Ineffective communication between master and pilot a factor in berthing contact

The US National Transportation Safety Board (NTSB) has said that the probable cause of the contact between cruise vessel Carnival Horizon (IMO 9767091) and Pier 90 was ineffective interaction and communication between the master and the docking pilot, who were manoeuvring the vessel, and the bridge team’s ineffective oversight of the docking manoeuvre. Contributing to the incident was the placement of the third officer in a location without view of the bow to monitor the close approach to Pier 90.

Cruise Ship Carnival Horizon hit Manhattan Cruise Terminal Pier 90, New York City, around dawn on August 28th 2018. There were no injuries, but the estimated damage was $2.5m.

There was clear visibility and southwest winds of 6 to 8 knots.

Carnival Horizon had 6,361 people on board while it was manoeuvring to berth no 2 at Manhattan Cruise Terminal’s Pier 88 in New York City, New York, when its bow struck the southwest corner of adjacent Pier 90. Pier 90’s walkway, roof parking garage, and facilities suffered extensive structural damage, and the ship sustained minor damage above the waterline.

The Carnival Horizon was returning to Manhattan from an eight-night Eastern Caribbean cruise.

A pilot from the Sandy Hook Pilots association boarded the Carnival Horizon for the inbound transit to the Manhattan Cruise Terminal around 01:40. At 03:29, after a master/pilot exchange about the ship and the inbound transit, the Sandy Hook pilot assumed navigational control. The master remained on the bridge, with overall responsibility for the safe navigation of the vessel for the duration of the arrival in port.

The distance between berth no. 2 at Pier 88 and berth no. 3 at Pier 90 was about 305ft.

Hiring an assist tugboat and a docking pilot to berth the vessel was not mandatory. However, the Carnival Horizon master had previously brought the ship to the Manhattan Cruise Terminal and had on occasion chosen this option when faced with strong ebb and flood currents at the pier. Therefore, due to the anticipated ebb current at the berth, the master determined it prudent to choose assistance with this docking.

As a result, the scheduled 6,000 horsepower (hp) assist tractor tugboat JRT Moran, with a docking pilot from Metro Pilots on board, awaited the Carnival Horizon. While awaiting the ship just west of Hudson River Park (Pier 57), the JRT Moran conducted two short drifts to estimate the amount of ebb current, which the docking pilot determined at the time (approximately 0446) to be about 2.3 knots.

At 05:30 the Metro docking pilot boarded the Carnival Horizon just west of Chelsea Pier 61, which was 1.25 miles from the final docking berth. About four minutes after boarding the docking pilot arrived on the bridge. He and the master conducted a master/pilot exchange of information while the Sandy Hook pilot continued to conn the vessel.

The Carnival Horizon master explained that he had requested the JRT Moran be positioned about midship on the cruise ship’s starboard side, below the fourth lifeboat, to serve as a pivot point and maintain a safe distance from the northwest corner of Pier 88 due to the anticipated ebb current at the berth.

The Metro docking pilot inquired about the distance from the ship’s bow to the navigation bridge; the bridge team and master replied 40 metres. The master then asked about the present speed of the ebb current, stating that at 03:39 he had noted it being as high as 4 knots. The Metro docking pilot replied that the current was ebbing at 2.3 knots, noting that low water was at 0418 and that they “have one hour of current left” and that “20 feet below the surface, 20 minutes before that it starts to flood down below.

At 05:37, as the ship was passing west of pier 76, the Metro pilot, after completing his discussion with the master, asked the Sandy Hook pilot at the conn what they were doing. The Sandy Hook pilot replied they were on a steady heading of 028 degrees and at 6 knots. Immediately after hearing that, the Metro pilot assumed the conn and issued a heading order of 030. After a few seconds’ pause, and another officer repeating the course order, the helmsman read back 030 and stated, “the pilot has the conn.”

The Sandy Hook pilot stayed on the bridge for the remainder of the transit. The Metro docking pilot had been a docking pilot for 28 years and told investigators he had berthed the Carnival Horizon at Pier 88 during the ship’s two most recent arrivals with the assistance of a tugboat, with the same master. He ad also piloted several hundred other cruise ships of similar size to the Carnival Horizon in the Port of New York.

As the Carnival Horizon continued north on the Hudson River toward the terminal, the pilot was supported by the ship’s bridge team, who manned various equipment and stations. The Carnival Horizon bridge team consisted of the staff captain, who was tasked to maintain an overview of the entire bridge operation and monitoring of the master and the pilot; a second officer, who was tasked to monitor and cross-check the person conning the vessel and the ship’s position using real-time navigation methods; and a deck cadet, who was tasked to maintain logs and checklists. There was also a helmsman and a lookout on the bridge.

The staff captain was in the vicinity of the enclosed starboard bridge wing, as was the Sandy Hook pilot. The second officer was positioned at the centreline of the bridge wheelhouse console and monitored navigational equipment, including visually displayed predictive software on the ship’s electronic chart display and information system (ECDIS).

The lookout was positioned on the port bridge wing and performed lookout duties for the port side of the vessel.

Civil twilight was to occur at 05:50, and sunrise was recorded at 06:19.

It was still dark outside as the ship approached the terminal The vessel’s third officer was stationed at the forward mooring platforms of the enclosed mooring deck as mooring officer. He relayed to the staff captain via handheld UHF radio the distances from the ship’s bow to the southwest corner of Pier 90. The staff captain repeated the distances to the bridge team while simultaneously keying his UHF radio to confirm the distance.

At 0539, the master transferred control from hand steering to the starboard bridge wing control console and operated the three bow thrusters and the two azipods with the separate controllers. The master then announced that he was turning both azipods outward 30 degrees with 50 propeller rpm on both; this was the last verbal communication about the propulsion settings for the azipods.

Two minutes later the pilot ordered the JRT Moran captain to position the tugboat on the starboard bow: “You can drop in on the starboard bow . . . Yeah, where we talked about.” The JRT Moran took up position on the starboard side just aft of the Carnival Horizon’s third bow thruster. No tow line was placed from the tugboat to the ship.

The pilot explained to investigators that the reason he did not want the JRT Moran positioned further aft (at the midship area, as the master preferred) was he thought the tugboat might get pinned between the ship and Pier 88 during the clockwise docking manoeuvre. Conning the Carnival Horizon, the pilot provided manoeuvring commands to both the Carnival Horizon master and the JRT Moran captain.

In response to the pilot’s heading orders, the master moved the azipod control levers individually to adjust the thrust angle and thrust amount for each azipod to bring the ship to that course. At 0541, the rpm on both azipods were increased from 50 to 60. Between 0545 and 0548, at a speed over ground of about 1.3 knots, the ship’s bow began to clear the corner of Pier 88 where the ship was to dock starboard side to. The pilot gave a series of thruster orders.

About 0548, with the ship on a heading of 038 degrees and a speed over ground of 1 knot, the master asked if they should “start bringing the stern in,” to which the pilot replied, “Easy, yes.”

The third officer on the starboard mooring platform was asked about the distance to the southwest corner of Pier 90. He answered that the distance was 50 metres. On hearing that, the pilot replied, “that’s good” and requested the JRT Moran push “ahead easy” from its position on the starboard bow. At that point, the ship was on a heading of 040 degrees and had a rate of turn of 12 degrees per minute to starboard with a ground speed of 1.1 knots

The pilot requested the bow thruster “full to port” as the third officer forward reported he was going to the port mooring platform to monitor the distance to Pier 90. Seconds later, he called the bridge and stated, “reducing the distance now” as the speed over ground increased to 1.3 knots. The bridge team members acknowledged the third officer’s estimated distances to Pier 90 from the port and starboard mooring platforms but did not cross-check his estimates with the increasing headway of the ship.

At 0549, the pilot said, “stop the bow,” meaning stop thrusting the bow, and requested “a little stronger astern.” Immediately thereafter, the third officer reported the distance to Pier 90 as “one five” meters. The rate of turn to starboard was 14 degrees per minute with a ground speed of 1.2 knots and a heading of 050 degrees. About 15 seconds later, the third officer reported they were “getting really close,” to which the pilot immediately responded with a request to “back; go back.”

At 0549, at a speed of 1.4 knots over ground ahead, on a heading of 054 degrees, the Carnival Horizon’s bow struck the second and third levels of Pier 90’s facility and parking garage. The pilot immediately ordered the azipods stopped, the bow thrusters full to port, and the JRT Moran to push full ahead from the starboard bow. With the pilot continuing at the conn, the docking manoeuvre was completed without further incident, with all mooring lines secured and the vessel starboard side alongside Pier 88 at 0618.

No one was injured in the accident nor did any pollution occur. Post-accident alcohol and drug testing was conducted on relevant crewmembers of the Carnival Horizon, the two pilots, and the JRT Moran crew as required. All results were negative.

The damage to the southwest corner of Pier 90 was structural and electrical, with concrete slab damage to the second and third levels. Three metal support beams and parking level concrete slabs totalling 250 cubic feet needed short-term repairs. On the Carnival Horizon a forward mast light on deck 4 was struck down, one of its posts ripped off from the main deck, and the three other posts completely buckled at the base. An associated roughly 8-inch-square hole was found in the deck plating; the plating had ripped out and was attached to the dislodged post of the light mast. The top plate of the bulwark on deck 4 between frames 409 and 410 was indented downward, and the associated centre bulwark and horizontal stiffeners were found slightly bent.

The NTSB noted that Carnival’s navigation policy required closed-loop communication and a process called “thinking aloud,” meaning “sharing verbally a mental model of the current situation and future situations,” which allowed for greater situational awareness of the bridge team, while closed-loop communications ensure that when an order or request was made, the person executing it understood and acknowledged that order.

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

The NTSB said that the ship’s bridge team could have been more effectively engaged in the ship’s manoeuvring to the dock.

The Metro docking pilot was conning the vessel, and the master was focusing on the starboard side, concerned about the ship being set onto the corner of Pier 88 due to the ebb current. Although Carnival’s navigation policy and task assignments required monitoring of the person conning the vessel, cross-checking of the ship’s position, and predicting track and headway, there was no evidence that any bridge team member probed or alerted the master and pilot of the headway of the vessel toward the corner of Pier 90.

2018-built, Panama-flagged, 133,596 gt Carnival Horizon is owned by Carnival Cruise Line care of manager Carnival Corp of Doral, Florida, USA. It is entered with Steamship (Americas Syndicate), UK Club (Americas G7 area group) and Gard P&I. It is entered for H&M with Royal & Sun Alliance, with Gard having a subscription position.

https://www.ntsb.gov/investigations/AccidentReports/Reports/MAB1929.pdf