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)
.
Regards
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.
I would totally agree with all your points and commend you on your honesty.
These two points particularly struck a chord with me……
- 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.*
- 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.
Thanks for your input.
Regarding the rudder angle indicator being in a poor spot… one ship I was on (only one of hundreds of misplaced rai’s) solved the problem by fastening two ordinary truck mirrors - the rectangular ones that mount outside the window - to the overhead. The first reflected the rai toward the conning station. The second was where the pilot could glance up and check it. A caution is necessary. It might seem like you could do it with one mirror in some cases but that would present a reversed image which could be confusing. The second mirror returns the image to a truly oriented state.
Really each of these should be their own thread, if you have any relevant discussion related to them. You’re not supposed to just post links.
I am very sorry , I thought it would be better to keep them in one place instead of littering the forum with separate incident threads. I am posting links without my comment and waiting patiently for smarter and more eloquent forum members to comment first as a gesture of respect . May be we should refer this issue to moderators and let them decide and give some directions .
and BTW i want a hot link badge too.
Totally get it. I just think it’s common forum etiquette to post a link to something if you have relevant discussion you want to participate in. Also to offer your opinion on an issue first rather than just, “here’s a news article!” I’m sure you have a ton of insight and experience to offer, that’s how we build a vibrant community with useful discussion, not just a thread of ongoing links every time a new article is posted with no context or content.
This topic will be ignored here as there is another post covering this topic under Marine Incidents . Check it out.
Unbelievable. In the bad old days before we had regulations regarding the functioning of things like ARPA stuff was dumped onboard and we had to read the manuals and get on with it. The first ARPA I sailed with required loading a bootstrap code by buttons before loading the program on a punched paper tape, transit satnav program was on wire.
That the autopilot wasn’t immediately disabled by turning the wheel is an epic failure of design but the most basic documentation should of highlighted overriding the autopilot.
There was a complete failure in implementation of the new equipment from management down.
This thread started as an analysis of the limitations of current incident and accident reports. It’s turned into links to random incidents.
