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General Aviation Safety
On May 14, 2007, about 0130 Alaska daylight time, the passenger vessel Empress of the North grounded at the intersection of Lynn Canal and Icy Straits, about 20 miles southwest of Juneau, Alaska, after the vessel failed to negotiate a turn to the west. No injuries resulted from the accident, but the vessel sustained significant damage to its underside and propulsion system. The 206 passengers were safely evacuated to assisting vessels and transported back to Juneau.
The National Transportation Safety Board recommends that the U.S. Coast Guard: Conduct a one-time inspection and correction of all deficiencies of evacuation slides last serviced by Marine Safety Services of Seattle, Washington. (Urgent)
Original recommendation transmittal letter:
Closed - Acceptable Alternate Action
Chatham Straits, AK, United States
Grounding of U.S. Passenger Vessel
Empress of the North
Addressee(s) and Addressee Status:
USCG (Closed - Acceptable Alternate Action)
Safety Recommendation History
In its Board Meeting on the Queen of the North accident, the Board addressed this recommendation as follows: In its August 21, 2007, response to Safety Recommendation M-07-10, the Coast Guard stated that inspectors who visited the service company, Marine Safety Services, after the accident had determined that "it would be extremely difficult to pack the slides incorrectly" without modifying the valises and that "[a]ny incorrect folding or orientation would likely make the slide impossible to deploy in any direction." The Coast Guard concluded that Marine Safety Services had serviced the slides correctly and that crewmembers had most likely "placed the valises upside down on the deck," causing them to deploy incorrectly. As described in the "Tests and Research" section [of the Queen of the North report], after receiving the Coast Guard’s response, investigators visited both Marine Safety Services and DBC Marine Safety Systems, the manufacturer of the equipment, to test the evacuation slides. The investigators simulated the scenario the Coast Guard had posited as most likely, that is, that the valises holding the slides had been placed upside-down on the deck. In that position, the stenciled instructions for positioning and inflating the slide, as well as the inflation cord, would have been on the bottom of the valise and therefore not visible to crewmembers. The chief mate told investigators that he could see the stenciled instructions on the valises when the crewmembers installed them on the deck. Further, inflating the slides would have been difficult if the valises were upside-down, because crewmembers would have had to lift the 60-pound gas cylinder to reach the inflation cord. It is thus unlikely that the crew placed the valises upside-down on the deck of the Empress of the North. On July 12, 2007, DBC Marine Safety Systems issued a service bulletin that instructed servicing facilities to mark the tops of the valises containing the evacuation slides "THIS SIDE UP" and the bottoms "TURN OVER." The company also prepared stencils to label the insides of the valises so that technicians could readily determine the correct orientation of the valises when packing the evacuation slides. The Safety Board judges that the company’s actions should eliminate any confusion about packing the valises or positioning them on deck and proposes no further action on this issue. Investigators also examined the two other possible ways the valises containing the evacuation slides could have been placed on deck. In tests with the valise placed right side up but backward (with the outboard arrow pointing inboard), the slide inflated upward and folded back against the test platform. On a vessel, the inflated slide would have blocked the exit. The chief mate identified a diagram, created by DBC Marine Safety Systems during the postaccident tests, in which a slide was inverted and folded back against the outside of the ship, thereby blocking the embarkation area, as matching the way the slides malfunctioned on the Empress of the North. Although it is possible that in the excitement after the accident the crew might have secured the valises backward on the deck, it is unlikely that after the first slide inflated upside-down the crew would have repeated the mistake. The chief mate told investigators that after the first slide inflated incorrectly, he examined the second slide’s position and had crewmembers check the position of the arrows. The chief mate also said that this was not the first time he had used the slides and that the valises were installed on deck as a part of regular crew training. The instructions on the valises were clear and concise: one arrow pointed outboard, the other pointed inboard, making it unlikely that the crew placed the valises backward on the deck. If the valises had been positioned correctly on deck, the slides could have inflated incorrectly only if the valises were mislabeled or the slides were packed incorrectly into the valises. Investigators examined a valise from the Empress of the North taken after the accident and determined that it was properly labeled. Investigators discussed the possibility of a packing error with the manufacturer and determined that the most likely error would have been to fold the slide correctly but place it in the top half of the valise instead of the bottom. Investigators determined that a slide packed upside-down would inflate upside-down, and that there would be no visible indications that the slide had been packed incorrectly. The Safety Board therefore concludes that the most likely reason the vessel’s evacuation slides did not inflate properly was that the service company had packed them into the wrong side of their valises. The Coast Guard concluded after its inspectors visited Marine Safety Services that the valises had probably been placed upside-down on the deck of the Empress of the North. Although the Safety Board’s analysis disagrees with the Coast Guard's conclusion, DBC Marine Safety System’s subsequent service bulletin should prevent any misunderstandings about the correct positioning of the valises on deck, and the instructions stenciled on the inside of the valises should prevent misunderstandings about how to pack the evacuation slides into them. The Board therefore classifies Safety Recommendation M-07-10 as Closed-Acceptable Alternate Action.
The Safety Board notes that in July 2007, inspection staff from U.S. Coast Guard Sector Seattle visited MSS, the facility that serviced the slides onboard the Empress of The North. Although the Board had believed that the action outlined in the Coast Guard’s August 29, 2007, letter had resolved this issue, our continuing investigation has indicated otherwise. Board investigators are working with your staff, the liferaft servicing facility, and the vessel crew to identify why the slide inflated improperly and to identify corrective measures. Pending the outcome of this effort, Safety Recommendation M-07-10 is classified Open Acceptable Response.
Letter Mail Controlled 8/29/2007 10:08:39 AM MC# 2070445: : We concur with this recommendation. On July 6, 2007, inspection staff from US Coast Guard Sector Seattle visited Marine Safety Services (MSS), the facility that serviced the slides on board the EMPRESS OF THE NORTH. We determined that Marine Safety Services had serviced only two valise packed slides that were manufactured by DBC Marine Safety (DBC) Systems Ltd. and were installed on the EMPRESS OF THE NORTH. Based on interviews with the servicing personnel and a review of the packing procedures, we determined that it would be extremely difficult to pack the slides incorrectly without making significant modifications to the valise. The pull cord especially must be oriented correctly inside the valise in order for it to be accessible at the flap. Any incorrect folding or orientation would likely make the slide impossible to deploy in any direction. We conclude that there were no deficiencies in the evacuation slide servicing by Marine Safety Services. It is likely that crewmembers, dealing with the stressful circumstances associated with the grounding, placed the valises upside down on the deck, leading to the slides deploying incorrectly. At the time of the casualty, the valises were marked only with inboard and outboard markings to indicate the correct orientation. The manufacturer has since added additional markings to ensure that the up and down sides are clearly indicated. Our action on this recommendation is complete and we request that it be closed.
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