analysis first identifies factors that can be eliminated as causal or 

contributory to the accident. It then discusses the safety issues identified in the 

accident investigation:

• Master’s decision to put an inexperienced third mate on watch without 

supervision or guidance.

• Junior third mate’s actions.

• Watchkeeping procedures. 

• Documentation deficiencies. 

• Malfunctioning lifesaving devices.

Exclusions

The weather at the time of the accident was cloudy and drizzly, but the 

evidence indicates that visibility (7 to 10 miles) was not restricted, winds were 

mild (8 to 10 mph), and the sea was calm. The flashing green navigation light 

on Rocky Island was clearly visible to the watchstanders on the bridge about 

4 minutes before the grounding, and the Coast Guard verified in a postaccident 

check of the aids to navigation in the area, including the light on Rocky Island, that 

all were functioning properly. 

The evidence further indicates that the vessel’s machinery was operating 

properly at the time of the accident, and that the vessel had experienced no 

propulsion, steering, or any other problems with the engineering plant before the 

grounding. (The vessel returned to Juneau under its own power after the accident, 

despite damage to its starboard propulsion drive sustained in the grounding.) 

Toxicological analysis of samples taken from the master, chief mate, helmsman, and 

junior third mate on watch were all negative for the presence of alcohol and illegal 

drugs. In addition, the chief mate, helmsman, and junior third mate had all had 

sufficient rest to perform effectively at the time of the accident. The Safety Board 

therefore concludes that the following were not causal to the accident: weather 

(including visibility, wind, sea, and current); aids to navigation; vessel propulsion 

and steering systems; use of alcohol or illegal drugs; watchstander fatigue. 
Analysis

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Accident

Carrying 206 passengers and 75 crewmembers, the Empress of the North left 

Skagway the evening of May 13 and traveled south on Lynn Canal at about 12 

knots. The trip was uneventful until about 8 hours later, when the vessel reached 

the intersection of Lynn Canal and Icy Strait. The bridge team consisted of the 

helmsman, who was an experienced AB, and the junior third mate, who was on 

his first ever underway watch as a licensed officer. 

To make the westward turn into Icy Strait, the vessel could take either a 

route that ran between Rocky Island and the mainland at Point Couverden or one 

that went around Rocky Island to the south before turning west. The decision, 

according to the master and the chief mate, was left to the individual watch officer. 

Both routes were marked on the vessel’s navigation charts. The second mate, who 

had the previous watch and who spent about 20 minutes with the junior third 

mate before the watch changed, recalled explaining the two possible routes but 

that the junior third mate did not indicate what his plans for the route were. 

About 3 minutes before the accident, the helmsman initiated an 80° turn 

to the west, indicating that he intended to pass between Rocky Island and Point 

Couverden. Shortly thereafter, without informing the junior third mate, the 

helmsman altered his course to the left. He then told the junior third mate that he 

did not think the vessel was turning fast enough. The junior third mate observed 

the helmsman increase the rate of turn and looked for the flashing green light on 

Rocky Island but could not see it. When he saw rocks, he issued his first steering 

order, “Hard left,” but it was too late to prevent the vessel from hitting the rocks. 

The Safety Board therefore concludes that the Empress of the North bridge team was 

attempting to negotiate an 80° turn at Rocky Island, a charted navigation hazard, 

but the vessel’s rate of turn was insufficient to prevent it from grounding on the 

rocks. 

Master’s Decision to Put Inexperienced Third Mate on Watch

The day before the accident, while the Empress of the North was in Skagway, 

the senior third mate was diagnosed with a gastrointestinal ailment and told to 

remain in isolation on the vessel. The master decided to replace the senior third 

mate on the midnight-to-0400 watch on May 14 with the newly arrived junior third 

mate. The junior third mate held an unlimited, any-ocean third officer’s license but 

had never before stood an underway watch on the vessel or traveled the waters of 

Lynn Canal. Deck officers, or officers of the watch, were required by the vessel’s COI 

to have either a pilotage endorsement or to have made four previous round-trips 

in those waters. The junior third mate met neither requirement. The implications 

of the vessel’s pilotage requirements are discussed further in the “Documentation 

Deficiencies” section.
Analysis

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According to interviews, the master originally planned to have the junior 

third mate stand his first watch with the senior third mate, who, while having 

charge of the watch, could also have helped familiarize the new officer with the 

bridge equipment and routine. Once the senior third mate fell ill, the master 

altered his plan and decided to assign the junior third mate to the midnight-to0400 watch in place of the ill crewmember. To compensate for the junior third 

mate’s inexperience, the master decided to assign the most senior AB as helmsman 

on the same watch. The master stated that he discussed his plan with the chief 

mate, who did not disagree with it. The junior third mate, when informed by the 

master that he would be standing the watch, also expressed no disagreement with 

the plan. The master did not make the watchkeeping decision under duress, such 

as during an emergency. Rather, to solve the problem posed by the senior third 

mate’s illness, the master had time to consider alternative actions. For example:

• He and the chief mate (although masters do not ordinarily stand watch) 

could have each stood 6 hours on watch and 6 hours off.

• He could have asked the company for an additional mate, one who met 

the pilotage requirements. 

• He could have asked the company for authorization to hire a local 

pilot. 

There is no evidence that the master considered any of these alternatives. 

Moreover, he did little to prepare the junior third mate for his first underway watch. 

Neither he nor the chief mate reviewed the route with the new officer, discussed 

the steering modes (manual or autopilot), or helped familiarize him with critical 

bridge components such as the radar. The standing orders for the Empress of the 

North required bridge watch officers to “have a thorough understanding of bridge 

equipment and electronics and their use.” The junior third mate stated during 

interviews that he was unfamiliar with the bridge equipment and the bridge 

procedures. During the accident voyage, the helmsman attempted to familiarize 

the junior third mate with the equipment while engaged in steering the vessel, but 

it was the watch officer’s responsibility to navigate, not the helmsman’s. 

The master told investigators that he considered the midnight-to-0400 watch 

an “easy” one. Nevertheless, the route contained at least one potential hazard 

(Rocky Island) and at least one critical decision for the watch officer (selecting 

the route from Lynn Canal into Icy Strait). A senior officer should have reviewed 

the merits and hazards of each with the junior third mate before he assumed his 

first watch. The junior third mate lacked any knowledge of the route and should 

not have been left to make this critical decision on his own. By assigning him to 

the watch, the master put the safety of the vessel and those on board at risk. The 

Safety Board therefore concludes that the master jeopardized the vessel’s safety by 

allowing the junior third mate to stand a bridge watch before he was familiar with 

the route and the bridge equipment. 
Analysis

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The junior third mate was unfamiliar with the route and during the accident 

voyage, relied on the helmsman for navigation and steering. The junior third mate 

told investigators that he understood that the helmsman “would be in control of 

the boat” and that he, the junior third mate, would be on the bridge because he 

was a licensed deck officer. Indeed, according to the VDR data, the helmsman 

steered without receiving commands from the junior third mate throughout the 

voyage. The helmsman did not inform the junior third mate of his intentions, and 

the officer did little to direct the helmsman until just before the accident. Thus, 

the junior third mate ceded his authority to make navigation decisions to the 

helmsman. 

Breakdowns in team performance can occur when the superior member of 

a team is perceived to have less experience than the subordinate. The Safety Board 

has examined previous accidents in which the effectiveness of operator teams broke 

down because the gradient of authority degenerated. In 1990, for example, a runway 

collision occurred in Detroit when an aircraft entered an active runway during 

conditions of limited visibility.65 The aircraft captain was on his first commercial 

flight in more than 6 years, after returning from medical leave and requalifying as 

captain. The first officer claimed to have greater knowledge of the area than the 

captain, and the captain deferred almost all navigation responsibilities to him. In 

its report on the accident, the Safety Board wrote:

The Safety Board believes that a nearly complete and unintentional reversal 

of command roles took place in the cockpit of the DC-9 shortly after taxiing 

began. The result was that the captain became overly reliant on the first 

officer. The captain essentially acquiesced to the first officer’s assumption 

of leadership. This role reversal contributed significantly to the eventual 

runway incursion.

Teams of operators are most effective when the lines of authority and 

responsibility are clear. The lines of authority on the Empress of the North were 

blurred because the experience of the two watchstanders was counter to that 

expected by their nominal roles in the team. The helmsman was superior to the 

officer on watch in knowledge, experience, and skill, and the junior third mate 

appeared to understand his role in relation to the helmsman, though it was contrary 

to the norm for bridge authority. The helmsman, probably in response to the junior 

third mate’s failure to exercise authority over the vessel’s navigation, exceeded his 

own authority by maneuvering the vessel in the absence of commands and, worse, 

failed to inform the officer of his intentions. In effect, the junior third mate and the 

helmsman switched roles during the accident voyage. Therefore, the Safety Board 

concludes that the master’s watch assignment created a poorly functioning bridge 

team in which an inexperienced officer in charge (the junior third mate) did not 

exercise authority and an experienced subordinate (the helmsman) exceeded his 

authority.

65 National Transportation Safety Board, Northwest Airlines, Inc., Flights 1482 and 299, Runway Incursion 

and Collision, Detroit Metropolitan/Wayne County Airport, Romulus, Michigan, December 3, 1990, Aviation 

Accident Report NTSB/AAR-91/05 (Washington, DC: NTSB, 1991).
Analysis

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The master’s decision to assign an inexperienced deck officer to the watch 

created the situation that led to the accident. The Safety Board examined the 

master’s decision to identify, if possible, the factors that influenced it. Two nights 

before the accident, the master received between 5 and 5 1/2 hours of sleep after 

a passenger fell ill and then died. The night before the accident, the master slept 

about 6 hours. Thus, on the two nights leading to the accident he received less than 

the 8 hours, plus or minus 1 hour, that researchers suggest most people require 

to function optimally.66 However, while the master’s accrued sleep deficit might 

have adversely affected his decision-making, other aspects of his decision do 

not suggest sleep deprivation. For example, the master told investigators that he 

decided to alter the watch schedule of the ABs so that an experienced AB would 

work with the junior third mate. He stated that the midnight-to-0400 watch was “an 

easy watch” and thus “a good place to start” for an inexperienced watchstander. 

He may also have considered other options, such as changing the schedules of 

the other licensed watchstanders to ensure that an experienced mate was on the 

bridge at that time, but he did not take them. 

The Safety Board examined the company to determine what role, if any, 

it played in the master’s errors. Despite the company’s implementation of a 

required safety management system for the Empress of the North, and despite the 

requirement to adhere to Federal regulations, the master did not follow critical 

aspects of either and did not establish on his vessel an ethos of compliance with 

all policies, rules, and regulations. The company should have been more aware 

before the accident of the actions of the master and the type of safety atmosphere 

that he had established. 

At the time of the accident, company personnel were involved in multiple, 

major corporate activities. A senior vice president of marine operations had 

joined the company about 2 months before the accident, but he told investigators 

that most of his time was spent integrating the operations of the two separate 

companies that had formed Majestic America Line. Just before the accident, the 

company acquired Windstar Cruises, and he was also responsible for overseeing 

their operations as well. The company official told Safety Board investigators that 

the safety management system under which the Empress of the North operated 

needed to be enhanced and that he intended to strengthen it. He had not been able 

to begin that activity before the accident. Therefore, the Safety Board concludes 

that Majestic America Line did not effectively monitor the master’s compliance 

with its policies and procedures. 

Company management accomplished several activities before the accident 

to enhance safety. The company, in assigning a person to the required position 

of designated safety official, hired a full-time employee dedicated exclusively 

to overseeing the safety of its operations. As many other companies have done, 

it could have assigned the duties of this position as collateral duties to another 

66 M. R. Rosekind, “Fatigue in Transportation: Physiological, Performance, and Safety Issues,” in National 

Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address 

Operator Fatigue, Safety Report SR-99/01 (Washington, DC: NTSB, 1999).
Analysis

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company official. Before the accident, the individual accepted the offer of the 

position, but he was not scheduled to join the company until after the accident. 

In addition, while not required, the company sent the junior third mate to the 

Empress of the North a full week before he was scheduled to report for duty, to 

enable him to become familiar with the vessel and its operations. That action 

should have communicated to the master the company’s intent to have the mate 

serve in a training capacity and not as a watchstanding officer until he had spent 

time observing vessel operations.

The deficiencies in the master’s decision-making appear to result not so much 

from impairment but rather from a failure to assess the skills and abilities of the 

mariners he assigned to the watch. The master failed to fully assess the junior third 

mate’s lack of knowledge about the vessel, the route, and the navigation display 

believing, as he told investigators, that the junior third mate’s license was sufficient 

to qualify him to stand the watch. This was a flawed assumption. The master was 

responsible for ascertaining the junior third mate’s readiness to serve as officer 

of the watch, a task that he did not perform effectively. The master also failed to 

articulate his expectations about the duties and responsibilities of the watchstanders 

on the midnight-to-0400 watch, apparently assuming that the junior third mate and 

helmsman understood their roles, duties, and responsibilities. However, by not 

articulating his expectations, he created a situation, as described above, in which 

each watchstander took on elements of the role, duties, and responsibilities of 

the other and which increased the likelihood that the watchstanding team would 

commit errors. Thus, the master’s original error in not fully assessing the skills and 

abilities of the junior third mate was compounded by further errors of judgment.

Junior Third Mate’s Actions

As the officer on watch, the junior third mate failed to avoid a navigation 

hazard that was clearly marked on the Empress of the North’s navigation chart and 

whose flashing green light both he and the helmsman had seen from less than a 

mile away. The charted rock was clearly marked and conspicuous, and both men 

on watch were aware of its location. The grounding therefore was the result of a 

gross navigation error. 

The junior third mate had no previous watch experience as a licensed 

officer before joining Majestic America Line, having graduated from California 

Maritime Academy less than 3 weeks before the accident. Lacking information 

from an employment record, the Safety Board assessed the junior third mate’s 

navigational knowledge and experience by visiting the maritime academy and 

examining his record. Transcripts of his grades and interviews with some of his 

instructors indicate that he was an average student who performed successfully 

both on actual vessels and on simulated vessel bridges.
Analysis

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To graduate from the academy and qualify for a Coast Guard third mate’s 

license, the junior third mate was required to demonstrate mastery of fundamental 

navigation skills. Because the accident occurred so soon after his graduation, he 

is unlikely to have forgotten the fundamentals of basic navigation by the time 

he began work on the Empress of the North. The Safety Board therefore concludes 

that the junior third mate’s failure to navigate the Empress of the North past Rocky 

Island did not result from deficiencies in his maritime training. 

The officer in charge of the navigational watch is responsible for the safe 

navigation of a ship. Although the junior third mate assumed the navigation watch 

for the first time without supervision and without being properly prepared, as a 

trained and licensed officer he was not without knowledge of ships or of how a 

navigation watch should be conducted. His statement that he understood that he 

was on the bridge because he had a license and that the helmsman “would be in 

control of the boat” did not free him from his responsibility to safely navigate the 

Empress of the North.

As a licensed officer, the junior third mate was duty-bound to make certain 

that he understood his watch duties. He had about 12 hours’ notice before the watch 

began. On his own, he could have used some of that time to acquaint himself with 

the navigation equipment and become thoroughly familiar with the chart and the 

geographical area he would be transiting, including lights, prominent points, and 

currents. For example, he might have consulted the Coast Pilot and discovered its 

warning about the inadvisability of passing between Point Couverden and Rocky 

Island because of the erratic currents there.

Once he assumed the watch, the junior third mate had a duty to take charge 

of the bridge. Instead, he allowed the helmsman to maneuver the vessel as he saw 

fit. Three minutes before the accident, the junior third mate gave his first indication 

of a maneuvering intention when he stated, “We’ll pass inside of that,” referring to 

the flashing green light on Rocky Island that he had just seen. (By “pass inside” he 

presumably meant pass between Rocky Island and Point Couverden.) The junior 

third mate had no experience with the ship and was in no position to judge how it 

would handle during an 80° turn while traveling at 12 knots at night.

Newly licensed third officers will often find themselves on a ship they have 

never sailed on, in an unfamiliar waterway they have never transited before, and 

in the company of a master and crew they have never served with before. These 

circumstances do not, however, absolve them of their responsibility to take charge 

as the officer of the watch when so assigned. Junior officers are also responsible 

for speaking up to their supervisors about any apprehension or uneasiness 

they might feel regarding their assigned duties. The junior third officer told 

investigators that he felt “comfortable” about assuming the watch. His expressed 

confidence, despite his lack of knowledge about the route, the vessel, the bridge 

equipment, and the bridge routine, suggests that he did not fully appreciate his 

duties and responsibilities and what was required to fulfill them. The Safety Board 
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therefore concludes that the junior third mate failed to understand and fulfill his 

responsibilities as a licensed officer on an underway navigation watch. 

The Empress of the North accident demonstrates that newly licensed third 

mates can be placed in situations for which they are unprepared. It is, however, 

incumbent on all licensed officers to thoroughly understand what is expected of 

them and to assess their ability to perform a task before they undertake it. The 

Safety Board therefore concludes that maritime academy cadets would benefit from 

learning about the circumstances of this accident, particularly their responsibility 

as newly licensed officers to prepare themselves for assigned duties and to express 

their concerns if placed in situations for which they are unprepared. Consequently, 

the Safety Board believes that the state and Federal maritime academies should 

teach their students the circumstances of this accident, including their responsibility 

as newly licensed officers to prepare themselves for assigned duties and to express 

their concerns if placed in situations for which they are unprepared. 

Watchkeeping Procedures

Companies, masters, and crewmembers share a responsibility for assuring 

the safe operation of a ship. Specifically, the company is responsible for setting 

forth policies and procedures that provide safeguards against damage (to property 

and the environment), injury, and loss of life; and masters and crewmembers are 

responsible for following those policies and procedures. The master of a ship 

must make watchkeeping arrangements that are adequate for maintaining a safe 

navigation watch, and officers of the watch are responsible for safely navigating 

the ship while they are on duty. International standards, such as those of the STCW 

convention and the ISM code, were established to promote safe watchkeeping 

practices and safe ship management. 

Majestic America Line was required to comply with international standards 

because one of its vessels, the Empress of the North, traveled in international waters. 

The company’s safety management system had been audited and approved by an 

external auditor as containing all the elements required by the ISM code. The safety 

management system was documented in an office safety manual and a manual 

of fleet instructions. Investigators examined those documents and compared the 

documents’ prescribed watchkeeping practices with actions taken, or not taken, 

before and during the accident voyage. Investigators found several deviations 

from sound watchkeeping practice, as described in the following paragraphs. 

Inadequate Voyage Plan. The fleet instructions for the Empress of the North

required the master to prepare an approved voyage plan. The voyage plan provided 

to the officers on watch for the night of the accident was basically an itinerary for 

the sightseeing cruise, with minimal indications of crew duties such as “test gear” 

and “security before underway.” Other items consisted of locations on the route 

and activities such as whalewatching. 
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The first entry for the accident day is “Security call for rounding Rocky Is, 

west bound,” at Point Couverden. The word “rounding” is the only indication to 

the watch officer of how to approach Rocky Island. “Rounding” is ambiguous and 

requires interpretation. If the intended meaning was “go around, not through 

the passage between the mainland and Rocky Island,” it was not stated clearly 

enough for purposes of safe navigation. 

For safety at sea, a voyage plan should lay out the entire route from dock 

to dock. Positions along the vessel’s track should be indicated, especially dangers 

or areas to be avoided. The appropriate navigation charts should be indicated and 

when to change from one chart to another. Call-in points should be indicated, 

along with the appropriate calling channel or frequency. Tides and currents 

specific to the track should be indicated, including speed and direction. Aids to 

navigation, such as the navigation light on Rocky Island, should be listed and 

described (color, light, frequency). Local information from the Coast Pilot should 

also be noted on the plan. If, for example, a voyage plan had been available that 

contained the information found in the Coast Pilot (“As currents are erratic in the 

channel between Rocky Island and Point Couverden, the slight saving in distance 

this channel offers does not warrant its use”), the junior third mate would have 

been warned not to attempt to pass north of Rocky Island. 

Lack of Night Orders. The midnight-to-0400 watch is the most unsupervised 

watch of the day (because the master and all crewmembers but the watchstanders 

are asleep). The master wrote no night orders for the night of the accident. According 

to the company’s fleet instructions, night orders were optional. However, had the 

master issued them, the night orders could have given instructions on the course 

to follow until the next morning, when the master would have been available to 

supervise operations. Limits on speed, steering instructions, when to remain in 

autopilot and when to shift to manual steering, how to meet or overtake other 

vessels, and navigational hazards (such as Rocky Island) should have been part of 

the orders. Especially for a newly hired officer standing his first watch, providing 

specific, written information about the route and its hazards should not have been 

considered optional. 

Nonessential Persons on Navigation Bridge. According to Coast Guard 

regulations at 46 CFR 78.10, persons who are not involved in navigation are not 

allowed on the bridge while a vessel is under way. The bridge watch standing 

orders for the Empress of the North reinforced that rule. Nevertheless, the VDR 

bridge recording shows that during the 20 minutes in which the bridge watch was 

changing from the second mate to the junior third mate, seven other crewmembers 

were either coming on or going off watch, including two crewmembers who had 

no duties on the bridge. 

The two crewmembers not assigned to the bridge arrived there at 2334 and 

engaged in social conversation for 10 minutes, during which time the VDR recorded 

almost no interaction between the watch officers. Thus, of the 20 minutes available 

to exchange important information during the watch change, half was taken up 
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with extraneous conversation. The only exchange recorded by the VDR during the 

watch change was vessel position and track, when to take fixes, vessel speed, and 

at the end, the second mate’s room number in case the junior third mate needed 

to call him. The presence on the bridge of crewmembers not engaged in vessel 

navigation was an unnecessary distraction to the officers engaged in the watch 

turnover and could easily have interfered with their exchange of information. 

Inappropriate Radar Setting. According to VDR data, the 3-centimeter radar 

on the Empress of the North was set to the 6-mile scale during the entire voyage. The 

company’s fleet instructions for using radar were to “select an appropriate range 

scale and ensure that plotting or systematic analysis is commenced in ample time.” 

The navigable water between Rocky Island and Point Couverden is less than 0.5 

mile wide. Though the rocks bounding the navigable water between Rocky Island 

and Point Couverden are visible in daylight because of the water washing against 

them, they might not be visible on radar at night, especially at the 6-mile scale. 

A lower setting on the range scale, such as 1 or 2 miles, would have shown more 

detail on and around Rocky Island and been more useful to the bridge team in 

assessing their progress through the turn. 

In addition, the bridge team failed to use radar aids that might have 

prevented the accident. If, for example, they had used the ARPA to acquire Rocky 

Island, they could have obtained information about the nearness of the vessel to the 

rocks and therefore about the risk of collision. Further, a predesignated distance 

alarm set to a predetermined safety zone around Rocky Island could have warned 

the bridge team that the vessel was entering that zone and given the team time to 

take evasive action. 

Inadequate Lookout. The watchstanding requirements in the Empress of the 

North fleet instructions state: “the Watch Officer should ensure . . . an alert allround visual and aural lookout.” The AB and deckhand who shared the lookout 

duty on the midnight-to-0400 watch had left the bridge at 0100 to conduct security 

rounds that lasted 30 to 40 minutes. Thus, no lookout was on the bridge while 

the junior third mate and helmsman were navigating the turn into Icy Strait. The 

helmsman was helping the junior third mate with his watch duties and explaining 

the steering system while adjusting the steering to come around to the vessel’s 

course into Icy Strait. The STCW code states that the “duties of the lookout and 

helmsperson are separate and the helmsperson shall not be considered to be the 

lookout while steering” except on small ships and when there is “no impediment 

to the keeping of a proper lookout.”

The watchstanders had to act as their own lookouts after the AB and 

deckhand went below. Shortly before the vessel struck the rocks, the junior third 

mate lost sight of the flashing green light on Rocky Island. If a lookout had been 

on the bridge, the lookout could have been monitoring the bearing of the light on 

Rocky Island as the Empress of the North approached. The light was flashing every 

4 seconds. As the ship turned to starboard, its bearing to the light would have 
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changed. A lookout could have kept the light in sight and warned the bridge team 

that they were headed straight for Rocky Island. 

Conclusion. In light of the inadequacies detailed above, the Safety Board 

concludes that the safety of the Empress of the North and all those on board was 

jeopardized by the failure of the master and watchstanders to follow sound 

watchkeeping practices, as contained in the STCW code and the company’s safety 

management system. Since the accident, Majestic America Line has completely 

overhauled its safety management system and has provided the Safety Board 

with documentation of many improvements to its vessel operations, as described 

earlier in the “Majestic America Line Actions Since the Accident” section. The new 

guidelines require masters to prepare a voyage plan, for example, and provide 

extensive checklists to verify that required tasks are accomplished. The Safety 

Board considers that the company’s actions have substantially improved the 

safety of its vessels, crews, and passengers and proposes no further action on this 

issue. The company discharged both the master and the junior third mate after the 

accident.

That the Empress of the North grounding caused no injuries was extremely 

fortunate, considering that the accident happened in the middle of the night in a 

remote area where the cold water would have posed a danger to persons entering it. 

As detailed above, the Safety Board’s investigation identified numerous violations 

of sound seamanship during the accident voyage, such as failing to keep an adequate 

lookout and allowing unauthorized persons on the bridge. Although Majestic 

America Line took action after the accident to prevent such unsafe practices, it 

is possible that safety shortcomings might exist in the operations of other U.S. 

passenger vessel companies, particularly because not all passenger vessels are 

required to have safety management systems. Consequently, the Safety Board is 

concerned that, despite the obvious errors identified in this accident, experienced 

mariners employed by other passenger vessel companies might commit similar 

violations of good seamanship. The Board therefore concludes that other 

passenger vessel operators might benefit from learning about the circumstances 

of the Empress of the North accident, particularly the need for masters to verify that 

officers on watch are familiar with a vessel’s route, handling characteristics, and 

bridge equipment. Consequently, the Board believes that the Passenger Vessel 

Association should, through its website, publications, and conferences, inform its 

members about the circumstances of this accident, including the need for masters 

to verify that officers of the navigation watch are familiar with a vessel’s route, 

handling characteristics, and bridge equipment. 

Documentation Deficiencies

The Safety Board’s investigation found deficiencies in the documentation of 

the Empress of the North and its crew with regard to both Federal and international 

regulations. 
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Crew Certification

The vessel’s COI, issued by the Coast Guard, required all deck officers to 

meet the requirements of first-class pilot on both designated and nondesignated 

pilotage waters. Coast Guard regulations allow crewmembers to serve as pilots if 

(1) they hold a Federal first-class pilot’s license with endorsement for the route, in 

accordance with 46 CFR 15.812(b)(1), or (2) they qualify as an “acting as” pilot, that 

is, if they are licensed and are at least 21 years old, maintain a current knowledge 

of the waters to be navigated (one round trip within the past 60 months), and have 

four round trips on the route, with at least one round trip in darkness if the route 

is to be traversed at night. 

The vessel’s safety management documents stated that the master was 

responsible for ensuring that his vessel was manned in accordance with its COI.

All the deck officers on the Empress of the North held valid Coast Guard licenses as 

masters or mates. However, none held a Federal first-class pilot’s license valid for 

the accident route (the master and senior third mate held first-class pilot’s licenses 

valid in Washington state). The senior third mate and the second mate had both 

joined the company recently and had not yet made their first round-trip on the 

accident route. The master and chief mate were therefore the only officers who 

had sufficient experience on the route to satisfy the vessel’s pilotage requirement. 

Although the junior third mate assigned to stand watch at the time of the 

accident was a licensed deck officer, he did not hold a Federal first-class pilot’s 

license or meet the requirements of a self-certified pilot because he had no current 

knowledge of the waters and had not been on any round trips on the route, in 

daylight or in darkness. The Safety Board therefore concludes that the junior third 

mate was not qualified to stand watch on the accident route because he did not 

hold a Federal pilot’s license or meet the requirements of a self-certified pilot. 

Further, the chief mate and the master were the only officers qualified to stand 

watch at the time of the accident. 

Vessel Certification

Majestic America Line was required to hold a valid document of compliance 

and a safety management certificate as evidence of compliance with the ISM code. 

At the Empress of the North’s last annual inspection, the Coast Guard determined 

that the vessel’s documentation was in order. The Coast Guard inspectors failed 

to notice, however, that the company’s document of compliance was not valid 

(because it had not received the required annual verifications), which meant that 

the Empress of the North’s safety management certificate was also out of compliance. 

Vessels that are required to comply with the ISM code may not sail if the company 

lacks a valid document of compliance. The Safety Board therefore concludes that 

the Coast Guard failed to identify critical deficiencies in the Empress of the North’s 

documentation during the vessel’s 2007 annual inspection. 
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After the accident, the company received a valid interim document of 

compliance (May 30, 2007) and a valid interim safety management certificate (June 

30, 2007) from the American Bureau of Shipping, for use during its 2007 season. In 

March 2008, the company obtained another valid interim document of compliance 

and another valid interim safety management certificate from the American 

Bureau of Shipping. As noted in the “Coast Guard Actions Since the Accident” 

section, officials from Sector Portland have taken a number of measures, such as 

increasing inspector training, reevaluating inspection checklists, and instituting 

advance preparation for inspections, designed to prevent vessel inspectors from 

overlooking vessel documentation deficiencies in the future. In addition, Coast 

Guard headquarters has arranged for the American Bureau of Shipping to inform 

it when an ISM document becomes invalid, after which the appropriate OCMI will 

be notified for action. The Coast Guard is also seeking similar agreements with the 

other classification societies that issue ISM documents to U.S. vessels. The Safety 

Board considers that those measures have addressed the identified safety issue 

and proposes no further action.

A manufacturer’s representative was inspecting the Empress of the North’s 

VDR on the same day (February 17) that the Coast Guard conducted its 2007 annual 

inspection. Although the VDR inspection report noted deficiencies, a certificate of 

compliance for the VDR was signed the next day. The Coast Guard would not have 

had either the VDR inspection report or the certificate of compliance to inspect on 

February 17, and therefore cannot be said to have overlooked the noncompliant 

VDR (which would not in any case have prevented the vessel from sailing). 

Survival Factors

Emergency Response 

Immediately after the Empress of the North struck Rocky Island, the master 

went to the bridge and took control, waking the crew, alerting the Coast Guard to 

the emergency, and waking the passengers and instructing them to dress and go 

with their lifejackets to their muster stations. Crewmembers checked all cabins to 

make sure that no passengers remained inside, and passengers were accounted 

for when they arrived at their muster stations. The master deployed the vessel’s 

liferafts when he learned that the belowdecks spaces were flooding, an appropriate 

precaution (even though the liferafts were not used in the emergency) in case it had 

become necessary to abandon ship, particularly if other vessels had not been in the 

area to assist. The engineering crew monitored the vessel for flooding, pumped out 

flooded spaces, and periodically updated the bridge on the status of their efforts.

The master contacted other vessels in the vicinity of the accident, and 

those masters agreed to help evacuate passengers from the cruise ship. The good 

Samaritan vessels included two fishing vessels, a small passenger vessel, and 
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a towing vessel. Although the master had ordered the liferafts to be launched, 

he told investigators that he wanted to avoid using them because of the elderly 

people on board. Even though the Empress of the North was flooding, it was a safer 

platform than the liferafts, especially in a remote area where the water temperature was 

40° F or less and where anyone who entered the water would have suffered cold water 

immersion injuries, loss of breath control, and possibly death.67 Using the liferafts 

would have required passengers to slide down the evacuation slides (which in 

any case did not deploy properly) and climb into the liferafts, a hazardous activity 

for anyone, but especially for the elderly or incapacitated (four passengers were 

wheelchair-bound and five needed help walking). 

All the responding vessels interrupted their normal work to assist the vessel 

in need. The first responding vessel, one of the fishing boats, arrived on scene within 

an hour of the grounding, and the second arrived about a half-hour after that. The 

calm seas and winds were ideal for an evacuation. The good Samaritan vessels 

provided a stable platform for the evacuees, who either walked directly onto the 

vessels or used the Empress of the North’s gangways. All passengers and nonessential 

crewmembers were safely evacuated within 4 hours of the grounding. 

The Coast Guard began coordinating the emergency response immediately 

after receiving word of the accident. Within 5 minutes, the Coast Guard had 

alerted helicopters in Sitka and issued an urgent marine information broadcast. 

Within 10 minutes, the Coast Guard cutter Liberty was tasked with responding 

to the accident and was under way within the hour. The Coast Guard eventually 

determined to transfer all evacuated passengers and crewmembers to an Alaska 

Marine Highway System ferry that had diverted to the scene after hearing the 

urgent marine information broadcast. 

The Coast Guard organized its response according to the incident command 

system, working closely with the city of Juneau. The area’s emergency response 

plan had identified a cruise ship disaster as a worst-case scenario and had laid 

out specific steps, including checklists. The Coast Guard oversaw the transporting 

of passengers back to Juneau, while the city prepared for their arrival, arranging 

for medical personnel to meet the passengers when they docked at Auke Bay 

and organizing shelter. The Coast Guard relayed the names of passengers to 

the command center as they were evacuated and checked the names against the 

passenger manifest at several stages. 

In the end, all 206 passengers and 46 nonessential crewmembers were 

safely evacuated from the Empress of the North and transported back to port, and 

no one was injured. The Safety Board therefore concludes that the response to the 

67 Research into survivability in cold water has found that the critical water temperature in incidents of 

cold water immersion is 59° F and that entry into water below that temperature “should be avoided” (Transport 

Canada, Survival in Cold Waters: Staying Alive, report TP13822E, Ottawa, Ontario: 2003). As described in 

the study, cold shock (a large gasp followed by hyperventilation and greatly increased heart rate and blood 

pressure) occurs during the first 2 to 3 minutes of immersion in water below 59° F; death from hypothermia 

can occur after 30 minutes of immersion.
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emergency by all those involved—the vessel’s crew, the master, the good Samaritan 

vessels, the Coast Guard, and the city of Juneau—was timely and effective. 

Lifesaving Equipment

Liferafts. When crewmembers attempted to launch the vessel’s 12 inflatable 

liferafts, half the hydrostatic release units malfunctioned, forcing the crew to cut 

the lines with knives to launch the rafts. The investigation revealed that the pistons 

on the pumps that were connected to the hydrostatic release units had not been 

lubricated every other year, as directed by the manufacturer. The company’s port 

engineer told the Coast Guard that 20 of the 22 manual release units had been 

on board the Empress of the North for over 2 years but had never been lubricated. 

The Safety Board therefore concludes that the company’s failure to properly 

maintain the vessel’s liferafts caused some of the remote-release units for the rafts 

to malfunction. 

The preventive maintenance documents the company prepared after the 

accident contain specific criteria for lubricating the Hammar remote-release pump 

units at least every 2 years. In September 2007, the Coast Guard issued Marine 

Safety Alert 4-07 regarding the Hammar remote-release pump units and stressing 

their maintenance schedule. The Safety Board considers that these measures should 

remedy the identified safety issue and plans no further action.

Evacuation Slides. The chief mate told investigators that the evacuation 

slides carried on the Empress of the North did not inflate properly when they were 

deployed after the accident. He described the inflated slides as inverted and folded 

against the side of the ship. On July 5, 2007, the Safety Board issued an urgent 

safety recommendation to the Coast Guard concerning the incorrect deployment 

of the evacuation slides:

M-07-10

Conduct a one-time inspection and correction of all deficiencies of 

evacuation slides last serviced by Marine Safety Services of Seattle, 

Washington. (Urgent)

In its response to Safety Recommendation M-07-10, the Coast Guard stated 

that inspectors who visited the service company, Marine Safety Services, after the 

accident had determined that “it would be extremely difficult to pack the slides 

incorrectly” without modifying the valises and that “[a]ny incorrect folding or 

orientation would likely make the slide impossible to deploy in any direction.” 

The Coast Guard concluded that Marine Safety Services had serviced the slides 

correctly and that crewmembers had most likely “placed the valises upside down 

on the deck,” causing them to deploy incorrectly.

As described in the “Tests and Research” section, after receiving the Coast 

Guard’s response, investigators visited both Marine Safety Services and DBC 
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Marine Safety Systems, the manufacturer of the equipment, to test the evacuation 

slides. The investigators simulated the scenario the Coast Guard had posited as 

most likely, that is, that the valises holding the slides had been placed upsidedown on the deck. In that position, the stenciled instructions for positioning 

and inflating the slide, as well as the inflation cord, would have been on the 

bottom of the valise and therefore not visible to crewmembers. The chief mate 

told investigators that he could see the stenciled instructions on the valises when 

the crewmembers installed them on the deck. Further, inflating the slides would 

have been difficult if the valises were upside-down, because crewmembers 

would have had to lift the 60-pound gas cylinder to reach the inflation cord. It 

is thus unlikely that the crew placed the valises upside-down on the deck of the 

Empress of the North. 

On July 12, 2007, DBC Marine Safety Systems issued a service bulletin 

that instructed servicing facilities to mark the tops of the valises containing the 

evacuation slides This Side Up and the bottoms Turn Over. The company also 

prepared stencils to label the insides of the valises so that technicians could readily 

determine the correct orientation of the valises when packing the evacuation 

slides. The Safety Board judges that the company’s actions should eliminate any 

confusion about packing the valises or positioning them on deck and proposes no 

further action on this issue. 

Investigators also examined the two other possible ways the valises 

containing the evacuation slides could have been placed on deck. In tests with 

the valise placed right side up but backward (with the outboard arrow pointing 

inboard), the slide inflated upward and folded back against the test platform. On 

a vessel, the inflated slide would have blocked the exit. The chief mate identified a 

diagram, created by DBC Marine Safety Systems during the postaccident tests, in 

which a slide was inverted and folded back against the outside of the ship, thereby 

blocking the embarkation area, as matching the way the slides malfunctioned on 

the Empress of the North.

Although it is possible that in the excitement after the accident the crew 

might have secured the valises backward on the deck, it is unlikely that after 

the first slide inflated upside-down the crew would have repeated the mistake. 

The chief mate told investigators that after the first slide inflated incorrectly, he 

examined the second slide’s position and had crewmembers check the position of 

the arrows. The chief mate also said that this was not the first time he had used 

the slides and that the valises were installed on deck as a part of regular crew 

training. The instructions on the valises were clear and concise: one arrow pointed 

outboard, the other pointed inboard, making it unlikely that the crew placed the 

valises backward on the deck.

If the valises had been positioned correctly on deck, the slides could have 

inflated incorrectly only if the valises were mislabeled or the slides were packed 

incorrectly into the valises. Investigators examined a valise from the Empress of 

the North taken after the accident and determined that it was properly labeled. 
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Investigators discussed the possibility of a packing error with the manufacturer and 

determined that the most likely error would have been to fold the slide correctly but 

place it in the top half of the valise instead of the bottom. Investigators determined 

that a slide packed upside-down would inflate upside-down, and that there would 

be no visible indications that the slide had been packed incorrectly. The Safety 

Board therefore concludes that the most likely reason the vessel’s evacuation slides 

did not inflate properly was that the service company had packed them into the 

wrong side of their valises. 

The Coast Guard concluded after its inspectors visited Marine Safety 

Services that the valises had probably been placed upside-down on the deck of the 

Empress of the North. Although the Safety Board’s analysis disagrees with the Coast 

Guard’s conclusion, DBC Marine Safety Systems’s subsequent service bulletin 

should prevent any misunderstandings about the correct positioning of the valises 

on deck, and the instructions stenciled on the inside of the valises should prevent 

misunderstandings about how to pack the evacuation slides into them. The Board 

therefore classifies Safety Recommendation M-07-10 as “Closed—Acceptable 

Alternate Action.” 

Fortunately, because other vessels were nearby to assist, neither the 

malfunctioning liferafts nor the malfunctioning evacuation slides were needed to 

evacuate passengers and crewmembers from the damaged Empress of the North. 

However, if the vessel had been in danger of sinking or if it had been necessary 

for another reason to abandon ship, the malfunctioning equipment could have 

endangered all those on board. In an emergency, time is critical. In the aftermath of 

the Empress of the North grounding, crewmembers lost valuable time in attempting 

to operate the liferaft releases and then in cutting the liferafts loose. Furthermore, 

the deckhands spent about 30 minutes trying to deploy the evacuation slides. If 

the ship had been sinking, that time could have meant the difference between 

life and death for those on board. The Safety Board therefore concludes that the 

malfunctioning liferaft release units and evacuation slides on the Empress of the 

North could have endangered the lives of those on board if other vessels had not 

been in the vicinity to help evacuate the damaged ship. 
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Conclusions

Findings

1. The following were not causal to the accident: weather (including visibility, 

wind, sea, and current); aids to navigation; vessel propulsion and steering 

systems; use of alcohol or illegal drugs; watchstander fatigue.

2. The Empress of the North bridge team was attempting to negotiate an 80° turn 

at Rocky Island, a charted navigation hazard, but the vessel’s rate of turn was 

insufficient to prevent it from grounding on the rocks.

3. The master jeopardized the vessel’s safety by allowing the junior third mate 

to stand a bridge watch before he was familiar with the route and the bridge 

equipment.

4. The master’s watch assignment created a poorly functioning bridge team 

in which an inexperienced officer in charge (the junior third mate) did not 

exercise authority and an experienced subordinate (the helmsman) exceeded 

his authority.

5. Majestic America Line did not effectively monitor the master’s compliance 

with its policies and procedures.

6. The junior third mate’s failure to navigate the Empress of the North past Rocky 

Island did not result from deficiencies in his maritime training.

7. The junior third mate failed to understand and fulfill his responsibilities as a 

licensed officer on an underway navigation watch.

8. Maritime academy cadets would benefit from learning about the circumstances 

of this accident, particularly their responsibility as newly licensed officers to 

prepare themselves for assigned duties and to express their concerns if placed 

in situations for which they are unprepared.

9. The safety of the Empress of the North and all those on board was jeopardized 

by the failure of the master and watchstanders to follow sound watchkeeping 

practices, as contained in the Seafarer’s Training, Certification, and Watchkeeping 

code and the company’s safety management system. 

10. Other passenger vessel operators might benefit from learning about the 

circumstances of the Empress of the North accident, particularly the need for 
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masters to verify that officers on watch are familiar with a vessel’s route, 

handling characteristics, and bridge equipment.

11. The junior third mate was not qualified to stand watch on the accident route 

because he did not hold a Federal pilot’s license or meet the requirements of a 

self-certified pilot. Further, the chief mate and the master were the only officers 

qualified to stand watch at the time of the accident.

12. The Coast Guard failed to identify critical deficiencies in the Empress of the 

North’s documentation during the vessel’s 2007 annual inspection.

13. The response to the emergency by all those involved—the vessel’s crew, the 

master, the good Samaritan vessels, the Coast Guard, and the city of Juneau—

was timely and effective. 

14. The company’s failure to properly maintain the vessel’s liferafts caused some 

of the remote-release units for the rafts to malfunction. 

15. The most likely reason the vessel’s evacuation slides did not inflate properly 

was that the service company had packed them into the wrong side of their 

valises.

16. The malfunctioning liferaft release units and evacuation slides on the Empress 

of the North could have endangered the lives of those on board if other vessels 

had not been in the vicinity to help evacuate the damaged ship.

Probable Cause

The National Transportation Safety Board determines that the probable 

cause of the grounding of the Empress of the North was the failure of the officer 

of the watch and the helmsman to navigate the turn at Rocky Island, which 

resulted from the master’s decision to assign to the midnight-to-0400 watch an 

inexperienced, newly licensed deck officer who was not familiar with the route, 

the vessel’s handling characteristics, or the equipment on the vessel’s bridge. 
Recommendations

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Recommendations

New Recommendations

As a result of its investigation of the Empress of the North accident, the National 

Transportation Safety Board makes the following safety recommendations.

To the State and Federal Maritime Academies:

Teach your students the circumstances of this accident, including 

their responsibility as newly licensed officers to prepare 

themselves for assigned duties and to express their concerns if 

placed in situations for which they are unprepared. (M‐08‐6)

To the Passenger Vessel Association:

Through your website, publications, and conferences, inform 

your members about the circumstances of this accident, including 

the need for masters to verify that officers of the navigation watch 

are familiar with a vessel’s route, handling characteristics, and 

bridge equipment. (M-08-7)

Previously Issued Recommendation Resulting From This Accident 

Investigation

To the U.S. Coast Guard:

M-07-9

Verify the functionality of Hammar model H20 remote-release 

units for liferafts by inspecting or delegating the inspection 

of a sample of the models, requiring authorized facilities to 

demonstrate functionality, or other equally effective method. 

(Urgent) 

Safety Recommendation M-07-9 was classified as “Closed—Acceptable 

Alternate Action” on April 23, 2008.
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Previously Issued Recommendation Classified in This Report

To the U.S. Coast Guard:

M-07-10

Conduct a one-time inspection and correction of all deficiencies 

of evacuation slides last serviced by Marine Safety Services of 

Seattle, Washington. (Urgent)

Safety Recommendation M-07-10 (previously classified as “Open—

Acceptable Response”) is classified as “Closed—Acceptable Alternate Action” in 

the “Survival Factors” section of this report’s analysis.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER DEBORAH A. P. HERSMAN 

Acting Chairman Member

ROBERT L. SUMWALT KathRYN O’LEARY Higgins

Member Member

STEVEN R. CHEALANDER

Member

Adopted: November 4, 2008

Member Sumwalt filed the following concurring statement on July 29, 2008, 

and was joined by Member Hersman.
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Member Sumwalt, Concurring:

The written report of this accident does a fine job of describing the crew 

errors that led to the accident. However, as Dr. James Reason68 has established, 

an examination of human error should assess the actions and decisions of the 

managers and designers at least as much, if not more, than the actions of the system 

operators. 

As I read the errors of those on board the ship, I could not help wondering 

how (or if) their inappropriate actions may have been influenced by organizational 

factors. I believe the draft report, even as revised by staff, did not fully address 

these issues. 

As discussed during the board meeting, Majestic America Line did not have 

in place several components associated with a healthy safety culture. For example, 

the company did not employ adequate controls to ensure that the Empress of the 

North was seaworthy when it sailed. This lack of oversight enabled the Empress of 

the North to be out of compliance with its annual verification for almost an entire 

year. As a result, the vessel’s document of compliance was invalid, along with its 

safety management certificate and thus, its Safety Management System (SMS). The 

company also failed to ensure that the vessel received internal and external audits 

and did not adequately perform risk assessments, which are all requirements of 

SMS. 

During the board meeting, a member of staff acknowledged that the 

company did have shortcomings in its safety processes, but staff was unable to 

establish a definitive link between the company’s poor safety performance and the 

crew’s performance. I accept their findings but wish to comment on the direction 

of the investigation and reporting process. Although the linkage between the 

company’s and the crew’s performance could not be determined in this accident, 

I believe the quality of the report could have been strengthened by documenting 

these factors as part of our investigation. The Safety Board has the reputation for 

doing thorough investigations. In order to maintain that reputation we must not 

only consider and investigate these factors; we must document our work as well. 

My hope is that this important part of the investigation be fully discussed 

in future reports brought to the board and that documentation of organizational 

factors will become the norm. Such discussions should not be delayed until a 

board meeting. It is critical that we investigate these factors, even if we end up 

ruling them out. 

68 Reason, James (1997). Managing the Risks of Organizational Accidents. Burlington: Ashgate 

Publishing Company. 
Recommendations

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Most accidents have organizational roots; if we don’t at least look for these 

underlying causes, it is likely we will not find them. As stated in the Columbia 

Space Shuttle Accident Investigation Report69: 

Many accident investigations make the same mistake in defining causes. 

They identify the widget that broke or malfunctioned, then locate the 

person most closely connected with the technical failure: the engineer who 

miscalculated an analysis, the operator who missed signals or pulled the 

wrong switches, the supervisor who failed to listen, or the manager who 

made bad decisions. When causal chains are limited to technical flaws and 

individual failures, the ensuing responses aimed at preventing a similar 

event in the future are equally limited: they aim to fix the technical problem 

and replace or retrain the individual responsible. Such corrections lead to 

a misguided and potentially disastrous belief that the underlying problem 

has been solved. 

In other words, if we focus our investigation on those individuals who 

committed the active error that led to the accident, we may be overlooking other 

systemic factors that caused the accident. In doing so, we miss valuable prevention 

opportunities which directly impacts our mission—preventing accidents. 

Robert L. Sumwalt, III

July 29, 2008 

69 National Aeronautics and Space Administration (2003). Columbia Accident Investigation Board 

(CAIB) Report. vol. 1, Washington, DC. 

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Appendix A

Investigation

The National Transportation Safety Board was notified of the accident by 

U.S. Coast Guard headquarters at 0730 eastern daylight time on May 14, 2007 

(2 hours after the accident). A four-member go-team launched at 1530 eastern 

daylight time on May 14 and arrived on scene in Juneau at 1800 Alaska daylight 

time the same day. The launch team consisted of specialists in engineering, deck 

operations, survival factors, and human performance. Board Member Kathryn 

O’Leary Higgins and her assistant traveled to the scene, as well as the acting deputy 

director of the Office of Marine Safety and a representative from the Board’s Office 

of Public Affairs. Also joining the team was an investigator from the Office of 

Investigations and Analysis at Coast Guard headquarters.

The investigators began their work on May 15. They interviewed 

crewmembers, company managers, and other personnel and obtained supporting 

documentation. On May 21, the investigator-in-charge and one other member 

of the investigative team traveled to Ketchikan, Alaska, where the Empress of the 

North was in drydock. After documenting the vessel’s underwater damage and 

obtaining more documents, the investigators concluded the on-scene investigation 

on May 24.

The Safety Board investigated the accident under the authority of the 

Independent Safety Board Act of 1974, according to the Board’s rules. The parties 

to the investigation were the Coast Guard and Majestic America Line.
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Appendix B

Voyage Plan
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Appendix C

 MAJESTIC AMERICA LINE -------FLEET INSTRUCTIONS 

 Empress of the North

Date Issued: 06/03/04 Date Revised: 06/03/04 Approved By: Randy 

Burns 

FLEET INSTRUCTIONS OAS 11 

 STANDING ORDERS M/V EMPRESS of the NORTH

) OBSERVE THE RULES OF THE ROAD (

1. The orders below must be read by each watch officer before taking their first watch on the bridge. 

He/she must sign on the appropriate line indicating that he/she understands these orders. 

2. When alone on the bridge you should keep in mind that the time to take action for the vessel’s 

safety is while there is still time. 

3. An officer should be on the bridge at all times when the vessel is underway. 

4. Before relieving the watch, the relieving officer will sign the night orders, acquaint themselves 

with the vessel’s position, course and speed, weather conditions, and any contacts visual or by radar 

and obtain any pertinent information the officer to be relieved may have to pass on. 

5. As watch officer of this vessel you are, when on duty, expected to keep a good watch and see to 

it that your lookout does the same. 

6. When visibility becomes poor or if you anticipate that visibility may become poor because of fog, 

mist, rain, snow, or any other reason, call me. In the meantime post lookouts, start Fog Signals, 

reduce speed to safe speed. If necessary, post one lookout on the bow with a radio for deck to 

bridge communication. 

7. Be sure your lookout is thoroughly familiar with his/her duties, that they keep alert and that they 

listen as well as look out for other vessels and possible hazards. He/she is not to be assigned other 

duties. When your personnel are on lookout, they should be properly dressed for the weather. If the 

weather is inclement, keep the lookout on the bridge. A lookout protected from the weather will keep 

a better watch.

8. CALL THE CAPTAIN ANY TIME WHEN IN DOUBT, but do so in ample time - better too soon 

than too late. Make sure the vessel is safe. Call me if the weather starts to make up or you think it 

might be necessary to change course or slow down. Do not allow the vessel to pound the seas. 

9. Give passing vessels a good berth in ample time. DO NOT try to bluff the other vessel out of their 

right of way. Let the other vessel know in plenty of time what you intend to do. 

10. Whenever underway, the radar must be turned on. Do not wait till fog or any other cause to shut 

around you. If using the short range, be sure to switch to the long range and intermediate ranges 

periodically.

11. Whenever underway, take a fix at a minimum of once every hour (radar, gps, visual bearing) 

and log it in the underway deck logbook. Always verify a fix taken with one type of gear, with 

information from another source and confirm sounding on the chart with the ship’s depth sounder. If 

there is discrepancy with regards to the ship’s position or the observed depth, call me. 

12. Check the course on the chart every time there is a change of course on your watch. Call the 

Captain immediately if there is an error or the course will lead the vessel into danger. 

13. This vessel is to be put into hand steering at all times a Pilot has the con, when maneuvering 

through a bridge and it’s supports, approaching or maneuvering in locks, when within 0.5 NM of 

another vessel in any situation, and when you, as the officer on watch, think it necessary. 

14. Call the Captain if you experience an unexpected power, steering, or other equipment failure, or 

Standing Orders
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 MAJESTIC AMERICA LINE -------FLEET INSTRUCTIONS 

 Empress of the North

Date Issued: 06/03/04 Date Revised: 06/03/04 Approved By: Randy 

Burns 

FLEET INSTRUCTIONS OAS 12 

if the ship begins to drag anchor, or you see or hear any type of distress signal. 

15. Give engineers a minimum of 15 minutes notice prior to maneuvering alongside if the 

bowthruster is required. 

16. Always check steering and engine controls prior to getting underway and maintain an active 

watch on VHF radio channels 16,13 and any other locally applied traffic channels (as in 14 for locks). 

17. Call the Captain when anchoring at night or in limited visibility. (ie. fog, rain snow). 

18. If it becomes necessary to take the vessel outside the buoyed or charted channel due to ship 

traffic, call the Captain immediately. Other than to let large ship traffic pass, stay in the channel. 

19. Keep all log books up to date while on watch. Entries in the radio log should be made by the 

operator in regards to a listening watch. Log all significant communications made on either VHF or 

SSB radios. This includes VTS check-in and out, Distress calls and all communications with any 

government agency.

20. Any significant change to the ship’s itinerary ( ie. Change in the ship’s destination or a significant 

change to the ship’s departure or arrival time) must be approved by the Captain prior to any 

implementation of said plans. 

21. A proper anchor watch is maintained by taking hourly observations of ranges prominent to 

landmarks, water depth and wind speed. Periodic observations should be taken in excess of hourly 

notations.

22. The officer of the watch is the Master’s representative and as that representative, the safe 

navigation of the ship is his/her primary responsibility. He/she should at all times comply with 

applicable regulations for preventing a collision at sea. It is essential that the officer of the watch 

appreciate that the efficient performance of their duties is necessary in the interest of safety and life 

and property at sea and the prevention of pollution of the marine environment. 

23. Please sign below indicating that you understand these standing orders, which will be 

supplemented by night orders each evening when the vessel is underway or at anchor when 

required. In signing you are also acknowledging that you have read and will comply with these 

guidelines. A copy of these Standing Orders is to be kept in the front cover of the logbook for 

reference.

_____________________________ _________________ 

MASTER DATE 

_____________________________ _________________ 

CHIEF MATE DATE 

_____________________________ _________________ 

SECOND MATE DATE 

_____________________________ _________________ 

THIRD MATE DATE 
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Appendix D

Excerpt from Bridge Audio Recording

The reader is cautioned that the transcription of a voyage data recorder 

audio recording is not a precise science but is the best product possible from a 

Safety Board group investigative effort. The transcript or parts of it, if taken out 

of context, could be misleading. The transcript should be viewed as an accident 

investigation tool to be used in conjunction with other evidence gathered during 

the investigation. Conclusions or interpretations should not be made using the 

transcript as the sole source of information.

2M Voice identified as second mate

3M-1 Voice identified as junior third mate

3M-2 Voice identified as senior third mate

AB-1 Voice identified as first AB (helmsman)

AB-2 Voice identified as second AB

CPT Voice identified as captain (master)

OS Voice identified as ordinary seaman

CM Voice identified as chief mate

CE Voice identified as chief engineer

OIL Voice identified as oiler

USCG Transmission from U. S. Coast Guard Sector Juneau

ES Transmission from Evening Star

PA Transmission made over vessel’s public address system

VHF Transmission made or received over VHF radio

UHF Transmission made or received over crew’s handheld 

emergency radios

? Unidentified voice

* Unintelligible word

# Expletive

@ Nonpertinent word

[ ] Editorial insertion

_____________________________________

NOTE: Times are Alaska daylight saving time. 

Generally, only radio transmissions to and from the accident vessel were transcribed. 

Words shown with excess vowels, letters, or drawn-out syllables are a phonetic representation of the 

words as spoken. A nonpertinent word, where noted, refers to a word not directly related to the operation, 

control, or condition of the vessel.
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Bridge Audio Recording from 4 Minutes Before Accident Until 30 Minutes 

Afterward

0126:24

AB-1 yeah. I’m kind of comin’ on the inside of our turn here comin’ around.

0126:27

3M-1 okay. **. flashing green ** yup there it is.

0126:43

AB-1 that is our flashing green isn’t it? 

0126:43

3M-1 yup.

0126:44

AB-1 way up there.

0126:48

3M-1 yeah broad on the starboard bow.

0126:52

3M-1 we’ll pass inside of that.

0126:53

AB-1 yup.

0127:12

3M-1 are these depths? on there are those in feet or they in uh fathoms?

0127:19

AB-1 fathoms.

0127:20

3M-1 oh # got plenty of water. 

0128:53

AB-1 comin’ around fast enough you think?

0128:55

3M-1 yeah.

0129:06

3M-1 turn it down *.

0129:27

AB-1 I don’t think so.

0129:28

3M-1 you don’t think so?

0129:30

AB-1 no.

0129:44

AB-1 we should go on that side. whaddyou think?

0129:52

3M-1 yeah let’s just steady up on this until we clear that light.

0129:58

3M-1 oh come left.

0129:59

AB-1 comin’ left. 
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0130:02

3M-1 hard left. 

0130:03

AB-1 hard left.

0130:07

3M-1 yeah we’re real close. we better call the captain. we better call the captain.

0130:10

AB-1 oh #.

0130:11

3M-1 call the captain.

0130:13

[sound of impact]

0130:16

[sound similar multiple warning alarms from GE console]

0130:21

? want your radio.

0130:23

3M-1 oh God. 

0130:25

? * captain *.

0130:29

? captain. 

0130:29

ab-1 oh he knows he’s comin’.

0130:30

CPT what was that? what was that?

0130:30

? that was the rocks sir.

0130:32

CPT the rocks.

0130:36

3M-1 ** rocks.

0130:37

CPT stop. 

0130:38

AB-1 stop stop stop.

0130:45

CPT we got to call the Coast Guard...hold it hold it here.

0130:46

? okay.

0130:47

CPT hold it.

0130:56

UHF-? report.

0130:59

? we just came inside the rocks.
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0130:59

? *.

0131:00

? what do we do now?

0131:03

3M-1 did you take the thrust off?

0131:04

AB-1 yes the thrust is off.

0131:05

3M-1 okay.

0131:09

? station bill.

0131:10

? ‘kay.

0131:13

OS you wanna like get some of these alarms?

0131:14

3M-1 no don’t don’t don’t touch anything.

0131:18

OS all right.

0131:23

? **.

0131:25

CPT augh get my radio.

0131:30

[sound similar to bridge phone]

0131:31

? I don’t like *.

0131:31

CPT get my radio from the office.

0131:34

AB-1 got it.

0131:39

CPT water in bilge void number one okay. we need to take uh take down a uh someone needs to 

start writing this down.

0131:50

? okay.

0131:52

CPT what? can you start sounding tanks please right away. sound tanks right away.

0132:04

Crew PACPTyeah crew all crew all crew this is an emergency this is an emergency I repeat this is an 

emergency. all crew members wake up get dressed wake up and get dressed...

0132:19

UHF-? bridge deck bridge deck.

0132:24

UHF-CM go from the bridge.
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UHF-? yeah we’ve got a breach in room nineteen.

0132:29

UHF-CM roger that.

0132:29

Crew PACPT...wake up get dressed and get your life jackets and come up to port side. wake up.

0132:30

CM breach water’s comin’ in room nineteen.

0132:33

OS cap I can’t find the radio.

0132:35

CPT its on my vest which could be in the uh thing.

0132:38

OS all right.

0132:51

UHF-? **.

0132:52

? **

0132:54

UHF-OIL ** I’m opening watertight number one.

0132:55

UHF-CE negative. 

0132:57

UHF-OIL I’m opening watertight number one.

0133:02

UHF-? Matt don’t open it. 

0133:08

VHF-CPT pan pan pan pan pan pan.

0133:15

CPT turn that down please.

0133:18

VHF-CPT this is the Empress of the North. Empress of the North. we have an emergency aboard. an 

emergency aboard. we are— .

0133:26

? *.

0133:34

CPT what’s the name of this rock and where? 

0133:35

? Coouverdeeeran.

0133:37

CPT its what?

0133:39

VHFUSCGEmpress of the North United States Coast Guard Sector Juneau what’s your emergency 

over?
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0133:43

VHF-CPT Coast Guard Sector Juneau Empress of the North we have uh hit some rocks. we have uh 

holed our vessel. we have holed our vessel...our our position is fifty eight degrees one zero 

point four north one three five zero three point five minutes west.

0133:44

? [sound of unintelligible conversation]

0133:53

UHF-? sounding deep * right now.

0134:14

VHFUSCGEmpress of the North Sector Juneau roger how many souls on board over?

0134:15

CPT people on board? 

0134:21

3M-1 uh two hundred eighty four uh two hundred eighty one.

0134:24

VHF-CPT uh we have two hundred eighty one persons on board at this time two hundred eighty one 

persons on board. we are— we have holed our vessel we are taking on water.

0134:36

CPT what’s the name of this rock here?

0134:39

3M-1 Cour—.

0134:41

CPT what?

0134:45

3M-1 Courvedeer— Cour— Courvedon Rock.

0134:45

CPT Courvedon?

0134:46

3M-1 C-O-U—.

0134:49

VHFUSCGEmpress of the North Sector Juneau can I get description of your vessel over?

0134:53

? hundred miles *.

0134:51

VHF-CPT description of the vessel is a three hundred sixty foot three hundred and sixty foot paddlewheel vessel and uh we’re white hull white hull with three decks over.

0135:00

UHF-? chief mate.

0135:04

UHF-CM go.

0135:15

3M-1 actually I think this might by Han— Hanus.

0135:18

UHF-CPT ‘kay uh engineering bridge uh please continue sounding all tanks.
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0135:24

VHFUSCGEmpress of the North Sector Juneau roger what’s on scene weather over?

0135:29

CPT on scene weather.

0135:37

CPT is it raining is it what’s going on?

0135:39

[bridge alarms are silenced]

0135:44

3M-2 little bit of rain. overcast.

0135:44

CPT what’s the wind and uhh?

0135:47

[sound similar to bridge phone]

0135:50

VHF-CPT Sector Juneau we have zero wind we have uh drizzle and uh its calm outside. we have uh 

drizzle at this time. seas and swells are slight calm and a uh slight chop.

0136:03

[background music is silenced] 

0136:18

CPT okay so we have uh awww we got the crew up.

0136:26

? passengers are up too captain.

0136:27

VHFUSCGEmpress of the North Sector Juneau do you have any idea * or how much longer you’ll have 

until you have to abandon over?

0136:35

VHF-CPT negative we don’t know at this time. we are showing an alarm in one bilge void in one bilge 

void. that’s all we got so far. we are not listing we are cur— currently sounding tanks.

0136:21

UHF-CM bridge chief mate. 

0136:50

UHF-3M-2 chief mate bridge. chief mate bridge.

0137:01

[sound similar to fire system alarm lasting 10 seconds]

0137:01

UHF-CPT chief mate go ahead.

0137:05

UHF-CM yes captain chief mate here room one nineteen oh excuse me one nine uh there’s air *. ** 

top side starboard side that area **.

0137:13

VHFUSCGEmpress of the North Sector Juneau roger ** stand by over.

0137:22

VHF-CPT yeah roger we’re standing by.
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0137:22

CPT yeah what room was he in?

0137:26

VHF-ES Empress of the North Evening Star on sixteen do you copy?

0137:26

VHF-CPT Evening Star Empress of the North.

0137:30

VHF-ES roger I’m only five miles from your position. I see you * we are fifty-six foot fishing vessel 

would you like me to come by and stand by for an assist possibly.

0137:37

VHF-CPT Evening Star Empress of the North roger please come by and stand by.

0137:44

VHF-ES roger we’re en route to your position should be about twenty-five minutes we’ll be there.

1037:48

CPT let’s flip out er uh someone go up there on the deck and flip out all our lights our emergency 

lights.

0137:55

3M-2 * over here.

0137:59

CPT yeah these.

0138:05

3M-2 captain.

0138:22

PA-CPT ladies and gentlemen ladies and gentlemen. this is the captain we are on the bridge there 

has been an emergency on board at this time. please do not panic everything is okay ladies 

and gentlemen. we wanted to inform you that uh we have uh run aground and uh folks that 

uh we are sounding our tanks and doing everything we can *. please stand by for further 

instructions at this time please just stand by for further instructions.

0138:47

VHF-ES Empress of the North Evening Star can I get your position one more time please?

0138:59

VHF-CPT yeah Evening Star Empress of the North we are fif— five eight degrees one zero point two 

minutes north one three five three zero three one three five degrees zero three point zero six 

minutes west.

0139:24

CPT what is the name of that rock? * the name of the rock.

0139:25

VHF-ES roger that bottom number was one three five point zero three point one five correct?

0139:32

VHF-CPT that is one three five degrees zero three point six minutes west.

0139:36

VHF-ES roger we’re en route.

0139:41

CPT um the name of the rock on the bottom.

0139:44

3M-1 isn’t it uhh Hanus Reef?
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0139:45

CPT Hanus?

0139:45

VHFUSCGEmpress of the North Sector Juneau can I get your geographical position over?

0139:47

3M-1 H-A-N-U-S reef. 

0139:52

CPT Hanus.

0139:59

VHF-CPT Sector Juneau Empress of the North say again.

0140:02

VHFUSCGEmpress of the North Sector Juneau can I get your geographical position over?

0140:09

VHF-CPT roger we’re just south of Hanus Hanus Rock just south of Hanus Rock. that is what we uh 

came against over.

0140:22

CPT man we are #.

0140:26

VHFUSCG

Empress of the North Sector Juneau uh can you spell that for me over?

0140:30

CPT spell that for me.

0140:34

3M-1 H-A-N-U-S.

0140:39

VHF-CPT roger that’s H-A-N-U-S. 

0140:41

CPT its the bottom end of what’s the island or that peninsula at the bottom down there? we’re 

just—.

0140:48

VHFUSCGEmpress of the North Sector Juneau roger stand by.

0140:59

CPT ** Icy Straits at the bottom *.

0141:03

VHFUSCG[sound of VHF-USCG pan pan announcement]

0141:08

CPT okay so...we’re gonna go for an evacuation *.

0141:13

? do you want the rafts launched?

0141:20

CPT no nope not at this time. okay we’re gonna go for an evacuation. I mean we muster the 

people into the—.
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0141:27

2M evacuation stations.

0141:30

CPT we need to get ready to uh get ready to uh evacuate.

0141:35

3M-2 okay why don’t we uh we need to pass the word captain. have them get dressed and get 

their life jackets.

0141:44

CPT yeah.

0141:49

PA-CPT attention on board the Empress of the North this is the captain on the bridge. I’d like to ask 

that all passengers all passengers will please get dressed at this time. I’d like to ask and 

this is a precaution at this point because we haven’t uh done a full— haven’t don’t a full 

damage control on exactly what is going on. we are have Coast Guard and other rescue 

personnel en en route to assist us. I would like to ask you all to please put on your clothing 

and if you would to to collect your life jackets located inside your armoire and slowly and 

uh if you would please quietly work our way down to our muster stations. that there we’re 

gonna make sure everyone is down there. please do this orderly and uh calmly work your 

way down to all those forward of the main stair tower go forward down the forward ladder 

outside ladder and into the showroom. all those aft of the main stair tower please move forward and down the uh stair tower and go in to the showroom er into the dining room. there 

you will be accounted for. ladies and gentlemen please help us do this safely and calmly we 

have plenty plenty of time ladies and gentlemen this is just a precaution.

0143:34

UHF-CPT okay crew uh we’re going to uh yeah.

0143:39

UHF-? what was that?

0143:40

UHF-CPT we’re going to move into an evacuation. I want you all to start calmly helping people to the 

evacuation stations.

0143:51

3M-2 we’re taking—. 

0143:53

CPT we’re starting to list can we note that we’re starting to list?

0144:05

VHF-CPT yeah this is the Empress of the North back roger I turned the radio down I was making a 

making a uh announcements to our passengers. we have had all passengers all passengers have are getting dressed and are getting their life jackets and we are proceeding to our 

muster stations where we will account for all passengers over. Sector Juneau Empress of 

the North please be advised we are we are uh sounding tanks at this time. we are hearing 

we have definitely breeched the hull we have water in some void areas. we are slowly starting to list.

0144:56

CPT okay so uh ** okay so uh we need um we need ** emergency evacuation procedures * 

they’re in our SMS. [stepped on by VHF communication] ...um we need to make sure—.

0145:45

? captain do you mind if we—.

0145:47

CPT what’s that? * all the deck lights on all the outside lights on there.
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0152:00

[captain orders IBA and slide launched]

0157:03

[chief mate reports port side IBA launched]

0159:12

[captain orders rafts to be launched] 

0201:16

[crew reports first raft in the water]
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Appendix E

Vessel Data Recorded Immediately Before Accident
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Appendix F

Contents Pages from Company’s New Safety Management Manual
Appendix F

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Appendix F

National Transportation Safety Board

MARINE

Accident Report

103
Appendix F

National Transportation Safety Board

MARINE

Accident Report

104
Appendix F

National Transportation Safety Board

MARINE

Accident Report

105
Appendix F

National Transportation Safety Board

MARINE

Accident Report

106
Appendix F

National Transportation Safety Board

MARINE

Accident Report

107
Appendix F

National Transportation Safety Board

MARINE

Accident Report

108
Appendix F

National Transportation Safety Board

MARINE

Accident Report

109
Appendix F

National Transportation Safety Board

MARINE

Accident Report

110
Appendix F

National Transportation Safety Board

MARINE

Accident Report

111
Appendix F

National Transportation Safety Board

MARINE

Accident Report

112
Appendix F

National Transportation Safety Board

MARINE

Accident Report

113