Background: The cruise ship NORWEGIAN SKY while approaching the Strait of Juan de Fuca en route to Victoria, B.C. with 2,975 persons, made a sudden unexpected hard turn to port. The vessel was operating on trackpilot when it suddenly received a signal to go to a new heading of 270 instead of the intended track of 090. The NACOS 45-3 Trackpilot navigation system had received an erroneous signal either due to equipment malfunction, or human error, or both. This caused the vessel to take an unexpected and violent turn. The vessel healed to starboard at least 8 degrees while rudder movements fluctuated between amidships and port 45 until the swing of the vessel was controlled using the non-follow up control at the main steering console on the bridge. 78 persons were injured, most of them resulting from the falling of unsecured objects such as arcade games, display cases, and tables. The technician called in to troubleshoot the Trackpilot system was unable to replicate the occurrence.

Lessons Learned: While the casualty investigation for the NORWEGIAN SKY is ongoing, there are several initial “Lessons Learned” that can be shared as follows:

1. Securing for Sea

Owners and operators of passenger vessels should review procedures and processes to ensure that t large items of equipment and other heavy objects are adequately secured to prevent movement or toppling in the event of sudden or violent ship movements. Of particular concern are video games and other large items found in children's recreation spaces, casino equipment, display cases and individual shelving (especially glass) within retail stores, or any other heavy objects that could shift or topple during a sudden or violent movement of the ship.

2. Trackpilot Systems

Trackpilot systems are complex navigation systems designed to be used in confined waters. Training and familiarity with the system are an important component of their safe use. Trackpilot malfunctions, in certain close quarter scenarios or heavily trafficked waterways, could result in a serious marine casualty such as a grounding or collision. Trackpilots have operational limits such as rudder limits that must be established and activated once the trackpilot is engaged. For example, proper rudder angle settings would limit the rudder to small course change increments even if a large variance in input data is perceived by the sensors. Trackpilot’s should be capable of being disengaged instantly in the event of a malfunction or improper operation. Owners and operators of passenger vessels should develop operational guidance and training programs to assure proper and correct trackpilot programming, crew familiarity and should develop and test contingency plans to assure proper crew response in the event of a trackpilot malfunction or failure.

-- Rich Marsh (, August 13, 2001


Good find. Just to be clear, the original incident referred to in the Coast Guard report was back in May of this year. I thought it was mentioned here on GICC but I couldn't readily find the posting in the archives.

For background on this specific 850-foot ship, see

Note, the vessel was launched in 1999.

Basically (like all these chips), this is a large hotel turned on its side and set loose upon the waves. As noted in the above Coast Guard report, seems like they forgot thay were a maritime vessel first, and a hotel second. I can't imagine not having everything bolted down, no matter how stable a large cruise ship may usually seem.

Here's a news item (, via their search engine) as a reminder of the incident in May. Interesting that the initial speculation focused on possible "natural" causes (wind, narrow channel, lots of other traffic) and not the fundemental problem, the computer autopilot run amok.

[begin news article]

Headline: Cruise ship's tilt terrifies passengers -- 16 injured off B.C. coast

Source: 21 May 2001, National Post, with files from The Canadian Press

U.S. coast guard officials say a 2,000-passenger cruise ship that listed sharply while executing a turn off the coast of British Columbia on Saturday, sending 16 people to hospital in Victoria, had its autopilot disengaged.

"This action caused the rudders to swing and the ship to momentarily swerve," Norwegian Cruise Lines said yesterday. "The ship's course was immediately corrected and manual operations commenced."

The accident occurred on Saturday at about 2 p.m., in high seas and in gale-force winds in the Strait of Juan de Fuca.

"People were flying around in chairs. I was afraid for my life," said Sharon Suttle, a travel consultant manager from Greensboro, N.C., interviewed at the dock in Seattle.

The gift shop was completely destroyed when the 77,000-tonne ship listed, she said.

"We were up on the 11th floor, in the cafeteria, and we'd just gotten in line to get our trays," Jean O'Neal, another passenger, told a local television station. "All of a sudden, the dishes and trays came forward, and we tried to hold them back. They just kept coming forward. They hit me and pushed me clear across the room."

Added Alice Crady, who was on the ship with her husband: "It really felt like it was going to tip over."

There were no life-threatening injuries, although some passengers were treated for broken bones, said Richard Reeve, maritime co- ordinator for the Canadian Coast Guard in Victoria. The cruise line arranged for the injured passengers to be transported from the dock to hospitals in Victoria. The ship then continued its journey to Seattle, where investigators boarded the ship to determine the cause of the accident.

The Norwegian Sky was returning from Alaska when the accident occurred in the strait on the Canada-U.S. border.

The area, where the open Pacific Ocean meets the shallower waters of the strait, can be difficult to navigate, said Mr. Reeve. The narrow passage creates a wind-tunnel effect, and there is often a lot of traffic merging in the area. To enter the strait, ships travelling southbound must turn sharply east.

"It's a place you watch out for," he said.

Large cruise ships, with multiple decks that tower above the water, tend to be more vulnerable to high winds than other vessels. The Sky, according to the company's Web site, has 12 decks.

Some of the passengers refused to reboard in Victoria, the TV station said.

-- Andre Weltman (, August 14, 2001.

Uh, "like all these SHIPS," not "CHIPS."

Must be Dr. Freud at work.

-- Andre Weltman (, August 14, 2001.

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