NTSB published the accident report of the passenger ferry “Commodore” on the East River near Bushwick Inlet off Brooklyn, New York, when the vessel lost primary steering and speed control to both of its port hull water jets and then grounded.
The incident
After 4 days idle at the pier per the normal schedule, the Commodore was scheduled to operate on June 5, 2021. About 1533, the Commodore departed the Sandy Hook Ferry Landing in Sandy Hook, New Jersey, with 107 passengers and 7 crew, en route to the East 35th Street NYC Ferry Terminal along the East River in midtown Manhattan.
The Commodore’s crew consisted of a captain, mate, engineer, and four deckhands. This was the vessel’s second transit to the East 35th Street terminal and the sixth overall arrival/departure terminal for the crew that day.
The captain undocked the vessel from the Sandy Hook Ferry Landing from the port wing control station. Shortly after departure, the captain transferred control to the main control station, operating in hand mode.
The transit was uneventful, and the vessel passed under the Brooklyn Bridge about 1603. A few minutes later, at 1607:09, while the vessel was transiting full ahead in a northerly direction in the East River about 1.3 miles from the East 35th Street terminal, the jet alarm panel actuated, providing audible and visual (flashing light) indicators that “control failure” had occurred in both the Port Jet Outer 1 and Port Jet Inner 2 water jet systems.
At the same time, display screen main A went blank. The vessel’s automatic identification system (AIS)-recorded speed at the time was 37.9 knots with a heading of 015°.
The vessel’s closed-circuit television (CCTV) on the bridge captured the captain and mate, who were seated at the main control station, as they sprang up from their chairs and looked at the main control console, assessing the situation.
The CCTV showed that neither the captain nor the mate silenced the control failure alarms on the jet alarm panel immediately following their activation or throughout the event.
Twelve seconds later, at 1607:21, the captain pulled both thrust levers back to the zero position (neutral), attempting to slow the vessel. The starboard water jets slowed from 1,750 rpm to 970 rpm, but the port water jets remained full ahead at 1,750 rpm, and the vessel immediately began turning to starboard.
According to AIS, the Commodore’s speed was reduced to about 16.9 knots with a heading of 076°. The captain tapped on the main B touchscreen and noticed two red triangles were flashing over the port water jet icons. He pressed on one of the two red triangles, attempting to “reconnect the water jet controls” to regain control, but he quickly realized that the system was not available because the water jet reconnect icon was “not flashing green.”
Seconds later, at 1607:45, the captain grabbed the thrust levers again and placed them in full reverse. The starboard-hull jets responded to the command inputs by lowering their reversing buckets and increasing the starboard engines’ rpm to about 1,400, providing full reverse thrust.
The port water jets and engines did not respond to the command inputs and remained at full ahead with their buckets raised. The vessel continued in a starboard turn. Seconds later, the mate announced via the vessel’s intercom for passengers to “take their seats” and “please remain seated.”
The captain told investigators that he then placed the throttles and steering controls in “harbor [auto] mode.” At 1608:08, both starboard engines reduced from 1,400 rpm to 750 rpm after the captain pulled the joystick backward, attempting to reverse the thrust direction on all water jets to stop the vessel’s forward movement. The main A display screen was still blank.
About 10 seconds later, the captain left the main control station and ran to the port wing station. At 1608:40, the captain transferred control to the port wing station via the port wing touchscreen display and tapped on one of the red triangles, again attempting to reconnect the water jet controls.
However, the captain told investigators that the system would not reconnect. The captain placed both thrust levers in the full reverse position and pushed the steering tiller hard to port. He told investigators that he believed he received the same nonresponse that he had received at the main control station.
Still in a starboard turn, the Commodore approached the entrance to Bushwick Inlet on the Brooklyn side of the East River, where the riverbank was predominated by seawalls and facilities.
At 1608:55 the mate again announced over the intercom to “please remain seated.” The vessel entered the mouth of the Bushwick Inlet, and at 1608:58 the port hull first struck the inlet’s old pilings, riprap, and bottom on the northern portion of the inlet entrance at 8.8 knots.
The starboard hull then contacted old, submerged pilings and riprap along the southern shoreline as the vessel passed over them. The port engines continued at 1,750 rpm, and the starboard engines continued at 750 rpm, as the vessel moved farther along the inlet’s southern shoreline and slowed.
At 1609:03, the captain left the port wing station and returned to the center console to transfer control back to the main control station via the main B display screen. He attempted several times to reconnect the port water jets without success.
Analysis
#1 Operator Actions:
Based on investigators’ review of CCTV footage, the captain was focused on the reconnection of the port water jets’ controls. He told investigators he believed that the main A display screen temporarily lost communication and would reconnect and restore steering and propulsion control.
Neither the captain nor the mate looked at or silenced (via the jet alarm panel) the control failure alarms for the two port water jet systems on the jet alarm panel to the left of the captain’s chair.
When the captain pulled the throttles and joystick back, the vessel did not respond as he expected and began to turn, and he could not determine why he was unable to regain control in the short time before the vessel entered Bushwick Inlet and then grounded.
Had the captain or mate recognized the control failure alarms and understood that they indicated the loss of primary control for the port engines and water jets, they would have realized that attempting to reconnect the primary control system would not work.
Per Seastreak’s SMS, in the event of an electrical failure in the main control system, the vessel could be operated by the back-up system. The SMS also contained instructions for manually steering the vessel, slowing down, and speeding up using the hydraulic control valves.
The captain should have transferred control from the primary controls to the back-up controls and maneuvered the vessel using hydraulic control valves.
However, the captain attempted to regain control by trying to reconnect the primary control system at both the main control station and port wing station.
He pulled back on the throttles, then put them in reverse, then tried to gain control by shifting into another operation mode. With only the starboard-hull jets and engines responding, the captain’s actions initiated and maintained a starboard turn and reduced the vessel’s speed.
#2 Training and Oversight: Following the casualty, the manufacturer of the control system concluded that the system bridge displays showed active failures, indicated by a red tab in the upper part of the display screen, for several days before the casualty.
Seastreak’s SMS required that, as part of vessel start-up, operators check that no system warnings or alarms were indicated in the control system display panels. However, the Commodore crew made several transits on the day of the casualty, and there was no indication that they identified or reported the active failures.
Had the active failures been identified and reported to the company, the company would have had an opportunity to take action. They may have attempted to troubleshoot, or they could have taken the vessel out of service.
They also could have contacted the manufacturer who may have resolved the problem with the SD card before it led to failure of the control system. An effective SMS would have ensured personnel were able to identify critical system alarms and knew how to address them.
The captain had means to control the vessel following the loss of primary control of the port hull’s engines and water jets, but he did not take the specific action required to gain control.
Crews should train and conduct emergency drills to appropriately respond when a primary control system failure occurs and use the back-up system to maneuver the vessel.
Vessel owners and operators should continuously evaluate vessel-specific operations and procedures and improve training programs to ensure effectiveness of crew drills and best practices.
Probable Cause
The National Transportation Safety Board determines that the probable cause of the grounding of the passenger ferry Commodore was the loss of the primary control system for the catamaran’s port water jets and propulsion engines due to a flaw in the system manufacturer’s software causing a memory card failure.
Contributing to the casualty was the company’s lack of clear safety management system procedures for primary control system failure and ineffective oversight of crew training on failure modes for loss of propulsion and steering control, resulting in the captain not identifying the nature of the loss of control and either engaging back-up control or using emergency engine shutdowns to stop the vessel.
Lessons learned
#1 Training for Loss of Propulsion and Steering: The loss of propulsion and steering control while transiting in channels or maneuvering near immediate hazards (grounding, traffic, objects), when response time is critical, demands crewmembers act quickly to mitigate potential casualties.
Safety management systems should identify potential failure modes and specific responses.
Effective company training on the loss of propulsion and steering controls builds crew confidence and proficiency and improves a crew’s ability to respond during an actual emergency.
Training should include requirements for the practical demonstration of loss of control procedures and use of emergency back-up systems. Vessel owners and operators should continuously evaluate training programs to ensure effectiveness of drills and implement changes to improve safety management system procedures.
EXPLORE MORE AT ntsb’S accident REPORT
standard emergency initiative guidelines(emergency stopped procedures) must be posted close to console monitor at the bridge. Inform emmediately duty Engineer for specific evaluation and action to be taken. Use single engine to avoid unbalance propulsion power output. Shift to manual system to avoid electronic or automation system signal failures.