NTSB: Ferry crash caused by
malfunction
Deductive / Inductive Reasoning
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Deductive
reasoning
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Inductive
reasoning
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The malfunction of a solenoid in the
propulsion system rendered one of the ships propellers unresponsive to
propulsion commands (Valid reasoning if the solenoid is the sole control of
the propellers)
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The ferry Andrew Barberi slammed into
the St George terminal (strong argument, dock damage, injury to persons)
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An audio / visual alarm to warn the
crew if the propeller was not responding may have prevented the incident (Valid
the ferry could have been steered away from the dock if there was time)
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Pilot house crewmembers were unaware
of the loss of propulsion control (weak reasoning, ferry speed would be
visual if the crewmembers were watching)
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Audio visual alarms are not required
on vessel types such as the Barberi (invalid, even though audio visual alarms
are not required, they can still be fitted as a safety devise)
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Andrew Barberi was involved in a
previous incident in 2003 (weak reasoning, the previous accident had no
bearing on this accident)
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Safety management systems had improved
since the 2003 incident (invalid, safety management systems couldn’t have
prevented engineering design / mechanical failures)
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