/

PB96-916403

NTSB/MAR-97/02

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT REPORT

GROUNDING OF THE LIBERIAN PASSENGER SHIP STAR

PRINCESS ON POUNDSTONE ROCK, LYNN CANAL, ALASKA,

JUNE 23, 1995

6595A

\ 1

———— —.. —.— -—. -—
Abstract: On June 23, 1995, the passenger vessel Star Princess, traveling from Skagway to

Juneau, Alaska, grounded on Poundstone Rock in Lynn Canal, about 21 miles northwest of

Juneau. The vessel’s bottom sustained significant damage. No injuries or deaths resulted from

this accident. The total cost resulting from required repairs and the delay before the vessel could

return to service was estimated at $27.16 million.

The major safety issues discussed in this report are the adequacy of the pilot’s physical

fitness for duty, the importance of bridge resource management, the pilotage practices in the

Alaskan cruise industry, and the need for search and rescue planning.

As a result of its investigation, the National Transportation Safety Board issued safety

recommendations to the U.S. Coast Guard, the State pilot commissions, the Alaska Board of

Marine Pilots, the Southeastern Alaska Pilots Association, the Alaska Coastwise Pilot

Association, the San Diego Bay Pilots Association, Inc., Princess Cruise Lines, the American

Pilots’ Association, and the International Council of Cruise Lines.

The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the

accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes

public its actions and decisions through accident reports, safety studies, special investigation

reports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza East, S.W.

Washington, D.C. 20594

(202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
GROUNDING OF THE LIBERIAN PASSENGER

SHIP STAR PRINCESS ON POUNDSTONE ROCK,

LYNN CANAL, ALASKA, JUNE 23, 1995

MARINE ACCIDENT REPORT

Adopted: June 20, 1997

Notation 6595A

National

Transportation

Safety Board

Washington, DC 20594

iii

CONTENTS

EXECUTIVE SUMMARY........................................................................................................... v

INVESTIGATION ........................................................................................................................ 1

Accident .......................................................................................................................................... 1

Preaccident Events .............................................................................................................. 1

Grounding............................................................................................................................ 6

Postaccident Events........................................................................................................... 11

Injuries........................................................................................................................................... 12

Vessel Damage.............................................................................................................................. 12

Crew Information .......................................................................................................................... 13

Pilot on Watch................................................................................................................... 13

Pilot off Watch .................................................................................................................. 14

Master................................................................................................................................ 14

Second Officer................................................................................................................... 14

Third Officer ..................................................................................................................... 14

Vessel Information ........................................................................................................................ 14

General .............................................................................................................................. 14

Equipment ......................................................................................................................... 15

Waterway Information................................................................................................................... 15

Lynn Canal ........................................................................................................................ 15

Accidents........................................................................................................................... 16

Aids to Navigation ............................................................................................................ 16

Currents ............................................................................................................................. 16

Vessel Bridge-to-Bridge Radiotelephone Act................................................................... 16

Pilot Licensing and Oversight ....................................................................................................... 17

Meteorological Information .......................................................................................................... 19

General .............................................................................................................................. 19

Visibility and Assessment of Distance from Poundstone Rock Buoy .............................. 19

Medical and Pathological .............................................................................................................. 19

Tests Conducted ................................................................................................................ 19

Pilot’s Condition ............................................................................................................... 20

Effexor................................................................................................................... 20

Fatigue................................................................................................................... 21

Bridge Resource Management ...................................................................................................... 22

General .............................................................................................................................. 22

PCL Company Policies ..................................................................................................... 23

VERs ............................................................................................................................................. 24

Survival Factors............................................................................................................................. 25

Other Information.......................................................................................................................... 25

Alaskan Cruise Industry .................................................................................................... 25

Navigation ......................................................................................................................... 27

Contingency Planning and Exercises ................................................................................ 27
iv

ANALYSIS................................................................................................................................... 29

Exclusions ..................................................................................................................................... 29

The Accident ................................................................................................................................. 29

Pilot Performance.......................................................................................................................... 29

General .............................................................................................................................. 29

Current............................................................................................................................... 31

Radar ................................................................................................................................. 31

Visual Navigation During Low Light Conditions............................................................. 32

Navigation on a Floating Marker ...................................................................................... 34

Communication ................................................................................................................. 34

Medical Factors ............................................................................................................................. 34

Fatigue............................................................................................................................... 34

Effexor............................................................................................................................... 35

Pilot Oversight............................................................................................................................... 37

BRM.............................................................................................................................................. 37

Survival Factors............................................................................................................................. 40

CONCLUSIONS ......................................................................................................................... 41

Findings......................................................................................................................................... 41

Probable Cause.............................................................................................................................. 41

RECOMMENDATIONS............................................................................................................ 42

APPENDIXES

Appendix A – Safety Board Investigation..................................................................................... 45

Appendix B – Pilot and Crew Information ................................................................................... 47

Appendix C - Pilot and Piloting Information................................................................................ 51

Appendix D - Effexor.................................................................................................................... 53

Appendix E – PCL Fleet Regulations, NAV.7.2. -- Pilotage....................................................... 55

Appendix F – Voyage Event Recorder Information...................................................................... 59

Appendix G – International Safety Management Code for the Safe Operation of Ships and for

Pollution Prevention.............................................................................................. 61

ACRONYMS AND ABBREVIATIONS USED IN THE REPORT....................................... 63
v

On the evening of June 22, 1995, the

Liberian-registered passenger vessel Star

Princess, carrying 1,568 passengers and 639

crewmembers, was en route from Skagway to

Juneau, Alaska, via the Lynn Canal under the

direction of a southeast Alaska pilot. At 0142 on

June 23, the Star Princess grounded on the

submerged Poundstone Rock in Lynn Canal,

about 21 miles northwest of Juneau. The

vessel’s bottom sustained significant damage on

the starboard side, including the rupture of oil

tanks, which resulted in the loss of at least 5

gallons of oil. The vessel was piloted to safe

anchorage at Auke Bay, Alaska, (about 10 miles

north of Juneau) to assess damage and debark

passengers. No injuries or deaths resulted from

this accident. The total cost resulting from

required repairs and the delay before the vessel

could return to service was estimated at $27.16

million.

The National Transportation Safety Board

determines that the probable cause of the

grounding of the Star Princess was the pilot’s

poor performance, which may have been

exacerbated by chronic fatigue caused by sleep

apnea. Contributing to the accident was the fact

that the pilot and the watch officers did not

practice bridge resource management.

The major safety issues discussed in this

report are:

• The adequacy of the pilot’s physical

fitness for duty,

• The importance of bridge resource

management,

• The pilotage practices in the Alaskan

cruise industry, and

• The need for search and rescue planning.

As a result of this accident, the National

Transportation Safety Board makes recommendations to the U.S. Coast Guard, the State pilot

commissions, the Alaska Board of Marine

Pilots, the Southeastern Alaska Pilots

Association, the Alaska Coastwise Pilot Association, the San Diego Bay Pilots Association,

Inc., Princess Cruise Lines, the American Pilots’

Association, and the International Council of

Cruise Lines.

EXECUTIVE SUMMARY

1

Accident

Preaccident events. -- The 805-foot-long

Liberian-registered passenger vessel Star

Princess (see figure 1), part of Princess Cruise

Lines (PCL),1

 began its first trip for the 1995

Alaska cruise season in Vancouver, British

Columbia, on May 15, 1995. Its regular cruise

itinerary called for a week-long cruise north from

Vancouver to Seward, Alaska, with port calls to

Ketchikan, Juneau, and Skagway, as well as

excursions into Glacier Bay and Prince William

Sound (see figure 2). The week-long return cruise

southbound from Seward to Vancouver followed

the same itinerary in reverse.

The Star Princess departed Vancouver for a

northbound week-long cruise on June 12,

arriving in Seward on June 19, where the vessel

disembarked northbound passengers and

embarked 1,568 passengers for the southbound

trip. About 20002

 on June 19, a boat drill was

conducted in compliance with the International

Convention for the Safety of Life at Sea

(SOLAS). Passengers gathered at their muster

stations and were instructed on the proper use of

their lifejackets and on emergency procedures,

including evacuation of the vessel using

lifeboats.

Two pilots remained on board the vessel

while it was in Alaskan compulsory pilot

waters, so designated by the State. With few

exceptions,3

 Alaska law requires that two pilots

be on board a passenger vessel in compulsory

pilotage waters. Only one pilot must be on duty

at a time.

On both the north and southbound cruises,

two Southeastern Alaska Pilots Association

 

1

A list of the acronyms and abbreviations used in this

report is provided on the last page of the document.

2

All times are given in Alaska daylight time.

3

A passenger vessel in transit of compulsory pilotage

waters must carry two pilots on board except during initial

entry transit between the pilot station and harbor, or during

a final exit from compulsory waters that is normally less

than 8 hours long.

(SEAPA)4 pilots5 had stood alternate watches.

The duration of each watch varied depending on

the length of time between port calls and was

subject to agreement by the pilots.

One pilot boarded the vessel at 0458 on

June 14 at the Point McCartey Pilot Station,

about 15 miles6

 south of Ketchikan, Alaska, to

pilot the vessel into Ketchikan. It was the pilot’s

first trip on the Star Princess in about 4 years.

After boarding, he held a brief master-pilot

conference, reviewing with the master the

tracklines and vessel information card. He

remained aboard for the remainder of the cruise

northbound and the southbound transit.

A second pilot also boarded the Star

Princess on June 14, at Ketchikan, to share the

piloting duties. This second pilot left the Star

Princess at 1453 on June 17 at the Bartlett Cove

Pilot Station, near the southern end of Glacier

Bay. At that time, the vessel was northbound, en

route to Seward by way of the Gulf of Alaska,

and was leaving compulsory pilot waters.

Because the Star Princess was southbound

and entering compulsory pilot waters on

June 21, another pilot boarded the vessel in

Glacier Bay about 1045, with the vessel en route

to Skagway from Seward. This pilot later

testified he did not have a master-pilot

conference after coming on board the vessel.

The master testified that he and the pilot talked

about what would “happen” during the voyage.

 

4

SEAPA is one of two associations that provide pilot

services in southeast Alaska. The other is the Alaska

Coastwise Pilot Association.

5

Pilots are typically considered to be self-employed,

and each is an individual contractor for the ship for which

he or she is providing pilotage. Nearly all pilots organize

themselves into pilot associations or corporations for their

area of operation. Pilots are hired because of their

knowledge of local navigation hazards, currents, and

winds. They either advise on conning matters or conn the

vessel.

6

“Miles” refers in this report to nautical miles. A

nautical mile measures 6,076 feet.

INVESTIGATION
Figure 1.- The Star Princess anchored in Auke Bay, Alaska, June 24, 1995
3

GULF OF ALASKA

~..*

7 Below

v

-

if

“ V ..—( 9

Noxtb Pacific Ocean ‘u● s4

Figure 2. – Accident site
4

For this part of the cruise, the two pilots

agreed to share piloting duties on a 6-hour

watch cycle. The pilot on watch during the

June 23 grounding had stood watch from 1230

to 1830 on June 21 and from 0030 to about 0600

on June 22 (when the vessel docked in

Skagway).

About 1930 on June 22, the Star Princess

departed from Skagway, bound for Juneau (see

figure 2). For the voyage from Skagway to

Juneau, the two pilots agreed to share the

piloting duties evenly for a 5-hour and 15-

minute watch each.

As was his normal practice, the master

maneuvered the vessel away from the Skagway

dock and headed it outbound. There were 2,207

people on board the vessel — 1,568 passengers

and 639 crewmembers. After the vessel was

outbound, one of the pilots took over the

conning of the vessel.

About 2345 on June 22, the 0000 to 0400

bridge watch, consisting of a second officer, a

third officer, a lookout, and a helmsman,

relieved the deck watch. The watch officers did

not involve the pilot in the change of the watch.

The master’s orders to the watch were for them

to observe the standing orders per fleet

regulations while carrying out duties and to call

him if they were in any doubt about maneuvers

or the safety of the vessel. The lookout stationed

himself on the port bridge wing. The lookout’s

standing orders were to report all lights, sound

signals, dangers, and hazards seen or heard to

the bridge watch officers. He was not given any

orders for his watch by either the second officer

or the pilot.

 The second officer was the senior deck

officer on watch at this time. While on watch,

this officer was responsible for the safety of the

ship. He was expected to monitor the pilot’s

passage, cooperate with the pilot, ensure that the

helmsman responded properly to steering orders,

and verify that the third officer plotted fixes on

the ship’s navigation chart. The third officer was

to plot fixes on the chart and carry out any

orders given by the second officer. The

helmsman was to follow the steering orders

issued by the pilot.

About 0010, on a true course (T) of 156°T

and at a speed of about 10 knots, the Star Princess passed Point Sherman, which is about 36

miles south of Skagway in the Lynn Canal (see

figure 2) and about 65 miles from Juneau. The

second officer determined that the vessel was

about 1 to 1 1/2 hours ahead of its scheduled

0515 to 0530 arrival time at the entrance to

Juneau harbor.

 To avoid arriving at Juneau before the

vessel’s scheduled arrival time, the second

officer asked the pilot to turn the vessel around

in Lynn Canal. Not wishing to take this action,

the pilot proposed, as an alternative, slowing the

vessel to less than 8 knots. The second officer

did not approve of this proposal, as he was

concerned that the vessel did not steer well at

speeds below 8 knots. He suggested that the

pilot turn the vessel around and circle back at

the present speed. The pilot later stated he

would have preferred to slow the vessel but had

no problem with making the turn because no

traffic was evident at the time and Lynn Canal

was about 7 miles wide in that area.7

 (See

figure 3, which was developed with the

information provided by the vessel’s voyage

event recorder [VER] for 0014 to 0142 on

June 23, 1995.) After some discussion with the

second officer, who insisted on his making the

turn, the pilot turned the Star Princess to the

right. He made what he called “a slow starboard

swing,” using a maximum of about 5° right

rudder at a speed of about 10 to 11 knots. It took

about 33 minutes for the vessel to complete the

circle (360° round turn).

About 0030 on June 23, while the Star

Princess was in the turn, the pilot on watch

requested that the second pilot be awakened to

relieve the pilot watch. About 0040, with the

turn almost completed, the pilot ordered the

vessel onto a course of 143°T, heading toward

Sentinel Island Light.

 

7

In their testimony, the two Star Princess pilots stated

it is safe, in their opinions, for cruise vessels to make slow

turns in the canal when they are ahead of schedule. Other

vessel operators and pilots for the area, as well as Coast

Guard representatives, told investigators that they

considered such a maneuver safe.
5

t

58 ’ 39 ’ N

i

t

-55” 35’N

--58 ' 31’N

Vanderbilt

Reef

● Littl e

Island

Ralston Island

0124\

0128

0130

0132

0135

0139

i n

 Sentinel

Island

0142 Poundstone

Rock

Favorite Channel

Auke Bay & Juneau

I

I

Figure 3. – Trackline of the Star Princess
6

—

Freud

“—’—”—”~..

P

n

s

T

A

R

B

o

A

R

D

—

Figure 4. – Star Princess wheelhouse layout

The pilot later testified that the vessel was at

this time about 1 mile to the west of his

intended trackline. He estimated that Sentinel

Island Light was about 8 miles to the southsoutheast and bearing about 2° to 30 on the Star

Princess’s starboard bow.

Grounding. -- About 0040 the other pilot

arrived in the wheelhouse. He and the pilot

leaving the watch discussed the vessel’s status

and other related navigation information. The

pilot being relieved oriented the other pilot with

the vessel’s position visually and by radar

without involving the watch officers. The first

pilot was relieved about 0045, and he departed

the wheelhouse about 0055.

The other pilot (hereafter referred to as “the

pilot”) later testified that he did not have any

discussion with the bridge watch officers and

that he did not announce his assumption of the

watch or give the bridge watch officers any

instructions. He also said he did not address the

lookout. The watch officers later testified that

neither of the two pilots on the Star Princess

ever looked at the ship’s chart for this part of

the voyage that showed the tracklines as plotted

by the navigator. The second officer also

testified that Alaska pilots typically did not

share navigation information with watch

officers.

The pilot testified that when he conned the

vessel he usually referred to the automatic radar

plotting aid (ARPA)8 radar next to the chair on

the starboard side of the wheelhouse (figure 4).

He said he usually kept the radar (which had a

12-inch screen) on the 6-mile scale, with the

center offset to provide a longer view forward.

He said he used the radar to check his vessel’s

position, vessel traffic, and his own vessel’s set

and drift.” He further testified that the

navigation crew used the ARPA radar next to

the navigation table aft of the far starboard

chair. He stated that he and the bridge crew used

two different radars so each would not interfere

with the settings used by the other while

navigating, taking fixes, or watching traffic.

8ARPAs are computer-based devices that process

radar signals and display selected navigation information.

9

Set is the direction toward which the water current

and/or wind is moving the vessel from its intended course

or trackline, and drift is the speed of these effects on the

vessel.
7

The pilot testified that about 0100 he did not

like his vessel’s “lineup” with Sentinel Island,

so he altered course left from 143°T to 126°T.

When the Star Princess was about 4 1/2 miles

from the Poundstone Rock buoy, he put the

electronic bearing line (EBL)10 on his radar

screen on 156°T. The pilot testified that about

0115, without fixing his vessel’s actual position

and expecting that the vessel’s path from the 30°

course change would “move me over east of

Poundstone Rock,” he altered course to 156°T

when the EBL crossed over the location of

Poundstone Rock buoy. The pilot later testified

that he believed the course change had moved

the vessel’s track to approximately 1 cable (600

feet) east of Poundstone Rock.

At 0116 the pilot ordered the course

changed to 155°T. The pilot later told

investigators he had intended that the vessel

would pass at least 2 cables (1,200 feet) east of

Poundstone Rock buoy as a minimum safe

margin. The pilot further testified that, “Once

you pass Vanderbilt [on the east side], I don’t

feel that the option to go to west [of Poundstone

Rock] is open any longer.”

About 0125 the pilot visually detected a

northbound vessel (later identified as the

passenger vessel Fair Princess) about 9 1/2

miles ahead, located “someplace around Aaron

Island,” which is about 6 miles south of

Poundstone Rock. He later testified, “And now

the question in my mind is, ‘Well, what’s the

Fair Princess going to do?’” The pilot further

stated that at the time he was not sure whether

the other vessel would go to the east or west of

Poundstone Rock. He said that he paid careful

attention to the vessel’s movements. He did not

call the oncoming vessel on the bridge-to-bridge

VHF radiotelephone11 to clarify the situation.

When questioned about this later, the pilot said

 

10An EBL is a luminous electronic radar cursor that

appears on the radar screen and can be used to measure the

distance and direction between any two points.

11The Bridge-to-Bridge Radiotelephone Act (33

United States Code 1201-1208, 33 Code of Federal

Regulations 26) applies to vessels operating on the

navigable waters of the United States and requires that

vessels transmit any information necessary for safe

navigation. The Lynn Canal is a navigable waterway of the

United States (46 Code of Federal Regulations 7.150).

he felt that, “We were both taking actions that

would allow a safe passage.”

Shortly after 0125, the pilot observed the

other vessel’s masthead and range navigation

lights change (“opened”)12 and saw its red port

side light. He later testified that the presentation

of these lights indicated to him that the vessel

had altered course to the right, which he

considered implied a port-to-port passage.

The third officer had been taking radar

ranges and bearings to plot the vessel’s transit of

the Lynn Canal. He plotted the position on the

chart and noted in the vessel’s rough log that the

Star Princess was abeam Vanderbilt Reef by 0.9

mile (about 4 miles north-northwest of

Poundstone Rock) at 0114. About 0130 the third

officer’s charted position showed the Star

Princess about abeam Benjamin Island (an

island north and east of Poundstone Rock) at a

distance of 1.24 miles. The bridge watch

officers did not project a course line from their

0114 and 0130 fixes to the Poundstone Rock

passage.

The third officer’s plotted 0130 position

was west of the Star Princess’s established

trackline, as drawn by the navigator and

approved by the master at the start of the cruise

season, by about 0.3 mile. (See figure 5.) The

second officer later testified that he was aware

the vessel was not following the track plotted on

the vessel’s chart. Both officers had previously

been through this passage with the same pilot on

this and other vessels. Both later stated that they

fully expected the pilot would clear east of

Poundstone Rock buoy. Neither of the two

officers asked the pilot his intentions, nor did

they offer any information. In their testimony,

the bridge watch officers made the following

statements about the pilot: “...he was piloting

the vessel, ...he is a professional, ...he knows

where we should be, ...he has been here before,

...he is making the necessary course changes.”

 

12“Opened” means that the relative distance between

the range and masthead lights appeared to increase, giving

the vessel the appearance that it was turning.
8

Vanderbilt

Reef

1

J

Poundstone

Rock .

Figure 5. – Established trackline of the Star Princess compared with

the actual trackline of the Star Princess (scale in miles)
9

The pilot testified that about 0135 he

ordered the course altered from 155°T to 153°T,

because he “didn’t like the lineup on

Poundstone Rock” and he expected that the

course change to 153°T would bring his vessel’s

margin with the buoy to 2 cables (1,200 feet).

VER data indicates that the vessel’s course

changed to 153°T about this time.

The pilot testified that after changing the

course to 153°T, he visually estimated the vessel

was going to clear Poundstone Rock buoy,

probably by less than 2 cables (1,200 feet). He

testified that by making the course change he

thought he had increased the vessel’s clearance

distance with the buoy. He also testified that

although he thought the 153°T course was

acceptable in the circumstances he faced, “If the

Fair Princess isn’t over there, I would be more

comfortable with 150°T or 145°T.”

Throughout the transit, the Star Princess’s

third officer was monitoring the helmsman to

ensure that he followed the pilot’s orders. The

pilot made no complaint about the helmsman’s

steering performance. Following the accident,

the vessel’s course recorder showed that the

pilot’s courses were accomplished by the

helmsman with minimum rudder swing and 1°

to 2° deviations in courses steered.

No radio contact was made by the Star

Princess pilot or the bridge watch officers with,

nor was any received from, the Fair Princess.

Meanwhile, the Fair Princess was northbound,

approaching the Poundstone Rock area from the

Favorite Channel (between the east side of

Shelter Island and the mainland). The pilot on

the Fair Princess testified that he had been

watching the Star Princess both visually and by

radar (see figure 6).

 The Fair Princess was steering a course of

about 336°T at a speed of 17.5 knots. The Fair

Princess VER information examined after the

accident showed that the vessel stayed about on

the 336°T course until it passed the Star

Princess after the accident.

The pilot on the Fair Princess later testified

that although vessels usually pass each other

above or below the Poundstone Rock area and

vessels sometimes leave Poundstone Rock to

their port when southbound, he thought it was

safe for two vessels to pass between Poundstone

Rock and Sentinel Island. Poundstone Rock and

Sentinel Island are about 1 mile apart, with

about 6 cables (3,600 feet [1/2 mile = 3,038

feet]) available for safe navigation. The Fair

Princess pilot testified that he had estimated that

the Star Princess and the Fair Princess would

pass port to port with about 1/2-mile closest

point of approach, just south of Poundstone

Rock.

The Fair Princess pilot testified that he

intended, once past Poundstone Rock, to alter

course to the left to allow a greater clearance for

himself from Sentinel Island. He testified that he

thought the preaccident approaches by each

vessel were normal, and he did not make a

bridge-to-bridge VHF radiotelephone call to the

Star Princess. He also testified that, although he

felt the Star Princess was a bit close to the

Poundstone Rock buoy, he did not think the

vessel was in danger of grounding. The Fair

Princess pilot further stated he was sure he had

not done anything that would have caused the

Star Princess pilot to misinterpret his intentions.

He stated that he usually would not make any

VHF radio communications in a meeting

situation because pilots allow each other a wide

berth.

About 0139, after the Star Princess passed

Sentinel Island, the Star Princess pilot rose from

the chair on the starboard side of the

wheelhouse and went to stand at the centerline

window forward. He later testified that he saw

the Fair Princess proceeding in his direction as

the Star Princess was approaching the

Poundstone Rock buoy. (According to the VER

plotting data, the Fair Princess was at this time

about 15° off the port bow of the Star Princess

at a distance of about 2 miles.) The second

officer was standing to starboard of the

maneuvering console. The third officer was

positioned at the radar to starboard of the

navigation table. The pilot and the second

officer both later testified that they lost sight of

the Poundstone Rock buoy as it came close

along the vessel’s starboard side.
10

—

L

y

n

n

a

t

_.—. —

0139

Buoy

Poundstone_,

Rock

Hump Island

; L

Y S

n

n

c

a

n

a

1

Gull

Island

Eagle

Reef

● * Aaron

Figure 6. – Tracklines of the Star Princess and the Fair Princess
11

At 0142 the Star Princess grounded on the

east side of Poundstone Rock. Poundstone Rock

was at a minimum depth of 24.3 feet below the

water (the rock was charted at 16.5 feet below

the water surface at mean lower low water

[MLLW],13 and the tide was about 7.8 feet).14

VER data showed that at 0142, the Star

Princess was on a heading of 153°T, and the

Fair Princess was about 1 mile southeast of

Poundstone Rock buoy and about 30° off the

port bow of the Star Princess.

The Star Princess pilot later testified that

when he first felt the ship shudder, he was not

immediately sure about the nature of the

problem. Both the second officer and the pilot

went to the starboard wing of the wheelhouse,

where they observed the buoy pass clear of the

starboard side. The pilot testified that it was at

this time that he realized the vessel had struck

Poundstone Rock.

Postaccident events. -- Within about 1 minute

after the grounding, the vessel had slowed to 3.5

knots and sheered to port to a heading of about

150°T. The helmsman brought the vessel to

course 155°T, and the vessel’s speed increased

to 7.6 knots.

The grounding awakened the Star Princess

master, the off-watch pilot, and the other deck

officers, all of whom went immediately to the

wheelhouse. When the master arrived in the

wheelhouse, the pilot told him that the vessel

had grounded. The chief engineer and assistant

engineers were awakened by the grounding and

quickly reported to the engineroom.

Also about 1 minute after the grounding, the

pilot on watch radioed the U.S. Coast Guard in

Juneau to notify it of the accident. About 0144,

the Star Princess and the Fair Princess passed

abeam about 1/2 mile from each other and about

1/4 mile south of Poundstone Rock. The Star

Princess master asked the off-watch pilot where

the vessel could be beached.15 The off-watch 

13MLLW is the average height of the lower of two low

waters each lunar day.

141995 West Coast of North and South America Tide

Tables, National Oceanic and Atmospheric Administration.

15If a vessel is in danger of sinking in deep water and a

suitable shallow area can be located quickly, it may be

purposely grounded or beached to prevent its sinking.

pilot explained that the water was too deep to do

so. After some discussion, he suggested that if

the vessel was stable, they should proceed to

Auke Bay, about 14 miles southeast of

Poundstone Rock.

The following vessels were in the Lynn

Canal or within about 15 miles of the accident

site: the Golden Princess, the Fair Princess, the

Universe Explorer, the Windward, and the

Glacier Bay Explorer. The master of the Star

Princess asked the Golden Princess, which was

south of the Star Princess and moving

northward, to follow his vessel in case

assistance was needed, which the Golden

Princess did.

The Star Princess master at once had the

staff captain (the officer next in command to the

master) check all the Star Princess’s internal

bottom tanks for seawater. The first check

showed no water ingress. Almost immediately

after hearing this report from the staff captain,

the master sent him back to recheck the tanks.

The second check revealed that water was

entering the ship’s double bottom tanks on the

starboard side. Flooding in four tanks was

reported, and some hydraulic oil was reported

lost from the starboard shaft lubrication system.

In all, about 1,800 tons of water entered the

ship’s double bottom tanks and increased the

vessel’s draft by about 5 inches. The tank tops

were not damaged. The chief engineer reported

nothing wrong with the propulsion, steering, and

other mechanical equipment.

The first officer, who was also the deputy

stability officer, reported to the wheelhouse

immediately after the grounding and determined

the Star Princess’s stability using the vessel’s

on-board stability computer with the

information provided by the staff captain and

chief engineer. He determined that the vessel

was stable and not in danger of sinking. He so

advised the master.

About 0150 the vessel was headed toward

Coghlan Island at the entrance to Auke Bay.

About 0155 the master addressed the crew on

the crew’s public address system. He advised

them that the vessel had struck a submerged

object, that the situation was not serious, that

they should remain calm and ready, and that

they should listen for further announcements.
12

He instructed them to advise passengers found

awake or up and about in public spaces of the

situation. He also had lifeboats readied (swung

out and lowered to the embarkation deck) in

case the vessel’s stability status should change.

The master later testified that because the vessel

was stable, he decided not to wake the sleeping

passengers either to inform them of the situation

or have them muster at “abandon ship” stations.

He testified he thought such action would have

unnecessarily alarmed the passengers.

The master requested and received

permission from the Coast Guard office in

Juneau to proceed into Auke Bay to anchor. As

he had piloted in Auke Bay before, the offwatch pilot relieved the pilot on watch about

0230 and piloted the vessel to anchorage in

Auke Bay. When the Star Princess was nearing

the entrance to Auke Bay, the master advised

the Golden Princess that its assistance was no

longer needed.

About 0330 the Star Princess anchored in

Auke Bay. Between 0437 and 0655, commercial

divers made an initial damage assessment of the

hull. When he was assured that temporary

repairs could be made and that the oil had

stopped leaking, the Coast Guard Captain of the

Port granted permission for the Star Princess to

make temporary repairs.

At 0918, while the vessel was at anchor in

Auke Bay, the master gave a complete briefing

on the situation to the passengers. Over the next

2 days, the 1,568 passengers were transferred

ashore by ship launches and arrangements were

made to transport them home. On the evening of

June 27, 1995, the Star Princess departed Auke

Bay for a shipyard in Portland, Oregon, where

permanent repairs were made.

Injuries

No fatalities or injuries occurred during the

grounding, the response effort, or the transfer of

passengers ashore.

Vessel Damage

The PCL, the operator of the Star Princess,

estimated the total accident cost at $27.16

million, of which about $7.16 million was in

damage and about $20 million was in lost

revenue. The repaired Star Princess resumed its

cruise schedule on August 7, 1995.

The vessel sustained damage to the keel and

the starboard hull bottom. The hull had two

8-inch-wide tears — one 40 feet long and the

other 100 feet long — amidships on the

starboard side. Altogether, 22 fuel tanks, ballast

(water) tanks, and cofferdams16 were damaged.

The starboard propeller blades sustained

damage and required repair. (See figure 7,

showing damaged hull plate areas.)

I

Damaged Hull at Tank Top Level is Shaded

Approximate Scale

o

~

50 100 Meters

Figure 7. – Approximate areas of damaged hull

plate replaced or repaired

It was estimated that as a result of the

grounding at least 20 liters (about 5 gallons) of

oil spilled into the water at Poundstone Rock.

By the time the vessel reached Auke Bay, no

further fuel or fluids were leaking from it.

Nevertheless, the Star Princess was encircled

with an oil containment boom in Auke Bay to

collect any oil that might leak from damaged

tanks while the vessel was at anchor. The PCL

reported that oil from damaged tanks was

‘

6

A cofferdam is the empty or void space between two

bulkheads separating the adjacent compartments to prevent

the liquid in one compartment from entering the other

should a bulkhead failure occur.
13

transferred within the vessel. Skimming or other

cleanup efforts were not considered necessary.

Crew Information

The Star Princess was staffed by Italian

deck and engineering officers with license

certificates from Italy and Liberia, while the

unlicensed crewmembers came from various

countries. (See appendix B for more detailed

information on the crewmembers.)

Pilot on watch. – The pilot on watch, age 57 at

the time of the accident, had enlisted in the U.S.

Navy in April 1956, graduated from the U.S.

Naval Academy in 1962, and served in the Navy

for a total of 24 years. He had served about 15

years at sea and upon retirement from the Navy

(in 1980) became a marine pilot for the State of

Alaska.

At the time of the grounding, he held a

Coast Guard 1,600-ton master’s license for

inland waters with unlimited tonnage first class

pilotage endorsements for southeast Alaska,

including the Lynn Canal and the area of the

grounding. This license had last been renewed

on January 9, 1995. As part of his Coast Guard

license renewal requirements, the pilot had been

tested for controlled substances pursuant to 46

Code of Federal Regulations (CFR) 16 and 49

CFR 40. The results were negative for the

presence of illegal drugs. He held a State of

Alaska marine pilot’s license, originally issued

on December 9, 1980. It had last been renewed

in December 1994.

In 1988, the Division of Occupational

Licensing of the Alaska Board of Marine Pilots

had placed the pilot’s State marine pilot license

on probation. The probation resulted from two

marine casualties that took place in the State in

1987. (On March 21, 1987, a vessel under his

pilotage collided with a log raft in Hobart Bay,

Alaska; on April 28, 1987, a vessel under his

pilotage grounded in Hobart Bay.) The pilot was

prohibited from piloting a vessel in the State for

18 months (from 1987 until 1989) and was

required to complete additional training in

shiphandling skills. He completed this training.

Subsequently, in December 1992, his license

was suspended for 6 months and placed on

probation for 1 year because of a June 1991

collision that took place between two vessels

near Skagway, Alaska, while he was piloting

one of them.17 As a result, he was required to

attend remedial training in shiphandling skills,

“rules of the road,” and radar use. He completed

all courses required to reinstate his license and

returned to piloting in May/June 1993.

The pilot testified that he was not sure of

the number of trips he had made as a pilot in this

area, but thought he had transited the Lynn

Canal 300 to 400 times during his Alaska

piloting career. He said he had completed about

six or eight trips up and down the Lynn Canal in

the 1995 season. He had previously served as a

pilot on the Star Princess for about 10 trips. He

had last been on the vessel for a 2-week

assignment that began on May 17, 1995. He

testified that he was familiar with the vessel and

its navigation equipment. He said he was

somewhat familiar with the navigating crew but

was not sure if he had worked before with the

second and third officers together.

Star Princess Pilot’s Activities

Before the Accident

Time Pilot’s Activity

1230-1830

(June 21)

Stood watch

1830-0030

(June 22)

Ate dinner and slept

0030-0600 Stood watch (docked in

Skagway at 0600)

0600-1200 Slept

1200-1400 Ate lunch and remained

awake

1400-1700 Slept

1700-1900 Awoke and ate dinner

1900-0025

(June 23)

Slept

0025-0040 Awakened, went to the

bridge

0040-0142 Stood watch till shortly after

the accident

 

17The Safety Board did not investigate any of the three

accidents cited in this paragraph.
14

At the time of the accident, the pilot had

been awake and on watch for about 1 hour and

10 minutes. His most recent continuous sleep

period had been about 5 1/2 hours long.

Pilot off watch. – The pilot off watch, age 67

at the time of the accident, testified that he

began sailing in Alaskan waters in 1963 as a

master with the Alaskan Marine Highway

System. Since his retirement from that agency,

he has served as a marine pilot with SEAPA. At

the time of the accident, he held a Coast Guard

unlimited inland master’s license, issued on

November 18, 1993. It included first class

pilotage endorsements for southeast Alaska,

including the Lynn Canal and the area of the

grounding. He also held an Alaska State pilot’s

license for southeast Alaska, including the Lynn

Canal and the area of the grounding. He originally obtained this license in 1970, and it had

most recently been renewed in January 1995. He

completed bridge resource management and

emergency ship handling training for pilots on

December 2, 1994, in Seattle, Washington.

Master. -- The master, age 54 at the time of

the accident, had served in the Italian navy for 3

years and been employed in the merchant

marine industry in various capacities since 1964.

He held Italian and Liberian unlimited master’s

licenses, issued January 11, 1971, and March 7,

1994, respectively.

Second officer. -- This officer, age 52 at the

time of the accident, had sailed on various types

of vessels in several capacities since

approximately 1970. He held an Italian

unlimited master’s license, originally issued on

November 29, 1977, and a Liberian license as

second mate, issued on April 17, 1991. He had

been employed by the PCL since March 21,

1991, as a second officer aboard the Star

Princess and the Dawn Princess.

Third officer. -- This officer, age 29 at the

time of the accident, had served on various

vessels in different positions since 1986. He

held an Italian second officer’s license for all

non-passenger vessels and a Liberian third

officer’s license for passenger ships. The

licenses were issued in November 1990 and

September 1992, respectively. The third officer

had been employed by the PCL since November

29, 1990, and had worked as a cadet aboard the

Regal Princess, the Crown Princess, and the

Star Princess. He had served about 7 months as

third officer on the Star Princess.

Vessel Information

General. -- The Star Princess, Lloyds Register

of Shipping number L8611398, is a conventional

steel-hulled, bulbous-bow, passenger liner designed for unrestricted international voyages. It

was constructed in 1989 at Chantiers de

L’atlantique of the Alsthom Group in St. Nazaire,

France. The vessel’s home port is Monrovia,

Liberia. The owner is Coseida Marine, Inc., a

Panamanian corporation. The operator is

Princess Cruises Liberia, Inc., Monrovia,

Liberia.

The Star Princess is certified to carry 1,646

passengers and a crew of 654. It holds the

highest vessel classification for construction

issued by Lloyds (+100 A1). The vessel has the

international certificates required for a vessel of

its class. Its principal characteristics are:

Gross Tonnage 63,524

Net Tonnage 32,185

Length Overall 245.60 M (805.8 ft.)

Breadth 32.23 M (105.8 ft.)

Depth (upon

departure from

Skagway)

7.65 M (25 ft., 11

inches) - Forward

8.00 M (26 ft., 3

inches) - Aft

Service Speed 19.5 knots

Horsepower 32,64018

Propellers 2 fixed pitch,

4 blades each

 

18The Star Princess is propelled by a diesel electric

propulsion system with four main diesel generators and two

electric motors using two fixed-pitch propellers. It is also

equipped with two bow thrusters of the variable pitch type,

combined power 1,780 kW/HP 2,421, and one stern thruster

unit, variable pitch type 1,060 kW/HP 1,441. Two folding fin

stabilizers limit the vessel’s roll and pitch. Steering is

provided by one rudder, controlled by an electric hydraulic

steering gear.
15

Following the accident, a Safety Board

investigator checked the Star Princess

navigational equipment and discussed its operation with the vessel’s deck officers. They

reported that all equipment was functioning

properly. The chief engineer of the Star Princess reported no problems with the vessel’s propulsion, steering, and other mechanical

equipment.

The pilot later testified that he felt that the

PCL vessels, with their high sides (which is

typical of all large cruise ships), had a windage19

problem. The pilot testified that in the

preaccident period he did not feel any wind

acting on the vessel, nor did he feel the vessel

being offset by the wind or current.

Equipment. -- The Star Princess was furnished with navigation and collision avoidance

equipment.20 The vessel was equipped with all

survival equipment required by SOLAS rules.

The Star Princess employed a public address

system throughout the vessel and had a closed

circuit television system with output in all staterooms and at public locations throughout the

vessel. The vessel was equipped with a separate

system for providing private announcements to

the crew.

The Star Princess had four radars (refer to

figure 4, the wheelhouse layout). The radar the

pilot used was beside the chair on the starboard

side of the wheelhouse. The antenna for this

radar was mounted on the ship’s bow. (The

bow-mounted antenna provided a better

presentation of small craft vessels, buoys, and

other objects that might be shadowed by the

ship’s bow and go undetected by a mastmounted antenna.)

 

19Windage is wind impinging on the large area of the

vessel’s side.

204 Radars - 2 Krupp Atlas, Model No. 8600 3 cm

and 10 cm Band with ARPA, 1 Krupp Atlas, Model No.

7600 3 cm Band with ARPA, and 1 RACAL-DECCA

(Bow radar) Bridge-Master 3 cm with ARPA; VHF radios -

2 Sailor (with dual monitoring capabilities); a Loran C -

Raytheon Raynav 780; a GPS - Magnavox MX200

professional GPS navigator; an RDF - STC International

Marine ADF-790; an Automatic Direction Finder; an

EchoGraph - Atlas 486 Digigraph; a Speed Log - Atlas

Dolog 20; a Gyro Compass - Anschutz Standard 4 (2x); an

Autopilot - Sperry SRP 2000; and a Course Recorder -

Sperry.

Waterway Information

Lynn Canal. -- The Lynn Canal extends north

from the junction of Chatham Strait and Icy

Strait at Hanus Reef in a north-northwest

direction for about 58 miles to Seduction Point.

Here it divides into two arms called the Chilkat

and Chilkoot Inlets. The latter inlet extends 25

miles farther north from Seduction Point to

Skagway. At Rocky Island, the canal is 5 miles

wide; from Point Howard to Ralston Island, it is

about 3 miles wide; from Ralston Island, it

averages 6 miles wide to Seduction Point. The

canal is nearly free of dangers, and the water is

generally very deep — over 22 fathoms (132

feet) to over 300 fathoms (1,800 feet), except

near islands and a few rocks marked with fixed

navigation lights or floating aids.

The last Coast Guard Waterway Analysis

and Management System (WAMS) study21 for

the Lynn Canal was completed in 1991.22 It

specifically included Lynn Canal to the north of

Poundstone Rock and both Saginaw and

Favorite Channels to the south of Poundstone

Rock.

 Lynn Canal was not deemed “navigational

critical”23 by the WAMS report. The report

found that the waterway was adequately marked

by the existing aids to navigation, which

included the Poundstone Rock buoy. In the

report, the Coast Guard stated that responders to

a questionnaire — including fishermen, pilots,

ship masters, and recreational boaters — were

generally pleased with the aids to navigation

provided in the Lynn Canal. Responders

reported that the aids were adequate to meet the

needs of mariners year-round.

The area studied contains no formal traffic

separation schemes. One area mariner told

Safety Board investigators that tradition,

possibly from the established ferry routes, has

accustomed local mariners to the routine that

northbound vessels transit the area between

 

21WAMS studies are conducted periodically as

directed by the Coast Guard District Commander to

determine navigation aid adequacy in an area.

22The U.S. Coast Guard Cutter Woodrush (WLB 407)

conducted and completed the study on November 15, 1991.

23If an area is found to be navigational critical,

additional navigation aids are needed for its safe transit.
16

Sentinel Island and Poundstone Rock, whether

they meet southbound traffic or not. Southbound

vessels not encountering northbound traffic are

accustomed to pass between Sentinel Island and

Poundstone Rock. When meeting northbound

traffic, southbound vessels en route to the

Favorite Channel are to use that part of the Lynn

Canal that lies to the west of Poundstone Rock.

The three SEAPA pilots (the two Star

Princess pilots and the Fair Princess pilot) who

testified about this accident stated that it is safe,

in their opinions, for two vessels to pass

between Poundstone Rock and Sentinel Island.

None could recall previously passing a vessel in

that exact area. All stated they preferred to use

the traditional meeting and passing scenario

(outlined in the preceding paragraph). All three

pilots testified that they considered 2 cables

(1,200 feet) a safe distance by which to pass

either Sentinel Island or Poundstone Rock.

Poundstone Rock is about 2.5 miles north of

Shelter Island and 1.1 miles south-southwest of

Sentinel Island. The rock has 2 3/4 fathoms

(16.5 feet) of water over it at MLLW and is

marked by a lighted bell buoy. From Poundstone

Rock, a relatively shallow area extends about 3

miles northwest toward Vanderbilt Reef. The

shallows have depths of 5 1/4 to 7 fathoms (31.5

to 42 feet) and are located about 1.4 miles

northwest of the rock.

Accidents. -- The Coast Guard lists one

marine accident as having occurred in the Lynn

Canal before this accident — a June 1991

collision of the motor vessel (M/V) Island

Princess with the M/V Regent Sea near

Skagway. The Coast Guard attributed the

accident to pilot error by both pilots. The pilot

who had been on watch on the Island Princess

during the June 1991 collision was the pilot on

watch on the Star Princess during the accident

investigated in this report.

Aids to navigation. -- The Poundstone Rock

buoy has the following characteristics: it flashes

a red light every 6 seconds, its range visibility is

4 miles, and it is painted with red and green

bands. The buoy is anchored in 67.5 feet of

water at MLLW. The buoy chain is 180 feet

long. Following the Star Princess grounding, a

Coast Guard buoy tender visited Poundstone

Rock on June 24. The tender’s commanding

officer determined that the buoy at Poundstone

Rock was on its charted position, operating

properly, and not damaged by the accident. The

buoy’s anchor (a concrete sinker) was found to

be 21 yards from the assigned position, within

its 150-yard position tolerance,24 and in the same

position it had occupied when last checked in

February 1995.

Currents. -- The velocities of currents in the

Lynn Canal vary from 0.3 to 1.0 knot in the

southern part, diminishing toward the northern

end of the canal. From Point Whidbey to Point

Sherman, the currents are regular and tidal.

Tides in Lynn Canal vary from approximately

15 feet in the southern part (the area of Funter

Bay) to 20 feet near Skagway in the north.

The Star Princess pilot and the ship’s bridge

watch officers testified that they had not

expected any significant currents during this

passage through the Lynn Canal. The pilot also

testified that his only explanation for the

grounding was a possible strong current that

could have set the vessel toward Poundstone

Rock when it emerged from the lee of Sentinel

Island about 0135.

According to the 1995 National Oceanic

and Atmospheric Administration Pacific Coast

of North America and Asia Tidal Current

Tables, the current setting the ship westerly

toward Poundstone Rock at 0135 on June 23,

1995, was about 1/2 knot.

Vessel Bridge-to-Bridge Radiotelephone Act. --

This act is applicable on navigable waters of the

United States inside the boundary lines

established in 46 CFR 7. The area of the Lynn

Canal is considered navigable waters of the

United States, so vessels25 operating in the Lynn

 

24Position tolerance is essentially the distance that a

buoy anchor may be expected to move from its prescribed

location. Each buoy is assigned its own position tolerance

by the Coast Guard based on the waterway bottom

composition (sandy or rocky, etc.), water depth, waterway

users, traffic, positioning references, and other factors. The

buoy, once positioned, should never extend outside its

assigned position tolerance.

25In this instance, “vessel” refers to a power-driven

vessel of over 300 gross tons, every vessel of 100 gross

tons carrying one or more passengers for hire, every towing

vessel of 26 feet or greater in length, and certain dredges

and floating plants.
17

Canal must comply with the Vessel Bridge-toBridge Radiotelephone Act.

The regulations require that vessels transmit

any information necessary for safe navigation.

Each vessel is required to maintain a listening

watch and, “when necessary, transmit and

confirm, on the designated frequency, the

intentions of his vessel and any other

information necessary for the safe navigation of

vessels.” The Star Princess and the Fair

Princess had the required radios on their bridges

to comply with the regulation, and the crews

were maintaining listening watches.

Because of this accident, on July 13, 1995,

the Alaska Marine Pilot Coordinator wrote to all

Alaska-licensed pilots reminding them to

communicate passing, crossing, or overtaking

intentions by use of VHF radiotelephone or

sound signals. In his letter, the Alaska Marine

Pilot Coordinator wrote, “[I]t is common

practice for passing agreements made by

radiotelephone to be substituted for required

whistle signals in our waters.” He further wrote,

“Failure to communicate effectively is a

contributing factor in most maritime accidents.”

Pilot Licensing and Oversight

Federal pilot licensing requires that pilots

annually pass a “thorough physical examination”26 that requires use of a form that addresses

the prospective pilot’s acuity of vision, color

sense, and general physical condition.27 The

Merchant Marine Personnel Physical Examination Report (CG-719K, revised in March 1995),

used to conduct this examination, contains a

block number 15 that directs the examining

physician to query the pilot being examined

concerning “Medications taken: include dosage,

purpose, and side effects.”

To obtain an original California pilot’s

license (or to renew the license), an applicant

must disclose whether he or she suffers from

depression or is using medications. California

law further provides authority for the immediate

disqualification of, or an additional evaluation

 

2646 CFR Part 10.710 (b).

2746 CFR Part 10.10.205 (d) (1).

for, any pilot diagnosed with active depression

within 1 year of the application.

Washington State pilot regulations require

that an applicant disclose whether he or she suffers from depression or is taking antidepressant

drugs. The regulations provide that an applicant’s existing need to use antidepressants or

anti-anxiety drugs can disqualify a pilot for license renewal. They also require that an

applicant with depression undergo an in-depth

evaluation before his or her license can be

renewed.

Alaska statutes and professional regulations

set licensing requirements for marine pilots. The

Alaska Board of Marine Pilots (ABMP) is

responsible for overseeing marine pilotage. The

ABMP was given the authority to set standards

under which pilots would receive licenses. The

authority states:

The Alaska Administrative Code

(‘regulations’) requires that any applicant for a pilot’s license provide evidence of a satisfactory physical

examination, whether for renewal or

original application. The required

physical examination must demonstrate

that the applicant is in all respects

physically fit to perform the duties of a

pilot and [include] an examination of

eyesight, hearing, and blood pressure.

Alaska State law and regulations do not go

into greater detail about the physical

requirements for obtaining a pilot’s license. The

physical and medical requirements for obtaining

a pilot’s license vary among pilot licensing

organizations in the United States.

The ABMP consists of seven members, each

appointed by the Governor: two licensed pilots

who have been actively engaged in piloting

vessels subject to Alaskan law, two registered

agents or managers of vessels subject to Alaskan

pilotage laws, two members of the public, and a

commissioner. The ABMP is responsible for,

among other things:
18

• Providing for the maintenance of

efficient and competent pilotage service

on the inland and coastal waters of and

adjacent to the State to ensure the

protection of shipping, the safety of

human life and property, and the

protection of the marine environment;

• Establishing the qualification of and

required training for pilots and providing

for the examination of pilots and the

issuance of original or renewal pilot

licenses;

• Auditing a pilot organization or an

individual pilot as necessary to

implement or enforce State pilotage

requirements; and,

• Making any other provision for the

proper and safe pilotage upon the inland

and coastal water of and adjacent to the

State, including: a mandatory drug and

alcohol testing program, including

random tests, postincident tests, and tests

based upon reasonable cause for pilots.

The ABMP may discipline a licensed pilot

or a marine pilot organization recognized by the

board. Sanctions include:

• Permanently revoking a license;

• Suspending a license for a specified

period;

• Censuring or reprimanding;

• Limiting the professional practice of a

licensee;

• Requiring remedial professional

education to correct deficiencies in the

education, training, or skill of a licensee;

• Imposing probation requiring a licensee

to report regularly to the board on

matters related to the grounds for

probation; and,

• Imposing civil fines on individual pilots

or on pilot organizations.

The board must discipline a pilot if it finds

that the pilot:

• Is incompetent in the performance of

pilotage duties;

• Is chemically impaired;

• Illegally possesses, uses, or sells narcotic

or hallucinogenic drugs;

• Makes a false statement to obtain a

license;

• Violates a provision of the pilotage

statutes or regulations;

• Is guilty of misconduct during the course

of employment; or,

• Has had a Coast Guard pilot license

conditioned, suspended, or revoked.

A pilot is required to notify the ABMP

marine pilot coordinator whenever a vessel

piloted by him or her is involved in a grounding

or “collides with another vessel or dock, meets

with any casualty, or is damaged in any way.”

No monetary minimum damage threshold is

specified, and the incident must be reported

within 72 hours. The marine pilot coordinator

may, at his or her discretion, investigate the

reported incident. Between January 1990 and

January 1997, 58 incidents/accidents were

investigated. In 39 cases, no action resulted. In

the remaining cases, 2 pilots surrendered their

licenses, 1 pilot’s license was placed on

probation, 1 pilot’s license was suspended, 1

pilot’s license was suspended (with probation),

1 pilot’s license was suspended (ultimately

surrendered), 3 warning letters were issued, 1

case was a Federal violation, 1 pilot died before

action was completed, 1 pilot retired, and 7

cases were pending.

The pilot in this accident was involved in a

license suspension/probation and a license

suspension/surrender. On July 5, 1995, the State

of Alaska suspended the license of the pilot for

his part in the Star Princess grounding. On

September 29, 1995, the State sought revocation

of the pilot’s license. On April 1, 1996, the pilot

surrendered his license and agreed to “never

again apply for a marine pilot license of any sort

issued by the State of Alaska.” The agreement

does not preclude the pilot from applying for a

pilot’s license in another jurisdiction.

Alaska requires that new pilots and pilots

renewing a license take training under which

they must meet pilot licensing requirements

through classroom training, familiarization trips,
19

and the satisfactory docking and undocking of

vessels at various ports within the State. The

ABMP may, for good cause, require a Statelicensed pilot to submit to a physical or mental

examination to determine fitness to perform

pilot duties. (General information on pilots and

piloting appears in appendix C.)

Meteorological Information

General. -- The weather and sea conditions

recorded in the Star Princess logbook between

0200 and 0400 on June 23 were cloudy skies,

force 3 winds (approximately 7 to 10 knots) out

of the east, and seas of 2 to 4 feet. Visibility was

at least 10 miles. The seawater temperature was

about 50°F.

High tide in Juneau was at 2252 on June 22,

with a height of 15.5 feet. Low tide was expected at 0458 on June 23 and to be 1.3 feet. At

the time of the grounding, the tide was

approximately 7.8 feet and dropping. An ebb

current of about 0.3 to 0.5 knot in an

approximate west-southwest direction was

anticipated in this part of the Lynn Canal. The

tide and current data were available through two

computer systems located on the bridge of the

Star Princess. The pilot on watch testified that

he was familiar with these tools.

Visibility and assessment of distance from

Poundstone Rock buoy. -- The pilot subsequently

testified that he had wanted to pass east of the

Poundstone Rock buoy by 2 cables (1,200 feet).

About 0115 the pilot turned the vessel to course

156°T using the EBL as a reference. The pilot’s

stated reason for making the course change to

156°T was to provide the 2-cable (1,200 feet)

offset to the east of the buoy. At the time of the

course change, Poundstone Rock buoy was

about 4 1/2 miles away. After making the EBL

course adjustment and during the 27 minutes

remaining before the grounding, the pilot relied

almost exclusively on visual cues for navigating

the vessel as it approached Poundstone Rock

buoy.

The pilot characterized visual conditions in

the hour before the accident as “a little darker

than twilight.” He testified that although it was

not entirely dark outside, the light was

insufficient for him to discern details of the

environment, such as the outlines of the Fair

Princess and the lighthouse on Sentinel Island.

He stated that he initially saw the flashing red

light of the buoy marking Poundstone Rock, as

well as the white light from the lighthouse on

Sentinel Island and the deck lights of the Fair

Princess, when he was several miles from them.

The pilot testified that as the vessel continued to

approach Poundstone Rock, all three sources of

light were distinctly visible. He specifically

recalled that, from his perspective, the brightest

light was generated by the lighthouse, followed

by the lights of the Fair Princess and the light

from the buoy marking Poundstone Rock.

Investigators contacted a vision researcher28

in an attempt to determine how well individuals

can appraise relative distances in low light conditions. The following information, as provided

by the researcher, was compiled by Safety

Board investigators.

Vision is normally binocular. Because the

eyes are separated, each eye receives a slightly

different view of the visual scene. This slight

difference in each eye’s image, known as

“lateral retinal image disparity,” is a primary

cue to depth. Stereo acuity permits the visual

resolution of small differences in depth or

distance by means of retinal disparity. Because

depth perception is heavily dependent on cues

that exist during daylight (such as those that

create such phenomena as contrast, texture

gradient, and linear perception), individuals

have difficulty accurately judging distances of

objects under conditions of little or no light.

Assessment of a single lighted object under such

environmental conditions is particularly difficult

because of the absence of these cues. Two or

more lighted objects that occur simultaneously

in the visual field allow for subjective

judgments as to their apparent relative distance

from each other and perceived relative intensity

(brightness), which are cues that create depth

perception.

Medical and Pathological

Tests conducted. -- On June 23, 1995,

selected Star Princess crewmembers and the

 

28Telephone conversation with Dr. D. Alfred Owens,

professor of psychology, Whitely Psychology Laboratory,

Franklin and Marshall College, Lancaster, Pennsylvania,

on May 3, 1996.
20

pilot who had been conning the vessel at the

time of the accident provided breath and urine

specimens pursuant to postaccident alcohol and

drug testing requirements.29 Toxicology testing

began at 0540, when the pilot supplied breath

and urine specimens that were tested for alcohol

and illegal drugs.30 Eleven crewmembers also

provided breath and urine specimens,

concluding with the master at 1007. The results

from the specimens from all individuals’ tests

were negative for the presence of alcohol and

illegal drugs.

Pilot’s condition. -- ABMP records showed

that the pilot on watch had last undergone a

physical examination, which included a vision

and hearing test, on October 31, 1994. The

certificate of medical examination completed by

the pilot and the examining physician on

October 31, 1994, did not specifically address

whether the pilot was taking medications. The

examining physician found the pilot physically

qualified to perform his duties as a marine pilot.

The form used for the exam asked the

applicant or licensee whether he or she had a

“medical disorder” or “physical impairment,” to

which the pilot responded that he did not.

Likewise, the form contained an entry to be

completed by the examining physician that

concerned the applicant’s “neurological and

mental health,” which the physician indicated as

“normal” for the pilot. The form did not address

whether the applicant suffered from specific

illness or was taking medication.

Effexor. -- The pilot who was conning the Star

Princess at the time of the accident later

testified that he was taking Effexor, a

prescription medication used to treat depression.

The pilot stated that he had been on this

medication for 3 years before the accident and

that he had been treated for depression for about

8 years. Most recently before the grounding, on

June 22, 1995, he had taken 75 mg of Effexor at

his normal time of about 1800.

The pilot testified that the medication

sometimes caused some moderate physical

 

29See title 46 CFR 4.06.

30Cocaine, amphetamines, cannabinoids, opiates, and

phencyclidines.

reactions (such as sweating). He stated that he

was not taking any other medications, and that

he did not have any other illness.

According to the 1995 edition of the Physician’s Desk Reference, Effexor (venlafaxine

hydrochloride) is indicated for the treatment of

depression. In controlled clinical trials, the most

commonly observed adverse effects associated

with Effexor were sweating, nausea, constipation, anorexia, vomiting, somnolence

(drowsiness), dry mouth, dizziness, nervousness,

anxiety, tremors, and blurred vision. The

Physician’s Desk Reference indicated that the

medication is not a controlled substance.

During this investigation, the Safety Board

requested the pilot’s physician (who initially

prescribed the Effexor) and several other

physicians to provide professional opinions on

how Effexor might have affected the pilot. One

physician stated that in controlled clinical studies

of Effexor, a low incidence of somnolence had

been indicated by some subjects in early stages of

use. He indicated that this finding was not

applicable to the pilot, who had been taking the

medication for more than 1 year. Additionally,

the physician stated that the dosage of Effexor

being taken by the pilot (75 mg) was “generally

the lowest clinical effective dose, so the incidence

[of sedation] is even lower statistically.”

Another physician stated that the pilot had

never been chemically impaired by his use of

Effexor, and neither the pilot’s depression nor his

use of the medication “constituted a physical or

mental disability or impairment that would impair

or interfere with his ability to practice as a marine

pilot.” A third medical consultant said that

Effexor “has been found to affect information

processing less than expected with classical

antidepressants.”31 He stated that little evidence

indicated Effexor impaired coordination or spatial

skills. (Additional information on Effexor appears

in appendix D.)

 

31Classical antidepressants may be considered those

used generally before the early 1990s. Newer classes of

antidepressants, of which Effexor is one, operate in such a

way as to have a less sedative effect on human beings than

the earlier medications did.
21

Fatigue. -- Previous accident investigations32

have identified three background factors related

to fatigue — cumulative sleep loss, continuous

hours of wakefulness, and time of day when the

incident occurred. Sleep research33 has

established that individuals require a certain

number of continuous hours of sleep each day to

be fully alert and functioning; the amount is

typically about 6 to 10 hours, depending on the

individual. Some evidence suggests that only 2

hours less sleep than is normally required can

degrade an individual’s alertness and

performance. During a thorough physical

examination conducted in November 1995, the

pilot reported he usually obtained 7 to 8 hours

of sleep each night when not piloting. He

reported that from the time he boarded the

vessel on June 21 until the accident, he had

obtained an average of just over 5 hours of sleep

per sleep period — a total of about 14 1/2 hours

of sleep in a 24-hour period. With respect to

continuous wakefulness, the pilot had been

awake slightly more than 1 hour when the

grounding occurred.

Researchers have established34 that two

periods of maximum sleepiness occur during a

24-hour period, determined by physiological

fluctuations controlled by the brain. These

periods are approximately from 1500 to 1700

and from 0300 to 0500. Research further

 

32See Safety Study -- Factors that Affect Fatigue in

Heavy Truck Accidents (NTSB/SS-95/01) and Aircraft

Accident Report -- Uncontrolled Collision with Terrain

American International Airways Flight 808 Douglas DC-8-

61, N814CK, U.S. Naval Station, Guantanamo Bay, Cuba,

August 18, 1993 (NTSB/AAR-94/04).

33(a) Carskadon, M. and Dement, W., “Normal Human

Sleep: An Overview,” Principles and Practice of Sleep

Medicine, pp. 16-26, section 1, chapter 2. W.B. Sanders

Company, Philadelphia, Pennsylvania, 1994. (b) Roth, T.,

Roehrs, T., Carskadon, M., and Dement, W., “Daytime

Sleepiness and Alertness,” Principles and Practice of Sleep

Medicine, pp. 40-50, section 1, chapter 4. W.B. Sanders

Company, Philadelphia, Pennsylvania, 1994. (c) National

Commission on Sleep Disorders Research, Wake Up

America; A National Sleep Alert, Vol. 1: Executive

Summary and Executive Report. Submitted to the U.S.

Congress and the Secretary of Health and Human Services,

1993.

34Rosekind, M., Gander, P., Connell, L., and Co, E.,

Crew Factors in Flight Operations X: Alertness

Management in Flight Operations. NASA/FAA Technical

Memorandum DOT/FAA/RD-93/18, 1994.

indicates that performance and alertness can

also be affected throughout the period from

0000 to 0800. Regardless of the amount and

quality of prior sleep, the body has a natural

tendency to sleep during these specified

periods.35 Individuals who are not sleep

deprived will, on average, require about 20

minutes to fall asleep when placed in a dark,

quiet room.36 A sleep researcher37 who tested the

Star Princess pilot several months after the

accident found that he (when tested on several

different nights) fell asleep in an average of

about 5 minutes when placed in a dark, quiet

room.

An attorney representing the pilot informed

the Safety Board in a November 2, 1995, letter

that the pilot had been diagnosed several weeks

earlier with sleep apnea. The letter stated that in

late October 1995, a physician specializing in

sleep disorders had informed the attorney that

an initial evaluation had suggested that the pilot

suffered from obstructive sleep apnea (OSA).

Additional tests conducted in a laboratory

setting had resulted in a diagnosis of OSA. The

Safety Board subsequently contacted two

independent sleep researchers38 and requested

that they evaluate the data and opinions

generated by the physician who made the

diagnosis. Both researchers corroborated the

validity of the physician’s findings and

acknowledged the presence of OSA in the pilot.

Sleep apnea is a syndrome in which

abnormal respiratory functions during sleep

prevent adequate breathing.39 Apnea means 

35Dinges, David, “Napping Strategies,” Fatigue

Symposium Proceedings, November 1-2, 1995, p. 48. The

National Transportation Safety Board and the NASA Ames

Research Center sponsored the symposium.

36Association of Sleep Disorders Centers Task Force

on Daytime Sleepiness: Sleep, 9(4):519-524, Raven Press,

1986.

37Dr. Noel Johnson, D.O., of the Seattle, Washington,

Sleep Disorder Center.

38Mark R. Rosekind, Ph.D., Chief, Aviation

Operations Branch, Light Management and Human Factors

Division, NASA Ames Research Center, Moffett Field,

California, and Allan I. Pack, M.D., Ph.D., Director, Center

for Sleep and Respiratory Neurobiology, University of

Pennsylvania Medical Center, Philadelphia, Pennsylvania.

 39Goldberg, P., Kaufman, D., Everybody’s Guide to

Natural Sleep, pp. 60-61, Jeremy P. Tarcher, Inc., Los

Angeles, California, 1990.
22

“without breath,” and sleep apnea is a condition

in which a sleeping individual ceases to breathe

for short periods. Sleep apnea was not identified

until the early 1970s. One sleep researcher

estimates that 1 to 4 percent of the U.S.

population, and 2 to 8 percent of the U.S. male

population, suffer from this syndrome.40

Researchers have identified three types of

sleep apnea — central apnea; obstructive or

upper airway apnea; and mixed apnea, which is

a combination of the other two conditions.

When an individual suffers from central apnea,

the respiratory effort discontinues altogether. In

cases of OSA, which are more common, the lack

of respiration automatically induces the body to

try to start breathing again, but a partial or total

obstruction of the breathing passage prevents

the free flow of air. Obstruction can be caused

by tonsils or adenoids, by fatty deposits or

excess tissue that reduce the diameter of the

airway, or by abnormalities in the throat or jaw

structure.41

Predisposing factors to sleep apnea include

being male, being obese, and having enlarged

tonsils, hypothyroidism, or acromegaly.42

Alcohol and sedative use predispose individuals

to snoring and apnea by relaxing the upper

airway dilating muscles. Problems caused by

apnea worsen with age, particularly after age 40.

Consequences of sleep apnea include excessive

daytime sleepiness, irritability, depression, and

impaired cognitive functioning and work

performance.

Research43 indicates that while individuals

may experience the symptoms of sleep apnea,

they typically are not aware until they have been

 

 40Dement, W., The Sleepwatchers, p. 66, Stanford: The

Portable Stanford Book Series, 1992.

 41Dotto, L., Losing Sleep: How Your Sleeping Habits

Affect Your Life, pp. 108-109, William Morrow and

Company, Inc., New York, New York, 1990.

42Acromegaly is a disorder marked by progressive

enlargement of the head, face, hands, feet, and thorax

caused by excessive secretion of a growth hormone by the

pituitary gland.

 43Catalano, E., Getting to Sleep: Simple, Effective

Methods for Falling and Staying Asleep, Getting the Rest

You Need, and Awakening Refreshed and Renewed, pp. 32-

33, New Harbinger Publications, Inc., Oakland, California,

1990.

medically evaluated that they suffer from this

syndrome. The sleep apneic may wake many

times during the night so briefly as to have no

recollection of having awoken. Sleep apneics

awaken poorly rested and, since they were

unable to obtain restorative, uninterrupted sleep,

go through the day feeling fatigued and

disoriented. Additional manifestations of sleep

apnea include morning headaches, excessive

daytime sleepiness, depression, intellectual

impairment, and memory deficit.

Bridge Resource Management

General. -- Bridge resource management

(BRM) may be defined as the effective use by

bridge watchstanders of all available resources,

in the form of information, equipment, and

personnel, to achieve safe operation. The

concept of BRM was developed to help

mariners recognize and correct operational and

human errors before they lead to an accident.

BRM is a model for effective communications

among bridge watchstanders, a means to trap

errors, and an aid to decisionmaking in an

operational environment.

One of the principles of BRM requires that

everyone on the bridge be familiar with the passage plan, know his or her responsibilities in

connection with the passage, and be able to

communicate observations on the progress of

the passage plan to other members of the bridge

watch freely and professionally. Sound BRM

requires that when a pilot boards a vessel, the

pilot’s knowledge and expertise concerning

local waters be communicated and integrated

into the watchstanders’ information flow.

The Safety Board has investigated a number

of marine accidents that have occurred because

members of the bridge watch and the pilot failed

to communicate, coordinate their efforts, recognize potential problems, and cooperatively

solve imminent problems.44 In its investigation

 

44Marine Accident Reports -- Grounding of the United

Kingdom Passenger Vessel RMS Queen Elizabeth 2 near

Cuttyhunk Island, Vineyard Sound, Massachusetts, August

7, 1992 (NTSB/MAR-93/01); Grounding of the U.S.

Tankship Star Connecticut, Pacific Ocean, near Barbers

Point, Hawaii, November 6, 1990 (NTSB/MAR-92/01);

Collision between the Greek Tankship Shinoussa and the

U.S. Towboat Chandy N and Tow near Red Fish Island,

Galveston Bay, Texas, July 28, 1990 (NTSB/MAR-91/03);
23

of these accidents, the Safety Board found that

they occurred largely because BRM techniques

were not being used and the bridge watches and

pilots failed to function as teams.

In the case of the Star Princess grounding,

the pilot on watch at the time of the accident

initially stated he considered himself and the

two bridge watch officers a team. He

subsequently stated that the team atmosphere on

the Star Princess bridge before the accident was

minimal. He further stated that he expected the

watch officers to keep tabs on his performance

and inform him of errors.

PCL company policies. -- The PCL advocates

the use of BRM for its cruise vessels. The PCL

has instituted BRM training for its watch officers, and some PCL officers had received BRM

training before the accident date. The Star Princess master had not been to BRM training before the accident. The two bridge watch officers

on duty when the Star Princess grounded had

also not received such training. The master

managed his vessel by following PCL fleet

regulations. Relevant PCL policies and regulations regarding acceptable performance of

bridge watch duties are reviewed in the following sections.

Watchstander duties. -- PCL company policy

concerning the activities of watchstanders is

reflected in the Princess Cruise Lines Fleet

Operations Manual under “Fleet Regulations,

Deck Standing Orders - Navigation.” (See

appendix E for additional information.) The

manual addresses requirements for plotting

navigation fixes, checking for gyro errors, and

summoning the master to the bridge. It states

that a lookout should be posted to observe

lights, sounds, vessels, or any obstruction to

navigation, and that the lookout should report

observations to the watch officer. It also states

that the individual should have no other duties

while acting as lookout.

 

and Ramming of the Spanish Bulk Carrier Urduliz by the

USS Dwight D. Eisenhower (CVN 69), Hampton Roads,

Virginia, August 19, 1988 (NTSB/MAR-90/01). Also,

Marine Accident Brief DCA-94-MM-035, Grounding of

the Netherlands Antilles Passenger Ship Nieuw Amsterdam

in Nichols Passage, near Ketchikan, Alaska, on August 8,

1994.

Plotting and recording of navigation fixes. -- Under the

section “Handing over the Watch,” the PCL

fleet regulations state:

When temporarily relieved in this

manner (master or pilot has the conn),

the officer-in-charge of the watch is to

continue to fix the ship’s position at

suitable and frequent intervals and to

report the results (recorded on charts or

in the telegraph and stations book or

recorded on the bridge tape recorder) of

such fixes.

The PCL fleet regulation for “Navigation

under Pilotage” states:

The fact that the captain, staff captain,

or pilot may have the conn does not

relieve the officer of the watch from

continuing to fix the ship at frequent

intervals, right up to or from the berth to

anchorage.

On the Star Princess, according to

testimony from the second officer on watch,

plotting fixes at suitable and frequent intervals

meant taking fixes approximately every 15

minutes during transit of the Lynn Canal.

Examination of the National Oceanic and

Atmospheric Administration Chart No. 17316

(Lynn Canal: Icy Strait to Point Sherman),

which was in use during the hours preceding the

accident, showed that fixes were being plotted

on the Star Princess at about 15-minute

intervals.

The PCL further requires that ship’s

positions be fixed at frequent intervals using all

possible aids, which are listed as “cross bearings

of land, leading lights or marks, soundings,

radar, and any electronic navigation aids.” The

PCL requires that positions be checked by

independent means whenever possible. The PCL

requires that careful attention be paid to the

steering, compass error, tides, and currents, and

that the ship’s position be fixed both before and

after every significant course alteration. The

PCL fleet regulations state that whenever a

vessel passes abeam of a major or significant

landmark, a fix should be taken and recorded in

the log book.
24

Oversight. -- The PCL acknowledges that it has

the responsibility and authority to monitor the

safety and pollution prevention aspects of its

vessels and to ensure that adequate resources

and shore-based support are provided to them.

To fulfill this responsibility, the PCL schedules

regular boarding of the vessels by company

officials to ensure that proper procedures are in

place and being carried out in conformity with

company policy.

VERs

The Star Princess and Fair Princess are

equipped with VERs (also known as VDRs, for

voyage data recorders). These devices were

operating during the accident and they recorded

time, global positioning system (GPS) position

(latitude and longitude), course, heading, speed

made good over the ground, and radar data from

various sensors. Audio data were also recorded

from several microphones located on the ship’s

bridge. The navigation information was later

used to reconstruct the actual tracklines of both

vessels. In addition, the audio portion of the Star

Princess VER provided investigators with

information concerning navigation orders and

discussions between individuals on the bridge.

This is the first time Safety Board investigators

have used event recorder data (other than from a

course recorder) on a marine accident

investigation.

In accordance with PCL requirements, after

the accident the VER recording tapes were

removed by the masters of both involved vessels

and sent to London, England, for review.45 Two

Safety Board investigators went to England in

December 1995 to observe the VER playbacks.

The recorded radar, GPS, and gyro data for the

June 23, 1995, periods from 0000 to 0145 (for

the Star Princess) and from 0135 to 0145 (for

the Fair Princess) as provided by the VERs

were used to reconstruct the vessels’ tracklines,

as displayed in figures 3 and 6.

The PCL provided investigators with a

transcript of conversations that took place in the

Star Princess wheelhouse from 0102 until 0159

on June 23. The bridge voice recording quality

was poor, and intelligible conversations were

 

45The VER readout equipment is in London.

broken and disjointed. The matters discussed by

the watch officers and pilot were not of a

navigational nature and were not related to

shipboard duties. For the 20 minutes preceding

the accident (from 0122), the conversations on

the bridge of the Star Princess as recorded by

the bridge voice recorder primarily concerned

personal grooming and family relationships.

Since 1976, the Safety Board has

recommended in various accident reports that

VERs be used to preserve vital navigation

information. (See appendix F for Safety Board

history on marine VERs.) In 1993, the

International Maritime Organization (IMO)

considered whether VERs were too complex to

justify a requirement for their use. Since then,

technology has expanded the capability of VERs

and reduced their cost. More marine companies

are installing these systems as means of

monitoring bridge watchstanding performance,

as well as for conducting accident

reconstruction. The PCL has installed VERs on

at least seven passenger ships, including the Star

Princess and the Fair Princess. P&O Lines,

Ltd., the parent company of the PCL, has

equipped most of its cargo vessels with VERs.

Since early 1996, the Coast Guard has been

working on VER policy with the IMO. Safety

Board staff have been monitoring the status of

this initiative. In an August 9, 1996, letter to the

Commandant of the Coast Guard, the Safety

Board wrote:

the U.S. Coast Guard has just returned

from the Subcommittee on Navigation

meeting in London where the IMO is

considering requirements for VDRs....

Now that the international community is

engaged in discussion on this important

matter, steps should be taken to avoid

any further delay in the international

adoption of at least a baseline standard

for VDRs. We understand that a

performance standard has been

submitted to the upcoming meeting of

the Maritime Safety Committee in

December [1996]. We further understand that a carriage requirement for

VDRs has been included in the draft

text of a comprehensive revision to

SOLAS Chapter V. Unfortunately, if the

Maritime Safety Committee does not
25

find itself in a position to approve the

entire text of SOLAS Chapter V, the requirement for VDRs may be delayed

until the next cycle of SOLAS requirements, possibly for another 4 years. The

Safety Board believes VDR requirements may be one of the most urgent

and significant amendments which are

being considered for SOLAS, and we

urge the Coast Guard to continue to play

a leading role on this issue at IMO, even

to the point of pressing to have the VDR

provisions considered separately from

other proposals amending Chapter V.

In August 1996, a Coast Guard initiative to

recommend VER use for all vessels operating

on international voyages was presented to the

Maritime Safety Committee (MSC) Subcommittee on Navigation. The subcommittee met at

the IMO’s headquarters in London, England, to

draft requirements for VERs. The United States

was one of three countries that presented the

requirements for consideration to the MSC in

December 1996. The VER requirements were

referred to the Design and Engineering Subcommittee, which is scheduled to present its

findings to the MSC in mid-1997.

Survival Factors

Star Princess passengers were requested to

provide information about their observations by

filling out a questionnaire. Summary of their

observations revealed that most responding:

• Had received a safety briefing instructing

them how to don life preservers, locate

their muster/lifeboat stations, and

identify the different alarm signals.

• Recalled seeing emergency placards

posted throughout the ship and in their

cabins.

• Had been asleep before the incident.

• Were alerted to the incident when they

felt a jolt or bump (the grounding), but

did not feel that they were in any danger

and so went back to sleep.

• Recalled hearing an announcement from

the captain the next morning informing

them of the situation and stating that they

were not in any danger.

• Were provided with a memo that

explained the procedures to be followed

to prepare to leave the Star Princess.

• Found the demeanors of fellow passengers “calm,” “reassured,” “quiet,”

“surprised,” and “disappointed” (that the

cruise was concluded).

• Thought there had been no panic and that

the crew had lowered lifeboats and was

prepared if they had to evacuate.

• Found the crew well-organized and

responsive to passengers’ questions.

(Some further stated that the crew

provided “first-class” treatment, doing an

“excellent” or “tremendous” job.)

• Did not feel that they had been in any

danger.

A few passengers told the Safety Board they

thought they should have been informed of the

grounding shortly after it occurred. Several

stated they believed that if passengers had been

informed earlier, they could have sooner

gathered their belongings and prepared to

disembark.

Other Information

Alaskan cruise industry. Traffic. -- According to

the Alaska Bureau of Tourism, passenger ship

cruising is a growing industry in Alaska and this

trend seems likely to continue. Large numbers

of ships operate in the region and tourists visit

relatively few areas. Passenger ship traffic can

be heavy near visited ports. The Coast Guard

has stated46 that in the area of cruise activity:

Alaska continues to experience soaring

growth. In the last 4 years alone, capacity in the inside passage has increased

by 39 percent, from 114,000 passengers

in 1992 to 158,000 passengers in

1995.... Some ports are reaching capacity; Juneau, Ketchikan, and Sitka, for

example, may host from three to five

ships on many days....

The Coast Guard further reported that in the

1995 season (between May and September), 7

 

46Report of the Cruise Ship Safety Review Task Force,

p. 7, October 31, 1995.
26

cruise ship companies were operating 29 vessels

in the Alaska cruise market. The Coast Guard

expected that more companies and ships were

planning to enter this market.

The traffic separation scheme (TSS) in

Prince William Sound for vessels traveling to or

from the oil terminal at Valdez, Alaska, has

been successful in preventing collisions between

vessels in this region. Other areas in the United

States with high traffic density or other risk

factors (such as the approaches to New York

Harbor, New Orleans, and Rhode Island Sound)

have TSSs designed to prevent accidents.

On June 8, 1996, the Marine Safety Task

Force published its Southeast Voluntary Waterway Guide. This reference was cooperatively

developed by the Coast Guard, the State of

Alaska, and industry and pilot associations in

Alaska. It provides recommended guidelines

intended to assist pilots, bridge teams, and the

cruise industry and (ship) agents in improving

safety in southeast Alaskan waters. The guidelines provide navigating watches with a standard

on which to base their navigating practices. The

guidelines, which are similar to a TSS, clarify

the routing or vessel separation in the areas

listed, including the Lynn Canal.

The area from Vanderbilt Reef to Poundstone Rock in Lynn Canal is cited in the guide.

The guide states that northbound vessels should

pass east of these obstructions and southbound

vessels should pass west of them. The guidelines particularly encourage southbound pilots

to navigate to the west of Poundstone Rock

whenever they expect to encounter a northbound

vessel between Poundstone Rock and Sentinel

Island.

Also listed in the guide are radio security

call points47 for the Poundstone Rock area. For

southbound vessels, the call point is Vanderbilt

Reef (about 5 miles north of Poundstone Rock);

for northbound vessels, the call point is Outer

Point (about 15 miles south of Poundstone

Rock) on the west side of Douglas Island.

Besides the Southeast Voluntary Waterway

Guide, mariners passing between Poundstone 

47Radio security call points are locations from which

vessels should broadcast radio security calls that provide

information that could be useful to other vessels in the area.

Rock and Sentinel Island have no other

commonly accepted written guidance to which

they can refer.

Use of pilots. -- The use of pilots in southeast

Alaska is different from that typically

encountered, where a pilot is responsible

primarily for conning the vessel into and out of

port. The southeast Alaska tourist trade is

conducted mainly in inland waterways or “pilot

waters.” In pilot waters, continuous use of pilots

is compulsory. A pilot, as designated by State or

Federal law, must be on board to assist the

master or navigation watch officer whenever the

vessel is in pilot waters. Consequently, in the

southeast Alaska cruise industry, pilots serve

aboard cruise vessels for extended periods, often

3 to 12 days.

Safety Board investigators requested

information from the American Pilots’

Association48 regarding the responsibilities of a

compulsory pilot. In a December 13, 1996,

letter, an association representative stated:

You have asked about the respective

roles and responsibilities of the compulsory pilot and a ship’s crew and about

the master-pilot relationship. Both, of

course, are the subject of considerable

discussion and debate. They are difficult

to define in brief statements. In addition, pilotage statutes and regulations

may affect in some degree the status,

role, and responsibilities of a state pilot.

For that reason, those aspects of compulsory pilotage may differ slightly

from State to State. With that caveat,

however, the following general principles of American maritime law would

be useful for your purposes.

The compulsory pilot has direct control

of the navigation of the ship, subject to

the master’s overall command of the

ship and the ultimate responsibility for

its safety. ‘It is always to be presumed,

in the absence of positive evidence to

 

48The American Pilots’ Association represents

approximately 60 pilot associations, which is nearly all

such associations in the United States. About 1,100 pilots

are members of these groups.
27

the contrary, that a local pilot employed

for the occasion and actually on the

bridge is in charge of the navigation of

the ship, subject to the authority of the

master.’ United States v. Jacksonville

Forwarding Co. ISF-2nd 39, 40 (5th

Cir. 1929)....

Territory. -- The area in which Alaska

passenger cruising takes places is vast. The

distance from the southern border with Canada

to Skagway, Alaska, is about 400 miles; from

Skagway to the Gulf of Alaska is about another

200 miles; and from the Gulf of Alaska to

Seward is another 400 miles. The distance that

the Coast Guard must watch over for the cited

area is roughly equivalent to the distance from

New York City to Miami, Florida.

Navigation. Fixed navigation aids and floating markers. --

The aids to navigation depicted on marine charts

comprise a system of fixed and floating markers

having varying degrees of reliability. The Coast

Guard Light List49 states:

Buoy positions represented on nautical

charts are approximate positions only,

due to the practical limitations of positioning and maintaining buoys and their

sinkers in precise geographical locations. Buoy positions are normally verified during periodic maintenance visits.

Between visits, atmospheric and sea

conditions, seabed slope and composition, [and] collisions or other accidents

may cause buoys to shift from their

charted locations, or cause buoys to be

sunk or capsized.

Buoy moorings vary in length. The

mooring lengths define a “watch circle,”

and buoys can be expected to move

within this circle. Actual watch circles

do not coincide with the symbols

representing them on charts.

CAUTION: Mariners attempting to pass

close aboard risk collision with a

 

49This is a complete Coast Guard list of lights, sound

signals, buoys, daybeacons, and radiobeacons. The list is

published in seven volumes that cover the U.S. coasts and

include the U.S. island possessions, the Great Lakes, and

the Mississippi River System.

yawing buoy or with the obstruction

which the buoy marks. Mariners must

not rely on buoys alone for determining

their positions due to factors limiting

buoy reliability. Prudent mariners will

use bearings or angles from fixed aids to

navigation and shore objects, soundings,

and various methods of electronic

navigation to positively fix their

position.

Contingency planning and exercises. Report of the

Cruise Ship Safety Review Task Force.50 -- In response to

four cruise ship accidents that took place in

summer 1995,51 the Coast Guard established a

task force to conduct a safety review of the

seagoing cruise ship industry (both U.S. and

foreign flag) “to determine if adequate

mechanisms are in place to ensure a continued

high level of safety for all passengers who

embark on cruise ship voyages from U.S. ports.”

While the task force considered cruise

shipping a “safe industry” overall, it found that

some areas could be improved. Among other

issues, the task force recommended that

improvements be made in crew training and

communications. The task force further found

that “greater emphasis should be placed on

contingency planning and exercises and [such

exercises] should be done in partnership with

the industry, emergency responders, and other

associated port entities.”

The Coast Guard task force found that the

approach of the International Safety

Management Code for the Safe Operation of

Ships and for Pollution Prevention (ISM) was

supportive of this more participatory industry

role in safety responses. (See appendix G for a

description of the ISM Code requirements.) The

task force said that the ISM Code is:

Intended to refocus the past approach to

regulatory compliance from the industry’s passive defect notification and cor-

 

50Issued on October 31, 1995, by the Coast Guard.

51The four cruise vessel accidents cited by the Coast

Guard that occurred in summer 1995 were the grounding of

the Royal Majesty on Nantucket Island, off Massachusetts;

the electrical fire on the Celebration, off the Bahamas; the

engineroom fire on the Regent Star, 65 miles southeast of

Valdez, Alaska; and the Star Princess grounding.
28

rection response mode to an aggressive

approach to safety. Under this proactive

approach, potential discrepancies are resolved by the companies themselves

before they can become significant

safety or environmental problems.

High Capacity Passenger Vessel (HCPV) Incident Response, Planning, and Risk Management Workshop.

52 -- Also

in response to the cruise ship accidents of summer 1995, the Coast Guard and the cruise ship

industry held an HCPV53 incident response,

planning, and risk management workshop, September 20-21, 1995, at the Massachusetts Maritime Academy in Buzzards Bay, Massachusetts.

The workshop included representatives of the

Coast Guard, the Massachusetts Maritime

Academy, other government agencies, the cruise

industry, and passenger vessel associations.

Workshop participants expressed awareness of

the potential for disaster should a cruise vessel

accident occur. In particular, the working group

developed to consider “Operational Procedures”

involved in cruise response efforts found:

Passenger vessels should not depend

solely on the availability of Coast Guard

assets for search and rescue, as [Coast

Guard] resources are limited by location, time of day, maintenance schedules, and capabilities of vessels/aircraft.

The working group developed to address

“Available Resources” recommended that, as

“Coast Guard response resources may be limited

due to distance, weather, repair and downtime,

capacity of the vessel/aircraft and competing

 

52Summary of High Capacity Passenger Vessel

Incident Response, Planning, and Risk Management

Workshop, Buzzard’s Bay, Massachusetts, 1995.

53The Coast Guard informally considers an HCPV to

be any ship that carries more than 600 passengers.

operations,” the industry should, “Conduct

exercises around contingency plans to test

availability of and limits to resources.” The

group further recommended that such plans be

implemented and reinforced by crew training.

The third HCPV working group focused on

“Communication.” The working group stated

that “Coast Guard/industry training programs

are an excellent medium to exchange ideas,

theories, and goals; continued participation [in

them] is to be recommended.” Many members

of this group agreed that a tabletop exercise

should be held in spring 1996.

Such a drill was held in Juneau, Alaska, in

March 1996 (as summarized below). Two more

exercises were held in spring 1997 – one in

Ketchikan, Alaska, and one in Key West,

Florida.

Cruise Ship Exercise 96-2, Juneau, Alaska. -- On

March 19-21, 1996, a command post exercise

designed to evaluate existing plans, procedures,

systems, and interactions that occur when a

major marine disaster takes place was conducted

in Juneau, Alaska, by Federal, State, local, and

cruise industry officials. The Coast Guard’s

exercise evaluation team published a report on

the exercise.54 Most of the comments in the

report relate to response structure and the

problems involving passenger accountability,

medical issues, and communication. The team

found that the exercise had been extremely

beneficial and recommended holding a cruise

ship exercise annually, before the start of each

Alaska cruise season, which begins in mid-May.

 

54Evaluation Report for Cruise Ship Exercise 96-2 in

Juneau, Alaska, on 19-20 March 1996. Prepared by staff

from the U.S. Coast Guard 17th District, Juneau, Alaska,

and the State of Alaska.
29

The analysis has three main parts. First, the

Safety Board identifies factors that can be

excluded as causal or contributory to the

accident as a result of the investigation. The

second section focuses on the accident

sequence, outlining the actions and events that

led to problem conditions. In the final section,

the report discusses those findings that concern

the safety factors identified in the investigation.

Exclusions

Visibility in the vicinity of the grounding

was clear to a distance of 10 miles, the sea was

calm, and the wind was light. The steering gear

and propulsion engines of the Star Princess

functioned satisfactorily before and after the

grounding. All electronic equipment used for

locating the vessel’s position, including the

GPS, was functioning satisfactorily.

Beginning approximately 4 hours after the

accident, breath and urine specimens were

obtained from 11 crewmembers of the Star

Princess and the pilot who had been conning the

vessel when the grounding took place. All

specimens were collected in a timely fashion

and all tested negative for the presence of

alcohol and illegal drugs.

No evidence was found to indicate that the

Star Princess helmsman did not steer courses as

ordered by the pilot.

The Accident

About 0040 on June 23, 1995, a pilot

arrived in the Star Princess wheelhouse to

relieve the pilot on duty. The pilot being

relieved acquainted this pilot with the vessel’s

position. The new pilot did not address the

navigating crew, nor did he announce his

assumption of the watch. The pilot did not

communicate with the lookout. The pilot left his

radar on a 6-mile scale.

About 0100 the pilot altered course left

(east) to 126°T from 143°T. About 0115,

without fixing his vessel’s actual position or

using the watch officer’s 0114 fix, and intending

to set a course that would be sufficiently far off

Poundstone Rock to allow for safe passage, he

used the EBL on the radar to alter the course to

156°T. Almost immediately thereafter (about

0116), he further altered course, based on a

visual estimate, to 155°T. About 0125 the pilot

visually detected a northbound vessel (the Fair

Princess) about 9 1/2 miles ahead. While he

later claimed he was concerned about the

oncoming vessel’s intentions, the pilot did not

call it on the bridge-to-bridge radiotelephone.

The third officer was taking radar ranges

and bearings to plot the vessel’s transit. The

third officer’s plotted 0114 and 0130 positions

were both west of the established trackline of

the Star Princess by about 0.3 mile. The second

officer was aware from review of the third

officer’s plotting that the vessel was not

following its established trackline. Neither

officer informed the pilot of the vessel’s offtrack position.

At 0135 the pilot ordered a 2° course

alteration to 153°T based on his visual

assessment of the navigation situation, in an

attempt to improve his vessel’s position for

passing Poundstone Rock safely. In the minutes

before the accident, the pilot visually estimated

that the vessel was going to clear Poundstone

Rock, but by only about 1 cable (600 feet) rather

than the 2 cables (1,200 feet) he would have

preferred. At 0142 the Star Princess grounded

on the northeast side of Poundstone Rock.

The Safety Board identified five main safety

factors affecting the accident; they are pilot

performance, medical issues, pilot oversight,

bridge resource management, and survival

factors.

Pilot Performance

General. -- The passage of Lynn Canal was a

standard and easy maneuver that the pilot had

successfully performed hundreds of times.

Familiarity could have induced him to consider

navigating the route a predictable and routine

ANALYSIS
30

procedure. The weather was clear, seas were

calm, and winds were light. He had served as a

pilot on the Star Princess some 10 times in the

past, he was accustomed to the vessel and its

navigation equipment, and he was familiar with

the two bridge watch officers.

While the transit was an accustomed

procedure to the pilot, he realized that he faced

an unusual situation in that another vessel would

be passing the Star Princess somewhere near

Poundstone Rock. All the SEAPA pilots who

testified regarding this accident stated that they

could not recall ever passing a vessel in the

specific vicinity of Poundstone Rock.

Safety Board investigators considered that

when he sighted the Fair Princess proceeding

northward in the Favorite Channel at about

0125, the Star Princess pilot had three general

options. He could have: (1) stayed essentially on

his current course, making minor navigational

adjustments to avoid Poundstone Rock when he

reached it; (2) made a course alteration to the

right (west) to allow the Star Princess to pass

Poundstone Rock on the port side; or (3) called

the Fair Princess on the bridge-to-bridge

radiotelephone, either to communicate his

intention of making a significant course

alteration to the left (east) or to request that the

Fair Princess reduce its speed so the two

vessels would not pass each other in the

Poundstone Rock area.

The pilot chose the first option, the response

requiring the least action on his part. He made

no course change at all for 10 minutes, until

about 0135, when he ordered the course altered

by 2°, from 155°T to 153°T. He made no further

course adjustments until the grounding. He later

acknowledged in his testimony that, under less

confined circumstances (without the Fair

Princess in the waterway), he would have

preferred a course of 150°T or 145°T to pass

this area. The pilot also admitted that he

estimated after changing to 153°T that the Star

Princess would clear Poundstone Rock buoy by

a distance less than 2 cables (1,200 feet), which

he had considered the minimum safe margin

between the vessel and the rock.

The pilot suggested in his testimony that he

did not take the second option – altering course

to the right (west) — because he had already

passed Vanderbilt Reef by the time he saw the

Fair Princess, and he thought that it was then

too late to make such a course adjustment.

Based on examination of the vessel’s recorded

trackline and the navigation chart of the area,

the Safety Board considers that the pilot had

sufficient time and depth of water to make a

course alteration to the right (west) at this time.

The third option open to the pilot was to call

the Fair Princess on the bridge-to-bridge radiotelephone either to communicate a course

change intention or to request the Fair Princess

to slow down. To move the Star Princess

significantly to the left (east) could have required the vessel to turn so that the bow of the

Star Princess would cross the track being followed by the Fair Princess. While the Star

Princess would only have been taking this

course temporarily to reset its track further off

Poundstone Rock, the pilot of the Fair Princess

might interpret the action as threatening a collision situation. This danger of misinterpretation

could have been addressed by ship-to-ship

communication. Alternatively, the Star Princess

pilot could have used the radio telephone to request the Fair Princess to slow down, so the

two vessels would not have to pass in the

limited area for navigation immediately around

Poundstone Rock.

The Star Princess pilot said that he did not

call the Fair Princess on the radiotelephone

because he felt that both he and the Fair

Princess pilot were “taking actions that would

allow a safe passage.” He did not specify the

actions to which he referred, but whatever they

may have been, they did not succeed in ensuring

safe passage for the Star Princess.

The Safety Board has not identified any

valid reason why the pilot did not call the Fair

Princess. Instead, the pilot chose to remain

essentially on a course that he acknowledged

took the Star Princess close to the underwater

hazard. The Safety Board concludes that the

pilot’s decision to stay essentially on his

existing course ultimately resulted in the

grounding of the vessel.

Evidence indicates that in these circumstances, if he had intended to clear Poundstone

Rock buoy by moving to the left (east), the Star

Princess pilot should have made a significant
31

course change of at least 5° or even 10° to the

left (east) to warn the oncoming Fair Princess

of his vessel’s movement and possible

intentions in the meeting situation. The 2°

change he elected to make would not have been

easily discernible visually or by radar, whereas a

5° or larger change could have been detected by

the other vessel (even had the pilot not communicated with it by radiotelephone), so the

other could react as necessary. Investigators

estimate that a 5° course change to the left (to

course 150°T) would not have caused the Star

Princess to cross the bow of the Fair Princess.

Because the Star Princess sustained damage

from the centerline (keel) to about a 50-foot

width of the hull on the starboard side, it

appears that any course change greater than 2°

taken at 0135 probably would have avoided the

grounding. The Safety Board therefore concludes that the 2° course change ordered by the

pilot 7 minutes before the accident was not sufficient to allow the Star Princess to clear

Poundstone Rock or to indicate his intentions to

the pilot of the Fair Princess.

Other facts suggest that the pilot was not

adequately responsive to the threat of grounding

on Poundstone Rock. The last navigation orders

recorded on the Star Princess bridge voice

recorder for the period before the accident

occurred about 0116, when the pilot issued the

course change to 155°T. The transcript of the

bridge conversations for the approximately 26

minutes remaining before the accident

established that these discussions were not

about navigation. Had the pilot been in doubt

about navigation developments or considering

more definite actions in response to them, some

recorded conversation likely would reflect

orders or discussion concerning the possibly

hazardous situation.

Current. -- The pilot testified that his only

explanation for the grounding was the possible

existence of a strong current at 0135 – a current

that could have set the vessel westerly toward

Poundstone Rock when the Star Princess

emerged from the lee side of Sentinel Island.

The pilot ordered the course changed to the left

(east) from 155°T to 153°T about this time.

(The order was not recorded on the bridge voice

recorder.) No cross current had been expected

by the pilot and the Star Princess watch officers

and, except for the minor 2° course change

ordered by the pilot, no course adjustment was

made between 0116 to 0135.

A cross current (a combination of water

current from the tide ebbing and the light winds)

probably did move the vessel to the west during

the 26 minutes before the accident, as indicated

by the comparison of the course steered and the

course made good. The plot of the track shows

that the Star Princess remained on a steady

heading toward Poundstone Rock, rather than

being offset from the buoy as the pilot had

intended when he turned to course 155°T at

0116. Although the vessel was steering a course

of 155°T, the effects of the current caused the

vessel to actually make a course of about 158°T.

Consequently, the 3° difference between the

course steered and the trackline indicates that

the vessel did encounter a cross current along its

track. The current setting the ship westerly

toward the rock, however, calculates only to

about 1/2 knot, not the strong current that the

pilot later speculated might have occurred. Such

a weak current acting on the vessel before the

grounding might have set the ship somewhat

toward the rock, which an effective pilot would

have taken steps to counteract.

If the cross current had not existed, the 2°

course change to the left (east) ordered by the

pilot at 0135 might have enabled the vessel to

miss the rock, although by less than 0.1 mile

clearance. But such a miss would have been

happenstance, so the pilot’s failure to maintain

the navigation limit clearance must be regarded

as dangerous in this case. It therefore appears

that no significant cross currents affected the

Star Princess as the vessel began to approach

the buoy, but when the vessel emerged from the

lee of Sentinel Island, a weak cross current

occurred. The Safety Board concludes that the

pilot should have been alert to the current and

taken appropriate actions in response to it.

Radar. -- The Star Princess pilot did not use

the full range of radar options available to him.

Instead of employing the radar proactively and

effectively, he took minimal advantage of the

radar’s capabilities and relied primarily on

visual distance estimates. The 2-cable (1,200

feet) safety margin that the pilot had mentally

established between the vessel and the

Poundstone Rock buoy was a visual estimate.

The pilot acknowledged that throughout his
32

piloting of the Lynn Canal, he based his

decisions primarily on his visual assessments,

rather than on radar presentations.

When the pilot did refer to the radar, the

fact that he left it on a 6-mile scale decreased

the accuracy achievable. At this scale, the

pilot’s radar scope would represent a distance of

0.1 mile by a length of 0.1 inch on the screen.

Theoretically, a reduction in distance between

the ship’s radar heading marker and the buoy

from 0.2 inch to 0.1 inch would have revealed a

danger that the ship would strike the rock. But

on the 6-mile scale that the pilot let stand, it

would have been difficult to discern such a

small radar change as 0.1 inch over a period of

minutes, particularly as the heading marker

oscillated in response to the helmsman’s minor

rudder adjustments. If the pilot had placed the

radar on the 3-mile scale when the buoy reached

that range, and later on the 1.5-mile scale, the

screen distances would have doubled and

quadrupled (respectively) and so have become

increasingly discernible. (See figure 8.) Had he

selected a more suitable radar screen scale, the

pilot might have been alerted to danger by the

more obvious radar presentation.

After the pilot set his 156°T course with the

EBL and then changed course to 155°T about 1

minute later (0116), he did not attempt to verify

his subsequent position estimates by any means,

including comparing them to the radar fixes the

bridge watch officers were plotting on the ship’s

chart. Review of the vessel’s trackline shows

that while the pilot thought he was on a course

of 155°T, he was actually making good a course

of 158°T. He had relied on his own mental

conjecture of the path of the vessel’s turn when

making the course change to move it 2 cables

(1,200 feet) to the east of Poundstone Rock. But

the maneuver, which he made based on his

visual estimates, did not move the vessel

sufficiently to the east of Poundstone Rock.

Comparison with the watch officers’ radar fixes

might have alerted him to the fact that the actual

course the vessel was on would take the Star

Princess very close to Poundstone Rock.

The pilot did not make full and active use of

the radar, such as by changing scales, plotting

targets, setting up danger bearings, or using

parallel indexing.55 Therefore, the Safety Board

concludes that the pilot’s limited use of the

radar hampered his ability to evaluate the

navigation situation accurately.

Visual navigation during low light conditions. --

The pilot had navigated vessels through this area

several hundred times. He appears to have been

combining this experience with the available

visual cues to direct the vessel past the

underwater obstruction of Poundstone Rock. To

make appropriate course adjustments, the pilot

had to be able to accurately choose a correct

course.

Even under good light conditions, visual

navigation can produce only rough distance

estimates. The estimation process involves

evaluating the distance to the reference buoy

and the angle it subtends with the imagined

extension of the ship’s centerline, and then

estimating the distance to the buoy that will

exist when the ship arrives abeam the buoy. In

any of these mental evaluations, knowledge of

the distance to the buoy is vital. The pilot must

combine this knowledge with his prior

experiences and recall the passing distances

associated with such angles. In darkness,

however, humans cannot accurately determine

the distance to a single point of light, or to a

blinking light, such as the one on the

Poundstone Rock buoy. The Safety Board

concludes that although it was not totally dark in

the period before the accident, the pilot’s sense

of distance to the Poundstone Rock buoy would

have been inaccurate due to the level of

illumination.

 

55A radar method used in conning or navigating a

vessel. First, a conspicuous navigation object is chosen.

Then, a line is drawn on the radar screen parallel to the

vessel’s course line heading flasher and the desired abeam

distance off the object. The object should appear to track

along the line drawn on the radar screen for as long as the

vessel remains on course. If the object drifts to either side

of the line, the conning officer will know that the vessel is

off course. The pilot should then make course corrections

as necessary.

34

Navigation on a floating marker. -- Using a

floating marker as the principal navigation

indicator is not a recommended piloting

practice. The anchors of floating aids may shift

from their charted positions if they are rammed

by a vessel, displaced by drifting ice, or acted

upon by various weather and sea conditions.

Also, buoys regularly move within the ranges of

their anchor chains, as they are subject to wind,

waterway currents, and tides. Mariners generally

do not attempt to pass too close to buoys

because they move. To positively affirm a

vessel’s position, the mariner should use

bearings on fixed aids to navigation, as well as

shore references, water depths, and various

electronic aids.

The pilot’s only EBL course was set on the

buoy marking Poundstone Rock. The buoy was

affected by the light wind and weak current,

which probably caused it to drift west on its

anchor chain, toward the rock and away from

the safe water to the east. By using this mobile

buoy as his primary navigation reference, the

pilot was basing his piloting on a floating aid

that was moving to the west and so reducing the

margin of safety between the Star Princess and

the rock. The Safety Board concludes that by

relying on visual reference to a floating aid, the

pilot did not follow sound navigation practices.

Communication. -- As has been noted, one

means of dealing with the navigation situation

that the Star Princess pilot faced would have

been to communicate with the Fair Princess to

establish an agreement that the Star Princess

would make a temporary maneuver to move

further off Poundstone Rock or to agree upon

other steps to deal with the situation. As soon as

the Star Princess pilot had any doubt whether

the Fair Princess might crowd his vessel in the

channel, good marine practice required that he

communicate with the Fair Princess.

The pilot testified that he was concerned

about the Fair Princess’s intentions as early as

0125, when he was not sure whether the other

vessel would go to the east or west of

Poundstone Rock. A radio call would have told

him exactly what the Fair Princess pilot

intended. Instead he assumed, based solely on

the changing aspects of the Fair Princess’s

lights, that the vessel was moving to the right.

The aspects of the vessel’s lights, however,

would have changed as the distance between the

two vessels decreased, as well as if the other

vessel had altered course to the right. In fact,

according to its VER information, the Fair

Princess’s course made good did not change.

At 0135, when the Star Princess pilot made

his course adjustment to 153°T, he moderated

the course change he would have preferred to

take to avoid Poundstone Rock because the Fair

Princess was in the channel. In essence, he decided to pilot closer than he would have liked to

Poundstone Rock because the Fair Princess was

nearby. Had he discussed these circumstances

by radio with the Fair Princess, he could have

piloted a course further off Poundstone Rock

without alarming the Fair Princess.

The Star Princess pilot had less room north

of Poundstone Rock than the Fair Princess pilot

had between Aaron Island and Poundstone

Rock, so the Star Princess pilot should have

initiated radio communication. Had he done so,

he could have requested that the Fair Princess

reduce speed or change course to allow the Star

Princess to make adjustments to provide for

greater clearance when passing Poundstone

Rock.

The Star Princess pilot made navigation decisions on the basis of unconfirmed assumptions

about the Fair Princess’s intentions and

modified his preferred course because the Fair

Princess was in the Favorite Channel. The

Safety Board concludes that before the pilot

tried to pass Poundstone Rock buoy, he should

have established communication with the pilot

of the Fair Princess.

Medical Factors

Fatigue. -- The Safety Board examined the

possibility that fatigue, associated with

previously undiagnosed OSA, might have

impaired the pilot’s ability to safely navigate the

Star Princess on the morning of the grounding.

It was medically determined after the accident

that the pilot suffered from OSA, a sleeping

disorder. OSA can cause an individual to

awaken repeatedly throughout a sleep period,

often without being aware of having done so.

This situation may have prevented the pilot’s
35

obtaining restful sleep, creating circumstances

that may have caused fatigue.

The fact that the pilot suffered from a sleep

disorder would likely affect any fatigue-based

performance criteria. One sleep researcher

found that the pilot fell asleep in an average of

about 5 minutes when placed in a dark, quiet

room. An individual who is not sleep deprived

will, on average, require about 20 minutes to fall

asleep under similar circumstances. Thus the

less time a person needs to fall asleep from the

20-minute average, the more the individual is

sleep deprived and in need of rest. In the case of

the pilot, during postaccident testing sessions he

fell asleep in about one-quarter the time

required for rested individuals. OSA is a chronic

disorder that is often present for years or

decades prior to diagnosis. Since daytime

sleepiness is almost uniformly present in

patients who suffer from OSA, chronic fatigue

is one of the hallmarks of the disorder.

Therefore, the Safety Board concludes that the

pilot was chronically fatigued as a result of

OSA.

The pilot claimed that because he was

unsure of what course the Fair Princess would

take, he paid careful attention to the vessel. If

such was the case, the pilot could have

concentrated on the Fair Princess to the

exclusion of maintaining a safe distance from

Poundstone Rock. Focus on a particular

stimulus to the exclusion of other critical data

can be one effect of fatigue on performance.

The pilot also stated that when he first felt

the ship shudder upon grounding, he was not

immediately sure as to the nature of the

problem. Only when he moved to the starboard

bridge wing and observed the buoy traveling

down that side of the vessel did the pilot realize

that he had struck Poundstone Rock. Not only

should the pilot have been aware of the location

of the buoy from transiting the area on previous

occasions, he had for several miles been

observing the buoy marking the rock. Under

normal conditions, such an experienced pilot

should have immediately deduced that he had

not safely passed Poundstone Rock when he felt

the vessel shudder. A fatigued pilot, however,

might not be sufficiently alert to realize that he

had grounded.

Because the available data suggest that the

pilot’s performance was degraded consistent

with the effects of fatigue, the Safety Board

concludes that fatigue may have reduced the

pilot’s ability to appropriately assess and

respond to the developing situation. Given the

detrimental effect that fatigue may have had on

the pilot’s performance in this accident, the

Safety Board believes that the Coast Guard,

State pilot commissions, and pilot associations

should advise pilots about the effect of fatigue

on performance and about sleeping disorders

such as sleep apnea.

Effexor. -- The Safety Board also evaluated

the pilot’s use of Effexor in the context of his

performance on the accident morning. Besides

the postaccident statements made by the pilot

about his Effexor use, the Safety Board obtained

and reviewed medical opinions concerning the

pilot’s use of this medication and what effect, if

any, it may have had on his performance.

The pilot himself stated that while the

medication tended to cause some minor physical

side effects, these did not affect his ability to

pilot the vessel. The physicians consulted by the

Safety Board were in agreement that Effexor

would have had no effect on the pilot’s

behavior. Their consensus was that the pilot was

not impaired by his medication at the time of the

accident, particularly given the low dosage of

Effexor he was taking. Based on the unanimity

of the professional opinions of all physicians

consulted, the Safety Board concludes that the

pilot’s use of an antidepressant (Effexor)

probably did not affect his performance.

While concluding that the pilot’s use of

medication was not causal or contributory to

this accident, the Safety Board remains concerned about the possible effects of medication

on pilot performance. The ABMP was not aware

that the pilot had been regularly taking the prescription medication Effexor, nor was the pilot

required to provide this information to the

agency. The pilot first provided the information

during testimony following this accident.

Use of medication by operators in the

transportation industry has been an issue in

previous accidents the Safety Board has

investigated. For instance, after its investigation

into the collision of the towboat Mauvilla and
36

its tow with a railroad bridge,56 the Safety Board

recommended to the U.S. Department of

Transportation (DOT) that it should:

I-94-5

Require the modal operating administrations to develop and disseminate

bulletins, notices, circulars, and other

documents that call attention to the need

for an employee reporting procedure

concerning use of medication (over-thecounter and prescription) while on duty

and that urge the transportation industry

to develop and implement informational

and educational programs related to this

subject.

The DOT developed a statement for use by

all operating administrations concerning the

potential threat to public safety posed by the onduty use of some over-the-counter and

prescription medications by persons performing

safety-sensitive duties, strongly urged employers

to include appropriate information to address

this issue in their employee training materials,

and encouraged employers to reiterate to their

employees the need to report use of such

medications when required by applicable DOT

rules or company policies. The DOT circulated

this statement to all departmental drug and

alcohol program managers, asking that it be

made available throughout the regulated

industries. Because these efforts satisfied the

intent of the recommendation, on October 26,

1995, the Safety Board classified Safety

Recommendation I-94-5 “Closed--Acceptable

Action.”

During the Star Princess accident investigation, Safety Board representatives found that,

in the marine transportation mode, the issue of

medication reporting may not be as familiar

with industry members as it could be. For instance, the pilot in this accident did not consider

it necessary to inform his professional association or the cruise line that hired him of his use

of the antidepressant Effexor. In particular, as

marine pilots are individual contractors rather

 

56See Railroad/Marine Accident Report -- Derailment

of Amtrak Train No. 2 on the CSXT Big Bayou Canot

Bridge near Mobile, Alabama, September 22, 1993

(NTSB/RAR-94/01).

than employees of firms that may have medication reporting requirements, it would be helpful

for them to be made aware of the possible effects that medications could have on their work

performance and of the safety benefits provided

by medication reporting policies.

Federal pilot licensing procedures require

that pilots annually pass a physical examination

that addresses vision, color sense, and general

physical condition. The Merchant Marine

Personnel Physical Examination Report (as

revised in March 1995), used to conduct the

examination, directs the examining physician to

report what medications the pilot is taking. (The

pilot who was on duty during the Star Princess

grounding had last renewed his Federal license

on January 9, 1995.)

At the State level, the medication reporting

situation is less clear. The Alaska State medical

certification procedure for pilot licensing does

not specifically require a pilot to declare

whether he or she is taking medications. Other

States’ pilot licensing organizations also do not

appear to require pilots to make full disclosure

regarding medications they may be taking.

Many medications have effects that could

negatively affect the performance of persons

with safety-sensitive responsibilities. The Safety

Board has previously discussed the need for

transportation employers to be aware that

employees are taking medication so that

employers can determine the potential effects of

the medication on the employee’s fitness for

duty.57 While pilots are not “employees” but

self-employed individual contractors, they

nevertheless have safety responsibilities in

marine transportation of valid concern to

licensing authorities.

The Safety Board believes that the State

pilot commissions and the Coast Guard,58

 

57See, for example, Marine Accident Report--

Grounding of the Panamanian Flag Passenger Carferry

M/V A. Regina, Mona Island, Puerto Rico, February 15,

1985 (NTSB/MAR-86/02) and Railroad Accident Report --

Derailment of Amtrak Train 87, Silver Meteor, Palatka,

Florida, December 17, 1991 (NTSB/RAR-93/02/SUM).

58The Coast Guard issues Federal pilot licenses. U.S.

vessels over 1,600 gross tons engaged in domestic trade

must be under the direction of a Federally licensed pilot in

certain domestic waters. Individual States require Statelicensed pilots for vessels in transit from foreign ports.
37

in consultation with experts in occupational

health, should review their medical standards,

guidelines, and examination forms to ensure that

they require the disclosure and appropriate

evaluation of the history or presence of any

medical conditions, symptoms, or medication

use that would affect an individual’s fitness to

pilot a vessel.

Pilot Oversight

The ABMP exercises remedial pilot

oversight. The oversight focuses on retraining

those pilots who cause serious accidents, thus

showing themselves to be negligent or

incompetent. Focusing on pilots after they cause

accidents is the traditional approach, which

many States take, to maintaining high-quality

pilotage services. The approach can be very

effective in weeding out pilots who perform

poorly, but it has a major shortcoming — the

oversight authority must wait until a pilot has

had one or more serious accidents before it takes

action.

The Safety Board considers that oversight

would be more effective before an accident

takes place. If pilots are under such observation,

deficiencies in their performance can be

corrected before they cause a serious accident.

Oversight is particularly necessary for pilots

operating passenger cruises in Alaska. In the

past 10 years, passenger carriage in Alaskan

waters has expanded rapidly. Considering the

unforgiving nature of the Alaskan marine

environment, with its deep, cold waters and

rocky shores, and the remoteness of the areas of

operation, an accident caused by the poor

performance of a pilot cannot be tolerated. Too

many lives are at risk.

The Safety Board concludes that pilot

performance would be improved if the ABMP

had a mechanism for obtaining feedback on

pilot performance. The Safety Board further

concludes that, considering the accident history

and medical condition of the Star Princess pilot,

the ABMP did not oversee his performance

adequately. Therefore, the Safety Board believes

that the ABMP should develop and implement a

mechanism for monitoring the performance of

pilots on a routine basis.

BRM

Investigators found that the Star Princess

pilot typically navigated the vessel without involving the ship’s watch officers in navigation

tasks or informing them of his piloting intentions. Watch officers stated that the pilot did not

look at the ship’s established trackline as drawn

on their chart, and that he did not inform the

watch officers of his own intended tracklines.

The pilot transferred the conn without involving

the navigational watch, thereby not

communicating to the watch officers the

information he considered important for the

ship’s safe navigation. For their part, neither of

the watch officers took the initiative to seek

such information or to communicate with the

pilot regarding navigation issues.

Although the second officer was responsible

for the ship’s safety during this watch, he did

not effectively monitor the pilot’s passage. He

did not question the pilot’s decisions, even when

he knew the pilot was not following the vessel’s

established trackline. Had he discussed the

tracklines with the pilot, the pilot might have

been more alert to the grounding danger.

The available information indicates that the

second officer and third officer left all

navigational decisions to the pilot, as they

considered him to be responsible for navigation.

While they plotted position fixes according to

standing policy, the watch officers did not use

the fixes to project the Star Princess’s course

based on time or distance. In the half hour

before the grounding, the watch officers took

two fixes (at 0114 and 0130) but did not make

any effort to project the ship’s future track from

these fixes. Had they done so, they should have

perceived that the pilot’s course would bring

them precariously close to Poundstone Rock.

The Safety Board concludes that had the watch

officers monitored the pilot’s navigation,

projected the course ahead from their fixes, and

communicated this information to the pilot, he

would have had time to take action to avoid

grounding.

The pilot and the watchstanders conducted

their parts of the watch almost independently of

each other. Moreover, neither the pilot nor the

watchstanders used the equipment available to

them to properly monitor the progress of the
38

Star Princess. The Safety Board concludes that

effective management of resources and

coordination of duties were not practiced on the

Star Princess at the time of, or immediately

before, the accident.

The Star Princess master and bridge watch

officers had not received BRM training before

the accident. The Safety Board has advocated

BRM training for all bridge watch officers as

well as pilots. The Safety Board notes that the

PCL is working to provide BRM training for all

its bridge watch officers. The American Pilots’

Association has supported the Safety Board

position on BRM training and has advocated

BRM training to its members. The Safety Board

is encouraged by the emphasis that both the PCL

and the American Pilots’ Association are

placing on BRM training for bridge watch

officers and pilots.

On June 25, 1993, as a result of the

investigation of the grounding of the United

Kingdom passenger vessel RMS Queen

Elizabeth 2 near Cuttyhunk Island, Vineyard

Sound, Massachusetts, on August 7, 1992,59 the

Safety Board issued Safety Recommendation M93-34 to the State pilot commissions, including

the ABMP. Safety Recommendation M-93-34

asked that each pilot commission:

Require pilots, upon boarding a vessel,

to conduct a conference with the master

and other relevant deck officers that includes a discussion of the pilot’s proposed route, including courses, speeds,

squat, and unique maneuvers that may

be encountered.

By a letter dated July 15, 1993, the ABMP

informed the Safety Board that Safety

Recommendation M-93-34 had been forwarded

to each of Alaska’s six pilot associations. In

part, the letter stated that:

The problem of pilot/master communications has been addressed informally

during several conversations to which

I’ve [Alaska Marine Pilot Coordinator]

 

59Marine Accident Report – Grounding of the United

Kingdom Passenger Vessel RMS Queen Elizabeth 2 near

Cuttyhunk Island, Vineyard Sound, Massachusetts,

August 7, 1992 (NTSB/MAR-93/01).

been party, and I appreciate the problems which are inherent to faulty or incomplete communications. A recommendation has been included in the

report on page 2 for State Pilot Commissions (Boards) to act upon.

I will include this item in the September

Board meeting agenda, however, I solicit your inputs in advance before public discussion to include in the package

for the Board members. I believe there

is validity in the recommendation and

look forward to receiving your comments....

On August 16, 1993, the Safety Board wrote

that:

The Safety Board is pleased that this

recommendation will be addressed at

the September pilot board meeting and

that copies of the recommendation have

been forwarded to the Alaska pilot associations soliciting their comments for

this meeting. Safety Recommendation

M-93-34 will be classified “Open--Acceptable Response” pending notification

on the action taken to implement this

recommendation. We have also enclosed a draft copy of a paper developed

by the Society of Naval Architects and

Marine Engineers, Marine Safety Panel,

that addresses the intent of M-93-34 and

recommend that you pass it along to

your constituency.

The State of Alaska has since amended its

State regulations to require all new applicants

for State pilot licenses to complete BRM

training and all renewal applicants for State

pilot licenses to have taken refresher BRM

training within the previous 6 years. According

to the Alaska Marine Pilot Coordinator, Alaska

pilot licenses are valid for 2 years, expiring at

the end of each even-numbered year. Therefore,

as of January 1, 1997, all original and renewal

applicants for Alaska pilot licenses are required

to have taken BRM training. Accordingly, the

Safety Board is classifying Safety

Recommendation M-93-34 “Closed--Acceptable

Action” for the State of Alaska. (The new

Alaskan pilot regulations were not in effect at
39

the time the pilots on the Star Princess last

renewed their State pilot licenses.)

The Safety Board considers that in Alaska,

given the relatively long periods pilots spend on

cruise vessels, pilots and bridge watch officers

would particularly benefit from attending BRM

training together. In the southeast Alaska cruise

industry, pilots typically serve aboard cruise

vessels for 3 to 12 days. Under such

circumstances, watch officers can become used

to, and rely too strongly on, the presence of a

pilot on the vessel. The watch officers on duty

during the Star Princess grounding were

convinced that the pilot had the situation under

control in part because they were used to relying

on this pilot and his expertise. They chose not to

interfere with his decisions or actions — even

though they knew the vessel was approaching

dangerously near to Poundstone Rock —

because they had full confidence in the pilot’s

abilities.

Providing BRM training would give pilots

and bridge watch personnel the opportunity to

interact with each other in a nonconfrontational

and safe environment. Joint training could also

provide pilots and bridge watch members with

greater understanding concerning the problems

faced in carrying out their respective

responsibilities. According to the director60 of a

major BRM training center:

• Training attended jointly by pilots and

deck officers is more realistic in that the

roles during simulations are played by

the actual parties.

• Training attended jointly by pilots and

deck officers has the advantage of

improving communication between the

two professions, as they can sharpen

communication skills with coaching in

an instructional setting rather than within

the pressures of the work setting. It

should be noted that communication

skills tend to be at their optimum at the

end of the training period and are expected to decline to some extent when

the parties return to their normal work

 

60Information obtained during a March 19, 1997,

telephone conversation with Harry J. Crooks, Director,

RTM STAR Center, Toledo, Ohio.

routines. Hence, recurrent training is expected and needed.

• Joint training provides an opportunity for

deck officers and pilots to become personally acquainted and to learn how the

other reacts during simulated portrayals

of critical incidents. In addition, they can

learn about the other’s corporate cultures

and company or organizational procedures.

The mutual understanding developed

through joint BRM training would contribute to

more efficient use of equipment and better

coordination of activities, which would result in

enhanced safety. The Safety Board concludes

that to learn how to work effectively as teams,

pilots and watch officers in Alaska should take

BRM training together.

The Safety Board understands that the

scheduling of such joint training is difficult. The

results, however, would be well worth the time

and effort. Training that provides opportunity

for interaction between pilots and watch officers

could make both pilots and watch officers

comfortable with a more supportive model of

bridge watch operations. Pilots would learn to

view monitoring by watch officers as a useful

tool rather than a challenge, and watch officers

would learn to contribute to the pilot’s

effectiveness. The Safety Board believes that

the PCL should coordinate with the Alaska pilot

associations to arrange BRM training between

its bridge watch officers and Alaska pilots.

The Safety Board further believes that the

International Council of Cruise Lines, the

American Pilots’ Association, the Southeastern

Alaska Pilots Association, and the Alaska

Coastwise Pilot Association should advise their

members about the Star Princess accident and

encourage those members that operate vessels or

navigate on vessels in the Alaska cruise trade to

participate in BRM training, including such

training that involves both bridge watch officers

and pilots.

Further, given the special nature of Alaskan

cruise operations and the fact that pilots in

southeast Alaska tend to spend more time on

cruise vessels than is common in many other

regions, the Safety Board believes that the
40

ABMP should encourage or require pilots of

passenger vessels operating in southeast Alaska

to take BRM training with bridge watch

officers.

Survival Factors

About 1 minute after the Star Princess

grounded, the pilot radioed the Coast Guard to

advise it of the accident. The master and crew

immediately began to check the vessel for

damage and flooding and, although four tanks

were flooding and hydraulic oil had leaked from

the starboard shaft lubrication system, the ship

was determined to be stable. As a precaution,

lifeboats were readied to be lowered. The master

also questioned the off-watch pilot about where

the vessel might be beached, if necessary.

At 0155 the master notified the crew of the

grounding and told crewmembers to advise

those passengers who were awake of the

accident. He did not wake the sleeping

passengers to tell them that there had been a

grounding, that the situation was under control,

or that they would be kept informed. He did not

direct any passengers to go to their muster

stations. The master said that he thought waking

the passengers would have upset them

unnecessarily.

On the other hand, the master also clearly

considered the situation serious enough to call

for the readying of lifeboats, and he explored

the possibility of beaching the damaged vessel.

The Coast Guard, too, had been alerted. The

alternative not taken by the master — notifying

all passengers shortly after the grounding —

would have allowed them time to prepare for a

possible evacuation, rather than being awakened

suddenly when and if the vessel became

endangered.

The damage assessment by divers was not

made until between 0437 and 0655. An announcement to all passengers informing them of the

situation was not made until 0918. Had the initial damage assessment in this instance been

incorrect and the vessel been more seriously

damaged, the passengers and crew could have

been exposed to undue risk. Given that 2,207

passengers and crewmembers were on the ship,

the delay before a thorough damage assessment

was made consumed valuable time that might

have been needed to muster everyone at lifeboat

stations had the ship been in danger and a rapid

evacuation necessary. The Safety Board concludes that the master did not give the passengers timely notification about the situation; had

the passengers needed to evacuate, they would

not have been prepared.

The Safety Board considers that passengers

and crew should receive timely public announcements concerning emergency situations

that may require evacuation of the vessel.

Timely notification allows passengers and crew

to effectively manage an evacuation, if

necessary, and avoids confusion and panic.

Therefore, the Safety Board believes that the

PCL should require its masters to notify both

passengers and crew immediately of emergency

situations that have been assessed as having the

potential to require evacuation of the vessel. The

Safety Board further believes that the

International Council of Cruise Lines should

encourage its members to ensure that masters

provide immediate notification to passengers

and crew of emergency situations that have been

assessed as having the potential to require

evacuation of the vessel. Likewise, the Safety

Board believes that the Coast Guard should

advise passenger vessel operators of the need for

masters to provide immediate notification to

passengers and crew of emergency situations

that have been assessed as having the potential

to require evacuation of the vessel.
41

Findings

1. Neither weather nor equipment failure

caused the grounding of the Star Princess,

neither the pilot nor the navigating

crewmembers were impaired by alcohol or

illegal drugs, and the helmsman steered

courses as ordered by the pilot.

2. The pilot’s decision to stay essentially on

his existing course ultimately resulted in the

grounding of the vessel.

3. The 2° course change ordered by the pilot 7

minutes before the accident was not

sufficient to allow the Star Princess to clear

Poundstone Rock or to indicate his

intentions to the pilot of the Fair Princess.

4. The pilot should have been alert to the

current and taken appropriate actions in

response to it.

5. The pilot’s limited use of the radar

hampered his ability to evaluate the

navigation situation accurately.

6. Although it was not totally dark in the

period before the accident, the pilot’s sense

of distance to the Poundstone Rock buoy

would have been inaccurate due to the level

of illumination.

7. By relying on visual reference to a floating

aid, the pilot did not follow sound

navigation practices.

8. Before the pilot of the Star Princess tried to

pass Poundstone Rock buoy, he should have

established communication with the pilot of

the Fair Princess.

9. The pilot was chronically fatigued as a

result of obstructive sleep apnea.

10. Fatigue may have reduced the pilot’s ability

to appropriately assess and respond to the

developing situation.

11. The pilot’s use of an antidepressant

(Effexor) probably did not affect his

performance.

12. Pilot performance would be improved if the

Alaska Board of Marine Pilots had a

mechanism for obtaining feedback on pilot

performance.

13. Considering the accident history and

medical condition of the Star Princess pilot,

the Alaska Board of Marine Pilots did not

oversee his performance adequately.

14. Had the watch officers monitored the pilot’s

navigation, projected the course ahead from

their fixes, and communicated this

information to the pilot, he would have had

time to take action to avoid grounding.

15. Effective management of resources and

coordination of duties were not practiced on

the Star Princess at the time of, or

immediately before, the accident.

16. To learn how to work effectively as teams,

pilots and watch officers in Alaska should

take bridge resource management training

together.

17. The master did not give the passengers

timely notification about the situation; had

the passengers needed to evacuate, they

would not have been prepared to do so.

Probable Cause

The National Transportation Safety Board

determines that the probable cause of the

grounding of the Star Princess was the pilot’s

poor performance, which may have been

exacerbated by chronic fatigue caused by sleep

apnea. Contributing to the accident was the fact

that the pilot and the watch officers did not

practice bridge resource management.

CONCLUSIONS
42

-- to the U.S. Coast Guard:

Advise pilots about the effect of fatigue

on performance and about sleeping

disorders such as sleep apnea.

(M-97-41)

Review, in consultation with experts in

occupational health, your medical

standards, guidelines, and examination

forms to ensure that they require the

disclosure and appropriate evaluation of

the history or presence of any medical

conditions, symptoms, or medication

use that would affect an individual’s

fitness to pilot a vessel. (M-97-42)

Advise passenger vessel operators of the

need for masters to provide immediate

notification to passengers and crew of

emergency situations that have been

assessed as having the potential to

require evacuation of the vessel.

(M-97-43)

-- to the State pilot commissions:

Advise pilots about the effect of fatigue

on performance and about sleeping

disorders such as sleep apnea.

(M-97-44)

Review, in consultation with experts in

occupational health, your medical

standards, guidelines, and examination

forms to ensure that they require the

disclosure and appropriate evaluation of

the history or presence of any medical

conditions, symptoms, or medication

use that would affect an individual’s

fitness to pilot a vessel. (M-97-45)

-- to the Alaska Board of Marine Pilots:

Develop and implement a mechanism

for monitoring the performance of pilots

on a routine basis. (M-97-46)

Encourage or require pilots of passenger

vessels operating in southeast Alaska to

take bridge resource management

training with bridge watch officers.

(M-97-47)

-- to the Southeastern Alaska Pilots Association:

Advise your members about the Star

Princess accident and encourage those

members that navigate on vessels in the

Alaska cruise trade to participate in

bridge resource management training,

including such training with bridge

watch officers. (M-97-48)

-- to the Alaska Coastwise Pilot Association:

Advise pilots about the effect of fatigue

on performance and about sleeping

disorders such as sleep apnea.

(M-97-49)

Advise your members about the Star

Princess accident and encourage those

members that navigate on vessels in the

Alaska cruise trade to participate in

bridge resource management training,

including such training with bridge

watch officers. (M-97-50)

-- to the San Diego Bay Pilots Association, Inc.:

Advise pilots about the effect of fatigue

on performance and about sleeping

disorders such as sleep apnea.

(M-97-51)

-- to Princess Cruise Lines:

Coordinate with the Alaska pilot

associations to arrange bridge resource

management training between your

bridge watch officers and Alaska pilots.

(M-97-52)

Require your masters to notify

passengers and crew immediately of

RECOMMENDATIONS
43

emergency situations that have been

assessed as having the potential to

require evacuation of the vessel.

(M-97-53)

-- to the American Pilots’ Association:

Advise your members about the effect

of fatigue on performance and about

sleeping disorders such as sleep apnea.

(M-97-54)

Advise your members about the Star

Princess accident and encourage those

members that navigate on vessels in the

Alaska cruise trade to participate in

bridge resource management training,

including such training with bridge

watch officers. (M-97-55)

-- to the International Council of Cruise Lines:

 Advise your members about the Star

Princess accident and encourage those

members that operate vessels in the

Alaska cruise trade to participate in

bridge resource management training,

including such training that involves

both bridge watch officers and pilots.

(M-97-56)

Encourage your members to ensure that

masters provide immediate notification

to passengers and crew of emergency

situations that have been assessed as

having the potential to require

evacuation of the vessel. (M-97-57)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

June 20, 1997
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45

APPENDIX A

Safety Board Investigation

Investigation

The U.S. Coast Guard notified the National

Transportation Safety Board of this accident on

June 23, 1995. Three investigators from the

Safety Board’s Washington, D.C., headquarters

were dispatched to Juneau, Alaska, and began

their investigation on June 24, 1995. The Safety

Board invited the American Pilots’ Association,

Princess Cruise Lines, the U.S. Coast Guard,

and the Liberian Office of the Deputy

Commissioner of Maritime Affairs to assist in

the investigation. All these organizations sent

representatives to Juneau, and all were parties to

the investigation.

The Safety Board investigated this accident

independently, under authority of Section

304(a)(1)(F) of the Independent Safety Board

Act of 1974.

The report is based on the information

developed as a result of the investigation and on

additional analysis made by the Safety Board.

The Safety Board considered all facts in the

investigative record that are pertinent to its

statutory responsibility to determine the cause or

probable cause of the accident and to make

recommendations.

Testimony

Sworn testimony regarding this accident

was taken on June 26 and 27, 1995, in Juneau,

Alaska, on June 29, 1995, in Seattle,

Washington, and on July 2, 1995, in Portland,

Oregon.
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47

APPENDIX B

Pilot and Crew Information

Pilot Nerup

Captain Robert K. Nerup, age 57, began his

maritime career in 1956 as an enlistedman in the

U.S. Navy. He was accepted to the U.S. Naval

Academy, from which he graduated in 1962. He

served 20 years of active duty and spent approximately 15 years of his active service at sea.

Before his 1980 retirement, he had been the

commanding officer aboard a U.S. Navy fleet

tugboat. Upon retirement from the Navy, he became a marine pilot in Alaska.

At the time of the grounding, Pilot Nerup

held a U.S. Coast Guard (USCG) 1,600 ton

master’s license for inland waters endorsed with

Federal first class pilotage for southeast Alaska,

including Lynn Canal and the grounding area.

Pilot Nerup’s USCG license had last been renewed on January 9, 1995. He also held a State

of Alaska marine pilot’s license applicable to

Lynn Canal and the area of the grounding. Pilot

Nerup was originally issued a State pilot’s license on December 9, 1980. It had most recently

been renewed in December 1994. (State law

requires that licenses expire in even-numbered

years and be valid for 2 years.)

Pilot Nerup was a member of the Southeast

Alaska Pilots Association (SEAPA) and was not

operating under authority of his Federal license

at the time of the accident. Pilot Nerup did not

serve as an Alaska marine pilot year-round; he

worked only during the summer cruise season.

Since 1987, Pilot Nerup had been piloting

vessels on four occasions (including this accident) when marine casualties occurred. In 1987,

Pilot Nerup was involved in two casualties (a

collision with a log raft and a vessel grounding)

in Hobart Bay, Alaska. Because of these accidents, he was not allowed to pilot vessels in

Alaska for a total of 18 months; placed on probation for 2 years; and required to meet proficiency requirements before piloting any vessel

in Hobart Bay. In 1991, Pilot Nerup was piloting

the cruise vessel Island Princess when it collided with the Regent Sea while maneuvering

into the dock in Skagway Harbor. Because of

this accident, the State suspended Pilot Nerup’s

license for 6 months. He was also required to

complete a 1-day radar course and a 2-week

course on advanced shiphandling and navigation

(including navigation management), pass a

Coast Guard examination on “rules of the road,”

and remain on probation for 1 year. Pilot Nerup

fulfilled the terms of the settlement and returned

to piloting in southeast Alaska in late spring

1993.

During his testimony, Pilot Nerup estimated

that he had made 300 to 400 trips through the

Lynn Canal. He had served as pilot aboard the

Star Princess on approximately 10 previous

trips. At the time of the grounding, Pilot Nerup

had been aboard the Star Princess for 2 days

and had been the pilot in command on 2 prior

shifts, alternating with Pilot Kutz. Of the two,

Pilot Nerup was the senior pilot aboard the Star

Princess.

Pilot Nerup had been suffering from depression for the last 8 years. His treatment had included the prescription of antidepressant drugs;

for the last 3 years, he has been taking the antidepressant Effexor, as prescribed. Before the

accident, Pilot Nerup last took Effexor at approximately 1800 on June 22, 1995.

Pilot Kutz

Captain Ronald J. Kutz, age 67, began his

maritime career in the 1940s on tugboats and

then served for 11 years on Washington State

ferries, ultimately achieving the position of relief master. In 1963, he became a master on an

Alaska Marine Highway vessel. He retired from

the Alaska Marine Highway System in 1987.

During his employment with the State of

Alaska, he also worked as a marine pilot. Following his retirement from State service in

1987, he served as a pilot on an as-needed basis

with SEAPA.

Pilot Kutz held a USCG unlimited inland

master’s license, which had last been renewed

on November 18, 1993, for 5 years. This license
48 APPENDIX B

was endorsed with Federal first class pilotage

for southeast Alaska, including Lynn Canal and

the grounding area.

Pilot Kutz also held an Alaska State pilot’s

license for southeast Alaska, including Lynn

Canal and the area of the grounding. He was

issued his initial Alaska State marine pilot’s license in January 1970. His State license was last

renewed in January 1995. Pilot Kutz completed

a training course in Bridge Resource Management and Emergency Shiphandling for Pilots on

December 2, 1994, in Seattle, Washington.

Before the accident voyage, Pilot Kutz had

been aboard the Star Princess once before,

about 4 years earlier. He joined the vessel on

June 14, 1995, at the Point McCartey Pilot

Station, about 15 miles south of Ketchikan,

Alaska, while the vessel was northbound from

Vancouver. He began splitting shifts with Pilot

Nerup, who joined the vessel on June 21, 1995,

near the southern end of Glacier Bay.

At the time of the grounding, Pilot Kutz was

not on duty and was in his cabin resting. He returned to the bridge to assist immediately after

the grounding.

Master

Captain Emanuele Chiesa, age 54, is a

graduate of the Nautical Institute of La Spezia,

Italy. He served in the Italian Navy for 3 years

and then went into the merchant marine. He has

served aboard vessels in various capacities since

approximately 1964. Captain Chiesa possessed

an Italian unlimited master’s license issued

January 11, 1971, and a Liberian unlimited

master’s license issued March 7, 1994. (It expires March 7, 1999.) At the time of the

grounding, Captain Chiesa was asleep in his

cabin. He went to the bridge immediately after

the grounding.

Second Officer

Second Officer Gampiero Landi, age 52,

had sailed on various types of vessels and in

several capacities since approximately 1970. He

held an Italian unlimited master’s license first

issued November 29, 1977, and a Liberian second mate’s license issued April 17, 1991.

Second Officer Landi had been employed by

Princess Cruise Lines since March 21, 1991, as

a second officer aboard the Star Princess and

the Dawn Princess. In all, he had worked aboard

the Star Princess for approximately 14 months

and made trips in Alaska for 3 summer seasons.

Second Officer Landi had made several previous

trips with Pilot Nerup and was familiar with

him. The accident voyage was the first time that

Second Officer Landi had worked with Pilot

Kutz. Second Officer Landi had transited Lynn

Canal more than 50 times before the accident

voyage.

Second Officer Landi was the senior bridge

officer on watch at the time of the grounding.

Before the grounding, he had been working with

the Third Officer to assist with Pilot Nerup’s

navigation of the vessel and to plot the ship’s

position.

Third Officer

Third Officer Vincenzo Alcaras, age 29, had

served aboard several ships in various capacities

since 1986. Third Officer Alcaras held an Italian

license issued in November 1990 and a Liberian

third mate’s license issued September 17, 1992.

Third Officer Alcaras had been employed by

Princess Cruise Lines since November 29, 1990,

and had worked aboard the Regal Princess, the

Crown Princess, and the Star Princess, first as a

cadet and later as third officer. He had worked

aboard the Star Princess for approximately 7

months in total and had previously cruised

Alaska for 1 summer season (2 years past).

Third Officer Alcaras had met Pilot Nerup once

before, approximately 2 years earlier. He had

never met Pilot Kutz before the accident trip.

Third Officer Alcaras was on watch at the

time of the grounding and had been working

with Second Officer Landi to monitor Pilot

Nerup’s navigation and to plot the ship’s position on the chart.

Helmsman

Quartermaster Basri Hasan, age 47, had

been sailing aboard vessels as an able seaman

since 1964. He had been employed by Princess

Cruise Lines since December 1991. He had

worked aboard both the Fair Princess and the

Star Princess. He was the helmsman on watch
APPENDIX B 49

at the time of the grounding and alternated each

hour between helmsman and lookout duties.

Lookout

Quartermaster Hilmi Masdar, age 31, had

been an able-bodied seaman for 17 years and

employed by Princess Cruise Lines since May

1991. He had worked aboard both the Fair

Princess and the Star Princess. He was the

lookout on watch at the time of the grounding

and was carrying out his duties standing on the

port bridge wing.
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51

APPENDIX C

Pilot and Piloting Information

A pilot is a person qualified, by local, State,

and/or Federal jurisdictions, by reason of

familiarity with certain navigational routes,

channels, and local dangers of the region

concerned, to conduct or guide vessels into or

out of port, along a coast or through restricted or

narrow waters. A pilot is hired for his or her

extensive local knowledge of the waters being

navigated.

Pilots are typically considered to be selfemployed, and each is an individual contractor

for the ship for which he or she is providing

pilotage. Nearly all pilots organize themselves

into pilot associations or corporations for their

area of operation. Each pilot owns a share of the

association’s property, which may include pilot

vessels and boats, automobiles, and real estate

(pilot offices and quarters). The association

normally performs the following functions:

dispatching pilots according to a rotation

system; collecting pilotage fees earned by the

pilots from the vessel owner, operator, or agent;

paying association expenses; and disbursing

pilot pay.

The term “piloting” refers to actions taken

to determine the position and direct the

movements of a vessel by reference to land and

sea marks, by measurements of depth, or by

radar. When piloting, the pilot should use every

method available to: obtain warnings of

approaching dangers; assess the ship’s position

accurately and frequently (by eye, by radar, and

with the assistance of the deck watch); and

determine the proper course of action to

navigate the vessel safely.

While the pilot is piloting, the senior watch

officer has the duty to intercede if the vessel is

moving into danger. He should call the pilot’s

attention to hazards and, if the pilot takes no

action, notify the master. Watch officers should

constantly check on the vessel’s position and

ensure that the pilot’s navigation orders are

carried out promptly.
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53

APPENDIX D

Effexor

According to the 1995 edition of the Physician’s Desk Reference, Effexor (venlafaxine

hydrochloride) is a medication indicated for the

treatment of depression. Clinical studies conducted on healthy individuals to examine the

effects of venlafaxine on behavioral performance revealed no clinically significant impairment of psychomotor, cognitive, or complex

behavior performance. The Physician’s Desk

Reference also states that since any pyschoactive drug may impair judgment, thinking, or

motor skills, patients should be cautioned

against operating machinery until they are

reasonably certain the medication will not adversely affect their ability to engage in such

activities.

The 1996 edition of the Complete Guide to

Prescription and Nonprescription Drugs states

that venlafaxine (brand name Effexor) is an

antidepressant drug used to treat mental depression. It states that Effexor increases the amount

of certain chemicals in the brain necessary for

the transmission of messages between nerve

cells. The text reports that common adverse

reactions or side effects of the drug include fast

heartbeat, blurred vision, increased blood pressure, stomach pain, gas, insomnia or drowsiness,

dizziness, decreased sexual drive, impotence,

nausea or vomiting, headache, diarrhea or constipation, dryness of mouth, skin flushing, rash,

loss of appetite, unusual tiredness, weakness,

strange dreams, sweating, tremors, and nervousness.

Less frequent possible adverse effects

caused by Effexor include lightheadedness or

faintness, mood or behavior changes, mental

changes, difficulty in urinating, weight loss or

gain, changes in taste, and ringing in the ears.

Rare possible side effects include seizures. In

the event of overdose, no symptoms may be

apparent, or extreme drowsiness, convulsions,

or rapid heartbeat may occur. The Complete

Guide to Prescription and Nonprescription

Drugs further states that individuals using the

drug should be warned not to drive or pilot an

aircraft until it is known how Effexor affects

them.
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55

APPENDIX E

PCL Fleet Regulations, NAV. 7.2 -- Pilotage
56 APPENDIX E
APPENDIX E 57
58 APPENDIX E
59

APPENDIX F

Voyage Event Recorder Information

 For more than 20 years, the Safety Board

has recommended the use of voyage event recorders (VERs) for accident reconstruction. As

a result of the investigation of the SS C.V. Sea

Witch - SS Esso Brussels collision and fire in

New York Harbor on June 2, 1973,1

 the Safety

Board recommended that the Coast Guard:

M-76-008

Require the installation of an automatic

recording device to preserve vital navigational information aboard oceangoing

tankships and containerships.

Following the investigation of the U.S.

tankship SS Marine Floridian collision with the

Benjamin Harrison Memorial Bridge in 1977,2

the Safety Board recommended that the Coast

Guard:

M-78-002

Conduct a formal study in coordination

with the Federal Maritime Administration and the shipping industry to determine a standard array of operational and

audio data that should be recorded

automatically with a view to establishing a requirement for the installation

and operation of suitable equipment in

U.S. vessels over 1,600 gross tons built

after 1965, and to submitting an initiative to the Intergovernmental Maritime

Consultative Organization (IMCO)3

 for

the adoption of a similar international

requirement.

 

1

Marine Accident Report – SS C.V. Sea Witch - SS

Esso Brussels Collision and Fire, New York Harbor,

June 2, 1973 (NTSB/MAR-75/06).

2

Marine Accident Report – U.S. Tankship SS Marine

Floridian Collision with Benjamin Harrison Memorial

Bridge, Hopewell, Virginia, February 24, 1977

(NTSB/MAR-78/01).

3

Now known as the International Maritime Organization (IMO).

As a result of a Safety Board special study

(Major Marine Collisions and Effects of Preventive Recommendations, MSS-81-1), the

Board recommended that the Coast Guard:

M-81-084

Expedite the study to require the installation of automatic recording devices to

preserve vital navigational information

aboard applicable ships.

The status of all three recommendations

cited above is “Closed—Unacceptable Action.”

The most recent response (May 21, 1982) from

the Coast Guard concerning these safety recommendations stated:

The Coast Guard generally supports the

concept of shipboard voyage recorders

as an aid in casualty analysis. Recently,

the U.S. Maritime Administration canceled their voyage recorder project and

IMCO removed voyage recorders from

their work schedule. In view of this and

the severe funding limitations within the

Department of Transportation, the Coast

Guard does not plan to actively pursue a

voyage recorder project at this time.

As a result of its investigation of the collision between the Netherlands Antilles passenger

ship Noordam and the Maltese bulk carrier

Mount Ymitos in 1993,4

 the Safety Board made

the following safety recommendations to the

Coast Guard:

M-95-5

Require all vessels over 1,600 gross

tons operating in U.S. waters to be

equipped with voyage event recorders.

 

4

Marine Accident Report – Collision of the Netherlands Antilles Passenger Ship Noordam and the Maltese

Bulk Carrier Mount Ymitos in the Gulf of Mexico, November 6, 1993 (NTSB/MAR-95/01)
60 APPENDIX F

M-95-6

Propose to the IMO that it require all

vessels over 500 gross tons to be

equipped with voyage event recorders.

In responding to a December 1, 1995, Coast

Guard letter concerning voyage event recorders,

the Safety Board wrote on February 6, 1996,

that because the Coast Guard was not taking

unilateral action as requested, Safety Recommendation M-95-5 had been classified

“Closed—Unacceptable Action.” Regarding

Safety Recommendation M-95-6, the Safety

Board wrote that it:

is aware of the IMO ‘panel of experts’

assembled to review the stability and

other related design matters of ‘RoRo’5

vessels after the sinking of the Estonia.

Because the Coast Guard’s letter does

not address the recommended action

that voyage event recorders be installed

on all vessels over 500 gross tons,

Safety Recommendation M-95-6 has

been classified ‘Open—Await Response.’ We request that the Coast

Guard inform the Safety Board of its

strategic action plan for implementing

this recommendation.

The Safety Board also made the following

recommendation to the International Council of

Cruise Lines: 6

M-95-8

Propose to members that all passenger

vessels over 1,600 gross tons operating

from U.S. ports be equipped with voyage event recorders.

 

5

Roll-on roll-off vessels that are designed with large

bow or stern ramps (or both) to allow trailers or cars to be

driven rather than lifted on and off the vessel.

6

The International Council of Cruise Lines is a major

association of cruise ship operators that represents some 19

cruise lines. Each year, its overnight cruise vessel operators

carry more than 4 million U.S. passengers on 87 ships.

On December 12, 1995, responding to an

International Council of Cruise Lines letter of

October 18, 1995, the Safety Board wrote that it

“...was pleased that the International Council of

Cruise Lines generally supports the Safety

Board’s position on this issue and has distributed copies of the recommendations to its constituency for their information and

consideration.” Accordingly, Safety Recommendation M-95-8 was classified “Closed—Acceptable Action.”

The Safety Board made the following

recommendation to Holland America Line

Westours, Inc.:

M-95-10

Review the management oversight program and implement measures to ensure

that company watchstanding policies are

followed on all ships.

 In an August 8, 1995, letter responding to

Safety Recommendation M-95-10, Holland

America advised the Safety Board that, along

with other management and oversight measures,

it was evaluating a VER that had been installed

on its passenger vessel Statendam. It stated that

if the VER package was satisfactory, Holland

America would install the system on other Holland America vessels. Because of Holland

America’s prompt action on this recommendation, including testing VERs for possible installation on all its vessels, Safety Recommendation

M-95-10 was classified “Closed—Acceptable

Action” on October 17, 1995.
61

APPENDIX G

International Safety Management Code for the Safe Operation

of Ships and for Pollution Prevention

The International Maritime Organization

(IMO), in November 1993, adopted the International Safety Management Code for the Safe

Operation of Ships and for Pollution Prevention

(ISM Code). The ISM Code recognizes and

codifies the responsibilities of shipping company management in ensuring adherence to

marine safety guidelines and environmental

protection standards. The objectives of the ISM

Code (Article 1.2.1) are to:

Ensure safety at sea, prevention of human injury or loss of life, and avoidance

of damage to the environment, in particular to the marine environment, and

to property.

A dominant theme of the ISM Code is accountability, which, according to the IMO, can

no longer be limited to shipmasters and crews,

but now must extend to the upper levels of company management. Compliance with the ISM

Code will require that companies1

 develop and

maintain a safety management system (SMS)

that will:

• Provide for safe practices in ship operation and a safe working environment;

• Establish safeguards against all identified risks; and,

• Improve the safety management skills of

personnel both ashore and on ships.

The SMS must include the following functional requirements:

• A safety and environmental protection

policy;

• Instructions and procedures to ensure

safe vessel operation and environmental

protection in compliance with relevant

international and domestic laws; 

1

“Companies” includes ship owners as well as other

persons or entities that have assumed responsibility for

operating a ship or ships and, by so doing, have also assumed responsibility for adhering to the ISM Code.

• Defined levels of authority and lines of

communication between and among

shipboard and shoreside personnel;

• Procedures for reporting accidents and

nonconformities;

• Emergency preparedness and response

procedures; and,

• Internal audit and management review

procedures.

The ISM Code also requires that companies

appoint a “designated person” (or persons)

ashore with direct access to the highest level of

management. The designee must have the

responsibility and authority to monitor the

safety and pollution aspects of each of the company’s ships and to ensure that adequate

resources and shore-based support are available

to maintain the SMS. The ISM Code states that

the company should clearly define and document the master’s responsibility regarding:

• Implementing the safety and environmental protection policy of the company;

• Motivating the crew in the observation

of that policy;

• Issuing appropriate orders and instructions in a clear and simple manner;

• Verifying that specified requirements

(such as marine regulations, operational

directives, etc.) are observed; and,

• Reviewing the SMS and reporting its

deficiencies to shore-based management.

Under procedures established by the IMO,

companies that demonstrate compliance with the

ISM Code will be issued a Document of Compliance. Vessels owned and/or operated by these

companies will be issued a Safety Management

Certificate to be displayed on board the vessel.

While the ISM Code was developed primarily

for deep-draft ships engaged in international

commerce, its provisions might be applied to all

sectors of the maritime industry,
62 APPENDIX G

including inland and coastal barge and towing

operations.

Compliance with the ISM Code is mandatory for companies operating large vessels in

international trade. Deadlines for compliance

are (1) July 1, 1998, for all passenger ships and

for oil tankers, chemical tankers, gas carriers,

bulk carriers, and cargo high-speed craft of more

than 500 gross tons, and (2) July 1, 2002, for all

other cargo ships and mobile offshore drilling

units of 500 gross tons or more. Companies that

fail to comply will be considered in violation of

the International Convention for the Safety of

Life at Sea and may be prevented from trading.
63

ACRONYMS AND ABBREVIATIONS USED IN THE REPORT

ABMP Alaska Board of Marine Pilots

ARPA automatic radar plotting aid

BRM bridge resource management

CFR Code of Federal Regulations

DOT U.S. Department of Transportation

EBL electronic bearing line

GPS global positioning system

HCPV high capacity passenger vessel

IMO International Maritime Organization

ISM Code International Safety Management Code for the Safe

Operation of Ships and for Pollution Prevention

MLLW mean lower low water

MSC Maritime Safety Committee

M/V motor vessel

OSA obstructive sleep apnea

PCL Princess Cruise Lines

SEAPA Southeastern Alaska Pilots Association

SMS safety management system

SOLAS International Convention for the Safety of Life at Sea

T true course

TSS traffic separation scheme

USCG U.S. Coast Guard

VDR voyage data recorder

VER voyage event recorder

WAMS Waterway Analysis and Management System