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the following came from:
http://www.ntsb.gov/itsa/bridge_communication_failures_le.htm

BRIDGE COMMUNICATION FAILURES LEAD TO QE2 GROUNDING: Failures by the pilot
and master of the Queen Elizabeth 2 to exchange critical information have
been cited as the probable cause of the ship's 1992 grounding off the coast
of Massachusetts, according to the NTSB. The vessel sustained $13.2 million
in damages as a result of the incident.

The QE2 ran aground 2.5 miles south of Cuttyhunk Island the evening of
August 7 after the ship's pilot and master failed to agree in advance on a
navigation plan for departing Vineyard Sound, according to the NTSB. It said
the crew also failed to maintain situational awareness after an unplanned
course change. A lack of information available to the crew about how speed
and water depth would affect the QE2's underkeel clearance contributed to
the accident, the Safety Board added.

The 963-foot long QE2, with 2,827 passengers and crew on board, was leaving
Vineyard Sound off the northwest coast of Martha's Vineyard when it struck a
rocky shoal.

The Safety Board concluded that the grounding would probably not have
occurred had a conference been held between the QE2's master and the state
pilot. Such a discussion would have made the master aware of the pilot's
intentions and would have permitted the two to agree on an appropriate route
to the pilot's disembarkation point.

The Safety Board said passengers who boarded the QE2 at Halifax had not
received a comprehensive safety briefing, nor did they participate in an
emergency drill. It said disabled passengers who travel by ship may require
additional precautions to prepare them to act in an emergency.

As a result of the accident, the NTSB issued 10 recommendations to the U.S.
Coast Guard concerning bridge resource management training, vessel
maneuvering information and procedures, safety briefings and emergency
drills for passengers, and toxicological testing following accidents.
Related recommendations were issued to Cunard Lines Ltd., operator of the
QE2, and the Massachusetts Pilots Commission.

The Safety Board recommended that NOAA include depth survey information,
such as descriptions of survey methodology and the dates of surveys, in the
"U.S. Coast Pilot" and on coastal charts.


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