96003 Official Report - Mississippi River

03 Jan 1996 MARS

Official Report
Mississippi River

REPORT No. OR96003


This Official Report concerns a collision betweena large cruise liner and a bulk carrier at the entrance to the MississippiRiver in November 1993. The collision resulted in nine crew members of thecruise ship being injured and considerable damage to both vessels. The reportwas published by the American National Transportation Safety Board and copiescan be obtained from; National Technical Information Service, 5285 PortRoyal Road, Springfield, Virginia 22161. Tel. (703) 487-4600.
On the night of the accident the cruise liner NOORDAM was bound for theport of New Orleans via the Southwest Pass and the Mississippi River. Shewas proceeding at 20 knots up the Southeast Safety Fairway and had a meandraft of 24 feet 6 inches. The weather was overcast and clear with a north-westerlywind of 30 knots. The Senior Second Officer (S2/O) was on watch from 1830to 2030 and had the 'con'. Assisting him was the Fourth Officer (4/O), ahelmsman and a lookout. The 10cm ARPA radar was set on the 12 mile rangescale and was north stabilised. Two deeply laden ships, a tanker and a bulkcarrier, were also in bound on the same route. At 1955 the NOORDAM reducedspeed to 18 knots and at 2001 she altered course to 333 degrees and beganovertaking the tanker. At 2008 the speed was further reduced. At 2013 thelookout was sent from the bridge to clear the anchors. Shortly after this,the tanker, which was on the port bow, unexpectedly altered course to starboardand into the path of the NOORDAM. The S2/O ordered the helmsman to altercourse to 340 degrees and attempted to telephone the Master in his cabin.He did not get a reply and so he sent the Junior Third Officer (J3/O), whohad just arrived on the bridge to find either the Master or the Chief Officer(C/O) and request assistance.

At 2015 the Pilot Station called, asked for the ETA of the NOORDAM andinstructed the S2/O to proceed directly to the Pilot boarding area. TheC/O arrived on the bridge at about 2019 by which time the tanker had beenovertaken. The S2/O explained that the vessel had been in a near-miss situation,was now clear but heading towards some oil platforms. The C/O advised analteration to port to return to the original track. At about 2025 the Mastercame to the bridge but was assured by the C/O that everything was undercontrol and the Master left again. The C/O then poured himself a cup ofcoffee and sat in the Master's chair whilst the S2/O was handing over thewatch to the J3/O behind the chart table. They discussed the recent incidentwith the tanker, the navigation situation and various administrative tasksto be completed before the vessel's arrival. They did not discuss plansfor embarking the Pilot, the C/O's role during the final approach to theSouthwest Pass, or the likelihood of encountering other traffic. The briefingended at 2030 and the J3/O took over the 'con'.

By 2031 the NOORDAM was doing 15 knots and was 10 minutes away from thesouthern edge of the Pilot boarding area. On the bridge were the C/O, theJ3/O, the deck cadet, helmsman and lookout, the 4/O was also in attendancewaiting to escort the Pilot to the bridge. In addition, the Chief Engineer,the Chief Officer's wife and the S3/O had come to observe the vessel's finalapproach to Southwest Pass. Neither the C/O or the J3/O had ever 'conned'a vessel through the approaches without supervision. From 2030 to 2034 theJ3/O continued to familiarise himself with the navigation situation andto work on the arrival checklist. He was also monitoring the 3cm radar.At 2035 the C/O directed the helmsman to apply 10 degrees of right rudderand to steady up on a heading of 000 degrees. Although the C/O did not communicatedirectly with the J3/O, his order to the helmsman signalled that he hadassumed the 'con'. At about the same time, the lookout returned to the bridgeand the J3/O observed the Racon "T" Platform on the 3cm radar.The J3/O said that the C/O was standing next to him when he took the bearingand range but neither of them detected the presence of the MOUNT YMITOS(bulk carrier), a second bulk carrier, a freighter, or an off shore supplyvessel, all of whom were operating within a 2 mile radius of the cruiseship. The NOORDAM had begun to respond to the helm order and had startedto swing to the right (starboard) by 2036. Shortly after that, the C/O visuallyobserved a cluster of white lights on the starboard bow. He took a secondlook with his binoculars and saw a green light bearing 3 to 4 points. Heimmediately ordered the helmsman to steady the helm, walked over to theARPA to switch from the 12 mile to the 6 mile range scale and detected atarget bearing between 010 and 025 degrees at a range of about 1.1 mile.He took no further action and the course recorder showed the vessel steadiedup on a heading of 345 degrees at 2037. The C/O stated that he concludedthe green light was an outward vessel on a reciprocal course and would passsafely down the starboard side. He was unaware of the other vessel's size,type or load condition and did not alert any other person on the bridgeor try to communicate with the approaching vessel.

About 2038, the 4/O, who was talking to the S3/O, visually observed ared light bearing about 4 points on the starboard bow. He looked throughthe binoculars, realised that the light was the port sidelight of an approachingvessel and cursed loudly enough to capture the attention of everyone onthe bridge. When the C/O saw the red light, he recognised the risk of collisionand ordered the J3/O to take a visual bearing. The J3/O "eyeballed"the red light briefly and reported that the vessel appeared to have a slightstarboard drift. The C/O ordered full left rudder and stopped the port engineto increase the swing. The bow swung approximately 45 degrees to port, whilethe bow of the approaching vessel, later identified as the MOUNT YMITOSmoved down the NOORDAM's starboard side. In an effort to swing the NOORDAM'sstern away from the approaching vessel, the C/O then ordered full rightrudder. At about 2041, before the helm could take effect, the bow of theMOUNT YMITOS struck the NOORDAM''s starboard quarter.

The MOUNT YMITOS was outbound from the SW Pass loaded with 42,000 tonnesof soybean meal and had a draft of 36 feet. Between 2011 and 2024, she passedbetween the breakwaters on a heading of 170 degrees. Once clear of the breakwatersshe altered to 145 degrees and reduced speed to 6 knots to create a leefor the departing Pilot. A second bulk carrier was about 1 mile astern andthe Pilot stated that shortly after leaving the river he had identified,both visually and by radar, five vessels to the south. He was tracking themon the ARPA and had reported their presence to the Master. Just before leavingthe bridge at 2025, the Pilot communicated by radio with the nearest vesseland agreed a starboard to starboard passing and told the Master and the3/O about this arrangement. He also told the Master that he had switchedthe VHF from CH 9 to Ch 16. The Pilot disembarked at 2027.

Immediately after dropping the Pilot, the Master of the MOUNT YMITOSincreased speed and directed the helmsman to steer 170 degrees. Shortlyafter, the first inward vessel passed clear down his starboard side. Atabout 2032 he ordered a course of 190 degrees. The Master and the 3/O statedthat after they had altered course they recognised the next vessel as apassenger ship. For several minutes they watched it emerge from the SouthEast Safety Fairway. Both of them assumed that the passenger ship, and theother vessels approaching from the south, had detected and were trackingthe movement of the MOUNT YMITOS. The Master also said that he assumed thatall four vessels were heading for the SEA buoy to pick up a Pilot. He saidthat he intended to favour the western edge of the fairway and let thesevessels pass down his port side but he did not try to communicate with anyof them. By 2035, the Master could see the NOORDAM's green sidelight, whichwas bearing between 1 and 2 points on the port bow at a distance of 2 miles.He was not concerned about a collision as he expected the passenger shipto alter course to starboard towards the SEA buoy. About 2036, when thetwo vessels were approximately 1 mile apart, the Master became concernedand ordered his helmsman to apply full right rudder. About 30 seconds laterthe MOUNT YMITOS began to swing slowly to starboard. About 2039, the Masterrealised that the NOORDAM had altered course to port. Her put the main engineon 'Stop' and then on 'Emergency Full Astern'. In addition, he made twoback-to-back attempts to contact the vessel on VHF whilst the 3/O was tryingto attract the NOORDAM's attention by shining the Aldis Lamp in their direction.At 2041, the bow of the MOUNT YMITOS struck the starboard quarter of theNOORDAM.

The conclusions of the inspectors into the incidentwere:

Neither weather nor sea conditions were factors in this incident: investigators found no significant defect in the propulsion, steering, and navigation equipment on either vessel; the technical qualifications of the Master and the bridge watchstanders on both vessels met or exceeded international requirements; the personnel involved were not impaired by lack of sleep and they tested negative for alcohol and drugs.

The Master demonstrated poor judgement by not being on the bridge during the brief transit from open sea to the pilot boarding area.

The S2/O's failure to communicate his intention to overtake the tanker CAPTAIN VENIAMIS demonstrated poor seamanship and placed the NOORDAM and its passengers and crew in an unsafe situation.

The Master's decision to rely solely on second-hand information provided by his Chief Officer led him to conclude incorrectly that his presence on the bridge was not needed.

The failure of the C/O, the S2/O and the J3/O to communicate important information during the 11 minutes preceding the accident left them ill-prepared to conduct a proper bridge watch.

The C/O and the J3/O were not maintaining a proper lookout for approaching traffic, either visually or by radar, because basic seamanship and watchstanding discipline were not being observed on the NOORDAM's bridge.

The NOORDAM's C/O's presumption that the MOUNT YMITOS was on a parallel and reciprocal course was based on too little information; when he saw the green light 5 minutes before the accident, he should have attempted to communicate with the approaching vessel and, if unsuccessful, he should have stopped or reversed the engines and sounded the danger signal.

By the time the C/O recognised the danger, the collision was probably unavoidable.

The watchstanders on the MOUNT YMITOS were maintaining a vigilant lookout for vessels operating nearby.

The MOUNT YMITOS's Master's expectations regarding the NOORDAM were reasonable; however, he knew the limitations of his deeply laden vessel, and he should have tried to communicate with the NOORDAM while successful evasive action was still possible.

The Holland America Line's 'oversight program' did not identify a number of departures from the company watchstanding policies; thus, additional measures are needed to assess bridge watchstanding performance on company ships.

If passage planning standards that require a discussion between the Master and the watchstanders before entering restricted waters had been developed and implemented, the risk of an accident would have been reduced.

The NOORDAM's Master's procedures for informing and providing responsible direction to crew and passengers were ineffective.
The National Transportation Safety Board determinesthat the probable cause of the collision was the failure of the NOORDAM'sC/O and J3/O to maintain a proper lookout, either by sight or by radar.Contributing to the accident was the failure of the Master of the MOUNTYMITOS to communicate with the NOORDAM until collision was inevitable.

Having the ARPA set on 12 mile range when approaching the pilot stationis also bad practice. The radars should be set on the most suitable rangefor the circumstances and used as an aid to navigation and collision avoidance.