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Safety Recommendation Details

Safety Recommendation M-93-018
Details
Synopsis: ON AUGUST 7, 1992, THE UNITED KINGDOM PASSENGER VESSEL RMS (ROYAL MAIL SHIP) QUEEN ELIZABETH 2 (QE2) WAS OUTBOUND IN VINEYARD SOUND, MASSACHUSETTS, WHEN THE VESSEL GROUNDED ABOUT 2 1/2 MILES SOUTH OF CUTTYHUNK ISLAND. NO INJURIES OR DEATHS RESULTED FROM THIS ACCIDENT. HOWEVER, DAMAGE WAS SIGNIFICANT; TEMPORARY AND PERMANENT REPAIRS COST ABOUT $13.2 MILLION. IN ADDITION, THE TOTAL REVENUE LOST FOR THE PERIOD BEFORE THE VESSEL RETURNED TO SERVICE ON OCTOBER 2, 1992, WAS ESTIMATED AT $50 MILLION.
Recommendation: THE NTSB RECOMMENDS THAT THE U.S. COAST GUARD: PROPOSE TO THE INTERNATIONAL MARITIME ORGANIZATION THAT STANDARDS AND CURRICULA BE DEVELOPED FOR BRIDGE RESORUCE MANAGEMENT TRAINING FOR THE MASTERS, DECK OFFICERS, AND PILOTS OF OCEAN-GOING SHIPS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Bays and Sounds, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA92MM034
Accident Reports:
Grounding of the United Kingdom Passenger Vessel RMS Queen Elizabeth 2
Report #: MAR-93-01
Accident Date: 8/7/1992
Issue Date: 6/25/1993
Date Closed: 7/25/2001
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Training and Education

Safety Recommendation History
From: NTSB
To: USCG
Date: 7/25/2001
Response: Because the Coast Guard took a leadership role in developing the 1995 Amendments to the STCW Code, which includes required BRM training and curricula for all masters, watch officers, and pilots on ocean-going vessels, Safety Recommendations M-93-18 and -19 are classified "Closed--Acceptable Action."

From: USCG
To: NTSB
Date: 7/31/2000
Response: Letter Mail Controlled 04/10/2001 6:26:50 PM MC# 2010309 CG states they responded in 1996 on these recommendations.

From: NTSB
To: USCG
Date: 7/14/1998
Response: NTSB REQUESTED A FOLLOWUP.

From: NTSB
To: USCG
Date: 5/21/1997
Response: THE SAFETY BOARD UNDERSTANDS THAT THE CG SUBMITTED THE ABOVE PROPOSALS TO THE IMO. ALTHOUGH THESE PROPOSALS WERE NOT WIDELY SUPPORTED AND NOT INCLUDED IN THE 1995 STCW AMENDMENTS, THE BOARD IS PLEASED THAT THE CG WILL CONTINUE TO PROMOTE THE DEVELOPMENT OF BRM TRAINING REQUIREMENTS AND THE ASSOCIATED COURSE CURRICULA AT THE IMO. THE BOARD WOULD APPRECIATE PERIODIC UPDATES ON THE STATUS OF THESE INITIATIVES. PENDING FURTHER REPLY, RECOMMENDATIONS M-93-18 AND -19 HAVE BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: NTSB
To: USCG
Date: 4/2/1997
Response: From the accident report the grounding of the Panamanian passenger ship Royal Majesty on Rose and Crown shoal near Nantucket, Massachusetts on June 10, 1995 (adopted 4/2/1997): On June 25, 1993, as a result of its investigation of the grounding of the United Kingdom passenger vessel RMS Queen Elizabeth 2 (near Cuttyhunk Island, Vineyard Sound, Massachusetts, on August 7, 1992, the Safety Board issued Safety Recommendations M-93-18 and -19 to the Coast Guard. The Safety Board requested that the Coast Guard: Propose to the IMO that standards and curricula be developed for bridge resource management training for the masters, deck officers, and pilots of ocean-going ships. (M-93-18) Propose to the IMO that the masters, deck officers, and pilots of ocean-going ships be required to successfully complete initial and recurrent training in bridge resource management. (M-93-19) On September 27, 1993, responding to Safety Recommendation M-93-18, the Coast Guard Commandant wrote: I partially concur with this recommendation. The U.S. will propose at the 25th Session of the IMO Subcommittee on STW that standards and curricula be developed for bridge resource management training for masters and deck officers of seagoing ships. However, the Coast Guard views pilot qualifications as a matter for port State regulation. I will keep the Board informed of our progress regarding this recommendation. On January 7, 1994, the Safety Board responded: The Safety Board agrees that, in the end, pilot qualifications are a matter for the port State to enforce. The intent of the recommendation is for the IMO to develop a specified standard that would serve as a model that the port States could adopt. The United States has recently been more receptive to the idea of developing a unilateral standard if it is included in the Standards of Training and Watchkeeping. Consequently, the Board encourages the Coast Guard to pursue this issue at the IMO. Because the Coast Guard states it will propose the recommendation to the IMO, Safety Recommendation M-93-18 has been classified “Open--Acceptable Response,” pending implementation by the IMO. On September 27, 1993, responding to Safety Recommendation M-93-19, the Coast Guard Commandant wrote: I partially concur with this recommendation. The United States will propose that IMO agree in principle to requiring masters and deck officers on seagoing ships to complete initial and recurrent training in bridge resource management. However, the Coast Guard views pilot qualifications as a matter for port State regulation. I will keep the Board informed of our progress regarding this recommendation. On January 7, 1994, the Safety Board responded that for the reasons stated in the discussion of Safety Recommendation M-93-18, the Safety Board encouraged the Coast Guard to actively promote the IMO’s acceptance of Safety Recommendation M-93-19. Because the Coast Guard had agreed to “proposing in principle” the recommendation, the Board classified Safety Recommendation M-93-19 “Open-- Acceptable Alternate Response,” pending the outcome of the Coast Guard’s efforts. Therefore, the Safety Board reiterates Safety Recommendations M-93-18 and -19 and urges the Coast Guard to work closely with the IMO in order to expedite the intended outcome of these recommendations. The Safety Board also believes that the Coast Guard, as part of the foreign flag passenger ship control verification examination program, should assess the adequacy of installed integrated bridge systems and verify that the ships’ officers are properly trained in their operation and possible failure modes. Furthermore, as part of the same program, the Coast Guard should verify that the watchstanding procedures of ships’ officers include the use of multiple independent means of position verification.

From: USCG
To: NTSB
Date: 8/6/1996
Response: THE CG SUBMITTED A PROPOSAL (STW 25/3/14) TO THE STW SUBCOMMITTEE'S 25TH SESSION THAT IMO SHOULD "OUTLINE THE ESSENTIAL ELEMENTS OF A BRIDGE RESOURCE TRAINING PROGRAM WHICH CAN BE USED AS A BASIS FOR APPROVING COURSE CONTENT." THIS PROPOSAL WAS NOT WIDELY SUPPORTED. HOWEVER, THE CG WILL CONTINUE TO PROMOTE THIS PROPOSAL WHEN THE IMO MODEL COURSE ON "SHIP SIMULATOR AND BRIDGE TEAMWORK" IS REVIEWED AND REVISED IN LIGHT OF THE 1995 STCW AMENDMENTS. SINCE THE RECOMMENDED PROPOSAL TO IMO HAS BEEN MADE, THE CG REQUESTS THAT THE STATUS OF THIS RECOMMENDATION BE CHANGED TO CLOSED--ACCEPTABLE ACTION.

From: NTSB
To: USCG
Date: 11/28/1994
Response: REMINDER TO USCG OF PENDING ACTION.

From: NTSB
To: USCG
Date: 1/7/1994
Response: THE BOARD AGREES THAT, IN THE END, PILOT QUALIFICATIONS ARE A MATTER FOR THE PORT STATE TO ENFORECE. THE INTENT OF THE RECOMMENDATION IS FOR THE IMO THE IMO TO DEVELOP A SPECIFIED STANDARD THAT WOULD SERVE AS A MODEL THAT THE PORT STATES COULD ADOPT. THE UNITED STATES HAS RECENTLY BEEN MORE RECEPTIVE TO THE IDEA OF DEVELOPING A UNILATERAL STANDARD IF IT IS INCLUDED IN THE STANDARD OF TRAINING AND WATCHKEEPING. CONSEQUENTLY, THE BOARD ENCOURAGES THE USCG TO PURSUE THIS ISSUE AT THE IMO. BECAUSE THE USCG STATES IT WILL PROPOSE THE RECOMMENDATION TO THE IMO, RECOMMENDATION M-93-18 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE," PENDING IMPLEMENTATION BY THE IMO.

From: USCG
To: NTSB
Date: 9/27/1993
Response: I PARTIALLY CONCUR WITH THIS RECOMMENDATION. THE U.S. WILL PROPOSE AT THE 25TH SESSION OF THE IMO SUBCOMMITTEE ON STW THAT STANDARDS AND CURRICULA BE DEVELOPED FOR BRIDGE RESOURECE MANAGEMENT TRAINING FOR MASTERS AND DECK OFFICERS OF SEAGOING SHIPS. HOWEVER, THE USCG VIEWS PILOT QUALIFICATIONS AS A MATTER FOR PORT STATE REGULATION. I WILL KEEP THE BOARD INFORMED OF OUR PROGRESS REGARDING THIS RECOMMENDATION.