Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was the application of left rudder by the helmsman of the Seadaniel when the pilot had ordered right rudder. Contributing to this accident was the failure of the ship's officers on the bridge to take any positive action to correct the helmsman's error and the failure of the pilot and master to more closely observe the helmsman's responses to rudder orders in this close quarters situation.
Recommendations
As a result of this accident, the National Transportation Safety Board made the following recommendations:
—to the owners of Testbank:
- Whenever possible, considering the various requirements for vessel safety and ports of call, require that containers with dangerous cargo carried on your vessels be stowed as near the centerline as possible, if "on-deck" stowage is utilized. (Class II, Priority Action) (M-81-36)
—to the U.S. Coast Guard:
- In conjunction with the Materials Transportation Bureau and the National Cargo Bureau, Inc., conduct an evaluation of the requirement for the stowage of containerized dangerous cargo and, if practicable, require that "on-deck" containerized cargo be stowed as close to the centerline as possible. (Class II, Priority Action) (M-81-37) If stowage of containerized dangerous cargo near the centerline is found to be practical, bring such a requirement to the attention of the appropriate IMCO subcommittee for adoption on the international level. (Class II, Priority Action) (M-81-38) Conduct an analysis of Mississippi River Gulf Outlet Canal traffic and economics to determine if restricting major vessel traffic to owe-way operation for designated time periods and in particular locations during dangerous cargo transit is warranted. (Class II, Priority Action) (M-81-39)
—to the Materials Transportation Bureau:
- In conjunction with the U.S. Coast Guard and the National Cargo Bureau, Inc., conduct an evaluation of the requirement for the stowage of containerized dangerous cargo and, if practicable, require that "on-deck" containerized dangerous cargo be stowed as close to the centerline as possible. (Class II, Priority Action) (M-81-40)
—to the National Cargo Bureau, Inc.
- In conjunction with the U.S. Coast Guard and the Material Transportation Bureau, conduct an evaluation of the requirement for the stowage of containerized dangerous cargo and, if practicable, require that "on-deck" containerized dangerous cargo be stowed as close to the centerline as possible. (Class II, Priority Action) (M-81-41)
