Crown Princess Severe Listing
298 Passengers and Crew Injured
July 18, 2006
At 1406 hours on July 18, 2006, the Bermuda-registered cruise ship M/V Crown Princess, 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. 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. 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. 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 hours, 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 hours, as recorded on the vessel’s VDR, 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.
From the dock to a point beyond where the pilot disembarked, the bridge crew controlled the vessel’s steering manually. At 1501 hours, on orders from the captain, the crew engaged the trackpilot, the autopilot function of the vessel’s integrated navigation system (INS). The INS on the Crown Princess was a NACOS (Navigation and Command System) manufactured by SAM Electronics of Hamburg, Germany.
The crew set the course to 100° in heading mode, one of three available steering modes in the trackpilot. 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 . 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.”
At 1505:06 hours, during the second heading fluctuation, when the rate of turnreached 9° per minute, the trackpilot’s rudder limit alarm sounded. According to the operating instructions for the NACOS, 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.
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 hours, the staff captain increased the rudder limit from 5° to 10°. At 1508 hours, 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 hours, the captain turned the conn over to the second officer. About 1519 hours, the vessel’s heading again began to fluctuate around the set heading. The captain and staff captain left the bridge at 1522 hours, and the relief captain left about a lookouts) remained on the bridge.
About 1523 hours, 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 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.”
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, 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 hours, the vessel reached a maximum angle of heel of about 24° to starboard. 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 hours. By then, its speed had slowed to 12 knots.
Princess Cruises, like other cruise lines, employed dedicated observers on both bridge wings 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, 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,
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 hours.
The type and number of recorded injuries to passengers and crewmembers in the accident are listed in the chart below. 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.
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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