USCG: Improving vessel maneuvering systems to prevent accidents

The United States Coast Guard issued Safety Alert 03-25 following a significant marine incident in which a high-speed passenger ferry collided with a pier in New York during docking. The collision resulted in minor injuries to passengers and caused damages exceeding $500,000 to both the ferry and the pier.

A joint investigation by the Coast Guard and the National Transportation Safety Board (NTSB) identified several safety issues, particularly with the ferry’s maneuvering control systems. The ferry was equipped with three identical navigation bridge control stations (center, port, and starboard), each capable of controlling both propulsion systems. On the day of the incident, the captain attempted to transfer control from the center station to a bridgewing station to improve visibility during docking. However, the control transfer failed, and the crew’s efforts to slow the vessel were insufficient, leading to the collision.

Key Findings

The investigation revealed several design and operational shortcomings:

Control Panel Design Issues:

The uniform appearance of pushbuttons caused confusion, especially during high-pressure situations. All buttons were the same color and size, with identical LED indicators, regardless of their functions or importance.

Technological Complexity:

The ferry’s advanced control system required extensive crew training due to its identical control panels across three locations and its multiple propulsion modes. The complexity made it challenging for operators to manage the system effectively, particularly during emergencies.

Regulatory Noncompliance Risks:

Federal regulations (46 CFR 121.620 and 46 CFR 184.620) mandate that vessels must have reliable propulsion control systems that can be manually overridden in case of failure. Additionally, 46 CFR Part 62 outlines the standards for vital system automation, requiring systems to be thoroughly tested for failure scenarios to ensure safe operation under adverse conditions.

Recommendations

To prevent similar incidents, vessel operators and designers should adopt the following best practices:

System Design Compliance:
- Ensure that new or upgraded maneuvering control systems adhere to recognized ergonomic and human factors standards, such as ASTM F1166 (Human Engineering Design for Marine Systems) and the American Bureau of Shipping (ABS) guidelines on ergonomic design for navigation bridges.
Training and Familiarization:
- Provide comprehensive training for bridge watchstanders to ensure they are fully familiar with the design and operation of control systems under normal and emergency conditions.
Rigorous Testing:
- Follow guidelines like those in Coast Guard CG-CVC Policy Letter 17-07 and Marine Safety Center (MSC) program guidelines to conduct thorough evaluations and tests of vessel automation and control systems. This includes testing for failure modes and verifying seamless control transfers between stations.