NTSB recommends propeller alarms after Staten Island Ferry probe

A Staten Island Ferry crash that injured 50 people in 2010 was caused by a solenoid failure that led to a loss of propulsion control in a cycloidal propeller, the National Transportation Safety Board (NTSB) said.

As a result of the accident, the NTSB recommends that passenger vessels be equipped with alarms that would warn the crew if propeller response doesn’t match commands from the bridge.

Andrew J. Barberi went out of control and crashed into its dock at St. George Ferry Terminal on May 8, 2010. Three passengers were seriously injured and 47 other people were hurt. In April 2012, the NTSB released a summary report stating that one of the 310-foot vessel’s two propellers behaved in an unusual manner without the captain’s immediate knowledge.

“A solenoid failure in a propulsion control panel on board the Andrew J. Barberi rendered one of the vessel’s two propellers unresponsive to propulsion commands from the pilothouse. The pilothouse crewmembers were unaware of the loss of propulsion control until seconds before the accident and, as a result, they were unable to take effective action to avoid the allision,” the NTSB report said.

“Had the Andrew J. Barberi had an audible and visual alarm to alert the pilothouse crewmembers to the loss of propulsion control, they may have been able to avoid the allision by implementing emergency response procedures,” the report said.

Investigators found that the ferry engineers had never changed the oil filters in the propulsion units, according to a Coast Guard marine safety alert in 2010. Lube oil samples were “highly contaminated,” and spool valves failed to operate as designed. Some were sluggish or stuck in various positions.

The vessel’s maintenance program did not include any instructions for routine replacement of the canister filters, and no one noticed. The safety alert urged all vessel operators to perform a “preventative maintenance gap analysis” to ensure that no vital procedures are being skipped.

The recent NTSB report did not specify whether the lack of filter maintenance contributed to the crash.

Passenger vessel safety consultant Clark Dodge, a former Washington State Ferries chief engineer, said the accident “should never have happened.” Failing to change oil filters and analyze oil quality is asking for trouble. Most ferries are equipped with alarms that warn the captain of any propulsion anomalies, said Dodge, who was not involved in the Barberi case.

“In my wildest dreams, I cannot imagine a filter not being changed on a schedule,” Dodge said. “You don’t run things down until they break. And you study the results. We cut the filter open and looked at it. We even went so far as putting a date on the filter with a marker” indicating when it should be changed.

“An oil analysis on this ferry would have showed the problem long before it was a problem,” he said. “A lot of companies think they don’t need to do that — that it’s a waste of money. … They think they’re saving money; then something like this happens.”

The way to prevent both problems is to ensure that there is good teamwork from the start of the design and shipbuilding process, Dodge said. That’s where the chief engineer must be closely involved with the director, captain, designer and builder, and the group should not be tempted to pinch pennies on alarms. They should make sure the maintenance manuals include everything they’re supposed to include.

Officials at the New York City Department of Transportation, which operates the Staten Island Ferry, declined to be interviewed for this article, said department spokesman Nicholas Mosquera. In a prepared statement, the department noted that the NTSB praised the ferry system’s safety management system. The department has agreed to install warning alarms on Barberi and the identical Samuel I. Newhouse.

“Following the hard landing, ferry engineers in 2010 replaced the mechanical unit that failed on the Barberi as well as similar units elsewhere on that vessel and aboard the sister ship in its class,” the statement said. “Beginning this summer, the ferries will be equipped with newer digitally controlled units with alarms.”

Barberi’s safety management system stemmed from a worse crash in 2003 that killed 11 passengers. The NTSB emphasized that emergency procedures benefited passengers in the 2010 incident.

“Our investigation showed positive safety improvements following the 2003 accident, in particular the … industry-leading safety management system,” said NTSB Chairman Deborah Hersman.

The NTSB recommends that all passenger vessels implement a safety management system.

The report said the Coast Guard should “require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response.”

Existing passenger vessels, “where feasible,” should be retrofitted with such alarms, the NTSB said.

By Professional Mariner Staff