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Notes from Video Presentation of the National Transportation Safety Board (NTSB) findings on 1-10-07.
- The Crown Princess listed or heeled 24%. This is much more than the original 15% reported by Princess cruise Lines and Carnival. Princess disagrees with the heal angle. The Coast Guard came up with a a lower number with a less precise heel calculation. It is still unclear at what angle the ship could have capsized.
- Over 4,000 passengers and crew were on board.
- Over 300 people were injured (likely underestimated since there were over 200 lawsuits filed and many people settled pre-suit and it is unclear whether the psychologically injured were included).
- The list / heel angle pictures are very dramatic. Most people on board would have thought the ship was capsizing. No one can reasonably suggest that the list it was a minor event.
- Audio quality of recordings of captain and crew were "fair' a disappointing quality given the fact that the ship was new. Alarms were going off and other noises affected recording quality.
- The captain made the critical error of ordering the ship to increase speed in shallow water to get ahead of some oncoming weather. High speeds in shallow water is dangerous if steering input is made to the helm either through the auto-pilot or manually.
- The ship was on auto-pilot when it was making a scheduled turn. The ship started to heel to an unreasonable level. The auto-pilot alarms caused the crew to jump on the wheel and start making adjustments. Crew error was a key factor in the list incident. It is unclear whether the auto-pilot also contributed to the accident by causing the initial heel.
- The excessive speed of the ship and shallow water effect also appears to have contributed to the list. It appears that the captain and crew did not have adequate knowledge and experience as to the effect of speed and shallow water on list factors and steering input. The Captain left the autopilot settings and increased speed to 'get ahead' of bad weather. Captain and crew should have reduced speed and centered the rudder to stabilize the vessel.
- 24% is extremely severe. Anything over 10% is very severe. Ship was never in any danger of capsize from a engineering point of view.
- if the second officer had never have taken helm, the ship might have stabilized on its own.
- If helmsman had been at the helm as opposed to the second officer, as opposed on look-out, he would have been available to take correct action. The helmsman is more experienced. Second officer did not bring the helmsman over before reacting to a perceived danger.
- There are examples of crew failure to follow standard procedures.
- The INS autopilot was improperly set and caused the ship to become unstable even before the crew took control of the helm. Rudder can only move at 3% per second no matter how much steering input.
- A port turn causes yaw to the starboard.
- The second officer should have reduced speed and turned the helm to centerline in order to correct the initial problem.
- Second officer only perceived a problem, which likely never existed. his initial wheel input was wrong, his subsequent back and forth was also incorrect.
- No instructions were provided by Captain when he left bridge about the steering problems which already existed. Second officer was left to apprehend the problem, find the cause of the problem and fix the problem. Clearly, the second officer panicked as he tried to deal with the situation.
- No standards for INS (autopilot) training or certification.