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Safety Recommendation Details

Safety Recommendation M-08-005
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: The National Transportation Safety Board therefore recommends that the Northrop Grumman Corporation Sperry Marine and SAM Electronics GmbH Automation, Navigation and Communication take the following action:Work with cruise lines and other vessel operators to develop a system that provides them with critical information regarding errors or potential problems in the use of integrated navigation systems or integrated bridge systems and apply the lessons learned to system design and crew training.
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: 1/5/2009
Addressee(s) and Addressee Status: Northrop Grumman Corporation, Sperry Marine (Closed - Acceptable Action)
SAM Electronics GmbH (Closed - Acceptable Action)
Keyword(s): Training and Education

Safety Recommendation History
From: NTSB
To: SAM Electronics GmbH
Date: 12/3/2008
Response: The Safety Board notes that SAM has taken the following action to address Safety Recommendation M-08-5: ·The company has developed a customer feedback process in case of errors or potential problems within the integrated navigation system NACOS. ·Incoming error reports about serious and potential problems within NACOS are now collected in a file by SAM’s quality assurance department. ·The incoming error reports are evaluated by SAM’s service, product support, and research and development (if required) departments to determine the required remedies. Corrective measures will be disseminated to customers by a minor change (bugfix) or new release. If needed, SAM will modify training and documentation. ·Information will be issued either directly to customers or by posting it on the SAM’s website. The Safety Board further notes that SAM has taken additional measures to improve safety. All relevant operating manuals have been revised to explain the influence of hydrodynamic effects and to highlight the need for correct, situation-related settings of Trackpilot parameters. SAM’s training facilities in Hamburg now will provide training modules for ship owners, related to INS, including a train-the-trainer program. This training includes information about the new squat warning, squat alarm, and rate-of-turn warnings and alarms. These actions of SAM Electronics GmbH satisfy the recommendation; accordingly, Safety Recommendation M-08-5 is classified Closed Acceptable Action.

From: SAM Electronics GmbH
To: NTSB
Date: 8/11/2008
Response: Letter Mail Controlled 8/11/2008 2:22:25 PM MC# 2080478: we acknowledge the receipt of your recommendation M-08-5 and would like to inform about the actions taken based on this recommendation: 1.Development of a customer feedback process in case of errors or potential problems within the integrated navigation system NACOS. 1.1Incoming error reports or potential problems about serious problems within the NACOS are collected in a file by quality assurance department. 1.2The incoming error reports are evaluated by service, product support and research and development (if required) to define the required actions. 1.3Depending on the type of error or potential problem: the solution will be developed and introduced by a minor change (bugfix) or new release. 1.4Depending on the type of error or potential problem training and documentation will be modified. 1.5Information to customers is issued if required directly or by posting it on the SAM website. Additionally the following measures have been taken to improve the safety: 2.Operation manuals: All relevant operating manuals (Radarpilot, Multipilot) have been modified with specific chapters explaining the influence of hydrodynamic effects like the squat effect on the steering behavior of a vessel. Furthermore the need of correct, situation related settings of Trackpilot parameters was also additionally pinpointed in the documents. 3.Training: The need for a good understanding of the functions and limitations of an integrated navigation system is essential. We have extended our training facilities in Hamburg, supporting shipowner in the development of training modules related to INS incl. a train-the-trainer program. 4.Squat warning / Squat alarm / ROT-alarm: New warnings and alarms have been implemented to inform the OOW in case a dangerous situation might occur. Dear Mr. Rosenker, we hope you find our response internally and towards our customers and users appropriate. Please be ensured, that the safety of transportation has and always will have priority in our company’s business. We hope that this incident puts some pressure on the international community to agree on proper training for integrated navigation systems, and we are committed to support the IMO and IEC work accordingly. Faithfully tours, Karl-Dietrich Erdmann Director of Quality Management, Dr Volker Kohler, Business Development

From: NTSB
To: Northrop Grumman Corporation, Sperry Marine
Date: 1/5/2009
Response: The Safety Board notes that after consulting with customers, Sperry Marine developed a process to provide customers a quick and efficient method of reporting problems with INS or IBS equipment. Customers may submit comments or report incidents directly through a link on Sperry’s website designated for their feedback. Sperry’s worldwide customer support and training staff review and respond to customers directly with corrective measures. In addition, Sperry Marine department heads and technical staff review customer feedback monthly, and reported incidents are evaluated for effectiveness of product design and the need for product modification and customer training. This action satisfies Safety Recommendation M-08-5; accordingly, this recommendation is classified Closed Acceptable Action.

From: Northrop Grumman Corporation, Sperry Marine
To: NTSB
Date: 6/18/2008
Response: Letter Mail Controlled 9/8/2008 11:41:37 AM MC# 2080541: Sperry Marine has been dedicated to the safe and efficient navigation of vessels for over 100 years with a proven track record of continual improvements in process, technology and training. We place high values on maintaining our positive relationships with the NTSB, our customers and other organizations engaged in the management and oversight of the maritime industry. We take the Board’s recommendations very seriously and appreciate this opportunity to respond to the following Safety Recommendation: Work with cruise lines and other vessel operators to develop a system that provides them with critical informotion regarding errors or potentiof problems in the use of integrated navigation systems or integrated bridge systems and apply lessons learned to system design ond crew training. (M -08-05) After consulting with the appropriate internal and customer representatives, we have determined to enact the following processes to provide our customers an effective method of submitting heeling and related incidents to Speny Marine in a timely and cost efficient manner. Our world wide web site now has a link, http://ww.spe~arine.northmm.com/customerfeedback.asD, specifically dedicated to customer feedback. Any information entered into this site will be automatically recorded in a database directly monitored by our manager of worldwide customer support and training. Management of this customer feedback database is governed by our IS09001 certified work instructions and entries have monthly visibility to department heads at the staff level. Upon receipt of an applicable feedback regarding a heeling or other navigation related incident, the-matter will be officially investigated and recommendations made to the appropriate departments to be considered in the product design, modifications and training of our products.