collision, allision, carnival

The NTSB released their report on the allision of the Carnival Pride cruise ship with the pier in Baltimore last may. It caused over $2 million in damages to the pier and the ship, and crushed several vehicles when the passenger access gangway collapsed onto them. Luckily, no one was under or on the walkway when it fell.  You can read the report here.

Pride

The report found that the second in command was conning the ship at the time.  He had too much speed and was at the wrong angle when he was approaching the pier.  The report states that the accident occurred because the captain misjudged the power available when shifting to an alternate method of control to stop the ship.  It states there may have been a problem with the controls, or maybe just human error.  It also concluded that the passenger gangway was extended into the path of the ship, and that it did not have to be extended until ready for passengers to debark.

collision, allision, carnival

Gangway collapse after allision

While I’m sure these findings are true, I wonder what the actual root causes would be?  If the findings are read as written, we are really only looking at Causal Factors, and only a few of those to boot.  Based on only this information, I’m not sure what corrective actions could be implemented that would really prevent this in the future.  As I’m reading through the report, I actually see quite a few additional potential Causal Factors that would need to be researched and analyzed in order to find real root causes.

YOUR CHALLENGES:

  1. Identify the Causal Factors you see in this report.  I know you only have this limited information, but try to find the mistakes, errors, or equipment failures that lead directly to this incident (assuming no other information is available)
  2. What additional information would you need to find root causes for the Causal Factors you have identified?
  3. What additional information would you like in order to identify additional Causal Factors?

Reading through this incident, it is apparent to me that there is a lot of missing information.  The problems identified are not related to human performance-based root causes; there are only a few Causal Factors identified.  Unfortunately, I’m also pretty sure that the corrective actions will probably be pretty basic (Train the officer, update procedure, etc.).

BONUS QUESTION:

For those that think I spelled “collision” wrong, what is the meaning of the word “allision”?  How many knew that without using Google?