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Safety Recommendation Details

Safety Recommendation M-93-030
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 CUNARD LINES, LTD.: REQUIRE THAT AFTER A PILOT BOARDS ONE OF YOUR VESSELS, YOUR MASTERS CONDUCT A CONFERENCE THAT INCLUDES A DISCUSSION BETWEEN THE PILOT AND OTHER RELEVANT DECK OFFICERS OF THE PROPOSED ROUTE, INCLUDING COURSES, SPEEDS, SQUAT UNIQUE MANEUVERS, AND DANGER AREAS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Bays and Sounds, United States
Is Reiterated: No
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: 11/15/1993
Addressee(s) and Addressee Status: Cunard Line Ltd. (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Cunard Line Ltd.
Date: 11/15/1993
Response: THE BOARD IS PLEASED THAT CUNARD MASTERS, BRIDGE TEAMS, AND PILOTS ARE NOW REQUIRED TO DISCUSS AND AGREE ON THE PROPOSED ROUTE, THE POTENTIAL HAZARDS, AND THE NEED TO ALLOW A MARGIN OF ERROR WHEN CALCULATING UNDER-KEEL CLEARANCE IN SHALLOW WATER. THEREFORE, SAFETY RECOMMENDATION M-93-30 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION." THE BOARD IS ALSO PLEASED THAT CUNARD HAS DISTRIBUTED A COPY OF RECENT UK NAUTICAL INSTITUTE PAPER ON BRIDGE RESOURCE MANAGEMENT. ENCLOSED IS A COPY OF A PAPER DEVELOPED BY THE SOCIETY OF NAVAL ARCHITECTS AND MARINE ENGINEERS, MARINE SAFETY PANEL, THAT ADDRESSES THE INTENT OF RECOMMENDATION M-93-30. WE ENCOURAGE YOU TO CIRCULATE IT AMONG CUNARD OPERATING PERSONNEL

From: Cunard Line Ltd.
To: NTSB
Date: 9/1/1993
Response: ALL CUNARD MASTERS HAVE BEEN MADE AWARE OF THE FINDINGS OF THE 3 AGENCIES THAT INVESTIGATED THE QE2 INCIDENT. INSTRUCTIONS HAVE BEEN ISSUED REQUIRING THAT MASTER, PILOT AND OTHER RELEVANT DECK OFFICERS DISCUSS AND AGREE THE PLAN FOR PASSAGE OF PILOTAGE WATERS AND THAT THEY CONSULT BEFORE CHANGES TO THE PLAN ARE IMPLEMENTED. BRIDGE TEAMS HAVE ALSO BEEN REMINDED OF THE NEED FOR CAUTION IN PILOTAGE WATERS, THE NEED TO CLEARLY IDENTIFY POTENTIAL HAZARDS, AND THE NEED TO ALLOW A MARGIN OF ERROR WHEN CALCULATING UNDER KEEL CLEARANCE PARTICULARLY WHEN THE CHARTED DEPTH IS LESS THAN 20 METERS. IN SUPPORT OF THESE INSTRUCTIONS, SHIPS HAVE BEEN PROVIDED WITH A BRIEFING PAPER ON BRIDGE RESOURCE MANAGEMENT RECENTLY ISSUED BY THE UK NAUTICAL INSTITUTE.