Official Report: Grounding of Cruise Ship
- Report No. 7042OR
The following extracts from the report by the USNSTBinto the grounding if the cruise ship ROYAL MAJESTY should be a warningto all navigators of the dangers of relying on one source of information. The ship went aground whilst on a cruise with over 1,000 passengers onboard. The GPS had reverted to DR Mode after an antenna cable had partedand was thus not giving an accurate fix. In spite of being in coastal waters,the watch officers placed over-reliance on the information given to themby the automated features of the integrated bridge system..
THE FINDINGS OF THE NSTB ARE:
The weather, the mechanical condition of the Royal Majesty, except for the Global Positioning System receiver, the officers' certifications, drugs, and fatigue were not factors in the incident.
Although Coast Guard personnel observed no indications that the officers had been under the influence of alcohol, alcohol could not be conclusively ruled out as a factor in the accident because of the delay in collecting the blood and urine specimens.
About 52 minutes after the Royal Majesty left St Georges, Bermuda, the GPS receiver antenna cable connection had separated enough that the GPS switched to dead reckoning mode, and the Autopilot, not programmed to detect the mode change and invalid status bits, no longer corrected for the effects of wind, current or sea conditions.
Openly routing the GPS antenna cable in an area where someone occasionally walked, increased the risk of damage to the cable and related connectors.
Had the fathometer alarm been set to 3 meters, as was the stated practice, or had the Second Officer chosen to display the fathometer data on the control console, he would have been alerted that the Royal Majesty was in far shallower water than expected and thus was off course. He would have been alerted perhaps as long as 40 minutes before the grounding and the situation could have been corrected.
The watch officers' monitoring of the status of the vessel's GPS was deficient throughout the voyage from St Georges.
Deliberate cross checking between the GPS and the Loran-C to verify the Royal Majesty's position was not being performed and should have been on the voyage from St Georges.
Even though it is likely that the watch officers were not aware of the limitation of using the position fix alarm to monitor course accuracy, it was not appropriate for them to rely solely on this feature to warn them of deviations from the ship's intended course.
The sighting of lights not normally observed in the traffic lanes, the second officer's inability to confirm the presence of the "BB" buoy, and the sighting of blue and white water should have taken precedence over the automation display on the central console and compelled the second officer to promptly use all available means to verify his position.
The chief officer and the second officer did not observe good watchkeeping practices or act with heightened awareness of the precautions that are needed when a vessel approaches the Boston traffic lanes and landfall.
The master's methods for monitoring the progress of the voyage did not account for the technical capabilities and limitations of the automatic equipment.
The watch officers may have believed that, because the GPS had demonstrated sufficient reliability over 3_ years, the traditional practice of using at least two independent sources of position information was not necessary.
All the watch standing officers were overly reliant on the automated position display of the NACOS 25 and were, for all intents and purposes, sailing the map display instead of using navigation aids or lookout information.
Because the industry standard National Marine Electronics Association (NMEA) 0183 data protocol did not provide a documented or standardised means of communicating or recognising that a DR positioning mode was in use by a hybrid, DR capable position receiver. Raytheon and STN Atlas adopted different design philosophies about the communication of position receiver mode changes for the 920 GPS and the NACOS 25.
STN Atlas should have, in order to help ensure safety and compatibility with different NMEA 0183 position receivers, programmed the Royal Majesty's NACOS 25 to recognise that the VALID/INVALID status bits in the NMEA 0183 data, including those specified in the NMEA 0183 vl.5 "RMC" recommended minimum GPS data sentence.
Had the NACOS 25 autopilot been configured to compare position data from multiple independent position receivers and had a corresponding alarm been installed that activated when discrepancies were detected, the grounding of the Royal Majesty would have been avoided.
Because the watch officers must verify proper equipment frequently, alternative sources of critical equipment status should have been displayed directly on to the console or on the repeaters located where they could be seen from the central console.
The brief aural alarm of the Raytheon 920 GPS receiver, the remoteness of the receiver's location, and the failure of the installer to connect the GPS external alarm resulted in the inadequacy of the aural warning sent to the crew when the GPS defaulted to the dead reckoning mode.
Performing failure modes and effects analyses of the Royal Majesty's integrated bridge system would probably have disclosed the short comings of the system's components.
The on job training program employed by Majesty Cruise Line to train watch officers in the operation of the integrated bridge system did not adequately prepare these officers to identify and respond to system malfunctions.
The Royal Majesty's integrated bridge system did not adequately incorporate human factors engineering.
Currently, there are no performance or training standards for integrated bridge systems, nor are they required to be inspected or certified.