Allision of the Liberian Freighter Bright Field with the Poydras Street Wharf, Riverwalk Marketplace, and New Orleans Hilton Hotel in New Orleans, Louisiana, December 14, 1996

(

PB98-916401

NTSB/MAR-98/01

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON,

D.C.

20594

MARINE ACCIDENT REPORT

ALLISION OF THE LIBERIAN FREIGHTER

BRIGHT

FIELD WITH THE POYDRAS STREET

WHARF, RIVERWALK MARKETPLACE, AND

NEW ORLEANS HILTON HOTEL IN

NEW ORLEANS, LOUISIANA

DECEMBER 14, 1996

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Abstract: On December 14, 1996, the fully loaded Liberian bulk carrier Bright Field

temporarily lost propulsion power as the vessel was navigating outbound in the Lower

Mississippi River at New Orleans, Louisiana. The vessel struck a wharf adjacent to a populated

commercial area that included a shopping mall, a condominium parking garage, and a hotel. No

fatalities resulted from the accident, and no one aboard the Bright Field was injured; however, 4

serious injuries and 58 minor injuries were sustained during evacuations of shore facilities, a

gaming vessel, and an excursion vessel located near the impact area. Total property damages to

the Bright Field and to shoreside facilities were estimated at about $20 million.

The safety issues discussed in this report are the adequacy of the ship’s main engine and

automation systems, the adequacy of emergency preparedness and evacuation plans of vessels

moored in the Poydras Street wharf area, and the adequacy of port risk assessment for activities

within the Port of New Orleans. This report also addresses three other issues: the actions of the

pilot and crew during the emergency, the lack of effective communication (as it relates to the

actions of the pilot and crew aboard the Bright Field on the day of the accident), and the delay in

administering toxicological tests to the vessel crew.

As a result of its investigation, the National Transportation Safety Board issued

recommendations to the U.S. Coast Guard, the U.S. Army Corps of Engineers, the State of

Louisiana, the Board of Commissioners of the Port of New Orleans, International RiverCenter,

Clearsky Shipping Company, New Orleans Paddlewheels, Inc., the New Orleans Baton Rouge

Steamship Pilots Association, the Crescent River Port Pilots Association, and Associated Federal

Pilots and Docking Masters of Louisiana, Inc.

The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established

in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to

investigate transportation accidents, determine the probable causes of the accidents, issue safety

recommendations, study transportation safety issues, and evaluate the safety effectiveness of

government agencies involved in transportation. The Safety Board makes public its actions and

decisions through accident reports, safety studies, special investigation reports, safety

recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 605-6000

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MARINE ACCIDENT REPORT

Adopted: January 13, 1998

Notation 6885A

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iii

CONTENTS

EXECUTIVE SUMMARY.........................................................................................................vii

INVESTIGATION

Synopsis .......................................................................................................................................... 1

Preaccident Events ..........................................................................................................................1

The Accident ................................................................................................................................... 5

Injuries...........................................................................................................................................10

Vessel Damage..............................................................................................................................10

Other Damage................................................................................................................................ 10

Crew Information .......................................................................................................................... 14

The Pilot................................................................................................................................. 14

The Master ............................................................................................................................. 14

The Chief Engineer................................................................................................................16

The Previous Chief Engineer................................................................................................. 17

Vessel Information ........................................................................................................................ 17

Bright Field............................................................................................................................ 17

Automated Propulsion Control System ..........................................................................18

Engine Lubricating Oil System.......................................................................................19

Cruise Ships ........................................................................................................................... 20

Gaming and Excursion Vessels.............................................................................................. 20

Waterway Information................................................................................................................... 21

River Stage............................................................................................................................. 21

Vessel Traffic Control............................................................................................................ 21

Port Information............................................................................................................................ 22

Dredging................................................................................................................................. 22

The Wharf Area...................................................................................................................... 23

Federal Jurisdiction................................................................................................................23

Meteorological Information ..........................................................................................................25

Toxicological Information.............................................................................................................25

Survival Aspects............................................................................................................................ 26

Bright Field............................................................................................................................ 26

Enchanted Isle........................................................................................................................26

Nieuw Amsterdam.................................................................................................................. 26

Queen of New Orleans...........................................................................................................27

Creole Queen ......................................................................................................................... 30

Riverwalk Marketplace..........................................................................................................32

Hilton Riverside Hotel ...........................................................................................................33

Emergency Response.....................................................................................................................34

Port of New Orleans Harbor Police ....................................................................................... 34

Coast Guard Group New Orleans ..........................................................................................35

Louisiana Office of Emergency Preparedness .......................................................................35

Police Departments ................................................................................................................35

New Orleans Fire Department ...............................................................................................35

New Orleans Department of Health and Emergency Medical Services................................. 35

Emergency Preparedness...............................................................................................................36

Riverwalk Marketplace..........................................................................................................36

New Orleans Hilton Riverside Hotel ..................................................................................... 36

Queen of New Orleans...........................................................................................................36

Safety Briefings............................................................................................................... 37

Signage............................................................................................................................ 37

Emergency Egress........................................................................................................... 37

Drills ............................................................................................................................... 38

Creole Queen ......................................................................................................................... 38

Inspections, Tests, and Research...................................................................................................38

Steering Gear.......................................................................................................................... 39

Main Engine—General .......................................................................................................... 39

Main Engine Lubricating Oil Sump.......................................................................................39

Main Engine Lubricating Oil Pumps/Motors......................................................................... 39

Main Engine Lubricating Oil System Second Filter/Strainer ................................................40

Main Engine Lubricating Oil Purifier.................................................................................... 40

Automatic Main Engine Lubricating Oil Trip Function ........................................................41

Alarms, Indicators, and Recorders.........................................................................................41

Remote Engine Control Tests ................................................................................................41

Preventive Maintenance.........................................................................................................41

Reports and Recordkeeping ................................................................................................... 41

Main Engine Lubricating Oil Testing and Analysis............................................................... 42

Spare Parts and Calibration Tools.......................................................................................... 42

Sulzer Inspection....................................................................................................................42

Chief Engineer’s Assessment................................................................................................. 43

Tests, Reports, and System Calibration ................................................................................. 43

Computer Simulation.............................................................................................................44

Other Information..........................................................................................................................44

Port Risk Analysis and Management—Coast Guard............................................................. 44

Port Risk Analysis and Management—Other Stakeholders .................................................. 45

Lower Mississippi River Safety Study............................................................................ 45

Louisiana World Exposition........................................................................................... 45

International RiverCenter................................................................................................ 46

New Orleans Aquarium of the Americas........................................................................ 46

Gaming Vessel Risks and Background........................................................................... 47

Operation Safe River....................................................................................................... 50

Changes Made Since the Accident......................................................................................... 51

River Front Alert Network.............................................................................................. 51

New Notices, Rules, and Operating Regulations............................................................ 51

Steering Loss Study ........................................................................................................ 53

Ship Drill Alarms............................................................................................................ 53

Riverwalk Marketplace Alert System............................................................................. 53

Vessel Egress..................................................................................................................54

Status of the Queen of New Orleans...............................................................................54

General .......................................................................................................................................... 55

ANALYSIS

Accident Overview........................................................................................................................55

Engineering Aspects......................................................................................................................56

Main Engine Shutdown and Restart....................................................................................... 56

Lubricating Oil Pump Operation............................................................................................ 57

General Condition of the Bright Field’s Engineering Plant................................................... 57

Vessel Owner’s Oversight of the Bright Field’s Engineering Plant...................................... 58

Communication............................................................................................................................. 59

Master-Pilot Briefing at the Anchorage .................................................................................59

Language Differences............................................................................................................. 60

Information Exchange During the Emergency....................................................................... 60

Emergency Response.....................................................................................................................62

Vessel Emergency Preparedness and Evacuation Plans................................................................ 63

Vessel Evacuation..................................................................................................................63

Emergency Drills....................................................................................................................65

Safety Briefings and Signage.................................................................................................66

Shoreside Emergency Alert and Response............................................................................. 67

Toxicological Testing.................................................................................................................... 68

Risk Assessment and Risk Management....................................................................................... 69

Findings......................................................................................................................................... 75

CONCLUSIONS

Findings......................................................................................................................................... 74

Probable Cause.............................................................................................................................. 76

RECOMMENDATIONS............................................................................................................ 77

APPENDIXES

APPENDIX A--Investigation........................................................................................................81

APPENDIX B--Chronology of Bright Field Engineering Problems ............................................ 83

APPENDIX C--Voyage Data Recorders (VDRs) .........................................................................89

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vii

Shortly after 1400 on December 14, 1996,

the fully loaded Liberian bulk carrier

Bright

Field

temporarily lost propulsion power as the

vessel was navigating outbound in the Lower

Mississippi River at New Orleans, Louisiana.

The vessel struck a wharf adjacent to a

populated commercial area that included a

shopping mall, a condominium parking garage,

and a hotel. No fatalities resulted from the

accident, and no one aboard the

Bright Field

was injured; however, 4 serious injuries and 58

minor injuries were sustained during

evacuations of shore facilities, a gaming vessel,

and an excursion vessel located near the impact

area. Total property damages to the

Bright Field

and to shoreside facilities were estimated at

about $20 million.

The National Transportation Safety Board

determines that the probable cause of this

accident was the failure of Clearsky Shipping

Company to adequately manage and oversee the

maintenance of the engineering plant aboard the

Bright Field

, with the result that the vessel

temporarily lost power while navigating a high-

risk area of the Mississippi River. Contributing

to the amount of property damage and the

number and types of injuries sustained during

the accident was the failure of the U.S. Coast

Guard, the Board of Commissioners of the Port

of New Orleans, and International RiverCenter

to adequately assess, manage, or mitigate the

risks associated with locating unprotected

commercial enterprises in areas vulnerable to

vessel strikes.

The major safety issues identified in this

investigation are the adequacy of the ship’s

main engine and automation systems, the

adequacy of emergency preparedness and

evacuation plans of vessels moored in the

Poydras Street wharf area, and the adequacy of

port risk assessment for activities within the

Port of New Orleans. This report also addresses

three other issues: the actions of the pilot and

crew during the emergency, the lack of effective

communication (as it relates to the actions of the

pilot and crew aboard the

Bright Field

on the

day of the accident), and the delay in

administering toxicological tests to the vessel

crew.

As a result of its investigation of this

accident, the Safety Board issued safety

recommendations to the U.S. Coast Guard, the

U.S. Army Corps of Engineers, the State of

Louisiana, the Board of Commissioners of the

Port of New Orleans, International RiverCenter,

Clearsky Shipping Company, New Orleans

Paddlewheels, Inc., the New Orleans Baton

Rouge Steamship Pilots Association, the

Crescent River Port Pilots Association, and

Associated Federal Pilots and Docking Masters

of Louisiana, Inc.

EXECUTIVE SUMMARY

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Synopsis

Shortly after 1400 on December 14, 1996,

the fully loaded Liberian bulk carrier

Bright

Field

temporarily lost propulsion power as the

vessel was navigating outbound in the Lower

Mississippi River at New Orleans, Louisiana.

The vessel struck a wharf adjacent to a

populated commercial area that included a

shopping mall, a condominium parking garage,

and a hotel. No fatalities resulted from the

accident, and no one aboard the

Bright Field

was injured; however, 4 serious injuries and 58

minor injuries were sustained during

evacuations of shore facilities, a gaming vessel,

and an excursion vessel located near the impact

area. Total property damages to the

Bright Field

and to shoreside facilities were estimated at

about $20 million.

Preaccident Events

According to vessel records, on September 2,

1996, the 735-foot, 36,120 gross-ton

Bright Field

completed loading a cargo of coal in

Banjarmasin, Indonesia. On September 12, 1996,

the vessel departed Indonesia with a 28-member

Chinese crew bound for Davant, Louisiana. The

estimated date of arrival at Southwest Pass,

Louisiana,

(the vessel’s entrance point to the

Mississippi River) was October 26, 1996. Shortly

after departure, the ship began to experience

problems with its engineering plant, necessitating

a 3-day layover in Singapore while repairs were

made to the main engine. After the repairs were

completed, the

Bright Field

continued its voyage.

The trip was interrupted on several occasions by

continuing main engine problems.

On November 21, 1996, the

Bright Field

arrived at a bulk coal-handling facility near

Davant, Louisiana (mile 55 AHP

), where it

Southwest Pass is the westernmost of the several

entrances to the Mississippi River and is the one most often

used.

Distances in the Mississippi River are measured in

statute miles “above head of passes” (AHP), which is

located 20 miles above Southwest Pass.

unloaded its cargo. (See figure 1.) After its holds

were prepared to load grain and after waiting for

a loading berth, the

Bright Field

arrived at

Cargill Terminal, located at mile 140 AHP in

Reserve, Louisiana, on December 9, 1996.

There the vessel loaded 56,397 metric tons of

corn in its seven cargo holds. The vessel left the

terminal at 1530 on December 11, 1996.

The

vessel moved from the terminal area to the

lower portion of La Place Anchorage at mile

135 AHP, where it remained at anchor for 2

days while scheduled repairs were made to the

main engine’s turbocharger and air cooler.

On December 14, 1996, the vessel’s agent

contacted the New Orleans Baton Rouge

Steamship Pilots Association (NOBRA) and

requested that a pilot be dispatched to the vessel.

The sailing time was set for 1030. The pilot who

was dispatched to the

Bright Field

stated that he

was called for duty about 0730. He said he was

told that the ship was headed to sea, which

meant that he would take the ship to a specified

location, where he would be replaced by a pilot

from the Crescent River Port Pilots Association

for the remainder of the trip downriver. The

pilot said he expected to be aboard the

Bright

Field

for about 3 hours.

The

Bright Field

third mate and chief

electrician stated that on the morning of

December 14 they completed all predeparture

tests for both bridge and engineering, including

testing the bridge main engine console lights and

alarms. With the successful completion of the

tests, the master ordered standby engines at 0943.

The pilot boarded the vessel via launch at 1040,

At the time of departure, the draft of the vessel was

11.96 meters (about 39 feet 4 inches) forward and 12.06

meters (about 39 feet 8 inches) aft.

Louisiana State law requires that a qualified and

certified State pilot be on board any vessel in foreign trade

navigating the Mississippi River in the State. Although

NOBRA, as well as other pilot associations, dispatches

pilots, bills and collects pilotage fees, and pays association

expenses, including staff and transportation fees, the pilots

themselves are self-employed and contract for their services

directly with vessel operators.

INVESTIGATION

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Figure 1 -- Lower Mississippi River

and the third mate escorted him to the

wheelhouse, where he was introduced to the

master at 1044.

The ship’s master spoke what the pilot

described as broken, but adequate, English. The

pilot said that, to facilitate communication, he

spoke slowly and used simple words, and he

believed that he and the master understood each

other. The master also stated that he was

satisfied with their ability to communicate. The

pilot said he gave helm orders in English to the

helmsman, who repeated them in English before

carrying them out. The second mate reported

that he also repeated (in English) the pilot’s

orders and then carried them out. Other than

orders and their repetition, the pilot said he had

no verbal exchanges with the second mate or the

helmsman.

The pilot, who had not previously handled

the

Bright Field

, said he asked if the ship’s

navigational equipment and engine were in good

working order. He stated that the master

answered with “just a simple ‘yes’ to both

questions.” The master stated that he asked the

pilot about the operational procedures for

departing the anchorage.

These were the only

items reported as being discussed during the

predeparture briefing. The pilot said he then

proceeded to acquaint himself with the

wheelhouse layout (figure 2) and with the

vessel’s posted maneuvering information. At the

time, the vessel’s main engine was being

operated from the wheelhouse.

At 1055,

the pilot began the normal

procedures for getting underway by ordering the

first engineering maneuvering bell (dead slow

ahead). According to the third mate, he (the

third mate) attempted to execute the pilot’s

order using the wheelhouse engine controls, but

the vessel’s main engine did not start. He then

called the engine control room and told the chief

engineer—in Chinese—that the engine did not

start. Engine control was transferred to the

engine control room. Both the master and the

chief engineer stated that their normal practice

This information typically includes, among other

details, the location of assist tugboats and the order in

which the two anchors are to be raised.

Times are taken from engine bell logs.

was to transfer engine control to the engine

control room in the event of a nonemergency

problem with the propulsion system.

After the engines were started (1055.5, dead

slow ahead), engine control was transferred

back to the wheelhouse. The pilot ordered stop

engine, and the engine was stopped. At 1110,

the pilot ordered dead slow ahead. Again, the

engine could not be started from the

wheelhouse, and again control was transferred

to the engine control room, from which the

engine was restarted. After the accident, the

pilot stated that he had not been advised of the

difficulties in starting the engine from the

wheelhouse, nor was he informed on those

occasions when engine control was transferred

to or from the engine control room.

The

Bright Field

departed the La Place

anchorage at 1112. Engine maneuvering control

was transferred back to the wheelhouse, and the

pilot ordered full ahead maneuvering speed (56

rpm) in order to familiarize himself with the

ship’s responsiveness to rudder and engine

orders. He said he determined that the

Bright

Field

handled as expected for a fully loaded

bulk cargo vessel operating in high-river-stage

conditions.

At 1134, the pilot ordered sea speed

(72 rpm) for better ship handling. The pilot said

it was necessary to operate the ship at maximum

speed in order to obtain the best maneuverability

in that operating environment.

Engine rpm was increased to sea speed

using wheelhouse controls. At 1159, as the

vessel approached Norco, Louisiana, the pilot

ordered the

Bright Field’

speed reduced to full

ahead maneuvering speed (56 rpm). The

Bright

Field

remained at full ahead maneuvering speed

until it reached the vicinity of Destrehan,

Louisiana, when the pilot again ordered sea

speed of 72 rpm, resulting in a ground speed

(speed of the ship plus speed of the current) of

about 16 knots.

About 1300, the pilot ordered the master to

send a seaman to stand by the anchors.

The

On the day of the accident, the river was at high river

stage, measuring 12.5 feet on the Carrollton gauge with an

approximate 4 1/2-mph current.

A Board of Commissioners of the Port of New

Orleans ordinance required that all vessels navigating

master sent the ship’s carpenter, with a handheld

radio, to serve as anchor watch.

A few miles

above Nine Mile Point, the pilot established

VHF communications

with an inbound tow

and inbound ship, both below Nine Mile Point.

The vessels agreed to a starboard-to-starboard

meeting, and all three vessels met at the point.

The pilot of the

Bright Field

said that, because

the inbound tow was farther off the bank than

anticipated, he maneuvered his ship

closer to the

left descending bank of the river. The

Bright

through the New Orleans Port area maintain an anchor

standby of at least one competent seaman, who was to be

stationed at the anchor windless and be prepared to drop

anchor if necessary.

Serving as anchor watch was a regularly assigned

duty of the

Bright Field

’s carpenter.

VHF channel 67 was assigned for routine bridge-to-

bridge (navigation/safety) communication in the Lower

Mississippi River.

Field

pilot sounded the danger signal

to alert

the workers at the Southport barge fleeting

facility

to the proximity of the

Bright Field

The

Bright Field

passed the area without

incident and continued down the river at sea

speed. The master told Safety Board

investigators that about this time he became

concerned that the pilot might be oversteering

the vessel, but he said he did not voice his

concerns to the pilot.

About 1350, the pilot made the first radio

call to the U.S. Coast Guard Gretna light

operator.

The Gretna light operator advised the

Five or more shorts blasts on the ship’s whistle.

fleet

in this instance refers to one or more tiers of

barges. A fleeting facility is the geographic area along or

near a river bank where a barge mooring service is located.

According to 33

Code of Federal Regulations

(CFR)

161.402(b), “Movements of vessels in vicinity of Algiers

Point, New Orleans Harbor,” during a high river stage,

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Figure 2 -- navigation bridge layout

Bri

ht Field

Bright Field

that the ship was cleared to transit

Algiers Point and that a seagoing tow boat was

inbound at the Point. The pilot stated that, while

the

Bright Field

was transiting under the

Crescent City Connection Bridges, he allowed

the vessel to acquire a current-induced swing to

port to facilitate the upcoming maneuver around

Algiers Point.

The Accident

The swing to port as the ship passed under

the Crescent City Connection Bridges pointed

the vessel toward the left descending bank, the

side of the river where the Poydras Street wharf

and the Riverwalk Marketplace shopping mall

were located and where gaming, excursion, and

cruise ships were docked. About 1406, while the

Bright Field

was still transiting under the

bridges, power output from the vessel’s main

engine dropped. At this time, the vessel’s

automated propulsion control system

reported

low main engine lubricating oil pressure and

main engine trip due to low oil pressure.

The pilot said he noticed that the vessel had

gotten quiet and that the engine-induced vessel

vibrations had stopped. He said he turned and

saw the master and the second mate

standing

beside the engine order telegraph (on the other

side of the bridge from the pilot), looking down

at something on the console. He said he asked

them if there was a problem, but got no

response. He said that he did not ask a second

time “because they didn’t answer me the first

time.” He reported that he then looked at the

engine rpm indicator and saw that engine rpm

movement of vessels around Algiers Point is controlled by

several Coast Guard-operated and maintained traffic lights,

including Gretna light at 96.6 miles AHP and Governor

Nicholls light at 94.3 AHP.

For the purposes of this report,

automated

propulsion control system

and related terms will be used to

refer to all main engine control, monitoring, and alarm

systems and subsystems.

The main engine was equipped with protection

devices that could slow down or stop the main engine

depending on the severity of the problem. See the “Main

Engine Description” section of this report for information

about the engine and its protective devices.

The second mate had come on duty at the noon

watch to replace the third mate who had been on duty when

the ship left the anchorage.

had dropped from about 70 to about 30,

indicating to him that the vessel had experienced

a significant reduction in engine power.

The master and the second mate said that

they also noticed that the ship’s normal operating

vibrations had stopped, and they observed that the

main engine rpm indicator showed a drop to

about 30 rpm. The master said the pilot “blurted

out, ‘What has happened?’” and he (the master)

thought he had answered the pilot by saying

there had been a reduction in main engine

power. The master said it was not clear to him

why engine rpm had dropped. He said he

instructed the second mate “to call the

engineroom to inquire about what happened,

what’s going on. I asked the second mate to

demand them to increase speed right away.” The

second mate said that he carried out the master’s

order immediately.

The pilot stated that when he realized that the

vessel had lost power, he “jumped” out of his

chair and called the Governor Nicholls Light

operator on VHF channel 67. He said that as he

made the call he was looking out the bridge

windows and was aware that the vessel was

swinging to port and toward the docked ships

along the left descending bank. The pilot told the

Governor Nicholls light operator that his ship had

lost power and that the operator should alert

everyone in the harbor.

The pilot said that, after calling the light

operator, he ordered hard starboard rudder as the

ship continued to swing to port. The helmsman

responded to the order by applying hard

starboard rudder, but the new rudder setting did

nothing to alter the vessel’s direction, and the

pilot began sounding the danger signal using the

ship’s forward whistle. He said he wanted to

attract the attention of the cruise ships and

public along the left descending river bank. The

pilot stated that he ordered the master on at least

two occasions to have someone stand by the

Information regarding radio transmissions using

VHF channel 67 is based on audio recordings made by the

tugboat

Lockmaster

, located on the side of the river

opposite the Poydras Street wharf. The

Lockmaster

was

also able to provide a videotape of radar images of the

Bright Field

as it approached and struck the wharf. The

traffic light stations were not equipped to record radio

transmissions.

anchors, but he did not hear the master

acknowledge the order. The pilot said he recalled

the master speaking Chinese on the radio and

that the master did not appear to be agitated, but

was “very nonchalant.”

When the pilot noted that the rpm indicator

continued to show a loss of power, he made

another call to the Governor Nicholls light

operator. He told the operator to warn the cruise

ships and gaming and excursion vessels that

were moored along the left descending bank.

The Gretna light operator advised the pilot that a

tugboat 1 mile upriver was coming to his aid.

The chief engineer on duty in the engine

control room

(figure 3) stated that,

immediately before the engine lost power, an

audible alarm sounded. He said he then looked

at a computer screen in front of him and saw a

visual alarm and an indication of a loss of

pressure in the lubricating oil system. (See

figure 4.) He said he looked at the analog main

engine lubricating oil pressure gauge and saw

that the system was rapidly “depressurizing”

below normal levels. He said he then noticed

that the main engine automatic slow down light

was on, and he noticed that main engine noise

was decreasing. He reported that he also

observed that engine rpm had dropped from 72

to between 30 and 35. He said that, as he turned

to the electrical switchboard behind him to

determine why the No. 2 lubricating oil pump

had not started automatically, the pump started.

He said that, except for the low rpm, everything

seemed to him to be back to normal almost

immediately.

According to the chief engineer, he was

about to call the bridge when the second mate

called him. He said that the second mate asked

him why the main engine was slowing down and

told him to increase the speed immediately, that

they were transiting the bridge at that time. The

chief engineer reported that the second mate

spoke to him in a normal tone of voice, without

At the time of the accident, Coast Guard regulations

did not require that engineering spaces be manned during

transit of the Mississippi River. Although the

Bright Field

was classed for unattended operation of machinery spaces,

company regulations required that the chief engineer and

two other engineers be on duty in the engine control room

whenever the vessel was entering or leaving a port.

repeating his message. The chief engineer said

he thought the second mate was concerned

about speeding up passage of the vessel beneath

the bridges. He said he did not know the nature

of the situation on the vessel’s bridge.

The chief engineer told the second mate that

he did not know the reason for the sudden drop

in the No. 1 oil pump pressure, but since the No.

2 pump had already come on line, the

pressurization problem was solved. Neither the

master nor the second mate attempted to clear

the trip condition and restart the engine, and

thus restore rpm, from the bridge controls. The

chief engineer and the second mate mutually

agreed to transfer engine control to the engine

control room, and the chief engineer began the

process of restoring engine power. He said that

engine rpm quickly reached about 52 rpm, after

which rpm continued to increase to about 60.

According to alarm logs, main engine power

was restored to the vessel at 1408, about 2

minutes after the logs indicated that the main

engine had tripped.

In postaccident testimony, the master was

asked if it had been necessary to transfer engine

control from the bridge to the engine control

room during the emergency. He said, “Under

normal circumstances, speed increase can be

done from the engine [control room] more

quickly.” The master was asked why the engine

control room had requested that engine control

be shifted from the bridge to the engineroom.

He said that it was “because the engineering

department [didn’t] realize the sense of urgency

or [that] there [was] any sense of urgency on the

bridge.” He said engine control room personnel

were not initially notified of the emergency

situation but were told later when the allision

was unavoidable even if vessel speed were

increased.

The pilot stated that at this time he was

devoting his attention to sounding the danger

signal to alert the moored ships along the left

descending bank and the Riverwalk complex

and that he was not immediately aware, nor was

In marine usage,

allision

refers to a moving ship

striking a stationary ship or other stationary object.

Figure 3 -- engine control room layout showing

reported positions of crewmembers when engine power

reduction occurred.

Bright Field

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Figure 4 -- Engineering control, monitor, and alarm console

he made aware by the mate or the master, that

vessel power had been restored. The pilot said

that he was not aware of what, if any, actions

the master or the crew were taking to restore

power. The master’s orders to the second mate

and the second mate’s conversations with the

chief engineer were in Chinese.

The vessel continued to swing to port and

toward the left descending bank. The pilot told

the master to prepare to drop anchors and

ordered the main engine full astern. The vessel’s

bell logger tape, which continuously captures

data and prints it out in 30-second intervals,

recorded that the full-astern order was made

from the bridge at 1409.5 and answered by the

engine control room at 1410.0. The chief

engineer stated that he reversed the engine and

ran the shaft speed to 20 to 40 (fluctuating) rpm

astern.

The pilot stated that, shortly thereafter, he

ordered the anchors dropped. The master said

the pilot ordered only the port anchor dropped,

that he concurred with that order, and that

though he did not acknowledge the order to the

pilot, he attempted to carry it out. The master

said that he attempted to call the carpenter on

the forecastle using the handheld radio. The

carpenter, who was standing by the anchors,

said that he could not hear radio transmissions

from the master because the danger signal was

still being sounded on the ship’s whistle, which

was located about 20 feet above his station on

the bow. The master said he made repeated

unsuccessful attempts to contact the carpenter

but did not ask the pilot to suspend the sounding

of the danger signal. The pilot stated that he

stopped sounding the signal only long enough to

make short radio transmissions to the traffic

light operators to urge them to call the New

Orleans Riverwalk complex and “tell the people

to get away from the dock.”

The master stated that he rushed out to the

port bridge wing and waved his arms to attract

the carpenter’s attention. When he realized that

the carpenter did not see him, the master went

back inside the bridge. Once back inside,

intermittent communications were established

between the master and the carpenter. By the

time reliable communication was established,

the ship had moved farther toward the wharf,

and the master said he believed that dropping

the anchor at that time would cause the ship to

take a sharp turn to the left and perhaps strike

one of the vessels docked there. He said he

therefore told the carpenter not to drop the

anchor. The master said that after the ship had

moved a little farther, he again contacted the

carpenter and told him to drop the anchor to

keep the ship from striking the docked vessels.

The carpenter said he turned the brake wheel to

let go of the port anchor and then ran from the

bow to avoid being injured in the imminent

allision. Postaccident review of an amateur

videotape of the allision indicated that the

anchor did not drop prior to impact.

According to statements of the pilot and

crewmembers, the pilot did not ask either the

master or second mate if the vessel’s power had

been restored or if the anchors had been

dropped, and no one volunteered that

information. The pilot said he had not felt any

engine vibrations, though he expected to. He

said, “When that big engine turns, you feel it.”

The master said the vibrations caused by the

engine when it started in reverse while the ship

was still moving forward were obvious. No

further communications were reported between

the pilot and master or the pilot and the second

mate before the allision.

Meanwhile, the cruise ship

Enchanted Isle

was docked at the Erato Street wharf on the left

descending bank of the river. Passenger

embarkation had begun about 1230, and about

200 passengers were on board. Crewmembers

aboard the cruise ship did not (and were not

required to) monitor VHF channel 67 and

therefore did not hear any radio announcement

from the traffic light operator regarding the

Bright Field

. They did state that they heard the

vessel’s danger whistle. The third officer said he

was on the bridge as the

Bright Field

passed

under the Crescent City Connection Bridges and

that he knew the vessel was in trouble when he

heard its whistle blow for the fifth time. He

stated that he ran out onto the outside deck and

saw the

Bright Field

passing his ship on a direct

path to the Riverwalk area. The ship’s master,

who had also heard the

Bright Field’

s whistle,

reached the bridge as the

Bright Field

went past.

The officers activated the public address system

and placed the bridge on standby to close the

watertight doors. The third officer said that he

and the master called for the forward dock lines

to be tightened to protect against gangway

displacement as the

Bright Field

bow wave

struck the vessel. They also notified the

gangway watchman of a possible river surge and

sent two crewmen to watch over the gangway

and report any trouble back to the bridge.

According to the third officer, the

Bright Field

was clear of the

Enchanted Isle

throughout the

accident sequence.

Moored about 150 to 200 feet downriver

from the stern of the

Enchanted Isle

was the

cruise ship

Nieuw Amsterdam

. The ship had

begun embarking passengers about 1330, and an

estimated 200 to 300 passengers were on board

at the time of the accident. The crew did not

(and was not required to) monitor VHF channel

67. The second officer said he was standing

behind the port-side radar when his attention

was drawn to a ship on the river sounding an

emergency alarm. The second officer reported

that he could not immediately determine which

vessel was sounding the alarm, so he and the

chief officer went out to the port side bridge

wing (the vessel was docked with its starboard

side toward the wharf) and saw the

Bright Field

passing under the Crescent City Connection

Bridges. They said they stood and watched the

Bright Field

as it headed toward their ship and

the Poydras Street wharf area. They entered the

wheelhouse to warn the on-duty third officer.

The

Nieuw Amsterdam

’s on-duty third

officer said he also had heard the multiple

whistle signals and had watched the

Bright

Field

as it passed under the bridges with its bow

pointing toward his vessel. He said that the

Bright Field

appeared to be about 1/2 nautical

mile away and moving at 8 to 10 knots. Based

on his observations of the

Bright Field’

direction of travel and the whistle sounding, he

said, he assumed the vessel was experiencing

steering or engine failure. He immediately

warned the master, who was in his stateroom

directly behind the bridge.

The

Nieuw Amsterdam

’s master instructed

the on-duty officer to tell the security officer at

the gangway to stop the embarkation of

passengers. The on-duty officer was then to

place the bridge on standby, close the watertight

doors, and activate the public address system.

The master instructed the second and third

officers to go to the stern of the ship with radios

and to evacuate the Lido deck aft, then clear the

decks on the port side and monitor the situation.

The crew said that after 2 or 3 minutes it was

apparent that the

Bright Field

would not strike

the

Nieuw Amsterdam

. The master and the on-

duty officer followed the progress of the

Bright

Field

from the port wing bridge. They assessed

the situation and determined that the

Bright

Field

would miss the

Nieuw Amsterdam

approximately 50 meters (164 feet).

The first mate of the gaming vessel

Queen

of New Orleans

, which was docked at the

Poydras Street wharf with its bow less than

1,000 feet downriver from the stern of the

Nieuw Amsterdam

, had overheard the

Bright

Field

pilot’s call to the traffic light operator on

VHF channel 67 (although the vessel was not

required to monitor the frequency) and had

immediately begun emergency evacuation of the

637 passengers and crewmembers aboard the

vessel.

Meanwhile, the excursion vessel

reole Queen

, which had been docked at the

Canal Street wharf downriver from the

Queen of

New Orleans

, was in the process of pulling

away from the dock with 190 passengers and

crew on board. The master said he heard the

pilot of the

Bright Field

radio the Governor

Nicholls light operator and report, “I’ve lost

everything. The ship is heading toward the

passenger vessels.” The master said that he

returned the vessel to the dock and ordered an

emergency evacuation.

According to the results of Safety Board

surveys, patrons and employees of the

Riverwalk Marketplace along Poydras Street

wharf and the adjacent Julia Street and Canal

Street wharves were unaware of the meaning of

the warning whistles from the

Bright Field

Several harbor police officers did recognize the

warning whistles and tried to clear the area.

While they did so, some marketplace patrons

and staff members noticed the

Bright Field

heading toward them, and large numbers began

to flee. Many individuals sustained injuries

during the evacuation. The harbor police were

able to move most of the crowd away from the

expected impact area. Many of those in the area

For a detailed discussion of all the vessel

evacuations, see the “Survival Aspects” section of this

report.

said that they did not know what was happening,

and because they had had so little advance

notice of a potential hazard, they did not have

the opportunity to obtain information from mall

employees or security officers.

About 1411, the port bow of the

Bright

Field

struck the Poydras Street wharf at a

location between the docked

Nieuw Amsterdam

and

Queen of New Orleans

. (See figure 5.) The

vessel struck the wharf at what witnesses said

was a 40- to 45-degree angle, went into the

wharf up to the end of the forecastle deck (about

50 to 60 feet), and then made a sideways

movement. The bow portion of the vessel

scraped and collapsed portions of the buildings

on the Poydras Street wharf, including a portion

of the Riverwalk Marketplace shopping mall, a

condominium parking garage, and part of the

Hilton Riverside Hotel. The ship came to rest

against the wharf with its stern about 200 feet

from the stern of the

Nieuw Amsterdam

and its

bow about 70 feet from the bow of the

Queen of

New Orleans

. (See figure 6.) The pilot ordered

the engine stopped, after which several tugboats

arrived to hold the ship against the dock. About

3 minutes had elapsed from the time the pilot

made his first emergency call to the Coast Guard

light operator until the ship struck the wharf.

Injuries

The accident resulted in 4 serious and 58

minor injuries to persons in the Riverwalk area,

aboard the

Queen of New Orleans

, or aboard the

excursion vessel

Creole Queen

, which was

docked near the

Queen of New Orleans

. (See

table 1.)

Vessel Damage

After striking the wharf, the bow of the

Bright Field

grated along the concrete and steel

wharf structure for a distance of about 600 feet.

The allision damaged the port side of the bow.

The hull of the vessel sustained two horizontal

gashes about 100 feet long that penetrated the

port side of the ship and extended down the port

side from the fore peak (bow) ballast tank and

into the No. 1 cargo hold. Both the breached

fore peak tank and the No. 1 cargo hold flooded.

A diver found a 100-foot section of the forward

hull resting on the river bottom adjacent to the

Poydras Street wharf. Total damages to the

Bright Field

were estimated to be about $2

million. (See figure 7.) The vessels that had

been docked in the allision area did not sustain

significant damage.

Other Damage

The One River Place condominium

building, located on the Poydras Street wharf,

sustained damage to its valet parking garage.

Residents of the building were evacuated

because of a loss of power and water. The

Riverwalk Marketplace, a mall with 100 stores,

3 restaurants with outdoor seating, and a large

wharf walkway, sustained damage to more than

350 feet of its wharf frontage. About 10 percent

of the mall shops and restaurants were affected.

The New Orleans Hilton Riverside Hotel, part

of which was situated on the Poydras Street

Table 1 -- Injuries Sustained in Bright Field Allision

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Table

based on the injury criteria (49 CFR 830.2) of the International Civil Aviation Organization, which the

Safety Board uses in accident reports for all transportation modes.

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ure 5 -- Path of Bri

ht Field (not to scale)

Figure 7 -- Damaged Bright Field being towed away from Poydras Street wharf en route to repair

facility, January 6, 1997

wharf, sustained damage to 40 of its 1,600

rooms. Total damages to all facilities were

estimated to be about $18 million. (See figures 8

and 9.)

Crew Information

The Pilot

-- The

Bright Field

pilot, age 46,

had been a NOBRA pilot for about 17 years. He

began his maritime career in 1969 when he

started working on the Mississippi River during

college summer vacations. He served as a

deckhand aboard the

Delta Queen

, a

paddlewheel passenger vessel, and as a

deckhand and mate aboard other passenger

vessels, including the

Mississippi Queen

and the

Natchez.

He also worked for a barge line

operating on the Illinois River between St. Louis

and Chicago.

In 1975, the pilot graduated from a 2-year

program at the National River Academy in

Helena, Arkansas. The program consisted of

periods of 2 months of classroom instruction

followed by 2 months on a river vessel. He

obtained his first Coast Guard license, an inland

mate’s license, in 1975. He was commissioned

by the New Orleans Baton Rouge State Pilots

Commission as a pilot on January 16, 1980. At

the time of the accident, he was a licensed river

master and first class pilot. The most recent

renewal of his license had been on May 5, 1995.

The pilot said that he had piloted on most of

the vessel types transiting the Mississippi River.

He said he navigated primarily foreign flag

vessels anywhere from the New Orleans general

anchorage to Baton Rouge. The majority of

these were deep-draft vessels, although he said

he occasionally worked a seagoing tug and

barge. He said he averaged about 7 vessel

assignments per week, totaling between 200 and

300 ships each year. He stated that he had not

attended any ship simulator training, and he

believed that only one NOBRA pilot had

attended such training. He said he had not

received any bridge resource management

(BRM)

training and was, in fact, unfamiliar

with the term and the concept.

Bridge resource management entails effective use of

all available resources to achieve safe operations.

The pilot stated he had been involved in

three previous accidents. In 1983, the vessel he

was piloting struck a bridge when a

crewmember raised a boom too high. The

second event occurred when the vessel he was

piloting lost steering shortly after he came

aboard. The vessel moved hard to starboard and

hit a ship launch dock. The third event took

place in spring 1996, when the pilot was

working on board a vessel that lost rudder

control and struck the river bank.

For the 4 days prior to the accident, the pilot

said, he had kept essentially the same

sleep/wake schedule, arising shortly after

daylight, about 0700, and retiring between 2230

and 2300. He reported that he had slept well the

night before the accident, did not have any sleep

abnormalities, and did not suffer from any

illnesses. He said he was not sick and that he

had taken no medications on the day of the

accident.

The Master

-- The

Bright Field

master, age

35, had been in the maritime industry for 14

years. He began as an able seaman before

becoming an apprentice officer. He then

progressed from third, to second, to first, to

chief officer, and then to master. He had been a

master for a little more than 1 1/2 years and had

served on three different ships. He said he had

been master of the

Bright Field

for about 15

weeks at the time of the accident (since August

25, 1996). During his time with the

Bright Field

he had spent about 3 months at sea and about 1

month in port. He said he had been to New

Orleans twice before, in 1983 and 1989;

however, this was his first trip as master. He

said he had never, on any vessel, experienced a

reduction in engine rpm of the kind that

occurred just prior to this accident.

The master attended the Dalien Maritime

Academy in China for 4 years and graduated in

August 1982. His training involved more than

40 deck officer-related courses. It also included

computer-based simulator training in ship

handling and maneuvering. He said he had

received additional simulator training on two

occasions at the Qingdao Mariner’s Training

School. The first occasion involved radar

plotting and ship handling to qualify for his

radar observer’s endorsement. The second

involved the handling of large vessels and

Figures 8 and 9 -- Postaccident scenes

occurred after he had passed his master’s

examination.

The master held a People’s Republic of

China Marine Certificate of Competency, which

certified that he was qualified to be a master of

ships of 1,600 gross tons or more. The most

recent endorsement of that certificate had been

on April 20, 1995. He also held a Republic of

Liberia license certifying his competence as a

master and radar observer on oceangoing vessels

of any gross tonnage. The most recent

endorsement of that license had been on October

3, 1996. Both licenses are valid for 5 years.

The master indicated he had received

training that emphasized coordination among

the bridge team, including the pilot. He said his

training covered the duties and responsibilities

of each individual and stressed the need to be

able to communicate with one another and assist

one another in the performance of their duties.

He said the training also stressed the integration

of the various responsibilities.

The master noted that, since he had held the

position of master, he had overruled pilots on

four occasions. On this trip he said,

I…instructed the carpenter not to drop

the anchor, which in effect…overruled

the pilot, because the pilot [had]

instructed [me] to drop the anchor. [I]

instructed the carpenter not to drop the

anchor because [it] would [cause the

Bright Field

to] swerve towards the

passenger ship. That, in effect, is a way

of overruling the pilot.

The master said he did not confer with the

pilot about the change in the timing of the drop-

anchor order because there was “no time.”

The master reported that he began to learn

English when he entered the maritime academy.

He characterized his English language skills as

“not bad among Chinese,” though he noted that

his ability to read the language was better than

his ability to speak it. He said he did not have

any difficulty understanding the pilot on this

trip.

The master stated that he was required to be

available 24 hours a day but that his normal

schedule involved going to bed at midnight and

arising at 0700 each day. He said he had kept

this schedule on the night before the allision,

arising about 0715 after a complete night’s

sleep. He reported that he was not suffering

from any long-term illnesses and that he was not

sick and took no medications on the day of the

accident.

The Chief Engineer

-- The

Bright Field’

chief engineer, age 34, began his maritime

career in 1979. He studied marine engineering at

the Jimei Maritime School, graduating in 1982.

He said he had been sailing aboard ships as an

engineer since his graduation. He said he had

been a chief engineer for 4 years, had been with

his current employer for 1 month, and had been

chief engineer aboard the

Bright Field

for 3

weeks prior to the allision. He came aboard the

Bright Field

for the first time on November 21,

1996, to replace the vessel’s previous chief

engineer (see below), who had been relieved of

duty upon the vessel’s arrival in New Orleans.

The chief engineer stated that he had served

on ships with both more and less automated

engineering equipment than the

Bright Field

and

that he was comfortable with the

Bright Field

’s

automation. He also said he had received

training on automated ship systems at the Dalien

Maritime Academy in 1993 and that the last

ship he served on before the

Bright Field

was

equipped with a similar system. While aboard

the

Bright Field

, he had been underway on short

transits on four occasions for a total of 11 hours.

During those occasions he said there were no

engine casualties or automation problems,

although various main engine repairs had been

made while the ship was at anchor during the 3

weeks he had been aboard.

The chief engineer held a People’s Republic

of China Marine Certificate of Competency,

which certified that he was qualified as a chief

engineer of ships of 3,000 kw (kilowatt, or

4,023 hp) propulsion power or more. The most

recent endorsement of that certificate had been

on October 27, 1993. He also held a Republic of

Liberia license certifying his competence as a

chief engineer on motor vessels of any

propulsion power. The most recent endorsement

of that license had been on May 23, 1995. Both

licenses are valid for 5 years.

The chief engineer reported that his normal

work day began at 0800 and ended at 1700. His

normal sleep schedule was to go to bed at 2300

and arise at 0700. In the 2 days prior to the

allision, the

Bright Field

was at anchor, and the

engineer was involved in some repairs. On

December 12, the turbocharger was repaired.

Work began in the evening and was completed

at 0220 the following morning, December 13.

The chief engineer said he then went to bed and

got up shortly after 1000. That night he went to

bed before 2300 and was awakened just after

0600 on December 14 by the air cooler

technician, who needed his signature. He said he

remained awake, but he did not actually start

working for the day until about 0920.

The chief engineer reported that he was not

suffering from any long-term illnesses and that

he was not sick and had taken no medications on

the day of the accident.

The Previous Chief Engineer

-- The

vessel’s previous chief engineer had joined the

Bright Field

in April 1996. He left the vessel in

New Orleans on November 21, 1996, after being

fired for what a company representative said

was his failure to comply with company orders

about the maintenance and operation of the

Bright Field’

s engineering plant.

Vessel Information

Four vessels were docked near the point at

which the

Bright Field

struck the wharf. The

Enchanted Isle

was docked at the Erato Street

wharf, and the

Nieuw Amsterdam

was docked at

the Julia Street wharf. The gaming vessel

Queen

of New Orleans

was docked at the Poydras

Street wharf in front of the Hilton Riverside

Hotel. The excursion vessel

Creole Queen

was

docked at the Canal Street wharf.

Bright Field

--The

Bright Field

, a bulk

cargo carrier with seven cargo holds, was built

in 1988 by Sasebo Heavy Industries Co. Ltd., of

Japan. At the time of the accident, the ship was

owned by Clearsky Shipping Company, a

Liberian corporation, and operated by Cosco

H.K. Shipping Company, of Hong Kong. The

Liberian-registered vessel was 735 feet long,

weighed 68,200 deadweight tons, and had a

maximum breadth of 106 feet.

The

Bright Field

was classed

by Det

Norske Veritas (DNV) for periodically

unattended machinery space. When the

Bright

Field

was delivered, the original owners elected

to have the unattended machinery space en-

dorsement include specifications for preventive

maintenance and routine testing of automatic

propulsion system components, and the

procedures were verified periodically by DNV.

The current owner of the vessel elected not to

continue the preventive maintenance

endorsement of the original class certification.

The vessel was equipped with an IHI Sulzer

RTA62 slow-speed, five-cylinder, two-cycle,

turbocharged, reversible diesel engine

manufactured by Ishikawajima-Harima Heavy

Industries (IHI) of Aioi, Japan. The 9,655-brake

hp (7,200 kw) engine was directly coupled to a

24-foot-diameter, four-blade, bronze propeller

capable of driving the vessel to a speed of 15.5

knots at sea speed.

A change from ahead to

astern required that the engine be stopped and

restarted with shaft rotation in the opposite

direction. A high-pressure compressed-air

system was used to start the engine in either

direction and also to stop its rotation during a

change from ahead to astern or vice versa.

The

Bright Field’

s engine was fitted with

protective devices (alarms and shut downs),

sensors (pressure, temperature, etc.), and

automatic control equipment. In support of

unattended machinery operation, the vessel was

equipped with engine controls located on the

bridge.

The

Bright Field

was configured as a

conventional bulk carrier with an aft

engineering plant and accommodation house.

The navigation bridge was fitted with a chart

table, navigation equipment, and an automatic

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Because of the relatively rapid river current on the

day of the accident, the

Bright Field

was traveling at an

effective speed that exceeded its rated sea speed.

radar plotting aid (ARPA)

in its after part.

Facing toward the bow, forward of the chart

table to starboard of centerline, was the engine

control console with engine order telegraph. To

the left of the console on the centerline was the

helm control console, comprising the helm, gyro

compass, and magnetic periscope compass.

Forward of the console and suspended from the

overhead was a rudder angle indicator and

engine order indicator. Below the forward

bridge windows was a gyro repeater, radar, VHF

marine radio, and manual buttons for the ship’s

whistles.

Although not required by U.S. or Interna-

tional Maritime Organization regulations, the

vessel was equipped with a course recorder. In-

vestigators determined that, at the time of this

accident, the unit was inoperative because of

leaking graph recording pens. Examination of

the course recorder paper determined that the

unit had probably been out of service for some

time. When in working order, the unit records

the ship’s gyro heading over time.

The vessel was equipped with an engine

telegraph logger that automatically recorded

engine telegraph orders (date and time) from the

bridge and acknowledgments of the orders from

the engine control room. The logger also noted

whether the engine was being operated from the

control room or wheelhouse. The time units

were recorded in hours, minutes, and half

minutes. The unit did not record the ship’s

actual engine rpm.

Automated Propulsion Control System

-- The

automated propulsion control system aboard the

Bright Field

used components from a number of

manufacturers, the primary two being IHI,

which provided the main engine control system,

and Terasaki, which provided the engineering

plant monitoring, alarm, and recording systems.

Most remote control functions affecting the op-

eration of the main engine, including the

automatic engine trip features, passed through

the IHI control system. Dual independent

Terasaki computers and monitors received sig-

nals from sensing probes on engineering plant

equipment and provided a status report,

ARPAs are computer-based devices that process

radar signals and display selected navigation information.

including operating and fault conditions.

Conditions falling outside the acceptable oper-

ating ranges were alarmed to appropriate

watchstanding and engineering personnel.

Sasebo Heavy Industries, the ship’s builder,

assembled and connected the various

components of the automated propulsion control

system, including the bridge and engineering

remote control consoles.

The

Bright Field’

s automated propulsion

control system provided for operation of the

main engine through use of either electro-

pneumatic controls from the wheelhouse or

pneumatic controls from the control room. The

engine could be controlled from the bridge using

a single maneuvering lever, which also acted as

an engine telegraph transmitter. Although the

bridge controls allowed the

Bright Field

engineroom to be unattended, company policy

required that the engine control room be

attended during operation in restricted waters

such as the Mississippi River. Although each

operating location was equipped with certain

engine function controls that were not available

at the other location, the main engine could be

started, stopped, reversed, accelerated, or

decelerated from either the wheelhouse or the

control room. Both control locations could

provide main engine throttle control over the

vessel’s two speed ranges: maneuvering mode

(from dead slow speed of 30 rpm to full speed

of 56 rpm) and sea mode (speeds up to the

maximum of 72 rpm).

During normal operations, the rate at which

the rpm of the

Bright Field’

s main engine could

be increased was subject to limitations imposed

by two independent components of the

automated propulsion control system: an

acceleration-limiting program and a scavenging

air pressure

limiter.

The automatic acceleration-limiting

program could be activated when the engine was

being operated in wheelhouse control. The

program allowed engine rpm to increase only

gradually, in accordance with a programmed

(variable) acceleration rate. The wheelhouse

control operator could activate a switch to

Scavenging air

is that air used to evacuate exhaust

gasses from the engine’s cylinders after combustion.

bypass this program when engine speed needed

to be increased quickly. The acceleration-

limiting program was automatically bypassed

when the engine was being operated from the

engine control room.

The scavenging air pressure limiter

functioned to reduce main engine exhaust

emissions. Overriding the limiter injected more

fuel into the engine, thereby increasing engine

rpm at a slightly faster rate. The limiter was

automatically overridden whenever wheelhouse

controls were moved to “crash (emergency)

ahead” or “crash astern.” Also, a crash

maneuvering pushbutton on the engine control

room console enabled engineering personnel to

override the scavenging air pressure limiter if

necessary. According to the second engineer,

the crash maneuvering pushbutton was used

only on the orders of a bridge officer, and such

an order was not given on the day of the

accident.

Transfer of engine operating control to or

from the wheelhouse and engine control room

required communication and coordination

between bridge and engine control room

personnel. Transfer of propulsion control was

physically initiated by the engineer in the

control room, who first matched control settings

in the control room with those on the bridge,

then set a selector switch to the desired mode.

Transfer of control was completed when a

crewmember in the wheelhouse pressed a button

on the bridge to acknowledge the transfer.

According to the

Bright Field

chief engineer,

the transfer normally required 20 to 30 seconds

from the time of the initial decision to make the

transfer until the changeover was accomplished.

This time was confirmed in postaccident testing.

Audible and visual alarms on the bridge and

in the engine control room were designed to

activate in the event of the following emergency

conditions: start failure (wheelhouse only),

emergency manual stop, automatic emergency

trip, automatic slowdown, low control air

pressure, low starting air pressure, control

power failure, telegraph power failure, and

automatic failure of wheelhouse controls (auto

control failure).

Automatic engine slowdown interrupts and

automatic engine trip due to high cooling water

temperature could be overridden without the

fault having been corrected. The other main

engine trips, including trips resulting from low

lubricating oil pressure, required that the faults

be corrected before engine operation could be

resumed.

Engine Lubricating Oil System

-- The main

engine lubrication oil system circulated 30-

weight high-detergent oil from the 14-cubic-

meter (about 3,700 gallons) sump located in the

main engine foundation. A suction line picked

up the oil from the sump and delivered it to two

separate oil lines. These oil lines passed the oil

through wire mesh basket strainers before

delivering it to two (designated as No. 1 and No.

2) high-capacity (180 cubic meters, or 47,550

gallons, per hour) lubricating oil pumps. (See

figure 10.) Each pump was capable of boosting

the oil pressure to approximately 4 bar.

The

discharge piping from each pump met at a

One bar is equal to .995 kg/cm

or 14.5 psi.

Figure 10 --

Bright Field

No. 1 (left) and No. 2

lubricating oil pumps

common header, from which the oil passed

through an oil cooler and a second filter. In the

second filter, the oil was passed through 16 fine-

mesh cylindrical strainers. At this point, the

system pressure would have dropped by

approximately 1/2 to 1 bar. Various oil

temperature and pressure sensors monitored the

condition of the oil and signaled the status to the

automated control system. After being

circulated through the engine, the lubricating oil

drained back into the crankcase sump, where the

cycle began again. A separate lubricating oil

purification system drew warm oil from the oil

sump, passed it through a centrifugal separator

where water and contaminants were removed,

and then returned the cleaned oil to the main

engine sump.

The chief engineer stated that the standard

configuration for maneuvering the

Bright Field

in restricted waters included remote engine

control from the wheelhouse, the No. 1

lubricating oil pump running, and the No. 2

lubricating oil pump on standby. If the

automated propulsion control system detected

main engine lubricating oil pressure below 2.5

bar, it was designed to sound and display an

alarm in the engine control room, on the bridge,

and in various locations in the accommodation

spaces. If the pressure dropped below 2.4 bar, a

pressure-activated changeover switch would

signal the automated control system to start the

standby oil pump. If the pressure dropped below

about 2.3 bar, the control system would, after a

brief time delay, trip (shut down) the main

engine.

Cruise Ships

-- The cruise ships at the Julia

and Erato Street wharves were normally moored

at this location on weekends to disembark and

embark passengers and to load supplies. The

cruise ship

Enchanted Isle

was owned by

Almira Enterprises, Inc., and operated by New

Commodore Cruise Lines, Inc. The vessel, built

in 1958, was 574 feet long and was 13,681 gross

tons. It was powered by a steam turboelectric

propulsion system. Maximum capacity was

1,198 persons.

The

Nieuw Amsterdam

, moored at the Julia

Street wharf, was owned by Hal Antillen, Inc.,

and operated by Holland America Line

Westours, Inc. The 704-foot, 16,027-gross-ton

vessel was built in 1983 and was powered by a

direct-drive diesel engine.

Gaming and Excursion Vessels

-- The

Queen of New Orleans

was owned by Hilton

New Orleans, Inc., and New Orleans

Paddlewheels, Inc., in an association known as

Queen of New Orleans Joint Venture. The

vessel operated from a dock located at the

Poydras Street wharf, on the riverfront behind

the New Orleans Hilton Riverside Hotel and

Riverwalk Marketplace. The vessel conducted

eight scheduled 90-minute cruises each day. The

vessel left its docking facility at the wharf every

3 hours, beginning each day at 0245 and ending

at 2345. Passengers were allowed on board for

gambling 45 minutes prior to and 45 minutes

after each cruise.

The six-deck, 1,470-gross-ton, 245-foot-

long vessel was built in 1993. It was powered by

a Sternwheeler Propulsion System paddlewheel.

Capacity was 300 crew and 1,500 passengers,

for a total capacity of 1,800. The master of the

vessel stated that the vessel had four decks

accessible to passengers. The first three decks

were all gaming areas; the fourth had a forward

café and an aft gaming area. On a normal day,

about 20 percent of the passengers would be on

the first deck. The most crowded deck would be

the second deck, with about 40 percent of the

passengers. About 30 percent of the passengers

would be on the third deck, with only about 10

percent on the fourth deck. At the time of the

accident, 637 persons were on board, including

14 marine crew, 96 gaming personnel, 38

security, nongaming, and miscellaneous

personnel, and 489 passengers.

The

Queen of New Orleans

master stated

that, on the day of the accident, the vessel was

not scheduled to leave the dock. Under normal

operations, if the river stage is “8 feet and

rising,” the vessel remains at the dock. New

Orleans Paddlewheels, Inc., has stated that the

vessel:

Does not leave the dock for regularly

scheduled cruises during foul weather,

including rain, thunderstorms, showers,

hail, fog and mist and wind conditions

in excess of 12 mph. Additionally, the

vessel does not sail during seasonal high

river stage when the Governor Nicholl’s

traffic light is in operation.

Finally, the

Queen of New Orleans

remains at dock

during port closures issued by the

Marine Safety Office. When the vessel

is dockside, the vessel remains open for

business and passengers are permitted to

remain on board.

According to the Board of Commissioners

of the Port of New Orleans (Dock Board), the

provisions of the Dock Board’s Emergency

Management Checklist and Guidelines were

applied to the

Queen of New Orleans

gaming

vessel and its shoreside terminal as part of a

permit process. The facilities and operations

were reviewed by a Dock Board consultant prior

to approval of the permit and found to be in

compliance with the guidelines.

The 3-deck, 397-gross-ton

Creole Queen

, a

1,000-passenger-capacity paddlewheel excur-

sion vessel, was 190 feet long and 40 feet wide.

It normally departed the Canal Street dock for

two daily sightseeing trips and one nightly

dinner cruise. The overnight mooring location

for the vessel was the Poydras Street wharf ad-

jacent to the office of New Orleans

Paddlewheels, Inc., the vessel’s owner. The

berth was destroyed as a result of being struck

by the

Bright Field

. After the accident, the

overnight mooring location was moved to the

Canal Street wharf.

Waterway Information

According to information provided by the

U.S. Army Corps of Engineers, the Mississippi

River has a Federal project depth of 45 feet from

over the bar at Southwest Pass thence to the head

of the passes and to mile 233.4 AHP, or about

135 miles above New Orleans. Various areas of

the Federal project are under constant

maintenance dredging. Southwest Pass has a

recommended draft limit of 45 feet.

According to records supplied to the Safety

Board by the Corps of Engineers, between 1983

and 1996, mean monthly water temperatures in

The company has told the Safety Board that since

this policy was developed, the traffic lights have been

placed in full-time operation; consequently, the policy is

now interpreted to refer to those times (high water stage)

when the traffic lights are actually controlling river traffic.

the Mississippi River ranged from a low of 43.2

F in January to a high of 83.3

F in August.

Mean water temperature over the period for the

month of December was 49.6

River Stage

On average, high river stage

occurs in April and the low river stage in

October. At New Orleans, the extreme

difference between high and low stage is 17

feet; the mean difference is about 8 feet. At

several places in the lower part of the river,

counter currents or eddies often are found near

the banks. This occurrence is especially

pronounced in the area of Algiers Point.

Records maintained by the Corps of

Engineers indicated that the Carrollton gauge at

mile 102.8 AHP on December 14, 1996, read

12.5 feet (above a datum at New Orleans) and

was falling. Based on this reading, the Corps of

Engineers’ best estimate of the current below the

Crescent City Connection Bridges in the area of

the accident on December 14, 1996, was 4.5 mph.

At times of extremely high river stage, the

Corps of Engineers has the option of opening

the Bonnet Carré Spillway, which, by diverting

1/4 million cubic feet of water per second

through the spillway, lowers the river by

approximately 4 feet while reducing the speed

of the current. According to the Corps of

Engineers, the spillway, located about 33 miles

above Canal Street, was built in 1932 to protect

communities downstream of the spillway from

floods, and to lower river stages generally, by

discharging floodwaters into Lake

Pontchartrain, then into the Gulf of Mexico.

According to the Corps of Engineers, under

normal operating conditions, opening the

spillway is a complex task that requires about 36

hours to complete. Prior to the

Bright Field

allision, the spillway had been opened seven

times since its construction, the last time in

1983.

Vessel Traffic Control

-- The only

operational vessel traffic control system serving

During what the Coast Guard termed

“unprecedented high waters on the Mississippi River” in

early 1997, the Bonnet Carré Spillway was opened for the

eighth time on March 17, 1997, to lower the water level

and combat strong river currents. The spillway remained

open until April 18, 1997.

the Mississippi River in the New Orleans area is

a series of traffic lights operated by the Coast

Guard. When the river reaches 8 feet on the

Carrollton gauge on the rising stage, and until

the gauge reads 9 feet on a falling stage, the

movement of all tugs with tows and all ships,

whether under their own power or in tow (but

excluding tugs or towboats without tows or river

craft of comparable size and maneuverability

operating under their own power) in the vicinity

of Algiers Point is governed by the Coast

Guard’s Governor Nicholls and Gretna traffic

lights. The lights are visible throughout the

entire width of the river and flash once every

second. A green light displayed ahead of a

vessel (in the direction of travel) indicates that

Algiers Point is clear and the vessel may

proceed. A red light displayed ahead of a vessel

(in the direction of travel) indicates that Algiers

Point is not clear and the vessel is not to

proceed.

Port Information

More than 6,000 oceangoing ships and

120,000 barge and tows travel through the Port

of New Orleans

each year. The port is

primarily a general cargo port. The frontage for

deep draft vessels within the port limits includes

approximately 34 miles along the riverbanks.

The city of New Orleans is the major

commercial area within the port limits. The Port

of New Orleans has more than 28 miles of

public and private wharves and related facilities.

The public docks can handle as many as 85

ships at a time.

Most of the wharves along the New Orleans

waterfront are public facilities under the control

of the Dock Board. The Dock Board consists of

members selected by the Governor of Louisiana

from a list of nominees compiled by 18 business

and civic associations. The Dock Board

maintains the depths of vessel berths adjacent to

its public wharves from the face of the wharf to

Information obtained from United States Coast Pilot

5, from the Dock Board, and from other local and national

reference sources.

The Port of New Orleans extends along both sides of

the river from mile 80.6 AHP to mile 115 AHP, and

encompasses the city of New Orleans, several parishes or

the river frontage of those parishes, and a number of

smaller communities.

100 feet into the river and assigns vessel berths

at its public wharves. The Coast Guard is

primarily responsible for control of navigation

in the river, and the Corps of Engineers is

primarily responsible for approving new

structures in or on the river.

Subject to the above Federal jurisdictions,

the Dock Board regulates activities related to

maritime commerce within the Port of New

Orleans and administers, controls, and regulates

the public wharf facilities in the port. About 3/4

of the wharf frontage is owned by the Dock

Board and operated by private operators under

occupancy agreements from the board.

Above New Orleans, the Mississippi River

is used by oceangoing vessels to Baton Rouge,

about 135 miles above Canal Street in New

Orleans. The river channel between New

Orleans and Baton Rouge for the most part is

deep and clear. Facilities on the Mississippi

River above New Orleans to Baton Rouge

include private and public terminals for

handling oil and other products on both sides of

the river.

The Erato and Julia Street wharves, adjacent

to the Poydras Street wharf, were used for

docking cruise ships from the Holland America,

Carnival, and New Commodore cruise lines, as

well as U.S. Navy ships and, during annual

Mardi Gras

, additional tourist ships, some of

which were used as hotels. The wharf area had

two passenger terminal buildings, a parking lot,

and harbor police facilities. This wharf area was

accessible only when cruise ships were at berth

and was the only open public area not managed

by a commercial tenant. Port of New Orleans

Harbor Police officers were detailed to the area

and monitored police radios. In the event of an

emergency, the harbor police officers provided

evacuation direction and assistance in the cruise

terminal area. The remainder of the Port of New

Orleans public areas were under the control of

the renters or lessees.

Dredging

-- The Dock Board is responsible

for dredging New Orleans Passenger Terminal

(passenger/cruise ships) and Riverwalk piers to

a distance of 100 feet out from the pier face. On

December 11, 1996, maintenance dredging was

completed in the Riverwalk Marketplace and

New Orleans International Terminal areas. The

Dock Board specified that the dredging would

extend to a 33-foot project depth. The passenger

terminal was dredged only to a depth sufficient

to accommodate the cruise ships that docked

there. At the time of the accident, the depth was

sufficient to accommodate the

Enchanted Isle

which had a draft of 28 feet. The docking area

of the

Queen of New Orleans

had not been

dredged since 1994 and had been left to silt in to

afford the vessel protection from ramming by

deep-draft vessels. With the silting, water depth

in the docking area was about 15 feet in average

river stage conditions. Because of the dredging

and the high river stage that existed on

December 14, 1996, the river was 45 to 48 feet

deep alongside the Poydras Street wharf in the

area of the Riverwalk Marketplace at the time of

the accident.

The Wharf Area

-- According to the Dock

Board, the Canal, Poydras, and Julia Street

wharves were constructed early in this century.

The wharves have been renovated or rebuilt

several times since their original construction,

but always on the same “footprint.” All of the

substructure and first level decks of the wharves

were designed and built, and are currently

owned, by the Dock Board. In 1977, the

International RiverCenter (IRC) constructed a

cruise ship terminal on the first level of the

Upper Poydras Street wharf. The terminal was

built in conjunction with the development of the

first phase of the Hilton Hotel. In 1983, the IRC

completed the riverside expansion of the Hilton

Hotel, which was constructed on old warehouse

piers on the river side of the levee flood wall.

No additional footings or wharf extensions were

erected beneath or beyond the original piers at

the site of the Riverwalk complex.

In the early 1980s, the Louisiana World

Exposition (LWE) selected the Upper Poydras

Street, Julia Street, and Erato Street wharves as

locations for the world’s fair’s riverfront

attractions. The last full year of cargo operations

at these wharves was 1981. In the LWE’s lease

agreement of July 1982, the Dock Board agreed

to discontinue cargo operation and assignment

of lay-up vessels at the Julia, Poydras and Erato

Street wharves between May 1 and November

15, 1984. The Dock Board’s lease with the

LWE required that the first 15 feet of the

wharves be kept unobstructed and inaccessible

to the public. Existing structures on the Julia

Street, Poydras Street, and Erato Street wharves

were significantly modified by construction of

facilities for the world’s fair, however, the

wharf deck profiles were not changed.

In 1986, the Rouse Company developed the

Riverwalk mall on portions of the Lower

Poydras, Upper Poydras, and Julia Street

wharves. The Rouse Company leased the land

rights from the IRC and the city of New

Orleans. The Rouse Company was required to

obtain construction permits for the Riverwalk

Marketplace from the city of New Orleans and

the New Orleans Levee Board. Rouse was

granted a consent agreement from the Dock

Board to construct and operate the Riverwalk

Marketplace. The Dock Board reviewed the

Riverwalk mall plans to determine the extent to

which the development might affect Dock Board

activities.

The One River Place condominium parking

garage was constructed above the lower Poydras

Street wharf and above the Riverwalk

development. The condominiums were

completed in 1989. One River Place was given a

lease agreement from the Dock Board to

construct and operate the condominiums. One

River Place was required to obtain all

appropriate city building permits.

In 1993, the Julia Street wharf cruise ship

terminal was opened, replacing the original

terminal constructed by the IRC. Also in 1993,

the Queen of New Orleans Joint Venture

widened a part of the Poydras Street wharf by

50 feet and constructed a boarding tower on the

wharf to accommodate a riverboat-style gaming

vessel. (See figure 11.) The widened wharf and

the addition of a boarding tower were permitted

by the Army Corps of Engineers, the Dock

Board, and the city of New Orleans. No barriers

were constructed outboard of these structures.

The construction of wharves extending into

the navigable waters of the United States is

subject to approval and issuance of a permit by

the Corps of Engineers. The Corps of Engineers

relies on the Coast Guard for any navigational

safety concerns that such constructions may

raise.

Federal Jurisdiction

-- While the Coast

Guard is responsible for promoting the safety of

life and property on the navigable waters of the

United States, the Corps of Engineers has final

authority to approve any structure built on or in

the navigable waters of the United States,

including the Mississippi River. A permit from

the Corps of Engineers is required to situate a

structure in or on any navigable waterway.

Under the

Rivers and Harbors Act of 1899

, the

Corps has jurisdiction over the establishment of

harbor lines and anchorages and the

maintenance of clear passage along navigable

waterways. A permit is required to construct

piers, wharves, jetties, permanent moorings,

permanently moored floating vessels, or any

other permanent or semipermanent obstacle or

obstruction.

Meteorological Information

At the time of the accident, winds were from

the east at 6 knots; clouds were scattered;

visibility was 7 miles; the temperature was 70

°F.

Toxicological Information

Postaccident alcohol and drug tests were

conducted after this accident on the pilot and

nine crewmembers who were on duty at the time

of the accident.

Testing was ordered for

crewmembers assigned to the noon watch. The

ship’s carpenter, who was acting as anchor

watch at the time of the accident, was not

assigned to the noon watch and was not tested.

The crew’s tests were conducted by a

specimen collection and testing company

retained by the ship’s agent. The breath tests,

using a portable testing device taken aboard the

ship, began at 2036, 6 hours and 25 minutes

after the accident. The last three tests done were

those of the helmsman at 2208, the master at

2235, and the chief engineer at 2241. These tests

were conducted 7 hours 57 minutes, 8 hours 24

minutes, and 8 hours 30 minutes, respectively,

after the accident. The results of all nine tests

As reported from the Naval Air Station, Belle Chase,

Louisiana.

The master, second mate, helmsman, bridge lookout,

chief engineer, second engineer, third engineer, electrician,

and motorman.

showed 0.00 percent blood alcohol

concentration (BAC).

The same collection and testing company

collected urine specimens from the nine

crewmembers between 2030 and 2230. The

specimens were sent to a Federally approved

testing lab in New Orleans and tested for the

presence of five categories of illicit drugs

specified in Coast Guard and Department of

Transportation regulations.

The specimens

were negative for the five drugs for all the tested

crewmembers.

The Safety Board requested a portion of the

specimens that remained after the lab completed

its testing. Those portions were forwarded to the

Center for Human Toxicology (CHT) in Salt

Lake City for additional testing. The second

testing confirmed that none of the five groups of

illicit drugs, nor any other drugs, were present in

the specimens. In addition, tests for urine

alcohol concentration were negative for all

specimens. Traces of caffeine and/or smoking

byproducts were the only chemicals found in

some specimens.

Urine and breath specimens for postaccident

alcohol and drug testing were obtained from the

pilot about 1 1/2 hours after the accident (at

1537 and at 1550, respectively). Results showed

a BAC of 0.00 percent and were negative for the

five groups of illicit drugs tested. Additional

testing requested by the Safety Board was

conducted on a portion of the urine specimen by

CHT. Caffeine was the only drug found in the

pilot’s specimen.

Coast Guard postaccident drug and alcohol

testing regulations (46 CFR Parts 4 and 16 and

33 CFR Part 95) require specimen collection to

occur “as soon as practicable following an

accident.” The chronology of specimen

collection in this accident (based on

recollections of the individuals involved) is as

follows:

1530 Ship’s agent learns of accident from the

vessel charterer.

The drugs specified in 49 CFR Part 40 are

marijuana, cocaine, opiates, amphetamines, and

phencyclidine.

1600 Coast Guard investigator on board ship.

Pilot not aboard. NOBRA was called to

ensure pilot was tested. NOBRA states

that testing was in progress. Investigator

looks for, but finds no evidence of

alcohol or drug impairment among crew.

1630 Ship’s agent representative on board.

Ship’s attorney on board.

1700 Coast Guard Marine Safety Office

(MSO) investigator orders ship’s

attorney to test crew for drugs and

alcohol.

1730 Ship’s agent general manager on board.

1834 Specimen collection and testing company

contacted by general manager when he

learns that the Coast Guard was

expecting the ship to call the drug testing

company.

1955 First of two collectors arrives at scene.

2010 First collector arrives on board ship after

difficulty getting past road blocks.

2030 First specimen taken.

2235 Second collector on board.

2245 Breath testing and urine specimen

collection complete.

Survival Aspects

Bright Field

-- The vessel master said the

crew was trained to respond to a particular

emergency alarm that is sounded in case of a

fire, a pollution incident, or other emergency.

The response normally entailed reporting to the

main deck. The master stated the most recent

fire and boat drill held aboard the

Bright Field

in accordance with international and Republic of

Liberia rules, was on November 17, 1996. He

said fire and boat drills included the sounding of

the emergency alarm and were normally held

weekly.

Enchanted Isle

-- The Port of New Orleans

Harbor Police arrived at the

Enchanted Isle

gangway a few moments after the

Bright Field

struck the wharf and requested that passenger

embarkation be stopped. Embarkation was

delayed 4 to 5 minutes as the river surged and

the situation was assessed. According to

witnesses, the gangway moved up and down

briefly with the swells, but no passengers were

on it at the time.

Nieuw Amsterdam

-- After the

Bright Field

impact, the second officer of the

Nieuw

Amsterdam

radioed the bridge that the

Bright

Field

had stopped moving and was

approximately 50 meters from the stern of the

Nieuw Amsterdam

. He said later he recalled

seeing tugboats arrive within moments to keep

the

Bright Field

stable against the wharf. He

said he reported to the bridge by radio that the

Bright Field

no longer posed a danger to the

Nieuw Amsterdam

, after which he returned to

the bridge. Upon receiving the radio call, the

third officer and the master assessed the

situation and returned the ship to its normal

operations.

At the Safety Board’s request, the master of

the

Nieuw Amsterdam

distributed a

questionnaire among the ship’s passengers.

While the actual number of passengers who

received the questionnaire is unknown, 137 of

them responded. Their responses are the source

of the information that follows.

Numerous passengers who were on the

Nieuw Amsterdam

at the time of the accident

observed the

Bright Field

as it passed by the

ship before hitting the wharf. These passengers

were on the Lido deck, port side. They said they

heard the vessel’s whistle, then noticed its

direction and speed. As the

Bright Field

passed

the

Nieuw Amsterdam

, most of the passengers

ran aft on the Lido deck, observed the

Bright

Field

strike the wharf, and watched the

emergency responders arrive.

Several passengers were on the

Nieuw

Amsterdam

gangway at the time the

Bright

Field

was approaching the Poydras Street wharf.

One couple first noticed the

Bright Field

as it

passed under the bridge because it was

repeatedly sounding its whistle, and they

became aware that the vessel was experiencing

problems because of the angle of its approach.

When they and other passengers were about

halfway up the gangway, ship personnel

instructed them to turn around, exit the

gangway, and return to the terminal. After the

Bright Field

struck the wharf, cruise terminal

employees instructed them to go into the

terminal for their own safety.

Another couple was on the dock when they

heard the

Bright Field’

s whistle, but they did

not understand its significance. They observed

harbor police scooters driving past them with

lights and sirens on. After the accident, cruise

terminal employees directed them to return to

the terminal, where they remained until they

boarded the

Nieuw Amsterdam

about 1/2 hour

later.

Other passengers were in the port terminal

when the

Bright Field

struck the wharf. They

were instructed to remain against the far side of

the terminal and became aware of an emergency

when they heard the

Bright Field’

s whistles,

observed harbor police officers moving toward

the wharf, and saw people begin “streaming” out

of the Riverwalk Marketplace. Although most

responding passengers recalled that emergency

responders arrived quickly, others recalled that

some time elapsed before emergency personnel

arrived.

Queen of New Orleans

-- The first mate on

the

Queen of New Orleans

(figure 12) stated that

he was monitoring channel 67 when he heard

the call from the

Bright Field

pilot to the

Governor Nicholls Light operator. He said he

immediately notified the master, who was on the

aft portion of the main deck. The master stated

that, when he approached the stairs to the

pilothouse (on the main deck forward), he noted

the

Bright Field’

s location and speed. He radi-

oed the first mate and instructed him to

immediately inform the deckhands

to prepare

the gangway for evacuation. The master said

that, as he continued up the stairs to the pilot-

house, he observed that the

Bright Field

was

heading directly toward the Poydras Street

wharf. He said he radioed the mate to begin the

emergency announcements over the loudspeak-

ers. According to representatives of the vessel’s

owners, the first mate initiated the first emer-

gency evacuation announcements at 1410:48.

The master, entering the pilothouse at the end of

the first emergency announcements, rang the

general alarm bell at 1411:22. The first mate

made several more emergency evacuation

announcements, after which the master in-

structed him to radio security and have them call

911. The master then told the mate to instruct

the chief engineer to prepare the engines for

getting underway, after which the chief engineer

started the engines.

The ship’s director of security and

surveillance said that he was on the second deck

when he heard the announcement instructing the

passengers to leave the vessel by the gangway.

While moving toward the bow of the vessel, he

began instructing gaming personnel to leave the

vessel after the passengers. He said that at the

bow of the second deck, he was blocked by a

crowd of passengers trying to evacuate over the

gangway. He said he looked out toward the

wharf and saw the

Bright Field

headed toward

his vessel. He said he immediately went out a

side door, then went around the crowd and

began to distribute life jackets and help the

passengers off the vessel. He stated that it was

not normally his responsibility during an

emergency to distribute the life jackets;

however, most of the team leaders, who were

responsible for distributing life jackets, were

assisting passengers in exiting the gangway or

were caught behind the crowd trying to evacuate

the vessel. In addition, the team leaders were

having difficulty reaching the life jackets at the

gangway because of the crowd. During

emergency drills, the passengers were usually

divided into different “refuge areas” and were

not all in the gangway area at the same time.

A nonoperating crewmember recalled

hearing the announcement to evacuate. As she

and the passengers evacuated from all three

decks, they merged together on the second deck,

where the gangway was located. She said that

she did not hear any announcements regarding

life jackets. The master said that he had not

made such an announcement because the vessel

was not scheduled to cruise that day. The

employee said that she saw the deckhands

obtaining life jackets, but that many passengers

were not wearing them because they were

running, and the deckhands were telling them to

keep moving. The crewmember said she did

recall hearing a horn blowing a few times, but

she said she heard this all the time on the river.

She recalled that “everyone was in a panic”

because they did not know what was going on

until they went outside and saw the

Bright Field

heading toward their vessel.

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vessel

Queen of New Orleans

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Another employee, who was on the stern of

the second deck, recalled hearing the evacuation

announcement, after which he began instructing

passengers to proceed to the gangway. As he

began moving forward, he said he heard the

whistle from the

Bright Field

He recalled

helping one wheelchair-bound passenger out of

the casino area, over the gangway, and to the

elevators of the hotel. He said he then returned

to help clear the casino floor of passengers and

moved to the bow of the vessel, where he began

distributing life jackets to passengers and

assisting those passengers who were panicking.

The only means of egress from the

Queen of

New Orleans

during the evacuation was a single

gangway from the second deck to a stairway and

elevator structure of the Hilton Hotel and the

wharf. When the

Bright Field

struck the wharf,

the vessel’s bow wave caused the

Queen of New

Orleans

to rise 4 to 6 feet. A deckhand called

the pilothouse and informed the first mate that

the gangway was “bouncing,” or rising up and

down, approximately 2 feet. According to

testimony of the master, the gangway plates

were “jumping” up and down for about 10

seconds. The master instructed the first mate,

who ordered the deckhands to stop the

evacuation. After about 10 to 15 seconds of

“bouncing,” the gangway stabilized again. The

evacuation resumed until the gangway again

began to bounce. The master again instructed

the deckhands to stop the evacuation, raise the

gangway, and report to their mooring stations.

Upon hearing this announcement, the

security director, who said he was not sure what

a mooring station was, assumed the instructions

were for the operating crew. He said he and a

few other crewmembers instructed the

passengers to “get back” and “run to the back of

the boat.” When the crowd became aware that

the

Bright Field

was heading toward the

Queen

of New Orleans

, people began to run toward the

stern of the vessel.

Following this call, the first mate went to

the bow of the second deck to assist the crew,

who had not yet raised the gangway because it

had “restabilized again.” Crewmembers

continued the evacuation from the gangway at

this time. The mate observed a steady flow of

passengers evacuating the gangway, which

again began “bouncing.” At this point, the

gangway was rising approximately 1 to 2 feet

above its normal position. The mate stopped the

evacuation again by stepping in front of the

passengers and physically blocking their path

from the vessel. After several seconds the

gangway again settled, and the evacuation

resumed. At this point, the

Bright Field

had

stopped moving down the wharf, coming to rest

about 70 feet from the bow of the

Queen of New

Orleans

. According to the master, between 70

and 80 percent of the passengers had been

evacuated. According to New Orleans

Paddlewheels, security videotapes from the

Queen of New Orleans

showed that about 90

percent of the passengers had been evacuated

when the

Bright Field

stopped moving, about 70

feet from the bow of the

Queen of New Orleans

Once all the passengers had left the vessel,

the master instructed several deckhands to go to

the dock and assist in crowd control and

emergency response. Vessel security instructed

the remaining gaming personnel to exit the

vessel, and only operating crew remained

onboard. At the same time, the first mate

instructed some deckhands to prepare the

lifeboats to launch. Deckhands were also

instructed to conduct a search of the vessel to

verify that all the passengers had been

evacuated. Another deckhand was instructed to

search the river for any signs of a person

overboard. Three gaming and security personnel

were sent to the front of the hotel to direct the

emergency responders.

Meanwhile, the master radioed the 24-hour

medic and sent him to the dock to provide

medical assistance to the injured. A medic,

contracted from a local ambulance service, was

aboard the

Queen of New Orleans

at all times to

provide medical assistance to passengers and

crew. The master called 911, and then instructed

the first mate to send several deckhands to the

Creole Queen

to offer assistance.

Questionnaires were sent to 74 persons who

had been either in or near the Riverwalk

Marketplace when the accident occurred or who

were among the passengers and crew of the

Queen of New Orleans

Creole Queen

at the

time of the allision.

A total of 12 responses

Injury reports were the only available sources for

identifying individuals who may have been on board the

were received from individuals who said they

had been aboard the

Queen of New Orleans

when the

Bright Field

struck the wharf. All of

them said they had boarded the vessel between

1300 and 1400. Nine of the passengers did not

recall receiving any information concerning

what to do in the event of an emergency and did

not recall observing any safety information

placards when they boarded the vessel. Seven of

these passengers did not receive a life jacket

when evacuating the vessel. Each of these

passengers recalled first learning about the

emergency when they heard the announcement

from the first mate over the public address

system.

Almost all of the injuries (generally limited

to fractures, abrasions, contusions, lacerations,

and back or cervical strains) occurred when the

passengers were pushed, shoved, or trampled

during the evacuation. One passenger recalled

that the crowd was “out of control, stampeding

like wild animals, pushing, shoving, and

screaming.” Another passenger said she saw

people running and yelling, trying to get out by

the stairwell. “I even saw one man take off

running and jump, trying to walk on people’s

shoulders to get out,” she said. She said that

“getting to or out of an exit to land was

impossible,” and that she was not aware of an

alternate escape route from the vessel.

Another passenger believed she would never

be able to get to the dock and decided to move

to the stern of the vessel and “pray for the best.”

As she began to move aft on the starboard side

of the vessel, she said, she heard a man on the

dock yelling for her to jump. She replied that

she could not jump; however, when she turned

and saw the

Bright Field

still heading in the

direction of her ship, she climbed over the rail

and jumped to the wharf. She sustained pelvic

and lower back fractures and was hospitalized

for 6 days.

Queen of New Orleans

or the

Creole Queen

at the time of

the accident or who may have been inside or near the

Riverwalk Marketplace when the

Bright Field

struck.

Crewmembers of the two ships were identified through

company documents. Other than crewmembers, the only

individuals who received Safety Board questionnaires were

those who had reported being injured during or subsequent

to the accident sequence.

Several passengers commented that the

vessel crew also seemed to panic and did not

appear to be trained for an emergency of this

type. One passenger said she observed some of

the crew running to get off the vessel along with

the passengers. She said she perceived that there

was “no order and no one seemed in charge”

during the evacuation.

According to New Orleans Paddlewheels,

Inc., the comments of these passengers do not

correspond to the surveillance videotape

showing the evacuation. Company officials said

the passengers may have seen some

crewmembers leaving the vessel during the

evacuation, along with the passengers; however,

these were the crewmembers who were not

assigned to assist in the evacuation. The

company said crewmembers with evacuation

responsibilities remained aboard the

Queen of

New Orleans

and provided assistance

throughout the evacuation. The company said

that its security videotape “clearly shows

passengers responding to announcements

immediately, orderly, and no one running.” The

Safety Board has reviewed the tape and did not

observe, in the locations of the vessel shown,

any of the passengers falling or being

“trampled” or knocked down. The videotapes

appear to show passengers exiting the vessel in

an orderly manner without apparent panic.

Creole Queen

-- The master of the

Creole

Queen

was monitoring two handheld radios, a

company radio with two channels and another

radio tuned to VHF channel 67. The main radio

in the wheelhouse also monitored channel 67.

The master stated that, at approximately 1400,

he instructed the deckhands to remove the lines

for the vessel’s second cruise. As the deckhands

let go of the lines and the master began using

the bow thruster to move the vessel away from

the dock, he heard the call from the

Bright Field

pilot to the Governor Nicholls Light operator.

As the master began to maneuver the vessel

back to the dock, he radioed his first mate and

instructed him to go starboard on the main deck,

look upriver, and report his observations. The

first mate reported back, “he’s headed straight

for the Riverwalk.” The master instructed the

first mate to “put the gangway down and begin

an evacuation.”

The first mate and a deckhand had gone to

the gate on the deck of the

Creole Queen

open it for the gangway. The first mate climbed

ashore and began to lower the gangway while

other deckhands tied up the vessel. Once the

vessel was secure, the gangway was positioned

for the passengers to begin evacuating. The first

mate said he positioned himself on the dock side

of the gangway as the deckhands, on the vessel

side of the gangway, helped the passengers

evacuate.

At this time, the master began making

emergency evacuation announcements to the

passengers. He recalled announcing,

Ladies and gentlemen, this is the

captain. Please exit the boat using the

gangway. Please do not panic. Please

exit the boat using the same entrance as

when you boarded. This is an

emergency. Please exit immediately.

The passengers began evacuating, and the

master rang the general alarm bell. Meanwhile,

the master could hear the

Bright Field’

s whistle

getting closer, but his view of the vessel was

obstructed by the

Queen of New Orleans

The first mate observed that the

Bright

Field’

s bow wave caused the

Queen of New

Orleans

to rise up “as if it were out on the ocean

and hit by a wave.” He said he called to the

deckhands to stop the evacuation of the

passengers. The master said he used the public

address system to caution the passengers to

“watch the gangway.” The master estimated that

at that time half of the passengers had evacuated

the

Creole Queen

and were waiting on the dock.

The bow wave and undertow from the

Bright

Field

pulled the

Creole Queen

away from the

dock, and the gangway began to slip aft along

the deck. The deckhands stopped the

evacuation; however, three passengers were still

on the gangway at the time. As the boat rose up,

it “was sucked out” away from the wharf, and

the gangway dropped off the

Creole Queen

and

down toward the water. The three passengers on

the gangway fell into the river between the ship

and the wharf.

The deckhand and some passengers who

were on the dock began to crank up and

reposition the gangway so that the evacuation

could be continued. Meanwhile, a passenger on

the main deck threw a life buoy and a child-size

life jacket to the three passengers in the water.

The first mate, from the dock, told the passenger

where to find an adult life jacket, and the

passenger then threw an adult jacket into the

water. The first mate then instructed a

crewmember on board to retrieve the ladder

from the rescue boat on board and to place it

over the side of the

Creole Queen

. Two of the

passengers in the water climbed the ladder and

entered the vessel. The third passenger, a 61-

year-old man, suffered a hip injury when he fell

into the water, and he was unable to climb over

the railing and into the vessel. The first mate

climbed onto the vessel from the dock and

assisted the crewmember in easing the passenger

into a Stokes Basket. They then pushed the

basket from the vessel over to the dock. While

this was underway, the master was attempting to

reposition the vessel to the fallen gangway. As

he was maneuvering the vessel, he continued to

make emergency announcements to the

passengers until the gangway was re-positioned

and the evacuation could be resumed.

Once the evacuation was complete, the

master requested, via the company radio to the

Queen of New Orleans

’s first mate, that the 24-

hour medic be dispatched to assist some of the

injured

Creole Queen

passengers. The mate on

the

Queen of New Orleans

told him that the

medic was already assisting the injured from the

Queen of New Orleans

. The master later told the

Safety Board that one of the problems he

encountered during the accident was the length

of time it took for emergency medical

technicians to arrive on scene. He recalled that

after he made this complaint to another person

after the accident, he was informed that the

delay in ambulances responding to the dock

where the

Creole Queen

was moored was due to

damage done by the

Bright Field

to the normal

emergency response access route to the wharf.

Three respondents to the Safety Board

questionnaire were individuals who said they

had been on the

Creole Queen

at the time of the

accident.

One passenger recalled boarding the

Questionnaires were sent only to the three

Creole

Queen

passengers who had reported being injured in the

accident. All three individuals responded.

vessel at 1310 and receiving information

concerning emergency procedures. He stated

that, about 1315, the first mate announced that,

if the passengers were required to immediately

evacuate the vessel, they should follow the

instructions announced over the public address

system. This passenger considered those

instructions of great value because the

evacuation was not a typical situation; it

involved little time to don life preservers, form

groups, or disembark to the pier or lifeboats. He

observed placards posted on the salon and

observation decks that provided emergency

information regarding the location of life jackets

and the procedures for donning them.

A couple, a 61-year-old man and 59-year-

old woman, both sustained injuries when they

fell into the water when the gangway collapsed.

They said they boarded the

Creole Queen

about

1350, and they did not recall receiving any

information about what to do in the event of an

emergency, nor did they observe any placards

that provided this information. The female

passenger recalled the master announcing they

were returning to the dock to disembark, and the

male passenger recalled six to eight repeated

calls for “abandon ship.” They observed people

on the Riverwalk running toward the Spanish

Plaza. The male passenger recalled that

passengers were confused when they heard

“abandon ship”; they were unsure whether to

jump into the water or remain on board, and the

crew was shouting, “get the life preservers,

where are the life preservers?” He recalled that

it seemed “like a continuous shouting match”

while the crew was attempting to find life

jackets and the three passengers remained in the

water.

Riverwalk Marketplace

-- In a letter to the

Safety Board, a couple said they were in a café

on the second level of the marketplace when

they heard the

Bright Field’

s whistles. The

husband got up from the table and went to the

window to see what was happening on the river.

When he had almost reached the window, the

Bright Field

struck the wharf, then broke

through the window of the cafe. Patrons seated

near the window “ran screaming and running

out of the café.” The man and his wife said they

heard a waitress yelling “get out” twice as they

ran to the restaurant doors. They turned around

and watched the ceiling and floor above crash

down and fold over the entire room, as the

Bright Field

continued to crash through the cafe.

They immediately left the area to evacuate the

mall.

As they attempted to go up to another level,

“the only route out of the mall [away from the

direction of the river],” they ran into a

“bottleneck,” a large crowd attempting to use

the escalators to reach the higher floors to

evacuate. As they were climbing up the “down”

escalator, they said, they feared a gas explosion

because they smelled gas. When they made it up

to another mall level, many mall customers on

the upper floors were still shopping, unaware of

the accident. At this time, the couple noticed

that they had not yet heard any alarms or public

address announcements, even though it had been

several minutes since the vessel struck the cafe.

They encountered security guards who did not

allow them to use emergency exits to evacuate.

They said they believed they were “strictly on

our own. The mall management apparently had

made no disaster plans for its merchants and

customers; if such plans existed, they were a

complete failure.”

The Safety Board received responses from

15 individuals who said they were either patrons

or employees of the Riverwalk Marketplace

when the accident occurred. One patron recalled

that she was on the first level of the Riverwalk

Marketplace, alongside the wharf, when she

heard the

Bright Field’

s whistle sounding. She

believed that the noise was “normal river noise”

and did not take notice. She then heard people

begin screaming “run,” and “get out.” She said

she turned around and saw the

Bright Field

coming into the wharf area. She said that, when

she turned to run out of the store, she was

knocked down by the crowd. She tried several

times to get up, and was repeatedly knocked

down. After the wharf was struck, a security

guard came to assist her, and he helped her out

of the store and over to a triage area. She was

taken to the hospital and admitted for blunt

abdominal trauma.

A family was shopping in a mall grocery

store at the time of the accident. They said they

heard the

Bright Field’

s whistles but did not

know the whistles were a warning signal. They

thought that a vessel was arriving, so they went

to the glass window on the wharf to watch the

Bright Field

approaching the dock. They said

they did not know that they were in danger until

they realized the vessel was not docking but was

actually striking the wharf. They said the store

clerk did not appear to be aware of what the

ship’s warning whistles meant and did not know

that the store should be evacuated.

As the vessel struck the wharf, the family

turned to flee the store. As the customers were

running, the store was collapsing behind them

and the roof began falling in. As the collapsing

walls shifted furniture, the doorway became

blocked, and they could not escape until the

falling ceiling shattered the front glass display

window. When they attempted to leave the mall,

by going up to the third floor, they could not go

up the escalators because there were too many

people exiting the same way. One of the family

members hit the stop button on the “down”

escalator, and they went up to the third floor via

that escalator. They said that when they left the

front of the Riverwalk Marketplace, they were

not given instructions on which way to evacuate.

Not until they were leaving the marketplace did

they see a police officer, and they did not

observe any other emergency responders.

Overall, the family recalled that there appeared

to be a lack of preparedness for an emergency

evacuation and that crowding was a problem in

finding an exit away from the damaged wharf.

Another couple was in a restaurant on the

wharf when they saw other people screaming

and running out of the mall. They did not hear

an emergency whistle from the

Bright Field

general mall emergency announcements; they

did hear a fire alarm ringing after the

Bright

Field

struck the mall shops. The couple were

injured when they were knocked down and

“trampled” by shoppers who were fleeing the

mall. The couple recalled the activities of the

mall personnel relating to visitor safety as

“poor,” both during and after the accident. They

recalled that the police and Coast Guard arrived

immediately, and that the fire department

arrived about 10 minutes later.

Riverwalk Marketplace has provided

videotapes to the Safety Board which company

officials say “show the mall being evacuated

within a matter of minutes with virtually no

significant personal injuries suffered by any of

the persons evacuated.” The Safety Board

viewed the tapes, which showed various

locations in the mall during the allision

sequence. The tapes were recorded by security

cameras using a loop system that recorded

frames from all camera locations on a single

tape. Continuous footage from a single location

was not available, and the frames from the tape

loop were made at intervals of about 4 seconds.

These videotapes do not appear to show patrons

being “trampled” or knocked down during the

evacuation.

In addition to providing videotapes to the

Safety Board, Riverwalk Marketplace also has

stated that public safety officers did block

certain emergency exits in accordance with

protocol and the evacuation plans and

procedures. “To allow individuals to exit freely

from any exit they chose might have placed

them in greater peril,” the company said. As for

the smell of gas reported by the patrons, the

company said that a member of the Marketplace

engineering department was on the wharf just

prior to the accident, saw that the allision was

inevitable, and immediately shut off all utility

service to the mall, including natural gas, to

prevent an explosion. The company said that

fire alarms did not sound prior to the allision

because of the absence of any alert or warning

prior to impact. The security central monitoring

station printouts showed the fire alarms

sounding at 1411:42 and 1414:11.

Hilton Riverside Hotel

-- When the

Bright

Field

struck the Hilton Riverside Hotel, the

public safety dispatcher received several 52 F

(fire) activation alarms, and housekeeping

called to inform the dispatcher that a vessel had

struck the riverside hotel. The dispatcher

notified the local fire and police agencies and

called the Director and Assistant Director of

Public Safety and Security. The hotel

Emergency Disaster Procedures Plan was put

into effect and the hotel emergency response

team was notified. The security supervisor on

duty received a call that a possible fire

emergency had occurred in the riverboat casino;

when he arrived in the hotel lobby, he

“discovered that a panic crowd was running

away from the area.” He instructed officers to

calm the crowd down and clear the lobby. He

attempted to use the radio to communicate with

other officers, but when the vessel struck the

building, it knocked out the power and,

therefore, communication capabilities. So he

instructed the officers in the lobby to assist him

in evacuating guests from the riverside building.

Meanwhile, a security officer who was

returning to his post from lunch was in the

Riverwalk parking lot when he was met by a

large crowd that informed him that a freighter

had hit the Riverwalk and many people by the

stairs in the rear lot were injured. He ran to the

location and observed people “falling down the

stairs and bleeding.” He attempted to stop the

people from running but to no avail. He found a

person with a cellular phone and called 911 to

report the emergency. He then assisted the

injured until the emergency medical services

arrived. He was then assigned to assist with

traffic control.

Another security officer, who was in front

of the hotel, heard a call from another officer

that a possible fire emergency had occurred on

the riverboat casino. He ran, along with other

officers, to the area and observed that a large

ship with heavy damage to the front section was

“docked” near the casino riverboat and that a

section of the Riverwalk mall and the hotel had

collapsed. They attempted to radio the security

supervisor on duty, but all communications had

been lost due to a power failure in the riverside

hotel building. So, the officers proceeded to the

damaged area of the hotel to evacuate everyone

from the building. They encountered the

emergency response team on the fifth floor as

they were responding to a report of a trapped

female guest.

This emergency response team consisted of

the security, maintenance, and engineering

departments. When the

Bright Field

struck the

hotel, the maintenance person on duty was

headed to the first floor when the building began

to shake violently. The engineering supervisor

was in the carpenter shop when he was notified

by the dispatcher that a vessel had struck the

building. He, the housekeeping supervisor, and

the maintenance person on duty, along with

hotel security officers, conducted a floor-by-

floor search of the hotel. A housekeeper

informed them that a female guest was trapped

in her room. They attempted to open the front

door to the room; however, it was blocked by

collapsed ceiling damage from the freighter’s

allision. They had to use a claw hammer to

break in the hallway wall to reach the guest. The

team was able to open a large hole in the wall of

the fifth floor, and the trapped guest was

evacuated from her room by 1425. According to

the emergency response team, the guest stated

that “there was no one else in room 5085 and

that she did not think that she was injured.”

Meanwhile, other members of the emergency

response team completed the evacuation search

by 1418, when the New Orleans Fire and Police

Departments arrived at the hotel. Another

intensive search of the hotel was conducted by

separate groups of local response agencies and

the hotel emergency response team.

At 1435, the Director of Security arrived at

the hotel, and set up a command post with the

fire, police, and harbor police inside of Kabby’s

restaurant. A printout of the occupied guest

suites was delivered, and all departments

verified the number and locations of their

employees. Once this information was collected,

a third search of the building was conducted. No

other guests were found trapped in their rooms.

According to Hilton Riverside Hotel, no

employees of the hotel were injured during the

Bright Field

allision. The riverside building was

completely evacuated. The engineering

department had notified the security director

that the team secured all utility lines, including

gas and electrical lines, and placed the building

on the back-up generator; power and

communications were restored once this

generator was hooked up to the repeater.

Emergency Response

Port of New Orleans Harbor Police

Harbor police officers were the first responders

on scene. They initiated rescue efforts

immediately, ordered emergency units, and

broadcast a description of the incident via police

radio. The harbor police were responsible for

immediate scene stabilization, traffic control,

pedestrian control, and support for the New

Orleans Fire Department. A triage center was

established at a Riverwalk Marketplace security

post, and emergency medical services units were

staged near the rear apron roadway. The

Medical Center of Louisiana’s Charity and

University campuses were notified of the

incident and designated as the primary treatment

facilities. The director of public safety and

security for the Port of New Orleans authorized

the request for additional enforcement and

rescue assistance from several surrounding

parish police and sheriff’s departments and from

the Louisiana State police. For the first 48 hours

after the accident, all available harbor police

officers and six recruits were called in to

provide security in both interior and perimeter

areas of the Poydras, Julia, and Canal Street

wharf area.

Coast Guard Group New Orleans

-- The

on-duty officer at Coast Guard MSO New

Orleans was notified of the accident at 1420 by

the Gretna traffic light operator. The initial

report indicated possible persons in the water

and significant damage to the

Bright Field

and

Poydras Street wharf buildings, resulting in

other casualties. At 1421, the MSO on-duty

officer designated Coast Guard Group New

Orleans as the search and rescue mission

coordinator. Group New Orleans requested an

immediate search and rescue response

detachment from Coast Guard Station New

Orleans to search for possible persons in the

water.

At 1422, the Mississippi River was closed at

mile 96 AHP in the vicinity of the accident. At

1430, a Coast Guard helicopter was dispatched

by the search and rescue coordinator to pick up

a rescue swimmer and report to the scene of the

accident. The MSO on-duty officer notified both

the captain of the port (COTP) and the chief of

port operations of the accident. At 1435, the

MSO notified the office of the commander of

the Eighth Coast Guard District.

The MSO chief of port operations

immediately went to the scene. After consulting

with the incident commander, he assessed the

damage and began searching for leaking fuel or

other dangerous conditions. He observed that

the ship was not secured to the wharf, and he

directed crewmembers and firefighters to attach

bow mooring lines.

At 1445, the MSO emergency response

team arrived and boarded the vessel, and the

Coast Guard on-duty officer also dispatched fire

and hazardous materials teams to the scene. At

1447, the helicopter was on scene and searching

the river for persons in the water. At 1550, two

Coast Guard infrared search teams were

dispatched to help search for persons in the

debris of the collapsed Poydras Street wharf. At

1750, the Coast Guard received an update that

no fatalities had been confirmed and that 100

injuries had been reported. All search and

rescue activities were terminated at 1000 on

December 16, 1996.

Louisiana Office of Emergency

Preparedness

-- About 1500, the Louisiana

Office of Emergency Preparedness responded to

the

Bright Field

accident, dispatching the

assistant director and the chief of operations to

the scene to offer State support and assistance.

At approximately 1630, a request was made for

light sets for possible night operations. The

Louisiana Army National Guard provided lights

later that evening.

Police Departments

-- The New Orleans

Police Department assisted the harbor police in

stabilizing the scene, controlling traffic and

pedestrians, and supporting the New Orleans

Fire Department in this accident. The initial call

was received at 1414 to assist the Harbor Police

Department with “unknown trouble...large

crowd of people running inside...possible

building cave in.”

New Orleans Fire Department

-- The

initial call to the fire department dispatcher was

received at 1413. The initial response was a

first-alarm response. When the incident

escalated into a three-alarm response, more than

40 units and 110 people responded. The fire

department established an incident command

system to oversee operations, evacuate the

affected areas, remove the injured persons,

triage and treat the injured, search for and

rescue trapped persons, control natural gas leaks

and utilities, and make arrangements for

perimeter security through the New Orleans

Police Department, the Coast Guard, and the

Port of New Orleans Harbor Police.

New Orleans Department of Health and

Emergency Medical Services

-- The New

Orleans Health Department, Emergency

Medical Services Division, assessed injuries,

treated and transported the injured to local

hospitals, and coordinated additional treatment

and transportation with area private providers.

The initial call was received at 1414 by the

Levee Board police dispatcher, and the first

emergency medical services responder arrived

on scene at 1417.

Emergency Preparedness

Riverwalk Marketplace

-- According to

Riverwalk Marketplace figures, approximately

13,500 persons visit the mall daily. The

Riverwalk Marketplace had a mall

emergency/catastrophe plan in place that

included emergency procedures and maps

indicating the locations of sprinkler systems and

zones, fire extinguishers and standpipes, smoke

detectors, chemical and hazardous materials

storage, main entrance feeders and disconnects,

gas shutdowns, water mains, and primary and

secondary emergency exits. Each emergency

exit from the Riverwalk Marketplace was

marked by a lighted sign with the words

“Emergency Exit” in white letters on a red

background.

The emergency procedures instructed mall

employees to first call the local fire department

in the event of an emergency, and then follow

up with calls to the management office. A

command post, if necessary, was to be

designated, and the emergency manager was to

determine, along with fire department officials,

whether to evacuate the mall.

The “Emergency Organization Guidelines”

in the

Mall Security Plan

manual listed

procedures for security officers on duty at the

time of an emergency. This manual provided a

separate emergency evacuation plan for each

level of the marketplace and specified duties and

responsibilities for security officers, dispatchers,

and public safety supervisors during an

emergency evacuation.

In documents provided to the Safety Board

on November 13, 1997, the Riverwalk

Marketplace stated that the Riverwalk policy

“is, and always has been,” that the senior

manager on duty at the time of any event is

responsible for determining whether to evacuate

the mall, or certain portions of the mall. In the

absence of the management, the senior security

supervisor on duty has the authority to call for

an evacuation of all or part of the mall,

depending on the circumstances. The decision to

evacuate is based upon an evaluation of the

safety threat posed to patrons and employees in

the mall. The company said that, once the

decision to evacuate is made, evacuation is

commenced prior to the arrival of firefighters or

police on the scene. Notification of the fire or

police departments, as necessary, is made

instantaneously and coincidentally with the

decision to evacuate the mall.

The company said that, for an emergency

involving a vessel striking the wharf, specific

emergency instructions were based on the

severity of the allision. Immediate procedures

were to contact the harbor police, identify the

damage to the wharf as major or minor,

immediately report the accident to a supervisor,

determine if city services were needed, and

begin safety measures.

New Orleans Hilton Riverside Hotel

-- The

employee manual of the New Orleans Hilton

Riverside Hotel details the procedures to be

followed during a fire or other emergency.

Included in the manual are the duties and

responsibilities of the hotel emergency response

team; the hotel management; the security

department; and the engineering, front desk,

bellstaff, catering, and housekeeping personnel.

The emergency directions include

notification of the fire department,

establishment of a command center, detailing of

evacuation procedures, and notification of

Hilton Hotel headquarters management. Sample

emergency announcement messages are

provided, as are crisis communication

guidelines for on-duty management personnel.

The decision whether to evacuate the hotel

is to be made by the senior manager on duty

prior to the arrival of fire or police officials. The

decision is to be based on the threat of injury to

hotel guests and employees, the extent of the

emergency, and the need to remain in control of

the evacuation while fire or police officials

assess the emergency. The New Orleans Hilton

Riverside Hotel did not have a section in the

emergency procedures or evacuation plan

manual that covered a vessel striking the wharf.

Queen of New Orleans

-- The

Queen of

New Orleans

Emergency Evacuation

Procedures in Moored Conditions

manual

provided instructions for evacuation routes,

including alternates, in the event of an

emergency. Each deck had a different escape

route for a specific number of passengers, based

on the number of persons permitted on that deck

and the space available for the exits. All primary

and alternate deck exit routes led to the

gangway located at the bow of the second deck.

This 12-foot-wide gangway led to a stairway

and elevator structure, then into the New

Orleans Hilton Riverside Hotel, or down to the

wharf. The master stated that the time was

insufficient during the

Bright Field

accident to

use the procedures outlined in the manual.

The

Safety and Vessel Operation Manual

for the

Queen of New Orleans

provided safety

information for the operating crew and other

personnel working on the vessel. It included

details concerning the evacuation of the vessel,

a description of the sounding of the alarm bells,

and an explanation of each alarm. It also

described the responsibilities of each

crewmember and specified the refuge area,

muster area, and designated team leader for each

position. According to the manual, the

nonoperating crew were responsible for

mustering passengers, warning passengers,

directing them to refuge areas, assisting them

with life jackets, keeping order in the stairways

and passageways, and generally controlling the

movement of passengers and maintaining their

safety.

Safety Briefings

-- Based on company

documents and the master’s statements, the

Queen of New Orleans

broadcast a vessel safety

videotape on two 27-inch television monitors in

the Hilton Hotel lobby and on one 27-inch

monitor on the boarding structure ramp. The

monitors in the hotel lobby were positioned just

below the ceiling on the wall adjoining the wall

through which a door led to the boarding ramp.

The monitor screens were visible to persons

passing through the door to the ramp if they

looked up and to the right. The boarding ramp

monitor was centered overhead at a point about

halfway up the ramp. The safety videotape

played continuously on the monitors and

demonstrated the donning of a life jacket and

the dangers of the river.

Before each cruise, a safety announcement

informed the passengers of the appearance and

locations of the boxes containing life jackets.

According to the master, an oral announcement

about life jackets was not made prior to the

Bright Field

accident because the vessel was not

scheduled to leave the dock. He stated that the

vessel is “an extension of the dock when we’re

not underway.”

In responding to Safety Board

questionnaires, a number of passengers on board

the

Queen of New Orleans

on the day of the

accident, some of whom had been on the vessel

several times before, did not recall ever having

noticed the video monitors.

Signage

-- The

Queen of New Orleans

had

emergency, safety, and life jacket signs posted

in various locations throughout the vessel.

According to the master’s testimony, the vessel

had overhead signage, including lighted

overhead exit signs at every exit door, directing

passengers to the exits of the vessel. The master

stated that he did not recall any signage near the

floor at designated exits that provided exit

instructions. He said signs were posted

throughout the vessel advising passengers which

level they were on and how to get to other

levels.

The information placards were covered with

thin, clear laminate and attached to the light-

colored bulkheads. An emergency evacuation

placard and casino station bill were posted on

the first and second decks, and three station bills

and an emergency evacuation placard were

posted on the hold deck. Life jacket placards

were found on the inside of the cover of all life

jacket boxes. The placards displayed

instructions for donning life jackets, along with

a photo displaying a properly donned life jacket.

An emergency evacuation placard and station

bill were posted on the fourth deck; a station bill

and emergency evacuation placards were posted

on the third deck. According to 46 CFR 199.80

(8)(c), vessel emergency instructions “must be

posted in each passenger cabin and in spaces

occupied by persons other than crew, and must

be conspicuously displayed at each muster

station.”

Emergency Egress

-- The

Safety and Vessel

Operation Manual

described both “dry” and

“wet” evacuations. The wet evacuation involved

putting passengers into the water with life

jackets and other emergency equipment. Dry

evacuations involved assisting passengers to

embarkation areas where they would disembark

via an emergency evacuation ramp/slide. The

location of this ramp/slide was not shown on the

vessel diagram in the manual, and no other

reference to the equipment was made.

According to company documents, at the time

the vessel was under construction, the owners

experimented with the slide, but they were not

satisfied with its safety and performance;

therefore, the slide was not incorporated into the

vessel design. According to the company, three

portable emergency gangways were maintained

aboard the vessel at all times and were designed

to be used in the event the main gangway

became inoperable.

Drills

-- According to the company, fire drills

for the

Queen of New Orleans

operating

crewmembers were held twice per week, one per

crew, with active participation mandatory. At

least weekly, each marine crew participated in

rescue boat drills in which the rescue boat davit

and motor were tested and the boat was lowered

into the water. To facilitate documentation and

management of the drills, a safety team leader

was designated for each area of the vessel. The

safety team leader assisted the master with

coordination and control of the drills. First aid

and CPR training were required for all security

supervisors, mates, masters, engineers, and lead

deckhands.

According to the master, the deckhands

participated in fire and emergency drills, and the

evacuation drills were incorporated into the

safety and security meetings. Detailed minutes

of the safety meetings were not kept, although a

brief description was included on special safety

and fire drill forms. During these meetings,

deckhands were instructed in the handling of the

flow of passengers through the vessel during an

emergency. The master stated that the

passengers “have to get out of the casino

themselves or walk out themselves, and then we

can direct them to the exit of the vessel.”

Security crew were instructed to assist in the

evacuation procedures as well. The master said

that passengers were not involved in the weekly

drills, so the crew had not practiced physically

moving passengers.

According to the master, the gaming staff

did not take part in the regularly scheduled

evacuation training. Instead, the safety team

leaders participated in the drills. Two safety

team leaders were assigned on each level of the

casino except on the fourth and first levels,

where there were few passengers and where one

team leader was assigned. The security staff was

involved with the safety meetings, as were

supervisory gaming employees. These

supervisors were instructed to inform the

remaining gaming staff about the content of the

meetings. According to the master, no formal

procedure existed for verifying that this

information was being relayed to gaming

employees. The master said he had randomly

checked gaming employees to verify that they

knew of the nearest safety equipment, knew

which exits to use, and knew how to don a life

jacket.

Creole Queen

-- The

Creole Queen

operations manual covered emergency

evacuations, emergency egress, and firefighting

procedures. The station bill section of the

manual required that a life jacket demonstration

be given before each cruise. The station bill also

included instructions regarding the sounding of

the vessel’s whistle and ringing of the general

alarm for emergency situations such as fire,

abandon ship, man overboard, and dismissal

from drills. The station bill also included a

description of the duties and responsibilities of

each crewmember during each of these

emergencies.

Inspections, Tests, and Research

Several days after the accident, Safety

Board investigators boarded a fully loaded

vessel that was similar to the

Bright Field

size, displacement, and power. During a transit

downriver in high water conditions similar to

those on the day of the accident, the pilot did

not use full speed to maneuver the ship.

Safety Board investigators boarded the

Bright Field

shortly after the accident to

examine shipboard systems. Because the

Bright

Field

was still alongside the damaged wharf at

this time and could not be moved, its direct-

drive engine could not be started during initial

tests and inspections. After conducting a general

survey of the engineering plant, Safety Board

investigators focused their efforts on the

engineering systems most closely associated

with the ship’s propulsion plant and related

control systems. These systems included the

steering gear, the main engine and associated

main engine auxiliary subsystems, the

automated propulsion control system, and the

maintenance and management infrastructure for

the vessel’s engineering plant.

Steering Gear

-- The

Bright Field’

s electro-

hydraulic steering gear consisted of a tiller, two

rams, four cylinders, two electric hydraulic

pumps, and an electro-hydraulic control system.

During the investigation, the steering unit was

inspected externally and was operationally

tested by timing the rudder movements in

accordance with SOLAS ’74 steering

performance standards. The

Bright Field’

steering system functioned normally.

Main Engine—General

-- Because the main

engine could not be started and run during initial

inspections, the initial survey of the condition of

the engine was based on visual inspection,

testimony of crewmembers, and review of

maintenance and operating documentation.

Visual inspection of the main engine revealed

nothing unusual. The second engineer stated

that the engine’s exhaust gas temperatures ran

abnormally high and that, as a result, the crew

had had to replace pistons and cylinder liners

several times since July 1996. His maintenance

records confirmed this fact. The repairs to the

air turbocharger and air cooler made during the

vessel’s New Orleans port call were an effort by

the vessel owners to correct the problem. The

engineering crew stated that the main engine

operated normally during the trip downriver on

the day of the accident; however, a review of the

Terasaki alarm printout for the early part of the

voyage indicated that the main engine was

experiencing cylinder jacket water cooling

alarms due to low jacket water cooling pump

pressure. The tape also recorded alarms

indicating main engine lubricating oil purifier

malfunction and high second filter pressure

differential. A more detailed review of

engineering reports, including information

received late in the investigation from civil

litigation depositions, is contained in appendix

B. From at least January 1996, the

Bright

Field’

s main engine experienced continued

problems with component failures.

Main Engine Lubricating Oil Sump

According to engineering drawings, the engine’s

normal lubricating oil sump level was 14 cubic

meters (about 3,699 gallons) when oil pumps

and machinery were off. With pumps and all

mechanical equipment running, the oil level in

the sump should drop to about 10.3 cubic meters

(about 2,721 gallons). The design plans

indicated that the low-oil-level alarm should be

set to activate at 8.16 cubic meters (about 2,156

gallons). With both lubricating oil pumps and

other machinery off, the oil level for the

Bright

Field’

s main engine lubricating oil sump was

measured by Safety Board investigators at 10.75

cubic meters (about 2,840 gallons). Safety

Board investigators examined the main engine

sump and found that, with pumps and

mechanical equipment running, the

Bright Field

gauge read 8.1 cubic meters (about 2,140

gallons). Investigators tested the

Bright Field

low-oil-level alarm and found that it activated at

about 7.25 cubic meters (about 1,915 gallons).

The chief engineer’s log book recorded that,

upon the

Bright Field’

s arrival at New Orleans

on November 21, 1996, the main engine oil

sump level was 7.5 cubic meters, with the

engine running. At about the time of the allision

on December 14, 1996, the Terasaki monitoring

system recorded a main engine low sump oil

level alarm.

Main Engine Lubricating Oil

Pumps/Motors

-- According to testimony of the

engineers, both No. 1 and No. 2 (electrically

driven) oil pumps were operating at the time of

the allision, and they had not been altered in any

way since the accident. The No. 1 oil pump was

noisy and exhibited a periodic rumbling sound,

as if the pump were cavitating.

Lubricating oil

temperature was approximately 56 °C (about

132 °F). Mean discharge pressure was about 2.8

bar, however, both suction and discharge gauges

were oscillating wildly, making it difficult to

obtain a reliable reading. When pump No. 2 was

stopped, the system pressure dropped to about

2.3 bar. Pump No. 2 was tested and operated

satisfactorily.

The pump

cavitates

when numerous vapor bubbles

form in the oil. Subsequent collapsing of the bubbles can

produce a distinctive rumbling sound in a piping system.

Investigators opened and examined both oil

pump basket strainers and found them intact and

clear. The No. 1 oil pump was restarted, but it

continued to produce only about 2.3 bar. The

pump was examined for possible suction-side air

leaks, but all flanges, seals, and joints appeared

to be intact. The pump was taken to a marine

engineering repair facility for disassembly,

inspection, and testing. Other than minor wear,

no significant defects were found, and all

clearances were within manufacturer’s

specifications. The pump was reassembled and

reinstalled in the

Bright Field

During additional testing witnessed by

Safety Board investigators about 2 weeks later,

the No. 1 oil pump was again examined, started,

and found to be running quietly. Suction

pressure was -0.3 bar, and discharge pressure

was about 4 bar by local gauges. The pump

pressure relief valve was found to be operating

in accordance with the manufacture’s

specifications. The following day, investigators

reexamined the oil pumps and found high noise

levels associated with both pumps, including the

“cavitation-like” sound. No obvious leaks were

found in the flanges and openings on the

suction-side piping, and both pumps generated

rated (4 bar) pressure. Close inspection of the

No. 2 oil pump discharge stop check valve

revealed that the stem was jammed in the valve

yoke, and the valve would not manually close

and seat. The “check” feature of the valve

appeared to function correctly when subjected to

back pressure. Both oil pumps evidenced

noticeable vibration and noise for the remainder

of the vessel’s stay in New Orleans, and the

cause of the abnormal operation could not be

determined with certainty.

Main Engine Lubricating Oil System

Second Filter/Strainer

-- The second

filter/strainer was designed for working pressure

of about 4 bar and a working oil temperature of

45 °C (about 113 °F). The filter was equipped

with two pressure switches. One switch

monitored differential pressure across the filter

and activated an automatic backwash system (to

clean the strainer) if the pressure differential

reached a certain level. The other switch was

designed to activate an alarm in the event of a

differential pressure drop across the filter

greater than 0.9 bar.

On December 17, 1996, Safety Board

investigators recorded second filter/strainer inlet

and outlet pressures of 3.4 and 2.4 bar,

respectively, with the lubricating system still

running in the same condition, including an oil

temperature of 56 °C, as at the time of the

accident. A high-differential-pressure alarm did

not sound. Safety Board investigators

determined that the differential pressure alarm

had been set at 1.3 bar.

Safety Board investigators opened and

examined the second filter and found that the

installation was consistent with design

drawings. No visible debris buildup or blockage

was found. The filter was cleaned, reassembled,

and tested with new oil. The differential

pressure was found to be approximately 0.7 bar.

The filter manufacturer recommends that the

second filter/strainer be opened and cleaned

every 6 months. No record was found in the

second engineer’s maintenance log to indicate

that the filter had been cleaned between late

July and December 1996.

Main Engine Lubricating Oil Purifier

The

Bright Field

third engineer told the Safety

Board that the lubricating oil purifier was

supposed to run continuously (whether or not

the engine was running), drawing oil from the

engine oil sump, removing water and sediment

from it by centrifugal action, and then returning

the cleaned oil to the sump. Because the purifier

functioned with warm oil only, an auxiliary

boiler was needed to heat the oil when the

engine was not running. The

Bright Field

chief

engineer, in a December 9, 1996, letter to the

vessel owner, stated that the purifier had not

been used because the auxiliary boiler had been

inoperative. At some point during the vessel’s

stay in New Orleans, and prior to the accident,

the auxiliary boiler was repaired, and the

lubricating oil purifier was restarted.

On January 3, 1997, Safety Board

investigators were present when the oil purifier

was stopped, cleaned, and restarted. On January

6, 1997, the purifier began to alarm due to loss

of water seal. When the purifier was opened and

examined on January 10, 1997, investigators

found heavy contamination from an asphalt-like

substance.

Automatic Main Engine Lubricating Oil

Trip Function

-- According to statements from

the chief engineer and other engineering

crewmembers, the normal practice for the

Bright

Field

while operating in restricted waters was to

have the No. 1 lubricating oil pump running and

the No. 2 pump on automatic standby and that

the vessel was operating in this configuration on

the day of the accident. On January 4, 1997,

Safety Board investigators tested the oil pump

automatic changeover feature by reducing the

lubricating oil pressure sensed by the device.

During these tests, the pressure switch failed to

activate the standby pump. While investigators

were conducting tests of other system

components,

Bright Field

engineering

crewmembers examined and further tested the

pressure switch. When Safety Board

investigators retested the pump changeover

feature a few days later, the switch functioned

and started the standby pump automatically. The

original pressure switch was removed from the

vessel for laboratory testing. Test conclusions

were that, “the contact resistance is abnormally

high,” and could, under certain conditions,

“cause a problem; i.e., giving erroneous …or

faulty readings.”

Alarms, Indicators, and Recorders

Safety Board investigators examined wheel-

house and control room engineering alarm lights

and found that the wheelhouse automatic slow-

down alarm light was burned out. In tests of the

wheelhouse and control room audible and visual

alarms using the manufacture’s test plan, the

system worked as designed.

The Terasaki monitoring and alarm system

was designed to record and print out alarm

conditions and propulsion control system events

that were activated by the automated system.

Manual actions taken by the operating crew

were displayed on video monitors in the engine

control room, but no printed record was made of

those actions. The alarm log printout for the day

of the accident showed engine trip due to low

oil pressure at 1406. The printout did not

indicate automatic starting of the No. 2

lubricating oil pump.

Investigators compared lubricating oil

pressure readings displayed on local analog

gauges with those recorded by the Terasaki

system. While the analog gauges displayed the

same readings, the monitoring and alarm system

recorded pressures that were higher than the

gauge readings by about 0.3 bar.

Remote Engine Control Tests

-- On

January 5 and 10, 1997, with representatives of

IHI, the

Bright Field

engineering and navigation

crew, and the Coast Guard in attendance, Safety

Board investigators observed testing of the

remote engine control using an IHI simulation

plan dated December 29, 1996. Control was

successfully shifted between the wheelhouse

and the control room, and the control room

answered all telegraph commands from the

wheelhouse. No unexplained anomalies were

noted at either control station. Similar tests were

later conducted with the vessel underway, and

all controls worked as designed. In testimony,

neither the chief engineer nor the chief

electrician could explain the two engine-starting

anomalies experienced by the vessel on

December 14 on the downriver voyage. During

testing, the problem could not be reproduced.

Preventive Maintenance

-- The

Bright

Field

was provided with owners’ instructions,

dated August 28, 1995, that described

requirements for periodic (based on engine

hours) inspection and repair of the vessel’s main

engine, auxiliary, and electrical equipment

(exclusive of equipment associated with the

automated propulsion control system). On

October 25, 1995, the owners, concerned about

“frequent cylinder liner cracks in the past 1 or 2

years,” instituted additional operating policy for

the maintenance of the

Bright Field

main

engine. Safety Board investigators were unable

to find evidence that the vessel’s crew(s)

complied with the periodic maintenance

requirements developed by the owner.

Reports and Recordkeeping

Engineering personnel on the

Bright Field

maintained several types of records that were

reviewed by investigators. The second

engineer’s daily log book recorded work done

on the vessel’s machinery. The log was

translated by the second engineer each month

and sent to the owner with other vessel reports.

The owner received periodic telexes from

the master documenting the severity of

engineering problems, delays in scheduling

resulting from the engineering problems, and

the inability of the engineering crew to make

permanent repairs. See appendix B for a detailed

chronologies of engineering problems

referenced in the monthly engineering reports

and in the master’s telexes to the

Bright Field’

owner.

Main Engine Lubricating Oil Testing and

Analysis

-- The

Bright Field’

s lubricating oils

were supplied by British Petroleum (BP) on

long-term contract. BP also periodically

processed oil samples provided by the owner for

test and analysis.

In a January 20, 1996, analysis of a

Bright

Field

main engine bearing oil sample, BP found

a reduced flash point and recommended

corrective action. Analysis by BP of an August

24, 1996, sample showed increased viscosity

and reduced flash point. BP oil analysts

concluded that the oil was contaminated by fuel

oil leaking from the main engine. The report

recommended immediately replacing the main

engine lubricating oil and correcting the fuel

leak. The second engineer stated that he

changed the main engine lubricating oil on

November 5, 1996, after the main engine

alarmed and went into emergency slowdown

because of a high density of oil mist in the

crankcase. The second engineer stated that he

suspected fuel oil contamination of the

lubricating oil system.

The engine manufacturer recommended to

the

Bright Field’

s owners in November 1996

that the engine oil be tested as soon as possible

to check for contamination by water and fuel.

The sample was drawn by the chief engineer on

November 20, but was not tested by BP until

June 1997. BP analysis of the oil indicated

elevated water content and viscosity compared

with BP’s oil specifications and the engine

designer’s recommended range of acceptable oil

properties. The analysis also recorded elevated

insolubles due to combustion byproducts

entering the lubricating oil.

A December 18, 1996, sample collected by

the

Bright Field’

s chief engineer was tested by

Saybolt, Inc. The analysis indicated excessive

water content and high viscosity when

compared to a clean sample of the BP oil.

Saybolt reported that the oil sample also

contained a significant amount of suspended

particulates. Additional analysis of lubricating

oil samples collected by Safety Board

investigators and analyzed by JET-CARE

International, Inc., confirmed elevated viscosity

and water content in excess of BP and Sulzer

specifications.

Spare Parts and Calibration Tools

-- The

second engineer’s maintenance record and

telexes from the master noted that spare parts

for the main engine, auxiliary boiler, water

maker, and other engineering equipment were

either in short supply, of poor quality, or not

available at all. According to the records, the

lack of readily available spare parts meant that

engineering personnel had to reuse worn or

damaged parts that could be made serviceable.

Calibration tools necessary to set the timing of

the main engine fuel pump were missing and

could not be located.

Sulzer Inspection

-- A representative of

New Sulzer Diesel, the designer of the

propulsion diesel engine, had inspected the

engine shortly after the

Bright Field

arrived at

New Orleans in November 1996. He identified

several sources of possible lubricating oil

contamination and noted the following problems

with the main engine:

•

Cracked cylinder liners;

•

Missing, worn, dirty, carbon-contaminated

components, including piston rings;

•

Clogged cylinder inlet ports and piston

cooling passages;

•

Clogged, dirty, damaged components to

charge air receiver; water leaks observed;

•

Fuel oil pump drain clogged and leaking

fuel oil into main engine lubricating oil

sump (recommended testing oil as soon as

possible);

•

Missing main engine turbocharger filters

and dirty internals;

•

Control air system valves clogged with

condensation;

•

Worn, loose, misaligned fuel oil pumps and

linkages.

Chief Engineer’s Assessment

-- On

December 9, 1996, the new chief engineer

corresponded with the

Bright Field’

s owners,

confirming the seriousness of engineering

problems observed by the Sulzer technician in

late November and indicating the status of

repairs. He reported the following:

•

Scavenging box showed serious accumula-

tion of sludge and carbon with blocked air

vents;

•

Charge air cooler separation panels pol-

luted, blocked, and rusted;

•

Scavenging box nonreturn air valves

blocked with sludge;

•

Missing, loose, worn piston rings; spare

piston rings of low quality;

•

High-pressure fuel oil pump residue

discharge pipes blocked, leaking fuel oil

into lubricating oil sump;

•

Cracked, welded cracks in No. 2 cylinder

liner; renewed piston head (only 360 hours

of operation since this cylinder liner was

last pulled);

•

No. 5 piston rings replaced;

•

Control air system contaminated;

•

One Terasaki computer monitor out of

commission; second monitor distorted;

•

Auxiliary boiler out of commission; fuel oil

pump not working and numerous plugged

(with debris) tubes from lack of

maintenance; main engine’s main bearing

lubricating oil not being purified;

•

Abnormal main engine cylinder cooling;

•

Smoke exhaust from main engine dark

because of problems with turbocharger

and/or charge air cooler;

•

Improper main engine fuel oil injection

timing;

•

Serious noise and vibration from both main

engine lubricating oil pumps;

•

Numerous auxiliary pumps, engines, and

motors not working or working poorly.

Safety Board investigators examined the

engineering plant following the accident and

determined that the vessel had sailed on

December 14, 1996, with the following

uncorrected engineering conditions:

•

Severe noise and vibration in both main

engine lubricating oil pumps;

•

Defective Terasaki monitoring equipment;

•

High differential pressure across the second

filter;

•

Poorly calibrated sensors (automated pro-

pulsion control system); and

•

Main engine lubricating oil quality and

quantity that did not meet specifications.

Tests, Reports, and System Calibration

The chief electrician’s log book reflected

electrical work completed, tests conducted,

problems encountered, and electrical machinery

(cranes, winches, motors) used each day. The

reports were translated by the chief electrician

and included with the vessel’s monthly reports.

(See appendix B for a record of problems

associated with the automated propulsion

control system.)

The chief electrician also conducted

quarterly testing of engineering safety devices,

such as alarms and sensors, and submitted a

report on their operation to the owner. The

quarterly testing did not evaluate the condition

of engineering safety control devices, such as

the pressure switch for starting the standby

lubricating oil pump. Also excluded were the

trip and slowdown set points. The chief

electrician stated that neither he nor the chief

engineer tested the calibration of the automated

propulsion control system set points.

The

Bright Field

was originally delivered

with a complete DNV-approved set of

automated propulsion control system test

procedures for periodically validating the

operability of the control system. The

Bright

Field’

s engineering crew stated that they were

unaware of any test procedures and did not

regularly test or calibrate the system. The

engineering crew could not produce a set of

automation test procedures. Copies of post-

delivery automation test procedures were found

in the crew’s library.

Technical manuals covering each

component of the automated propulsion control

system were on board the

Bright Field

. Most of

the manuals were found in the staterooms of

individual engineering officers.

Computer Simulation

-- The Vehicle

Performance Division of the Safety Board’s

Office of Research and Engineering digitized

and analyzed data retrieved from a video made

by the tugboat

Lockmaster

as the vessel’s radar

tracked the

Bright Field

. Engineers attempted to

compute vessel motion parameters; however, the

radar data were of low resolution and did not

provide an accurate depiction of the

Bright

Field’

s movement. The Safety Board contracted

with the Corps of Engineers to perform an

engineering computer simulation to determine

the path of the

Bright Field

during the accident

sequence. The simulation was based on

computer modeling of the

Bright Field

and the

Mississippi River at the accident site. Because

of the limited number of parameters available

upon which to base the simulation, the Corps of

Engineers simulation results were also

inconclusive.

Other Information

Port Risk Analysis and Management—

Coast Guard

-- The Coast Guard, under the

Ports and Waterways Safety Act of 1972

, was

charged by Congress with monitoring,

managing, and communicating risk in all U.S.

ports and taking actions to maintain risk at an

acceptable level. The act empowers Coast Guard

COTPs to monitor the risk levels in their port

areas and maintain “an acceptable level of risk.”

The Coast Guard

Marine Safety Manual

defines

the elements of waterways risk assessment to be

considered by the COTP as vessel properties,

waterway properties, cargo properties, and

environmental conditions.

General port risk management is the

responsibility of the Coast Guard’s Office of

Marine Safety and Environmental Protection,

which is charged with protecting the public, the

environment, and United States economic

interests by preventing or mitigating the effects

of marine accidents and incidents. According to

the “Program Principles” section of the Office

of Marine Safety and Environmental

Protection’s

1996 Performance Report

risk

management is the “business” of the office. The

report states:

Preventing low probability-high

consequence events, such as major loss

of life on passenger vessels, and

medium and major oil spills, is a

cornerstone of our risk management

approach. To improve our decision

making, we need to strike a balance,

allowing field commanders to employ

existing risk analysis tools for routine

risk management decisions, while

establishing a formal program policy for

high level risk analysis projects, such as

comprehensive port risk models.

Appendix III of the report, “Risk

Management & Risk Analysis,” defines risk as

“the probability of suffering a degree of harm

from one or more hazards.” The document

quantifies this definition with the formula:

RISK = Probability x Consequence

The document states that the risk equation

implies that some risks are greater than others

and that risk management involves choices

about “how, and to what degree, we will try to

reduce the probability and/or consequences of a

potentially harmful event.” The document states

that a complete risk management process

includes

risk analysis

risk management

, and

risk communication

Risk analysis

, according to the document, is

the process of systematically identifying,

estimating, and ranking risks according to their

probabilities and consequences. From that

ranking of risk, a risk-ranking matrix (figure 13)

can be developed. The document states that the

The 1996 report on the office’s progress toward

goals contained in Commandant Instruction 16000.2

(series),

Business Plan for Marine Safety and

Environmental Protection

Office of Marine Safety and Environmental

Protection’s overall risk management strategy

using this matrix is to select the higher risks that

can be influenced and try to reduce their

frequency and/or consequence in order to

minimize their contribution to overall risk in the

waterway.

Risk management

, according to the

document, is the systematic selection of options

for treating different risks. “Options may

include measures aimed at reducing the

probability and/or consequences of particular

risks, eliminating risks, shifting risks in space

and/or time, or tolerating risks.”

The document defines

risk communication

as the “continuous, two-way process of

communicating with stakeholders

about the

risks associated with [the] system of concern.”

Port Risk Analysis and Management—

Other Stakeholders

During the past 20 years,

various stakeholders in the greater New Orleans

port area have commissioned numerous risk

assessment and reduction studies.

Stakeholders

refers to parties of interest, from both

public and private sectors, in the Port of New Orleans area.

Lower Mississippi River Safety Study

The

objective of this 1981 study by Louisiana State

University was to develop recommendations

concerning the way in which communications,

electronics surveillance, aids to navigation, and

traffic management could best be used to

enhance river safety and protect the

environment. The study identified problems

among port and waterway uses, determined

traffic patterns and volume in the area,

synthesized accident data from the Coast Guard

and other sources, identified areas of hazard

created by natural and artificial conditions and

structures on the river, surveyed those who use

the river to ascertain their opinions about river

safety and what was needed to improve it, and

developed a prototype system to enhance river

safety.

Louisiana World Exposition

-- Prior to the start

of the 1984 world’s fair, LWE officials prepared

an environmental impact statement that

addressed safety concerns associated with

marine accidents. An analysis of vessel

incidents between January 1973 and September

1981 revealed that only one vessel had struck

the Julia Street wharf during that period, with no

injuries reported. The Poydras, Julia, and Erato

Street wharves were determined to be the areas

least associated with vessel strikes.

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LWE officials recognized that fair structures

and activities could adversely affect safe

navigation along the Mississippi River. For

example, fair officials were concerned that

nighttime illuminations, including fireworks

displays, could interfere with the night vision of

mariners. To minimize these risks, the LWE

requested that the COTP establish a “safety

zone,” within which the Coast Guard would

regulate marine traffic when the fair held special

events on the river. The safety zone was

established, and mariners received notices from

the Coast Guard cautioning them to navigate

vessels with extreme care in the vicinity of the

world’s fair.

The Dock Board refused to allow the

berthing of barges and houseboats at the Julia,

Erato, and Poydras Street wharves during the

fair. The Dock Board rejected the LWE’s

request to place exhibit pavilions (that would be

expected to have large numbers of visitors) on

floating barges moored along the river.

The

Dock Board did permit the mooring of tall ships,

oceangoing passenger vessels, large

sternwheelers, and visiting foreign warships in

the area.

International RiverCenter

-- Prior to the

expansion of the Hilton Hotel, the IRC was

required to obtain construction permits from the

city of New Orleans, the Corps of Engineers,

and the New Orleans Levee Board. The Dock

Board required that the plans be submitted for

review and executed a lease with the IRC for the

development. The Dock Board reviewed the

plans to determine the extent to which the

development might interfere with Dock Board

activities.

According to the IRC, during the time when

the IRC was negotiating a lease with the Dock

Board, the Dock Board advised the IRC that

vessels had had allisions with wharves within

the Port of New Orleans, but that no allisions

had occurred at the Lower Poydras Street wharf.

The IRC representatives were shown

photographs of the allisions at other wharves.

Information regarding activities of the Dock Board

during the fair was provided by the Dock Board and

confirmed by a former Dock Board chief executive officer.

These photographs, according to the IRC,

“depicted only minimal damage.”

An IRC official was not aware of any

preconstruction risk assessments that were

carried out in connection with the Hilton Hotel

expansion in the early 1980s, and the IRC was

unable to provide the Safety Board with any

other information regarding previously

completed risk assessments regarding their

properties built on the river side of the levee.

The damaged properties, including portions of

the Riverwalk Marketplace mall, the

condominium parking garage, and the Hilton

Hotel are being rebuilt on the same footprint. No

physical barriers against accidents involving

river traffic have been constructed at this

location.

New Orleans Aquarium of the Americas

--In

1987, before construction of the Aquarium of

the Americas, the Audubon Institute contracted

for a risk analysis for construction of the

aquarium on the riverfront outboard of the

levee. The contractor was asked to assess the

safety risk from marine traffic at the site of the

proposed Riverfront Park, including aquarium

structures and park area. The scope of work

included a study of 20 years of Port of New

Orleans records documenting damage to

waterfront facilities at and near the site of the

proposed Riverfront Park, as well as the

potential consequences of an allision of a vessel,

barge tow, or boat with Port of New Orleans

wharves such as the Bienville Street wharf,

where the proposed aquarium was to be located.

The report concluded that vessels and tows

moving downriver, with the current, have less

water moving across the rudder, rendering them

less maneuverable and their pilots less able to

adjust to emergency situations. This hazard

increases with higher river stages, which deliver

faster currents. The study concluded that, if an

outbound ship or tow were to lose steering,

power, or control, or if it were to become

slightly out of shape to navigate the bend around

Algiers Point, the Bienville Street wharf area

would be less likely to be damaged, since the

downriver current would probably carry the

vessel past this area. Vessel damage would more

likely occur in the areas of the Governor

Nicholls, Esplanade, or Mandeville Street

wharves, which are located in the Algiers Point

bend of the river, about 3/4 mile below the

Bienville Street wharf. According to the report,

because Bienville Street wharf is high in the

bend, it faced low risk of being struck by an

outbound vessel.

A Port of New Orleans review of records for

1967 through 1987 indicated that the Bienville

and adjacent Toulouse Street wharves had

received no major vessel strikes; however,

major vessel strikes had occurred along the

wharves at and downriver from Governor

Nicholls Street.

Analysis of wharf damage from ship, barge,

and tow strikes revealed that such damage rarely

penetrated beyond 25 to 50 feet inward of the

fender line. The shock from such an accident

could be felt for a distance along the wharf; but

the impact load was not sufficient to

compromise the overall stability of the wharf.

The report concluded that any major

structure located 100 feet or more from the edge

of the wharf would not be in danger from river

marine traffic. The report recommended that the

area within 50 to 100 feet of the wharf be

considered a buffer zone that, while open to

pedestrian traffic, should be free of building

structures. The report stated that this buffer zone

could be most effectively isolated from the inner

wharf area by a motion control joint, installed

parallel to the fender line, that would reduce any

vibrations from a ship strike.

Gaming Vessel Risks and Background

-- In

1991, the Dock Board initiated a series of

planning initiatives related to riverboat gaming.

These initiatives included commissioning the

Coast Guard and the Louisiana State University

National Ports and Waterways Institute to

conduct a navigation risk assessment. The Dock

Board also contracted with a safety consultant to

review the safety of Dock Board properties and

to develop guidelines for gaming vessel

operation. The consultant’s study addressed

public-safety aspects of riverboat gaming,

focusing on fire protection, police response, and

emergency medical services. It focused

particular attention on ways of ensuring that

gaming vessels had adequate access and egress.

The Coast Guard COTP determined that

about 350 incidents of steering and power loss

were reported annually in the COTP-NOLA

zone.

The COTP requested that the Dock

Board provide a navigational risk assessment in

preparation for berthing the riverboat gaming

vessels. The Dock Board contracted with the

National Ports and Waterways Institute, in

cooperation with the George Washington

University, to conduct the risk assessment that

went beyond the scope of the Coast Guard’s

request to consider a wide range of safety

aspects along the Mississippi River. The

assessment incorporated input solicited from

waterway users, including local pilots. The

study did not address the high-capacity

passenger cruise ships that use the Julia or Erato

Street wharves as bases of operations.

Phase I of the study, completed in July

1994, concluded that the addition of gaming

boats to the Mississippi River increased both the

probability of a marine casualty and the

potential impact of such a casualty. While the

increase in the probability of an incident was

comparatively small, the increase in potential

injuries and loss of life was large in relation to

casualties involving nongaming vessels. The

study determined that the increased risk was

primarily a function of the operating

environment, not of the vessels themselves. The

study asserted that restricting the conditions

under which gaming vessels may cruise could

reduce, but could not eliminate, the risk.

Accident data (figure 14) for the Port of

New Orleans from 1983 through 1993 (a total of

166 rammings along the left descending bank

between miles 91 and 101 AHP) were analyzed

and the results tabulated to identify a mooring

area for gaming vessels of “lowest historical

allisions on the left bank.” The study stated, “It

should be noted, however, that no area of the

left bank downbound was completely free of

allisions during the eleven year period.”

The phase I report made the following

recommendations:

•

Gaming vessels moored on the left

descending bank of the Mississippi River

The COTP-NOLA zone extends along the

Mississippi River from the Arkansas border to the Gulf of

Mexico.

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should be moored in the area of lowest

historical accident rate (Poydras Street to

First Street);

•

Gaming vessels should remain moored

during periods of low visibility, high winds,

or high river stage;

•

The potential for protecting the moored

gaming vessel by allowing berths to silt in

should be investigated;

•

Fully equipped rescue craft capable of

handling the volumes of passengers should

be available, either through the public sector

or by contracts with the private sector;

•

Contingency and disaster management plans

should be developed, and routine

preparedness drills should be held;

•

The issue of providing emergency egress

from passenger vessels to other vessels, to a

dock, or to a river bank should be

investigated. The objective must be to

remove passengers when underway or

moored during a crisis without having

persons resort to leaping into the water.

The phase I study reported expert opinion

that “high river stage was an important factor in

river casualties” and stated that this opinion was

supported by casualty data. According to that

data, casualties (allisions and collisions) show a

seasonal trend, with the high water months of

February, March, April, and May experiencing

two to three times the number of casualties as

the low-water months of July through October.

The phase I study did not determine the

frequency with which high-risk events were

likely to occur and thus could not provide an

overall estimate of risk for the port.

The phase II study developed methods to

further quantify the risk levels and thus enable

an evaluation of the overall risk, as well as risk

reduction, due to the mitigation measures

identified in phase I. A simulation of the Port of

New Orleans integrated the expert assessments

of phase I using available data, and simulation

results were validated against historical casualty

statistics. The simulation estimated that 2.24

vessels incidents per month could be expected in

the port area from miles 80 to 106 AHP and

that, of these incidents, 0.75 incident per month

could be expected between miles 90 and 95

AHP.

The phase II report reached the following

conclusions regarding gaming vessels:

•

The probability of occurrence of an incident

at high river stage is 10 times greater than at

low river stage;

•

A 25 percent increase in traffic in the river

would result in a 37 percent increase in the

number of vessel incidents that could be

expected.

One phase II study recommendation for

minimizing the risk of high-capacity passenger

vessel operation in the Port of New Orleans was

the following:

The Coast Guard and the Port of New

Orleans should ensure that response

plans and resources are adequate to deal

with a casualty involving a high-

capacity passenger vessel. Although the

probability of an incident involving one

of these vessels can be minimized, the

only way to minimize the potential

impact of such an event is to invest in

the resources and planning required to

effectively respond to such a casualty.

In 1993, the Governor’s Task Force on

Maritime Industry,

which addresses safety

issues on the Mississippi River and Mississippi

River—Gulf Outlet, formed a Marine Safety

Committee to address the issue of gaming

vessels berthing on the Mississippi River. The

committee was to solicit and promulgate

suggestions from local mariners regarding

protection of the areas in which gaming vessels

would be operating. The committee was later

subsumed into the Coast Guard Passenger

Vessel Safety Committee and other groups

formed by the Port of New Orleans to address

the issue of minimizing casualties from a

collision between a deep- or shallow-draft

vessel and a gaming vessel. This committee

functioned as an advisory group to the

Mile 95 AHP is at the approximate location of the

allision.

Governor’s Task Force and made the following

suggestions:

•

Assign a rescue boat to the immediate

vicinity of the gaming vessels and equip it

for handling a large number of passengers in

case of a casualty;

•

Station in the area a fully equipped fire boat,

which could be utilized as an additional

rescue boat;

•

Install a weather and river monitoring sys-

tem;.

•

Assign a dedicated communications marine

radio channel to be used by vessels

transiting the area;

•

Post and otherwise publicize notices to

mariners advising of this controlled zone;

•

Conduct joint Coast Guard, harbor police,

fire department, and police department

emergency preparedness drills;

•

Establish a fire and rescue station equipped

with a helicopter pad to provide rapid

evacuation in case of a casualty;

•

Ensure that all vessels are in full compliance

with classification society and Coast Guard

requirements;

•

Meet with all gaming interests to review

designs and recommendations of safety

programs.

One member of the advisory group

recommended that the area from the Crescent

City Connection Bridges to Canal Street be

allowed to silt in, forming a barrier 150 to 200

feet into the river to prevent deep-draft ships

from reaching the moored gaming vessels.

Operation Safe River

-- In January 1994, Coast

Guard Group New Orleans, together with the

New Orleans Port Authority Harbor Police, the

Crescent River Port Pilots Association, the City

of New Orleans Office of Emergency

Preparedness, and the Southeast Louisiana

Search and Rescue Organization, conducted a

joint search and rescue exercise on the

Mississippi River between the Crescent City

Connection Bridges and Algiers Point. The

exercise area included the section of the river

where gaming vessels were planned to berth and

operate. The exercise simulated a major marine

incident in the Mississippi River involving a

high-capacity passenger vessel. Weather

conditions during the exercise included an air

temperature of 40 °F and a water temperature of

34 °F. This real-time exercise demonstrated that,

during daylight hours with the resources

available, only 20 to 30 percent of people in the

water could be expected to be rescued.

Based on the results of this exercise and the

large number of vessel casualties—particularly

bridge allisions—that had occurred during 1993-

94, the Eighth Coast Guard District

implemented Operation Safe River to improve

safety on the Lower Mississippi River. The

operation initiatives called for a higher standard

of care by mariners and ordered COTPs to take

a harder line on enforcement and penalty

sanctions. The operation also included

initiatives to review the riverboat gaming vessel

program, focusing on the number of vessels and

their docking sites, as well as ferry vessel safety

pertaining to manning and operation.

According to Coast Guard officials,

initiatives developed as a result of Operation

Safe River have resulted in the following:

•

An extension of the regulated navigation

area for barge fleeting, resulting in a

reduction in barge breakaway incidents

because of improved barge fleeting

operating practices;

•

Improved reporting of vessel power and

steering losses by river pilots, and an

increase in the number of incidents in which

a pilot refuses to sail vessels with

navigational or engineering deficiencies;

•

Increased awareness by owners and

operators of their responsibility for safe

navigation in the river, resulting in a

reduction of incidents of vessel power or

steering loss;

•

Better adherence by owners and operators to

river draft requirements, resulting in a

reduced number of mid-channel groundings;

and

•

Year-round operation of the Algiers traffic

light.

Changes Made Since the Accident

Several steps were taken after the

Bright Field

accident to enhance safety in the Port of New

Orleans area.

River Front Alert Network

-- The Coast Guard

and the Dock Board, on March 11, 1997, agreed

to a memorandum of understanding establishing

a River Front Alert Network to provide early

warning of potential shipping disasters in the

area of the Port of New Orleans. The River

Front Alert Network is an 800 MHz emergency

radio alerting and communications system

installed at the Coast Guard’s Governor

Nicholls traffic light control tower and the Port

of New Orleans Harbor Police Department. The

system links the Governor Nicholls light, the

Harbor Police Department, the Delta Queen

Cruise Terminal, the Riverwalk Marketplace,

the Hilton Hotel, One River Place condomini-

ums, and the Aquarium of the Americas.

The River Front Alert Network is designed

to provide a capability to directly notify the Port

of New Orleans Harbor Police Department and

Port of New Orleans property tenants of a

potential threat caused by vessels navigating in

the vicinity of Algiers Point. Under the

memorandum of understanding, the alert signal

is initiated by the Governor Nicholls light

operator, who contacts the harbor police

dispatcher and the security officers of the

riverfront properties whenever an abnormality

or irregularity that could affect the riverfront

properties is identified or reported by a vessel in

the Algiers Point regulated navigation area. The

light operator is to transmit a short warning

message over the network describing the

situation. The dispatcher and the security

officers are to monitor the situation on the

marine radio and make their own judgments

about the appropriate response at their

properties. The network system is to be

activated as early as possible to provide the

maximum advance notice to the riverfront

properties. Once the situation is no longer a

threat, an “all clear” message is to be initiated

by the light operator.

Under the memorandum, the Dock Board is

responsible for installing and maintaining the

River Front Alert Network system hardware,

including system design, maintenance, support,

problem identification, and repair. The Port of

New Orleans is responsible for coordinating a

program to regularly test the network, including

the scheduling, participation, conduct, analysis,

and corrective action required to ensure the

system is functioning properly. The harbor

police are to implement standard operating

procedures defining the actions to be taken

when the network is activated during a possible

emergency incident, situation, or condition. The

port is to coordinate with the property tenants to

define the emergency actions to be taken when

the network is activated.

According to documentation provided by

the Dock Board on November 3, 1997, the board

has worked with the property tenants who

participate in the River Front Alert Network to

develop and implement standard operating

procedures for emergency evacuations. The

Dock Board reports that property tenants within

the River Front Alert Network zone have

updated their emergency plans to incorporate

the network alarm system and to provide

instructions for security officers to follow in the

event the Coast Guard light operator activates

the River Front Alert Network radio. Under the

updated procedures, security officers are to

listen to the broadcast from the Coast Guard

light operator, monitor VHF channels 16 or 67,

visually assess the situation on the river, and on

the basis of this information, determine whether

to order an evacuation of the property. The

security officers are authorized to initiate an

evacuation immediately based on the nature and

immediacy of the apparent river danger. Upon

determination that an evacuation is necessary,

security officers are to make public address

announcements of the evacuation and

implement those evacuation procedures that

have been established for their particular

locations.

New Notices, Rules, and Operating Regulations

In January 1997, the New Orleans COTP

identified passenger vessels deemed to be at risk

from allisions and issued written COTP orders

directing these vessels to (1) maintain a constant

bridge watch whenever passengers are

embarked, (2) maintain a constant monitoring

watch on VHF-FM channel 16 or other

appropriate emergency and bridge-to-bridge

radio frequency, and (3) be able to alert

passengers and other crewmembers and have the

ability to direct initial action in the event of an

emergency.

Also in January 1997, the New Orleans

COTP issued a notice that on vessels of more

than 1,600 gross tons, the anchors are to be kept

ready for immediate release and that, while the

anchor watch is in effect, effective

communications are to be provided between the

bridge and the foredeck.

On March 21, 1997, the commander of the

Eighth Coast Guard District issued temporary

rules applying new operating requirements to

self-propelled vessels of 1,600 gross tons or

more operating in the Mississippi River between

the South and Southwest Passes and mile 233.9

AHP. According to the Coast Guard, the new

requirements were prompted by the

Bright Field

accident and by subsequent unprecedented high

water levels in the river, which had led to “a

marked increase in vessel accidents.” These

temporary rules were extended twice; the

second extension was set to expire on October

31, 1997.

Before the expiration of the temporary rules,

the Coast Guard, on October 30, 1997,

published the new requirements as an interim

rule (33 CFR Part 165) in the

Federal Register

Interested parties have until December 29, 1997,

to comment. In its discussion of the rule, the

Coast Guard stated that the new requirements

were needed to “protect vessels, bridges,

shoreside facilities, commercial businesses and

the public from a safety hazard created by deep-

draft vessel operations along the Lower

Mississippi River.” The Coast Guard noted that

during 1995 and 1996, more than 300 self-

propelled vessels of 1,600 gross tons or greater

experienced loss of power, loss of steering, or

engine irregularities while operating in the

Mississippi River. It stated that the new rules

would enhance safe navigation of the river by

requiring that masters and engineers take

measures to minimize the risk of steering

casualties or engine failures/irregularities.

Under interim 33 CFR 165.810(e),

passengers vessels with one or more passengers

on board that are anchored or moored in the

Lower Mississippi River below mile 233.9 AHP

are required to keep a continuously manned

pilothouse,

and to

monitor river activities and marine VHF

emergency and working frequencies of

the port so as to be immediately

available to take necessary action to

protect the vessel, crew and passengers

in the event that an emergency radio

broadcast, danger signal or visual

indication of a problem is received or

detected.

Under interim 33 CFR 165.810(f), self-

propelled vessels of 1,600 gross tons or more

operating in the regulated area are to comply

with the following:

(1)

The engine room shall be

manned at all times while un-

derway in the RNA [Regulated

Navigation Area].

(2) Prior to embarking a pilot when

entering or getting underway in

the RNA, the master of each

vessel shall ensure that the ves-

sel is in compliance with 33

CFR Part 164 [specifying tests

of steering gear, internal vessel

control communications, emer-

gency generators, storage

batteries for emergency sys-

tems, and main propulsion

machinery, ahead and astern, all

of which are to be completed

prior to entering or getting

underway in U.S. navigable

waters].

(3)

The master shall ensure that the

chief engineer has certified that

the following additional oper-

ating conditions will be

satisfied so long as the vessel is

underway in the RNA:

(i) The main propulsion plant

is in all respects ready for

The rule exempts ferryboats and small passenger

vessels of less than 49-passenger capacity from this

requirement to maintain a manned pilothouse.

operations including the

main propulsion air start

systems, fuel systems,

lubricating systems, cooling

systems and automation

systems;

(ii) Cooling, lubricating and

fuel oil systems are at

proper operating tempera-

tures;

(iii) Automatic or load limiting

main propulsion plant

throttle systems are oper-

ating in manual mode with

engines available to im-

mediately answer maneu-

vering commands; and

(iv) Main propulsion standby

systems are ready to be

immediately placed in

service.

Steering Loss Study

-- After the

Bright Field

accident, a number of maritime, port

community, and public stakeholders in the Port

of New Orleans began to work together to

address mutual concerns. One result was a study

of propulsion and steering losses experienced in

the Lower Mississippi River, which was

expanded as a national issue for the Coast

Guard’s Navigation Safety Advisory Council

(NAVSAC). In April 1997, the NAVSAC

Navigation Equipment Committee concluded

that loss of propulsion and steering by vessels

while navigating the Mississippi River is a

national problem and that the nature of these

incidents is of great concern to all stakeholders.

The committee is exploring solutions, regulatory

and nonregulatory, that can be implemented to

help prevent steering and propulsion casualties.

Another area of concern to stakeholders was

development of objectives for a vessel traffic

system (VTS) for the Lower Mississippi River.

After the

Bright Field

allision, an ad hoc

committee produced in January 1997 a

“foundation of needs,” which addressed a

number of government, industry, and public

objectives for improved river safety. According

to the Coast Guard, it has designated the Lower

Mississippi River as the location of a

demonstration project for a new “silent” VTS

system that is expected to begin limited

operation in mid-1998. Under the silent VTS

system, vessels will be equipped with

transponders that will transmit a wide range of

vessel description and position information that

can be displayed on computer screens aboard

any vessel in the area. The system will provide

instantaneous and positive vessel information

while reducing VHF radio traffic.

Ship Drill Alarms

-- Immediately following the

Bright Field

accident, the president of the Port

of New Orleans issued a letter to the cruise line

owners at the Julia Street wharf asking them to

suspend the sounding of their ships’ whistles

during drills in order to avoid confusion about

the source and meaning of the whistle. The

letter requested that the cruise lines suspend the

drills and whistle soundings until they have

departed the Julia Street wharf. In addition, the

Port of New Orleans revised its general rules

and regulations to read:

No vessel, whether a cruise ship or an

excursion boat, shall sound a distress,

fire or emergency alarm as part of its

preparation drills while it is docked at

or near the Board’s wharves from Robin

Street to Governor Nicholls Street

except for such alarms required as part

of a vessel’s quarterly drills required to

maintain U.S. Coast Guard certification.

In the latter event, each vessel shall

notify in advance of such, the

surroundings of the Board’s Harbor

Police Department, the Hilton Hotel,

One River Place and the New Orleans

Riverwalk Associates. To the extent that

a vessel needs to familiarize passengers

with the sounds of such alarms as part

of its on-board safety drills, these

exercises should be conducted when the

vessel is either below the Governor

Nicholls Street wharf or above the

Robin Street wharf.

Riverwalk Marketplace Alert System

-- According

to minutes taken during a public Dock Board

meeting on February 6, 1997, the Riverwalk

Marketplace plans to install three cameras that

will monitor and display river traffic to all mall

merchants. The River Front Alert Network

provides an alarm to the Riverwalk security

desk, which then monitors maritime activities by

marine radio and visual monitoring. The

security desk determines the appropriate course

of action, including the sounding of evacuation

alarms. In addition, representatives of the

complex proposed the installation of a color-

coded alarm system display monitor that will

notify merchants of the type of evacuation

protocol to follow in the event of an emergency.

According to representatives of the

Riverwalk Marketplace, the public address

system in place at the time of the accident

operated through the mall’s Simplex alarm

system, which used speakers mounted at alarm

locations throughout the mall interior.

Emergency instructions were broadcast through

these speakers. Since the accident, the system

has been modified so that emergency messages

can be broadcast throughout the mall via the

background music system. Riverwalk is

investigating the possibility of a dual strobe-

horn combination alarm system that would alert

the mall tenants, employees, and patrons to the

type of evacuation required under various

emergency scenarios.

In an August 22, 1997, letter to the Safety

Board, a Dock Board official stated that the

Dock Board had encouraged the IRC to widen

the remaining portion of the Upper Poydras

Street wharf by 50 feet to match the portion of

the wharf that was previously widened to

accommodate gaming vessels. The Dock Board

also recommended that silt be allowed to

accumulate under the wharf as an additional

safety factor. The letter noted that the Dock

Board has no authority to compel the IRC to

carry out these modifications.

Vessel Egress

-- The Dock Board, in its

Public Protection and Emergency Management

Guidelines for Gaming Vessels and Berthing

Areas

, states that “a powered mobile elevating

platform suitable for emergency access or

casualty removal from upper decks is

conveniently available in the wharf area.” Also

in its August 22, 1997, letter, the Dock Board

described how the gaming vessel located at the

Poydras Street wharf has complied with the

Dock Board’s guidelines. The letter stated that

the

Queen of New Orleans

had provided an

elevator-equipped gangway and a wharf-

mounted crane.

The same guidelines state that “for

passenger use, at least two regular gangways

leading directly to the wharf are necessary.”

This guidance applies to all three vessels owned

by New Orleans Paddlewheels, Inc., (the

Queen

of New Orleans

, the

Creole Queen

, and the

Cajun Queen

). In its August 22, 1997, letter, the

Dock Board stated that:

The excursion vessels have aluminum

gangways as a secondary means of

egress in addition to their primary

gangways. The Flamingo (

Queen of

New Orleans

) has such emergency

gangways at all levels. The

Creole

Queen

and the

Cajun Queen

have

secondary emergency gangways and

additional gangways are currently on

order.

According to the Dock Board’s letter, both

the board and the Coast Guard require that

riverboat gaming vessels, excursion vessels,

riverfront commercial properties, and

oceangoing cruise ships prepare their own

emergency response plans and conduct related

training and drills. The Dock Board stated that it

had recently reviewed all such plans.

Status of the Queen of New Orleans

According to documentation received by the

Safety Board on October 22, 1997, the gaming

license of the

Queen of New Orleans

expired on

September 30, 1997, and the vessel was not

expected to resume operations in the Port of

New Orleans. Arrangements were reportedly

underway to have the vessel moved from the

Poydras Street wharf.

General

The following factors were determined not

to have been causal or contributory to the

accident involving the

Bright Field

: weather,

fatigue, malfunctioning of vessel steering gear

or equipment on the bridge, and alcohol or other

drugs. (See “Toxicological Testing” section of

this report for additional information.) The pilot

was properly licensed and certified by the State

of Louisiana and was qualified to serve in his

position. All officers of the

Bright Field

were

properly licensed and certified by the Liberian

government and were qualified to serve in their

positions.

The

Bright Field

was not, nor was it

required to be, equipped with a voyage data

recorder (VDR). (See appendix C.) Had it been

equipped with a fully configured VDR, valuable

information such as the vessel’s exact position,

course, rudder setting, throttle setting, engine

speed, and vessel speed at each point along the

accident track may have been available to

investigators. Such information could have been

used to perform a comprehensive computer

simulation that might have proved helpful in

evaluating engineering and human performance

on the day of the accident.

The major safety issues identified in this

investigation and discussed in this analysis are

the adequacy of the ship’s main engine and

automation systems, the adequacy of emergency

preparedness and evacuation plans for vessels

moored in the Poydras Street wharf area, and the

adequacy of port risk assessment for activities

within the Port of New Orleans. This analysis

also addresses three other issues: the actions of

the pilot and crew during the emergency, the

lack of effective communication (as it relates to

the actions of the pilot and crew aboard the

Bright Field

on the day of the accident), and the

delay in administering toxicological tests to the

vessel crew.

Accident Overview

The event that precipitated this accident, the

sudden and unexpected reduction in engine

power at a critical point in the

Bright Field’

navigation down the Mississippi River, was of

relatively short duration. However, the

combination of vessel speed, vessel direction,

river current, and high river stage left little

margin for error in responding to the emergency.

The

Bright Field

struck the wharf in an area

between two docked vessels, missing one of

them by less than 170 feet and coming to rest

only about 70 feet from the other. Thus, by

sheer chance, an allision with an occupied

passenger, gaming, or excursion vessel—and the

associated high risk of numerous serious

injuries—was barely averted. Even so, patrons

of a popular commercial district were placed in

jeopardy when the

Bright Field

struck portions

of shoreside buildings or undermined their

foundation supports. Had this accident occurred

during the evening, at night, or in the morning

hours, most of the hotel rooms that were

destroyed in the accident would probably have

been occupied. It is unlikely that even the River

Front Alert Network would have been able to

awaken the sleeping guests, alert them to the

danger, and evacuate them in time to prevent

serious injury or possible death.

The significant reduction in the

Bright

Field’

s engine power resulted from low main

engine lubricating oil system pressure and the

nonautomatic starting of the backup (No. 2)

lubricating oil pump. With main engine power

reduced and the ship swinging toward the

Riverwalk, the time and options available to the

pilot and crew to avoid an allision were limited.

The options involved pulling ahead and

maneuvering out of danger, slowing and steering

away, or stopping; however, exercising any of

these options would have required more time,

propulsion power, or steering control than were

available to the

Bright Field

in the moments

before the allision. The Safety Board could

therefore not determine whether the pilot or

crew could have done anything to prevent this

accident. The same constraints on power and

ANALYSIS

control that hindered efforts to prevent the

accident also may have rendered ineffective the

actions that the pilot and crew did take prior to

the allision. Thus, the final rest position of the

Bright Field

may have resulted from the

combined forces of the ship and the river rather

than from the efforts of the pilot or crew. The

substantial role played by chance in this

accident has important implications for

assessing risk in and around the river, as will be

discussed below.

The investigation of this accident revealed a

history of maintenance and operational

problems associated with the main propulsion

engine of the

Bright Field

. These problems were

known to the vessel’s owners, who did not

correct them in a timely fashion. On the open

sea, in good weather, temporary malfunctions in

the vessel’s main engine may be tolerable;

however, in the close quarters of the Mississippi

River, where safe maneuvering is directly

dependent upon a responsive main engine, a loss

of power can, as it did in this instance, present

an immediate threat to other vessels and to

shoreside facilities.

Complicating the emergency created by the

loss of engine power on the

Bright Field

was the

interaction between the river pilot and the ship’s

master and crew on the vessel’s bridge. At

several points prior to and during the

Bright

Field

emergency, the pilot, master, and crew of

the vessel did not exchange important

information about the nature of the emergency

and its potential outcome. In slightly different

circumstances, the limited communication

between the pilot and the ship’s crew could have

compromised the vessel’s ability to recover

from a threatening situation.

Some of the injuries resulting from the

accident were sustained by gaming and

excursion vessel passengers as they attempted to

escape what appeared to be an imminent

allision. The lack of adequate numbers of

readily available egress routes, in addition to the

lack of effective evacuation procedures and

plans aboard the vessel on which numerous

injuries occurred, contributed to the number and

severity of injuries. The lack of advance

warning to the patrons and employees of the

Riverwalk Marketplace also contributed to the

number of injuries.

This accident demonstrates the risk

represented by heavily loaded, (relatively) high-

speed vessels navigating a twisting waterway

bordered both by populated wharves and

mooring areas for passenger vessels. While the

absolute elimination of all risk associated with

this operating environment would be impossible,

in the view of the Safety Board, opportunities

exist to reduce the risk of vessel collisions and

allisions and to reduce the vulnerability of

shoreside facilities.

Engineering Aspects

Main Engine Shutdown and Restart

About 1406 on the day of the accident, as the

Bright Field

was passing under the Crescent

City Connection Bridges, the vessel’s automated

propulsion control system reported low main

engine lubricating oil pressure and main engine

trip (shutdown) due to low lubricating oil

pressure. The chief engineer stated that, when

the alarms sounded, he noted that the lubricating

oil system had depressurized.

The complete shutdown of the main engine

was not immediately apparent to those on the

bridge or in the control room because the

“windmilling” effect as the vessel moved

through the water kept the propeller (and thus

the directly connected engine) turning at about

30 rpm. In fact, the engine probably did not

come to a complete stop before the chief

engineer cleared the fault indication and

restarted the engine. The alarm log printout

indicated that the power reduction was the result

of main engine trip due to low main engine

lubricating oil system pressure.

When Safety Board investigators boarded

the

Bright Field

2 days after the accident, both

the No. 1 and No. 2 lubricating oil pumps were

running. Had the oil pump backup system been

functioning on the day of the accident, and had

it been set to automatic mode, the No. 2 oil

pump would have started automatically when

the system sensed a drop in main engine oil

pressure. The system alarm log printout for that

day, however, did not indicate the automatic

starting of the second pump. Moreover, Safety

Board tests showed that the pressure switch that

would have automatically started the second

pump may have been inoperative on the day of

the accident and therefore would have been

unable to effect the changeover, even with the

No. 2 oil pump set on automatic standby. On the

day of the accident, then, either the automated

propulsion control system was not set up for

automatic starting of the standby lubricating oil

pump or the switch that accomplishes the

changeover failed to respond properly to the

drop in system pressure.

During interviews with Safety Board

investigators, no crewmember acknowledged

manually starting the No. 2 pump; however, the

pump could only have been started either

automatically—which would have been

recorded on the alarm log printout—or

manually. The evidence indicates, therefore, that

a crewmember did, in fact, manually start (by

either turning the switch to auto start or by

initiating a manual start on the pump motor

control panel when the changeover switch

failed) the standby oil pump after the

Bright

Field’

s main engine shut down because of low

lubricating oil pressure. The restoration of

sufficient oil pressure allowed the engine to be

restarted.

Lubricating Oil Pump Operation

Although the main engine lubricating oil system

pressure with the No. 1 lubricating oil pump

running was consistently observed over a period

of several days after the accident to be about 2.3

bar, the exact cause of the low pressure in the

lubricating oil system could not be determined.

Following teardown, cleaning, adjustment, and

reassembly of the No. 1 lubricating oil pump,

the outlet pressures reached the rated pressure of

4 bar. Shortly after the pump was reinstalled, it

again displayed the vibration and noisy

operation that had been noted in earlier

inspections and that had been reported to the

vessel owners by the chief engineer before the

accident. The source of the vibration and noise

could not be determined; however, the No. 1

lubricating oil pump continued to produce rated

pressure.

According to the system monitor printout, at

1400 on the day of the accident, main engine

lubricating oil pressure was 2.64 bar. Although

system pressure was in the acceptable range, it

was critically close to the system’s low-

pressure-alarm level. This slight differential

between the system’s operating pressure and the

alarm/trip pressure settings (2.5/2.3 bar) was

due primarily to the pressure drop across the

second filter, which resulted when contaminants

in the oil clogged the fine mesh screen of the

second filter’s strainers. This determination is

consistent with the repeated second filter high-

differential-pressure alarms recorded during the

December 14 voyage as well as with the results

of testing of the second filter.

At 1406, the pressure had dropped below

2.3, as evidenced by the protection system’s

tripping the main engine off line. Several causes

of this sudden pressure drop were considered,

then discounted, because they would have

produced outcomes that were inconsistent with

information gathered in the investigation. Those

causes include heavy pump cavitation from

aeration of the lubricating oil; failure of the No.

2 oil pump’s discharge stop check valve, which

would have allowed “backflow” of oil through

the No. 2 pump; a faulty pressure relief valve on

the No. 1 pump, which would have allowed oil

to backflow to the suction side of the No. 1

pump; catastrophic failure of the main engine

lubricating oil system’s piping; and manual

intervention.

Several other possible causes of the sudden

drop in lubrication oil system pressure could not

be discounted. These included the vibration and

noise problem in both oil pumps that had been

noted by the chief engineer weeks before the

accident and was never corrected and the

abnormally low level of lubricating oil in the

main engine sump. Incessant pump and piping

vibration could have precipitated a transient air

leak in the fittings associated with the No. 1 oil

pump. Or the No. 1 oil pump may have become

airbound after pulling in air through the oil

sump suction pipe inlet because of the low level

of oil in the sump. Either condition would have

allowed air to be drawn into the suction side of

the pump, resulting in the rapid oil system

depressurization observed by the chief engineer.

In such an event, unless the standby pump is

started immediately, the depressurization can

result in engine trip; as previously noted, the

No. 2 pump was either not on automatic

standby, or the automatic switching mechanism

failed to operate on the day of the accident.

General Condition of the Bright Field’s

Engineering Plant

-- Safety Board

investigators’ examination of the engineering

plant and maintenance records for the

Bright

Field

revealed, as noted earlier, engine

lubricating oil that was not within the allowable

specifications of the oil supplier or engine

designer, excessive differential pressure across

the second oil filter, and uncorrected vibration

and noise from both main engine lubricating oil

pumps. Among other deficiencies identified

were marginal lubricating oil sump level,

incorrectly calibrated sensing devices, reuse of

worn parts, and numerous other problems

associated with the main engine and various

auxiliary systems/machinery. While many of the

deficiencies noted by the New Sulzer Diesel

technician and chief engineer were corrected

before the December 14 voyage, the vessel

sailed with several significant engineering

problems uncorrected.

A review of the vessel’s records dating back

to January 1996 revealed that the engineering

crew responded to recurring engineering failures

with repairs that were sufficient to keep the

vessel operating most of the time. However, the

crew apparently was not able to make

permanent repairs to the vessel’s main engine

and associated engineering systems; as a result,

these problems became a continuing source of

voyage disruptions. In the 3 months prior to the

accident, the

Bright Field

added about 1 month

to its schedule due to delays attributed to

engineering problems.

The crew was not required to use the

automated propulsion control test procedures

that were delivered with the vessel in 1988 or to

periodically test the functional operability of the

automated propulsion control system. The

engineering plant on the

Bright Field

was

equipped with a number of safety devices, and

the chief electrician submitted a report

concerning the status of these devices to the

vessel’s owners quarterly. But the report was

based only on a survey of alarms and sensors.

No one regularly performed operational testing

and maintenance of safety control devices such

as the oil pressure switch that was supposed to

start the standby oil pump in case of a drop in

main engine lubricating oil pressure.

While the

Bright Field’

s owners provided

each vessel in their fleet with general

requirements for periodic testing and

maintenance of the main engine, including

regular analysis of the main engine lubricating

oil, Safety Board investigators determined that

critical main engine components were run until

failure occurred and that periodic preventive

maintenance was not routinely accomplished.

The Safety Board concludes that the

Bright

Field

showed evidence of recurring engineering

problems that affected vessel main engine

reliability, and had all engineering systems been

kept in good repair and regularly tested, the

vessel may not have unexpectedly lost power

during its voyage down the Mississippi River.

The Safety Board believes that Clearsky

Shipping Company should perform a baseline

engineering assessment of the

Bright Field’

engineering plant and correct all conditions not

in conformance with manufacturer’s

specifications.

Vessel Owner’s Oversight of the Bright

Field’s Engineering Plant

-- The

Bright Field’

owners, Clearsky Shipping Company, received

regular engineering and maintenance reports on

the

Bright Field

and thus had knowledge of the

vessel’s engineering problems. Serious

engineering problems were reported to the

owners as early as January 1996. In addition to

reports from the engineering crew, the owners

had received periodic telexes from the master

documenting the severity of engineering

problems, delays in scheduling resulting from

the engineering problems, and the inability of

the engineering crew to make permanent repairs.

The Safety Board acknowledges that, on at least

one occasion in 1996, the

Bright Field’

owners’ representatives visited the vessel

because of concerns about the operation of the

engineering plant. The owners also replaced the

Bright Field’

s chief engineer when the vessel

arrived in New Orleans on November 21

because, they said, the engineer had been

unresponsive to the owners’ orders. The

documented problems with the

Bright Field’

engineering plant, however, existed at least as

early as 1995, which predated the arrival on

board of the previous chief engineer. These

engineering deficiencies are indicative of long-

term, recurring problems that cannot be tied to

the competence or job performance of a single

individual.

The Safety Board concludes that the

Bright

Field

owners’ oversight of testing and

maintenance of the vessel’s engineering systems

was inadequate and led to unreliable

performance of the engineering plant and

contributed to the shutdown of the main

propulsion engine on the day of the accident.

The Safety Board believes that Clearsky

Shipping Company should institute an

engineering testing, maintenance, repair, and

company oversight program for the

Bright Field

that will ensure safe and reliable operation of

the vessel’s engineering plant.

Communication

Quite by chance, the

Bright Field

came to

rest between two docked ships in a space not

significantly larger than the ship itself. While

the actions of the pilot and crew during the

emergency may have been reasonable, their

actions were not well coordinated. Because a

computer simulation of the accident scenario

was inconclusive, the Safety Board could not

determine how changes in the nature or timing

of the crew’s actions may have affected the

outcome. The Safety Board therefore concludes

that insufficient information was available to

determine whether any actions taken by the pilot

and crew of the

Bright Field

would have been

effective in preventing the allision or mitigating

its effects. The Safety Board also concludes,

however, that at several points prior to and

during the

Bright Field

emergency, the pilot,

master, and crew of the vessel did not exchange

information that under other circumstances

could have prevented or at least mitigated the

effects of the accident.

In the view of the Safety Board, the

performance of the

Bright Field

pilot and crew

could have benefited from effective application

of the principles of BRM, which entails

effective use of all available resources to

achieve safe operations. The Safety Board has

long supported mariners’ use of BRM

techniques and has advocated professional

training in BRM.

Underlying effective BRM is an

understanding that every officer, crewmember,

and pilot on board a vessel is responsible for

acting and for using resources in close

coordination with others on the watch. The

master, pilot, and conning officer use leadership

skills and command authority to integrate the

resources for any given passage or watch. At the

same time, they must convey their receptivity to

operating information that originates with

subordinates. The role of those on the watch is

to perform their assigned tasks responsibly, to

know about or participate in determining the

plans for navigation of the vessel, to be alert to

departures from plans or from the expected

performance of others, and to make those

discrepancies known in time to avert an

operational error. The practice of BRM by pilots

and crew can be handicapped by intercultural or

language differences, but these can often be

overcome by deliberate and clear

master/pilot/crew briefings.

Master-Pilot Briefing at the Anchorage

The pilot of the

Bright Field

did not advise the

master of his plans for making the river transit,

including the fact that he intended to operate the

ship at sea speed. Had the pilot offered, or had

the master requested, information on the transit

plans, not only would both men, as well as the

bridge crew, have known when and where to

expect various actions, but the flow of

information could have enhanced coordination

and confidence between the pilot, master, and

crew.

If, for example, the master had asked, or the

pilot had offered, information on the pilot’s

intended transit speed, that issue could have

been discussed, and together they could have

evaluated the operational consequences of

proceeding at sea speed. Navigational situations

can develop at any time for which an increase in

speed (to improve rudder control or avoid

collision) is a viable option, but, when a ship is

already operating at top speed, that option is no

longer available. If the pilot and master had

discussed the intended speed, they could have

reached a consensus on the best way to operate.

Although a discussion of intended actions

can take place at any time during a transit,

predeparture discussions generally provide the

greatest latitude in both time and options. A

predeparture discussion also avoids some of the

practical logistical problems (related to

obtaining another pilot) that could arise if a

serious disagreement occurs between a master

and a pilot once a trip begins. Thus, discussing

and agreeing on transit plans before getting

underway is more efficient.

A transit plan should include intended

speeds, areas of high risk due to traffic

concentration, shoreside structures, or river flow

characteristics, and actions to be taken in the

event of various ship power or control

difficulties. According to their statements, each

man felt confident of his own abilities and

assumed that the other was qualified to perform

any duties that might be required. The lack of

discussions between the master and pilot

regarding emergency maneuvering procedures

did not cause this accident. Still, if the actions to

be taken in an emergency had been established,

cooperation and coordination in the emergency

that developed would probably have been

enhanced, tasks could have been clearly

delineated, and orders (such as the order to drop

anchor) could perhaps have been given and

complied with more quickly.

While the pilot was not forthcoming with

information about his transit plans, the master

did not tell the pilot of the inability to start the

main engine from the bridge either at 1055 or

when the same difficulty was encountered at

1110. In each case, engine control had to be

transferred to the engine control room and back,

but this information was not made known to the

pilot. Had the pilot been made aware of the

situation, he and the master could have

discussed options, including the location of

engine control (control room or wheelhouse) or

use of tug escorts. If the pilot and master could

not agree, the pilot could have refused to get

underway from the anchorage.

Language Differences

-- Even though the

ship’s master and crew were Chinese and spoke

their native language among themselves,

interchanges between the crew and the pilot

took place in English. The language difference

between the pilot and the crew does not appear

to have been a significant impediment to

communications on the bridge.

The fact that the crew spoke Chinese among

themselves, however, eliminated an adjunct

source of information for the pilot. For example,

because conversations between master and crew

were in Chinese, the pilot was not aware of the

engine starting difficulties, the content of the

second mate’s conversation with the chief

engineer, or the master’s order to drop the

anchor. Of course, critical operational

information should be clearly stated, and no

operations should depend exclusively on

overhearing a conversation. But the language

differences on the bridge, combined with the

fact that the ship was sailing in restricted waters,

made it even more important that the master and

crew convey all operations-related information

to the pilot. If the master and crew did not take

this initiative, then the pilot should have

specifically requested that he be kept informed

of all activities and conversations on the bridge

affecting vessel operation. Such ongoing

communication did not occur on the bridge of

the

Bright Field

Information Exchange During the

Emergency

-- If more information had been

exchanged during the brief period after power

reduction and before the allision, the actions of

the pilot and crew could have been better

coordinated and perhaps more timely. Even

though the eventual outcome would probably

have been the same in this case, in different

circumstances, more effective communication

could have helped avoid or mitigate an accident.

When the pilot noticed the cessation of

vibration in the vessel, he asked if there was a

problem. Even though he stated that neither the

master nor the mate responded, he did not ask a

second time. By not following up and

attempting to determine the exact nature of the

problem, the pilot denied himself information

that may have influenced the nature or the

timing of his navigational decisions and orders.

When the pilot realized that the vessel had,

in fact, lost power, he again did not converse

with the master or mate. Consequently, he was

unaware of what they were doing or could do to

address the problem. Although the master and

the mate were attempting to restore engine rpm,

they did not tell the pilot of their actions.

A limited information exchange took place

among the master, second mate, and chief

engineer. The master instructed the second mate

to call the engine control room and demand an

immediate increase in speed. The second mate

complied. In response, the chief engineer said he

understood what had happened (a sudden drop

in the pressure of the lubricating oil pump), but

not why it happened, and told the second mate

so. He also told the second mate the

pressurization problem had already been solved

by the No. 2 pump coming on line. He then

asked if the second mate wanted to switch

engine control from the bridge to the engine

control room. The second mate said yes, and the

transfer of control began.

During the postaccident investigation, the

master explained why engine control was

transferred. He said it was standard procedure to

give the engineroom control whenever a

problem occurred that involved the engine, and

that under normal circumstances, the engine rpm

could be brought up more quickly from the

engineroom. Following this normal procedure

would seem to make sense, since the master

acknowledged that he did not know the nature of

the problem that caused the rpm reduction.

However, the transfer of control takes 20 to 30

seconds and must be completed before engine

speed can begin to be restored.

In this case, since the pressurization

problem had already been corrected, the rpm

could have been restored from the bridge as

quickly as from the engineroom. If that had been

done, the transfer time could have been saved.

However, the second mate apparently did not

recognize the implication of the chief engineer’s

comment, which was that the second engineer

could increase rpm himself. So when the chief

engineer asked if engine control should be

transferred, the second mate agreed. The second

mate was quite likely simply following the

master’s order to have “them” (the chief

engineer and his staff) increase speed. If the

chief engineer had supplied information to the

bridge about the time necessary for him to

assume control and restore engine rpm, this

information may have altered the nature and

timing of the master’s and pilot’s orders.

The second mate also did not immediately

pass on the information about the lubricating oil

repressurization to the master. If he had, the

master may have recognized his option to

increase rpm from the bridge, and the normal

practice of sending engine control to the engine

control room in the event of engine-related

problems may not have been followed, thereby

saving the control transfer time. Likewise, if the

second mate had given the chief engineer

additional information about the direction in

which the ship was headed, the chief engineer

could have made a more informed decision

concerning the options for increasing rpm, such

as activating the crash maneuvering feature or

perhaps not transferring engine control to the

engine control room. After the accident, the

master testified that the engineering crew was

not made aware of the emergency situation until

the allision was unavoidable.

Had the above additional information been

supplied during these exchanges, it may not

have altered the outcome. Nevertheless,

additional information should have been

exchanged to facilitate decisions.

Another information exchange between the

pilot and master affected the order to drop

anchor. During the accident sequence, the pilot

first ordered the master to have someone stand

by the anchors and, later, to drop the anchors.

The orders were heard and understood by the

master, though the pilot was unaware of that

because the master did not acknowledge either

order. The master attempted to carry out the

order to drop anchor, but his radio

communications with the carpenter at the bow

were impeded by the sound of the ship’s

whistle. The master did not tell the pilot of the

communication problem created by the whistle;

instead, he went out to the bridge wing and tried

to attract the carpenter’s attention by waving his

arms. When this effort failed, the master tried

the radio again, finally establishing intermittent

contact. He still did not tell the pilot of his

difficulties.

In the meantime, the pilot did not realize

that he was preventing his own order from being

carried out by continuing to sound the ship’s

whistle. Transmission of the order was delayed

so long that when the master finally reached the

carpenter on the radio, he deemed dropping the

anchor to be an inappropriate order and

countermanded it. By the time the master

decided to drop the anchor, the carpenter could

make only a brief effort to carry out the order

before having to flee to escape injury in the

imminent allision. As a result, and as confirmed

by an amateur video of the accident, the anchor

was not dropped before the

Bright Field

struck

the wharf.

The fact that the pilot issued the order to

drop anchor indicates that he believed that some

value, however small, could be gained by

dropping one or both anchors. Had he not

believed that dropping anchors could mitigate

the emergency, he was obligated to relay that

information to the master so the carpenter could

be told to abandon the anchor watch and remove

himself to a safer position. Yet the pilot made

no real effort to determine if his order had been

carried out, even when he saw the master go to

the bridge wing and wave his arms. If he did not

recognize that effort as an attempt to

communicate with the anchor watch, he should

have inquired about the meaning of the master’s

unusual actions at such a critical time.

The lack of information exchange and

feedback on the part of the master is also

notable. For example, he did not tell the pilot

that he had countermanded the drop-anchor

order, only to reissue it a little later. Earlier in

the accident sequence, he did not ensure that the

pilot was fully aware of the actions he was

taking to restore engine rpm. While the pilot

could have inferred the master’s actions from

the rpm indicator, the master should have

removed any ambiguity by advising the pilot of

what he was doing at all times. Likewise the

master could have given the pilot an estimate of

the time it might take to restore engine power. If

he did not know the amount of time needed, he

could have asked the chief engineer. The pilot

could have used each of these pieces of

information as he determined which orders to

issue at what time.

The need to exchange information and

ensure that orders are heard, understood, and

carried out is basic to the operation of any

vessel. These needs are not new and have long

been familiar to mariners; however, they have in

recent years been formalized as central elements

of BRM. The Safety Board concludes that use of

BRM precepts on board the

Bright Field

would

have enhanced the exchange of information and

the coordination of actions among the pilot,

master, and crew during the accident sequence.

The Safety Board has issued several

recommendations concerning BRM since 1991.

Due in part to those recommendations and the

efforts of the Coast Guard, the International

Maritime Organization (IMO) has issued

amendments to its Standards of Training,

Certification and Watchkeeping that

incorporate BRM training for watch officers

effective February 1, 1997. A 5-year phase-in

period (from February 1, 1997) to certify

licensed watch officers will follow. Signatory

countries are to have plans for such training

programs in place by February 1, 1998. All

signatory countries, including the United States

and Liberia (flag of the

Bright Field

), will

require officers of vessels such as the

Bright

Field

to have BRM training. Pilots will not be

subject to the same training unless they hold a

Coast Guard license.

Training in BRM typically includes five

generic categories of knowledge and skill

development: (1) the development and perform-

ance of watch or pilot briefings; (2)

maintenance of situational awareness; (3) identi-

fication of error chains (and error trapping); (4)

implementation of effective bridge/vessel com-

munication; and (5) integration (coordination)

of bridge/vessel resources. In whole or in part,

most of theses elements were missing during the

Bright Field’

s December 14, 1996, voyage.

The Safety Board believes that NOBRA

should encourage its members to participate in

initial and recurrent BRM training that

emphasizes team coordination between the pilot

and crew. The Safety Board further believes that

Clearsky Shipping Company should provide its

bridge and engineroom watchstanding officers

and crewmembers with initial and recurrent

BRM training that includes communication and

coordination between pilots and members of the

bridge and engineroom watches and that

addresses their use of bridge and engineroom

systems.

Emergency Response

After the allision, rescue efforts were

initiated at once, and emergency units were

ordered. The harbor police dispatcher notified

the city of New Orleans Fire, Police, and Health

and Emergency Services Departments. More

than 25 agencies responded; fire, police, and

emergency medical service units arrived on

scene within minutes. After being contacted by

the Gretna light operator, the Coast Guard began

an immediate search and rescue response. In

addition to providing assistance through

multiple city agencies, the city of New Orleans

contacted the Louisiana Office of Emergency

Preparedness to provide notification and request

standby for possible assistance.

Passengers aboard the cruise ships and the

gaming and excursion vessels, as well as several

Riverwalk Marketplace patrons, in response to

Safety Board questionnaires recalled the

emergency response as prompt and efficient.

Although initial access to the area was hindered

by damage occurring when the

Bright Field

struck the wharf, the emergency responders

were able to locate and use an acceptable

alternate route to respond to the incident, assist

the injured, and provide crowd control. The

Safety Board concludes that the response to the

Bright Field

accident by local emergency

response agencies was timely and appropriate.

Vessel Emergency Preparedness and

Evacuation Plans

Four vessels were docked alongside the

wharf in the area of the

Bright Field

accident:

the

Enchanted Isle

, the

Nieuw Amsterdam

, the

Queen of New Orleans

, and the

Creole Queen

In the view of the Safety Board, the actions of

the captains and crews aboard the cruise ships

Enchanted Isle

and

Nieuw Amsterdam

in the

moments preceding the allision were adequate

for the circumstances. An emergency evacuation

was not attempted because of the limited

amount of time that elapsed from the first

awareness of the emergency until the

Bright

Field

passed clear of the two vessels.

Vessel Evacuation

-- According to Safety

Board surveys of passengers, when the first

mate of the

Queen of New Orleans

made the

initial evacuation announcement, some

passengers did not respond immediately. When

a second announcement was made ordering the

immediate evacuation of the vessel, passengers

and nonoperating crewmembers began running

toward the gangway. About this time, the

Bright

Field

struck the wharf and was continuing to

move toward the bow of the

Queen of New

Orleans

. Even though the bow wave from the

Bright Field’

s approach destabilized the second

deck gangway of the

Queen of New Orleans

several times during the evacuation process,

passengers were not provided with an

alternative means of access to the dock.

According to the

Queen of New Orleans

’

Emergency Evacuation Plan for Moored

Conditions

, the vessel can be exited only from

the bow section of the second deck. The plan

states that to evacuate the vessel in an

emergency, every passenger is to be directed to

this gangway. The owner of the vessel noted

that three portable emergency gangways, which

are designed to be used in the event the main

gangway is inoperable, were aboard the vessel.

The vessel’s emergency evacuation plan,

however, does not refer to these portable

gangways, or provide instructions on how to

make them operable in an emergency, or give

guidance for directing passengers to them. The

evacuation plan also does not take into account

the time needed to alert the crew to take action

or for crewmembers to stage the portable

gangways and ensure their safe operation.

Because the emergency gangways were not used

during the

Bright Field

accident, the only exit

available was the second deck bow gangway.

New Orleans Paddlewheels, Inc., provided

security camera videotapes that show areas of

the vessel being evacuated in what company

officials call “a calm and orderly evacuation.”

The Safety Board did not see, on these tapes,

any passengers sustaining injuries during the

evacuation. Nonetheless, some passengers were

injured, as documented by medical records.

While the Safety Board recognizes that the

number of questionnaire responses was small

relative to the number of passengers aboard the

vessel, the responses are nevertheless

meaningful and illustrate the panic induced

when the crowd was confronted with no means

of escape from a vessel directly threatened by an

oncoming freighter. Furthermore, had the vessel

been filled to its capacity of 1,800 passengers

and crewmembers, the number of persons

unable to evacuate in time could have been

significantly higher. The ensuing panic most

likely would have been more hazardous,

possibly resulting in a higher number of, and

more severe, injuries. The Safety Board

concludes that evacuation of the

Queen of New

Orleans

was hampered, and passenger risk

increased, by the fact that only one gangway

was made available for passenger egress during

the emergency.

The

Creole Queen

, a New Orleans

Paddlewheels, Inc., excursion vessel with a

capacity of 1,000 passengers and crew, was

docked astern of the

Queen of New Orleans

. At

the time of the accident, 190 passengers and

crewmembers were aboard. Following the

master’s instructions to evacuate, passengers

exited the vessel across a single dockside

gangway. When the bow wave from the

Bright

Field

passed the

Creole Queen

, the gangway

dropped from the side of the vessel, and three

passengers on the gangway fell into the river.

One passenger was seriously injured; the other

two sustained minor injuries. By this time,

approximately one half of the

Creole Queen

’s

passengers had been evacuated. The remaining

passengers could not exit the vessel until the

gangway was repositioned.

The Safety Board acknowledges the efforts

of the senior officers of both vessels to evacuate

a large number of passengers. Even so, if the

36,000-ton

Bright Field

had struck the

Queen of

New Orleans

, the remaining passengers still on

board the gaming vessel, regardless of the exact

number, would have been in grave danger.

The Safety Board believes that New Orleans

Paddlewheels, Inc., must make better provisions

for all its vessels in the event of an impending

allision or other emergency. Consequently, the

Safety Board issued the following safety rec-

ommendations to New Orleans Paddlewheels,

Inc., on September 5, 1997:

Work with the U.S. Coast Guard to

review the

Emergency Evacuation Plan

for Moored Conditions

of the

Queen of

New Orleans

and amend it regarding

current evacuation procedures and the

number of immediately accessible

gangways and disembarkation locations,

to ensure timely and orderly exiting of

passengers in the event of emergency

evacuation. (M-97-62)

Work with the U.S. Coast Guard to

develop and implement procedures for

evacuation under moored or docked

conditions for all your excursion vessels

to ensure that passengers can exit each

vessel in a timely and orderly manner

should an emergency evacuation be

necessary. (M-97-63)

In a September 29, 1997, letter to the Safety

Board, New Orleans Paddlewheels, Inc., replied

that its emergency evacuation plan for the

Queen of New Orleans

in moored conditions

addresses the evacuation of all areas on

board the vessel. We purposely did not

include portable gangways because they

are to be used only when the primary

evacuation gangway is inoperable. Our

deck crew is regularly trained and

drilled on how to use these portable

gangways in multiple locations.

Portable gangways were not used in this

emergency. The Safety Board is concerned that

the evacuation plan for the

Queen of New

Orleans

does not provide a readily available

additional means of escape that does not require

staging in an emergency. The Safety Board’s

intent in issuing Safety Recommendation M-97-

62 was to prompt New Orleans Paddlewheels,

Inc., to amend the

Queen of New Orleans

’s

Evacuation Plan for Moored Conditions

not

only to enhance evacuation procedures, but also

to address the need to provide for more than one

immediately accessible disembarkation location

to ensure a timely and orderly exiting of

passengers.

Further, although the September 29 letter

states that the deck crew is trained and drilled

on use of the portable gangways, the letter does

not address the training of the nonoperating

crewmembers, who are responsible for assisting

passengers to the egress areas of the vessel

during emergencies. The

Evacuation Plan for

Moored Conditions

provides no guidance on the

use of portable gangways to the numerous

nonoperating crew on board the vessel who are

responsible for directing passengers and

assisting their escape. Moreover, the specific

plan to which all crewmembers are to look for

guidance in responding to emergency situations

does not provide any information on these

gangways or how to guide passengers to them.

Based on the failure of New Orleans

Paddlewheels, Inc., to effectively address these

concerns, the Safety Board classifies Safety

Recommendation M-97-62 “Closed--

Unacceptable Action.” New Orleans

Paddlewheels, Inc., has not responded to Safety

Recommendation M-97-63 concerning the

development of evacuation procedures for

moored or docked conditions for all its

excursion vessels. Therefore, Safety

Recommendation M-97-63 remains classified

“Open--Await Response.”

The Safety Board, also on September 5,

1997, issued the following safety recommenda-

tion to the Coast Guard:

Work with New Orleans Paddlewheels,

Inc., to review and amend the

Emer-

gency Evacuation Plan for Moored

Conditions

of the

Queen of New

Orleans

regarding current evacuation

procedures and the number of immedi-

ately accessible gangways and

disembarkation locations, and to

develop and implement procedures for

evacuation under moored or docked

conditions for all New Orleans Paddle-

wheels, Inc., excursion vessels to ensure

that passengers can exit each vessel in a

timely and orderly manner should an

emergency evacuation be necessary.

(M-97-59)

In a November 18, 1997, letter, the Coast

Guard responded that the New Orleans COTP

had already required a review of evacuation

procedures for all high-capacity gaming vessels,

but that the Coast Guard believes this safety

recommendation should be expanded to cover

all passenger vessels operating in the

Mississippi River in the New Orleans area. The

letter stated the Coast Guard’s belief that,

It would be prudent to develop

reasonable, practical and appropriate

evacuation criteria for the different

types of passenger vessels based upon

their type, configuration, passenger and

crew capacity, and the extent which

passengers are normally aboard the

vessel while dockside. To this end, we

have discussed the expansion of this

recommendation with Captain of the

Port New Orleans and will require

further review and development of this

initiative.

The Safety Board is pleased that the Coast

Guard has not only addressed the specific intent

of Safety Recommendation M-97-59 regarding

the

Queen of New Orleans

, but has also

expanded the scope of the recommendation to

cover all high-capacity passenger vessels

operating within the Port of New Orleans. While

the Coast Guard response does not specifically

address evacuation plans for New Orleans

Paddlewheels excursion vessels, the Safety

Board notes that these vessels will be covered

by the evacuation criteria the Coast Guard plans

to develop for all passenger vessels operating in

the New Orleans area of the Mississippi River.

Pending further information from the Coast

Guard regarding the proposed review of

evacuation plans for such vessels, and

specifically those vessels belonging to New

Orleans Paddlewheels, Inc., the Safety Board

classifies Safety Recommendation M-97-59

“Open--Acceptable Response.”

Emergency Drills

-- The company

operating manuals and station bills for both the

Queen of New Orleans

and the

Creole Queen

clearly stated that nonoperating crewmembers

were responsible for distributing life jackets,

keeping order in the stairways and passageways,

and controlling the movement of passengers to

ensure their safety. During the

Bright Field

emergency, however, several nonoperating

crewmembers experienced difficulty in

performing their duties. For example, when the

first mate directed the crewmembers to go to

their mooring stations during the evacuation of

the

Queen of New Orleans

, the vessel’s director

of security did not understand or appreciate the

implications of this announcement. Also,

nonoperating crewmembers did not distribute

life jackets to passengers aboard the

Creole

Queen

during the emergency.

Drills held aboard the

Queen of New

Orleans

had not simulated an evacuation while

moored. Moreover, the drills and training

sessions that were held involved only

supervisory gaming staff, who were expected to

inform other gaming staff crewmembers of their

content. No formal methods were used to verify

whether the nonoperating crewmembers were

advised of the content of the safety meetings or

the nature of drills performed. Unless it requires

accountability for the flow of safety information

from supervisory gaming staff to the rest of the

nonoperating staff, management cannot ensure

that the latter receive safety information that

could be critical in an emergency. The Safety

Board concludes that nonoperating crewmem-

bers of the

Queen of New Orleans

and the

Creole Queen

had not received training covering

the full range of emergency scenarios and were

unprepared to properly carry out their

responsibilities in this accident.

As a result of its investigation of a 1994 fire

aboard the small passenger vessel

Argo

Commodore

the Safety Board issued the

following recommendation to the Passenger

Vessel Association (PVA):

Develop and provide to your members

crew drills for on-board crew emer-

gency procedures/standards that include

preincident planning for a variety of

shipboard emergencies, including fires,

and the deployment of crew resources

for proper response to the emergency

without compromising passenger safety.

(M-95-43)

This recommendation was later placed on

the Safety Board’s list of Most Wanted Safety

Improvements. In 1997, the PVA made available

to the Safety Board its recently published

Training Manual for Passenger Vessel Safety

which incorporates a “Non-marine Crew Train-

ing” section that outlines a comprehensive

training program for nonoperating crewmem-

bers. The introduction to this section states that

specialized safety training for nonoperating

employees “makes sense when management

realizes that, more often than not, [these

employees] will be the first person[s] on the

scene in any kind of emergency.”

Based on the PVA’s support for the concept

of comprehensive training for nonoperating

employees and its development of the training

manual, the Safety Board classified Safety

Recommendation M-95-43 “Closed--Acceptable

Action.” The Safety Board notes that New

Orleans Paddlewheels, Inc., which is a PVA

member, has apparently not yet implemented

the training program for nonoperating

crewmembers set forth by the PVA in its

training manual. The Safety Board believes that

New Orleans Paddlewheels, Inc., should, in

Marine Accident Report--

Fire Aboard U.S. Small

Passenger Vessel

Argo Commodore

in San Francisco Bay,

California, December 3, 1994 (

NTSB/MAR-95/03).

accordance with the guidance published by the

PVA, require that nonoperating crewmembers

on all its vessels participate in formal

emergency training and drills in the proper

handling of emergencies that have the potential

to affect the persons in their charge. The

company should also maintain written records to

verify nonoperating crew proficiency levels and

skill retention.

Safety Briefings and Signage

-- According

to the vessel master, when the

Queen of New

Orleans

was to remain moored, he did not make

any safety announcements because he believed

the vessel was an extension of the dock when

not underway. The

Queen of New Orleans

broadcast a vessel safety videotape throughout

the vessel’s queuing area; however, a significant

number of passengers on board the vessel on the

day of the accident, some of whom had been on

the vessel several times before, did not recall

ever having seen or heard the safety broadcast.

Because the scheduled cruise had been canceled

owing to the high river stage, no safety briefings

were provided prior to the

Bright Field

accident.

However, the master stated that he had

instructed the engineer to start the engines to

prepare for leaving the dock to avoid being

struck by the

Bright Field

. Had the vessel left

the dock, the master probably would not have

had time to provide passengers with such basic

instructions as the location of life jackets.

The Safety Board concludes that the lack of

effective recurring safety briefings for

occupants of the

Queen of New Orleans

regarding emergency and evacuation procedures

may have contributed to the confusion and panic

reported among passengers and crew during the

vessel evacuation. The Safety Board believes

that New Orleans Paddlewheels, Inc., should

review the existing methods of providing safety

information to boarding passengers and make

the necessary improvements to ensure that all

vessel occupants receive recurring safety

briefings, regardless of whether the vessel is

scheduled to leave the dock.

Emergency instruction placards and sign

aboard the

Queen of New Orleans

were not

conspicuously displayed and were not readily

visible during the emergency. The safety

instructions, printed on plain white paper with

clear laminate, were subject to destruction in an

emergency such as that involving fire.

Moreover, the paper on which the instructions

were printed was similar to the color of the

walls upon which they were affixed, negating

their effectiveness in an emergency

characterized by haste, panic, or reduced

visibility. According to a number of the vessel’s

passengers on the day of the accident, they did

not see emergency instruction signage or egress

diagrams.

The Safety Board concludes that the

instruction placards and signage aboard the

Queen of New Orleans

were ineffective in

disseminating emergency instructions and vessel

information to passengers. The Safety Board

therefore believes that New Orleans

Paddlewheels, Inc., should post, on all its

vessels, emergency instructions that are printed

on fire- and heat-resistant material and that are

clearly visible to all passengers both under

normal conditions and during emergencies when

lighting and visibility may be diminished.

Shoreside Emergency Alert and

Response

-- Under River Front Alert Network

procedures established after this accident,

individual riverfront commercial properties

were to make their own determinations about

the proper actions to be taken after receiving

notification of an emergency involving a vessel

on the river. According to evacuation plans that

were initially in effect for property tenants, a

lengthy procedural chain of command was in

place that could delay a decision to evacuate. In

the view of the Safety Board, such a potential

for delay could endanger the employees and

patrons of riverfront properties. Therefore, on

September 5, 1997, the Safety Board issued the

following safety recommendation to the New

Orleans Dock Board:

Develop, as part of the River Front Alert

Network, an emergency evacuation

announcement for broadcast by the

harbor police department dispatcher

using a public address system linked to

river front properties that provides for a

timely and efficient evacuation in the

event of an impending collision or other

emergency. (M-97-60)

Documentation received by the Safety

Board on November 3, 1997, outlining the

actions to be taken in the event of the activation

of the River Front Alert Network appears to

address the Safety Board concerns that

prompted the issuance of Safety

Recommendation M-97-60. Under the specific

evacuation protocols developed for responding

to the activation of the River Front Alert

Network, the procedural chains of command

within each property’s evacuation plans have

been eliminated, and property security officers

have been given authority to initiate an

evacuation immediately upon hearing a River

Front Alert Network broadcast and assessing the

danger. Because these revised evacuation plans

meet the intent of the safety recommendation,

the Safety Board classifies Safety

Recommendation M-97-60 “Closed--Acceptable

Action.”

The River Front Alert Network system did

not require that vessels docked or moored in its

vicinity monitor the alert broadcast from the

Coast Guard traffic light operator to the harbor

police dispatcher indicating a vessel irregularity

or loss of steering in the vicinity of the

riverfront properties. The Safety Board was

concerned that, unless these vessels monitored

the network for emergency broadcasts, vessel

occupants would be subject to delays in

notification similar to those that occurred in this

accident and that contributed to the disorderly

evacuation and numerous injuries. Therefore, on

September 5, 1997, the Safety Board issued the

following safety recommendation to the New

Orleans Dock Board:

Require all vessels which dock or moor

in the area encompassed by the River

Front Alert Network to monitor the

River Front Alert Network radio for any

emergency broadcast to provide maxi-

mum advance notice of an emergency.

(M-97-61)

In a September 15, 1997, reply to the Safety

Board, the Dock Board said that the intent of

this safety recommendation should be met by

the postaccident COTP order requiring that all

large passenger vessels docked in the area have

a manned pilothouse and that they monitor all

emergency and working marine channels. While

agreeing that monitoring working and

emergency radio channels should give moored

passenger vessels advance warning of

potentially hazardous situations on the river, the

Safety Board noted that the COTP order

requiring such monitoring was an interim, and

possibly temporary, measure. The Coast Guard

has since published an interim rule that, when

issued as a final rule, will make permanent the

COTP order. In anticipation that the interim rule

regarding manned pilothouses and radio

monitoring will become permanent as 33 CFR

165.810(e), the Safety Board classifies Safety

Recommendation M-97-61 “Closed--No Longer

Applicable.”

Also on September 5, 1997, the Safety

Board issued the following safety recommenda-

tion to the Coast Guard:

Require that all commercial vessels that

operate within the River Front Alert

Network zone participate in the network

and notify the U.S. Coast Guard traffic

light operator whenever they experience

an irregularity or abnormality that could

result in a safety risk to the Port of New

Orleans area. (M-97-58)

In its November 18, 1997, letter to the

Safety Board, the Coast Guard stated that

existing regulations and local marine practice

are now serving to meet the intent of this safety

recommendation. The letter stated that,

[Title] 33 CFR 160.215 requires vessels

to immediately notify the nearest

Marine Safety Office or Group of

hazardous conditions aboard or caused

by the vessel. Currently, the vessels in

the vicinity of the traffic light notify the

traffic light operator who is responsible

to the Marine Safety Office. Through 33

CFR 26.03 or existing Captain of the

Port orders, ALL vessels, including

moored passenger vessels, must monitor

Channel 67 VHF. Therefore, when a

hazardous condition is reported to the

traffic light operator, he activates the

Riverfront Alert Network by calling the

Harbor Police on the Network radio.

The police then notify the impacted

participating facilities and vessels.

Between the Channel 67 notifications

and subsequent Riverfront Alert

Network radio calls, ALL vessels and

facilities are notified.

Based on this response, the Safety Board

classifies Safety Recommendation M-97-58

“Closed--Acceptable Action.”

Toxicological Testing

Two Coast Guard regulations (33 CFR Part

95 and 46 CFR Part 4) require that postaccident

alcohol tests be conducted on the pilot and

Bright Field

crewmembers directly involved in

this accident. Those regulations specify that

marine employers or their representatives are to

ensure that urine specimens (for drug testing)

and breath or blood specimens (for alcohol

testing) are obtained as soon as is practicable

following an accident.

In this case, the self-employed pilot supplied

both breath and urine specimens in a timely

manner. His specimens were negative for

alcohol and drugs.

Bright Field

crewmembers

also supplied breath and urine specimens, and

the results were negative.

The Safety Board is

concerned, however, that breath testing, which

is a time-sensitive procedure, was not conducted

in a timely fashion on some

Bright Field

personnel and, in fact, was conducted too late to

have any practical value. Because of the rate at

which humans metabolize alcohol,

evidence of

alcohol consumption is usually eliminated from

the body in about 8 hours. For example, an

individual could be legally intoxicated (0.10

percent BAC) at the time of an accident and

have a 0.00 percent BAC about 8 hours later.

Consequently, to produce meaningful results,

testing should occur within that time span.

In this case, tests of the master, chief

engineer, and helmsman were conducted

between 7 hours and 57 minutes and 8 hours and

30 minutes after the accident. Given that amount

of time, it cannot be clearly determined through

these tests whether alcohol had a role in this

accident, although no other information

suggested that alcohol was a factor. On the

contrary, the first Coast Guard investigator

aboard observed the crew by sight, sound, and

The results of the alcohol tests on the pilot and nine

crew members showed .000 percent BAC.

The elimination rate ranges between about .015

percent and .020 percent per hour.

smell for signs of alcohol or other impairment

and found none.

Postaccident testing could have begun

sooner. The ship’s agent learned of the accident

1 hour and 20 minutes after it occurred, and he

and the ship’s attorney were aboard in about 2

1/2 hours. The first Coast Guard investigator

went aboard 2 hours after the accident, and an

hour later (3 hours after the accident), he

ordered the ship’s attorney to have the crew

tested. Either of them could have facilitated

initiation of the testing process. Instead, the

ship’s agent general manager came aboard 3 1/2

hours after the allision and was there for another

hour before he arranged for testing. Tests were

not started sooner because the general manager

erroneously thought the Coast Guard would

make the arrangements. Further delay was

incurred in locating someone to conduct the

tests, which finally began 6 1/2 hours after the

accident. Each of these delays diminished the

value of the tests. Further, by conducting the

breath tests of the helmsman, master, and chief

engineer last, 8 hours or more after the accident,

the value of those tests was essentially negated.

Besides arranging for the testing, the agent

had to decide whom to test. The regulations

state that he should do so by determining who

was directly involved in the incident. The ship

agent’s decision was to test all crewmembers

assigned to the noon watch, which was on duty

at the time of the allision. However, the ship’s

carpenter, who was acting as the anchor watch,

was not tested. He was apparently inadvertently

overlooked for testing because he was not

regularly assigned to the noon watch. Since no

testing of the carpenter was done, no definitive

conclusions can be made about drugs or alcohol

with respect to his activities, though as with the

other crewmembers, no information was

obtained that would suggest that either had a

role.

Arrangements for and timing of the alcohol

testing illustrate several problems. For example,

the Coast Guard investigator was fully aware of

the agent’s responsibilities, but the agent was

not. Time was lost until the agent became fully

aware. Additional time was lost while a

qualified tester was contacted and brought

aboard. Also, the regulations themselves do not

adequately address the physiological need to

conduct alcohol testing within 8 hours if the

results are to be meaningful.

The Safety Board has observed these same

problems in previous accidents, and several

potential solutions exist. One recent accident

involved the vessel

Julie N

, which struck a

bridge support in Portland, Maine, on December

4, 1996. Because the problems and solutions

associated with the timing of postaccident drug

and alcohol testing were explored in a March

13-15, 1997, public hearing on that accident and

will be comprehensively addressed in the Safety

Board’s upcoming

Julie N

accident report, they

are not further discussed here.

Risk Assessment and Risk Management

This accident demonstrates that the many

and diverse stakeholders in the area of the Port

of New Orleans, including the Coast Guard, the

State of Louisiana, the Dock Board, the pilot

organizations, and the owners and operators of

riverfront properties and nearby moored

passenger ships, did not adequately prepare for

or mitigate the risk of a marine casualty

affecting people and property within the Port of

New Orleans. Some of the stakeholders, most

notably the Dock Board, had commissioned

partial risk assessment studies at various times

for the assets in the harbor area. Despite their

limitations (in either geography or scope), these

studies did provide adequate information for the

stakeholders to recognize the possibility of an

accident similar to the one involving the

Bright

Field

For example, risk assessment projects

predicted an increase in accidents involving

collisions, rammings, and groundings due to

increased river traffic. The Louisiana State

University risk assessment project, in 1994,

concluded that no sections of the Port of New

Orleans waterfront were free of ship allisions,

including the area where the high-capacity

passenger vessels, gaming vessels, and

riverfront properties were located. Analysis of

accident data for the Port of New Orleans from

1983 through 1993 (a total of 166 rammings

along the left descending bank between miles 91

and 101 AHP) identified a mooring area for

gaming vessels that had seen the fewest

“historical allisions on the left bank.” The study

acknowledged, however, that no area of the left

descending bank of the river had been

completely free of vessel strikes during the 11-

year period studied.

Port stakeholders did take risk management

initiatives such as providing barriers and

controls for some of their assets. At the time of

the planning for the Louisiana world’s fair in the

early 1980s, a proposal was made to tie up

barges (exhibit pavilions with large numbers of

patrons or visitors) along the riverfront fair site

at the location now occupied by the Riverwalk

Marketplace. The Dock Board rejected the plan.

The Audubon Institute, as a result of a

preconstruction risk assessment in 1987,

decided to construct the Aquarium of the

Americas some 100 feet behind the levee so that

it would be safe from vessel strikes. More

recently, the mooring areas for the gaming,

excursion, and ferry vessels were silted in to

possibly protect these vessels from ramming by

other ships.

Despite this history of some sensitivity to

risk within the port area, the Riverwalk

complex, including the condominium garage

and the Hilton Hotel Riverside, were

constructed on old warehouse piers on the river

side of the levee. This location offered no

“crush zone” that could absorb the impact of a

marine ramming, and despite the fact that the

piers themselves were not built to withstand

being struck by a heavy vessel, no physical

barriers were constructed outboard of the new

buildings to offer them protection. According to

the IRC, during the time when the IRC was

negotiating a lease with the Dock Board, the

Dock Board advised the IRC that vessels had

had allisions with wharves within the Port of

New Orleans, but no allisions had occurred at

the Lower Poydras Street wharf. The IRC

representatives were shown photographs of the

allisions at other wharves, but these photographs

depicted only minimal damage. The IRC

apparently did no further risk assessment, and

neither the initial construction of the mall nor

the initial construction of the riverside portion

of the Hilton Hotel resulted in any new structure

extending farther into the Mississippi River.

Rather, these structures were built entirely on

top of existing wharves.

In contrast, the 1987 Audubon Institute-

sponsored risk assessment similarly determined

that there had been few allisions at the Bienville

Street wharf and that because it is high up in the

bend, it faced low risk of being struck by an

outbound vessel. Nonetheless, recognizing low

incidence, but a potential for high consequences,

the Audubon Institute placed the Aquarium of

the Americas behind the levee with a 100-foot

buffer zone to protect the shoreside structure.

No similar safety feature was considered or

constructed for the Hilton Hotel or the

Riverwalk Marketplace.

The IRC obtained construction permits for

the riverside expansion of the hotel from the city

of New Orleans, the Corps of Engineers, and the

New Orleans Levee Board. In addition, the

construction plans were approved by the Dock

Board. According to the Dock Board, it may

make recommendations to the IRC or other

stakeholders in the area to widen the wharf, to

allow silt to accumulate, or to further increase

the robustness of construction in the area

immediately outbound of their structures;

however, it has no authority to compel such

action. Currently, the damaged portions of the

Riverwalk Marketplace mall, the parking deck,

and the Hilton Hotel are being rebuilt in the

same location. No physical barriers have been

included in the rebuilding of these facilities. As

with the initial construction, all permits were

granted, and all plans were approved.

Given the hazardous operating environment

in the Port of New Orleans and the number of

instances of loss of propulsion and steering, any

number of which could have resulted in similar

accidents or far more serious ones, the Safety

Board does not understand the property owners’

reluctance to provide adequate barriers to

protect their assets in the port area. Although the

River Front Alert Network is a commendable

effort to alert the harbor police and security

officers in the event of a need to evacuate the

area, such efforts are unlikely to result in a

complete evacuation under even slightly

different circumstances. For example, the

Bright

Field

rammed the Hilton Hotel during daylight

hours when, fortunately, few guests were

occupying rooms and no cleaning personnel

were in the immediate area. Had this accident

occurred during the evening, at night, or in the

morning hours, most of the rooms would

probably have been occupied. It is unlikely that

even the River Front Alert Network would have

been able to awaken the sleeping guests, alert

them to the danger, and evacuate them in time to

prevent serious injury or possible death.

The Safety Board is concerned that, despite

the historical record of marine incidents and

accidents in that section of the Mississippi

River, the Dock Board permitted the placement

of a commercial facility within about 20 feet of

an unprotected wharf. More than 13,500 people

a day visit the Riverwalk Marketplace. Those

visitors have a reasonable expectation that the

Port of New Orleans will assert its responsibility

to protect their safety by exercising the power to

disapprove a building plan that does not

adequately account for a known risk. The Safety

Board concludes that the IRC and the Dock

Board did not conduct adequate risk assessment

nor perform adequate safety management

oversight to protect their properties and the

people that use them from an allision such as

that involving the

Bright Field

While the construction of a shopping mall

and a hotel in such a high-risk area was ill-

advised, the Safety Board recognizes that

economy and practicality argue against

attempting to correct the error by relocating

those facilities. Nonetheless, the

Bright Field

accident highlights the risk to shoreside

structures within the Port of New Orleans and

the need to consider that risk in the approval

process for future construction there. The Safety

Board believes that the Dock Board, as part of

the permit-approval process for new commercial

and residential development along the wharves

within its jurisdiction, should require that any

new construction of occupied space be sited

behind a buffer zone sufficient to protect

persons and property by safely absorbing the

impact should a vessel strike a wharf.

After this accident, the Dock Board, in

effect, identified a buffer zone for the Riverwalk

Marketplace. The Dock Board “encouraged” the

IRC to widen the Upper Poydras Street wharf by

50 feet. The company had already widened the

wharf by that amount in one area to

accommodate a gaming vessel, and the Dock

Board suggested that the remainder of the wharf

be extended as well. The Safety Board concurs

in this suggestion and believes that the IRC

should enhance the safety of the patrons and

employees of the Riverwalk complex by

immediately undertaking to widen, by a

minimum of 50 feet, that length of the Poydras

Street wharf that has not previously been

extended. Such an extension prior to this

accident would have added a “crush zone” that

would probably have prevented the structural

damage and threat to persons that resulted from

the

Bright Field

accident.

Several passenger vessels, including

gaming, tour, and cruise vessels, were allowed

to dock along the left descending bank, the side

of the river at highest risk. Had the

Bright Field

lost power some time later and the same

accident scenario evolved, the ship would likely

have rammed the gambling vessel, resulting in

substantial loss of life. The cruise vessels, which

had even less warning time, would quite likely

also have sustained serious passenger injuries or

loss of life.

While silting around the vessels’ docking

areas may offer some protection from ramming

by deep-draft vessels at average river stages, the

silt layer did not reduce water depth sufficiently

to retard a runaway ship when the river was

high, as it was on the day of the

Bright Field

accident, nor did it protect the moored vessels

from ramming by shallow-draft vessels such as

tows and barges. The Safety Board is not aware

of any engineering evaluations conducted to

assess the effectiveness of the silting efforts.

The property owners and other stakeholders

within the Port of New Orleans clearly had the

responsibility to establish and maintain a

reasonable level of safety in the port area. The

Safety Board concludes that the Coast Guard,

the Dock Board, and the property owners did

not adequately address the risks posed to

moored vessels along the Erato, Julia, Poydras,

and Canal Street wharves; as a result, under

certain conditions, those vessels were vulnerable

to ramming by other marine traffic. The Safety

Board believes that the Coast Guard and the

Dock Board should reassess the risk of locating

passenger vessels along the left descending bank

of the Mississippi River and determine whether

to remove the vessels to a less vulnerable

location or put in place procedural, operational,

or physical barriers that will protect them from

ramming by riverborne traffic.

Additionally, no tugboats were used either

as escorts or as a “barrier” to prevent a runaway

ship from ramming the shore or colliding with

another marine asset. And no environmental

controls, such as the Corps of Engineers’

opening of the Bonnet Carré Spillway, were put

in place to reduce river flow or current.

On the river itself, the

Bright Field

was

operating at full speed in high-river and high-

current conditions. Apparently, neither the pilot

nor crew considered procedures that might be

employed to maximize the time available to

respond to an emergency. For example, the main

engines were being operated in bridge control,

and although this may have created a time

penalty in responding to an emergency, the pilot

and bridge crew did not discuss engine control

location prior to commencing the trip

downriver. In his testimony, the pilot claimed

that it was necessary to operate the

Bright Field

at maximum speed to attain reasonable

maneuverability of the vessel in the operating

environment of high water, rapid current, and a

heavily laden ship designed to be maneuverable

at lower speeds.

Several days after the accident, Safety

Board investigators boarded a fully loaded

vessel of similar size, displacement, and power

to the

Bright Field

that was operating

downbound in similar high water conditions.

During this transit, the pilot did not use full

speed to maneuver the ship. Each ship handles

differently, but the operation of the

Bright Field

at full speed left no margin for error. For

example, the main engine tripped off line

because of a temporary loss of lubricating oil

pressure. The oil pressure and engine operation

were restored within about 2 minutes, which is a

reasonable amount of time. However, operating

at full speed in high-river conditions, the ship

had no room to maneuver out of the emergency.

The Safety Board concludes that operating a

vessel at full speed in the restricted waters of the

Mississippi River may not allow sufficient time

or distance to recover from an emergency. The

Safety Board believes that the Coast Guard

should take the lead in working with the pilot

associations serving the Port of New Orleans to

evaluate the impact of operating vessels at full

speed in the Mississippi River and incorporate

that information in its risk-management and

risk-reduction strategies for the port area.

High-river conditions are repeatedly cited as

cause for concern. For example, various port

risk assessments cite local experts, in interviews

and in response to questionnaires, clearly

expressing that high river stage is an important

factor in river casualties. This opinion is

strongly supported by available data. Eleven

years of casualty data from the Port of New

Orleans and the Coast Guard clearly show a

seasonal trend to river casualties. The high

water months of February, March, April, and

May experience two to three times the casualties

that occur during the low-water months of July

through October.

In addition, the studies point out that the

Coast Guard acknowledges the fast Mississippi

River current and low seasonal water

temperatures as creating a very hostile

environment. No matter how many Coast Guard,

State, local, and other resources respond to a

casualty involving a large number of persons in

the water, it would be difficult to rescue

everyone. The Coast Guard 1994 search and

rescue exercise lead to the conclusion that,

under adverse conditions, the Coast Guard could

expect to rescue and save only a small

percentage of the people in the water. This

finding should be unacceptable to the Coast

Guard and the Port of New Orleans, and the two

agencies should consider alternative means to

deal with this emergency. For example, prior to

the

Bright Field

accident, the Bonnet Carré

Spillway had only been opened seven times to

alleviate high water conditions, apparently

because of the cumbersome and lengthy tasks

necessary to do so. Nonetheless, the risks

associated with high water and rapid current

were considered “unusual” enough that in

March 1997, the spillway was opened for the

eighth time. The Port of New Orleans, the Coast

Guard, and the Corps of Engineers might

consider more aggressive use of the Bonnet

Carré Spillway to alleviate these high water

conditions and to deal with the safety issues

created by them. Further, if the major

impediment to opening the spillway is the time

and effort it takes to do so, it may be appropriate

for the Corps of Engineers to consider ways to

make the spillway more usable and to employ it

for risk mitigation as well as for flood control.

No practical physical barrier aboard ship

exists that will safely stop a runaway vessel. In

such an emergency, a safe outcome depends on

the successful interaction of several physical

and operational factors. For example, if main

engine power is lost, adequate steering can

usually be maintained until the ship slows

enough for the anchors to be dropped. If a vessel

loses its steering, engine power can be used to

either slow the vessel (astern power) or, if it is a

twin-screw vessel, to maneuver the ship.

Anchors are perceived as providing some

level of protection by serving as “brakes” that

will stop or at least slow a ship. But anchors are

neither designed nor adequate for stopping a

heavily loaded ship traveling at high speed. Had

the

Bright Field’

s anchors been released, the

anchor chain would quite likely have payed out

at a speed that could not be controlled by the

windlass brake, and the chain would simply

have continued to run out until it parted from

the ship. In this accident, the dropping of the

anchor and paying out of chain could not have

been expected to significantly slow, let alone

stop, the ship.

Since this accident, the Coast Guard has

placed renewed emphasis on having anchors at

the ready (backed out of the hawsepipe,

disengaged from the windlass, and being held by

the brake), with a two-person forecastle watch.

While having the anchors manned and at the

ready may prove beneficial in certain

circumstances, it is unlikely to achieve anything

meaningful aboard a heavy vessel operating at

relatively high speeds in the Mississippi River.

Further, “increased emphasis” on having the

anchors at the ready may even provide a false

sense of security without effectively addressing

the dangers inherent in operating heavy vessels

at high speed in proximity to shoreside

businesses and passenger vessels.

The notable characteristic of all previous

risk assessment studies commissioned by the

Coast Guard or the Dock Board was their

limited scope. Most were conducted in light of

specific proposals, such as the addition of

gaming vessels to the port. Investigators

determined that no comprehensive study has

been done that considers all types of risks to all

port properties and people. The Safety Board

concludes that the stakeholders within the Port

of New Orleans, including Federal, State, and

local agencies; private commercial entities;

shipowners; and pilot associations have not

determined the overall level of risk associated

with the full range of activities within the port

area and have not provided adequate protection

for persons and property in that area.

The Coast Guard has overall responsibility

for maintaining public safety in the Port of New

Orleans area. Under the

Ports and Waterways

Safety Act of 1972

, the Congress charged the

Coast Guard with monitoring and managing risk

in all U.S. ports and taking actions to maintain

risk at an acceptable level. In carrying out this

role, the Coast Guard must assess and manage

the risk that is inherent in all commercial

activities within U.S. ports. In fact, in its

1996

Performance Report

, the Coast Guard’s Office

of Marine Safety and Environmental Protection

asserts that managing risk is its primary mission.

The Safety Board concurs with this assessment

and notes that the Coast Guard has the authority,

the responsibility, and the experience to direct a

comprehensive assessment of risk in the Port of

New Orleans.

The Safety Board believes that the Coast

Guard, with the cooperation of all stakeholders

within the Port of New Orleans, should conduct

a comprehensive risk assessment that considers

all activities, marine and shoreside, within the

port area. In addition to those risk factors

discussed earlier, this assessment should

consider the risks to people and property,

including shoreside businesses and passenger

vessels, that are associated with relatively high-

speed navigation of the river, high river stage

and rapid river current, railroad and highway

bridges spanning the waterway,

and the

carriage of cargoes such as bulk oil or other

hazardous materials or chemicals that can cause

pollution, fire, or explosion.

The Safety Board notes that many of the

risk factors associated with river commerce

within the port area have already been identified

in previous risk assessment studies and, further,

that these factors may be amenable to known

risk-reduction or risk-mitigation initiatives.

For more information, see Highway-Marine

Accident Report--

U.S. Towboat

Chris

Collision

with the

Judge William Seeber Bridge, New Orleans, Louisiana,

May 28, 1993

(NTSB/HAR-94/03).

Such initiatives might include reducing vessel

speed, opening the Bonnet Carré Spillway on a

more regular basis, using tugboats either as

escorts or as a “barrier” to protect marine assets,

adequately assessing the protection afforded by

silting-in of vulnerable areas, and moving the

passenger vessels to a safer location. The Safety

Board believes that the Coast Guard should, in

cooperation with the appropriate stakeholders,

including Federal, State, and local agencies;

private commercial entities; shipowners; and

pilot associations, implement risk-management

and risk-mitigation initiatives that will ensure

the safety of people and property within the Port

of New Orleans. The Safety Board further

believes that the Corps of Engineers, the State

of Louisiana, the Dock Board, the IRC

(including the New Orleans Hilton Riverside

Hotel), New Orleans Paddlewheels, Inc., the

New Orleans Baton Rouge Steamship Pilots

Association, the Crescent River Port Pilots

Association, and Associated Federal Pilots and

Docking Masters of Louisiana, Inc., should

participate with other stakeholders in instituting

risk management and mitigation initiatives that

will ensure the safety of people and property

within the Port of New Orleans.

Findings

The following factors were not causal or

contributory to the accident involving the

Bright Field

: weather, fatigue, malfunc-

tioning of either the vessel’s steering gear or

equipment on the bridge, alcohol or other

drugs, crew health, crew qualifications, or

crew experience.

The

Bright Field

showed evidence of

recurring engineering problems that affected

vessel main engine reliability, and had all

engineering systems been kept in good

repair and regularly tested, the vessel may

not have unexpectedly lost power during its

voyage down the Mississippi River.

The

Bright Field

owners’ oversight of

testing and maintenance of the vessel’s

engineering systems was inadequate and led

to unreliable performance of the engineering

plant and contributed to the shutdown of the

main propulsion engine on the day of the

accident.

Insufficient information was available to

determine whether any actions taken by the

pilot and crew of the

Bright Field

would

have been effective in preventing the

allision or mitigating its effects.

At several points prior to and during the

Bright Field

emergency, the pilot, master,

and crew of the vessel did not exchange

information that under other circumstances

could have prevented or at least mitigated

the effects of the accident.

Use of bridge resource management

precepts on board the

Bright Field

would

have enhanced the exchange of information

and the coordination of actions among the

pilot, master, and crew during the accident

sequence.

The response to the

Bright Field

accident by

local emergency response agencies was

timely and appropriate.

Evacuation of the

Queen of New Orleans

was hampered, and passenger risk increased,

by the fact that only one gangway was made

available for passenger egress during the

emergency.

Nonoperating crewmembers of the

Queen of

New Orleans

and the

Creole Queen

had not

received training covering the full range of

emergency scenarios and were unprepared

to properly carry out their responsibilities in

this accident.

10.

The lack of effective recurring safety brief-

ings for occupants of the

Queen of New

Orleans

regarding emergency and evacua-

tion procedures may have contributed to the

confusion and panic reported among pas-

sengers and crew during the vessel

evacuation.

11.

The instruction placards and signage aboard

the

Queen of New Orleans

were ineffective

in disseminating emergency instructions and

vessel information to passengers.

12.

The International RiverCenter and the

Board of Commissioners of the Port of New

Orleans did not conduct adequate risk

assessment nor perform adequate safety

management oversight to protect their

properties and the people that use them from

an allision such as that involving the

Bright

Field

13.

The U.S. Coast Guard, the Board of

Commissioners of the Port of New Orleans,

and the property owners did not adequately

address the risks posed to moored vessels

along the Erato, Julia, Poydras, and Canal

Street wharves; as a result, under certain

CONCLUSIONS

conditions, those vessels were vulnerable to

ramming by other marine traffic.

14.

Operating a vessel at full speed in the

restricted waters of the Mississippi River

may not allow sufficient time or distance to

recover from an emergency.

15.

The stakeholders within the Port of New

Orleans, including Federal, State, and local

agencies; private commercial entities;

shipowners, and pilot associations have not

determined the overall level of risk

associated with the full range of activities

within the port area and have not provided

adequate protection for persons and

property in that area.

Probable Cause

The National Transportation Safety Board

determines that the probable cause of this

accident was the failure of Clearsky Shipping

Company to adequately manage and oversee the

maintenance of the engineering plant aboard the

Bright Field

, with the result that the vessel

temporarily lost power while navigating a high-

risk area of the Mississippi River. Contributing

to the amount of property damage and the

number and types of injuries sustained during

the accident was the failure of the U.S. Coast

Guard, the Board of Commissioners of the Port

of New Orleans, and International RiverCenter

to adequately assess, manage, or mitigate the

risks associated with locating unprotected

commercial enterprises in areas vulnerable to

vessel strikes.

As a result of its investigation of this

accident, and in addition to the safety

recommendations issued previously to the U.S.

Coast Guard, to the Board of Commissioners of

the Port of New Orleans, and to New Orleans

Paddlewheels, Inc., the National Transportation

Safety Board makes the following safety

recommendations:

--to the U.S. Coast Guard:

In cooperation with the Board of

Commissioners of the Port of New

Orleans, reassess the risk of locating

passenger vessels along the left

descending bank of the Mississippi

River and determine whether to remove

the vessels to a less vulnerable location

or put in place procedural, operational,

or physical barriers that will protect

these vessels from ramming by

riverborne traffic. (M-98-1)

Conduct, with the cooperation of all

stakeholders, a comprehensive risk

assessment that considers all activities,

marine and shoreside, within the Port of

New Orleans. (M-98-2)

Take the lead in working with the pilot

associations serving the Port of New

Orleans to evaluate the impact of

operating vessels at full speed in the

Mississippi River and incorporate that

information in your risk-management

and risk-reduction strategies for the port

area. (M-98-3)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-4)

--to the U.S. Army Corps of Engineers:

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-5)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-6)

--to the State of Louisiana:

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-7)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-8)

--to the Board of Commissioners of the Port

of New Orleans:

As part of the permit-approval process

for new commercial and residential

development along the wharves within

your jurisdiction, require that any new

construction of occupied space be sited

behind a buffer zone sufficient to

protect persons and property by safely

absorbing the impact should a vessel

strike the wharf. (M-98-9)

RECOMMENDATIONS

In cooperation with the U.S. Coast

Guard, reassess the risk of locating

passenger vessels along the left

descending bank of the Mississippi

River and determine whether to remove

the vessels to a less vulnerable location

or put in place procedural, operational,

or physical barriers that will protect

these vessels from ramming by

riverborne traffic. (M-98-10)

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-11)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-12)

--to International RiverCenter:

As previously suggested by the Board of

Commissioners of the Port of New

Orleans, immediately enhance the safety

of the patrons and employees of the

Riverwalk complex by widening, by a

minimum of 50 feet, that length of the

Poydras Street wharf that has not

previously been extended. (M-98-13)

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-14)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-15)

--to Clearsky Shipping Company:

Perform a baseline engineering assess-

ment of the

Bright Field’

s engineering

plant and correct all conditions not in

conformance with manufacturer’s speci-

fications. (M-98-16)

Institute an engineering testing, mainte-

nance, repair, and company oversight

program for the

Bright Field

that will

ensure safe and reliable operation of the

vessel’s engineering plant. (M-98-17)

Provide your bridge and engineroom

watchstanding officers and crewmem-

bers with initial and recurrent bridge

resource management training that in-

cludes communication and coordination

between pilots and members of the

bridge and engineroom watches and that

addresses their use of bridge and en-

gineroom systems. (M-98-18)

--to New Orleans Paddlewheels, Inc.:

In accordance with the guidance

published by the Passenger Vessel

Association, require that nonoperating

crewmembers on all your vessels

participate in formal emergency training

and drills in the proper handling of

emergencies that have the potential to

affect the persons in their charge.

Maintain written records to verify

nonoperating crew proficiency levels

and skill retention. (M-98-19)

Review the existing methods of

providing safety information to

boarding passengers and make the

necessary improvements to ensure that

all vessel occupants receive recurring

safety briefings, regardless of whether

the vessel is scheduled to leave the

dock. (M-98-20)

On all your vessels, post emergency

instructions that are printed on fire- and

heat-resistant material and that are

clearly visible to all passengers both

under normal conditions and during

emergencies when lighting and visibility

may be diminished. (M-98-21)

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-22)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-23)

--to the New Orleans Baton Rouge

Steamship Pilots Association:

Encourage your members to participate

in initial and recurrent bridge resource

management training that teaches the

principles of resource management and

that emphasizes team coordination

between the pilot and crew. (M-98-24)

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-25)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-26)

--to the Crescent River Port Pilots

Association:

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-27)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-28)

--to Associated Federal Pilots and Docking

Masters of Louisiana, Inc.:

Participate with the U.S. Coast Guard

and other stakeholders in a comprehen-

sive risk assessment that considers all

activities, marine and shoreside, within

the Port of New Orleans. (M-98-29)

In cooperation with the appropriate

stakeholders, including Federal, State,

and local agencies; private commercial

entities; shipowners; and pilot associa-

tions, implement risk-management and

risk-mitigation initiatives that will en-

sure the safety of people and property

within the Port of New Orleans.

(M-98-30)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

January 13, 1998

APPENDIX A

Investigation

The Safety Board learned of the accident involving the Bright Field about 1700 on

December 14, 1996. A five-person investigation team consisting of an investigator-in-

charge, an engineering specialist, an operations specialist, a human performance

specialist, and a survival factors specialist arrived on scene on December 15, 1996,

accompanied by representatives from the Safety Board’s Offices of General Counsel and

Public Affairs. Member Hammerschmidt was the Board Member on scene.

This accident was investigated jointly by the Safety Board and the U.S. Coast Guard

under the authority of section 304(a)(1)(E) of the Independent Safety Board Act of 1974 and

in accordance with 49 CFR 850, “Coast Guard-NTSB Marine Casualty Investigations.” The

Coast Guard invited the Government of Liberia to participate in the investigation, in

accordance with the IMO resolution A637, “Co-Operation in Maritime Casualty

Investigations.” The Government of Liberia accepted the invitation and a representative

participated fully in all aspects of the investigation.

Hearing / Deposition

The Safety Board did not conduct a public hearing in connection with this accident.

However the Safety Board was a participant in the U.S. Coast Guard Marine Board of

Investigation public hearings held in New Orleans, Louisiana, on December 17-21, 1996;

January 6-11 and 29-30, 1997; and March 19-20, 1997.

this page intentionally left blank

APPENDIX B

Chronology of

Bright Field

Engineering Problems

October 1995

25th Owner notes concern about continuing cracking problems on Sulzer RTA62 main engines

and attributes problem to design, material, manufacturer, operation and handling.

Provides specific instructions to masters and chief engineers about operation and

maintenance parameters.

January 1996

1st Chief engineer reports to owner about serious engineering problems on the Bright Field

including cracked main engine cylinder liners, and loss of power while transiting the

Panama Canal due to low main engine lubrication oil system pressure because of an

excessive pressure drop across the second filter.

February 1996

2nd Master telexes owner that he has to run at reduced rpms because of main engine

overheating problems and frequent “auto slowdowns”.

March 1996

Master telexes owner that engineering equipment malfunctions frequently due to the age

and condition.

April 1996

Bright Field dry docked in Nan Tung, China.

May 1996

20th Master telexes owner about severe damage to the main engine’s No. 2 cylinder and

piston. No spare parts available.

Appendix B—Cont.

June 1996

2nd Second engineer’s maintenance log reports repairs to the main engine’s No. 2 and 3

cylinder liners and pistons.

July 1996

5th 0900, arrived Long Beach, California.

23rd Anchored, Japan.

26th Renewed #2 piston, cylinder liner and rings to main engine.

August 1996

3rd Trouble with a pneumatic control valve 14B in automated propulsion pneumatic logic

control.

4th Removed #5 piston and cylinder liner to main engine, replaced cylinder liner.

5th Removed #4 cylinder liner and piston rings to main engine, replaced piston rings with

“used” rings.

6th 1500, departed for Indonesia.

16th 0440, arrived Pulau Laut, Indonesia.

18th 1245, departed Pulau Laut, Indonesia for Hong Kong.

26th Arrived Hong Kong. Owner’s representative boards vessel.

27th Repaired main engine pneumatic control valve 38A

28th 0005, departed Hong Kong

September 1996

2nd Arrived Banjarmasin, Borneo, Indonesia to load cargo of steaming coal.

3rd Renewed #1 cylinder liner and piston to main engine (liner cracked, piston head burnt and

dented).

5th Master informs owner must purchase fresh water, evaporator can only make 10 metric

tons, vessel consumes 15 metric tons daily.

6th Owner telexes Bright Field that main engine lubrication oil analysis shows low flash

point and high viscosity with possible fuel oil leakage into sump.

9th Ordered replacement parts for main engine fuel injection pump, cracked valve

12th Departed Banjarmasin, Indonesia, enroute Davant, Mississippi River (e.t.a. Oct 26th)

17th 0400, #4 piston rings seized and broken, running at reduced speed (65 rpms). Master

hopes to make Singapore for repairs. Chief engineer recommends lifting out #4 piston for

repairs.

Appendix B—Cont.

18th 0500, drifting while repairing rings to #4 piston, changed piston crown to #4 broken

piston crown bolts and no more spares. Also found water leakage in #4 cylinder by piston

crown damage. Discovered ring damage to #1, 2, 4, 5 pistons, found blocked holds where

cylinder oil is injected. #5 cylinder not working correctly, found cylinder liner cracks. Not

enough spare parts for piston ring and cylinder liner repairs, Master telexes owner,

“Serious trouble! Except for #1, all cylinder liners leaking gas. Not sure of safety”.

18th 0448, stopped main engine for repairs. Renewed #4 piston rings and piston crown.

Welded cracked in cylinder liner.

19th Rough seas main engine still under repair. Notes high level of impurity in main engine

and blockage of filters.

20th Master reports vessel in area of typhoon. Main engine damage is serious with no spare

parts available. Welded cracks in #5 cylinder liner. Replaced #4 cylinder liner with old

used liner (old #1). Engineering crew exhausted.

21st Dirty air cooler. Can not dismantle to clean because of sea conditions.

22nd 1600, completed temporary main engine repairs. #4 cylinder liner still leaking, running at

reduced rpms enroute Spore, Singapore for repairs main engine, air cooler e.t.a. 30 Sept.

25th High main engine scavenging temp due to malfunctioning sea water cooler and main

engine air cooler.

26th Repairs to both main high pressure air compressors.

28th Evaporator out of commission due to faulty pump.

29th Main engine slowdown.30th , 0700 arrived Spore, Singapore.

October 1996

1st Chief electrician tests some temp/pressure sensors.

2nd Telephone conversation between second engineer and owner concerning the quality of the

main engine’s lubrication oil. In telex to owner, master reports that the chief engineer has

increased main engine cylinder oil flow rate.

3rd Owner’s representative boards vessel and reports concern about poor operating condition

of Bright Field’s main engine and lack of confidence in chief engineer. Master telexes

repairs completed, enroute Devant, LA, via Suez Canal, e.t.a. 15 Nov

4th Urgent request for spare parts at Suez for high pressure air compressor, boiler fuel oil

burning pump, evaporator.

7th Revised e.t.a. Devant, LA, Nov 21th.

9th Mmaster requested permission to reduced main engine speed to 63 rpms due to high

exhaust gas temps and ‘overloads’. Reports continued cylinder cracking problems if

speed isn’t reduced.

10th Main engine temp problems due to air/electrical valve in speed control system. Chief

engineer overhauls 14A, 4B, and 7D pneumatic control valves.1st , renewed #1 piston

rings. Renewed #4 cylinder liner.

Appendix B—Cont.

11 Main engine fuel timing cannot be adjusted.

17th Response to owner message, can’t increase speed more.

21st 1400, arrived Suez Canal.

21st No. 2 & 3 cylinder leaking past piston rings and stuffing boxes. #2 piston found to have

dented head, planned to lift out #2 and #3 pistons to inspect/change damaged rings before

departure from Suez.

23rd Renewed #2 and #3 piston rings.

24th Main engine repairs completed. Ring damage attributed to poor quality of rings. main

engine cylinder oil consumption is 1.32 g/hp-h. Departed Port Said, e.t.a. Devant, LA is

Nov 16th.

28th Second engineer looking for tools to set main engine fuel oil injecting timing.

30th Main engine calibration tools found on board surveyed in response to owner request.

November 1996

4th Reduced rpm to 61 due to high exhaust gas temperatures (508C vs. alarm at 515C).

Request repair of CRT monitors and main engine fuel injection pump timing.

5th 2200, slow down caused by the high crank case oil mist alarm. Heavy smoke emitted

from main engine, repair work underway.

6th 1800, stopped main engine, found hole in #5 piston head cracked and leaking exhaust

gases through stuffing box into crank case, contaminating lube oil. Found #5 main engine

piston head burn through. Replaced with old used piston head. Engineering crew renews

main engine sump lubricating oil due to concern about low flash point of oil. Only

replaced 8.4 cubic meters of oil (all that was in storage). Owner informed main engine

sump was cleaned.

7th 2300 underway again running at reduced speed (61 rpms) due to high exhaust

temperatures.

8th Request for spare parts: 2 piston heads, piston rings, main engine fuel injection valve.

Request for 14 tons of main engine lubrication oil (no spare), 10 tons for storage and 4

tons to be added to the main engine sump. New e.t.a is Nov 20th.

12th Chief engineer notes that vessel does not have proper tools to set main engine fuel oil

pump timing correctly. Consulting instruction books. 1200 hours stopped to try to adjust

fuel pump timing based on instructions from owner. 1800 work completed underway

again.

13th New e.t.a. Nov 21st

14th Requesting 14,000 liters of main engine lube oil on arrival Davant. Auxiliary boiler FO

boost pump ooc (requested spare parts on August 27th ), no spare parts. Must use diesel

oil instead of bunker fuel oil every time main engine and G/Es are started and stopped.

14th Master requests main engine expert meet vessel to solve problems, no one on board

knows how to fix problems. Attempted to increase rpms from 61. At 63 turbocharger

inlet temp rose to 510 (alarm at 515C). Reduced speed to 61 rpms.

Appendix B—Cont.

15th Master notes last d/d 04-28-96 and last special survey 17-09-95.

20th Second engineer still looking for missing tool to set main engine fuel oil injector timing.

21st 0610 at sea buoy, set manned engine room. Chief engineer relieved of duty and replaced.

1630 along side Davant coal dock to off load coal.

21st Sulzer technical representative checks main engine. Identifies several sources of possible

lube oil contamination. Notes many serious problems with the main engine.

22nd Master reports results of Sulzer survey to owner.

24th Tested main engine emergency shut downs.

25th 0849 coal discharge completed, anchored Mississippi River to clean cargo holds.

25th Overhauled #2 main engine cylinder, new piston head.

26th Bunkering fuel oil and diesel oil.

27th Vessel fails cargo hold inspection. Engineering crew rebuilds main engine injector pumps

and set timing with help of Sulzer technical representative. Vessel receives approximately

8,000 liters of main engine lubrication oil.

28th Overhauled #5 main engine cylinder, replaced piston rings, found three small cracks in

liner.

30th Repaired defective main engine emergency stop valve.

December 1996

1st Master requests engineering spare parts. Notes status of repair work; #2 and #5 cylinders

cracked and piston rings worn (poor quality), cleaned stuffing boxes and scavenging air

boxes, air/water separator for air cooler and exhaust manifold, M/E fuel oil pump timing

with assistance of Sulzer, main engine emergency stop system repaired 3 control air

valves.

2nd Crew attempted unauthorized repair to Terasaki monitors.

5th Vessel passed hold inspection. Repaired main engine control air supply pressure reducers

(A-124HA,124HB).

7th Tested main engine with sea trial data and found continued high turbocharger inlet temps.

Recommended repairs to turbocharger and /or air cooler.

9th Chief engineer sends notice to owner confirming seriousness of engineering problems

observed by Sulzer technician. At 1200, along side Cargil (Reserve) grain loading facility

to load cargo.

11th Found turbocharger rotor rings worn. 1317 completed loading corn.

12th Renewed #5 cylinder piston rings. Chief engineer sends off main engine lube oil sample.

12th Anchored Mississippi River for repairs to turbocharger and air cooler by local

engineering repair service.

13th ETD December 14, 0800. Next port of call is Cristobal, Panama with an ETA of

December 19th at 1600.

14th 0700, engineering repairs completed, 0945, vessel underway from Reserve, sailed from

Appendix B—Cont.

anchorage at 1112, draft forward 11.96m, draft aft 12.06m., ETA Kashima, Japan on

January 18, 1997.

14th 1055 and 1110, main engine will not start in W/H control.

14th 1158 and 1235, main engine experiences overheating alarms/problems due to jacket water

cooling problems.

14th 1406, loss of main engine lube oil pressure. Failure of standby lube oil pump to start. Low

pressure alarm and main engine trip.

APPENDIX C

Voyage Data Recorders (VDRs)

The Safety Board has long considered that marine VDRs (also known as voyage event

recorders, or VERs), when used as management oversight tools, can provide valuable

information, not only on engineering plant performance, but on crew performance and training

needs. Use of a VDR to monitor crew performance can provide management with a means of

measuring training effectiveness and identifying needed changes in training or procedures. When

used as accident reconstruction tools, VDRs help investigators determine how an accident

occurred so that they can develop measures to help prevent similar accidents.

The Safety Board has promoted the use of VDRs of various types since the 1970s and is on

record in support of the value of these systems as management tools as well as accident

investigation tools. Safety Board staff has been extensively involved in aviation and surface

vehicle data recorder readout, data analysis, rulemaking, and technical standards development for

VDRs. The Safety Board has been working closely with the Coast Guard for more than 1 year in

an effort to develop International Maritime Organization (IMO) carriage requirements and

technical standards for VDRs.

The IMO’s Navigation Subcommittee has requested that the International

Electrotechnical Commission (IEC) develop an international technical testing standard for VDRs.

The standard will be based on the IMO recommendations. The IEC working group (TC-80/WG-

11) commenced work in March 1997 and expects to publish a standard in 1999. Representatives

from the Safety Board are working with the IEC group to develop the standard.

The IMO is expected to require the installation of VDRs on roll-on roll-off (RORO)

passenger ferries as early as 1998, followed by a requirement for VDRs on all vessels of more

than 1,600 gross tons within the next 4 to 5 years. While the Safety Board would prefer more

timely deployment of VDRs, it is encouraged that this significant issue is finally receiving

international attention and action.