ACCIDENT REPORT

NTSB/mAR-08/01

Nationa PB2008-916401 l

Transportation

Safety Board

marine

Heeling Accident on M/V Crown Princess

Atlantic Ocean Off Port Canaveral, Florida

July 18, 2006

National

Transportation

Safety Board

Marine Accident Report

Heeling Accident on M/V Crown Princess

Atlantic Ocean Off Port Canaveral, Florida

July 18, 2006

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

NTSB/MAR-08/01

PB2008-916401

Notation 7963B

Adopted January 30, 2008
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National Transportation Safety Board. 2008. Heeling Accident on M/V Crown Princess, Atlantic Ocean 

Off Port Canaveral, Florida, July 18, 2006. Marine Accident Report NTSB/MAR-08/01. Washington, DC.

Abstract: This report discusses the July 18, 2006, accident on the cruise ship Crown Princess in which the 

vessel heeled at a maximum angle of about 24°, resulting in injuries to 298 passengers and crewmembers. 

The vessel’s second officer, the senior watch officer on the bridge, had disengaged the automatic steering 

mode of the vessel’s integrated navigation system and taken manual control of the steering in an effort to 

counteract a perceived high rate of turn to port. He turned the wheel first to port and then between port 

and starboard several times, causing the vessel to suddenly heel and people to be thrown about or struck 

by unsecured objects. The Crown Princess incurred no structural damage, although unsecured interior 

items were damaged.

The Safety Board’s investigation of the accident identified the following safety issues: actions of the 

captain, staff captain, and second officer; training in the use of integrated navigation systems; reporting 

of heeling incidents and accidents; and emergency response following severe incidents.

On the basis of its findings, the Safety Board made recommendations to the U.S. Coast Guard, to the 

Cruise Lines International Association, and to SAM Electronics and Sperry Marine (manufacturers of 

integrated navigation systems).
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Contents

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

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

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

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

Injuries.....................................................................................................................................10

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

General ...............................................................................................................................11

Captain...............................................................................................................................11

Staff Captain......................................................................................................................11

Second Officer...................................................................................................................12

Vessel Information ................................................................................................................13

History and Construction................................................................................................13

Classification and Inspection ..........................................................................................13

Propulsion and Steering ..................................................................................................14

Voyage Data Recorder.....................................................................................................14

Waterway Information .........................................................................................................16

Meteorological Information.................................................................................................16

Toxicological Testing ............................................................................................................16

Survival Factors .....................................................................................................................17

Shipboard Response.........................................................................................................17

Shoreside Response..........................................................................................................18

Tests and Research ................................................................................................................19

Postaccident Steering Tests ............................................................................................19

Heel Angle Determination ..............................................................................................20

Stability Considerations...................................................................................................22

Vessel Dynamics ...............................................................................................................23

Shallow Water Effects .....................................................................................................24

Operational and Management Information ......................................................................28

Corporate Organization...................................................................................................28

Princess Cruises Operations ...........................................................................................28

Additional Information ........................................................................................................31

Heeling Incidents on Cruise Vessels..............................................................................31

Integrated Navigation Systems .....................................................................................34

Analysis............................................................................................................................43

General....................................................................................................................................43

Exclusions ...............................................................................................................................43

Accident..................................................................................................................................43

Actions of Captain and Staff Captain............................................................................44

Second Officer’s Actions..................................................................................................45
Contents

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Training in Use of Integrated Navigation Systems ..........................................................47

Postaccident Crew Response ..............................................................................................50

Monitoring of Heeling Incidents.........................................................................................51

Conclusions.....................................................................................................................53

Findings ..................................................................................................................................53

Probable Cause ......................................................................................................................54

Recommendations..........................................................................................................55

Appendixes 

A: Investigation..................................................................................................................59

B: Voyage Data Recorder Data Plots .............................................................................60

C: Voyage Data Recorder Audio Transcript.................................................................65

D: Pertinent Regulations and Guidelines ....................................................................79

E: Model Curriculum Proposed by International Maritime Organization ............82

F: International Maritime Organization Guidance on Integrated Navigation 

System Training............................................................................................................92

Contents
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Acronyms and Abbreviations

AIS automatic identification system

ARPA automatic radar plotting aid

CFR Code of Federal Regulations

CLIA Cruise Lines International Association

COTP Captain of the Port

ECDIS electronic chart display and information system

GPS global positioning system

ICCL International Council of Cruise Lines

IBS integrated bridge system

IMAC integrated monitoring, alarm, and control 

INS integrated navigation system 

ISO International Organization for Standardization

LORAN LOng RAnge Navigation

MSC Maritime Safety Committee

NACOS Navigation and Command System

QE2 Queen Elizabeth 2

SOLAS International Convention for Safety of Life at Sea

STCW Standards of Training, Certification, and Watchkeeping for 

Seafarers

STW Standards on Training and Watchkeeping

VDR voyage data recorder
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Executive Summary

On July 18, 2006, the cruise ship Crown Princess, which had been in service 

about a month, departed Port Canaveral, Florida, for Brooklyn, New York, its 

last port on a 10-day round-trip voyage to the Caribbean. Slightly more than an 

hour after departing, while on a heading to intersect its track to Brooklyn, the 

vessel’s automatic steering system began a turn to port. In an effort to counter 

the effects of a perceived high rate of turn, the second officer, the senior watch 

officer on the bridge, disengaged the automatic steering mode of the vessel’s 

integrated navigation system and took manual control of the steering. The second 

officer turned the wheel first to port and then from port to starboard several times, 

eventually causing the vessel to heel at a maximum angle of about 24° to starboard. 

The heeling caused people to be thrown about or struck by unsecured objects, 

resulting in 14 serious and 284 minor injuries to passengers and crewmembers. 

The vessel incurred no damage to its structure but sustained considerable damage 

to unsecured interior components and to cabinets and their contents. 

The National Transportation Safety Board determines that the probable cause 

of the Crown Princess accident was the second officer’s incorrect wheel commands, 

executed first to counter an unanticipated high rate of turn and then to counter 

the vessel’s heeling. Contributing to the cause of the accident were the captain’s 

and staff captain’s inappropriate inputs to the vessel’s integrated navigation 

system while the vessel was traveling at high speed in relatively shallow water, 

their failure to stabilize the vessel’s heading fluctuations before leaving the bridge, 

and the inadequate training of crewmembers in the use of integrated navigation 

systems.

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

safety issues:

• Actions of captain, staff captain, and second officer.

• Training in use of integrated navigation systems.

• Reporting of heeling incidents and accidents.

• Emergency response following severe incidents.

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

the U.S. Coast Guard, to the Cruise Lines International Association, and to SAM 

Electronics and Sperry Marine (manufacturers of integrated navigation systems).
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Factual Information

Accident Narrative

At 14061 on July 18, 2006, the Bermuda-registered cruise ship M/V Crown 

Princess (figure 1), operated by Princess Cruises, departed Port Canaveral, Florida, 

for Brooklyn, New York, on the last leg of a 10-day round-trip voyage to the 

Caribbean (figure 2). It was the vessel’s fourth voyage after being christened in 

Brooklyn on June 14. A total of 4,545 persons were on board—3,285 passengers 

and 1,260 crewmembers. A Florida state harbor pilot had the conn—that is, was 

in control of the ship’s movement.2 The ship’s captain, staff captain (second in 

command on Princess Cruises vessels), relief captain, second officer, two fourth 

officers, and two helmsmen were also on the bridge.3 According to the captain, 

the wind was light, the sky was clearing, visibility was good, and the sea state was 

“slight” as they left Port Canaveral. 

At 1437, according to the ship’s log, the pilot left the bridge, disembarking 

soon afterward, and the captain assumed the conn. The captain then began 

increasing the ship’s speed in increments of 10 propeller revolutions per minute. 

At 1456, as recorded on the vessel’s VDR,4 the captain told the chief engineer, “We 

want to go as fast as we can for the time being for the weather.” The staff captain 

told investigators that the captain was hoping to “get ahead of” a developing storm 

along the vessel’s route. Around the same time, the captain shifted control of the 

engines to the engineroom. The chief engineer, now in direct control of the vessel’s 

propulsion system, continued to increase the ship’s speed.

1 Times in this report are eastern daylight time according to the 24-hour clock. Times on the vessel’s 

various clocks, logs, and other recording devices (such as onboard cameras) differed. Investigators’ efforts 

went into determining the time a particular event occurred. The approach was to synchronize all times with 

those recorded by the vessel’s voyage data recorder (VDR) from a global positioning system (GPS) receiver. 

VDR time was then converted to local time (eastern daylight time) in the accident area. 

2 A Florida-licensed state pilot is required for all foreign-registered vessels in foreign trade and for all 

vessels over 500 gross tons operating into or out of Port Canaveral, unless specifically exempted by the port 

director.

3 The Crown Princess was staffed with more than one second officer and more than one fourth officer. 

The report refers only to those on watch during the accident sequence. One of the fourth officers on the bridge 

was observing. The relief captain was on board because he was scheduled to relieve the captain at the ship’s 

next port of call (Brooklyn). See “Personnel Information” section for details about the watch officers.

4 The VDR continuously recorded audio data from the bridge, in addition to collecting data related to 

the ship’s operation. For more information, see “Voyage Data Recorder” section. VDR data from the Crown 

Princess are plotted in appendix B. A transcript of the vessel’s VDR audio recording is found in appendix C. 
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From the dock to a point beyond where the pilot disembarked,5 the bridge 

crew controlled the vessel’s steering manually. At 1501, on orders from the 

captain, the crew engaged the trackpilot, the autopilot function of the vessel’s 

integrated navigation system (INS).6 The INS on the Crown Princess was a NACOS 

(Navigation and Command System) manufactured by SAM Electronics of 

Hamburg, Germany.7

The crew set the course to 100° in heading mode, one of three available 

steering modes in the trackpilot.8 According to the ship’s log, the seas were calm 

and there was a gentle breeze from the northeast. Shortly after the course was set, 

the captain noticed that the vessel’s heading was fluctuating, and he reviewed the 

trackpilot settings (table 1). According to the second officer, the course fluctuations 

were causing “quite an excessive rate of turn.” The second officer said that he 

asked the captain, “Would you like to go back into hand steering?” and the captain 

said, “No, I’ve got the conn.”9

5 Pilots ordinarily board and disembark about 1 mile southeast of whistle buoy 3 in Canaveral Harbor 

(National Oceanic and Atmospheric Administration, National Ocean Service, United States Coast Pilot, vol. 4 

[Atlantic Coast: Cape Henry, VA, to Key West, FL], 2004, p. 419).

6 The International Maritime Organization, a specialized agency of the United Nations, defines an INS 

as follows: “A combination of systems which are interconnected in order to allow centralized access to sensor 

information or command/control from workstations, with the aim of increasing safe and efficient ship’s management 

by suitably qualified personnel.” (International Maritime Organization document STW 36/3/1 “Validation of Model 

Training Courses,” August 12, 2004, p. 27.) See “Integrated Navigation Systems” section for more information.

7 SAM Electronics, formerly STN Atlas Marine Electronics, is a wholly owned subsidiary of 

L3 Communications Corporation, New York.

8 The other steering modes were course mode and track mode. For details, see “Integrated Navigation 

Systems” section.

9 The second officer’s statement was made during an investigative interview. Investigators were unable 

to verify the exchange on the VDR audio recording from the bridge. See “Voyage Data Recorder” section for 

a discussion of the limitations of the VDR audio recording.

Figure 1. The Crown Princess sailing past the Statue of Liberty as it arrived in New York 

from the shipyard in Italy. The cruise ship was nearly 1,000 feet long, had 19 decks, and 

could carry more than 4,000 people. (Photo courtesy Princess Cruises)
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Figure 2. The Crown Princess was returning to New York from a Caribbean cruise with 

ports of call at Grand Turk Island, Ocho Rios, Jamaica, and Grand Cayman Island when 

it heeled about 10 nautical miles east of Port Canaveral, Florida. Inset shows the ship’s 

track from Port Canaveral to the accident site. Water in the area was relatively shallow, 

about 26 feet below the vessel’s keel.
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Table 1. Sequence of events while the trackpilot was engaged.

Time Event

1501 Crew shifts steering from manual to trackpilot

1503 Captain notices heading fluctuations

1505:06 Trackpilot rudder limit alarm sounds

1505:38 Captain: “We’re wandering all over the place”

1506:09 Captain: “At the moment she is not responding other than 10 degrees at a 

time”

1506:27 Rudder limit alarm sounds

1507:07 Staff captain increases rudder limit to 10°

1508:00 Rudder limit alarm sounds

1512 Staff captain: “Is it okay now?” Captain: “No” 

1513 Staff captain discusses trackpilot settings with captain

1513 New course input to trackpilot, vessel begins turn to port

1514:33 Captain: “Stay in that turn . . . OK, we’ll run like that”

1518:14 Captain to second officer: “Okay, you got the conn”

1522 Heading approaches ordered course of 040°, again begins to fluctuate

1522 Captain and staff captain leave bridge

1523 Relief captain leaves bridge

At 1505:06, during the second heading fluctuation, when the rate of turn 

reached 9° per minute, the trackpilot’s rudder limit alarm sounded.10 According to 

the operating instructions for the NACOS,11 the rudder limit alarm indicates the 

following:

The set rudder limit value has been reached; with this rudder limit, the 

maneuver cannot be performed without a deviation, or, the present rudder 

angle lies outside the rudder limit. Remedy:

• Increase the rudder limit,

• Wait until the rudder angle becomes less than the rudder limit, or

• Switch over to manual steering.

10 The rudder limit was a trackpilot function that the crew could set to limit the extent of rudder 

movement.

11 SAM Electronics, Operating Instructions: Radarpilot 1100, Chartradar 1100, Conningpilot 1100, item 

ED 3051 G 032 (revision 2005-01), p. 268. International Electrotechnical Commission standard IEC 60945 

requires manufacturers to provide crew operating and service manuals. The NACOS operating manual for 

crewmembers was 293 pages long, divided into sections for radar functions, automatic identification system, 

conning displays, trackpilot functions, VDR, alarms, and care and maintenance. Instructions related to the 

trackpilot covered operational and steering modes, definitions of terms, data displays, and adapting the 

trackpilot settings to actual states such as weather. A separate, later section included 35 trackpilot alarms in 

a listing of all alarms to the operator. 
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After the alarm sounded, the captain called the staff captain over and said, 

“We’re wandering all over the place . . . we put her into NACOS-1.”12 At 1506:09, 

the captain said, “At the moment she is not responding other than 10 degrees at a 

time.” At 1506:27, the rudder limit alarm sounded again. The staff captain checked 

the INS settings. He told investigators that the rudder limit was set at 5°. VDR data 

show that the vessel’s speed was about 19 knots at the time.

About 1507, the staff captain increased the rudder limit from 5° to 10°. The 

staff captain later explained to investigators: 

. . . you exceed this alarm of too much [rudder] and with basically 5 degrees 

[of rudder limit] set, the ship cannot go back on track within a certain time 

. . . so I intervened with the captain still having the conn and increased the 

rudder limit up to 10 and . . . we regained the intended heading that he 

wanted. 

The staff captain further explained:

To increase the rudder limit, it doesn’t really mean . . . that the system 

will apply ten degrees of rudder. Normally, that gives us more allowance 

and a little bit more faster response . . . but, of course, it doesn’t mean that 

by setting the [rudder] limit that the limit is used constantly. The limit is 

only there if there is a need for using it by the system. . . . Since you are in 

heading mode, it doesn’t really make a difference because this applies only 

when you move from heading or course mode down to track mode.13

The staff captain added that he was not aware of guidance from the cruise line or 

the manufacturer on when to change the rudder limit.14

At 1508, the rudder limit alarm sounded again. At 1513, the vessel began 

a turn to port to intersect the first plotted track to New York. The course change, 

from a heading of 100° to a heading of 040°, was executed through several small 

adjustments to the autopilot’s set heading. The vessel’s speed had now reached 20 

knots. The captain directed the second officer: “Stay in that turn . . . OK, we’ll run 

like that.” The captain then asked the second officer for the heading of the next 

navigation track.

At 1518:14, the captain turned the conn over to the second officer. About 

1519, the vessel’s heading again began to fluctuate around the set heading. The 

captain and staff captain left the bridge at 1522, and the relief captain left about a 

12 NACOS-1 was the Princess Cruises term for trackpilot 1. The term is not consistent with the SAM 

Electronics designations. Its origin was not determined.

13 See “Integrated Navigation Systems” section.

14 General instructions for setting the rudder limit were given in the SAM Electronics Operating Instructions, 

“Trackpilot Functions,” section 26.2, “Adaptation to Suit the Weather and the Type of Waterway,” as follows: 

“The rudder limit value should be reduced if a constant course is to be steered for a long time on the open sea 

or if, for example because of the loading state or other reasons, large angles of the rudder are not permitted. 

In coastal approaches, the rudder limit value must be suitably increased so that the ship can turn with a small 

radius or can be controlled at low speed” (p. 208).
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minute later. The second officer, the two fourth officers, and the two helmsmen (as 

lookouts) remained on the bridge. 

About 1523, the vessel reached a turn rate of about 10° per minute to 

starboard. The turn then shifted to port, and the rate of turn reached nearly 20° 

per minute. The rate-of-turn indicator (figure 3) displayed red for turns to port, 

green for turns to starboard. The indicator did not show turn rates beyond 30° per 

minute in either direction, although a turn rate of any size was displayed digitally 

next to the indicator. The second officer told investigators that shortly after he 

took the conn, the rate-of-turn indicator “was a bright color red . . . my eyes were 

instantly drawn to it.” 

At 1524, the second officer disengaged the trackpilot and, because he was 

closer to the wheel than either of the helmsmen, took manual control of the steering.15

The second officer told investigators, “I just saw the rate of turn and instinct took 

over, I thought . . . we’re going to be swinging to port really fast here and I’ve got to 

get hand steering . . . [to] try to stop the swinging.” VDR data show that for about 

15 The trackpilot was disengaged during the entire accident sequence. Disengaging the trackpilot also 

disengaged the rudder limit setting and the rudder economy setting (described later in the report).

Figure 3. Trackpilot display on the Crown Princess. The rate-of-turn indicator is at the 

top, abbreviated ROT. The highest rate of turn displayed in either direction on that indicator 

was 30° per minute. The digital display on the right above the indicator could show any 

rate of turn. The rate of turn displayed here is 18.7° to port.
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a minute after disengaging the trackpilot, the second officer repeatedly turned the 

wheel back and forth between port and starboard (table 2). VDR data also show 

that after the second officer disengaged the trackpilot, the speed at which he moved 

the wheel exceeded the rudders’ ability to respond to his commands.16 Thus, the 

rudders lagged the wheel inputs. The vessel’s response lagged the steering inputs 

even farther (see “Vessel Dynamics” section for details).

Table 2. Sequence of events after the second officer disengaged the trackpilot and began steering 

manually. Wheel commands indicate manual inputs to vessel steering, not the resulting rudder 

movement.

Time Event

1524:05 Second officer disengages trackpilot, switches to manual steering mode

1524:11 Wheel command: port 10°

1524:18 Wheel command: starboard 10°

1524:20 Fourth officer: “Port ten”

1524:21 Second officer: “I know”

1524:22 Fourth officer: “Port ten . . . man you are port ten, you are port ten”

1524:23 Second officer: “Yeah, I am coming over to starboard”

1524:26 Wheel command: port 30°

1524:26 Warning sound (continues for 1 min 49 sec)a

1524:28 Fourth officer: “You are at port ten”

1524:29 Second officer: “Yeah, I am coming over . . .”

1524:36 Warning sounds (last less than 1 sec)

1524:42 Wheel command: starboard 10°

~1524:40-1525b Captain, staff captain, and relief captain return to bridge

1524:43 Relief captain: “Reduce the speed, reduce the speed”

1524:45 Wheel command: starboard 30°

1524:48 Warning sound (continues for 1 min 6 sec)a

1524:49 Wheel command: port 35°

1524:49 Second officer pulls back on throttle, orders 0 revolutions per minute

1524:50 Wheel command: port 45°

1524:59 Wheel command: starboard 5°

1525:00 Wheel command: 0° (midships)

1525:00 Captain: “Stop the engines, stop the engines, stop the engines”

1525:34 Wheel command: starboard 45°

1526:20 All audible warnings stop

 a Investigators could not determine which device sounded the warning.

 b The officers arrived back on the bridge over a period of several seconds. Time was estimated from the VDR audio record 

and interview statements.

16 The Crown Princess was equipped with two rudders. See “Vessel Information” section.
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The second officer first turned the wheel to port 10°. He told investigators 

that he had meant to turn to starboard, but instead went to port. He was unable 

to explain his action. Eight seconds after turning to port, he turned the wheel to 

starboard 10°. The fourth officer on watch immediately alerted the second officer 

that the rudders were at port 10°. (Although the second officer had already turned 

the wheel to starboard, the rudders required several seconds to respond.17) The 

second officer acknowledged the fourth officer’s statement, saying, “Yeah, I am 

coming over to starboard,” but he then turned the wheel to port 30°. 

Several seconds after being reminded, “You are at port ten,” and after again 

telling the fourth officer that he was “coming over,” the second officer turned the 

wheel to starboard 10°. The VDR recorded numerous audio alerts around this time, 

along with the sound of objects falling to the bridge deck. The second officer told 

investigators, “I’ve never seen a ship lean over that far before.” He further stated, 

I don’t remember just like moving the wheel around and I can’t say which 

way I was doing it and how much I was doing it because by then, the ship 

was leaning over so much that I was just basically trying to do anything 

that I thought was going to assist in getting the ship upright.

The captain, staff captain, and relief captain ran to the bridge, arriving over 

a period of several seconds. The relief captain, who arrived first, ordered, “Reduce 

the speed, reduce the speed.” Two seconds later, the second officer turned the 

wheel to starboard 30°, followed 4 seconds later by a turn to port 35°. The second 

officer then pulled back on the throttle, ordered zero revolutions per minute,18

and turned the wheel to port 45°. Ten seconds later the captain ordered, “Stop 

the engines, stop the engines, stop the engines.” By that time, the wheel had been 

turned to midships and the staff captain had arrived. 

About 1525, the vessel reached a maximum angle of heel of about 24° to 

starboard (see “Heel Angle Determination” section). At the same time, the vessel’s 

rate of turn reached a maximum of 80° per minute. Immediately after the vessel 

reached its maximum heel, the staff captain turned the wheel hard to starboard. 

All audible warnings ceased at 1526:20, and the vessel returned to even keel about 

1527. By then, its speed had slowed to 12 knots.

17 As explained in the “Vessel Information” section, either 14 or 28 seconds were required for the steering 

gear to move a rudder from hard over in one direction to hard over in the opposite direction, depending on 

how many rudder pumps were operating. According to the International Convention for Safety of Life at Sea 

(SOLAS) 1974, as amended, chapter II-1, regulation 29, “Steering Gear,” section 3.2: “The main steering gear 

and rudder stock shall be capable of putting the rudder over from 35° on one side to 35° on the other side with 

the ship at its deepest seagoing draught and running ahead at maximum ahead service speed and, under the 

same conditions, from 35° on either side to 30° on the other side in not more than 28 s [seconds].” The rudders 

on the Crown Princess moved about 3° per second.

18 As noted earlier, the captain had passed engine control to the engineroom. Because the bridge did not 

have direct control of the engines when the second officer issued the engine order, the engine speed was not 

immediately reduced.
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Princess Cruises, like other cruise lines, employed dedicated observers on 

both bridge wings19 to monitor the balconies for fire. After the accident, the captain 

asked the observers whether they had noticed any passengers or crewmembers 

fall overboard. They told him that they had not. The captain decided against 

mustering the passengers because of the information from the observers and his 

sense that the passengers were “in shock” as a result of the accident. 

Responses to a Safety Board questionnaire, which was sent to most 

passengers who were evacuated to hospitals and 200 other passengers selected 

at random,20 describe the passengers’ reactions to the ship’s sudden heeling. 

Passengers in cabins saw televisions fall from their bases and tables and chairs 

move rapidly about the cabins, while those in public areas observed similar 

occurrences for both light and heavy objects. A 54-year-old man who was entering 

the buffet on the fifteenth deck wrote, 

They had reset the tables for dinner with wineglasses and china. The ship 

began to list to the starboard. The glasses and plates began to slide off the 

tables and I saw my sister-in-law fly off her chair. I fell off my chair, [I] 

tried [to] grab my wife and slid across the room. My sister-in-law seriously 

injured her hand and was taken off by ambulance. My son jumped off his 

bunk bed and hurt his knee. I was scraped and hurt my hamstring.

During the accident, water, people, and objects spilled out of the ship’s 

swimming pools. A 44-year-old woman, who was near one of the pools at the time 

of the accident, reported: 

I first realized something was wrong when I felt the boat tilt and it was 

uncomfortable to stand upright. We (my husband and I) noticed the water 

slowly coming out of the pool and drinks on tables falling. A second tilt 

occurred and we moved quickly towards the railing for support, and 

watched [as] “a small wave” of water, people, and belongings moved out 

towards the starboard side. The tilting stopped for a few seconds and then 

a much greater tilt occurred with a “large wave” [spilling] out knocking 

over people, chairs, tables, and miscellaneous belongings. 

The captain made several announcements over the vessel’s public address 

system after the event. Following the first announcement, he asked the senior 

physician on the vessel about the condition of any injured passengers. She 

recommended, and he agreed, to return to port to enable those who needed more 

extensive medical treatment than available on the ship to be taken to hospitals. 

The Crown Princess returned to Port Canaveral and docked with gangways down 

at 1836.

19 The bridge wings were enclosed extensions of the bridge on either side.

20 Of the 278 questionnaires that were sent, 117 were completed and returned to the Safety Board.
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Injuries

The type and number of recorded injuries to passengers and crewmembers 

in the accident are listed in table 3. Princess Cruises provided investigators with 

the names of 239 passengers who sought medical treatment, along with such 

information as cabin number, sex, age, date of birth, triage tag number, hospital, 

and injury description. Many names did not have entries for triage tag number or 

injury description. Princess Cruises also provided investigators with a list of 57 

crewmembers who received injuries during the accident. The injuries were similar 

to those of the passengers.

Table 3. Injuries sustained in the Crown Princess accident. 

Injury Type Crew Passengers Total

Fatal 0 0 0

Serious 0 14 14

Minor 57 227 284

None 1,203 3,044 4,247

Total 1,260 3,285 4,545

NOTE: Title 49 Code of Federal Regulations (CFR) section 830.2 defines a fatal injury as any injury that results in 

death within 30 days of an accident. It defines serious injury as that which requires hospitalization for more than 48 

hours, commencing within 7 days from the date the injury was received; results in a fracture of any bone (except simple 

fractures of fingers, toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon damage; involves any internal 

organ; or involves second- or third- degree burns, or any burns affecting more than 5 percent of the body surface. A 67-

year old male passenger on the vessel died 37 days after the accident, according to his death certificate, as a result of 

sepsis and pneumonia, secondary to metastatic preexisting lung cancer.

Listed injuries included sore extremities, minor bruising, scratches, 

lacerations needing stitches, broken bones, and chest pains. Minor injuries such 

as scratches and bruises were not recorded. A medically trained passenger who 

assisted vessel medical personnel in the dining facility, designated as a medical 

center in the event of a large-scale emergency, estimated that over 125 passengers 

were treated there. Investigators determined the number of injured passengers 

based on information provided by Princess Cruises and on records of shoreside 

hospitals and fire and rescue agencies.

The Safety Board obtained 57 medical records of passengers treated at local 

hospitals, 10 describing injuries considered serious. They included a passenger 

with a dislocated shoulder, a passenger with muscle tissue lacerations, and 

passengers with fractures to the ribs, humerus, wrist, or foot. The remaining 

passengers sustained minor injuries such as contusions, lacerations, sprains, 

strains, or reported pain. Injuries resulted primarily from people striking objects 

on the vessel or objects on the vessel striking people. An additional four seriously 

injured passengers were identified from the passenger questionnaires; no medical 

records were received for those passengers.
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Personnel Information 

General

The captain was in command of the Crown Princess. Thestaff captain reported 

to the captain, and the senior first officer and the other first officer reported to the 

staff captain. The senior second officer and other second officers reported to the 

first officers, and the third and fourth officers reported to the second officers. 

Captain

The captain, a United Kingdom national aged 54 at the time of the accident, 

joined P&O Cruises21 as a third officer in 1973 after graduating from a British 

maritime academy, and served on both passenger and cargo vessels. From 1977, 

he worked exclusively on passenger vessels. The first vessel on which he served 

as captain was the Island Princess, in 1997. In 1999, he was captain of the Grand 

Princess, the first of the current generation of large vessels he commanded. He 

was the first captain of the Crown Princess, from its delivery voyage through 

the time of the accident. All performance appraisals in his personnel file were 

positive. 

According to Princess Cruises records, the captain completed courses in 

automatic radar plotting aids (ARPA) in September 1985, a 3-day computer chart 

systems class in July 1997, a 3-day course in the NACOS INS at the SAM Electronics 

facility in Germany, also in July 1997, and a course in electronic chart display and 

information systems (ECDIS)22 in November 2001. In addition, he completed a 

5-day course in bridge resource management in December 1995. 

Three nights before the accident, the captain went to sleep at 2100 and arose 

at 0500. Two nights before the accident, he went to sleep at 2200 and arose at 0600. 

The night before the accident, he went to sleep at 2200, and he awoke at 0500 the 

day of the accident.

Staff Captain

The staff captain, an Italian national aged 43 at the time of the accident, 

graduated from an Italian maritime academy in 1981. He spent the next 10 years 

on various cargo vessels, including tankers, bulk carriers, refrigerated cargo 

vessels, container vessels, and general cargo vessels. He joined Princess Cruises

21 As explained in the “Operational and Management Information” section, P&O Cruises, like Princess 

Cruises, became a subsidiary of Carnival Corporation.

22 ECDIS is a navigation system that combines electronic navigation information, including vessel 

position, waterway information, and other critical parameters, into a single navigation display that can be used 

in lieu of paper navigation charts.
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in March 1991 as a second officer and had served as a deck officer exclusively on 

its vessels since. The performance appraisals in his Princess Cruises personnel file 

were positive.

According to Princess Cruises records, the staff captain completed a 

5-day course in bridge resource management in January 1995, a course in spoken 

English,23 and a 4-day course on the NACOS system at the SAM Electronics facility 

in Germany in 2002. The staff captain told investigators that he regularly availed 

himself of opportunities to learn about the NACOS INS:

I’ve done some personal training, including the various [INS] set ups on 

the new ships with . . . electronics technicians. Every time that . . . a new 

updated version of generation of [INS] systems [was installed], because 

I’m very keen with electronics, I always tend to have some more updates. 

So, continually I’ve done three new ships in a row, the Coral Princess, the 

Diamond Princess, and this is the other one. I think I received probably extra 

training from SAM Electronics.

Three nights before the accident, the staff captain went to sleep at 2200 and 

awoke at 0600. Two nights before the accident, he went to sleep at 2200 and awoke 

at 0700. The night before the accident, he went to sleep at midnight and awoke at 

0500.

Second Officer

The 27-year-old second officer, a United Kingdom national, was enrolled 

in a British maritime institute from 1996 through 2000. While a student, he 

served as a cadet on Cunard Lines vessels,24 receiving positive appraisals of his 

performance. In June 2000, on graduating from the institute, he joined Cunard 

Lines as a third officer and served on passenger vessels through the time of the 

accident. Performance appraisals in his personnel file were generally positive. 

After joining Cunard Lines, the second officer alternated between the 

Queen Elizabeth 2 (QE2), the Vistafjord (later rechristened the Caronia), and various 

Seabourn vessels.25 He served on the QE2 until April 2006 and then went on leave. 

On his return to duty in June, he served on the Diamond Princess for 2 1⁄2 weeks, 

then reported to the Crown Princess on July 7, 2006. He spent 5 days familiarizing 

himself with the vessel, then assumed the responsibilities of second officer. 

23 Princess Cruises required officers who were not native speakers to demonstrate proficiency in the 

English language. Students had to pass an examination in spoken English to earn a certificate of proficiency 

after taking this course. 

24 The operations of Cunard Lines, which became a subsidiary of Carnival Corporation, were combined 

with those of Princess Cruises and P&O Cruises, also acquired by Carnival Corporation. See “Operational and 

Management Information” section.

25 Seabourn was part of the Princess/Cunard/P&O organization.
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Princess Cruises records indicate that the second officer completed a 5-day 

bridge resource management course in the United Kingdom in June 2001 and a 

3-day course on the NACOS INS in July 2004, in Germany, conducted by SAM 

Electronics. The first vessel on which the second officer served that had a NACOS 

INS was the Diamond Princess. However, he told investigators that because the vessel 

operated almost entirely in Alaskan waters, where manual steering predominated, 

the INS “wasn’t really utilized” and he did not interact with an INS until joining 

the Crown Princess. He also said that the QE2 did not have a NACOS.

26

In the 3 days before the accident, the second officer was on watch from 

midnight to 0400 and from noon to 1600. He then slept from 0430 to 1100, except 

on the day before the accident, when he slept from 0430 to 1000 and from 1730 to 

midnight. He slept again the morning of the accident from 0430 to 1100.

Vessel Information

History and Construction

The Crown Princess was constructed in Monfalcone, Italy, by Fincantieri 

Cantieri. The manufacturer conducted sea trials of the vessel in March 2006. The 

trials included maneuvering tests, inclining (stability) tests, checks of mechanical 

and electrical systems, and checks of NACOS components. The vessel sailed to 

Brooklyn, New York, and entered service there in June. 

The gross tonnage of the Crown Princess was 113,561. The vessel had 19 

decks and was 947 feet long, 195 feet high, and had a beam of 159 feet including 

the bridge wings (the beam was 118 feet without considering the bridge wings). 

The vessel’s maximum speed was 21.5 knots. Its forward draft on the day of the 

accident was 8.36 meters (27.4 feet), and its aft draft was 8.76 meters (28.7 feet).

Classification and Inspection

The Crown Princess was registered in Bermuda. The ship was dual-classed 

by Lloyd’s Register and Registro Italiano Navale. The Crown Princess was inspected 

by its flag-state authority, the Bermuda Maritime Administration. Under the 

control verification system, the U.S. Coast Guard examined the vessel and issued 

a passenger vessel certificate of compliance.27 

26 According to SAM Electronics, the QE2 was retrofitted with a NACOS 35-4 INS in 2004.

27 The Coast Guard’s control verification program was established to monitor the safety of foreignflag vessels that embark passengers from U.S. ports. Vessels are subjected to initial, annual, and quarterly 

examinations. A passenger ship control verification certificate is issued on satisfactory completion of the 

annual examination, which includes tests of emergency systems as well as observation and evaluation of crew 

actions and of communication dealing with emergency situations (U.S. Coast Guard Office of Marine Safety, 

Security and Environmental Protection, “Report of the Cruise Ship Safety Review Task Force,” October 31, 

1995 <www.uscg.mil/hq/g-m/nmc/pubs/studies/pas_vsl.htm>).
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Propulsion and Steering

The Crown Princess was powered by four V-16 and two V-12 Wartsila ZA40S 

diesel engines that provided power through two 19-megawatt Siemens electric 

propulsion motors to two fixed-pitch, six-bladed propellers. The two rudders28

were capable of being turned a maximum angle of 45° but were limited to 35°.29

Each rudder had two pumps, only one of which operated while the ship was at 

sea. With one pump operating, 28 seconds were required for the steering gear 

to move a rudder from hard over in one direction to hard over in the opposite 

direction. Half that time, or 14 seconds, was needed with both pumps operating. 

The port and starboard rudders were synchronized, so that the same rudder 

order from the bridge control system went to each steering gear unit. 

The Crown Princess was equipped with a SAM Electronics NACOS 65-5. 

In the SAM Electronics numbering system, the first two digits refer to the 

configuration of components in the system, while the third refers to the particular 

NACOS generation.30 NACOS generation 5 was the most modern NACOS 

equipment at the time the Crown Princess was launched.

The vessel’s steering gear units were controlled through one of two 

electronic steering control systems on the bridge. The first, a Sperry Marine 

Navipilot 4000, was a basic heading control system or autopilot. Sperry Marine 

also supplied the manual steering-control system. The second was the SAM 

Electronics trackpilot system. A steering mode selector switch was located on the 

bridge center control console. In general, the trackpilot was used mostly in open 

waters, with manual steering normally used when arriving to and departing 

from port or in pilotage waters. Princess Cruises allowed the officer on watch 

to select the steering mode (see “Operational and Management Information” 

section).

Voyage Data Recorder

As required by SOLAS 1974, as amended, the Crown Princess was equipped 

with a VDR.31 The ship’s VDR, model VER3000 manufactured by Broadgate Ltd., 

recorded inputs from 9 audio channels, 16 data channels, and a video source 

(ARPA radar). The recording period was 12 hours, after which the data were 

recorded over. The data were retained in a hard disk drive that was removed after 

the accident and taken to the Safety Board’s recorder laboratory in Washington, 

28 The rudders were of the compensated spade type. Spade refers to the rudder shape. Compensated

means that part of the blade area was forward of the stock or pivot point.

29 After the ship reached 5 knots, the rudders were limited to 35° of motion in either direction by a relay 

in the steering control.

30 See “Integrated Navigation Systems” section.

31 SOLAS chapter V, regulation 20, requires passenger ships constructed on or after July 1, 2002, to 

carry VDRs. The VDR on the Crown Princess met the requirements of International Maritime Organization 

resolution A.861 (20) and International Electrotechnical Commission performance standards for shipboard 

voyage data recorders, as listed in IEC 61996.
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DC. A simplified schematic of a representative VDR system architecture is shown 

in figure 4. The schematic is similar to, but does not match, the architecture of the 

VDR installed on the Crown Princess. 

VDR audio data were recorded by eight microphones on or near the ship’s 

bridge and from transmissions and receptions on channel 16 of the ship’s VHF 

transceiver.32 Safety Board investigators characterized the quality of the audio 

recording as “fair.”33 The size of the bridge made it possible for crewmembers 

to converse too far from any of the microphones for their voices to be recorded 

accurately. Princess Cruises personnel told investigators that they were researching 

options available to improve the quality of the recordings, which included seeking 

the advice of professional audio engineers.

32 Two microphones were in adjacent spaces, two on the bridge wings and four on the bridge itself, in 

addition to the one that recorded the ship’s VHF radio.

33 According to the Safety Board’s VDR audio data report: “The majority of the crew conversations were 

intelligible. The transcript that was developed may indicate passages where conversations were unintelligible 

or fragmented. This type of recording is usually caused by noise that obscures portions of the voice signals or by 

a minor electrical or mechanical failure of the VDR system that distorts or obscures the audio information.” 

Figure 4. Generic VDR system architecture. Among the parameters recorded on the 

Crown Princess VDR were latitude and longitude, wind speed and direction, rate of turn, 

heading (magnetic and true), speed (ground and water), rudder (order and position), water 

depth below keel, engine (command and response), time (hour, minute, second), date 

(day, month, year), main alarm–hull opening (watertight and fire doors), and radar image. 

Data were sampled and recorded once per second. The recorded radar video was updated 

about every 9 seconds.
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Waterway Information

Port Canaveral is located on the Atlantic coast of Florida, approximately 

50 miles southeast of Orlando. A dredged entrance channel, 7 nautical miles long 

and 400 feet wide, runs into the port from the southeast (refer to figure 2). The 

channel is divided into outer, middle, and inner reaches; cruise ships dock in the 

inner reach.34

The accident occurred in the open ocean about 10 nautical miles east of 

Port Canaveral, in U.S. territorial waters. According to the navigation chart for 

the area,35 water depths near the accident site range from 45 to 62 feet (13.7 to 18.9 

meters). The significance of water depth to vessel performance is discussed in the 

“Shallow Water Effects” section.

Meteorological Information

The National Weather Service marine forecast for Flagler Beach, Florida, 

to Cape Canaveral, issued at 0353 on July 18, 2006, read: “. . . variable winds 

5 to 10 mph. Seas 2 feet. Intracoastal waters smooth. Scattered showers and 

thunderstorms.” 

At 1100 on July 18, the National Hurricane Center issued a tropical storm 

watch for eastern North Carolina. According to the Hurricane Center’s bulletin, 

a tropical depression had formed off the coast about 220 miles south-southeast of 

Cape Hatteras that “could become a tropical storm later today or tonight.” The 

depression developed into tropical storm Beryl.

Toxicological Testing

Princess Cruises, in accordance with the requirements of 46 CFR 4.06-1(b),36

directed deck and engineering crewmembers on duty at the time of the accident 

to provide samples for toxicological analysis. Samples were obtained from the 

captain, staff captain, relief captain, second officer, fourth officer on watch, relief 

fourth officer, two helmsmen, and five engineering crewmembers. All samples 

tested negative for the presence of alcohol and illegal drugs.

34 United States Coast Pilot, vol. 4, pp. 418-420.

35 Ponce de Leon Inlet to Cape Canaveral, chart 11484, Coast Survey, United States–East Coast, Florida 

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

Ocean Service, 1997).

36 The regulation, which applies to foreign-flag ships operating in U.S. territorial waters, states, in part, 

“The marine employer shall take all practicable steps to have each individual engaged or employed on board 

the vessel who is directly involved in the incident chemically tested for [illegal] drug and alcohol use.” Samples 

are tested for the presence of alcohol, marijuana, opiates, amphetamines, cocaine, and phencyclidine.
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Crewmember involvement in vessel operations and in the response to the 

accident precluded testing them for alcohol and drugs immediately afterward. 

That circumstance is provided for by Coast Guard regulations at 46 CFR 4.06, 

which require that alcohol tests be conducted within 2 hours of a serious marine 

incident37 and that drug tests be conducted within 32 hours “unless precluded by 

safety concerns directly related to the incident.”38 Alcohol testing is not required 

more than 8 hours after a serious marine incident.39

Officers and crewmembers were breath-tested for the presence of alcohol 

between 1918 and 1953 on July 18 (4 to 5 hours after the accident). Except for one 

sample that was collected the morning of July 19, urine samples for drug analysis 

were collected between 2100 and 2230 the evening of the accident. Thus, all 

samples were collected within the regulatory time limits. 

Survival Factors

Shipboard Response

As required by SOLAS chapter IX, the Crown Princess had written emergency 

response procedures and regulations in place before the accident. They included 

checklists and contingency plans for 17 different potential shipboard emergencies, 

among them collision, fire at sea, man overboard, medical emergency, and oil 

spill. 

Princess Cruises fleet regulations instructed that in an emergency, captains 

were “to maintain an overview of the entire situation” without becoming overly 

involved in the actual response to the emergency. Captains were to make “such 

announcements as are necessary to reassure and advise both passengers and ship’s 

company.”40

Immediately after confirming that the vessel was under control, the Crown 

Princess captain told passengers, over the vessel’s public address system, to sit 

down and stay in place. He explained that there had been a steering failure and 

that he would give them more information shortly. Subsequent announcements 

included calls to muster the stretcher party and the passenger-assistance party. The 

37 A serious marine incident is defined at 46 CFR 4.03-2 as (a) a marine casualty or accident that results 

in any of the following: (1) one or more deaths, (2) injury that requires medical treatment beyond first aid and 

renders the individual unfit to perform routine duties, (3) property damage exceeding $100,000, (4) actual or 

constructive total loss of an inspected vessel, or (5) actual or constructive total loss of any uninspected vessel 

that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of oil into U.S. waters; or (c) the release 

of a reportable substance into the environment of the United States.

38 Title 46 CFR 4.06-3 (a) (1) (i-ii) and (b) (i-ii).

39 Title 46 CFR 4.06-3 (a) (iii).

40 Princess Cruises, Fleet Regulations, Fleet Instructions, Emergency Response, EME 1.2, “Emergency 

Duties—Captain and Senior Officers.” 
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captain also announced to the passengers that they should return to their cabins. 

He did not sound the general emergency alarm after the incident, which would 

have signaled passengers to go to their muster stations. As noted earlier, he asked 

the observers on the bridge wings whether they had seen anyone fall overboard, 

and they replied that they had not. 

Medical facilities on the Crown Princess consisted of a primary medical center 

and a dining hall available for use as a secondary medical facility. The primary medical 

center was made up of five wards, or rooms, containing seven beds and various basic 

first aid supplies, as well as a pharmacy, cardiac equipment, and an x-ray machine. 

Two physicians and three nurses were on the staff. About 16 crewmembers were 

billeted to the stretcher party, which was divided into four teams. 

Both physicians reported that they were in their cabins when the ship began 

to heel. The senior physician indicated that she suspected that there would be 

injuries after items in her cabin began falling over. Because the other physician 

had experienced a similar heeling incident on another Princess Cruises vessel, the 

Grand Princess, 5 months before the accident,41 he quickly recognized the severity 

of the event and the potential for injuries. Both physicians went immediately to 

the medical center. They were joined by passengers with medical training, who 

provided medical assistance under the supervision of the ship’s physicians. 

The most seriously injured patients remained inside the vessel’s medical 

center to enable medical personnel to monitor them. Passengers with less serious 

injuries were asked to wait in the area outside the medical center, and chairs were 

brought for them. A third area was set up in a dining room for those with minor 

injuries such as scratches or bruises. Two emergency medical technicians were put 

in charge of injured passengers in the dining room. The ship’s nurses assisted in the 

medical center and also accompanied stretcher parties to assist injured passengers 

throughout the vessel. Several passengers with medical training offered to help, 

and they assisted in the shipboard response. 

Shoreside Response

About 1600, the Brevard County, Florida, sheriff’s office learned of the 

accident from the ship’s agent. The sheriff’s office contacted the fire chief at 

Canaveral Fire Rescue to advise him of the situation and to inform him of the need 

to transport between 20 and 50 injured people to hospitals. The fire chief activated 

the rescue service’s mass casualty plan and departed for the cruise terminal.42

Triage and transport vehicles were in place before the Crown Princess arrived. 

41 On February 4, 2006, the Grand Princess returned to the port of Galveston, Texas, after a passenger 

suffered a medical emergency. During the return, the vessel heeled an estimated 12° to 15°, injuring two 

crewmembers and one passenger. Neither the Coast Guard, the Safety Board, nor the flag state investigated 

the accident. Princess Cruises attributed the accident to poor communications and poor bridge resource 

management among the bridge crew.

42 Canaveral Fire Rescue participates in a mass casualty drill once a year in Melbourne, Florida.
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Coast Guard Station Port Canaveral received initial notification of the 

accident from a passenger on the Crown Princess at 1550. Coast Guard personnel 

in Port Canaveral established direct communication with the vessel, via VHF 

radio, around 1600. The master reported a steering casualty that caused the vessel 

to abruptly turn, resulting in injuries to several persons on board. Station Port 

Canaveral briefed Coast Guard Sector Jacksonville, which contacted Princess 

Cruises management. Company management informed Sector Jacksonville that 

the vessel planned to return to port. The Coast Guard Captain of the Port (COTP) 

later issued a verbal order denying entry to the vessel until a Coast Guard marine 

inspector could board and verify that the steering gear was functional. 

At 1710, a Coast Guard 47-foot patrol boat departed Station Port Canaveral 

with two Canaveral Fire Rescue officers and two Coast Guard marine inspectors 

on board to meet the Crown Princess while it was returning to Port Canaveral. They 

boarded the vessel at 1733. The marine inspectors observed a satisfactory basic 

steering gear test, which was completed at 1743, and conveyed the information 

to the COTP. About 1800, as the vessel continued its return to port, the COTP 

rescinded his order, and the vessel was allowed to enter the port. The vessel 

continued its return to Port Canaveral and lost no time en route as a result of these 

Coast Guard actions.

After the vessel docked at 1836, helicopters airlifted two seriously injured 

people to hospitals. Ambulances then transported 101 people—93 passengers 

and 8 crewmembers—to local hospitals, four in the Cocoa Beach/Melbourne 

area, one in Orlando, and one in Daytona Beach. A total of 97 fire, rescue, and 

ambulance department personnel from 10 different agencies, with 9 fire engines, 21 

ambulances, and 2 helicopters, responded to the accident, all under the command 

of the Cape Canaveral Volunteer Fire Department chief, who served as the incident 

commander. 

Tests and Research

Postaccident Steering Tests 

On July 20, after the passengers had disembarked and the crew had 

inspected the vessel and its critical components, the Crown Princess departed Port 

Canaveral for New York. An authorized SAM Electronics technician boarded the 

vessel at Port Canaveral to test the vessel’s NACOS system, with Safety Board 

investigators, Coast Guard representatives, and a Lloyd’s Register surveyor on 

board to supervise the tests. A representative of Bermuda, the vessel’s flag state, 

joined the group on board.

Before the vessel sailed, the technician performed a comprehensive steering 

gear test and found that it operated within acceptable limits. During the sailing, 
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the crew activated the NACOS trackpilot, with course changes completed in both 

heading and course modes. At the captain’s direction, the vessel was kept below 

full speed until it reached the open ocean (July 21). Other vessel conditions during 

the test were similar to those at the time of the accident, except that no passengers 

or their baggage were on board and the swimming pools were empty. Data from 

the vessel’s trackpilot showed that the system performed as designed in all test 

phases. The Crown Princess reached New York on July 21.

At the Safety Board’s request, SAM Electronics reviewed the short-term 

voyage recording in the NACOS for evidence of a system malfunction. After 

the review, company personnel stated, “No malfunction of the Trackpilot could 

be found in the recording.”43 The company concluded that an improper rudder 

economy setting44 and rudder limit setting “can lead to a nonproper function of 

steering in Heading mode for this ship’s speed of 18 to 20 knots together with the 

measured water depth.” The company further concluded, “It must be assumed 

that the squat effect influenced the steering ability of the ship. The rudder gain 

setting by the crew for the Trackpilot (Rudder Economy = 5 is a tolerant value) 

has been too low for [these] conditions.” (See “Shallow Water Effects” section for 

more information.)

Heel Angle Determination

As a result of limitations in the onboard Siemens integrated monitoring, 

alarm, and control (IMAC) system sensor, only heeling values from starboard 15° 

to port 15° were measured. The vessel’s VDR did not record heeling data, nor was 

it required to do so. The IMAC retained the heeling data, which were retrieved by 

Safety Board investigators after the accident. 

Because of the likelihood that the vessel’s maximum heel angle exceeded the 

limits of the IMAC data, Safety Board investigators sought other information for 

determining the maximum angle. Princess Cruises provided the Safety Board with 

images taken at regular intervals by videocameras positioned at various locations 

on the ship. One set of images was taken every 2 to 3 seconds by a camera on the 

vessel’s port side. The date and time were stamped on each image.45 Investigators 

determined that images recorded during and after the event, from July 18 at 1113:38 

through July 19 at 0814:00, were of interest in determining maximum heel angles at 

specific times during and after the event.

Safety Board investigators digitized part of the video to a computer-based 

video system so they could review and extract still images. The investigators then 

43 The response from SAM Electronics was dated September 6, 2006. 

44 The rudder economy setting allowed operators to enter one of 10 levels of weather/sea state conditions, 

with corresponding increases or decreases in rudder movement limits. See “Integrated Navigation Systems” 

section for details.

45 The basis of the time stamped on the images is unknown but is consistent with Central European time, 

offset by 1 hour for daylight saving time.
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used two methods to determine the maximum angle of vessel heel from the images 

taken by the shipboard camera. One method was to measure the angle formed by 

the apparent horizon in an image and the vertical axis of the vessel, taking into 

account the distortion created by the camera lens (figure 5). 

The other method was to measure the difference between the angle of the 

shadow created by the vessel on a reference point on the images and the angle that 

would have been created by the ship’s orientation to the sun at that time, given the 

sun’s angle over the horizon and the ship’s orientation. Investigators obtained the 

sun’s angle from U.S. Naval Observatory data and the ship’s orientation to the sun 

from VDR data. The maximum angle of heel calculated from the shadow images 

was 24.2° to starboard at 1524:57 (figure 6).46

46 The ship’s VDR clock time was different from the time stamped on the videocamera image. To 

synchronize the times, investigators assumed that the ship reached its peak heel angle at VDR time 1524:57, 

halfway between the first and last 15° angles recorded by the vessel’s heel sensor. 

Figure 5. Image of the Crown Princess taken by a ship’s videocamera at the maximum 

angle of heel, with reference lines added by investigators. Stamped time corresponds to 

1525:02 eastern daylight time. The apparent bending of the horizon is an artifact of the 

wide-angle camera lens, which causes straight lines to appear curved and bow outward 

from the image center.
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Stability Considerations

At the Safety Board’s request, the Coast Guard reviewed the stability 

conditions of the vessel relative to applicable standards of the International 

Maritime Organization. The Coast Guard found that the ship complied with all 

International Maritime Organization intact stability47 requirements for passenger 

ships at the time of the accident.48 The Coast Guard’s report found that the 

maximum righting arm49 occurred around 32°.50 

47 Intact stability is a naval architecture term referring to how an intact, or undamaged, vessel responds 

when heeled over.

48 Code on Intact Stability for All Types of Ships Covered by IMO Instruments (London: International 

Maritime Organization, 2002), chapter 3.

49 The concept of the “righting arm” relates to a vessel’s ability to restore itself to an upright position. 

When a vessel heels, both its center of gravity and its center of buoyancy shift to the side, but the center of 

buoyancy shifts faster. The horizontal difference, known as the righting arm, creates an imbalance that makes 

the vessel tend to right itself. The righting arm increases as the heel angle increases, but only to a point—the 

“angle of maximum righting arm.” When the heel angle increases beyond that point, the righting arm will 

decrease. When it reaches zero, the vessel will continue to heel until it capsizes.

50 Details of the Coast Guard stability review are found in Coast Guard Marine Safety Center Memorandum, 

Serial H2-0603148, November 24, 2006. 

Figure 6. Calculated and recorded heel angles of the Crown Princess. The maximum 

heel angle calculated from shadow images was 24.2°; that calculated from the apparent 

horizon line was slightly less (23.4° to 23.5°).
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Vessel Dynamics

Safety Board investigators studied the vessel dynamics both before and 

after the second officer took manual control of the steering. The investigators used 

VDR data from about 5 seconds before the trackpilot was disengaged until about 

15 seconds after the commanded rudder oscillations ceased. Figure 7 plots the 

second officer’s wheel (rudder) commands against the rudder response and the 

heeling angle. 

The data show that after the second officer disengaged the trackpilot at 

1524:05, the vessel’s rudder positions corresponded to the rudder commands for 

about 10 seconds. Then, at 1524:15, the rudder positions began to deviate from the 

wheel input as the rudders lagged the wheel commands.51 The deviation lasted 

until shortly after the rudders were commanded to midships (1525), after which 

the vessel gradually returned to even keel. The vessel’s response lagged both 

the rudder commands and the rudder positions. From 1524:30 to 1525:10, while 

the rudders remained at port, the vessel’s heading diverged from its direction of 

motion. That difference is known as the drift angle. The greater the drift angle and 

the greater the speed, the greater the resultant heel angle. The vessel’s maximum 

heel occurred about 1524:57, as shown by the red line in figure 7. 

51 Lag results when the rate of wheel inputs exceeds the rudder response rate, which for the Crown

Princess was 3° per second.

Figure 7. After the second officer began steering the vessel manually, he turned the 

wheel faster than the rudders could follow, as shown by the divergence between the 

rudder commands (light blue line) and the rudder responses (dark blue line). As the vessel 

attempted to respond to the commands, it heeled increasingly to starboard (red line).
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Shallow Water Effects 

As shown in figure 8, the water depth was about 5 meters (about 16 feet) 

below the keel of the Crown Princess during the first part of the trip, gradually 

increasing to 8.3 meters (27.2 feet) at 1524, when the second officer assumed the 

conn, and reaching 10.7 meters (35.1 feet) at the end of the accident sequence. 

When a vessel moves through shallow water, it experiences a complex 

hydrodynamic phenomenon that affects both its clearance above the waterway 

floor, known as squat, and its steering precision. As a vessel’s speed increases, 

the water level around the hull is lowered, because as water moves under the 

hull, the velocity and kinetic energy of the water increase. To compensate for the 

increase in kinetic energy, the potential energy (energy of a system derived from 

elevation rather than motion) must reduce, because the total energy of a system 

must remain constant. The reduction in potential energy is achieved through the 

lowering of the water level around the hull. Squat is approximately proportional 

to the ship’s speed squared; hence, halving the speed reduces the squat effect by a 

factor of four.52

52 Navigation and Vessel Inspection Circular No. 2-97, change 1, COMDTPUB P16700.4; Ch-1 

<http://www.uscg.mil/hq/g-m/nvic/2 97/n2-97ch1.htm> (accessed May 3, 2007). 

Figure 8. Underkeel clearance of the Crown Princess during the accident sequence, 

from data recorded by the vessel’s VDR.
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The greater a vessel’s speed in shallow water, the less predictable its 

steering.53 That holds true whether the vessel is steered automatically or manually. 

Test trials performed on model ships in tanks show that turning radius increases 

exponentially with a reduction in water depth under the keel. Some trials show that 

a ship’s turning diameter increases 60 to 100 percent at a water depth of 1.25 times 

ship’s draft.54 A ship’s draft of 8.5 meters (27.9 feet) and an underkeel clearance of 

8 meters (26.3 feet) equals a water depth of 16.5 meters (54.1 feet), giving a ratio 

of water depth to ship’s draft of about 2:1 and meeting the general definition of 

shallow water.55

Princess Cruises informed its crewmembers about squat effects in its fleet 

regulations and deck standing orders:56

...The effects of squat can have an adverse affect on the ship’s handling 

characteristics, and these must be borne in mind when in confined waters:

• The vessel’s stopping distance and turning circle is increased.

• The propellers and rudder become less effective. 

The company also posted information about squat effects on the bridge of 

the Crown Princess (table 4). 

Table 4. Information about squat effects posted on the Crown Princess bridge.

Draft Increase (Loaded)

Underkeel Clearance Ship’s Speed (knots) Estimated Maximum Squat (meters)

4 meters 24 3.48

14 1.18

4 0.01

8 meters 24 3.0

4 0.08

 NOTE: The notice posted on the bridge also included other information.

53 A. J. Jurgens. and A. D. Jager, “Controllability at Too High Speeds in Too Shallow Water,” Proceedings 

of MARSIM 2006 (International Conference on Marine Simulation and Ship Manoeuvrability), Terschelling, 

The Netherlands, 2006.

54 Edward V. Lewis (ed.), Principles of Naval Architecture, vol. 3, Motions in Waves and Controllability

(Jersey City, New Jersey: Society of Naval Architects and Marine Engineers, 1989), pp. 280-281.

55 Princess Cruises defined shallow water as “depths less than twice [vessel] draught” (NAV.7, Fleet 

Regulations and Standing Orders). Other sources define shallow water as either two or three times ship’s 

draft. Principles of Naval Architecture (vol. 3, p. 279) defines shallow water as a water-depth-to-ship’s-draft 

ratio of 3 or less.

56 Princess Cruises, Fleet Regulations, Deck Standing Orders, Navigation, NAV 7.10, “Squat.”
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After the Crown Princess accident, SAM Electronics commissioned a 

university to determine the effect of shallow water and high vessel speed on 

the maneuvering characteristics of a large vessel. The study found that in water 

depths of about 6.8 meters (22.3 feet) below the keel, the yaw-checking ability 

of a vessel the size of the Crown Princess will be “significantly reduced,” and the 

INS’s ability to control the vessel steering will be reduced as well. The author 

concluded:57

. . . Our analysis could show that due to the large beam of the vessel, a 

steady heel results in a large alteration of the hydrodynamic blockage 

which then results in a large impact on squat as such. A secondary yawing 

moment is generated due to the steady heel which forces the vessel into 

a turning circle exactly to the side of the heel. If the heel is initiated by 

an initial turning motion, then the secondary heeling moment will clearly 

amplify this turning motion, which can then only be compensated by more 

rudder action. 

. . . As the rudder action required to yaw check the first turning must result 

in a large rudder moment, all this results in a hunting where the amplitude 

of that hunting gradually increases. . . . According to our analysis, the only 

way to control the hunting is to keep the yawing instability of the ship 

under a certain limit, which must also reduce the squat effect. . . .

As the auto pilot sees a completely different system compared to its deep 

water design characteristics, there is according to our results no possibility 

for the autopilot to cope with such kind of situation.

After receiving information from its customers and the university study, 

SAM Electronics made several changes to its NACOS equipment (the updates are 

available as an option to vessel owners and only on generation 5 NACOS) as well 

as to its training material and operating manual:

• The NACOS autopilot will operate normally until the ratio of water 

depth to ship’s speed reaches a theoretical threshold at which shallow 

water effects become apparent (based on the formula d < 0.085v2, where 

d = depth in meters, v = speed in knots). At that point, the operator hears 

a warning sound. If the water-depth-to-speed ratio goes lower (based on 

the formula d < 0.065v2), a second alarm alerts the operator that the ship 

has entered the critical squat range, below which limit, according to the 

university study, the ship’s maneuverability changes significantly.58 The 

alarm points are set based on vessel-specific information. Both alarms 

57 S. Kruger, “Determination of the Squat Effect on the Course-Keeping Ability of a Large Cruise Liner” 

(Hamburg: Technische Universität Hamburg-Harburg, Institut für Entwerfen von Schiffen und Schiffssicherheit, 

2007), p. 3.

58 The coefficients 0.085 and 0.065 are based on theoretical computations. For the value 0.085, the 

university study stated that it is well known that shallow water influence can be found if the wavelength of the 

ship’s own wave system is greater than two times the water depth. This results in a relation between water 

depth (d) and ship’s speed (v) of d = 0.085v2, when ship’s speed is in knots. The value 0.065 comes from 

theoretical computations for a hull form equivalent to that of the Crown Princess. The influence of shallow 

water was found to be significant for depths equal to or below 0.065v2. 
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can be activated and deactivated independently. They are activated 

only if the trackpilot is engaged and the limit values persist for a defined 

period. 

• A “low rudder limit” alarm sounds if the rudder limit is set so low that 

the next turn in track mode cannot be executed with the preplanned 

turn radius. In addition, a “high rudder limit” alarm operates using a 

new parameter called “maximum allowed rate of turn,” which is used 

to calculate an upper limit for the rudder limit set by the operator. Its 

value is determined by the ship’s turning ability and its speed. 

• Information on shallow water and high-speed effects (such as squat) on 

vessel maneuverability was added to the NACOS training curriculum 

and the NACOS operating instructions. The following warning about 

the squat effect was added to the operating instructions:59

Shallow water may effect [sic] the dynamics and manoeuvrability 

of a vessel. Shallow water is considered to be a depth of less than 

2.5 times the draught of the vessel. If sailing with high speed in 

shallow water the draught of the ship may increase considerably 

caused by the squat effect. The squat effect increases with higher 

speed and lower water depth.

These effects may change the designated steering behavior of 

the ship in a material manner. Previously set parameters for the 

TRACKPILOT ability to steer the ship will no longer match with 

that ship behavior.

After the accident, as noted earlier, an authorized SAM Electronics 

technician tested the vessel’s NACOS INS. He also prepared a one-page guidance 

document on the trackpilot for Princess Cruises bridge crews. The document listed 

the trackpilot parameters and summarized the control given by the various rudder 

economy settings, as well as the weather conditions under which they should be 

used. The rudder limit definition from the operating manual was also reproduced, 

with the following comments and recommendations:

The rudder limit setting is a parameter that must be manually adjusted 

depending on the vessel’s speed and sea conditions. At high sea speeds 

a small rudder angle should be entered, i.e. 5 degrees. At slower speeds, 

when more rudder angle is required to perform a turn (required rate of 

turn not attainable with the smaller limit) a larger rudder limit should be 

utilized, i.e. 15 degrees. 

Acknowledgment of the [rudder limit] alarm silences the buzzer only, but 

continues the rudder limitation.

59 SAM Electronics, Operating Instructions, section 36.1.
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Operational and Management Information

Corporate Organization

Princess Cruises, founded in 1965, became a subsidiary of the Carnival 

Corporation in 2003.60 In fall 2004, after acquiring Cunard Cruise Lines, Carnival 

Corporation merged the fleet operations of Cunard Lines and P&O Cruises of 

Australia with those of Princess Cruises.61 At the time of the accident, Princess 

Cruises, Cunard, and P&O Cruises operated under a single management structure, 

while retaining separate brand identities. Princess Cruises considered deck officers 

to be interchangeable on the vessels of the three companies. 

Crewmembers on Princess Cruises, Cunard, and P&O ultimately reported to 

the vessel captains, while the captains reported to the Princess Cruises fleet captain, 

marine operations. The fleet captain and senior vice president, fleet operations, 

reported to the executive vice president, fleet operations. The executive vice president 

reported to the chief executive officer of Princess Cruises. The chief executive officer 

of the three cruise lines was a director of Carnival Corporation & PLC and reported 

to the vice chairman and chairman of the board of the corporation.

Personnel at both Princess Cruises and Holland America Line, another 

Carnival Corporation subsidiary, indicated that the corporation allowed the 

individual cruise line subsidiaries latitude in overseeing vessel operations. That 

latitude extended to personnel selection, training, safety management systems, 

and vessel design and acquisition.

Princess Cruises Operations

Fleet Oversight. Princess Cruises management personnel told Safety Board 

investigators that they had known the fleet captains for many years and were 

familiar with both their strengths and their weaknesses. Management personnel 

regularly visited the vessels to observe vessel operations. All ship’s officers met 

with their superiors at the midpoints and ends of their assignments to review and 

discuss their performance. The performance appraisals were then sent to the senior 

vice president, marine operations, and finally to the fleet captain.

60 See Princess Cruises website <www.princess.com/news/article.jsp?newsArticleId+na735&submit 

=pk> (accessed December 10, 2007).

61 The corporate website states: “Carnival Corporation & plc is a global cruise company and one of the 

largest vacation companies in the world. Our portfolio of leading cruise brands includes Carnival Cruise Lines, 

Holland America Line, Princess Cruises and Seabourn Cruise Line in North America; P&O Cruises, Cunard 

Line and Ocean Village in the United Kingdom; AIDA in Germany; Costa Cruises in southern Europe; and 

P&O Cruises in Australia” <http://phx.corporate-ir.net/phoenix.zhtml?c=200767&p=irol-prlanding> (accessed 

October 10, 2007).
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The fleet captain, marine operations, oversaw a staff of two marine 

inspectors who visited each vessel at least once a year to observe operations and 

ensure compliance with procedures. The inspectors operated independently of 

the auditors that the company dispatched as part of its required internal safety 

management system audits. The inspectors reported their findings to the vessel 

captains, with suggestions for improvement, if necessary, as well as to Princess 

Cruises management. The company began the program because the demands 

of overseeing its growing fleet prevented senior management from visiting the 

vessels as often as they would have liked. 

Princess Cruises also read out VDR data and listened to VDR conversations 

after all incidents of concern to the company. Management personnel estimated 

that in the 3-year period before the accident, they had read out and listened to 

about 12 VDRs.

Watchkeeping Policies and Procedures. Princess Cruises watchkeepers 

had the discretion to steer using an automated INS mode or manually, within 

the standards that the vessel captains established in their standing orders. Deck 

standing order NAV.7.14 of the company’s fleet regulations62 advised crewmembers 

to use the INS because “it ensures [that the] maximum information is available to 

officers.” However, it advised crewmembers not to rely exclusively on the INS 

for navigation information but to verify the information against chart and other 

navigational information. As the order stated, “The Integrated Bridge System is 

not a substitute for maintaining a safe navigational watch.”63

Standing order NAV.7.14 attached the following provisos to the selection of 

the trackpilot’s operational mode: 

Operation in Heading Mode should be selected when a steady heading is 

required, particularly when in close proximity to other vessels. If a closequarters situation is developing, then Heading Mode should be selected in 

preference to Course or Track Mode.

Operation in Course Mode may be appropriate when necessary to deviate 

from the System Track when a set CMG [“course made good,” that is, 

course over the ground] is desirable.

Operation in Track Mode may be used provided the System Track and/or 

Electronic Chart positioning has been confirmed as reliable and traffic 

conditions permit. Particular attention shall be paid to Position and Speed 

Sensor status, as well as the Horizontal Chart Datum in use prior to 

selection.

62 Princess Cruises, Fleet Regulations, Deck Standing Orders, Navigation NAV.7.14, “Integrated Bridge 

Systems (IBS),” reissued May 2002.

63 Princess Cruises referred to its INS as an integrated bridge system (IBS). Until recently, the terms IBS 

and INS were used interchangeably. However, International Maritime Organization regulations now distinguish 

between them. An INS is considered to be a component of an IBS, which includes other components such as 

communications, security, and cargo control.
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The standing order directed second officers and deck officers of higher 

rank on ships having integrated bridge systems to complete “an appropriate 

training course” before being permitted sole charge of the watch while at sea. In 

addition, Princess Cruises advised its watchkeeping officers to “be familiar with 

[the system’s] alarm messages, their meaning, and the action to take on their 

activation.”

Postaccident Actions. Within days of the Crown Princess accident, Princess 

Cruises issued a letter to its deck officers instructing them not to use the NACOS 

trackpilot or speed pilot systems on their ships until they were satisfied that all 

watchkeeping officers fully understood the “correct and safe operation” of the 

equipment. Watchkeeping officers were also instructed to reread the NACOS 

instruction literature. Over the next several months, additional instructions were 

issued regarding the use of checklists for transferring the conn, for assuring deck 

officers’ familiarity with bridge procedures and emergency equipment, and for 

engaging or disengaging automated steering. The cruise line also cautioned 

officers about the effects of shallow water on steering, reminding them to be 

especially careful about using the trackpilot in shallow water “at higher speeds.” 

In a fleet regulation reissued in May 2007,64 captains were informed that “. . . good 

seamanship would require that following a departure from a port anchorage either 

they or their designee (staff captain) should remain on the Bridge until satisfied 

that the ship and the Bridge Watch are settled.”

The cruise line informed the Safety Board that it had increased the 

complement of its bridge crew by adding a third officer. In addition, the company 

said that it was undertaking a trial period on nine of its vessels in which the 

first officers would divide the 0400-to-0800 and 1600-to-2000 watches, to create 

increased flexibility in the oversight by first officers of new officers during 

“demanding times on their watches.”

In a fleet regulation reissued in September 2007,65 Princess Cruises required 

the reporting of marine casualties “wherever they occur” to the flag state. The 

regulation stated: “. . . if the casualty occurs outside U.S. territorial waters but 

the ship is bound directly to a U.S. port, then a report must be made to the [Coast 

Guard].” In a related regulation,66 the cruise line required the immediate notification 

of its corporate offices if any on a list of 13 incidents occurred, to include “any 

incident causing the vessel to heel more than 5 degrees.”

Princess Cruises managers told the Safety Board that after the accident, they 

established a professional marine standards department to enhance the standards, 

protocols, and procedures of their operations, and to develop a program of human 

64 Princess Cruises, Fleet Regulations, Deck Standing Orders, Bridge Procedures BRP.3.1, “Company 

Navigation Orders,” reissued May 2007.

65 Princess Cruises, Fleet Regulations, Fleet Instructions, Legal and Documentation LEG.7.2, “Marine 

Casualties,” reissued September 2007.

66 Princess Cruises, Fleet Regulations, Fleet Instructions, Communications COM.2.2, “Incident Reporting 

to Shore Management,” reissued September 2007.
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element understanding. No additional information was provided regarding the 

composition of the department, its location in the Princess Cruises management 

hierarchy, or the manner in which the department would carry out its duties.

Princess Cruises also sent its SAM Electronics–certified NACOS trainer to 

its vessels to conduct 3-hour on-site training sessions in the use of the NACOS 

INS. The training was intended to serve as both refresher training for those who 

had previously completed a NACOS course and initial training for those who had 

not. In addition, the cruise line informed the Safety Board that it had employed 

an inhouse bridge team equipment trainer, approved by SAM Electronics to 

conduct NACOS training. The individual was to give bridge personnel one-to-one 

instruction on their NACOS equipment during 3-day visits to their vessels. Princess 

Cruises also required all captains to attend a 5-day bridge resource management 

course, irrespective of the year in which they had first completed such training. 

Princess Cruises managers indicated that they were revising a course for deck 

officers that would include practicing emergency scenarios in a full 360° bridge 

simulator, using a variety of scenarios. 

Princess Cruises also implemented the use of a new technological aid 

for accounting for passengers after a mishap, in addition to developing new 

procedures for responding to mishaps both on vessels and at its corporate offices 

and for reporting mass casualty incidents to authorities. The cruise line indicated 

that it recommended that user-friendly guidance from operations manuals specific 

to vessel bridge equipment be developed and placed in a readily accessible location 

on vessel bridges.

Additional Information

Heeling Incidents on Cruise Vessels

Previous Occurrences. As part of the investigation of the Crown Princess

accident, Safety Board investigators interviewed representatives of other cruise 

lines based in the United States67 regarding heeling incidents on their vessels in 

the 15 years before the accident. To focus on more severe episodes, investigators 

defined a heeling incident as an unexpected and unplanned heeling of a vessel 

during a turn, reaching an angle equal to or greater than 6°. Cruise lines that 

provided heeling incident data to the Safety Board maintained different recordkeeping systems with varying definitions of heeling incidents and accidents, and 

employed different investigation procedures. 

67 Norwegian Cruise Lines, Holland America Line, and Royal Caribbean/Celebrity cooperated with the 

Safety Board’s investigation, in addition to Princess Cruises, which, at the Safety Board’s request, voluntarily 

submitted internal information on heeling incidents and accidents that had not been investigated by government 

agencies.
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Most of the incidents were not required to be reported to a government 

agency because of their location or the scope of the event, and therefore most 

were not investigated by such agencies. The cruise lines themselves supplied most 

of the data on incidents. Because the intent of the Safety Board’s review was to 

determine whether commonalities were present among operator errors in the use 

of INSs, incidents not involving INS use, such as collision-avoidance maneuvers, 

were not considered.

Safety Board investigators reviewed information on 13 accidents and 

incidents involving large passenger cruise vessels (those carrying more than 1,000 

passengers) equipped with an INS. Five cases were found in which the incident 

arose exclusively from a technical malfunction in either the vessel’s steering system 

or its INS.

In a 1994 incident, a vessel turned sharply to port after the second officer 

shifted vessel steering control from heading mode to track mode in the vessel’s 

INS. The cruise line investigated the incident, which occurred outside U.S. 

territorial waters. The bridge officer on watch was unaware of a requirement that, 

before making the shift between the two modes, the ship had to be within 5° of 

the proposed course heading. The proposed track heading diverged 24° from the 

proposed heading, and with the rudder limit having been increased from 5° to 

10°, the vessel turned sharply to the proposed heading. Thirteen passengers and 

crew received minor injuries in the incident. The cruise line determined that the 

operating manual did not provide guidance on this type of situation, and that it 

had no policy to train deck officers in using the INS. It later revised its own INS 

operating procedures and training standards to address those issues.

In a 1999 incident, a passenger vessel turned sharply to starboard when a 

watchkeeper engaged the INS after manually steering the vessel. The cruise line, 

which investigated the incident, determined that the watchkeeper had entered an 

incorrect rudder limit, one that was considerably beyond the maximum rudder 

limit that the vessel permitted. However, the INS accepted it and then attempted 

to turn the vessel sharply. Further examination revealed a fault in the system that 

was subsequently corrected. 

In 2001, a passenger vessel turned sharply and heeled, injuring 28 

passengers and crew. The Coast Guard, which investigated the incident, found 

that a watchkeeper had entered a heading into the INS that was 180° different 

from the desired course. The vessel turned sharply to the “new” course. The Coast 

Guard initially restricted the vessel’s use of the INS until the reason for the failure 

could be determined. Subsequent investigation found no fault in the system and 

no reason for the erroneous entry. The cruise line revised its INS policies, reducing 

the maximum allowable rudder limit from 20° to 5°. In addition, the Coast Guard 

and the International Council of Cruise Lines (ICCL) prepared and distributed 

a safety alert on the importance of securing equipment for rough seas, and on 

the need to develop policies and training programs to ensure the proper use of 

autopilot systems. 
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Seven months later, a different vessel of the same cruise line heeled to an 

estimated 6° to 7°, slightly injuring one passenger. The Coast Guard, which did not 

investigate the incident, worked with the cruise line to obtain and examine data 

from the event. Coast Guard correspondence indicates that it was satisfied that 

the changes regarding training and INS use that the cruise line had implemented 

in response to the heeling event 6 months earlier had addressed the deficiencies 

identified in both events. 

In 2005, a cruise vessel with a pilot on the bridge turned sharply after the 

helmsman implemented a pilot-requested course change through the INS, and the 

vessel turned beyond the selected heading. The vessel heeled to 6°, but no one on 

board was injured. The cruise line, which investigated the incident, attributed it 

to the deck officer’s incorrect method of entering the new course into the vessel’s 

INS, which allowed the autopilot to exceed the set rate of turn.

Monitoring and Reporting. There is no Coast Guard or International 

Maritime Organization requirement for cruise lines to report heeling incidents that 

do not meet accident-reporting criteria to either INS manufacturers or government 

agencies, although steering and propulsion failures must be reported. 

Sperry Marine and SAM Electronics representatives told investigators 

that they learned about INS-related heeling incidents from the news media, local 

technical representatives, or directly from their customers. Both companies indicated 

that, when informed of a heeling incident or accident, their primary concern was to 

identify system malfunctions rather than operator errors. Sperry Marine indicated 

that the only formal investigation it conducted of an accident involving a vessel 

supplied with its system was the one involving the Exxon Valdez.68

SAM Electronics’s response to an incident or accident was dictated by 

a formal mechanism it had developed and implemented. The vessel, type of 

equipment on board, and the nature of the involvement of its product in the 

perceived cause of the incident determined the company’s response. If it was 

determined that its product was not causal to the incident, no further action 

was taken, other than reporting the information to its corporate parent. If it 

was determined that its product played a role in the cause of the incident, SAM 

Electronics would designate an individual to direct internal and external activities 

in response. SAM Electronics personnel were also assigned to analyze the data 

and propose product modifications, as needed.

SAM Electronics maintained a record of steering-related incidents and 

accidents involving vessels equipped with NACOS equipment. Its record contained 

12 incidents and accidents, from 1995 to the Crown Princess accident. One incident 

involved a 1995 grounding, one a 1996 incident of uncertain type, and one a heeling 

incident that resulted from an avoidance maneuver. Two involved cargo vessels 

68 National Transportation Safety Board, Grounding of U.S. Tankship Exxon Valdez on Bligh Reef, Prince 

William Sound Near Valdez, Alaska, March 24, 1989, Marine Accident Report NTSB/MAR-90/04 (Washington, 

DC: NTSB, 1990).
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that experienced faults in NACOS components, and one involved a 2004 incident 

of uncertain type. 

The Safety Board obtained information on 13 steering-related incidents, as 

well as a list of 23 minor incidents provided by a cruise line. Nine of the incidents 

in the Board’s records were on SAM Electronics’s list.

Integrated Navigation Systems 

Design. INS equipment is approved by government test and approval 

agencies on the basis of the standards and guidelines established by the International 

Maritime Organization and the performance and testing standards set forth by the 

International Electrotechnical Commission.69 Manufacturers design the systems 

to conform to classification society standards,70 requirements of the International 

Maritime Organization and International Electrotechnical Commission, and the 

standards and requirements of the flag state holding the vessel’s registration. 

Bermuda, the flag state of the Crown Princess, accepted the NACOS type-approval 

of the German government agency.71

According to Sperry Marine personnel, at the time of the accident, about 

80 percent of cruise vessels were supplied with a NACOS INS, about 10 percent 

with a Sperry INS, and about 10 percent with equipment supplied by four other 

manufacturers. Princess Cruises vessels, like most large passenger vessels, were 

equipped with NACOS INS equipment.

Early 1980s versions of the NACOS contained radar information with 

ARPA, display of navigation information, and automatic warning and alarms. 

Subsequent generations introduced predicted path displays, electronic charting 

(referred to as chartpilot), chartradar and multipilot, with VDR and automatic 

identification system (AIS).72

69 Regulations and guidelines pertaining to the NACOS at the time of the accident are discussed in 

appendix D. 

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

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

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

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

as their own national standards. 

71 The International Electrotechnical Commission had not established INS test standards when the 

NACOS was installed on the Crown Princess. The German approval agency BSH (Bundesamt für Seeschifffahrt 

und Hydrographie) type-approved the NACOS as a track control and heading control system. Approval of 

the trackpilot system was according to International Electrotechnical Commission standard 62065, “Track 

Control Systems–Operational Performance Requirements, Methods of Testing and Required Test Results,” 

based in turn on International Maritime Organization Maritime Safety Committee resolution MSC.74(69), 

Annex 2, “Recommendations on Performance Standards for Track Control Systems.” Approval of the heading 

control system was according to Maritime Safety Committee resolution MSC A.342(IX), “Recommendation on 

Performance Standards for Heading Control Systems,” as well as International Organization for Standardization 

(ISO) standard 11674, “Ships and Marine Technology—Heading Control Systems.”

72 AIS is a shipboard broadcast system that provides identifying information on other vessels within 8 to 

10 nautical miles of a ship, with such additional information as location, heading, speed, and rate of turn.
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NACOS generation 5 was introduced in 2005. (As noted earlier, the Crown

Princess was equipped with model 65-5.) Generation 5 featured changes in the 

trackpilot that conformed to mandatory changes required by the International 

Maritime Organization. In addition, the latest version featured a fully integrated 

VDR that captured radar data.73 The NACOS model on the Crown Princess 

contained the following components: radarpilot, chartpilot, multipilot, conning 

pilot, and trackpilot.

The radarpilot displayed radar information about the environment around 

the vessel as seen by the radar system. The trackpilot could be controlled and 

monitored from the radarpilot workstation, thus enhancing the vessel’s basic 

autopilot function with information on nearby vessels. 

The chartpilot combined nautical information, route planning, and 

geographical information with digital charts. It provided route-monitoring 

information including position, gyroscope heading, rate of turn, speed, course, 

date, time, distance to next way point or object, time to next way point or object, 

wind direction and velocity, engine power, propeller pitch, shaft revolutions per 

minute, rudder position, and thruster position, if available.

The multipilot combined ECDIS with radar information to display planned 

and actual position, with location of nearby vessels, on an electronic chart. Among 

the information provided to the officer having the conn were heading, rate of turn, 

course, drift angle, extent off course, extent off track, estimated time of arrival 

to next way point or position, time to travel to next way point or position, water 

depth, wind velocity and direction, and engine and rudder information.

Steering through the trackpilot could be set to one of three modes: heading 

mode, a mode comparable to a conventional autopilot in which the gyrocompass 

would determine the vessel heading; course mode, in which the true course would 

be maintained with compensation for drift and wind; and track mode, which would 

steer the vessel along a predetermined track using either specific navigation points 

entered by the operator or navigation points along a predetermined route, with 

compensation for drift and wind. Track mode steering could be fully automated, 

requiring crewmember confirmation only in the case of a course alteration. 

Trackpilot provided all the information included in the previous components 

with such additional information as GPS position, rudder economy setting, 

rudder limit, selected limit on course, distance from track (or drift), rhumb line 

(line of constant bearing) to track, time to next way point, course correction, and 

information on the track itself. 

Among the trackpilot parameters that could be selected at the option of 

the watchstanders were rudder economy, rudder limit, and course limit. The 

rudder economy setting allowed operators to enter one of 10 levels of weather/sea 

73 The International Maritime Organization did not require VDR integration, an optional item in NACOS 

generation 5.
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state conditions, with resulting rudder movement limits increased or decreased, 

according to the setting. Level 1 was for calm seas and wind conditions, while 

levels over 6 were to be used when conditions were “very bad” (terms in quotes 

indicate terms from the NACOS operating manual). Level 5, the rudder economy 

setting that had been set into the vessel’s trackpilot at the time of the accident, 

was to be used when conditions were “bad.” With increases in rudder economy 

setting, designed to be used for increasingly rough seas, vessel heading was 

allowed to fluctuate increasingly. The NACOS manual described steering in level 1 

as “precise” and, as the levels increased, steering became increasingly “tolerant.” 

Operators were expected to apply higher rudder movement restrictions 

during rough seas by inputting higher rudder economy settings. The NACOS 

operating manual stated:74

Economically advantageous optimisation between track-keeping and 

frequency of changing of the rudder angle, depending on sea state and 

wind, is achieved by means of the “rudder economy” parameter. This is 

comparable to a combination of the control variables “rudder,” “counter 

rudder” and “yaw” of a conventional autopilot. A common feature of the 

following [rudder] limits is that, when the set value is reached or exceeded, 

a corresponding alarm appears. The rudder angle setting which the 

trackpilot specifies as the maximum value for the rudder control system 

can be set under Limits in the Rudder Field. The rudder limit value should 

be reduced if a constant course is to be steered for a long time on the open 

sea or if, for example because of the loading state or for other reasons, 

large angles of the rudder are not permitted. When the rudder limit value 

is reached, the TP [trackpilot] Rudder Limit alarm appears [emphasis in 

original].

At higher vessel speeds, SAM Electronics recommended setting the 

rudder limit lower than at lower speeds to prevent excessive rates of turn and 

vessel heeling. The trackpilot manual specified: “The rudder limit value should 

be reduced if a constant course is to be steered for a long time on the open sea or 

large rudder angles are not permitted.” 

The INS recorded INS data independently of the VDR, which recorded data 

mandated by the International Maritime Organization.75 On the Crown Princess, INS 

data were registered on both a short-term and a long-term recording, stored in 

the chartpilot unit and capable of being replayed by specialized hardware and 

software (the chartpilot electronics unit). In addition, the system recorded errors 

in a log file that was stored on the multipilot radar unit.

Training. Neither the International Maritime Organization, Bermuda (the 

state of registry of the Crown Princess), nor the Coast Guard required mariners to 

be trained in INS use. Ship owners or operators decided on the type of training, if 

74 SAM Electronics, Operating Instructions, pp. 207-208. 

75 No international requirements address VDR storage of inputs to vessel INS units. See “Voyage Data 

Recorder” section.
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any, to be provided. INS manufacturers were required only to provide customers 

with user manuals and system documentation. 

The International Maritime Organization developed an IBS/INS “model 

course” that presents a curriculum on system use (appendix E). Member nations 

are not required to adopt the model curriculum or to certify IBS/INS courses. 

There is no International Maritime Organization requirement that students 

completing IBS/INS courses demonstrate proficiency in using the systems, or that 

a maximum period be permitted to elapse before someone who has completed 

an IBS/INS course can work with a shipboard IBS/INS while serving as a watch 

officer. In addition to developing the model course, the International Maritime 

Organization’s subcommittee on Standards on Training and Watchkeeping 

(STW), at its session in 2006, considered the need for a comprehensive review 

of the International Convention on Standards of Training, Certification, and 

Watchkeeping for Seafarers (STCW) and the STCW code, and proposed a work 

item with a target completion date of 2008.76

At the 2007 meeting of the International Maritime Organization’s Maritime 

Safety Committee, revised performance standards for INS and guidelines on the 

application of SOLAS regulation V/15 related to INS, IBS, and bridge design were 

adopted.77 Included was guidance to equipment manufacturers for familiarizing 

mariners with INS use on board vessels (appendix F). 

Representatives of Sperry Marine told investigators that the company 

conducted a 40-hour class in the use of its ECDIS at its Charlottesville, Virginia, 

facility. A typical class consisted of 30 hours on a multiconsole INS installation 

that mimicked a typical ship’s bridge and about 10 hours on an ECDIS simulator. 

Within the 40-hour time frame, instructors generally tried to match class time 

with demonstrated student progress. Crewmembers were taught the relationship 

between sea state, rudder movement, and rudder hunting. That is, during rough 

seas, the Sperry system would limit rudder movement, and as a result vessel 

yaw fluctuations would become limited around a given heading. A crewmember 

could also select a particular sea state that would have the same effect on rudder 

movement.

SAM Electronics conducted training in the NACOS system at its Bremen, 

Germany, training facility. Customers could order the training and take it in Bremen 

or at another site they selected. Carnival Corporation conducted NACOS training, 

using a SAM Electronics–certified instructor, at its training center in Southampton, 

England. Regular training began about March 2006. Classes could cover vesselspecific NACOS designs, but because a typical class contained students from 

different vessels, the classes usually dealt with generic systems.

76 The STCW code sets minimum international training standards for professional mariners. It was last 

amended in 1995. 

77 Report of the International Maritime Organization Maritime Safety Committee, 83rd session, October 

2007. The performance standards for INS are found in resolution MSC.252(83), and the guidance to SOLAS 

regulation V/5 is found in SN.1/Circ.265.
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The standard SAM Electronics NACOS training was conducted in a 4-day 

class. The first day included an overview of the company, the purpose of an INS, 

and a history of the NACOS. The design and system architecture of the current 

NACOS were outlined. The second day covered the operation of major NACOS 

components, including radar, ARPA, and ECDIS. The third day focused on the 

operation of the multipilot and trackpilot, including trackpilot modes, trackpilot 

accuracy and limitations, and track and speed control. On the last day, students 

completed exercises in voyage planning, execution, and monitoring using NACOS. 

The course material was then reviewed and new system elements discussed. If 

time allowed, students were presented with a system failure and asked to respond 

effectively. Exercises were conducted on computer-based simulators that displayed 

NACOS information matching actual vessel displays.

SAM Electronics representatives told investigators that because the 

company considered the effects of shallow water and high vessel speed on 

vessel steering to be part of the basic knowledge of navigational officers, NACOS 

trainers did not discuss the issue before the Crown Princess accident (see “Shallow 

Water Effects” section). After the accident, SAM Electronics modified its NACOS 

software so that it will warn operators when vessel speed is excessive for water 

depth. A warning is given for decreasing water depth and an alarm is sounded 

for shallow water at high speed. The warnings are based on formulas developed 

in a postaccident study, as detailed in the “Shallow Water Effects” section. SAM 

Electronics modified its training material to instruct students about the warnings.

Princess Cruises sent its watchkeeping deck officers to the Carnival 

Corporation training center in Southampton for NACOS training conducted by an 

employee that SAM Electronics certified to serve as a NACOS trainer. Deck officers 

on the Crown Princess were trained both at the SAM Electronics Bremen facility and 

at Southampton. Princess Cruises required captains to interview all deck officers 

assigned to a vessel for the first time in order to verify their understanding of and 

familiarity with the NACOS and other vessel systems. 

Princess Cruises personnel estimated that in the 2 years before the accident, 

as many as six crewmembers were directed to receive additional NACOS training. 

Either a vessel captain or a supervisor had recommended the additional training 

after reading the VDR in response to a concern about vessel operation. Company 

policy called for monitoring the VDR of a voyage after a concern about vessel 

operation was reported.

In response to heeling incidents and other occurrences on its vessels, 

Holland America Line reviewed its operations and modified its bridge resource 

management class. The curriculum, while adhering to content requirements of the 

STCW code, featured simulator-based scenarios taken from actual incidents and 

accidents on the cruise line. Students in the class, all company deck officers, were 

presented with the scenarios and observed for the quality of their responses. Data 

on vessel position, speed, proximity to other vessels, weather and sea conditions, 

and the like were taken from actual events, with modifications to reduce the 
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likelihood that students would recognize a specific event. Students were sent to 

the facility every 5 years, and the scenarios were scheduled to be modified on a 

5-year cycle so that students would not be presented with the same scenarios in 

successive classes.

Royal Caribbean International also reviewed its heeling incidents and 

created a lessons-learned exercise for deck officers based on selected incidents. 

The company described the incidents and highlighted crewmember errors leading 

to the incidents. The objective of the exercises was for deck officers to apply the 

lessons learned from the incidents to enable them to avoid similar errors.

Previous Board Action. On August 7, 1992, the United Kingdom–registered 

vessel QE2 was outbound in Vineyard Sound, Massachusetts, when it grounded 

about 2 1⁄2 miles south of Cuttyhunk Island. No injuries or deaths resulted from the 

accident, but the vessel sustained significant damage. The Safety Board determined 

that the probable cause of the grounding was the errors in communication made 

by the pilot, master, and watch officers regarding a navigation plan for departing 

Vineyard Sound and their failure to maintain situation awareness regarding vessel 

navigation after an unplanned course change. Contributing to the accident was 

“the lack of information available on the Queen Elizabeth 2 about how speed and 

water depth affect the ship’s underkeel clearance.”78

The Board’s investigation found that the vessel’s master and pilot, while 

generally aware of the phenomenon of squat on vessels operating at high speed 

in shallow water, had underestimated the effects of squat on the QE2. After the 

vessel cleared local marine traffic and headed toward the open ocean, the master, 

with the pilot’s agreement, directed the speed to be increased to 25 knots so the 

vessel would arrive in New York on schedule. 

The pilot asked for a course change to the right of the intended course. 

The second officer, who was on the bridge, observed that the projected path of 

the vessel would cross a shoal area and informed the captain (through the first 

officer). The captain expressed his concern to the pilot, who ordered a course 

change south of the projected track. The second officer noticed that the new 

trackline would pass over a 6-1⁄2-fathom (39-foot) sounding but did not express his 

concern. Both the pilot and the master considered the 39-foot sounding, with the 

tide of plus 1 1⁄2 feet, to be sufficient for safe vessel passage. Neither recognized 

that the effects of the high vessel speed over the relatively shallow water would 

lead to the squat that caused the vessel to ground on the 39-foot shoal. Their lack 

of recognition may have been the result of the lack of widespread distribution of 

information regarding squat effects on vessel motion. 

As a result of its investigation of the QE2 accident, the Safety Board made 

the following recommendation to the Coast Guard:

78 National Transportation Safety Board, Grounding of the United Kingdom Passenger Vessel RMS 

Queen Elizabeth 2 Near Cuttyhunk Island, Vineyard Sound, Massachusetts, August 7, 1992, Marine Accident 

Report NTSB/MAR-93/01 (Washington, DC: NTSB, 1993).
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M-93-23

Widely publicize the particulars of this accident concerning the large squat 

for ships operating at high speeds in shallow waters.

In response, the Coast Guard commandant, on September 27, 1993, wrote:

I concur with this recommendation. Copies of the Coast Guard’s 

investigation report on this casualty are being provided to IMO 

[International Maritime Organization] to disseminate the research 

information regarding vessel squat. In addition, we will develop material 

for publication in a Notice to Mariners, Proceedings of the Marine Safety 

Council, or other maritime publications. I will provide copies of the articles 

to the Board when published.

The Coast Guard disseminated information about the accident, specifically 

about the crew’s knowledge of squat effects, within the marine community. 

The accident was a cover story in a 1993 Coast Guard publication distributed 

to professional mariners. As a result of the Coast Guard’s action, on March 20, 

1997, the Safety Board classified Safety Recommendation M-93-23 as “Closed—

Acceptable Action.”

Three years later, on June 10, 1995, the Panamanian-registered vessel Royal 

Majesty grounded approximately 10 miles east of Nantucket Island, Massachusetts, 

about 17 miles west of its intended track.79 None of the 1,509 persons on board 

was injured, but the vessel sustained several million dollars worth of damage. 

The Safety Board determined that the probable cause of the accident was the deck 

officers’ overreliance on the vessel’s INS,80 Majesty Cruises’s failure to ensure that 

its deck officers were adequately trained in the automated features of the INS and 

in the implications of this automation for the INS, deficiencies in the design and 

implementation of the INS and in its operational procedures, and errors the second 

officer committed in failing to detect cues that the vessel was off course.

The Royal Majesty had been equipped with a NACOS 25 (the NACOS version 

STN Atlas was manufacturing at the time) that included an autopilot integrated 

with radar information, presented through an ARPA display that could steer 

the vessel along a track of selected navigation points (similar to the trackpilot, 

track mode, on the Crown Princess’s NACOS 65-5). The vessel, which obtained 

position data from both GPS and LORAN,81 began to deviate from its intended 

course after the cable connecting the GPS antenna to the receiver separated and 

the GPS automatically reverted to dead reckoning without bridge watchkeepers 

79 National Transportation Safety Board, Grounding of the Panamanian Passenger Ship Royal Majesty 

on Rose and Crown Shoal Near Nantucket, Massachusetts, June 10, 1995, Marine Accident Report NTSB/

MAR-97/01 (Washington, DC: NTSB, 1997).

80 Note that in its report, the Safety Board used the term IBS rather than INS.

81 LORAN (LOng RAnge Navigation) is a ground-based navigation system using low-frequency radio 

transmitters for transoceanic navigation.
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recognizing the change. The GPS did not signal the INS that it had reverted to 

dead reckoning, nor was it required to.

At the time of the accident, Majesty Cruises offered NACOS training to its deck 

officers through on-the-job training, under the supervision of the vessel’s navigator. 

The cruise line provided simulator sessions to deck officers to practice navigation 

using the INS, but it did not make training checklists available to the navigators who 

provided on-the-job training. STN Atlas had offered training in the use of NACOS to 

its customers, but Majesty Cruises did not order or receive such training.

As a result of its investigation of the Royal Majesty accident, the Safety Board 

issued the following recommendation to the Coast Guard:

M-97-5

Propose to the International Maritime Organization that it develop 

appropriate performance standards for the training of watch officers 

assigned to vessels equipped with integrated bridge systems and require 

this training.

In response, on November 6, 1998, the Coast Guard wrote:

We do not concur with this recommendation. The fact that the watch 

officers in this incident did not perform their watchkeeping duties properly 

does not establish a need for special international standards of training for 

watch officers on vessels equipped with integrated bridge systems. There 

is no indication that the existing international standards of qualification 

are inadequate. The 1995 amendments to the International Convention 

on Standards of Training, Certification, and Watchkeeping for Seafarers, 

1978, (STCW) provide ample international standards and regulations 

which, if followed, would prevent incidents such as the grounding of the 

Royal Majesty. For example, regulation 1/14, STCW requires a company 

that owns or operates a ship to ensure that “seafarers, on being assigned 

to any of its ships, are familiarized with their specific duties and with 

all ship arrangements, installations, equipment, procedures, and ship 

characteristics that are relevant to their routine or emergency duties.”

Officers in charge of a navigational watch are required to have the “ability 

to determine the ship’s position by use of electronic navigational aids,” and 

one criterion to evaluate the officer’s competence in navigation is that “the 

reliability of the information obtained from the primary method of position 

fixing is checked at appropriate intervals.” Watchkeeping requirements 

specify that “during the watch, the course steered, position and speed 

shall be checked at sufficiently frequent intervals, using any available 

navigational aids necessary, to ensure that the ship follows the planned 

route.” STCW also requires that masters and chief mates be proficient in 

effective bridge teamwork procedures. 

We anticipate that the 1995 STCW amendments, combined with the 

requirements of the International Safety Management code (ISM code), 
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will improve watchkeeping practices. The Coast Guard plans no further 

action on this recommendation, and requests that it be closed.

Because the Coast Guard planned no action on the recommendation, on April 20, 

1999, the Safety Board classified Safety Recommendation M-97-5 as “Closed—

Unacceptable Action.”

Also as a result of the Royal Majesty accident, the Safety Board issued the 

following recommendation to the ICCL:

M-97-21

Recommend that its members provide initial and recurrent formal training 

on essential technical information, equipment functions, and system 

operating procedures to all bridge watchstanding personnel on their ships 

that are equipped with integrated bridge systems. 

In its response of October 11, 1999, the ICCL wrote:

ICCL member lines provide initial and recurrent formal training to their 

bridge personnel through “in-house” initial training/familiarization 

programs and recognized shoreside crew training facilities such as the Star 

Center in Dania, FL, and Marine Safety in Rotterdam. ICCL member vessels 

comply with the International Maritime Organization (IMO) requirements 

for crew training and certification. The International Convention, 

Standards of Training, Certification and Watchkeeping (STCW), sets the 

minimum standards for the training and certification of crew members 

onboard all vessels engaged in international voyages. Further, independent 

authorities, in accordance with the International Safety Management code 

(ISM) certify all ICCL member lines. This system ensures that the training, 

watch standing practices and procedures are in accordance with accepted 

international maritime practices.

On March 21, 2000, the Safety Board responded to the ICCL, classifying 

Safety Recommendation M-97-21 as “Closed—Reconsidered”:

While the ICCL did not provide information on how it recommended, 

encouraged, or advised its members as requested, the Safety Board 

understands that these recommendations were discussed and reviewed 

in detail at the ICCL’s technical committee meeting in July 1999. The 

Safety Board notes that member companies have implemented some of 

these recommendations. As stated in our February 19, 1999, letter, and 

as discussed at the Safety Board/ICCL meeting this past fall, the Safety 

Board understands that the ICCL does not make recommendations 

to its membership. Therefore, the Safety Board will address future 

recommendations to the individual cruise ship companies that are 

affected. 
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Analysis

General

The analysis first identifies factors that can be eliminated as causal or 

contributory to the accident. It then discusses the following safety issues identified 

in the accident investigation:

• Actions of captain, staff captain, and second officer.

• Training in use of integrated navigation systems.

• Reporting of heeling incidents and accidents. 

• Emergency response following severe incidents.

Exclusions

The Crown Princess had been in service only a month at the time of the 

accident. The vessel’s steering and propulsion systems and NACOS were tested 

during sea trials before the accident, as well as in tests conducted after the accident. 

Both pre- and postaccident testing found that the systems performed as designed. 

The weather and sea state were mild and unlikely to have affected the vessel’s 

performance.

Toxicological analysis of samples taken from the deck officers on duty 

during the accident were negative for the presence of alcohol and illegal drugs, 

and the officers had maintained regular sleep and work schedules in the days 

before the accident. Therefore, the Safety Board concludes that the following were 

not factors in the accident: vessel’s mechanical condition, weather, sea state, and 

behavioral or physiological impairment of the crew. 

Accident

The Crown Princess’s departure from Port Canaveral was uneventful. The 

pilot had the conn at departure and the crew steered the vessel manually. After the 

pilot disembarked and the vessel entered the open ocean, the crew engaged the 

trackpilot and the captain ordered an increase in the vessel’s speed to stay ahead 

of forecast adverse weather. The captain and staff captain left the bridge, turning 

the navigation watch over to the second officer. The second officer, concerned by 
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indications of a high rate of turn to port, disengaged the trackpilot and began 

steering the vessel manually. His first turn was opposite to his intended direction. 

A minute later, the vessel heeled hard to starboard. The heeling caused passengers 

and crew to strike the vessel’s structure or objects on the vessel or to be struck by 

objects, resulting in almost 300 injuries. The Crown Princess was traveling at 20 

knots, nearly full speed, when it heeled. The vessel was in relatively shallow water 

at the time of the accident, with 8.3 meters (about 26 feet) of water under the keel.

Actions of Captain and Staff Captain

According to information from both the VDR and interviews of the captain, 

staff captain, and second officer, about 1503 the vessel’s heading began to fluctuate 

around its designated 100° heading. Two minutes later, the trackpilot rudder limit 

alarm sounded. In response, the staff captain increased the rudder limit from 5° 

to 10°. At the time, the rudder economy was set to level 5, normally intended for 

rough seas. 

The captain and staff captain, both experienced mariners, should have 

realized that because the vessel was operating in relatively shallow water, its 

response to rudder movements would lessen and its maneuverability become 

unpredictable. The trackpilot, whose performance was predicated on deep-water 

vessel characteristics, would likewise perform unpredictably in shallow water at 

high speeds. These hydrodynamic effects were so obvious to SAM Electronics that 

its representatives told Safety Board investigators that they saw no need to address 

the topic in their NACOS training. They assumed that, irrespective of experience, 

all mariners would be aware that operating at high speed in shallow water would 

affect vessel performance. Both the captain and the staff captain, despite their 

experience, apparently failed to recognize that the INS would be unpredictable 

at a speed of 20 knots in waters 8 meters deep under the keel. The Safety Board 

therefore concludes that the captain and staff captain did not recognize that high 

speed and shallow water were adversely affecting the vessel’s course stability. 

In addition to the effects on vessel steering of high speed in shallow water, 

the staff captain further enabled the vessel’s course deviations by increasing the 

rudder limit while maintaining the trackpilot’s rudder economy setting at level 

5. As described in the NACOS operating manual, the selection of the rudder 

economy limit was to be based on the sea state and weather conditions. Level 5 

was to be used when conditions were “bad,” according to the manual. Rudder 

economy settings allow increases in vessel heading fluctuations with increases in 

the rudder economy level. Such increases are desirable in rough seas but not in 

calm seas, where large rudder motion can increase passenger discomfort and wear 

and tear on the steering system.

Neither the staff captain nor the captain appears to have recognized that 

the rudder economy setting was related to the rudder limit alarms that had led 

the officers to increase the rudder limit. They should have understood that the 
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rudder economy had been set to a level inappropriate to the operating conditions 

(sea state). When the captain said, “We’re wandering all over the place,” neither 

he nor the staff captain seemed to realize that the “wandering” was influenced 

by the vessel’s high speed in relatively shallow water and was exacerbated by 

the rudder economy setting. Increasing the rudder limit, particularly given the 

inappropriate rudder economy setting, was inappropriate as well because it 

allowed greater heading fluctuations. The proper response to the rudder limit 

alarm, given the sea state and operating conditions, would have been to assess the 

cause of the alarm, that is, the inappropriate rudder economy setting, and readjust 

the setting to the appropriate level. The Safety Board therefore concludes that the 

captain and staff captain inappropriately adjusted the trackpilot’s rudder limit in 

response to unintended deviations in the vessel’s set heading, and they failed to 

adjust the rudder economy setting, which was inappropriate for the sea state and 

was exacerbating the course deviations. 

The captain turned the conn over to the second officer at 1518, 6 minutes 

before the second officer disengaged the trackpilot. However, the fluctuations in 

the vessel’s heading that the captain and staff captain had attempted to address 

through the INS continued, leading the second officer to attempt to correct them 

by taking manual control of the steering. The captain transferred the conn without 

determining the cause of the heading fluctuations, and worse, left the bridge without 

verifying that they were lessening. The evidence of his previous experience as 

captain and his actions in turning over the conn suggest that the captain believed 

either that the INS would stabilize the heading or that the second officer would 

remedy the problem. However, neither outcome was realized. The Safety Board 

therefore concludes that the captain should not have transferred the conn to the 

second officer and left the bridge unless he could verify that the vessel’s heading 

fluctuations had diminished. 

Second Officer’s Actions

The Crown Princess was operating at nearly full speed when the second 

officer took the conn. He immediately faced the problem of navigating a vessel 

that exhibited both increasing course deviations and high rates of turn. The second 

officer told investigators that his eyes “were instantly drawn to” the red color of 

the rate-of-turn indicator on the bridge, which indicated a high rate of turn to port. 

He responded immediately by disengaging the trackpilot82 and turning the wheel 

10° to port, when he should have turned it to starboard to counteract the turn.

After his initial turn to port, the second officer manually steered back 

and forth between port and starboard in increasingly wider turns. Rather than 

remedying the problem, the second officer’s actions exacerbated the course 

fluctuations and high turn rates, and caused larger and larger heel angles. The 

result was an increasing heel to starboard that eventually peaked at about 24°. 

82 Disengaging the trackpilot disengaged the rudder limit and rudder economy settings.
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As detailed in the “Vessel Dynamics” section, the second officer moved 

the wheel faster than the rudders could follow. Numerous cues were available to 

inform the second officer that the vessel was not responding as he commanded 

or expected. Visual cues came both from what he could see outside the window 

and from bridge instruments that indicated the vessel’s rate of turn and course. In 

addition, he would have received vestibular cues about angular acceleration. That 

is, he would have felt the speed with which the vessel was heeling and turning. 

The second officer’s three turns to port temporarily slowed the rate of heel. 

However, the overall effect was to increase the heel to starboard, because, as shown 

in figure 7, the rudders remained to port and the vessel’s drift angle (the difference 

between its heading and its track) continued to increase. Thus, after his initial 

command to port, each time the second officer commanded rudder movements, 

the heel rate temporarily slowed, giving the perception of correcting the starboard 

heel angle. However, this effect was at the overall expense of a greater starboard 

heel angle, a result that contradicted the desired outcome. That is, the second 

officer’s wheel inputs increased the starboard heel over the duration of the event 

rather than decreasing it. It could not be determined whether the second officer’s 

initial turn was due to a “slip”83 or to a misdiagnosis of the situation. 

Because the second officer was, as he stated, “instantly drawn to” the red 

color on the rate-of-turn indicator, and because the vessel did not respond as he 

expected, he reacted in a manner consistent with someone under stress. Stress 

would have limited the second officer’s ability to diagnose and respond effectively 

to the situation he faced. As has been observed: “Stress narrows people’s field 

of attention to a limited number of central aspects. Under perceived danger, a 

decrease in attention has been observed for peripheral information.”84 The second 

officer, according to what he told investigators, focused almost exclusively on the 

vessel’s rate of turn. The second officer’s repeated turns of the wheel thereafter 

were futile and inappropriate attempts to slow the turn rate and correct the heeling. 

His activity only made the situation he faced worse, his stress level higher, and his 

ability to comprehend and respond appropriately to the situation he faced more 

difficult. 

In such circumstances, a crewmember who was fully aware of the situation 

would most likely have taken two actions—held a steady course, and reduced 

speed. Because of the second officer’s inappropriate steering, the turn rate 

increased and the vessel heeled hard to starboard. The relief captain was the first 

person to return to the bridge when the vessel began heeling and immediately 

ordered, “Reduce the speed.” Slowing the vessel, in addition to disengaging 

the trackpilot, was a course of action that the second officer, as an experienced 

mariner, should have known to take in response to a possible steering failure. 

83 The second officer’s initial turn to port, when he meant to turn to starboard, can be considered an error 

of execution. James Reason (Human Error [New York: Cambridge University Press, 1990]) refers to such an 

error as a “slip,” a relatively minor error that contrasts with a high-level cognitive error such as misdiagnosing 

a situation. In a slip, a person means to do one thing, but the execution differs from the person’s intention.

84 M. R. Endsley, “Toward a Theory of Situation Awareness,” Human Factors 37 (1995), p. 52.
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The Safety Board concludes that the Crown Princess heeled because, after the 

second officer disengaged the trackpilot and turned the wheel to port rather than 

turning it to midships and slowing the vessel as he should have, his subsequent 

steering commands to both port and starboard, at angles ranging from 10° to 

45°, led to vessel responses that he did not expect, did not understand, and was 

therefore unable to correct. 

The Safety Board examined the second officer’s training and experience 

to determine whether deficiencies in either might have played a role in his 

performance during the accident. His training in the British maritime academy 

was equivalent to that of the other British-trained deck officers that Princess 

Cruises employed, and his record indicates that he would have been exposed to 

the same training scenarios as other British students in maritime training at that 

time. His experience, which was entirely with Princess Cruises and a predecessor 

company, was consistent with that of a second officer who had been out of school 

for 6 years. In addition, the record indicates that he performed satisfactorily in his 

training and as a deck officer. Thus, there was no evidence of shortcomings in his 

training or background and no evidence that he performed less than satisfactorily 

in either. Therefore, the Safety Board concludes that no deficiencies in the second 

officer’s training or background could account for his inappropriate steering 

commands. 

Training in Use of Integrated Navigation Systems

The captain and staff captain of the Crown Princess made several errors with 

regard to the INS trackpilot. Specifically, they failed to recognize the following: 

• Effects of high vessel speed in shallow water on course stability.

• Effects of rudder economy level 5 on rudder performance.

• Effects on fluctuations around the heading of increasing the rudder limit 

from 5° to 10°.

In examining other heeling accidents and incidents, the Safety Board found 

common antecedents—crewmembers not fully understanding the INS they were 

using, not anticipating the effect of their actions on the INS, or both. Integrated 

navigation systems, whether manufactured by SAM Electronics, Sperry Marine, 

or another company, are sophisticated devices that monitor, display, and control 

considerable information about a vessel’s position, direction, and path, the sea state 

in which it operates, and related information about nearby vessels. The systems 

integrate previously developed individual components (such as AIS, ARPA, and 

ECDIS) with steering to allow the display of information and control of components 

at a single workstation. The systems also offer options as to the amount and type 

of information presented and the type of vessel navigation and control desired. 

As both hardware and software technology have advanced, designers have added 
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capabilities to the systems, further increasing an operator’s choices in information 

and vessel control.

The Safety Board found shortcomings in training that may have contributed 

to the errors in INS use that played a role in some of the other heeling incidents 

reviewed in this investigation. For example, under the current system, completing 

INS training does not assure mastery of the system because students are not 

required to demonstrate mastery of an INS at the completion of many formal INS 

training programs. 

Given the amount of information an INS can present and its many control 

and display options, a crewmember who completes INS training and then does 

not use the system on a vessel for several years may not remember much of the 

class material or be able to apply it. Further, neither the Coast Guard nor the 

International Maritime Organization requires licensed mariners to complete formal 

INS instruction before using an INS. There is also no requirement that mariners 

who have completed INS instruction take courses thereafter. A system that allows 

users to interact with such sophisticated systems as an INS with the training 

shortcomings noted is deficient and increases the likelihood that crewmembers will 

commit INS-related errors. The Safety Board therefore concludes that the errors 

of the captain and staff captain in operating the INS resulted from inadequate 

training. 

The Safety Board identified deficiencies in INS training 10 years earlier 

in its investigation of the grounding of the Royal Majesty and issued Safety 

Recommendation M-97-5 to the Coast Guard. The Coast Guard disagreed with 

the recommendation, and the Safety Board classified it as “Closed—Unacceptable 

Action.” 

Since the Safety Board issued its recommendation, errors in INS use have 

continued. Although in recent years the International Maritime Organization 

has recognized the need for additional attention to INS training for bridge watch 

officers, the training is still not mandatory. The record of passenger vessel incidents 

and accidents related to deficiencies in INS training since the Royal Majesty accident 

contradicts the outcome foreseen by the Coast Guard when it responded to Safety 

Recommendation M‐97-5 that “there is no indication that the existing international 

standards of qualification are inadequate” and that “the 1995 amendments to the 

international convention on standards of training, certification, and watchkeeping 

for seafarers, 1978 (STCW) provide ample international standards and regulations” 

governing INS training. 

The International Maritime Organization has developed a model training 

curriculum for INS and IBS equipment (appendix E). The curriculum, which is 

advisory only, addresses many of the shortcomings in INS training requirements 

that the Safety Board noted in its investigation of the Crown Princess accident. For 

example, it details a 40-hour class, with instructional objectives related to INS/

IBS use, and devotes segments of class time to particular topics. In addition, it 
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suggests simulator exercises to allow students to apply the information addressed 

in class and offers guidance on testing or evaluating a student’s knowledge at 

course end. 

However, because there is no international requirement for INS training, the 

proposed model curriculum may not be effective in addressing the shortcomings 

in INS training noted in this investigation. Until crewmembers are required to 

demonstrate mastery of INSs and IBSs through formal, well-designed training 

programs, there can be no assurance that watchkeepers are proficient in the use 

of these sophisticated systems. The model International Maritime Organization 

curriculum, or other training endeavors that meet similar instructional objectives, 

if implemented and made mandatory with mariner participation in the training, 

would increase the likelihood that crewmembers will use INS or IBS equipment 

effectively in all operating conditions. Therefore, the Safety Board believes that the 

Coast Guard should propose to the International Maritime Organization that, in 

conjunction with the upcoming revisions to the STCW, it make training in INS and 

IBS mandatory for watchkeepers on vessels equipped with such systems. 

As a result of the Royal Majesty accident, the Safety Board issued 

recommendation M-97-21 to the ICCL, now the Cruise Lines International 

Association (CLIA). The ICCL did not agree with the Safety Board, citing the 

training its members received at shoreside training facilities and the adequacy of 

STCW requirements and ISO certification. The Safety Board accepted the ICCL’s 

stated inability to recommend particular courses of action to its members. In 

the Safety Board’s opinion, however, the Crown Princess accident indicates that 

passenger cruise lines should ensure that all deck officers are thoroughly versed 

in INS operations. The Board recognizes that it will take time for the International 

Maritime Organization to mandate INS training. Therefore, the Safety Board 

believes that, until the International Maritime Organization makes INS training 

mandatory, CLIA should recommend to its members that they voluntarily 

provide initial and recurrent training in INS operation to crewmembers having 

watchkeeping responsibilities on vessels equipped with such systems, and include 

in that training a requirement for a demonstrated level of proficiency. 

Further, the circumstances of this accident suggest that even experienced 

deck officers may not recognize how operating at high vessel speed in shallow 

water can affect rudder, vessel, and INS performance. In its investigation of 

the 1992 QE2 grounding, the Safety Board found that the crewmembers lacked 

knowledge of shallow water effects on their vessel. (They were operating off 

the coast of Massachusetts at a speed of 25 knots.) As a result, the Safety Board 

issued Safety Recommendation M-93-23 to the Coast Guard, which it classified as 

“Closed—Acceptable Action” after the Coast Guard publicized the circumstances 

of the accident. Partly because of this action, information on squat was prominently 

posted on the Crown Princess bridge. 

Nonetheless, the circumstances of the Crown Princess accident suggest that 

the officers, while familiar with squat, did not recognize that high vessel speed 
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in shallow water could also adversely affect the precision of vessel steering. In 

addition, the second officer’s actions indicate that he lacked the emergency shiphandling skills that would have allowed him to respond effectively to the vessel’s 

unexpected behavior. The Safety Board is concerned that other officers in charge of 

the navigational watch may also be unprepared for serious, unexpected incidents 

such as a vessel heeling. Therefore, the Safety Board believes that the CLIA 

should, through its website, publications, and conferences, inform its members 

about the circumstances of this accident and urge them to incorporate into their 

safety management systems and training programs for officers in charge of the 

navigational watch (1) information about the effects on vessel performance of highspeed vessel operations in shallow water, and (2) initial and recurrent training 

for emergency ship-handling scenarios based on the lessons learned from serious 

marine incidents and accidents. 

After the Crown Princess accident, SAM Electronics addressed shortcomings 

in its NACOS training by including in its material specific references to shallowwater effects on INS performance. Before the accident, the company had 

assumed that mariners did not need such instruction because they were already 

knowledgeable about shallow-water effects, but that assumption proved to be 

mistaken. The manufacturer’s action of adding an alarm to signal the bridge when 

a vessel is entering shallow water at high speed should help avoid situations that 

diminish vessel maneuverability and INS performance such as the Crown Princess 

experienced.

After the accident, Princess Cruises required senior deck officers to repeat 

bridge resource management courses and provided all deck officers with additional 

NACOS training. Princess Cruises also urged its personnel to place user-friendly 

guidance from bridge operations manuals in readily accessible locations on vessel 

bridges. While there is no evidence that the complexity or inaccessibility of the 

NACOS manual or other operations manuals affected the crew’s actions in the 

Crown Princess accident, making equipment guidance easier to use and more 

accessible could enhance crew response in future unexpected or nonroutine 

situations.

Holland America Line and Royal Caribbean have also taken steps to 

improve the training of their deck officers, such as developing lessons-learned 

programs based on previous heeling incidents.

Postaccident Crew Response 

With almost 300 passengers and crew injured on the Crown Princess, 

the captain’s quick decision to return to port enabled injured passengers and 

crewmembers to be treated at shoreside medical facilities. The ship’s medical 

personnel helped those in need with transport to shoreside medical facilities. 

Before the vessel reached the dock, the medical team established a triage of the 
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injured, identified and treated the most seriously injured, and communicated to 

the captain the severity of the injuries. Therefore, the Safety Board concludes that 

the captain acted properly in returning to Port Canaveral after the accident, and 

that the crew responded effectively in administering medical care to the injured. 

The Safety Board examined the captain’s decision not to muster passengers 

after the accident. The captain told investigators that, shortly after the accident, he 

checked with the two bridge lookouts who were monitoring for balcony fires, and 

they informed him that they had not seen anyone fall overboard. Therefore, the 

captain decided not to ask the passengers to report to their muster stations but, 

rather, told them to report to their cabins.

Directing passengers to report to their muster stations would certainly 

have enabled the crew to account for the passengers. However, although the 

captain did not say so, it is unlikely that anyone would have fallen overboard 

unnoticed because many passengers and crew were on the outside decks in the 

bright, mid-afternoon daylight conditions. Further, given the debris on the vessel 

after the accident, including water from the pools, broken glass, and displaced 

and overturned furniture, directing passengers to their muster stations could have 

exposed them to hazards of slips, falls, and blunt or lacerating injury. In addition, 

the number of injured passengers and crew and the severity of their injuries 

were uncertain. Having passengers report to muster stations could have delayed 

treatment of the injured. Therefore, the Safety Board concludes that the captain’s 

decision not to order passengers to their muster stations after the accident was 

appropriate. 

The captain’s decision, while appropriate under the circumstances of the 

Crown Princess accident, might be inappropriate under other circumstances. After 

the accident, Princess Cruises implemented the use of a new technological aid 

for the accounting of passengers after an emergency. The aid should reduce the 

burden on crewmembers of attempting to account for all passengers while they 

are busy responding to the aftereffects of an incident.

Monitoring of Heeling Incidents

The investigation found that there is no systematic way of providing 

information or feedback regarding INS- or IBS-related incidents to the system 

designers or trainers. The current system, by which companies learn of incidents 

through media reports or directly from a cruise line, is informal and unsystematic. 

Further, it does not provide manufacturers with complete data on how their 

systems are used or misused. 

Manufacturers focus primarily on data that inform them of hardware 

or software flaws. That information, while important, provides an incomplete 

account of actual operations. Worse, neither designers nor trainers may learn of 
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incidents that could lead to design or training changes because there is no system 

of reporting such incidents. 

Data on errors in INS or IBS use may point to flaws in the system interface 

or suggest areas of improvement in the system design or training. Without such 

information, manufacturers have no reliable method of learning whether their 

products are being used as intended and whether their products or training 

programs are meeting their objectives. The Safety Board therefore concludes that 

the systematic collection of data on mishaps related to INSs and IBSs will enhance 

the systems’ design, procedures, and training. Therefore, the Safety Board believes 

that SAM Electronics and Sperry Marine should work with cruise lines and other 

vessel operators to develop a system that provides them with critical information 

regarding errors or potential problems in the use of INSs or IBSs and apply the 

lessons learned to system design and crew training. 

Safety Board investigators determined the Crown Princess’s maximum 

angle of heel from images taken by videocameras installed on the vessel for 

purposes other than accident investigation. The VDR, which was designed to 

collect data for use in accident investigations, did not record heel angles. There 

is no requirement for VDRs to record heel angles. The vessel’s IMAC retained 

heeling data, but only measured angles of heel between starboard 15° and port 

15°. Data that accurately record a vessel’s angle of heel can considerably assist 

those attempting to understand the nature of a heeling event. The Safety Board 

therefore concludes that the Crown Princess accident demonstrates the need for 

obtaining and archiving data on vessel angles of heel. Consequently, the Safety 

Board believes that the Coast Guard should propose to the International Maritime 

Organization that it mandate the recording on VDRs of heel angles through the 

complete range of possible values. 
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Conclusions

Findings

1. The following were not factors in the accident: vessel’s mechanical condition, 

weather, sea state, and behavioral or physiological impairment of the crew.

2. The captain and staff captain did not recognize that high speed and shallow 

water were adversely affecting the vessel’s course stability.

3. The captain and staff captain inappropriately adjusted the trackpilot’s rudder 

limit in response to unintended deviations in the vessel’s set heading, and they 

failed to adjust the rudder economy setting, which was inappropriate for the 

sea state and was exacerbating the course deviations.

4. The captain should not have transferred the conn to the second officer and left 

the bridge unless he could verify that the vessel’s heading fluctuations had 

diminished.

5. The Crown Princess heeled because, after the second officer disengaged the 

trackpilot and turned the wheel to port rather than turning it to midships and 

slowing the vessel as he should have, his subsequent steering commands to both 

port and starboard, at angles ranging from 10° to 45°, led to vessel responses that 

he did not expect, did not understand, and was therefore unable to correct. 

6. No deficiencies in the second officer’s training or background could account 

for his inappropriate steering commands.

7. The errors of the captain and staff captain in operating the integrated navigation 

system resulted from inadequate training. 

8. The captain acted properly in returning to Port Canaveral after the accident, and 

the crew responded effectively in administering medical care to the injured.

9. The captain’s decision not to order passengers to their muster stations after the 

accident was appropriate.

10. The systematic collection of data on mishaps related to integrated navigation 

systems and integrated bridge systems will enhance the systems’ design, 

procedures, and training.

11. The Crown Princess accident demonstrates the need for obtaining and archiving 

data on vessel angles of heel.
Conclusions

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Probable Cause

The National Transportation Safety Board determines that the probable cause 

of the Crown Princess accident was the second officer’s incorrect wheel commands, 

executed first to counter an unanticipated high rate of turn and then to counter 

the vessel’s heeling. Contributing to the cause of the accident were the captain’s 

and staff captain’s inappropriate inputs to the vessel’s integrated navigation 

system while the vessel was traveling at high speed in relatively shallow water, 

their failure to stabilize the vessel’s heading fluctuations before leaving the bridge, 

and the inadequate training of crewmembers in the use of integrated navigation 

systems.
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Recommendations

As a result of its investigation of this accident, the National Transportation 

Safety Board makes the following safety recommendations.

To the U.S. Coast Guard: 

Propose to the International Maritime Organization that, in 

conjunction with the upcoming revisions to the Standards of 

Training, Certification, and Watchkeeping for Seafarers, it make 

training in integrated navigation systems and integrated bridge 

systems mandatory for watchkeepers on vessels equipped with 

such systems. (M-08-1)

Propose to the International Maritime Organization that it 

mandate the recording on voyage data recorders of heel angles 

through the complete range of possible values. (M‐08‐2)

To the Cruise Lines International Association:

Until the International Maritime Organization makes training 

in integrated navigation systems mandatory, recommend 

to your members that they voluntarily provide initial and 

recurrent training in integrated navigation system operation to 

crewmembers having watchkeeping responsibilities on vessels 

equipped with such systems, and include in that training a 

requirement for a demonstrated level of proficiency. (M‐08-3)

Through your website, publications, and conferences, inform your 

members about the circumstances of this accident and urge them 

to incorporate into their safety management systems and training 

programs for officers in charge of the navigational watch (1) 

information about the effects on vessel performance of high-speed 

vessel operations in shallow water, and (2) initial and recurrent 

training for emergency ship-handling scenarios based on the lessons 

learned from serious marine incidents and accidents. (M‐08-4)

To SAM Electronics and Sperry Marine:

Work with cruise lines and other vessel operators to develop a 

system that provides you with critical information regarding 

errors or potential problems in the use of integrated navigation 

systems or integrated bridge systems and apply the lessons 

learned to system design and crew training. (M‐08‐5)
Recommendations

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BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER ROBERT L. SUMWALT

Chairman Vice Chairman

DEBORAH A. P. HERSMAN KathRYN O’LEARY Higgins

Member Member

STEVEN R. CHEALANDER

Member 

Member Hersman filed the following dissenting statement on January 15, 2008.

Notation 7963B

Member Hersman, Dissenting: 

I voted against Recommendation #1 to the Coast Guard to propose that IMO 

make training in INS and IBS mandatory for watchkeepers on vessels equipped 

with such systems because I do not believe it addresses the shortcomings identified 

in this accident investigation.

Our report very clearly states that the NTSB believes that mariners should 

be required to take INS training, yet at the same time, we acknowledge that 

such training may be ineffective if mariners cannot demonstrate mastery of the 

subject matter or currency. In this case, the crew had all received INS training 

at the manufacturer’s facility: the Captain completed a 3-day course in 1997; the 

Staff Captain completed a 4-day course in 2002; and the Second Officer completed 

a 3-day course in 2004. Nevertheless, our report concludes, “The errors of the 

captain and staff captain in operating the INS resulted from inadequate training.” 

Moreover, our investigators’ analysis found shortcomings in INS training that may 

have contributed to errors that played a role in other heeling incidents reviewed in 

this investigation. 

Under the current system, completing INS training does not assure mastery 

of the system because students are not required to demonstrate mastery of an 

INS at the completion of most formal INS training programs. Further, neither the 

Coast Guard nor the IMO require licensed mariners who have completed initial 

INS training take courses thereafter. Because this crew had received training, our 

recommendation to require training without addressing competency and currency 

does not fully address the concerns identified in the report and would not prevent 

a similar event from recurring. 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

Mark V. Rosenker Robert L. Sumwalt

Chairman Vice Chairman

Deborah A. P. Hersman Kathryn O’Leary Higgins

Member Member

Steven R. Chealander

Member

Adopted: January 30, 2008
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At the Board meeting on January 10, my colleagues were reluctant to include 

competency and currency training in our recommendation to the Coast Guard 

because that would be asking for too much too soon. There was the argument 

that the IMO must first establish through delicate negotiations with many other 

countries a requirement for mandatory INS training before it can entertain a 

suggestion by the Coast Guard to also require a demonstration of proficiency or 

recurrent training. While I understand the sensitivity of the Coast Guard’s position 

with the IMO regarding any such recommendation, I also do not believe it is our 

role to determine what the negotiating posture of the Coast Guard should be. Our 

report seems to build an argument for a fuller, more inclusive, recommendation. I 

believe we should have put forth the more inclusive recommendation, leaving it up 

to the Coast Guard to determine what it will encourage the IMO to accomplish. 

I note that the IMO has already developed an INS/IBS “model course.” 

In addition, in 2006, the IMO’s Subcommittee on Standards on Training and 

Watchkeeping (STW) considered the need for a comprehensive review of the 

Seafarer’s Training, Certification, and Watchkeeping (STCW) Convention and 

the STCW code, and proposed INS/IBS training as a work item with a target 

completion of 2008. In an effort to not ask for too much, our new recommendation 

may be asking for something already underway, and perhaps it is asking for even 

less than what is already underway. 

The NTSB determines what happened in an accident and, as an independent 

voice of safety, recommends changes to prevent future accidents. It is up to others 

(industry, labor, regulators, government officials) to determine whether or not 

to adopt our recommendations. We are not the regulator bound by cost-benefit 

analysis, nor are we the international negotiator bound by political concerns. If 

we begin to anticipate how the recipients of our recommendations will respond, 

and modify our recommendations according to what can be accomplished in the 

near term, we are neglecting to promote broader safety initiatives that can be 

accomplished in the long term. As the sentinels of safety, we must issue candid 

and uncensored recommendations designed to encourage safety improvements 

for the immediate future as well as for many years to come. 

 

Deborah A. P. Hersman

 January 15, 2008

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Appendix A 

Investigation

The Safety Board was notified of the Crown Princess accident by the Board’s 

communication center at 1725 on July 18, 2006. The Board launched a team of three 

investigators from Washington, DC, to Port Canaveral, Florida. The investigatorin-charge arrived the evening of July 18, boarded the ship, and retrieved the data 

from the vessel’s voyage data recorder. The next morning, the two other Board 

investigators (specialists in marine engineering and survival factors) arrived and 

joined investigators from the U.S. Coast Guard on board the ship. The team was later 

joined by a representative of Bermuda, the vessel’s flag state. No Board Member 

traveled to the scene. The investigative team interviewed witnesses, including the 

officers on the bridge watch at the time of the accident, and traveled with the crew 

and others on a postaccident test of the vessel’s navigation and steering equipment 

on July 20 and 21. The on-scene investigation concluded on July 22.

The Safety Board investigated the accident under the authority of the 

Independent Safety Board Act of 1974, according to the Board’s rules. The parties 

to the investigation were the U.S. Coast Guard, Princess Cruises, and SAM 

Electronics.
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Appendix B

Voyage Data Recorder Data Plots 
Appendix B 

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PLOT 2 

Appendix B
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Appendix B
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Plot 4 

Appendix B
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Appendix C 

Voyage Data Recorder Audio Transcript

The reader of this report is cautioned that the transcription of a bridge voice 

recorder audio recording is not a precise science but is the best product possible 

from a Safety Board group investigative effort. The transcript or parts thereof, if 

taken out of context, could be misleading. The transcript should be viewed as an 

accident investigation tool to be used in conjunction with other evidence gathered 

during the investigation. Conclusions or interpretations should not be made using 

the transcript as the sole source of information.

Transcript of a Broadgate voyage data recorder installed on cruise ship 

Crown Princess, which was involved in a heeling indicant that resulted in 298 

injuries shortly after departing Port Carnival on July 18, 2006.

BAM Bridge area microphone voice or sound source

CAPT Voice identified as the captain 

2/O Voice identified as the second officer

S/CAP Voice identified as staff captain

S/CAP(T) Voice identified as staff captain on telephone

4/O Voice identified as 4th officer

REL CAP Voice identified as relief captain

AB/HELM-1 Voice identified as able body helmsman

INTCOM Intercom communication

INT COM (e) Intercom from engineroom 

Radar Video VDR radar video image

* Unintelligible word

# Expletive

@ Nonpertinent word

( ) Questionable insertion

[ ] Editorial insertion

Note 1: Times are expressed in eastern daylight time (EDT). 

Note 2: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the 

words as spoken.

Note 3: A nonpertinent word, where noted, refers to a word not directly related to the operation, control, or 

condition of the vessel.
Appendix C 

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Local 

Time

VDR 

Time Source Content

14:44:31 18:49:08 2/O Forty-five

4/O Forty-five

14:44:34 18:49:11 S/CAP Did you ask the Captain? 

14:44:36 18:49:13 REL CAP I think we should pass this...

???? I’m pretty sure...

14:44:39 18:49:16 S/CAP No No .So it is a CF buoy

2/O It is

14:44:43 18:49:20 S/CAP Ah Ok 

14:44:44 18:49:21 S/CAP So forty-five, round number

2/O Um full away at forty-five

14:44:53 18:49:30 INT COM (e) Ok what’s that sorry 

S/CAP forty-five

2/O At forty-five 

14:44:58 18:49:35 INT COM (e) forty-five Louie

???? Unintelligible

14:45:23 18:50:00 S/CAP Nostromo all flags

CAPT definitely star...

4/O ninety RPM

2/O ninety RPM

???? Right it’s time to go 

???? ...so actually 

CAPT So what exactly is the weather?

???? me ah...do ah ...

CAPT ...web site...

S/CAP (T) so is the bow.... cleared for sea?

14:47:03 18:51:40 S/CAP Ok
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Local 

Time

VDR 

Time Source Content

14:47:05 18:51:42 S/CAP Anchors secured eh

2/O Anchors secured yea got that.

14:47:40 18:52:17 S/CAP ...he is outside the...

14:47:42 18:52:19 CAPT ninety-five

2/O ninety-five

14:47:44 18:52:21 S/CAP It’s just ah - a depression they call it tropical. 

14:48:32 18:53:09 CAPT one two nine

14:48:34 18:53:11 AB/HELM one two nine

14:51:13 18:55:50 ECR twenty two point two

14:51:15 18:55:52 2/O twenty two point two, yea the captain will speak to 

the chief.

ECR Ok

14:51:19 18:55:56 2/O That was it, and...

14:51:23 18:56:00 BRIDGE Sound of Phone ring....

14:51:28 18:56:05 CAPT Hello Captain...

14:51:35 18:56:12 CAPT Hay Carlo, we want to go as fast as we can for the time 

being for the weather.

14:52:00 18:56:37 CAPT Port three

14:52:02 18:56:39 AB/HELM Port three

14:52:32 18:57:09 CAPT five-degrees

14:52:34 18:57:11 AB/HELM five-degrees

14:56:01 19:00:38 CAPT one zero zero

14:56:03 19:00:40 AB/HELM one zero zero

14:57:24 19:02:01 AB/HELM Heading one zero zero sir.

14:57:27 19:02:04 CAPT Ok

15:00:51 19:05:28 CAPT three thirty NACOS-1

2/O right sir
Appendix C 

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Local 

Time

VDR 

Time Source Content

15:01:10 19:05:47 BAM Sound of switch

15:01:15 19:05:52 2/O NACOS-1

15:01:16 19:05:53 CAPT NACOS-1

15:01:17 19:05:54 2/O Engaged

15:01:18 19:05:55 AB/HELM ...NACOS....

15:01:19 19:05:56 2/O Wait there a second.

15:01:28 19:06:05 2/O ECR coming down to one set of steering motors now.

15:01:33 19:06:10 ECR OK one steering motor.

15:01:37 19O6:14 2/O Ok we will do one and three

15:01:41 19:06:18 ECR You need to keep the watertight doors closed

CAPT Yes still...

15:01:45 19:06:22 2/O Yes please we will keep them closed for the time being.

15:02:47 19:07:24 CAPT Looks like a tour boat....fish watching.

15:02:54 19:07:31 ???? ..... turning

15:02:59 19:07:36 S/CAP Fish watching...

15:03:00 19:07:37 CAPT yea ok

15:03:01 19:07:38 ???? Right Adam

15:03:02 19:07:39 2/O Sir

15:03:03 19:07:40 CAPT You go ahead come around. Come around here.

15:03:07 19:07:44 2/O Alright.

???? unintelligible

15:03:13 19:07:50 CAPT Were over there because you won’t put it in

15:03:17 19:07:54 CAPT Otherwise ...traffic see the buoy see the buoy

15:03:19 19:07:56 2/O Sir 

15:03:20 19:07:57 S/CAP that’s the buoy

15:03:21 19:07:58 CAPT and it’s being able to access.
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Local 

Time

VDR 

Time Source Content

15:03:22 19:07:59 2/O Speeding up to max on 6

15:03:49 19:08:26 S/CAP What’s the range to that vessel....

15:03:51 19:08:28 CAPT I don’t know what.....

15:03:53 19:08:30 CAPT NACOS-one?

15:03:54 19:08:31 2/O NACOS-one

15:03:56 19:08:33 CAPT Reese?????

15:03:57 19:08:34 2/O parameters....set-up

15:04:01 19:08:38 CAPT Rudder group set up

15:04:03 19:08:40 CAPT set at ten....Yea

15:04:07 19:08:44 CAPT She’s applying port helm

15:04:12 19:08:49 CAPT and you can stop two pumps running... yes it’s always a 

start

15:04:17 19:08:54 CAPT Now she’s coming back

15:04:27 19:09:04 CAPT ....what are you set?

15:04:37 19:09:14 CAPT I think we’re better off with...

15:04:46 19:09:23 BAM beep beep

15:04:55 19:09:32 CAPT alright we’re in NACOS, heading mode

15:04:59 19:09:36 CAPT zero nine nine

15:05:01 19:09:38 CAPT now we’re going to port...

15:05:04 19:09:41 CAPT Steadying up

15:05:05 19:09:42 CAPT OK

15:05:06 19:09:43 BAM beep beep beep.... (TP rudder limit, identified from radar 

image)

15:05:08 19:09:45 2/O Rudder limit alarm.

???? unintelligible

15:05:19 19:09:56 CAPT Hopeless

15:05:22 19:09:59 2/O I don’t think we’re on....

15:05:26 19:10:03 ???? alright 
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Local 

Time

VDR 

Time Source Content

15:05:31 19:10:08 BAM sound of click

???? unintelligible switches

15:05:32 19:10:09 BAM sound of click

15:05:33 19:10:10 2/O I don’t see why it is

15:05:36 19:10:13 CAPT Dominico

15:05:37 19:10:14 S/CAP yes sir

15:05:38 19:10:15 CAPT We’re wandering all over the place..., we put her into 

NACOS-1

15:05:43 19:10:20 CAPT There’s nothing wrong with the steering pumps, the helm is 

responding.

15:05:53 19:10:30 BAM sound of phone ring

CAPT something

15:05:58 19:10:35 S/CAP lendis parma (phone answer)

15:06:00 19:10:37 S/CAP Ok...

15:06:05 19:10:42 S/CAP next course

15:06:06 19:10:43 BAM click

15:06:07 19:10:44 S/CAP you alright with that?

15:06:09 19:10:46 CAPT At the moment she is not responding other than10 degrees 

at a time

15:06:13 19:10:50 S/CAP we are out of its range...for sure.

15:06:16 19:10:53 CAPT Ah ha

15:06:20 19:10:57 CAPT take the helm Louie

15:06:22 19:10:59 ???? say again

15:06:24 19:11:01 ???? Ok

15:06:27 19:11:04 BAM Arr Arr (warning) followed by and simultaneous with beep 

beep beep....

15:06:29 19:11:06 ???? You recommend it
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Local 

Time

VDR 

Time Source Content

15:06:30 19:11:07 ???? well done... 

15:06:47 19:11:24 BAM click

15:07:07 19:11:44 Radar Video Rudder limit changed from 5 to 10 degrees

15:07:20 19:11:57 CAPT ten degrees port ....; If we can’t steer a track (questionable 

text)

15:07:23 19:12:00 S/CAP Eddy, ?????

15:07:34 19:12:11 S/CAP I have just increased rudder and the course; gain; and now 

it is left.

15:07:42 19:12:19 S/CAP Unintelligible - approaching

15:07:48 19:12:25 S/CAP five

15:08:00 19:12:37 BAM beep beep beep...(rudder limit alarm)

15:08:03 19:12:40 Radar Video Alarm List – TP Rudder Limit

15:08:07 19:12:44 S/CAP

15:08:09 19:12:46 CAPT Yea

15:08:25 19:13:02 ???? unintelligible

15:08:37 19:13:14 BAM sound of alarm five-tones

15:09:28 19:14:05 ???? unintelligible

15:09:35 19:14:12 CAPT What

15:09:36 19:14:13 S/CAP ... there is a party with ah course limit..... 

15:10:32 19:15:09 2/O ...Captain

15:10:34 19:15:11 S/CAP ..increase too much..., we’re at maximum 

15:10:38 19:15:15 CAPT No idea but I don’t want her to (turn and drift). 

15:10:43 19:15:20 BAM high pitch alarm

15:10:53 19:15:30 S/CAP unintelligible (laugh)

15:11:04 19:15:41 2/O alright hang on 

15:11:08 19:15:45 BAM (sound of click) followed by high pitch tone

15:11:18 19:15:55 S/CAP unintelligible
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Local 

Time

VDR 

Time Source Content

15:11:23 19:16:00 S/CAP wait turn around .. we are just in the middle don’t move it, 

so what am I management ....

15:11:46 19:16:23 CAPT master...according to our officers...

15:11:48 19:16:25 S/CAP (Italian) si,... to a one hundred-meters....OK. (consistent 

with phone conversation)

15:11:53 19:16:30 BAM sound of phone hung-up.

15:11:59 19:16:36 S/CAP Is it ok now?

15:12:00 19:16:37 CAPT No, ah no because, it was up to ten (meters )four miles, 

We’re bring it down to radius two.

15:12:23 19:17:00 CAPT Is it alright

15:12:26 19:17:03 S/CAP No no its better to do it by hand.

15:12:29 19:17:06 S/CAP it’s applies

15:12:33 19:17:10 CAPT you just applied it

15:12:34 19:17:11 S/CAP applied within this, every time you change it applied, where 

she is adapting at this point.

15:12:36 19:17:13 CAPT yea yea.

15:12:39 19:17:16 S/CAP ....so if you give it a change like oh (ten or fifteen) degrees 

you will adapt to that 4-mile range. But if you keep 

changing one by one then (it never or the number) stops it 

needs to...

15:13:03 19:17:40 2/O I can just look at it

15:13:06 19:17:43 S/CAP Yea, actually when you (hold or alter) this switch, it will 

show you continuous curve to the next track. And may be 

its when....applies...(unintelligible - ends at 15:13:20)

15:13:10 19:17:47 2/O unintelligible

15:13:12 19:17:49 BAM Phone ringing

15:13:23 19:18:00 CAPT Ok

15:13:39 19:18:16 CAPT Ok...put in nine nine nine

15:13:41 19:18:18 S/CAP (conversation in Italian – continues until 15:15:16)

15:14:33 19:19:10 CAPT stay in that turn,.....Ok we’ll run like that.
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Local 

Time

VDR 

Time Source Content

15:14:42 19:19:19 CAPT unintelligible

15:15:05 19:19:42 CAPT Where is the track?

15:15:07 19:19:44 2/O unintelligible

15:15:15 19:19:52 CAPT the track

15:15:24 19:20:01 CAPT What’s the next track

15:15:30 19:20:07 4/O zero eight

15:15:35 19:20:12 CAPT How do you check it?

CAPT Did you check it?

15:15:38 19:20:15 CAPT How do you check it?

15:15:41 19:20:18 CAPT Maybe the navigator put in the wrong number.

15:15:48 19:20:25 CAPT ..... we better check it.

15:15:50 19:20:27 S/CAP We can catch the liar

15:15:55 19:20:32 CAPT No, that’s only if you...

15:16:11 19:20:48 S/CAP That number can not be dialed, there is ah another one 

that can be I want him, I want him to dial another one, 

larger that I can see from here.

CAPT Oh yea yea.

15:16:20 19:20:57 S/CAP logically I can see from here not that I could put that .. but 

that number is on the first leg on the track line so that’s 

come from..

15:16:33 19:21:10 CAPT still good to check

15:16:36 19:21:13 S/CAP still good to check. Put the EBL on and ah. 

15:16:38 19:21:15 CAPT That’s Ok; 

15:16:39 19:21:16 S/CAP This is reversed.

15:16:40 19:21:17 CAPT I’ am going to leave on “O” 4, {then, check please check 

back.} are you happy?

15:16:44 19:21:21 2/O I am sir

15:16:45 19:21:22 CAPT Check each ...zero four zero..{unidentified background 

conversation}
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Local 

Time

VDR 

Time Source Content

15:16:55 19:21:32 2/O Can not.

15:16:56 19:21:33 CAPT Alright

15:16:57 19:21:34 S/CAP Had a job for the gadget.

15:16:59 19:21:36 CAPT I don’t know how long {he’s been with it}

15:17:01 19:21:38 2/O nine seven zero ..You guessed it...

15:17:03 19:21:40 S/CAP One hundred percent

15:17:04 19:21:41 CAPT Yes 

15:17:05 19:21:42 2/O Check

15:17:06 19:21:43 REL/CAP We were we have some office books booklets which are 

in an envelope... we have some big big books so many 

books...[continued background conversation until 19:22:58]

15:17:13 19:21:50 CAPT Anchors secured for... 

15:17:14 19:21:51 BAM Sound of two sharp bangs followed by two beeps.

15:17:15 19:21:52 CAPT the doors ....one hundred and thirty.... 

15:17:18 19:21:55 2/O Sixtieth

15:17:20 19:21:57 S/CAP It is nine o’clock...quarter past eleven..

15:17:23 19:22:00 2/O and the depth?

15:17:23 19:22:00 S/CAP [background conversation (lottery betting etc.) continues 

until19:22:59]

15:17:28 19:22:05 CAPT Ahm...just before they open.... you have the starboard 

side?

15:17:40 19:22:17 CAPT You happy with the books, the staff captain books?......

15:17:41 19:22:18 2/O yes sir 

15:17:43 19:22:20 ???? You know...

15:17:46 19:22:23 CAPT It’s only going to be a few minutes...and

2/O I know

???? Unintelligible 

15:18:02 19:22:39 ???? It’s not that at all
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Local 

Time

VDR 

Time Source Content

15:18:04 19:22:41 S/CAP You’ll have to check with your Bosun.

???? What’s the ...?

15:18:08 19:22:45 ???? I’m trying to get near...

15:18:09 19:22:46 ???? Remember you can use that without bringing it up

15:18:12 19:22:49 2/O Yea

15:18:14 19:22:51 CAPT Ok you got the conn.

15:18:16 19:22:53 2/O I have the conn.

15:18:18 19:22:55 2/O Luigi....

15:18:20 19:22:57 4/O Yes sir

15:18:32 19:23:09 S/CAP We have also got four charts from the area, so that ah we 

will also have paper charts for the gadget.

15:18:39 19:23:16 ???? For what?

15:18:39 19:23:16 CAPT The wind sensors slipped has it?

15:18:41 19:23:18 ???? Ah this....

15:18:43 19:23:20 CAPT starboard wing

15:18:44 19:23:21 2/O ...could be arriving in

15:18:45 19:23:22 S/CAP New York

15:18:46 19:23:23 S/CAP So that Luigi can check in the track on the chart; which 

one, check the track no put ah.. 

15:18:51 19:23:28 REL/CAP Which one is the pilot..? 

15:18:57 19:23:34 CAPT Yea we have the wind beside us.

15:18:58 19:23:35 ???? You said that..

15:19:10 19:23:47 ???? Ah ______watch

15:19:14 19:23:51 CAPT I think I will go and put my feet up.

15:19:18 19:23:55 ???? Feet up Feet up

15:19:20 19:23:57 S/CAP Yeah.... I was thinking the same, but ah I can’t do it too late 

now, too late.
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Local 

Time

VDR 

Time Source Content

15:19:28 19:24:05 S/CAP Ah, I’ll see you later minute second second ....... here.

15:19:34 19:24:11 S/CAP The chief is doing ah, oh ah he has to change a couple of 

things and one operator.... that’s fine.

15:19:42 19:24:19 S/CAP 

15:19:47 19:24:24 CAPT ...I would like to walk through another..

15:19:50 19:24:27 S/CAP No No not for this ship no....

15:19:54 19:24:31 S/CAP (unintelligible conversation) 

15:20:17 19:24:54 ???? ....captain

15:20:23 19:25:00 CAPT Pick it up

15:20:24 19:25:01 CAPT Adam

15:20:28 19:25:05 CAPT It’s all happening Adam this is the Captains handing over

15:20:31 19:25:08 2/O And...

15:20:56 19:25:33 2/O I printed it out... (unintelligible conversation)

15:21:08 19:25:45 2/O ...I just wanted to double check

15:21:10 19:25:47 S/CAP Ah you want to check mine against yours?

15:21:12 19:25:49 2/O yeah

15:21:24 19:26:01 CAPT ...safety..

15:21:26 19:26:03 S/CAP I am still available to go through that with you check.

15:22:02 19:26:39 S/CAP Ok Nico I’ll see you later I am going to ...office.

15:22:09 19:26:46 REL/CAP ....chart.

15:22:11 19:26:48 2/O sorry

15:22:11 19:26:48 2/O No but from New York we’ll have the charts from New York

15:22:21 19:26:58 REL/CAP We don’t have any charts here, we don’t have any charts 

from here to New York

15:22:26 19:27:03 2/O We do but just for the cadets for training purposes, we’ve 

ordered a few extra charts so they can do some practicing, 

ah when we arrive in New York
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Local 

Time

VDR 

Time Source Content

15:22:37 19:27:14 REL/CAP Anyway next time we use the parallel index, we go with the 

parallel indexing and you see how much ..... 

15:22:44 19:27:21 ???? I use the (questionable text) one here....

15:22:50 19:27:27 REL/CAP Ah the line

15:23:11 19:27:48 4/O You are still ah, you are still ah, turning

15:23:14 19:27:51 2/O Sorry

15:23:11 19:27:48 4/O You are still turning

15:23:17 19:27:54 2/O Na na, it’s a, well a few degrees at a time Luigi not much.

15:23:24 19:28:01 REL/CAP Anyway Adam ....

15:23:28 19:28:05 2/O Alright

15:23:31 19:28:08 REL/CAP I want this because I detected something....

15:24:00 19:28:37 2/O ....on the wheel

15:24:02 19:28:39 Helm We got it, we got the wheel

15:24:05 19:28:42 BAM sound of click

15:24:13 19:28:50 4/O She She’s making me ill

.

15:24:20 19:28:57 4/O port ten

15:24:21 19:28:58 2/O I know

15:24:22 19:28:59 4/O Port ten Adam, man you are port ten, you are port ten...

15:24:23 19:29:00 2/O Yah I am coming over to starboard

15:24:26 19:29:03 BAM Sound of warning (Beep, Beep continues until 19:30:52)

15:24:28 19:29:05 4/O Adam you are at port ten

15:24:29 19:29:06 2/O Yah I am coming over; get a fin out

15:24:32 19:29:09 4/O Yes

15:24:36 19:29:13 BAM Additional warning sounds for less than second.

15:24:38 19:29:15 4/O Adam

15:24:39 19:29:16 2/O OK

15:24:41 19:29:18 4/O Adam push on the button, push on the beep
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Local 

Time

VDR 

Time Source Content

15:24:43 19:29:20 REL/CAP Reduce the speed, reduce the speed, reduce the speed

15:24:45 19:29:22 BAM Sound of objects falling to deck. (continues until 19:29: 39)

15:24:46 19:29:23 ???? unintelligible (sorry)?????.....

15:24:47 19:29:24 BAM Sound similar to door opening.

15:24:48 19:29:25 REL/CAP Reduce the speed.

15:24:48 19:29:25 BAM Sound of warning, ( continues until 19:30:31) 

15:25:00 19:29:37 CAPT Stop the engines Stop the engines 

15:25:02 19:29:39 REL/CAP Stop the.....operating again

15:25:04 19:29:41 2/O Stop the engines sir

15:25:11 19:29:48 CAPT Stop; stop the engines ask for op...

???? unintelligible

15:25:15 19:29:52 S/CAP ...we need some engines now.

15:25:16 19:29:53 CAPT ...we need to inspect the tanks...

15:25:21 19:29:58 S/CAP we need some engines now; we need some engines

15:25:26 19:30:03 BAM Sound of tones that precede Public Address System 

announcement.

15:25:33 19:30:10 CAPT ....sit-down where you are ......there is a problem with the 

steering gear and we are bring the ship back.... 

 

15:26:06 19:30:43 2/O ...fuse boxes check on all the fuse buttons

15:26:11 19:30:48 ???? starboard.

15:26:12 19:30:49 S/CAP Keep her to starboard

15:26:15 19:30:52 BAM All audible warnings stop.

15:26:20 19:30:57 ???? What time is it?

15:26:21 19:30:58 CAPT Alright every body get round quickly, see what has 

happened, there must be some people hurt, call the ah 

surgery, ...call the surgery.
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Appendix D

Pertinent Regulations and Guidelines

When the Crown Princess entered service, the following regulations and 

guidelines pertained to the NACOS system:

• International Electrotechnical Commission standard 62065 (2002), 

“Maritime navigation and radiocommunication equipment and 

systems—Track control systems—Operational and performance 

requirements, methods of testing and required test results.”

• International Maritime Organization Maritime Safety Committee 

(MSC) resolution 74 (69), May 12, 1998. Adoption of new and amended 

performance standards [regarding GPS/GLONASS receivers, track 

control systems, AISs, and echo-sounding equipment].

• International Electrotechnical Commission standard 61174 (2001). 

“Maritime navigation and radiocommunication equipment and 

systems—electronic chart display and information system (ECDIS)—

operational and performance requirements, methods of testing and 

required test results.”

• International Convention for Safety of Life at Sea (SOLAS) chapter 

V, regulation 15, “Principles relating to bridge design, design and 

arrangement of navigational systems and equipment and bridge 

procedures.” 

• International Maritime Organization MSC circular 1061, issued 

January 6, 2003, “Guidance for the operational use of integrated bridge 

systems.”

Since the vessel entered service, the International Maritime Organization 

has taken actions pertinent to the INS system on the Crown Princess. These 

include:

• International Maritime Organization MSC 82/WP.8, issued 

December 8, 2006, “Draft report of the Maritime Safety Committee on 

its Eighty-second Session.”

• Standards of Training and Watchkeeping (STW) 38/17, issued 

February 8, 2007, “Report to the Maritime Safety Committee.”
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International Electrotechnical Commission standard 62065 established 

performance standards for an autopilot system that steers a vessel along a 

predetermined track. At the time the NACOS 65 was developed, the International 

Electrotechnical Commission had not yet developed INS standards. As a result, 

the NACOS system on the Crown Princess met the trackpilot standards of 

International Electrotechnical Commission standard 62065, the pertinent standards 

of MSC 74(69), and classification society approval for an INS but not International 

Electrotechnical Commission standards for an INS. In 2006, the International 

Electrotechnical Commission adopted standard 6192, which established operational 

and performance standards for INSs. SAM Electronics told the Safety Board that 

the next NACOS generation INS will meet the operational and performance criteria 

of International Electrotechnical Commission standard 61924.

SOLAS chapter V, regulation 15, provides the basic foundation for the design 

and arrangement of navigational systems, so that they enhance the performance of 

deck watchkeepers and bridge crewmembers. 

MSC circular 1061 calls for companies to incorporate their policies on the 

use of automation and the INS in their vessel operating manuals. The circular 

also addresses training in INS use, stating that companies, “in cooperation with 

the relevant manufacturers, should establish a training programme for all officers 

which have operational duties involving the INS.” 

MSC 82, the 82nd meeting of the MSC, produced several working papers and 

suggestions for action. Its human element working group recommended that the 

International Maritime Organization include ergonomic criteria in the application 

of SOLAS regulations to INSs and in training related to INS use. 

The report of the full MSC includes information regarding British research 

that had been “aimed at developing guidance for the mitigation of human error in 

automated shipborne maritime systems.” As the report noted:

The research had identified a range of problems which could result from 

inappropriate or incorrect specification, design, selection, installation and 

use of automated systems, and suggested some methods of mitigation. 

In their opinion, the findings of this research should be considered by 

designers, shipbuilders, trainers, shore-based company management, shipbased management and seafarers themselves, to assist in the safe, effective 

and efficient use of automation aboard ships. (82/15.14)

In addition, in 2006 the MSC instructed its STW subcommittee to review 

the International Convention on Standards of Training, Certification, and 

Watchkeeping for Seafarers (STCW code). In 2007, the MSC specified that such a 

review should include an issue involving the understanding of “automatic systems 

through familiarization training. . . .” Specifically, the subcommittee reported to 

the MSC that it:
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Identified that training recommendations given by performance 

management guidelines such as Integrated Navigation Systems, Integrated 

Bridge Systems and Bridge and Engine-room Resource Management, 

should be included within the STCW Convention with a view to seafarers 

understanding the limitations and weaknesses of automated systems 

and instructed STW 38 to consider this under its existing agenda item, 

“Compressive Review of the STCW Convention and the STCW Code.”1

1 STW 38/17, February 8, 2007, “Report to the Maritime Safety Committee,” p. 31.
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Appendix E

Model Curriculum Proposed by International Maritime 

Organization

The suggested curriculum on IBS/INS system use developed by the 

International Maritime Organization assumes that the student has knowledge of 

deck operations and navigation but no IBS/INS experience. The model course is 

intended to serve as a guide for member states that are developing or certifying 

IBS/INS systems. States may use the curriculum, but the International Maritime 

Organization does not mandate such a course and does not specify when a mariner 

should take it, or the length of time that can elapse between when someone has 

completed the course and when that person uses an INS in actual vessel operations. 

The general objective of the course is noted in the Standards on Training and 

Watchkeeping (STW) circular, as follows:

The safe and efficient use at sea of IBS and INS requires a level of knowledge 

beyond that normally given in the training of an officer in charge of a 

navigational watch. It is not just a matter of learning to use new controls, 

display techniques or how to switch on and off automatic functions. More 

importantly, it is learning the decision making process that must be applied 

in order [to] gain the full benefits of the integration in a safe manner and 

avoid the new problems that automatic controls and integrated systems 

can sometimes provide (p. 4).

The STW circular includes a detailed instructor’s guide, a teaching syllabus, 

guidance on specific subject areas, recommendations both paper-and-pencil and 

simulator-based student exercises to demonstrate competence in the material, and 

guidance for evaluating a student’s knowledge of the material at the completion 

of the training. 

In addition to developing the model course, the International Maritime 

Organization’s STW subcommittee, at its 37th session (STW 37) in 2006, considered 

the need for a comprehensive review of the STCW convention and the STCW 

code, and proposed a work item with a target completion date of 2008. In May 

2006, the Maritime Safety Committee (MSC 81)1 endorsed the proposal of STW 

37 and included in the provisional agenda for STW 38 a high priority item on

“Comprehensive Review of the STCW Convention and the STCW Code,” with a 

target completion date of 2008. At the subsequent meeting of the MSC, a resolution 

was passed instructing STW 38 to consider addressing the issue of human error 

in operator interactions with integrated bridge systems and the need for “basic 

1 Report of the Maritime Safety Committee 81st session, MSC/81/25, paragraph 23.57.2.
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education and familiarization training of seafarers” as an agenda item in its 

“Comprehensive Review of the STCW Convention and the STCW Code”.2

The following pages reproduce the detailed teaching syllabus from the 

model IBS/INS course developed by the International Maritime Organization’s 

subcommittee on standards of training and watchkeeping. In addition to outlining 

the contents of the curriculum, the syllabus contains references to relevant 

publications and to teaching aids. 

2 Report of the Maritime Safety Committee, MSC 82/24, paragraph 15.50
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Appendix F 

International Maritime Organization Guidance on Integrated 

Navigation System Training
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