by Kim Smiley

On May 14 2007, the 300 foot cruise ship, Empress of the North, grounded out on rocks while rounding Rocky Island during a trip through Alaska’s Inland Passage.  There was significant damage to the hull and the two starboard propellers needed to be replaced.  Costs of repairs totaled more than $4.8 million.  Luckily no one was injured, but over two hundred passengers had to be evacuated from the ship.

This is a common route for cruise ships and the rocks were a well-known hazard clearly marked on navigation charts.  So what happened?

A root cause analysis shows that there were many causes that contributed to the accident.  One of causes is that there were no lookouts at the time of the accident.  The crew members who would have acted as lookouts were performing security rounds.  This was in violation of regulations requiring lookouts at all times and appears to have been a common practice for the crew.

When determining causes it’s important to ask, what is different?  In this case, this was the first watch as Deck Officer for the officer in charge.  He had recently graduated, was newly licensed and inexperienced.  He was not familiar with the deck procedures and the equipment. There was a lot of confusion about watch team roles and he didn’t attempt to take charge of the ship’s navigation until seconds before the grounding occurred.  The National Transportation Safety Board (NTSB) found that the actions, or inaction as the case may be, of the Deck Officer were one of the major factors contributing to the accident.

It’s tempting to stop at this point, but the analysis needs to go farther than just identifying the actions of the Deck Officer as a cause to do a thorough investigation.  Why was he standing watch if he wasn’t fully qualified?  Why wasn’t he prepared adequately prior to being given the responsibility?

The crew member originally assigned the watch was ill.  There are a limited number of possible replacements on a ship this size.  The Master of the ship believed the watch would be a good training watch because it was an easy watch with minimal course corrections needed.  It was also not the practice of the crew to have specific night orders for the overnight watches so the newly arrived junior third officer found himself standing the midnight to 4 am watch with minimal guidance.

Many investigations lead back to human error, but it’s important to ask questions beyond that point.  Changing how people are trained, improving the environment, and providing specific writing inspections can help prevent human errors in many cases.

(The photo above is an official Coast Guard photo.)