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Carnival Horizon Manhattan Cruise Terminal Pier 88 / 90 NTSB Report

Carnival Horizon Manhattan Pier

On the morning of 28 August 2018, the cruise ship Carnival Horizon, with a total of 6,361 people on board, was manoeuvring to berth No. 2 at Manhattan Cruise Terminal’s Pier 88 in New York City, New York, when its bow struck the southwest corner of adjacent Pier 90. No one was injured and no pollution occurred, but Pier 90’s walkway, roof parking garage, and facilities suffered extensive structural damage, and the ship sustained minor damage above the waterline, totalling about $2.5 million in cumulative damage.  Illustrated in the NTSB report is a screenshot from the Carnival Horizon’s ECDIS, showing the vessel’s track beginning at 0539 and ending at 0611.  (An illustration of Carnival Horizon appears here by kind courtesy on NTSB ©).

Probable Cause

The National Transportation Safety Board determined that the probable cause of the Carnival Horizon’s contact with Pier 90 was the ineffective interaction and communication between the master and the docking pilot who were manoeuvring the vessel, and the bridge team’s ineffective oversight of the docking manoeuvre. Contributing was the placement of the third officer in a location without a view of the bow to monitor the close approach to Pier 90.

Findings

At the time of the contact there was clear visibility at 10 miles with winds SW at 6–8knots, an ebb current of 1.3knots.

Carnival Horizon was returning to Manhattan from an eight-night Eastern Caribbean cruise, and at 0318 on the morning of the accident, the ship arrived at the entrance to New York harbour. There, a pilot from the Sandy Hook Pilots Association boarded the Carnival Horizon for the inbound transit to the Manhattan Cruise Terminal. About 0329, after a master/pilot exchange about the ship and the inbound transit, the Sandy Hook pilot assumed navigational control of Carnival Horizon. The master remained on the bridge, with overall responsibility for the safe navigation of the vessel for the duration of the arrival in port.

There were no reported problems with  Carnival  Horizon’s  machinery,  steering, thrusters or propulsion systems at the time of the accident.

Data recorded

The ship was equipped with an Interschalt VDR-G4e voyage data recorder. Investigators were  able to extract data from the recorder, including bridge and engine control room audio, navigational information, bow thruster and azipod orders and response, and radar images, to analyse the events leading up to and during the accident.

During interviews with the master, the staff captain, and the third officer, investigators inquired about the position of the forward lookout. The third officer stated that he went back and forth between the port-and starboard-side mooring platforms to estimate the distance from the bow to Pier 90 by line of sight.

When switching position between the port and starboard mooring platforms, he would have to walk about 15metres across the mooring deck. No crewmember was positioned on the tip of the bow to observe the clearing distances. The master and the staff captain both stated that, in the future, they would place a crewmember on the tip of the bow (one deck higher and farther forward than during the accident) for docking manoeuvres.

In a subsequent interview, the master told investigators that during the ship’s next return trip to Pier 88 on 5 September 2018, a crewmember was placed at the tip of the bow. In fact, the ship’s standard operating procedures were revised to include the addition of a crewmember on the bow specifically for manoeuvres where the bow is expected to come in close proximity of objects while manoeuvring in and out of port.

The New  Jersey  Maritime  Pilot  &  Docking  Pilot  Commission conducted  its  own investigation  and  concluded  that  the  Metro  docking  pilot  failed  to  perform  the  appropriate pilot-to-pilot and master/pilot exchanges

Carnival’s navigation policy requires closed-loop communication and a process called ‘thinking aloud,’ meaning ‘sharing verbally a mental model of the current situation and future situations,’ which allows for greater situational awareness of the bridge team, while closed-loop communications ensure that when an order or request is made, the person executing it understands and acknowledges that order. By repeating it back (acknowledging the order), the likelihood of miscommunication and  misunderstanding  is  significantly  reduced.

There was  little  audible evidence that the thinking-aloud concept was in practice during this accident sequence. While the pilot was issuing bow thruster and tug orders, the master used the stern azipods with the intention to bring the ship closer to Pier 90, but did not verbalize his actions to the pilot or bridge team.

Bridge team’s actions

The ship’s bridge team could have been more effectively engaged  in  the  ship’s manoeuvring to the dock. The Metro docking pilot was conning the vessel, and the master was focusing on the starboard side, concerned about the ship being set onto the corner of Pier 88 due to the ebb current.

Although Carnival’s navigation policy and task assignments require monitoring of the person conning the vessel, cross-checking of the ship’s position, and predicting track and headway, there was no evidence that any bridge team member probed or alerted the master and pilot of the headway of the vessel toward the corner of Pier 90. For example, the staff captain was responsible for overseeing the entire bridge operation and monitoring the master and the pilot, yet he never voiced concern about the vessel’s speed of approach toward Pier 90 before impact.

 

The NTSB Report is available here: https://www.ntsb.gov/investigations/AccidentReports/Reports/MAB1929.pdf

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