Incident / Accident Analysis

Question about dockets on the NTSB site: why do they in some cases only publish a summary of the interview rather than the interview itself? Is this negotiated as well?

USS Fitzgerald and ACX Crystal collision: The Fifth Circuit Court of Appeals delineates the reach of personal jurisdiction (

In footnotes 5 through 7 of the majority Opinion, the Court felt it was important to place the Opinion in further context.

The Court emphasized that NYK was a time charterer of the ACX Crystal, and that time charterers typically have little or no control over the vessel’s navigation. As such, a time charterer “almost never bears liability for a collision stemming from navigational error.

Citing Moore v. Phillips Petroleum Co., 912 F.2d 789, 792 (5th Cir. 1990).

Thus, in the Court’s view, even if plaintiffs could establish personal jurisdiction over NYK, “their claims would face other substantial hurdles.”

Including the fact that the after-accident reports issued by the National Transportation Safety Board and the Japanese Transport Safety Board largely fault the United States Navy for the collision and, according to the Court, neither places any fault on NYK.

The Court noted that the personal representatives of the deceased sailors and the injured sailors and their families also sued the owner of the ACX Crystal, Olympic Steamship Company, and its bareboat charterer, Vega Carriers Corporation, both Panamanian corporations, in Japan for the same injuries at issue in this lawsuit.

Source: US Court of Appeals



Name: ACX CRYSTAL (effective 2008-08) !
IMO Number: IMO 9360611
Flag: Panama (effective 2021-06)

Panama (effective 2008-08)
Philippines (effective 2008-08) !
Call sign: 3ESV6
MMSI: 370439000
Ship UN Sanction: Not on list
Owning/operating entity under UN Sanction: Not on list


Type:|Container Ship (Fully Cellular) (effective 2008-08)
|Date of build:|2008-08||
|Gross tonnage:|29,060||


|Registered owner:||Olympic Steamship Co SA||(effective 2008-11-30)|
|IMO Company Number|[4021665]IMOCompanyNumber=4021665)|
|Nationality of registration|Panama|
|Address|Care of Sea Quest Ship Management Inc , 1418, San Marcelino Street, Ermita, 1000 Manila, Philippines.|
|Company status|Active||

Is this Guy something or is He something?? Have just finished watching and my jaw dropped.

Surely the fourth edition of stability booklet will not help him as it appears neither did the 1st .

May be there should be a separate thread??? : debunking SAL.

I got really pissed off today as in one of the very first of his episodes he claimed to make a VERY THOROUGH research on every topic .

quote: each of these containers can hold as

much as 40 tons " end quote.

What do You think??

(97) How Does A Ship Capsize at a Berth? - YouTube

Cargo ship with containers capsized at Iskenderun port, VIDEO – Maritime Bulletin


EMSA-Navigation-Accidents-Summary-report-V1.pdf (

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Human Actions accounted for 75% of grounding investigations.

Fatigue represented the highest percentage in individual factors.

Can this be associated with the “Ever Forward” incident?

I believe so.

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CHIRP-Feedback-2022_09.pdf (

The human element in incident investigation: What to watch - SAFETY4SEA

MARS 347 September 2021.pdf (

Think there will be any analysis of the Sunshine State not avoiding Ian???

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Safer Seas 2020 (

What was the outcome? I wound up taking a detour through the Bahamas to get greater separation from Ian’s potential track. Very happy to only deal with residual swell after it passed when I went through the Florida Straits.

MARS Report 360 - October 2022.pdf (

6686-stoploss-74-v4-english.pdf (



Published: 20 October 2022

BY Simon Rapley

Emergency response on board vessels is normally comprehensively covered by the Emergency Guidance Manual or similar publication within the vessel’s Safety Management System. An Emergency Guidance Manual will ordinarily address the issue of ship / shore / management interaction. However, often a very important interface is either overlooked, or given scant attention, and that is the interaction between the bridge and engine room teams.

From our experience in P&I dealing with serious marine casualties, it needs to be remembered that in many cases the incident may not be a single event and, for example, a collision may also lead to subsequent pollution, or a fire may involve injuries and fatalities. Therefore, be prepared for multiple scenarios.


Remember the three priorities that should be considered when dealing with an incident and these will be drivers for the flow of information between the bridge and engine room teams and vice versa:

  1. Life – this is your first priority, as it cannot be replaced.
  2. Environment – this is your second priority, as usually pollution incidents can be rectified with time and expenditure.
  3. Property – your ship, cargo and third party assets can always be replaced and hence why these are priority number three.

Remember ‘Life / Environment / Property’, or LEP, when dealing with an emergency situation.

After an incident the following factors will need to be communicated clearly and concisely, using simple language to ensure all involved are aware of what is occurring and enabling them to provide the most appropriate support from one team to another, as well as ensure that the most suitable help can be sought from third parties, be it port state authorities or the vessel’s managers:

  1. What has happened?
  2. Where has it occurred?
  3. Why has it taken place?
  4. When did it happen?
  5. Who is affected?

Initially sufficient information needs to be provided so that appropriate actions can be instigated. Time is key following an incident and further advice can be provided later, hopefully once a situation stabilises. You need to be open in relation to the information shared: trust is important in being a strong team and can only ease the flow of advice while holding back information is likely to be unhelpful. Remember to remain calm, shouting down the telephone or radio helps nobody. Being calm will also reinforce to others that you are in control and hopefully provide a peaceful influence at a time of confusion and stress. It is important that messages given to the bridge or engine room teams, as well as to others onboard, such as an emergency response team, or fire party, are consistent.


It needs to be remembered that when one team, be it the bridge or engine room, is principally dealing with an incident that they will be busy and repeated calls from the other team asking for updates may well be unhelpful and a hindrance. Therefore, you should ensure that all communications are measured, necessary and proportionate, while also considering that a deterioration in the situation will need to be promptly promulgated to all parties. Often one party will call the other and upon not receiving an answer, will repeatedly call in quick succession. However, it may well be that the other team are aware of your call, but they are just not in a position to answer at that time, and repeated calls can become an unwelcome distraction. Generally, the other team will get back to you as soon as they can.

You should retain an awareness of time. Information will periodically need to be shared between the two teams, and if time passes by without an update, incorrect assumptions misinformation, or rumours may arise. Even if there is nothing further to tell the other team, just being in contact periodically in an emergency can be reassuring. Where possible, you should provide an update on when you expect further information to be available, as having a rough timeline to follow is helpful in such a stressful situation.

When a disturbing event occurs, it is only natural that people will revert to speaking in their mother tongue as that feels more natural and is what they are most comfortable with. Almost invariably, there will be a number of nationalities onboard, ordinarily conversing in the working language of the ship which is usually English. However, when a person reverts to their mother tongue, this can lead to confusion as to exactly what has occurred. Although it is difficult to change such a natural reaction, it is recommended that, as part of onboard safety training, this particular issue is highlighted to crew. In the unfortunate event of a serious incident occurring, they should be encouraged to try to stay calm, think about what message they want to convey, and then promptly pass on the information clearly and concisely so that the necessary actions can be instigated as quickly as possible.


Of crucial importance is the means of communication between the bridge, engine control room, engine side and steering flat. Ordinarily, telephones will be the principal means of communication and will not need to be tested as they are used on an almost daily basis. However, secondary and other back-up means of communication will require periodic testing and should be included within the vessel’s Planned Maintenance System (PMS). Sound powered telephones, talk-back systems and remote telephone handsets which are infrequently used should be subject to periodic testing. A worthwhile exercise, if not undertaken already, is to test any handheld walkie talkie system, be this VHF or UHF, to determine where any “dead-spots” may exist within the machinery spaces, which could hinder communications with the bridge team in an emergency situation. To be aware of any areas of very poor, or no radio communication signal, in advance makes dealing with the issue, at a time of high stress, slightly more manageable.

Remember that the bridge and engine room teams will need to work together in an emergency situation, and clear, concise and measured communication is a key factor in ensuring a successful outcome for all parties. This further highlights the absolute necessity and importance of conducting frequent realistic onboard drills to best prepare the crew for stressful emergency situations. Ashore, this would also include the use of simulator training where specific emergency scenarios can be rehearsed.

“I decided to troll through various accident reports. Human factors is an interesting subject and having worked in this profession I can relate to many of the findings.“

I was asked to review this report once. I’m curious to see if you noticed the same things I did.

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I really don’t know where to start on this report…….there were so many human failures, from all participants, on that bridge. I would generalise and agree that there was a complete breakdown in BRM.

Putting a loaded vessel, proceeding at ten knots, back to DSA whilst fitted with a high cross section CPP is a recipe for disaster. If the vessel has inherently poor directional stability the impeded water flow over the rudder is not going to end well. The course change was also ordered concurrently with the reduction in CPP pitch setting…….not good.

Both the Master and Pilot made mistakes. The entire ship’s bridge team were Croatian nationals so there was little power distance affecting their performance. There would have been a degree of power distance between the Pilot and bridge team.

The issue with directional stability should have been noted on the Pilot Card and this should have been pointed out to the Pilot during the MPX.

Being mindful of this issue, all parties should have been glued to the Rudder Angle Indicator and the helmsman should have been instructed from the outset to pass on any problems with his task.

In short……this was a complete clusterf…ck!

The only vessel I have ever been master of with a Becker rudder and CPP was a small container vessel. As an exempt master for most of the ports I called at I did not experience any sheer but my reductions in speed were probably more measured when berthing without tugs.
At stop it was possible to move the vessel bodily sideways with the rudder and bow thruster. Power for the bow thruster was from the shaft generator.

You picked up right away on the crucial issue. The NTSB report praised the CP propeller and Schiller or Becker rudder, but experienced mariners know the horror of slowing down with this arrangement and having the vessel go berserk. That very thing happened on the vessel’s inbound trip and the investigators were informed of it. The idea that one of the causes of the accident was the master’s failure to inform the pilot of the defect is ludicrous. I took a survey of our association’s apprentice pilots when I wrote my review of their report. All of them were well aware of the dangers of this combination. When the Coast Guard “tested” the ship’s steering they did it at anchor and during a routine passage without any maneuvering and declared the steering satisfactory. They did NOT test under the conditions of the accident.

The reason for the initial correspondence was that the NTSB sent me some accident reports asking me to give them my opinion on whether squat was a factor in any of the incidents. I did not find squat to be a factor in any of them, but I found the reports to be deeply flawed, incomplete and inaccurate. The NTSB does well with machinery problems, but they have no experience with ships or navigation. I have often suggested they include experienced mariners in their investigation teams but they don’t do it.

I decided to take the opportunity to make a case for experienced investigators by writing a review of the accident reports pointing out the flaws and items that the investigators misunderstood or missed altogether. I was hoping for a dialog with the NTSB about the rudder/propeller issue and other problems I took the time to point out but I never heard back from them.

The Orange Sun report was pretty bad. The review I wrote is attached as a .pdf.

I’d like to hear what you think about the rest of the review (attached)
NTSB Orange Sun Investigation.pdf (73.9 KB)


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After they’re stopped and in routine transit they’re fine, but the danger comes when one wants to get them down to slow speed quickly in an emergency. That can be a nightmare.

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I would totally agree with all your points and commend you on your honesty.
These two points particularly struck a chord with me……

  1. The large console in the center of the bridge acted as a substantial obstacle that prevented the pilot or captain from simply reaching over and taking control away from the helmsman when it became apparent that he was frozen in confusion. There needs to be some recognition that these consoles contribute to accidents by blocking passage between the windows where conning is done and the navigation equipment.*
  2. It appears from the photos that the rudder angle indicator was located where it would be directly over the pilot’s head on the ceiling when he is standing in the usual conning position. This would make it awkward for him to check the rudder position without considerable contortion. The helmsman’s error might have been more easily caught and corrected had the instrument been properly located on the wall in front of the conning station.

The siting of the RAI in this type of bridge design was always a problem and invariably moved me away the normal conning position to behind the console so that I could instantly check the indicator.

I was an absolute stickler, when training and checking new Pilots, on checking the indicator for every helm order. If they were caught once not checking then the check was failed. We were Piloting very large heavy ships in a very narrow channel. A wrong way helm unchecked was death.

Which leads me on to another very good point that you have made…….the duty mate logging the vessel’s position in Pilotage waters taking one set of eyes off more important tasks. This is 2022 where we have AIS technology and invariably an active and recording Pilot PPU.

The following is not a criticism but an observation. I find it interesting that the NTSB reporting structure covers so many arenas……Aviation, Marine, Highway, Pipeline and Railroad. The Highway investigations must absorb a great deal of their funding. In Australia, our NTSB equivalent (ATSB) is funded for investigating Aviation, Marine and Railroad and are limited to 10 investigations per annum. One of our fellow posters on here claims that there will be no report provided on the “Ever Forward” grounding which I find concerning to say the least. Surely, there are lessons to be learnt with associated improvements………


I fully agree with point 4 and 5. I once had to remove the helmsman and replace him with the OOW. Until a new helmsman arrived on the bridge no one logged the position by the old method but it was in fact monitored by two independent methods.

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Swedish-Club-November-2022-MSS-2022_11.pdf (