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Safety Recommendation Details

Safety Recommendation M-08-002
Details
Synopsis: At 1406 on July 18, 2006, the Bermuda-registered cruise ship Crown Princess, which was operated by Princess Cruises and had been in service about a month, departed Port Canaveral, Florida, for Brooklyn, New York, its last port on a 10-day round-trip voyage to the Caribbean. The vessel was equipped with an integrated navigation system1 that included a trackpilot (autopilot). About an hour after leaving port, the crew shifted from manual steering to the trackpilot. Two minutes later, the vessel’s heading began to fluctuate around the set heading. In response to an alarm indicating that the rudder had reached its set limit of movement (5° ), the staff captain increased the trackpilot’s rudder limit setting to 10° . Shortly afterward, the captain and staff captain left the bridge, leaving the second officer in charge of the navigation watch. The vessel was traveling at nearly full speed, about 20 knots, by that time.
Recommendation: TO THE UNITED STATES COAST GUARD: Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Port Canaveral, FL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA06MF018
Accident Reports:
Heeling Accident on M/V Crown Princess
Report #: MAR-08-01
Accident Date: 7/18/2006
Issue Date: 2/5/2008
Date Closed: 5/13/2014
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 5/13/2014
Response: We note that the requested performance standards were adopted by the IMO’s Maritime Safety Committee (MSC) in June 2013 under Resolution MSC.363(92), which includes a requirement for a digital interface for providing heel angle information to a VDR. We are pleased that this new requirement, applied in conjunction with the existing VDR standard (which provides for a connection to the inclinometer) and the performance standard for the S-VDR (which specifies that any additional items should be recorded when the data are available, in accordance with international digital interface standards), establishes a complete set of standards and requirements. Accordingly, Safety Recommendation M-08-2 is classified CLOSED—ACCEPTABLE ACTION.

From: USCG
To: NTSB
Date: 1/28/2014
Response: -From Peter V. Neffenger, Vice Admiral, Deputy Commandant for Operations: Performance standards were adopted by the International Maritime Organization's Maritime Safety Committee (MSC) at its 92"d session in June, 2013 under Resolution MSC.363(92). They include a requirement for a digital interface for providing heel angle information to a voyage data recorder (VDR). This new requirement applied in conjunction with the existing VDR standard that provides for a connection to the inclinometer and the performance standard for the S-VDR that any additional items should be recorded when the data is available in accordance with international digital interface standards establishes a complete set of standards and requirements to address the Board's recommendation. As such, I consider the Coast Guard's action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
Date: 7/8/2013
Response: Thank you for the April 5, 2013, letter signed by Vice Admiral Peter V. Neffenger, Deputy Commandant for Operations, to the National Transportation Safety Board (NTSB) containing your semiannual update regarding actions to address 42 safety recommendations that the NTSB issued to the US Coast Guard. To assist with future updates and to align our records, we are enclosing a copy of the NTSB’s safety recommendation database history for these 42 recommendations. This response letter will be divided into four parts: • Part 1 – Evaluation of actions to address Safety Recommendations M 09 15 and 16 and M-10-2, recommendations for which Admiral Neffenger provided a substantive update. • Part 2 – List of 6 safety recommendations previously closed. • Part 3 – List of 7 safety recommendations that were the subject of a recent Coast Guard update and that the NTSB is currently evaluating; these recommendations will be addressed in detail in separate correspondence. • Part 4 – List of 26 safety recommendations for which the Coast Guard did not provide a substantive update or for which status has not changed since the last update. Part 1 – Safety Recommendations Updated in the April 5, 2013, Letter: We issued Safety Recommendations M-09-15 and -16, stated below, to the Coast Guard on October 20, 2009, as a result of a review of the involvement of obstructive sleep apnea (OSA) in several accidents investigated by the NTSB. M-09-15 Implement a program to identify licensed mariners subject to the Navigation and Vessel Inspection Circular on Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (NVIC 04-08) and who are at high risk for obstructive sleep apnea, and require that those mariners provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. M-09-16 Develop and disseminate guidance for mariners, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that mariners who have OSA that is effectively treated are routinely approved for continued medical certification. We are encouraged that the Merchant Mariner Medical Advisory Committee is planning to review and revise Navigation and Vessel Inspection Circular 04-08, including Enclosure (4), Guidance on Specific Medical Conditions, which details the medical decision making criteria for common conditions (including sleep disorders such as OSA) as they relate to determining merchant mariner fitness for duty. Pending completion of these efforts, Safety Recommendation M-09-15 is classified “Open—Acceptable Alternate Response” and Safety Recommendation M 09-16 is classified “Open—Acceptable Response.” We issued Safety Recommendation M-10-2, stated below, to the Coast Guard on August 11, 2010, as a result of two recent maritime accidents involving Coast Guard patrol boats: the December 5, 2009, collision of the CG 25689 with the small passenger vessel Thriller 09 in Charleston, South Carolina, and the December 20, 2009, collision of the CG-33118 with a 24 foot recreational vessel in San Diego, California. M-10-2 Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. The Coast Guard’s recent revision of Coast Guard Boat Operations and Training (BOAT) manual, volume I, COMDTINST M16114.32C, section F.2, prohibits the use of cellphones/texting devices and phone applications aboard all boat force assets without the permission of the coxswain, which will only be granted on a case-by-case basis and only when operational safety is not compromised. Because this action satisfies Safety Recommendation M 10-2, it is classified “Closed—Acceptable Action.” Part 2 – Safety Recommendations Previously Closed: M-06-5 (Closed—Acceptable Action, March 14, 2011) Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. M-06-6 (Closed—Acceptable Action, March 14, 2011) Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. M-06-7 (Closed—Unacceptable Action, March 14, 2011) Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. M-06-8 (Closed—Unacceptable Action, March 14, 2011) Until such time as you revise the passenger weight standard as requested in Safety Recommendation M-06-5 and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation M-06-7, develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations. M-06-9 (Closed—Unacceptable Action, March 14, 2011) Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection. M-11-11 (Closed—Acceptable Action, November 13, 2012) Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. Part 3 – Recommendations Recently Updated and Under Evaluation by the NTSB: M-10-5 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders that meet the international performance standard on new ferry vessels. M-10-6 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders on ferry vessels built before the enactment of voyage data recorder carriage requirements that will record, at a minimum, the same video, audio, and parametric data specified in the International Maritime Organization’s performance standard for simplified voyage data recorders. M-12-1 (Open Initial Response Received; USCG Update February 12, 2013) Require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-2 (Open Initial Response Received; USCG Update February 12, 2013) Where technically feasible, require existing U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be retrofitted with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-3 (Open—Initial Response Received; USCG Update February 12, 2013) Require all operators of U.S.-flag passenger vessels to implement safety management systems, taking into account the characteristics, methods of operation, and the nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. M-12-6 (Open—Initial Response Received; USCG Update March 21, 2013) Develop and implement a policy to ensure adequate separation between vessels operating in the Bayport Channel and Bolivar Roads Precautionary Areas and any other similarly configured precautionary areas in the Houston Ship Channel. M-12-7—(Open Initial Response Received USCG Update March 21, 2013) Graphically delineate precautionary areas on appropriate Houston Ship Channel nautical charts so they are readily identifiable to mariners. Part 4 – Safety Recommendations Not Substantively Updated in the April 5, 2013, letter: M-02-5 (Open—Acceptable Response, February 4, 2013) Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. M-07-1 (Open—Acceptable Response, February 4, 2013) Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. M-07-6 (Open—Acceptable Response, February 4, 2013) Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. M-08-2 (Open—Acceptable Response, February 4, 2013) Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-4 (Open—Acceptable Response, February 4, 2013) Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. M-09-10 (Open—Unacceptable Response, February 4, 2013) Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-14 (Open—Acceptable Response, February 4, 2013) Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-09-17 (Open—Unacceptable Response, February 4, 2013) Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 (Open—Acceptable Response, February 4, 2013) Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety. M-11-4 (Open—Acceptable Response, February 4, 2013) Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue. M-11-8 (Open—Acceptable Response, November 13, 2012) Develop and implement procedures for your special purpose craft–law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. M-11-9 (Open—Acceptable Response, November 13, 2012) Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. M-11-10 (Open—Acceptable Response, November 13, 2012) Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. M-11-12 (Open—Acceptable Response, November 13, 2012) Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. M-11-13 (Open—Acceptable Response, November 13, 2012) Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, determine from that whether the risk is unacceptable, and if so, develop risk mitigation strategies. M-11-14 (Open—Acceptable Response, November 13, 2012) Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. M-11-15 (Open—Acceptable Response, November 13, 2012) Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. M-11-16 (Open—Unacceptable Response, November 13, 2012) Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. M-11-23 (Open—Unacceptable Response, June 12, 2012) Establish standards for new and existing commercial fishing industry vessels of 79 feet or less in length that (1) address intact stability, subdivision, and watertight integrity and (2) include periodic reassessment of the vessels’ stability and watertight integrity. M-11-24 (Open—Unacceptable Response, June 12, 2012) Require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use of vessel stability information regardless of plans for implementing the other training provisions of the 2010 Coast Guard Authorization Act. M-11-25 (Open—Unacceptable Response, June 12, 2012) Require each person on deck of a commercial fishing industry vessel to wear a flotation aid at all times. M-11-26 (Open—Unacceptable Response, June 12, 2012) Require owners of commercial fishing industry vessels to (1) install fall overboard recovery devices appropriate for the vessel, (2) periodically ensure the functionality of such equipment, and (3) regularly conduct drills in which crewmembers demonstrate their competence in the use of such devices. M-11-27 (Open—Unacceptable Response, June 12, 2012) Require all crewmembers to provide certification of completion of safety training before getting under way on commercial fishing industry vessels, such training to include both prevention of and proper response to emergency situations as well as actual use of emergency equipment. M-12-8 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard military personnel with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-9 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard civilian personnel, seeking appropriate legislative authority if necessary, with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-10 (Open—Await Response) Disseminate guidance within the Coast Guard so that commanding officers have unambiguous instruction detailing the requirements for timely drug and alcohol testing of Coast Guard military and civilian personnel whose work performance may be linked to a serious marine incident. Thank you for your commitment to marine safety. We look forward to receiving further updates on the action being taken to implement the following safety recommendations: M-02-5 M-07-1 M-07-6 M-08-2 M-09-4 M-09-10 M-09-14 M-09-15 M-09-16 M-11-3 M-11-4 M-11-8 M-11-9 M-11-10 M-11-12 M-11-13 M-11-14 M-11-15 M-11-16 M-11-23 M-11-24 M-11-25 M-11-16 M-11-27 M-12-8 M-12-9 M-12-10

From: USCG
To: NTSB
Date: 4/9/2013
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Please find enclosed our agreed upon semiannual update of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board and are awaiting Coast Guard response. There are currently 42 safety recommendations with an "open" status issued to the Coast Guard. Of those, we attest that our actions are complete for six, six are pending resolution, and five require long-term agency action. Updates for the remaining 25 have been or will be provided in separate correspondence. Enclosure (1) provides specific information for each recommendation. There has not been a change in the status since the last update for the following four recommendations: M-07-6 Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. (Supersedes M-00-10) M-08-2 Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-14 Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-11-4 Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue.

From: NTSB
To: USCG
Date: 2/4/2013
Response: The NTSB notes that at the 90th session of the IMO’s Maritime Safety Committee, the Committee adopted revised performance standards for shipborne VDRs in its resolution MSC.333(90). These revised standards include the following operational requirement: 5.5.18 Rolling motion. The VDR should be connected to an electronic inclinometer if installed. The recording method should be such that the rolling motion can be reconstructed during playback. The NTSB notes that this action is an interim step toward mandating the inclusion of heel angle data on voyage data recorders and, before such a requirement can be imposed, the IMO must (1) develop and approve performance standards for electronic inclinometers and (2) once the performance standards are finalized, establish the carriage requirements for electronic inclinometers. The NTSB further notes that these steps are already underway, as the IMO’s Navigation Subcommittee is developing the performance standards for electronic inclinometers with a target completion and adoption by the Maritime Safety Committee at its 92nd session, scheduled for 2013. Pending completion of these efforts at IMO, Safety Recommendation M-08-2 remains classified OPEN—ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 8/15/2012
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: This proposal was made and at its 90th session, the International Maritime Organization's Maritime Safety Committee adopted revised performance standards for shipborne voyage data recorders (VDRs) in its resolution MSC.333(90). These revised standards include the following, new operational requirement: 5.5.18 Rolling motion The VDR should be connected to an electronic inclinometer if installed. The recording method should be such that the rolling motion can be reconstructed during playback. This is viewed as an interim step to mandating the inclusion of heel angle data on voyage data recorders. Before such a requirement can be imposed, the IMO must: (I) development and approval of performance standards for electronic inclinometers and (2) once the performance standards are finalized, establish the carriage requirements for electronic inclinometers. These steps are already underway, as the IMO's Navigation Subcommittee is developing the performance standards for electronic inclinometers with a target completion and adoption by the Maritime Safety Committee at its92nd session in 2013. We consider our action on this recommendation complete for and request that it be closed.

From: NTSB
To: USCG
Date: 11/16/2011
Response: This letter concerns 29 open safety recommendations, enclosed, that the National Transportation Safety Board (NTSB) issued to the U.S. Coast Guard between 1995 and 2010. For some of these recommendations, the NTSB has not received an update in almost 3 years regarding the status of action either taken or planned to address the important safety issue that the recommendation addresses. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. NOTE TO FILE (not in original letter): The 29 safety recommendations are: M-95-013, M-98-033, M-98-037, M-99-001, M-00-004, M-01-001, M-02-005, M-04-003, M-05-006, M-06-001, M-06-002, M-07-001, M-07-006, M-07-007, M-08-001, M-08-002, M-09-001, M-09-002, M-09-003, M-09-004, M-09-009, M-09-010, M-09-014, M-09-015, M-09-016, M-09-017, M-10-005, M-10-002 and M-10-006.

From: USCG
To: NTSB
Date: 5/12/2010
Response: NMC # 103404: Update: On May 22, 2009, we submitted the attached Note to the International Maritime Organization (lMO) in preparation for the 55th session of the IMO's Sub-Committee on Safety of Navigation (NAV 55), held in July 2009, proposing the addition of ship's heel angle 16732 to the list of required data items to be recorded by voyage data recorders. At NAV 55, the Technical Working Group developed draft text of revised performance standards for voyage data recorders (VDR). The following language is included in the draft text: 5.4.18 Inclinometer The angle of heel or list of the vessel should be recorded. Where a ship is not equipped with a suitable inclinometer, one should be included as an integral part of the VDR system. The revised performance standard is expected to be finalized at NAV 56 in July 2010 and adopted at MSC 88 in November 2010.

From: NTSB
To: USCG
Date: 4/8/2010
Response: NMC # 103404: Please provide a brief update on Safety Recommendations M-08-1 & -2 from the Crown Princess accident. Both had to do with 'proposing to IMO." It has been more that a year since our last exchange and my bosses are asking me for some updated status

From: USCG
To: NTSB
Date: 3/25/2010
Response: Attached is the U. S. Note submitted to NAV 55. At NAV 55, the Technical Working Group developed draft text of revised performance standards for voyage data recorders (VDR)(resolution A.861(20)). The following language is included in the draft text: 5.4.18 nclinometer The angle of heel or list of the vessel should be recorded. Where a ship is not equipped with a suitable inclinometer, one should be included as an integral part of the VDR system. The revised performance standard is expected to be finalized at NAV 56 in July 2010 and adopted at MSC 88 in November 2010.

From: NTSB
To: USCG
Date: 1/5/2009
Response: The Safety Board is pleased that the Coast Guard concurs with this recommendation and will make the recommended proposal to the IMO. Pending notification of the outcome of this proposal, Safety Recommendation M-08-2 is classified OPEN -- ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 8/15/2008
Response: Letter Mail Controlled 9/3/2008 10:40:13 AM MC# 2080531: - From James A. Watson, Director, Prevention Policy: We concur with this recommendation. We will work with the Board to develop a proposal to the International Maritime Organization’s Maritime Safety Committee (MSC) to consider amending the performance standards for voyage data recorders to include heel angles. We will keep the Board informed of our progress on this recommendation. James A. Watson, Rear Admiral, Director, Prevention Policy U.S. Coast Guard.