Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 1 of 205 CONFIDENTIAL June 21, 2018 UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF FLORIDA Case No.: 16-20897-CR-SEITZ UNITED STATES OF AMERICA v. PRINCESS CRUISE LINES, LTD., Defendant. ________________________________/ FIRST ANNUAL REPORT OF THE COURT APPOINTED MONITOR (2017-2018) I. TABLE OF CONTENTS Executive Summary .............................................................................................................. 1 A. CAM Findings: Progress .................................................................................................... 3 B. CAM Findings: Unresolved Barriers and Opportunities for Improvement ....................... 4 II. Introduction and Background ............................................................................................. 5 A. Overview of CAM Annual Report ..................................................................................... 5 B. History of Vessel Pollution Cases ...................................................................................... 6 C. History of Current Case ..................................................................................................... 8 1. Criminal Conduct ....................................................................................................... 8 2. Guilty Plea, Conviction, and Judgment ................................................................... 10 3. Court Oversight........................................................................................................ 11 D. Regulatory Regime .......................................................................................................... 12 III. Company Capabilities to Meet ECP Objectives: Progress ............................................. 13 A. No Repeat of the Underlying Offenses ............................................................................ 13 B. Substantial Implementation of Enumerated ECP Year One Requirements ..................... 13 C. Qualified and Dedicated Compliance Personnel ............................................................. 14 D. Employee Cooperation and Awareness of Environmental Obligations........................... 16 E. Initiatives Beyond the Enumerated ECP Requirements................................................... 19 F. CSMART Training Center ............................................................................................... 21 G. Review and Improvements to Internal Investigation Process .......................................... 23 H. Culture Survey ................................................................................................................. 24 i Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 2 of 205 CONFIDENTIAL June 21, 2018 IV. Company Capabilities to Meet ECP Objectives: Unresolved Barriers and Opportunities for Improvement ........................................................................................ 25 A. Challenges of the Complex Corporate Structure ............................................................. 25 1. Lack of Centralized Policies, Practices, and Procedures ......................................... 26 2. Lack of Clarity as to Responsibility, Accountability, and Authority for Environmental Compliance ..................................................................................... 27 B. Blame Culture and Lack of Learning Culture .................................................................. 30 C. Ineffective Internal Investigations.................................................................................... 33 1. Background .............................................................................................................. 33 2. Observations ............................................................................................................ 35 3. Investigation Illustrations ........................................................................................ 36 D. Environmental and ECP Violations ................................................................................. 40 V. 1. Environmental Incidents .......................................................................................... 40 2. Failure to Provide CCM with ECP-Required Authority.......................................... 42 Environmental Incidents .................................................................................................... 42 A. Incident Reporting Mechanisms ...................................................................................... 42 B. Data Analysis of Incident Reports ................................................................................... 43 1. Context and Significance ......................................................................................... 43 2. Recurrent Incident Categories ................................................................................. 44 3. Recurrent Incident Examples ................................................................................... 46 C. Data Analysis ................................................................................................................... 55 VI. Evaluation of the TPA ........................................................................................................ 58 A. Engagement with the TPA ............................................................................................... 58 B. TPA Audit Process .......................................................................................................... 59 C. TPA Audit Reports........................................................................................................... 60 D. TPA Receptiveness to CAM Feedback ............................................................................ 61 VII. Evaluation of Internal Audit Function ............................................................................. 61 A. Overview of Internal Audit Process ................................................................................. 61 B. CAM Assessment of Internal Audits and Audit Reports ................................................. 63 1. Shipboard Audits ..................................................................................................... 63 2. Audit Reports ........................................................................................................... 64 3. Employee Interviews ............................................................................................... 65 ii Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 3 of 205 CONFIDENTIAL June 21, 2018 C. TPA Assessment of Internal Audit Function ................................................................... 67 D. Overall CAM Observations ............................................................................................. 67 VIII. Areas of Focus for Year Two ............................................................................................ 68 A. Culture Survey ................................................................................................................. 68 B. Investigations ................................................................................................................... 69 C. Training ............................................................................................................................ 69 D. Resources for Operations and Compliance ...................................................................... 70 E. Shoreside Support for Vessels ......................................................................................... 71 F. Personnel .......................................................................................................................... 72 1. Environmental Officers............................................................................................ 72 2. Engineers ................................................................................................................. 73 3. Ratings ..................................................................................................................... 73 G. Company Vessel Visit Programs ..................................................................................... 73 Appendix A: CAM’s Methodology and Activities Appendix B: Notable Company Initiatives Beyond Enumerated ECP Requirements Appendix C: Organizational Charts Appendix D: Status of ECP Year One Requirements Appendix E: ECP Year One Incidents Tracked by the CAM Attachment 1: Superseding First Annual Work Plan and Budget of the Court Appointed Monitor iii Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 4 of 205 CONFIDENTIAL June 21, 2018 I. EXECUTIVE SUMMARY The defendant in this case is Princess Cruise Lines (“Princess”). Princess is a wholly- owned indirect subsidiary of Carnival Corporation & plc (“Carnival Corp.”), “the world’s largest leisure travel company.” http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irolprlanding. Carnival Corp. currently is structured to include four groups or operating lines that each operate one or more brands: (1) Holland America Group, which manages the Princess, Holland America Line, Seabourn, and P&O Australia brands; (2) Carnival Cruise Line, which manages the Carnival Cruise Line brand; (3) Carnival UK, which manages the Cunard and P&O Cruises UK brands; and (4) Carnival Maritime Group, which manages the Costa Cruises (“Costa”) and AIDA Cruises (“AIDA”) brands. Carnival Corp. also maintains an office in Miami, Florida that, among other functions, “monitors and supervises environmental, safety, security, and regulatory requirements for Princess and other Carnival brands.” Joint Factual Statement, Dkt. No. 2-1 (“Joint Factual Statement”) at 1. On December 20, 2016, Princess pleaded guilty to seven felony counts arising out of vessel pollution and efforts to conceal that pollution carried out on the Caribbean Princess from 2005-2013: one count of conspiracy; four counts of failure to maintain accurate records; and two counts of obstruction of justice. According to the Joint Factual Statement, four other ships in the Princess fleet are known to have engaged in similar practices. This was not the first violation by a Carnival Corp. entity. Notably, in 2002, Carnival Corp. pleaded guilty to six felony counts after falsifying records to conceal vessel pollution on six ships, and an Environmental Compliance Plan (“ECP”) was imposed as a condition of probation (“2002 ECP”). The 2002 ECP began applying to all Princess ships in 2003, following a merger of Carnival Corporation 1 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 5 of 205 CONFIDENTIAL June 21, 2018 and P&O Princess Cruises. At the time the illegal activity on the Caribbean Princess began in 2005, the ship was still subject to the 2002 ECP. On April 19, 2017, this Court sentenced Princess to pay a $40 million criminal penalty and to serve a five-year term of probation. Among the Special Conditions of Supervision, Princess and Carnival Corp. must fund, implement, and abide by an ECP for five years. The terms of the ECP apply to all of the Company’s ships authorized to operate in United States waters (seventy-five ships as of the end of ECP Year One) and to all shoreside employees and shipboard crews involved with the operation and technical management of those ships. The Company also must retain an outside independent third party auditor (“TPA”) and fund a court appointed monitor (“CAM”) to report to the Court and the Office of Probation. The ECP provides that “[d]uring the entire probationary period, a CAM shall monitor [the Company’s] compliance with this ECP.” ECP § VI.A. During ECP Year One,1 the CAM Team visited more than twenty vessels and shoreside offices, conducted hundreds of interviews, and reviewed thousands of documents. See Appendix A. Based on its review, the CAM made the following findings regarding the Company’s capabilities to meet ECP objectives and attain continuous improvement:2 1 ECP Year One is April 19, 2017 through April 18, 2018. ECP Year Two is April 19, 2018 through April 18, 2019. 2 The CAM provided the Company and the United States Department of Justice (“DOJ”) a copy of this CAM Annual Report in advance of its submission and received comments from both parties. The CAM took these comments into account; however, the comments did not alter the substance of the Report. The Company also has indicated that it may provide additional comments to the Court in a separate filing. 2 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 6 of 205 CONFIDENTIAL June 21, 2018 A. CAM Findings: Progress The CAM’s findings related to the Company’s progress regarding ECP objectives are: (1) No Repeat of the Underlying Offenses. The CAM is not aware of any Covered Vessels3 having repeated the conduct for which the sentence was imposed. Specifically, there were no known instances during ECP Year One of intentional bypass of pollution prevention equipment to discharge oily waste water coupled with falsification of records and conspiracy to conceal such illegal acts.4 (2) Substantial Implementation of Enumerated ECP Year One Requirements. The Company appears to have substantially implemented the many ECP Year One requirements, such as installation of seals and locks, delivery of training, and development of a sampling program, which required the efforts of hundreds of employees, on ship and on shore. (3) Qualified and Dedicated Compliance Personnel. The ECP requires the Company to appoint a Corporate Compliance Manager (“CCM”), and Operating Line Compliance Managers (“OLCMs”). The Company selected a CCM and OLCMs with significant maritime experience and clear dedication to their work. (4) Employee Cooperation and Awareness of Environmental Obligations. Employees, both on ship and on shore, were nearly universally cooperative and forthcoming in their interactions with the CAM Team and the TPA and evidenced broad comprehension of their environmental obligations. Indeed, the CAM learned about significant employee concerns related to compliance during ECP Year One only because 3 Covered Vessels are those vessels that are subject to the ECP—i.e., all oceangoing vessels that are owned, operated, and/or manned by Carnival Corp. and any of its operating lines and that carry a Certificate of Financial Responsibility (“COFR”), except those vessels that have been bareboat chartered to an unaffiliated third party. ECP §§ I.A, I.D, and XI. A COFR is a certificate which demonstrates that a responsible party has the ability to meet its statutory liability limits. It is required by the Oil Pollution Act of 1990 for a ship to enter United States ports. Dkt. No. 58-1 (“Joint Glossary of Terms”) at 3. The list of Covered Vessels has changed throughout ECP Year One. As of April 18, 2018, there were seventy-five Covered Vessels: twenty-six for Carnival Cruise Line; seventeen for Princess; fourteen for Holland America Line; four for Seabourn; four for AIDA; four for P&O Cruises UK; three for Costa; and three for Cunard. See April 2018 USPO Supervision Report, Attachment 4. 4 However, as discussed below under Unresolved Barrier Finding #4 (“ECP Violations”), other types of prohibited discharges and record falsifications have occurred. 3 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 7 of 205 CONFIDENTIAL June 21, 2018 employees were willing to share that information in confidence with the CAM Team.5 (5) Initiatives Beyond the Enumerated ECP Requirements. The Company has implemented a variety of initiatives related to environmental compliance that go beyond the enumerated requirements of the ECP. (6) CSMART Training Center. The Company has used its existing sophisticated training resource, the Center for Simulator Maritime Training (“CSMART”) in Almere, The Netherlands, to implement some of the training required by the ECP. (7) Review and Improvements to Internal Investigation Process. The Company engaged a third party, DNV GL, to assess the Company’s investigation process, identify areas and options for improvement, and identify the stakeholders at Carnival Corp. responsible for performing incident investigations and implementing action plans. The Company has stated it will retain DNV GL to help implement those recommendations. (8) Culture Survey. The Company agreed to the CAM’s request to conduct an environmental compliance culture survey. The goal is for the survey to set a benchmark for the Company’s current culture and identify areas where change and improvement may be needed. B. CAM Findings: Unresolved Barriers and Opportunities for Improvement The CAM’s findings of unresolved barriers and opportunities for improvement are: (1) Challenges of the Complex Corporate Structure. Personnel at almost every level of the Company state that the complex corporate structure and lack of centralization impede efforts towards continuous improvement. They point to a need for greater clarity as to responsibility, accountability, and authority for environmental compliance. The Company also has not given the CCM the ECP-required “authority to ensure full implementation of [the] ECP.” ECP § III.A.2. (2) Blame Culture and Lack of Learning Culture. The Company appears to have a blame culture, with a focus on identifying errors and disciplining individuals rather than also evaluating systemic issues that may need to be addressed. This blame culture was exhibited in the response to the crimes that occurred on the Caribbean Princess, as well as in the response to incidents that have been reported since then. 5 The CAM relies throughout this Report on information gathered from Company employees. Citations to interviews with Company employees do not identify the employee(s) interviewed, and will be referred to as “Employee Interview Notes.” 4 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 8 of 205 CONFIDENTIAL June 21, 2018 (3) Ineffective Internal Investigations. The Company’s internal investigations are critically flawed. There is no consistent, reliable means to investigate incidents or near misses and identify root causes that can lead to meaningful corrective actions.6 (4) Environmental and ECP Violations. During ECP Year One, the Company violated environmental laws and the ECP. See infra, § V and Appendix E. In addition, as discussed above under Unresolved Barrier Finding #1 (“Challenges of the Complex Corporate Structure”), the Company has not given the CCM the “authority to ensure full implementation of [the] ECP” required by ECP Section III.A.2. The CAM appreciates the opportunity to serve the Court in this matter. Additionally, the CAM could not have performed his work during ECP Year One without the extensive support and cooperation of the Company’s employees, both on ship and on shore. The CAM recognizes the significant efforts undertaken by Company employees to implement the ECP. Some of those efforts fell short, but the CAM views the corporate governance and culture issues described above as the more significant barriers to creating a sustainable compliance culture. II. INTRODUCTION AND BACKGROUND A. Overview of CAM Annual Report The Court tasked the CAM to serve as its “eyes and ears” within the Company and to provide the “big picture” of the Company’s compliance efforts. Status Conf. Tr. at 16 (Oct. 18, 2017); Status Conf. Tr. at 45 (Dec. 4, 2017). The TPA’s report provides a more granular review of vessel and shoreside audit findings as to ECP requirements. 6 As noted above under Progress Finding #7 (“Review and Improvements to Internal Investigation Process”), the Company has engaged a third party to assess the Company’s investigation process and identify areas and options for improvement. 5 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 9 of 205 CONFIDENTIAL June 21, 2018 This first CAM Annual Report begins with background regarding past vessel prosecutions and the regulatory regime in which the Company operates. The Report then describes in greater detail the CAM’s findings identified in the Executive Summary, both as to the Company’s progress toward meeting ECP objectives and as to unresolved barriers and opportunities for improvement. These observations provide context for a discussion of environmental incidents identified by the CAM, the TPA, and the Company. The ECP also requires the CAM to assess both the TPA and the Company’s internal audit function. Accordingly, this Report evaluates the performance and independence of the TPA and provides observations on the Company’s internal audit process, which is housed in Carnival Corp.’s Risk Advisory and Assurance Services (“RAAS”) department. Finally, the Report identifies areas of focus for ECP Year Two. B. History of Vessel Pollution Cases Since the 1990s, DOJ has had a “program of prosecuting shipping companies and crew for the intentional discharges of pollutants from ocean‐going vessels.” DOJ, ENRD Accomplishments Report Fiscal Year 2016 at 72, available at https://www.justice.gov/enrd/page/file/925411/download (“ENRD 2016 Accomplishments Report”). Working through the United States Attorneys’ Offices and the Environmental Crimes Section of the Environment and Natural Resources Division (“ENRD”), the Vessel Pollution Initiative has prosecuted individuals and corporations involved in the knowing pollution of the ocean by ships and the knowing falsification of ship records in order to conceal such acts. See DOJ, Vessel Pollution Enforcement (Apr. 13, 2015), https://www.justice.gov/enrd/vesselpollution-enforcement (“DOJ Vessel Pollution Enforcement”). These prosecutions have involved violations of the International Convention for the Prevention of Pollution from Ships 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 10 of 205 CONFIDENTIAL June 21, 2018 (“MARPOL”),7 an international environmental treaty, and associated criminal offenses, such as obstruction of justice, 18 U.S.C. § 1505, false statements, id. § 1001, and conspiracy, id. § 371. Nearly every segment of the commercial maritime industry—including cruise ships, container ships, oil and chemical tankers, and cargo ships—has faced prosecution. In some cases, the same defendant has been convicted more than once. See DOJ Vessel Pollution Enforcement. As of 2016, criminal penalties totaled over $360 million. ENRD 2016 Accomplishments Report at 72 (this amount does not include the $40 million penalty paid in 2017 by Princess). Sentences often have included detailed and complex environmental compliance programs as a condition of probation. These programs have required, among other things, equipment modifications to deter and detect future discharges, outside independent audits, and court appointed monitors. Past vessel pollution cases against major cruise lines have involved facts similar to those in the present case—intentional discharges of oily waste water and falsification of ship records in violation of MARPOL and Title 18 of the United States Code over an extended period of time. Indeed, other Carnival Corp. entities have pleaded guilty to felony charges for similar conduct. In 1998, a Holland America Line company pleaded guilty to felony charges after illegally discharging oily waste water and failing to properly record such discharges on the S.S. Rotterdam. U.S. v. HAL Beheer BV, No. 3:98-cr-00108 (D. Alaska). In that case, the defendant paid $2 million in criminal penalties and agreed to a five-year compliance program to be implemented on all Holland America Line ships. In 2002, Carnival Corp. pleaded guilty to six felony charges after falsifying records to conceal oily waste discharges on six ships. U.S. v. 7 MARPOL is implemented in the United States by the Act to Prevent Pollution from Ships (“APPS”), 33 U.S.C. §§ 1901-12. 7 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 11 of 205 CONFIDENTIAL June 21, 2018 Carnival Corp., No. 1:02-cr-20350 (S.D. Fla.). Carnival Corp. paid $18 million in criminal fines and community service payments and agreed to a five-year, court-supervised ECP for its entire fleet (including Princess ships following a 2003 merger8).9 Examples of similar cruise line prosecutions include: U.S. v. Royal Caribbean Cruises, No. 1:99-CR-00509 (S.D. Fla.); U.S. v. Royal Caribbean Cruises, No. 1:02-CR-20350 (S.D. Fla.); and U.S. v. Norwegian Cruise Lines, No. 1:02-CR-20631 (S.D. Fla.). See Dkt. No. 26 at 9-10. Princess also had at least two other prior environmental convictions: the first, in 1993, for knowingly discharging plastic bags of garbage in the ocean off the Florida Keys, U.S. v. Princess Cruises, Inc., No. 93-6058 (S.D. Fla.); and the second, in 2007, for failing to operate safely in the vicinity of humpback whales in waters near Alaska. U.S. v. Princess Cruise Lines, Inc., No. 3:07-cr-00005 (D. Alaska). It is against this backdrop of numerous prior cases, and the prior court-imposed compliance programs, that the crimes giving rise to the current prosecution occurred. C. History of Current Case 1. Criminal Conduct For approximately eight years, from 2005 until 2013, the Caribbean Princess illegally discharged oily bilge water10 into the ocean through various methods that bypassed or otherwise 8 The 2002 ECP initially applied to Carnival Cruise Line, Holland America Line, and Cunard. In 2003, following a merger of Carnival Corporation and P&O Princess Cruises, see infra, § IV.A, the Company agreed to also apply the existing 2002 ECP to Princess. 9 In a related prosecution in 2004, the former Holland America Line Vice President for Operating Line Compliance pleaded guilty to delivering false reports that indicated that Holland America Line was complying with the audit program required by the 2002 ECP when, in fact, no such program existed. 10 Bilges are the lowest portion of a ship inside the ship hull where liquids, including oil, accumulate. Joint Glossary of Terms at 1. 8 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 12 of 205 CONFIDENTIAL June 21, 2018 defeated pollution prevention equipment, including diluting oily bilge water with sea water when using the Oily Water Separator.11 See Joint Factual Statement at 3. During this time, the ship’s engineers falsified the ship’s Oil Record Book12 to conceal these acts. These crimes were not detected during audits and inspections over the years by various parties, including Company auditors, third party auditors, and government agents. Nor did any of the employees involved come forward, until August 2013, when a recently hired junior engineer walked off the ship in Southampton and informed the United Kingdom’s Maritime and Coast Guard Agency of illegal discharges having been made. Joint Factual Statement at 2. When it was learned that the illegal conduct had been reported, evidence was tampered with or destroyed, and crew members were instructed by senior ship engineers to lie. See id. at 2, 6-7. As a result, witnesses gave false statements during the subsequent United States government investigation. See id. Despite these efforts at obstruction, the federal investigation confirmed the illegal activity on the Caribbean Princess, and also determined that the activity was not an anomaly. Id. at 11. “Four other ‘Grand Class’ vessels in the Princess fleet are known to have engaged in similar practices to the Caribbean Princess [including] with regard to the dilution of oily bilge water with sea water during the use of the oily water separator . . . Those ships were the Golden 11 An Oily Water Separator is a piece of pollution prevention equipment used to separate oil and water mixtures into their separate components. The equipment is designed to produce effluent with oil content not exceeding 15 parts per million, as required by MARPOL Annex I. Id. at 12. An integral part of an Oily Water Separator is an Oil Content Meter, a device that measures and records the oil content in a moving stream of water to determine if it meets regulatory standards prior to discharge. Id. at 8-9. 12 An Oil Record Book is a log in which all of a ship’s overboard discharges of oily waste water, among other items, must be recorded. It is required by MARPOL, Annex I, reg. 17 and 36, as well as United States Coast Guard regulations at 33 C.F.R. § 151.25. Joint Glossary of Terms at 9. 9 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 13 of 205 CONFIDENTIAL June 21, 2018 Princess, Coral Princess, Grand Princess, and Star Princess.” Id. As on the Caribbean Princess, these illegal discharges were concealed, went unrecorded in the ships’ respective Oil Record Books, and no employees are known to have made efforts to stop or report the issues. “Numerous crewmembers were aware of this longstanding practice and the failure to record the discharges in the Oil Record Book, both of which took place over a period of many years.” Id. As described above, the activity on the Caribbean Princess also was not the Company’s first violation. The illegal conduct on the Caribbean Princess began while the ship was still subject to the 2002 ECP imposed as a condition of Carnival Corp.’s probation after pleading guilty to similar environmental crimes.13 2. Guilty Plea, Conviction, and Judgment On December 20, 2016, Princess pleaded guilty to seven felonies arising out of the vessel pollution and efforts to conceal that pollution by the Caribbean Princess: one count of conspiracy in violation of 18 U.S.C. § 371; four counts of failure to maintain accurate Oil Record Books in violation of APPS, 33 U.S.C. § 1908(a); and two counts of obstruction of justice in violation of 18 U.S.C. § 1505. See Judgment, Dkt. No. 30 (“Judgment”) at 1. On April 19, 2017, this Court sentenced Princess to pay a $40 million criminal penalty and to serve a five-year term of probation. The following day, the Court issued a written 13 Company personnel who were present throughout these time periods have stated that corporate leadership on environmental compliance waned following the early termination of the 2002 ECP in August of 2006. As one employee put it, the Company “took their foot off the gas.” See Employee Interview Notes. An analysis of the Caribbean Princess incident prepared by the Company’s Chief Maritime Officer, Vice Admiral William R. Burke (Ret.), also notes that: “Following completion of the previous ECP, the environmental officers were not trained as well and were given additional responsibilities so that they no longer had the knowledge, the focus or the shipboard status to do the jobs we hoped they would. Finally, shore management lost focus on environmental issues.” See Bilge water discharge violation root cause assessment (undated) (provided to the CAM Team by the Company) (“Chief Maritime Officer Root Cause Analysis”). 10 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 14 of 205 CONFIDENTIAL June 21, 2018 Judgement, including Special Conditions of Supervision. Id. As one such Condition, the Company must fund, implement, and abide by an ECP for five years. Id. The Company also must retain an outside independent TPA14 and fund a CAM15 to perform the duties set forth in the Conditions of Supervision and the ECP, and to report to the Court and Office of Probation. Id. 3. Court Oversight i. Quarterly Status Conferences and Status Reports As part of its oversight of the Company’s compliance with the ECP and other conditions of probation, the Court has ordered the Company and the Government (collectively, the “Parties”), as well as the Probation Office, the CAM, and the TPA, to report to the Court on a quarterly basis. Dkt. No. 54. The Court also ordered the Parties to file Joint Status Reports prior to each quarterly Status Conference. Id. Status Conferences have been held on October 18, 2017, December 4, 2017, and April 3, 2018. ii. CAM Reports At the April 3, 2018 hearing, the Parties, the CAM, and the Court agreed that the CAM would prepare CAM Quarterly Reports for the Court, in addition to the CAM Annual Reports. On April 26, 2018, the Court issued an order setting a schedule for CAM Quarterly and Annual Reports and subsequent Status Conferences. Dkt. No. 66. The CAM’s first Quarterly Report is due on September 18, 2018. 14 The TPA is ABSG Consulting, Inc. (“ABSG”), an advisory and technical services provider for the marine and other sectors. 15 The CAM is Steven P. Solow, a partner at Katten Muchin Rosenman LLP (“Katten”). The CAM retained Katten and the marine consulting firm Martin & Ottaway as advisors to the CAM (collectively, the “CAM Team”). 11 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 15 of 205 CONFIDENTIAL June 21, 2018 D. Regulatory Regime Cruise ship companies operate within a comprehensive regulatory regime that reflects the fact that a cruise ship is akin to a floating city. Like cities of comparable size, cruise ships generate a number of regulated waste streams, including garbage, sewage, wastewater, food waste, waste oil, and air emissions. Unlike cities, however, cruise ships face unique challenges when it comes to environmental compliance because they spend most of their time at sea. As Carnival describes in its 2017 10-K: “Our ships are regulated by numerous international, national, state and local laws, regulations, treaties and other legal requirements that govern health, environmental, safety and security matters in relation to our guests, crew and ships. These requirements change regularly, sometimes on a daily basis, depending on the itineraries of our ships and the ports and countries visited.” Carnival 2017 10-K at 22. Carnival goes on to state that: The primary regulatory bodies that establish maritime laws and requirements applicable to our ships include: The International Maritime Organization (“IMO”): All of our ships, and the maritime industry as a whole, are subject to the maritime safety, security and environmental regulations established by the IMO, a specialized agency of the United Nations. The IMO’s principal sets of requirements are mandated through its International Convention for the Safety of Life at Sea (“SOLAS”) and [MARPOL]. Flag States: Our ships are registered, or flagged, in The Bahamas, Bermuda, Italy, Malta, the Netherlands, Panama and the UK, which are also referred to as Flag States. Our ships are regulated by these Flag States through international conventions that govern health, environmental, safety and security matters in relation to our guests, crew and ships. Representatives of each Flag State conduct periodic inspections, surveys and audits to verify compliance with these requirements. Ship classification societies: Class certification is one of the necessary documents required for our cruise ships to be flagged in a specific country, obtain liability insurance and legally operate as passenger cruise ships. Our ships are subject to periodic class surveys, including dry-docking inspections, by ship classification societies to verify that our ships have been maintained in accordance with the rules of the classification societies and that recommended repairs have been satisfactorily completed . . . 12 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 16 of 205 CONFIDENTIAL June 21, 2018 National, regional, state and local authorities: We are subject to the decrees, directives, regulations and requirements of the European Union (“EU”), the U.S., U.S. states and more than 400 other international ports that our ships visit every year. Port regulatory authorities (Port State Control): Our ships are also subject to inspection by the port regulatory authorities, which are also referred to as Port State Control, in the various countries that they visit. Such inspections include verification of compliance with the maritime safety, security, environmental, customs, immigration, health and labor requirements applicable to each port, as well as with regional, national and international requirements. Many countries have joined together to form regional port regulatory authorities. Id. III. COMPANY CAPABILITIES TO MEET ECP OBJECTIVES: PROGRESS A. No Repeat of the Underlying Offenses The CAM is not aware of any evidence of a recurrence on any of the Company’s Covered Vessels during ECP Year One of the same criminal conduct that occurred on the Caribbean Princess. Based on the CAM’s own vessel visits and interviews, a review of the TPA audits, and an assessment of corporate incident tracking, there has been no observed evidence of intentional bypass of pollution prevention equipment to discharge oily waste water coupled with intentional falsification of records and conspiracy to conceal such illegal acts. However, there have been violations of environmental laws and the ECP, including four known instances of record falsification and numerous instances of prohibited discharges. See infra, §§ IV.D and V, and Appendix E. B. Substantial Implementation of Enumerated ECP Year One Requirements The ECP required the Company to implement policies, procedures, training, and changes to equipment. The Company expended considerable efforts to meet the ECP Year One requirements, and has substantially complied with them, as set forth in detail in Appendix D. As a further example of the Company’s efforts, the Company took steps designed to ensure that 13 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 17 of 205 CONFIDENTIAL June 21, 2018 Carnival Cruise Line’s new Carnival Horizon ship, delivered on March 28, 2018, is ECP compliant. These efforts included: performing a vulnerability assessment;16 ordering ECP critical spare parts; providing ECP training to all 1,400 Carnival Horizon team members before the ship’s delivery date; verifying that Health, Environmental, Safety, & Security (“HESS”) systems and procedures were in place; and holding an environmental compliance visit several weeks prior to delivery to oversee ECP implementation and set up training. The Company reports that, despite challenges, these tasks were completed. C. Qualified and Dedicated Compliance Personnel The individuals selected for the CCM and OLCM positions have significant maritime experience and display a commitment to environmental compliance. Each of the OLCMs retains an existing corporate position within the operating line in addition to the ECP-required OLCM position. Chris Donald, Carnival Corp.’s CCM and Vice President of Corporate Environmental Compliance, began his career as a marine engineer in 1997, serving at sea for approximately ten years, including for ExxonMobil, Windstar Cruises, and Holland America Line. Mr. Donald moved shoreside in 2007 to Carnival Corp., where he was involved in policy development and the Company’s internal audit and investigations program, which later became RAAS. See Status Conf. Tr. at 11 (Apr. 19, 2017). He was appointed as the CCM in or around October 2016. 16 For purposes of this case, a vulnerability assessment is a “methodology to identify the pipework connections required to be controlled to prevent unauthorized use, in accordance with [this] ECP.” Environmental Compliance Notice #09-2017-A1 at 2; see also ECP § IX.B.1 (requiring the Company to implement an Environmental Control System “to help prevent unauthorized usage or connections within the engine room and machinery spaces,” and which requires “crew members to use numbered seals, locks, or welds (on flanges) to prevent the unauthorized connection to, and discharge through, piping systems that are or may be connected to the oily bilge system or overboard discharge connections”). For photographs of ECP Environmental Control System seals and locks, see Section V.B.3.ix. 14 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 18 of 205 CONFIDENTIAL June 21, 2018 Alessandro Bertorello, Carnival Maritime Group’s OLCM and Director of Environment, began his career in 1999 as a Project Manager of the Marine Pollution Prevention Service for the Italian Ministry of the Environment. Mr. Bertorello then worked at Costa Crociere from 20012015, including as an inventory officer, Environmental Officer, environmental superintendent, and environmental management director. He joined Carnival Maritime Group in August 2015 and became Carnival Maritime Group’s Director of Environment in January 2017. Peter Hutchison, Carnival UK’s OLCM and Vice President of Governance, began his career as a deck cadet at Carnival Corp. in 1996, where he remained for around fourteen years holding various positions within several brands, ultimately attaining the rank of Chief Officer. In 2010, he joined Holland America Line and Seabourn as the Manager of the Maritime Investigations Program. In 2011, he returned to Carnival Corp., first as the Manager of Maritime Audit Services and then as the Director of RAAS. Mr. Hutchison left Carnival Corp. in 2013 and spent approximately one year as Marine Manager at a London-based law firm specializing in marine shipping and trade, and approximately three years as Head of Quality, Health, Safety, and Environmental & Marine Operations at a maritime crewing company. Mr. Hutchison joined Carnival UK as its Vice President of Governance in June 2017. Paul McClelland, Holland America Group’s OLCM and Vice President of Environmental Compliance, began his career in 1986 with the United Kingdom’s Royal Fleet Auxiliary. In 1989, he joined the cruise industry, working as a Merchant Naval Officer at P&O Cruises and Princess Cruises from 1989-1996. McClelland then worked in various positions at Lloyd’s Register, a classification society, for approximately twenty years. He joined Holland America Group in February 2017. 15 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 19 of 205 CONFIDENTIAL June 21, 2018 Domenico Rognoni, Carnival Cruise Line’s OLCM and Vice President and Chief Compliance Officer, began his career in 1976 as a Junior Officer for Costa Cruises. He then served in the Italian Navy from 1978-1980 before joining Carnival Cruise Lines in 1980. Since then, Mr. Rognoni has held various positions both ship and shoreside within Carnival Cruise Lines, including as Captain and as Vice President of Compliance, Environmental and Occupational Safety. In May 2018, Rognoni became Carnival Cruise Line’s Vice President and Chief Compliance Officer. Each of these individuals has demonstrated themselves to be knowledgeable, forthright, and committed to the goal of achieving a sustainable environmental compliance program. As discussed in Section IV.A.2, however, the CCM has not been given the ECP-required “authority to ensure full implementation of [the] ECP.” ECP § III.A.2. In addition, questions remain as to whether the CCM and OLCMs have sufficient resources to fulfill their respective mandates under the ECP. D. Employee Cooperation and Awareness of Environmental Obligations The Company has over 120,000 employees worldwide, and more than 11 million guests sail on its ships to more than 700 ports each year. See http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irol-prlanding. On any given day, Carnival’s over 100 ships transport more than 300,000 guests and crew around the world. Id. The ships’ crews do a remarkable number of things successfully, starting with their highest obligation of transporting thousands of people safely from one place to another. Anyone who has been aboard a well-functioning cruise ship cannot help but be amazed at what happens each day. On a ship of roughly 4,000 guests and over 1,000 crew members, there will be some 25,000 meals prepared each day, along with commensurate tasks of cleaning, making up rooms, 16 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 20 of 205 CONFIDENTIAL June 21, 2018 providing laundry service, managing garbage and sewage, and various other tasks. See Employee Interview Notes. The ship will experience all of the myriad needs of a small, floating city, while at the same time providing all the entertainment and other services of a shore-based resort. Visiting these vessels and the shoreside offices that support them is a critical part of the CAM Team’s work. The CAM’s ability to fulfill his broad mandate to monitor the Company’s compliance with the ECP, see ECP § VI.A, depends on the Company’s cooperation in facilitating the CAM Team’s access to the Company’s facilities, vessels, personnel, and records. Although the Company initially attempted to limit the number and scope of the CAM Team’s visits, once the Court clarified its expectations, vessel and shoreside visits have proceeded smoothly. On balance, the Company has provided a high level of cooperation during ECP Year One. The crew and officers of the more than forty vessels visited by either the CAM Team or the TPA (or both) were open, cooperative, and forthcoming. They described their environmental obligations clearly, and offered frank assessments of what they considered to be aids, challenges, or barriers to their ability to perform their compliance tasks. The CAM Team has not encountered significant obstacles during interactions with personnel on either ships or shore. The CAM Team’s vessel and shoreside visits are not audits. The CAM Team’s role is to assess broader issues related to ECP compliance and the support for a broader culture of corporate compliance and continuous improvement. To make these assessments, the CAM Team reviews engineering, training, organizational, and procedural requirements. In addition, the CAM Team seeks to gauge support for, and barriers to, compliance and to evaluate the sufficiency of audits by the TPA and the Company’s RAAS group. The CCM, his colleagues, and numerous other corporate personnel have facilitated these visits with usually one week or 17 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 21 of 205 CONFIDENTIAL June 21, 2018 less of notice. In some instances, the CAM Team has arrived to a ship to find that the entire crew had no apparent notice of the CAM Team’s impending visit. In other instances, the Captain has been made aware of an impending CAM Team visit only a day or two before the CAM Team’s arrival. Once onboard, the vessels’ officers and other crew have been cooperative and helpful. On each visit during ECP Year One, CAM Team members have spoken with a wide range of crew members, including members of the ship’s leadership team, environmental officers, engineers, and ratings.17 The CAM Team has been provided with space for private interviews. Vessel crew have facilitated access to ship documentation and machinery spaces, including the engine room. Meetings with shipboard employees—from the Captain, Chief Engineer,18 and Head of Hotel to the engine room ratings and cabin stewards—demonstrated employee awareness of the ECP and the ship’s environmental obligations.19 See Employee Interview Notes. The Environmental Officers were knowledgeable and expressed their personal commitment to environmental compliance. Based on a review of the Environmental Officers’ records, it appears that Environmental Officers fulfilled their requirements to train crew, conducted ECP-required 17 Ratings are members of a ship’s crew other than the Captain or an officer. International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended (“STCW Convention”), Annex, Ch. 1, Reg. I/1.13. Engine room ratings include wipers, motormen, plumbers, and fitters. 18 The Chief Engineer is “the senior engineer officer responsible for the mechanical propulsion and the operation and maintenance of the mechanical and electrical installations of the ship.” Id. at Reg. I/1.8. 19 The CAM notes, however, that in some instances language barriers limited the extent to which certain crew members were able to engage in a substantive discussion with the CAM Team regarding the ECP. This issue arose primarily with ratings. 18 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 22 of 205 CONFIDENTIAL June 21, 2018 visits to the engine room, and endeavored to become a compliance resource to ship personnel regarding environmental requirements. In both formal interviews and informal discussions, crew members were willing, and often eager, to engage with CAM Team members about ECP implementation. In particular, Environmental Officers and Chief Engineers have been frank regarding the challenges they face, including the scope of Environmental Officer duties, the Environmental Control System seal/lock program, see ECP IX.B, crew training requirements, and the level of support to the ships from shoreside management. This candor is essential to identifying what is working to support and encourage environmental compliance, as well as what may not be successful or effective. Similarly, during shoreside visits, numerous individuals, beyond the CCM and OLCMs, have exhibited a strong commitment to creating a sustainable culture of environmental compliance. These individuals have suggested areas of inquiry, responded promptly to requests for information, and have been candid about positive and negative experiences with respect to the Company’s approach to environmental compliance and culture. During shoreside visits, the CCM and the OLCMs also have worked to facilitate such conversations and appear to have promoted a constructive attitude towards the CAM. E. Initiatives Beyond the Enumerated ECP Requirements As noted above, the ECP contains enumerated requirements, and the Company has substantially complied with those requirements. See supra, § III.B. In addition, the Company has instituted a number of additional initiatives and adapted some pre-existing programs to further the goals of the ECP and environmental compliance. 19 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 23 of 205 CONFIDENTIAL June 21, 2018 While the ECP applies only to Covered Vessels, the Company “voluntarily extended the ECP requirements to all of [its] ships across the entire Carnival Corporation fleet.” April 2018 USPO Supervision Report, Attachment 3. The Company hired a third party auditor, Bureau Veritas, to perform ECP-based audits on those vessels not covered by the ECP. Id. The Company also implemented the Operation Oceans Alive program. Launched in January 2018, the Company describes Operation Oceans Alive as “a call to action for all ECP Covered Personnel20 . . . designed to create a higher level of environmental awareness via various communication methods.” April 2018 USPO Supervision Report, Attachment 3. This initiative includes a “Top 5” program through which the Company “identified 5 key areas of environmental concern/risk and ha[s] commenced an initiative to reduce the number of issues and further alleviate those risks.” Id. The initiative also features an “Environmental Excellence Awards” program that seeks to “acknowledge the strong commitment our ships have toward achieving their environmental objectives and targets as well as continuous improvement and doing the right thing.” Id. In addition, as described in its Monthly Supervision Reports to the Office of Probation, the Company has pursued a variety of initiatives it believes will move the Company towards the goal of a sustainable environmental compliance culture. The initiatives are varied in approach and scope, and reflect efforts to standardize the approach of the operating lines to areas such as communication, engineering, training, environmental policies and procedures, and incident investigations. See, e.g., id. (describing actions taken by the Company “to notify employees, 20 Covered Personnel are those Company employees who are subject to the ECP—i.e., “all shore-side employees and shipboard crews involved with the operation and technical management of the Covered Vessels.” ECP §§ I.B. and I.D. 20 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 24 of 205 CONFIDENTIAL June 21, 2018 stockholders, victims or the public regarding the organization’s conviction and action it is taking to prevent reoccurrence”). For a fuller description of voluntary measures that the Company has taken or is taking related to environmental compliance, see Appendix B. F. CSMART Training Center The Company has made a significant investment into training and mentoring its ship officers through a state-of-the-art training center in The Netherlands called CSMART or The Arison Maritime Center. Initially opened in 2009 as a P&O Cruises and Princess Cruises training center for bridge21 officers, CSMART has since expanded into a 110,000 square foot facility that is reported to be capable of annually training over 6,500 bridge and engineering officers from across the Company’s ten brands. See http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irol-newsArticle&ID=2185532. Among other things, CSMART uses simulators to provide training on navigational and technical scenarios. The simulation facilities and other interactive equipment and machinery appear to be without peers. The following photographs of a CSMART Engine Control Room simulator and a Bridge simulator (alongside an actual Engine Control Room and Bridge), indicate how closely the simulators copy the reality of ship operations. [See photographs on following page.] 21 The bridge of a ship is the room or platform from which the ship is commanded and where navigational equipment is housed. See https://www.marineinsight.com/marine-navigation/10types-of-decks-every-seafarer-should-know/. 21 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 25 of 205 CONFIDENTIAL June 21, 2018 CSMART Engine Control Room (left) and Carnival Inspiration Engine Control Room (right). CSMART Bridge (left) and AIDAvita Bridge (right). The Company has made use of CSMART in connection with ECP-required environmental training. As of April 2018, the Company has conducted twenty-eight Environmental Officer training courses for 230 Environmental Officers at CSMART. See April 2018 USPO Supervision Report, Attachment 3. These courses are taught by two full-time Environmental Officer course instructors and an operating line instructor. Id. In October 2017, the Company began providing environmental training to all engineers and deck officers attending CSMART for technical and nautical training. Id. This training program, called “Compliance to Commitment,” is described by the Company as an effort to further communicate corporate 22 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 26 of 205 CONFIDENTIAL June 21, 2018 commitment to environmental compliance and stewardship and detail the events that occurred onboard the Caribbean Princess.” Id. In addition, the Company has demonstrated a desire to improve the content and efficacy of its environmental training. It has created new training videos, redesigned its Environmental Officer training program, and engaged an instructional design consultant to review the CSMART Environmental Officer training program. See id. For additional discussion of CSMART and the Company’s training-related initiatives, see Appendix B. G. Review and Improvements to Internal Investigation Process As discussed in Section IV.C, there are significant concerns regarding the weakness of the Company’s internal incident investigation process. Recognizing this problem, the Company recently engaged DNV GL, a classification society with maritime advisory services, to review its investigation process, policies, and structures and to provide recommendations for improvement. In May 2018, DNV GL issued a report with detailed findings and recommendations. See DNV GL, Towards improving Carnival’s incident investigation process, Report No. 2018-0209, Rev. Final (May 8, 2018), PCL_ECP00052001-52050. DNV GL’s recommendations include developing: a more clearly defined and consistent incident investigation process with clear lines of authority across the brands, improved training on investigations, consistent investigation and reporting methodology, and methods for tracking and trending this information across the fleets to identify and manage key areas of risk. Id. at PCL_ECP00052035-39. Acting on these recommendations is necessary if the Company wishes to understand and address the causes of incidents, including those that already have been reported to the Court. 23 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 27 of 205 CONFIDENTIAL June 21, 2018 The CAM understands that the Company’s Chief Audit Officer is leading the effort to implement many of DNV GL’s recommendations. See Employee Interview Notes. The CAM will track the Company’s progress in this area during ECP Year Two. See infra, § VIII.B. H. Culture Survey The Court recognized, at the outset of this matter, the importance of a strong organizational culture to achieving sustainable compliance beyond the term of probation.22 For this reason, the Court has emphasized its interest in evaluating progress and growth in the Company’s compliance culture over the term of probation. See e.g., Sentencing Hr’g Tr. at 13 (Apr. 19, 2017) (“[I]t concerns me that the culture really needs to be changed . . . if [a culture of compliance] is not ingrained in the people that you hire and in the people that you train and in the leadership, this [probation] is not going to accomplish anything and we'll be back here again.”). The Court challenged the Company to demonstrate its leadership: The proof is in the pudding, and I truly believe in inspiring people to rise to their highest level. . . . That requires great leadership, so that your troops, so to speak, know that the person at the top cares for them, gives them the tools that they need to perform the job, gives them the training that they need to be the best to grow, encourages the crew to spot problems and bring them to the attention, be proactive. That's the kind of attitude that is critical. . . . [T]hat seems to be at the base of what one needs to make this the success that I want it to be and the success that I’m sure that Carnival would like it to be. Id. at 15-16. Counsel for Carnival responded: “Yes, Your Honor. Understood.” Id. at 16. The Company’s representative, the then-General Counsel for Holland America Group, also reinforced the Company’s position: [W]e don't want to be back before you, in particular in this matter or ever again, and we’re committed to working with the court-appointed monitor and the third-party auditor 22 At the December 2016 plea hearing, the Court stated that “what concerns me is that there obviously was a culture, at least on this ship, if not on other Princess ships, that promoted dishonesty and the willingness to help each other out in getting around doing the right thing.” Plea Hr’g Tr. at 32 (Dec. 20, 2016). 24 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 28 of 205 CONFIDENTIAL June 21, 2018 over the next five years to continue to enhance our compliance program even more, and our focus is a culture of compliance. You know, the rules are easy to tick them off. But we are looking for a culture of compliance and that is what our focus is going to be over the next five years. Id. at 36. In addition to these statements to the Court, the Company agreed not only to support the CAM’s request to conduct a survey to assess the corporate environmental compliance culture, but also requested that the CAM’s survey be administered to additional shipboard crewmembers and key shoreside personnel worldwide. See infra, § VIII.A. IV. COMPANY CAPABILITIES TO MEET ECP OBJECTIVES: UNRESOLVED BARRIERS AND OPPORTUNITIES FOR IMPROVEMENT A. Challenges of the Complex Corporate Structure Carnival Corp. is a large multi-national corporation formed through a series of mergers and acquisitions. It has become the largest cruise company in the world. See Information, Dkt. No. 1 and http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irol-corporatetimeline. “Over the years, Carnival has acquired representation in virtually every market segment of the cruise industry, including premium operator Holland America Line in 1989. . .; luxury brand Seabourn in 1992; Genoa, Italy-based contemporary brand Costa Cruises, Europe’s number one cruise operator, in 1997; and venerable premium/luxury operator Cunard Line in 1998. . . .” http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irol-history. In 2003, a “combination of Carnival Corporation and P&O Princess Cruises – comprised of Princess Cruises, P&O Cruises, AIDA, P&O Cruises Australia, and tour operator Princess Tours – [was] completed, creating the first global cruise company.” http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irol-corporatetimeline. The Company’s four operating lines—Holland America Group, Carnival Cruise Line, Carnival UK, and Carnival Maritime Group—operate with a high degree of independence. As a 25 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 29 of 205 CONFIDENTIAL June 21, 2018 result, Carnival Corp. is closer to an association of companies rather than a coordinated and integrated corporation. See Employee Interview Notes. Carnival Corp. states on its website that its “rise to the world’s largest cruise operator can be attributed to its ability to manage brand autonomy, with each major cruise line maintaining separate sales, marketing and reservation offices, as well as through the industry’s most aggressive shipbuilding program.” http://www.carnivalcorp.com/phoenix.zhtml?c=200767&p=irol-history. Similarly, the Documents of Compliance required by the International Safety Management (“ISM”) Code for companies operating ships are held by the relevant subsidiary brand or group, and not by Carnival Corp. See Employee Interview Notes. 1. Lack of Centralized Policies, Practices, and Procedures In his annual report to the HESS Committee of the Company’s Board of Directors, the CCM recognized that one of the “larger, organizational challenges” the Company needs to address is that the “current organizational and operational structure does not readily support a highly centralized approach to operations management.” PCL_ECP00046433 at 3. Although the Company has made some efforts to standardize the policy-making function through Carnival Corp.’s Maritime Policy and Analysis group, the operating lines also set policy and develop operational systems for their respective organizations, resulting in inconsistencies across the Company. Individuals at nearly every level of the Company have indicated that this lack of centralization and uniformity impedes efforts to share information and to foster continuous improvement. See Employee Interview Notes.23 23 As set forth further in Appendix B, the Company is working to unify HESS procedures across all operating lines and brands into a new “Global HESS” system. However, the Company asserts that variation in Flag State requirements, shipboard equipment, and staffing make it impossible to standardize all policies and procedures. See Employee Interview Notes. 26 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 30 of 205 CONFIDENTIAL June 21, 2018 For example, operating lines take inconsistent approaches to incident and near miss reporting. There appears to be a wide range in the nature and quality of reporting forms, reporting standards (i.e., rules about what types of incidents to report), and tracking systems. Holland America Group has developed its own internal applications and spreadsheets for tracking and reporting incidents and near misses that are not used by other operating lines. See PCL_ECP00046433 at 12, 22-23; see also Employee Interview Notes. Similarly, Holland America Group has developed its own tools for tracking investigations, ECP audit findings, and ECP training. See PCL_ECP00046433 at 11-12, 15, 37-38; see also Employee Interview Notes. Based on CAM Team observations during the TPA audit of Holland America Group shoreside facilities, many of these tools reside on the computers of individual employees, rather than on shared dashboards within the Company’s shared Global HESS system. See Employee Interview Notes. The lack of centralized applications within Carnival Corp. means there is no way to “control and document workflow and insure consistency to reports.” See PCL_ECP00046433 at 37. Employees also have observed that the Company’s largely decentralized management and compliance operations mean that best practices are not consistently shared across operating lines and brands. In one small example, a crew member learned of an improved practice related to waste offloading at another operating line only through a chance conversation. He expressed frustration that this information had not been shared and said that he felt shoreside, in general, did not share information readily. See Employee Interview Notes. 2. Lack of Clarity as to Responsibility, Accountability, and Authority for Environmental Compliance Effective compliance requires, among other things, that the individuals with responsibility for compliance be “given adequate resources [and] appropriate authority.” See 27 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 31 of 205 CONFIDENTIAL June 21, 2018 U.S. Sentencing Guidelines, § 8B2.1(b)(2)(C). This is a commitment that the Company has yet to meet. Moreover, the Company’s organizational charts, see Appendix C, do not make clear, as the Court has asked, “where the buck stops” for compliance responsibility and authority. Status Conf. Tr. at 42 (Apr. 3, 2018). Consistent with the U.S. Sentencing Guidelines language noted above, the ECP requires the Company to both (1) assign the CCM “overall responsibility for implementation of this ECP,” ECP § III.A.1; and (2) give the CCM “the authority to ensure full implementation of this ECP.” ECP § III.A.2 (emphasis added). While the CCM appears to have responsibility for implementing the ECP, it is acknowledged by many in senior management that he does not have the authority to implement the ECP, as required by ECP Section III.A.2. The CCM is not in control of environmental compliance. He does not have authority over environmental capital or operating budgets, does not have authority to fully direct the operating lines’ compliance activities, and does not have authority over the Company’s development and dissemination of environmental policies and procedures. See Employee Interview Notes. During ECP Year One, the CCM had a staff of three: a paralegal, a manager, and a senior manager—all of whom are capable and hard-working. Aside from these individuals, the CCM can neither order anyone in the operating lines to do anything, nor prohibit anyone from doing anything ordered by operating line management. The following chart shows the Carnival Corp. environmental compliance organization structure: [See chart on following page.] 28 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 32 of 205 CONFIDENTIAL June 21, 2018 Carnival Corp. Environmental Compliance Organizational Chart (as of February 9, 2018). PCL_ECP00040761. The OLCMs report to the CCM via a dotted line because they have additional job titles, functions, and lines of report within their respective organizations. OLCM performance reviews currently are prepared by their group or brand supervisors and not by the CCM. See Employee Interview Notes.24 Other critical environmental compliance functions are not controlled by the CCM. For example, Carnival Corp.’s Maritime Policy & Analysis Department, which is overseen by the Chief Maritime Officer, develops HESS policies, standards, and procedures. See Employee Interview Notes and Carnival Corp. Form 14A (proxy statement filed Mar. 2, 2018). The Maritime Quality Assurance Department monitors the implementation of HESS policies. See 24 However, the Company has informed the CAM that the CCM will have a role in the OLCM performance review process in the future. See id. 29 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 33 of 205 CONFIDENTIAL June 21, 2018 Employee Interview Notes. The Company has an Environmental Compliance Advisor, who does not formally report to the CCM, but instead formally reports to the Chief Maritime Officer. The Company also has a Vice President of Ethics and Compliance who is tasked with overseeing the Open Reporting System hotline, see ECP §§ I.D and III.D, and reports to the General Counsel. The CCM does not have authority over any of these functions as they relate to environmental compliance. B. Blame Culture and Lack of Learning Culture A pivotal event in 2012 revealed the need for the Company to enhance its efforts regarding the safe operation of its ships. More than 30 lives were lost when the Costa Concordia sailed too close to shore and partially sank. This incident galvanized efforts within the Company and in the broader cruise industry to drive systemic change, including changing shipboard culture.25 Many in the Company view the Caribbean Princess prosecution as an analogous opportunity to change culture with regards to environmental compliance. At present—based on conversations at all levels of the Company, as well as assessments by the TPA and the Company’s own consultants—the Company has signs of a blame culture as opposed to a learning culture.26 That is, a culture where failures are attributed to individual error 25 Speaking about the Costa Concordia tragedy, Bud Darr, Senior Vice President of Cruise Lines International Association (“CLIA”), said: “I believe it was a galvanising event that led to the entire industry coming together. It was a catalyst that helped bring us all together under CLIA . . . Whether we’re talking about safety, the environment, or anything else, the footprint of the organisation is now so much bigger and the unity of the industry is now so much broader.” https://fairplay.ihs.com/safety-regulation/article/4280616/five-years-after-costa-concordiaassessing-the-safety-legacy. 26 For purposes of this Report, a “blame culture” is defined as the tendency within an organization to look for a person or persons that can be held responsible or blamed for an adverse event; as opposed to “just culture” in which an organization, while appropriately holding individuals accountable, also holds itself accountable for how systems or approaches it designs and implements contribute to unwanted behaviors and adverse events. 30 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 34 of 205 CONFIDENTIAL June 21, 2018 or misconduct without fully considering the possible role of systemic issues or causes. This is true with respect to the crimes that occurred on the Caribbean Princess, as well as with respect to incidents that have been reported since then. After the Caribbean Princess incident, the Company expressed views blaming employees rather than taking broad corporate responsibility for the violations the Company admitted to in the plea agreement. See, e.g., Statement from Princess Cruises (Dec. 1, 2016), available at https://www.princess.com/news/notices_and_advisories/cbresponse/?utm_source=princess.com/r esponse&utm_medium=mixed (“We are extremely disappointed about the inexcusable actions of our employees who violated our policies and environmental law when they bypassed our bilge water treatment system and discharged untreated bilge water into the ocean.”) (emphasis added).27 This blame culture approach also was evident at the sentencing hearing in this case. Carnival’s counsel stated, “I worry about a broad brush painted by the very unfortunate and terrible actions of the engineers that were described in the joint statements of facts.” Sentencing Hr’g Tr. at 33 (Apr. 19, 2017) (emphasis added). Following the sentencing hearing, during CAM discussions with corporate management, a high level Carnival Corp. executive ascribed the crimes on the Caribbean Princess to a “few bad apples.”28 27 In contrast, following the discovery by regulators that Volkswagen had installed defeat devices in its diesel cars to evade emissions standards, the then-CEO stated at a media reception: “We are – I am – truly sorry for that and I would like to apologize once again for what went wrong at Volkswagen . . . [O]ur most important task in 2016 is to win back trust . . . It’s not only our cars we have to fix. We have to repair our credibility, too.” Volkswagen boss apologises to America for cheating diesel emissions tests (Jan. 11, 2016), https://www.theguardian.com/business/2016/jan/11/volkswagen-boss-apologises-to-america-forcheating-diesel-emissions-tests (emphasis added). 28 This tendency for companies to reflexively blame unwanted behavior on “bad apples” is discussed by Matthew Syed in Black Box Thinking: Why Most People Never Learn From Their Mistakes, But Some Do: “[T]he truth is that companies blame all the time. It is not just because managers instinctively jump to the blame response. There is also a more insidious reason: managers often feel that it is expedient to blame. After all, if a major company disaster can be 31 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 35 of 205 CONFIDENTIAL June 21, 2018 Likewise, following the discovery in June 2017 that the Environmental Officer onboard the Diamond Princess falsified ECP training records, see infra §§ IV.D.1.i and V.B.3.ii, the cruise line sent a message to the fleet. The email stated that an Environmental Officer “had breached key tenets of our Code of Conduct,” the “EO’s actions were unacceptable,” and the “Environmental Officer involved is no longer employed by our organization.” Email to Princess Fleet (June 23, 2017). The communication did not describe the incident, did not identify what rules were violated, and did not provide context for the “breach,” leaving some employees to wonder what level of “breach” warrants dismissal. The e-mail, like the shipboard investigation preceding it, placed sole blame on the individual and lacked any discussion of other possible causes or lessons learned. A blame culture detracts from the development of a learning culture. It encourages employees to hide mistakes rather than report them, and the Company cannot learn from mistakes if it is not made aware of them in the first place.29 Blame culture also makes it acceptable, and in fact routine, for a company to accept that the root cause is (individual) human error and not one or more broader, more systemic issues. As a result, a company cannot understand—much less hold itself accountable for—how its systems or approaches may cause or contribute to an incident.30 conveniently pinned on a few ‘bad apples,’ it may play better in PR terms. ‘It wasn’t us; it was them!’” Id. at 225. 29 As noted by Syed, “if [employees] think they are going to be blamed for honest mistakes, why would they be open about them? If they do not trust their managers to take the trouble to see what really happened, why would they report what is going wrong, and how can the system adapt?” Syed, supra note 28, at 225. 30 For example, in the Joint Status Report filed before the December 4, 2017 Status Conference, which included a discussion of more than thirty reported incidents and findings, the Company stated that “[t]here is no indication that these issues are symptomatic of broader issues.” Dkt. No. 52 at 31. In that same report, the Government observed that the Company failed to recognize the systemic or recurring nature of many of the incidents. E.g., id. at 4 (“Carnival’s 32 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 36 of 205 CONFIDENTIAL June 21, 2018 C. Ineffective Internal Investigations 1. Background The Company’s internal investigations are critically flawed. It was only in 2013 that the Company centralized its investigation process and housed it in the RAAS department of Carnival Corp. See Employee Interview Notes. This group, however, does not conduct or oversee all incident investigations in the fleet. See HMP-1302, Event Investigation (Level 1 and 2). Instead, the Company’s relevant policies set forth four tiers of incidents based on the severity of the consequences of the incident, and the severity level determines the group charged with leading the investigation. See id; HMP-1303, Event Investigation (Level 3 and 4). Investigations of Tier 1 and 2 environmental incidents (consisting of, among other things, unintended discharges of less than specified quantities of pollutants and any amount of noncompliant fuel burned in an Emission Control Area31) are to be led by operating line management. See HMP-1302-A1. Investigations of Tier 3 environmental incidents (consisting of, among other things, unintended releases above specified quantities of pollutants or an intentional deviation from Company policy regarding discharge control) are to be led by the operating line “with RAAS providing independent assurance.” See id. Investigations of Tier 4 response treats this as an isolated issue. The government is aware of other instances where [similar violations occurred].”); id. at 12 (“The United States understands that at least five vessels have not implemented [the same] requirement which suggests a larger problem. A key component of prudent management and goal of the ECP is to identify trends and root causes rather than address each issue in isolation.”); id. at 14 (Carnival “fails to recognize that the problem is larger than simply missing samples.”); id. at 18 (“The government views the issues presented as extremely significant and is concerned that the violations and underlying causes are systemic and ongoing.”). 31 Emission Control Areas are designated areas where stringent standards for the sulphur content of fuel and nitrogen oxide emissions from engines apply to ships at all times. See EPA, Frequently Asked Questions about the Emission Control Area Application Process (Jan. 2009) at 1-2, available at https://nepis.epa.gov/Exe/ZyPDF.cgi/P1002UMP.PDF?Dockey=P1002UMP.PDF. 33 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 37 of 205 CONFIDENTIAL June 21, 2018 environmental incidents, which are “[v]iolations of MARPOL or Environmental procedures, at the same levels listed in Severity level 3, which are believed or alleged to be a result of misconduct,” are to be led by RAAS. See id.32 Although the policies specify the group charged with leading the investigation, they do not specify the person or group charged with conducting the investigation. See HMP-1302-A1. Tier 1 incident investigations commonly are conducted by personnel on the ships. See Employee Interview Notes; see also HMP-1302 (“Investigations of Severity Level 1 and 2 . . . may be led by a ship officer or shore manager as per Company instructions,” and listing it as the Captain’s responsibility to “[c]onduct investigation of incidents occurring onboard.”). Tier 2 investigations commonly are conducted by ship superintendents. Id. Tier 3 investigations are led by the operating lines, but “there is a mixture of approaches with some having dedicated investigators, some using ad-hoc resources, some contracting external parties to lead investigations and some contracting RAAS to conduct level [Tier] 3 investigations.” DNV GL Investigations Report at PCL ECP00052014. Tier 4 investigations generally are conducted by RAAS investigators. Employee Interview Notes; DNV GL Investigations Report at PCL ECP00052014. In some instances, however, the Company or operating line will go outside this structure to retain outside counsel (with or without asserting a claim of privilege), as has been done in some instances during ECP Year One. See Employee Interview Notes. The Company’s procedures governing incident investigations—HMP-1302 and HMP1303—give very little guidance as to how to conduct investigations. For example, although the 32 These tiers, focused on the size of discharges and the intent of those presumably to blame (e.g., whether the discharge was “unintended” or the result of “misconduct”), illuminate how the structure of the Company’s approach is skewed towards blame for individuals and not on possible systemic issues. 34 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 38 of 205 CONFIDENTIAL June 21, 2018 procedures provide that investigation reports should include a “root cause analysis,” they do not define the term “root cause analysis,” nor do they provide a procedure for conducting a root cause analysis. See HMP-1302 and HMP-1303. Similarly, the procedures provide that “[t]he scene of any event . . . will be secured to ensure its integrity,” but do not provide a procedure for doing so. Id. Anecdotally, on one ship, the Captain noted that he had been taking part in an internal investigation, yet he had no training as to how he should preserve evidence. 2. Observations A comprehensive and well-established investigation process serves multiple roles. It is a crucial means to identify the most efficient and effective ways to learn from mistakes and misconduct, thereby reducing risk and enhancing compliance. In addition, a solid investigation process supports both a just culture and a sustainable compliance culture. An investigation process viewed by employees as principled and successful in determining true root causes leads employees to have faith that investigations will lead to just outcomes, thereby encouraging reporting and expanding corporate understanding of how to deploy compliance resources. During its audit of the Carnival Corp. offices, the TPA found that investigators were not consistently updating RAAS on the status of Level 3 investigations, as required by the Company’s investigation policies. See ABSG, Carnival Corporation & PLC Environmental Compliance Audit Report (Aug. 25, 2017) at 4, 7. In at least one instance, “the information learned from the ongoing investigation, including the notification of procedure change, ha[d] not been circulated to all the Operating Lines as required by the HESS‐MS Procedure.” Id. at 4. The TPA also observed that there were delays in investigations when operating lines relied upon their own employees as investigators. See id. at 7. 35 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 39 of 205 CONFIDENTIAL June 21, 2018 The Company appears to understand that its investigation process requires significant improvement. See supra § III.G. In response, the Company has engaged DNV GL to review its investigation process, policies, and structures and to provide recommendations for improvement. Going forward, the CAM’s areas of focus will include how the Company proposes to implement DNV GL recommendations—i.e., raise the quality of investigations, improve communication and implementation of lessons learned, adopt a proactive approach, and support a learning culture. See infra, § VIII.B. 3. Investigation Illustrations The following examples of faulty investigations reflect lost opportunities for learning. i. Caribbean Princess Incident In the case of the criminal conduct on the Caribbean Princess, while there may have been a privileged investigation conducted by counsel, the only analysis the CAM has been provided is by Chief Maritime Officer Burke. See Chief Maritime Officer Root Cause Analysis. This twopage assessment does not identify the sources of information relied upon and does not indicate what, if any, causal analysis method was employed. Chief Maritime Officer Burke makes the following conclusions: If I had to assign a single root cause, it would be excessive frugality which permeated to the lowest levels of our shipboard teams and led to their actions, caused us to reduce our emphasis on [Environmental Officers], and dismantled the environmental oversight in our shore management which resulted in not even ensuring compliance. Unless we change this frugality and establish a stronger environmental culture where compliance is not the goal but the minimum standard, we could begin this cycle again at the end of the ECP. Id.33 33 Indeed, in conversations throughout the Company, including among the rank and file of the engine room, there remains concern that the Company’s current level of support for expending 36 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 40 of 205 CONFIDENTIAL June 21, 2018 Chief Maritime Officer Burke’s root cause analysis was not done as part of the Company’s investigation process and does not seem to have been undertaken in coordination with any RAAS internal investigation. His report was provided to the Carnival Corp. CEO as well as to the brand Presidents and Executive Vice Presidents. See Employee Interview Notes. A summary of key findings from the root cause analysis also were incorporated into the training materials for the CSMART “Compliance to Commitment” training program for engine and deck officers, discussed in Section III.F and Appendix B. See id.; see also PCL_ECP00052913 at PCL_ECP00052916.34 Despite these efforts, lower-level employees have expressed frustration due to their uncertainty as to what happened on the Caribbean Princess and how to ensure it does not happen again. ii. AIDAvita White Box Tampering Incident In December 2017, an alert Environmental Officer on the AIDAvita learned that a Second Engineer35 had tampered with the ship’s pollution prevention equipment by trying to adjust the flow switch on the White Box36 using two metal rods. See PCL_ECP00046678. Recognizing the seriousness of an engineer’s attempt to tamper with pollution prevention equipment (even resources on environmental compliance is temporary and will expire with the probationary period. See Employee Interview Notes. 34 The CAM Team will review these training program materials in connection with its efforts to focus on training during ECP Year Two. See infra, § VIII.C. 35 A Second Engineer is “the engineer officer next in rank to the chief engineer officer and upon whom the responsibility for the mechanical propulsion and the operation and maintenance of the mechanical and electrical installations of the ship will fall in the event of the incapacity of the chief engineer officer.” STCW Convention, Annex, Ch.1, Reg. I/1.9. 36 The White Box, also known as a Bilge Control Discharge Box (“BCDB”), is a locked metal cage. The White Box contains an Oil Content Meter, which is in addition to the Oil Content Meter on the Oily Water Separator. The White Box is the final check on the oil content of bilge water before such water can be discharged overboard. In addition to oil content, the White Box records data such as: discharge volume, valve positions, flow through the Oil Content Meter, overboard flow, door position, vessel position, and time. See Joint Glossary of Terms at 1-2. 37 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 41 of 205 CONFIDENTIAL June 21, 2018 though it was apparent that no pollution event had occurred), the vessel immediately reported the incident. In accordance with the investigation policy for incidents involving “intentional deviation from company release/discharge control procedures” and “which are believed or alleged to be a result of misconduct,” HMP-1302-A1, RAAS planned to send a team to conduct an investigation. Indeed, a RAAS team was nearby and was ready to go. However, “[s]ubsequently, as per the Environmental Compliance Advisor and General Counsel Carnival Corporation, RAAS was requested to not get involved in the investigation (despite having communicated that [RAAS] had two available investigators in Europe at the time).” RAAS Investigation Memo No. 11 /2018: AIDAvita -Alleged Tampering with the Bilge Control Discharge Box (BCDB) at PCL ECP00046675. The Company instead retained a former solicitor as a consultant, who had maritime experience and who lived near the ship’s current port of call. Although RAAS “routinely communicates and provides comments and support on brand lead investigations,” RAAS had no communications with the consultant until it received the report in final form, nearly 100 days later, on March 28, 2018. Id. Shortly after receiving a report of the tampering, on December 13, 2017, the TPA and CAM joined the vessel. They did so to observe the conduct of the investigation and because it was possible that the Second Engineer might not be available for an interview at a later time. While on the ship with the TPA and the CAM, the Company’s consultant said that he had not been asked to write a report and did not have a plan for further interviews other than those he already had concluded. The consultant ultimately produced a report on March 7, 2018. See AIDAvita Report on Incident on 10th December 2017 involving [Name Withheld], PCL_ECP00046677- 46691. The report focuses both on the incident and, to a significant degree, 38 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 42 of 205 CONFIDENTIAL June 21, 2018 on the consultant’s efforts to observe the CAM. Id. Although the report employs no structured root cause analysis, it concludes: “The Second Engineer was simply trying to perform his duties albeit in a highly unorthodox and incorrect manner. It also was clear that there was never a risk of an illegal discharge taking place. As to the reasons for [the Second Engineer] behaving in this way, based on the various discussions with him, the view of the undersigned is that it arose partly from a level of arrogance on his part regarding his engineering abilities and partly due to a lack of job specific training.” Id. at PCL ECP00046685-46686. Once the report was completed, RAAS was asked to “review the proposed actions and also review them with Costa group [the relevant operating line] to see whether [it] agree[s] with them.” RAAS Investigation Memo at PCL_ECP00046675. RAAS responded: [I]n order to provide substantive comments, we would have to have had some proximity to the investigation of which in this case we have had none. What we can say about the report is that it does not take into account, mention or fully review our robust HESS-MS requirements relating to environmental responsibilities, training, oversight, drug and alcohol testing, recruitment or disciplinary process areas that are all key in this case to assist with the determination of corrective and preventive measures . . . Consideration should be given for action plans relating to the reiteration of current HESS-MS procedures relating to accountability and responsibility for ensuring that environmental training is not only carried out but is also effective to ensure that equipment operators are fully versed on their responsibilities, company expectations and record keeping requirements. On shore the Human Resources function should initiate an internal review of the case of the [Second Engineer] involved in this event and determine any improvement opportunities to internal processes related to promotion. Id. at PCL_ECP00046676. In addition to the shortcomings of the consultant’s report and recommendations identified by RAAS, it is notable that in a matter closely connected to the issues of concern in this case (tampering with pollution prevention equipment), the Company’s own investigation procedures were not followed. Moreover, the hiring of a lone consultant, even one who was experienced 39 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 43 of 205 CONFIDENTIAL June 21, 2018 and competent, with no express direction to produce a comprehensive report calls into question Company management’s commitment to and development of a learning culture. D. Environmental and ECP Violations 1. Environmental Incidents The purpose of the ECP is “to ensure that the Covered Vessels fully comply with all applicable marine environmental protection requirements established under applicable international, flag state, port state, coastal state law, and United States laws . . . and [] the additional requirements and policies established by this ECP itself . . . [and] also to ensure that environmental compliance Best Practices (as defined herein)37 are used by the Covered Vessels and related shore-side operations.” ECP § I.C. During ECP Year One, there were violations of environmental laws and the ECP, including: (i) four instances of record falsification; (ii) over fifty-five reports of prohibited discharges or emissions attributable to voyage planning;38 and (iii) numerous other incidents, such as incidents related to the maintenance and operation of pollution prevention equipment, ECP training, and ECP seal and lock requirements. While these incidents are concerning, the Company’s deeper and more pressing barriers to compliance relate to its larger corporate governance and culture issues. See supra, §§ IV.A-C. i. Falsification of Records The Company reported four instances of record falsification on Covered Vessels during ECP Year One. Two of these instances relate to the falsification of ECP-required training 37 Best Practices are “those policies and procedures that, based on experience and research, consistently and reliably prevent an Audit Finding [during an audit required under this ECP].” ECP § I.D. 38 There were additional prohibited discharges and emissions attributable to other factors, such as equipment malfunctions. See infra, § V and Appendix E. 40 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 44 of 205 CONFIDENTIAL June 21, 2018 records, and two relate to the falsification of maintenance and operational records of pollution prevention equipment. These incidents are discussed in Section V.B.3.ii and Appendix E. ii. Voyage Planning During ECP Year One, Covered Vessels made numerous prohibited discharges and emissions that appear to be attributable to a failure to develop and follow effective voyage plans. See ECP Corporate Compliance Manager Annual Report (2017-2018) at PCL_ECP0004643435; see also Carnival Corporation & plc HESS Weekly Flash Reports. Before any voyage, a ship must prepare a voyage plan that identifies, among other things, where certain discharges or emissions are allowed or prohibited based on a ship’s location and the applicable restrictions (such as the special requirements that apply in United States marine sanctuary waters and in Emission Control Areas). The ship’s route must take into account “the marine environmental protection measures that apply, and avoid[], as far as possible, actions and activities which could cause damage to the environment.” Joint Glossary of Terms at 10. Environmental incidents resulting from voyage planning may reflect broader, more systemic issues about how the Company focuses its time, attention, and resources on the voyage planning process. As discussed in Section V.B.3.xi, the CAM Team identified over fifty-five reports of incidents attributable to voyage planning. For example, during June 2017, multiple Carnival Cruise Line vessels discharged sewage and/or food waste in Bahamian Archipelagic waters in violation of Company requirements and/or MARPOL. According to the Company, the cause of these events “appears to be associated with the interpretation of [the relevant Company] procedure.” See infra, § V.B.3.xi. Additional examples are discussed id. and Appendix E. iii. Other Incidents As described in Section V and Appendix E, there were numerous additional incidents during ECP Year One that violated environmental laws and/or the ECP. 41 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 45 of 205 CONFIDENTIAL June 21, 2018 2. Failure to Provide CCM with ECP-Required Authority The ECP requires the Company to give the CCM “the authority to ensure full implementation of this ECP.” ECP § III.A.2. As discussed in Section IV.A.2, most senior executives to be asked about this issue acknowledged that the CCM does not have this authority. V. ENVIRONMENTAL INCIDENTS A. Incident Reporting Mechanisms The ECP sets out four primary ways for reporting incidents to the CAM and/or to the Interested Parties: (1) TPA Audit Findings. Each year, the TPA audits all Princess Covered Vessels and a sub-set of other Covered Vessels, as well as shore-based Company offices. In these audits, the TPA findings fall into three categories (from most to least serious): Major Non-Conformities, Non-Conformities, and Observations. a. A “Major Non-Conformity” is “an observed situation where objective evidence indicates a violation of a Marine Environmental Protection Requirement [collectively, MARPOL, APPS, the Clean Water Act, and the Oil Pollution Act of 1990] or policies established by this ECP that consists of or contributes to the discharge or potential discharge of oil, or oily wastes, or other prohibited wastes into the water. It may also include the discovery of pollution prevention equipment determined to be incapable in terms of processing and monitoring capabilities or inadequate with respect to the quantities of wastes such equipment is required to process.” ECP § I.D. An example of a Major Non-Conformity is a discharge of oily waste water in violation of MARPOL or an inoperable Oily Water Separator. b. A “Non-Conformity” is “an observed situation where objective evidence indicates a violation of [a Marine Environmental Protection Requirement] or a policy or procedure established by this ECP, regardless of whether it is immediately repaired or remedied. All audit line items which are not completely compliant with the requirements of this ECP are NonConformities.” Id. An example of a Non-Conformity is a finding that an incident investigation did not follow the requirements of the relevant Company procedures. c. An “Observation” is “a statement of fact made during an audit and substantiated by objective evidence that could lead to a Non-Conformity if not addressed. If pollution prevention equipment requires a repair of any kind to be operational for a proper test by any auditor, it will be defined as an Observation.” Id. An example of an Observation is a finding that the garbage 42 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 46 of 205 CONFIDENTIAL June 21, 2018 room on a vessel is cluttered and overloaded with waste and recycling, creating a poor work environment that could lead to errors or injuries. (2) Company Notices of Violation (Probation Notices). Within three days of any breach of the ECP, the Company must notify the Probation Officer, the CAM, and the TPA of the breach, including a description of the nature, date, and time of the breach. Judgment; Special Condition of Supervision 13. (3) Company Notices of Environmental Open Reports (Hotline Reports). The Company must disclose to the CAM any Hotline Report “containing a credible allegation of a violation by Covered Personnel of any Marine Environmental Protection Requirement or requirement of this ECP,” including any documents or files that are part of the report. ECP § III.D.6. The CAM must disclose any such reports and materials to the Interested Parties. Id. (4) CAM Interested Parties Notifications. The CAM must report to the Interested Parties information it receives “regarding a Major Non-Conformity, or a failure of [the Company] to consider and act upon, as appropriate, an Audit Finding or recommendation of the TPA.” ECP § VI.F. In addition to these ECP-mandated reporting mechanisms, the Company uses informal means, such as emails and phone calls, to notify the CAM of incidents. The Company often has provided prompt informal notice of matters that are the subject of formal notification processes. The Company also provides the CAM Team and TPA with its weekly internal Flash Reports, which are prepared for use by the Company and contain summaries of HESS incidents that occur both on vessels and on shore. B. Data Analysis of Incident Reports 1. Context and Significance The use of data as a compliance tool is a standard practice in many industries. In order to do so, companies often use “Key Performance Indicators” (“KPIs”) to identify compliance trends or to detect misconduct. It does not appear that the Company has developed a set of KPIs for environmental compliance. See Employee Interview Notes. 43 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 47 of 205 CONFIDENTIAL June 21, 2018 As for the data provided to the CAM, the CAM Team has tracked the type and frequency of incidents reported during ECP Year One through formal and informal reporting mechanisms, including TPA audit findings, Notices of Violation, Hotline Reports, and Flash Reports.39 The CAM Team tracks both (i) general trends based on total reported incidents; and (ii) incidentspecific trends based on categories of recurrent incidents that the CAM Team has identified, such as training, voyage planning, or recordkeeping issues, as described more fully below. The data provided, even when trended, do not paint a full picture of the direction of the Company’s compliance efforts. A vessel or operating line reporting a higher number of incidents may be more vigilant about reporting than other vessels or operating lines. Nor are all incidents equally significant or concerning. Without more sophisticated internal investigations and near-miss analyses, the data alone cannot address the challenge of identifying the causes of significant or recurring issues. Hypothetically, a series of leaks may be a sign that purchasing has obtained defective seals for a hydraulic system, that maintenance schedules are not optimal, that training is not optimal, or that employees are overworked. Thus, the data provided are only the start of the process of identifying issues and potential obstacles to compliance. 2. Recurrent Incident Categories The CAM Team developed the following general categories of recurrent incidents. Incidents may fall under more than one category: 39 The CAM’s incident tracking covers (i) the operating line and vessel; (ii) details of the incident (e.g., facts, date, and location); (iii) notification method (e.g., Flash Report); (iv) Company personnel involved; (v) the Company’s immediate response and corrective actions, to the extent provided; (vi) investigation efforts, follow-up information, and related findings; (vii) CAM Team assessments, including whether the incident falls into one of the recurrent incident categories identified by the CAM; and (viii) any Interested Party notification and follow-up information. 44 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 48 of 205 CONFIDENTIAL June 21, 2018 Category Exhaust Gas Cleaning Systems (“EGCSs”)40 Falsification of Records Lifeboat and Tender42 Systems Oil Content Meters Oil Record Books Oily Water Separators and White Boxes Recordkeeping Description Incidents related to the EGCSs on vessels, including, for example, (i) EGCS washwater discharges;41 (ii) EGCS equipment malfunctions; and (iii) failures to use the EGCS in protected Emission Control Areas. Incidents related to falsified records, entries, and other representations by Company personnel. This includes falsified entries in training records, Oil Record Books, or any other log or record required under the ECP, Company policy, MARPOL, or other international, national, or local law or regulation. These incidents also are tracked Recordkeeping incidents. Incidents relating to the Oil Record Book also are tracked as Oil Record Book incidents. Incidents related to discharges from lifeboats, tenders, liferafts, rescue boats, and associated equipment. This includes discharges of oil, as well as discharges of items that may qualify as “garbage” under MARPOL Annex V (e.g., glass panes, doors, plastic containers, canvas covers). Incidents related to failures or other malfunctions of Oil Content Meters associated with Oily Water Separators or White Boxes. Incidents related to inaccurate or incomplete recordkeeping of the Oil Record Book. This includes missing or inaccurate entries or signatures, whether due to human error, intentional falsification, or other reasons. These incidents also are tracked as Recordkeeping incidents. Incidents relating to record falsification also are tracked as Falsification of Records incidents. Incidents related to failures or other malfunctions of an Oily Water Separator or a White Box, or their component parts. Incidents related to inaccurate or incomplete recordkeeping or document maintenance, including in an Oil Record Book, Garbage Record Book,43 or any other log or record required under the ECP, Company policy, MARPOL, or other international, national, or local law or regulation. Incidents relating to record falsification also are 40 An EGCS is a cleaning system (often referred to as a scrubber) that removes sulphur oxides from a vessel’s engine and boiler exhaust gases. See EPA, Exhaust Gas Scrubber Washwater Effluent (Nov. 2011), available at https://www3.epa.gov/npdes/pubs/vgp_exhaust_gas_scrubber.pdf. 41 EGCS washwater is waste water generated by an EGCS that can contain various contaminants, including combustion by-products, fuel, and lubricants. See id. at 3. 42 A tender is a ship used to transport people or supplies to and from shore or another ship. See http://www.memidex.com/tender+ship-boat. 43 A Garbage Record Book is a log where a ship records the discharge, disposal, or incineration of garbage. It is required under MARPOL Annex V. Joint Glossary of Terms at 6. 45 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 49 of 205 CONFIDENTIAL June 21, 2018 tracked as Falsification of Records incidents. Incidents relating to the Oil Record Book also are tracked as Oil Record Book incidents. Incidents related to refrigerant gas leaks, including recordkeeping issues. Incidents related to ECP Environmental Control System seal and lock requirements. This includes missing or damaged seals as well as recordkeeping issues (e.g., the Critical Valves, Fittings, and Tank Hatches List and Seal Log required under ECP Section IX.B). Incidents related to inadequate or missed training. This includes (i) failures to perform required ECP trainings; (ii) recordkeeping issues, including falsification of training records (also tracked under Falsification of Records category); and (iii) incidents which appear to be attributable to inadequate training, including incidents where additional training is implemented as a part of the Company’s corrective action or other response. Incidents related to prohibited discharges or emissions that appear to be attributable to voyage planning (e.g., inaccurate boundary maps or miscommunication between deck and engine room). Refrigerants Seals and Locks Training Voyage Planning For the reasons noted above, these categories are not used to reach conclusions regarding compliance success or weakness, but simply to identify whether particular brands or vessels are facing repeat or recurring problems with these issues. 3. Recurrent Incident Examples i. EGCS The CAM Team identified over thirty reported incidents on Covered Vessels related to EGCSs during ECP Year One. Many of these incidents relate to unexpected EGCS shutdowns resulting in violations of air emission requirements. For example, the Carnival Ecstasy experienced multiple ECGS shutdowns in May, July, and October 2017 due to equipment malfunctions. See Carnival Corporation & plc HESS Weekly Flash Reports (June 23, 2017, July 27, 2017, and Oct. 18, 2017). As a result, the ship impermissibly burned heavy fuel oil in Emission Control Areas without an EGCS online. See id. Other EGCS incidents involve the discharge of EGCS washwater. For example, in October 2017, the Ruby Princess discharged EGCS washwater into United States marine 46 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 50 of 205 CONFIDENTIAL June 21, 2018 sanctuary waters in violation of both federal marine sanctuary regulations and Company requirements. See Carnival Corporation & plc HESS Weekly Flash Report (Oct. 11, 2017). Similarly, in November 2017, the Queen Mary 2 discharged EGCS washwater while alongside in Hamburg, Germany in violation of Company requirements. See Carnival Corporation & plc HESS Weekly Flash Report (Dec. 6, 2017). ii. Falsification of Records The Company reported four instances of record falsification on Covered Vessels during ECP Year One. Two of these instances relate to the falsification of ECP-required training records, and two relate to the falsification of maintenance and operational records of pollution prevention equipment. ECP Training Records. In June 2017, the Environmental Officer on the Diamond Princess was found to have falsely recorded that (i) the Captain and Staff Captain had completed ECP-required training when they had not; (ii) eight crew members had completed ECP-required training before arriving on the vessel when they had not; and (iii) 172 crew members had completed training on dates that differed from their actual training dates. The Company terminated the Environmental Officer’s employment. See CAM Incident Reference #04-2017. Similarly, approximately one month later on July 22, 2017, the Costa Luminosa reported that an Environmental Officer had falsified certain training records. That Environmental Officer also was dismissed. See CAM Incident Reference #06-2017. The Company reports that, following this incident, it instructed all operating lines to review the onboard environmental training records for accuracy, correct any deficiencies by a date certain, and immediately report any inaccuracies to the Company. Since the Costa Luminosa incident, the Company has not 47 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 51 of 205 CONFIDENTIAL June 21, 2018 reported any other instances of an Environmental Officer intentionally creating inaccurate training records. Maintenance and Operational Records. On July 6, 2017, the Sun Princess reported that a valve and a bypass solenoid (an electromagnetic coil that controls a valve) were missing from the vessel’s Oily Water Separator. The Company’s investigation revealed that a watchkeeping engineer had removed the parts and made a false entry into Holland America Group’s planned maintenance system. The same engineer then replaced the valve with a new one and restored the Oily Water Separator to normal operation. See Corporation & plc HESS Weekly Flash Report (July 6, 2017). A few months later, in October 2017, a corporate investigation onboard the Carnival Valor revealed that the Oil Content Meter was falsely recorded in the Oil Record Book as having been cleaned. The engineering team, however, had not cleaned the equipment because it had not been used since the previous cleaning operation. See Corporation & plc HESS Weekly Flash Report (Nov. 8, 2017). iii. Lifeboat and Tender Systems The CAM Team identified over forty-five reported incidents on Covered Vessels related to the maintenance and operation of lifeboat and tender systems during ECP Year One, including numerous incidents where oil leaked or spilled from lifeboats or tenders due to corroded fuel tanks, incomplete engine combustion, mechanical failures, or other causes. For example, on August 18, 2017, approximately one liter of hydraulic oil spilled overboard from one of the Coral Princess’s lifeboats due to a failed gasket. See Carnival Corporation & plc HESS Weekly Flash Report (Aug. 24, 2017). 48 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 52 of 205 CONFIDENTIAL June 21, 2018 There also were numerous incidents involving solid objects going overboard, such as glass panels, doors, liferaft shells, canvas covers, and other objects. For example, on December 25, 2017, a canvas hook cover from one of the Emerald Princess’s lifeboats fell overboard and could not be retrieved. “The cover had not been properly secured and was blown overboard by strong winds.” See Carnival Corporation & plc HESS Weekly Flash Report (Jan. 10, 2018). iv. Oil Content Meters The CAM Team identified over forty reported incidents on Covered Vessels related to the Oil Content Meters of Oily Water Separators and/or White Boxes. In many of these incidents, the Oil Content Meter failed or produced inaccurate readings due to equipment malfunctions, the accumulation of dirt/oil, or other unspecified or unidentified causes. These issues often required the Oily Water Separator or White Box to be taken out of service so that the Oil Content Meter could be serviced, cleaned, or removed and replaced. For example, on April 1, 2018, an Oily Water Separator on the Diamond Princess was taken out of service because a “defective” Oil Content Meter was giving inaccurate oil content readings. See Carnival Corporation & plc HESS Weekly Flash Report (Apr. 4, 2018). Similarly, on January 1, 2018, a White Box on the Queen Mary 2 was taken out of service due to a failed Oil Content Meter component. See Carnival Corporation & plc HESS Weekly Flash Report (Apr. 4, 2018). v. Oil Record Books The CAM Team identified over forty-five reported incidents on Covered Vessels related to inaccurate or incomplete Oil Record Books. Examples are discussed in Sections V.B.3.ii and V.B.3.vii. 49 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 53 of 205 CONFIDENTIAL June 21, 2018 vi. Oily Water Separators and White Boxes The CAM Team identified over seventy reported incidents on Covered Vessels related to failures or other malfunctions of Oily Water Separators and White Boxes or their component parts, such as Oil Content Meters,44 valves, coolers, flow meters/switches, pumps, or alarms. These issues often resulted in the Oily Water Separator or White Box being taken out of service, sometimes for extended periods of time. See Carnival Corporation & plc HESS Weekly Flash Reports. While an Oily Water Separator or White Box is out of service, the ship may be unable, or have reduced capacity, to process oily waste water. See id. For example, from August 8-13, 2017, an Oily Water Separator on the Carnival Imagination was taken out of service due to a “malfunctioning unit.” See Carnival Corporation & plc HESS Weekly Flash Reports (Aug. 17, 2017). During this six-day period, the ship was unable to process oily waste water. Id. On December 27, 2017, both of the Oily Water Separators on the Carnival Victory were taken out of service due to issues with their respective Oil Content Meters (one a cracked glass cell and the other a blocked water sample line). The ship did not have any spare Oil Content Meters onboard at the time. A third-party manufacturer’s technician visited the ship the following day to complete repairs. See Carnival Corporation & plc HESS Weekly Flash Reports (Jan. 3, 2018). vii. Recordkeeping The CAM Team identified over eighty reported incidents on Covered Vessels related to recordkeeping, including the four falsification incidents discussed above in Sections IV.D.1.i and in V.B.3.ii. Many recordkeeping incidents involve missing entries and/or signatures in the Oil Record Book or other required ship records. For example, the Company reported that the Oil 44 Such incidents also are tracked under the Oil Content Meter category. 50 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 54 of 205 CONFIDENTIAL June 21, 2018 Record Book on the Carnival Pride was missing entries for the flushing/cleaning of the Oil Content Meter between April 19 and July 28, 2017 because the responsible engineer “was not completely familiar” with the relevant Company policy. See Carnival Corporation & plc HESS Weekly Flash Report (Aug. 17, 2017). Similarly, on November 27, 2017, the Carnival Freedom reported that the Garbage Record Book was missing the Captain’s signature on a single page due to “an oversight by crew.” See Carnival Corporation & plc HESS Weekly Flash Report (Dec. 6, 2017). Other incidents have involved entire record books going missing altogether. For example, on September 28, 2017, the Carnival Breeze reported that six Oil Record Books were missing in violation of MARPOL and Company procedures. “A subsequent search was unsuccessful and it is believed that the [Oil Record Books] may have been removed during a past audit/inspection but not returned.” Carnival Corporation & plc HESS Weekly Flash Report (Oct. 11, 2017). Similarly, on September 29, 2017, the Carnival Miracle reported that two Garbage Record Books were missing in violation of MARPOL and Company procedures. “A search was unsuccessful and it was concluded that the [Garbage Record Books] may have been filed with other Bridge documents that had subsequently been disposed of following their retention period.” Carnival Corporation & plc HESS Weekly Flash Report (Oct. 11, 2017). Additionally, during a CAM Team ride-along with the TPA on its audit of the Caribbean Princess in February 2018, an entire page of the ship’s hazardous waste log (covering a span of 10 days) was missing. See ABSG, Princess Cruise Line Environmental Compliance Audit Report: Caribbean Princess 06 February – 11 February 2018 (Feb. 26, 2018) (Non-Conformity03). The Company has not provided an explanation for the missing page. See Employee Interview Notes. 51 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 55 of 205 CONFIDENTIAL June 21, 2018 viii. Refrigerants The CAM Team identified over seventy reported incidents on Covered Vessels related to refrigerant gas leaks from refrigeration, air conditioning, and other systems on ships. These incidents include leaks of ozone-depleting substances45 and non-ozone-depleting substances. Causes of the leaks include corroded or cracked pipes, faulty valves, and general age-related deterioration. See Carnival Corporation & plc HESS Weekly Flash Reports. For example, on July 13, 2017, an air conditioning system on the Carnival Splendor leaked 267 kilograms of nonozone-depleting refrigerant gas due to a “failure of a discharge valve.” See Carnival Corporation & plc HESS Weekly Flash Report (Aug. 24, 2017). On August 15, 2017, an air conditioning compressor on the Carnival Fantasy leaked fifty-seven kilograms of an ozone-depleting substance due to a “failed shaft seal,” in violation of MARPOL. See Carnival Corporation & plc HESS Weekly Flash Report (Mar. 14, 2017). ix. Seals and Locks The CAM Team identified over seventy-five reported incidents on Covered Vessels related to ECP Environmental Control System seal and lock requirements. See ECP § IX.B. The following photographs show examples of locks (left) and a seal (right): [See photographs on following page.] 45 Ozone-depleting substances are “those substances which deplete the ozone layer and are widely used in refrigerators, air conditioners, fire extinguishers, in dry cleaning, as solvents for cleaning, electronic equipment and as agricultural fumigants,” including chlorofluorocarbons (commonly called “CFCs”). See http://www.environment.gov.au/protection/ozone/ozonedepleting-substances. Ozone-depleting substances are regulated under MARPOL. See https://www.marineinsight.com/environment/what-are-ozone-depleting-substances-on-ships/. 52 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 56 of 205 CONFIDENTIAL June 21, 2018 ECP Environmental Control System locks (left) and a seal (right). Most of the reported incidents involve missing or damaged seals. Often, the Company was unable to identify the cause of the missing or damaged seals, attributing the incidents to accidents or carelessness and stating in a conclusory manner that “no unauthorized access had taken place.” See, e.g., Carnival Corporation & plc HESS Weekly Flash Reports (Aug. 30, 2017 and Sept. 6, 2017). For example, on August 26, 2017, a seal on an Oily Water Separator on the Carnival Magic was found missing. “[I]t was concluded that the seal may have been broken and lost during cleaning work carried out in the area. There was no apparent damage or tampering with the [relevant component of the Oily Water Separator] itself.” Carnival Corporation & plc HESS Weekly Flash Reports (Aug. 30, 2017). Similarly, on February 9, 2018, two seals in a sewage room on the Carnival Triumph were found missing. “No signs of tampering were found. The seals are believed to have been damaged during maintenance work.” Carnival Corporation & plc HESS Weekly Flash Reports (Feb. 14, 2018). x. Training The CAM Team identified ninety reported incidents on Covered Vessels related to training, including failure to perform ECP-required training and falsification of ECP training 53 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 57 of 205 CONFIDENTIAL June 21, 2018 records. See, e.g., supra, § V.B.3.ii. This category also includes incidents where inadequate training appears to have contributed to an incident. These incidents arise in a wide range of contexts. For example, on December 17, 2017, a bucket of oil-based paint spilled overboard from the Carnival Vista, in violation of MARPOL. See Carnival Corporation & plc HESS Weekly Flash Reports (Dec. 27, 2017). The Company found that painting procedures and best management practices “were not followed by the crew.” Id. On January 5, 2018, approximately two cubic meters of grey water46 overflowed from a tank into the bilges on the Royal Princess because an engineer “did not recognize the high-level alarm for the tank.” Carnival Corporation & plc HESS Weekly Flash Reports (Jan. 5, 2018). xi. Voyage Planning The CAM Team identified over fifty-five reports of incidents on Covered Vessels related to voyage planning. These incidents involve prohibited discharges or emissions that appear to be attributable to misunderstandings or miscommunications about the ship’s location or relevant environmental requirements. For example, between June 4-16, 2017, the Carnival Elation discharged approximately 1,270 cubic meters of treated sewage and 22 cubic meters of food waste in Bahamian Archipelagic waters in violation of MARPOL and Company requirements. See Carnival Corporation & plc HESS Weekly Flash Reports (July 13, 2017). Likewise, on June 15, 2017, the Carnival Conquest, Carnival Liberty, Carnival Magic, and Carnival Vista made prohibited discharges of sewage and food waste in Bahamian Archipelagic waters. According to the Company, the cause of these events “appears to be associated with the interpretation of [the 46 Grey water includes drainage from dishwater, shower, laundry, bath, wash bin basins, and the production of food. It does not include drainage from toilets, urinals, hospitals, animal spaces, and cargo spaces. Joint Glossary of Terms at 6. 54 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 58 of 205 CONFIDENTIAL June 21, 2018 relevant Company] procedure.” See CAM Incident References #005_2017-EL.5, #005_2017EL.4, #005_2017-EL.3, and #005_2017-EL.2. Similarly, in November 27, 2017, the Carnival Vista discharged cleaning chemicals into Bahamian Archipelagic waters in violation of Company requirements “due to a misinterpretation of territorial waters.” Carnival Corporation & plc HESS Weekly Flash Reports (Dec. 6, 2017). On July 27, 2017, the Carnival Imagination discharged oily bilge water in Californian waters in violation of Company requirements because the responsible engineer “did not ask for a confirmation from the Bridge to commence the discharge.” Carnival Corporation & plc HESS Weekly Flash Reports (Aug. 3, 2017). C. Data Analysis For incidents reported during ECP Year One, the CAM Team tracked and analyzed 779 Flash Report incidents, eighteen Notices of Violation, five Hotline Reports, and nine TPA Major Non-Conformity findings.47 Table 1 shows these incidents by brand: Table 1: Incident Report Counts Brand Flash Report Incidents Notices of Violation Hotline Reports AIDA Carnival Cruise Line Costa Cunard Holland America Line P&O Cruises UK Princess Seabourn Total 22 344 37 56 122 89 96 13 779 3 1 2 0 5 1 5 1 18 0 3 0 0 0 0 2 0 5 47 TPA Major NonConformities 0 1 0 1 2 0 5 0 9 These totals reflect only a subset of the total numbers of incidents reported to the CAM Team during ECP Year One—specifically, those incidents that relate to environmental issues on Covered Vessels (including vessels that were on the Covered Vessels list during ECP Year One and later removed) and that the CAM Team, in its discretion, is tracking. The data in Tables 1-7 do not include incidents on Non-Covered Vessels. 55 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 59 of 205 CONFIDENTIAL June 21, 2018 The number of incidents, whatever their significance may be, also are a function of the relative sizes of the respective fleets. For example, there are twenty-five vessels in Carnival Cruise Line covered by this data, and only three vessels from Cunard. Table 2 shows weighted ratios to reflect rates of Flash Report incidents relative to the size of each fleet of vessels. Table 2: Weighted Index of Flash Report Incidents by Operating Line Brand AIDA Carnival Cruise Line Costa Cunard Holland America Line P&O Cruises UK Princess Seabourn Total Incident Index Incident Count Covered Vessels48 % Incidents % Covered Vessels 22 4 2.82% 5.26% 0.54 25 3 3 44.16% 4.75% 7.19% 32.89% 3.95% 3.95% 1.34 1.20 1.82 14 5 18 4 76 15.66% 11.42% 12.32% 1.67% 100.00% 18.42% 6.58% 23.68% 5.26% 100.00% 0.85 1.74 0.52 0.32 344 37 56 122 89 96 13 779 (% Incidents / % Covered Vessels) Table 3 provides an overview of the recurrent incidents that occurred during ECP Year One. Training and Recordkeeping are the most prevalent issues across all brands. Tables 4 and 5 provide a breakdown of the brands that have experienced Training and Recordkeeping incidents, with Carnival Cruise Line experiencing the highest counts. [See tables on following page.] 48 As noted supra note 47, the Covered Vessels column includes vessels that were on the Covered Vessels list during ECP Year One (including vessels that later were removed), with one exception: it does not include the Carnival Horizon because it joined the Carnival Cruise Line fleet very near the end of ECP Year One (on March 28, 2018) and had no reported incidents during ECP Year One. 56 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 60 of 205 CONFIDENTIAL June 21, 2018 Table 3: Overall Incident Count Table 4: Training Incident Count Table 5: Recordkeeping Incident Count Incident Category Count Brand Count Brand Count Falsification of Records 4 AIDA 4 AIDA 6 EGCS 34 Oil Content Meters Lifeboat and Tender Systems 41 Carnival Cruise Line Costa 48 Cunard Oil Record Books 49 Voyage Planning Oily Water Separators/White Boxes Refrigerants Seals or Locks Recordkeeping Training Total49 58 Holland America Line P&O Cruises UK 71 72 77 82 90 8 Carnival Cruise Line Costa 7 Cunard 39 66 5 1 3 Holland America Line P&O Cruises UK 1 Princess 14 Total 81 Seabourn 1 Total 85 9 2 626 Finally, Tables 6 and 7 provide an overview of the vessels, irrespective of brand, with the highest and lowest counts of incidents throughout ECP Year One. The underlying reasons for these numbers are not known, and, as noted above, could merely reflect different rates of reporting.50 Thus, while the data are presented in the interest of transparency, they should serve only as a prompt for further analyses. [See tables on following page.] 49 Not all reported incidents will have a recurrent incident category, and some incidents may have more than one recurrent incident category. Therefore, the total will not equal the total of reported incidents. 50 Differences in the number of seal or lock incidents also may be a function of the differences in the number of seals or locks installed on the different ships. For example, the CAM Team understands that some ships installed under 150 seals, and more than 1,500. See Employee Interview Notes. 57 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 61 of 205 CONFIDENTIAL June 21, 2018 VI. Table 6: Covered Vessels with Highest Incident Count Table 7: Covered Vessels with Lowest Incident Count Vessel Incident Count Vessel Incident Count Queen Mary 2 Costa Atlantica Carnival Dream Carnival Ecstasy Carnival Fantasy Carnival Freedom Carnival Magic Carnival Liberty Carnival Pride Zuiderdam Carnival Glory Carnival Miracle Carnival Valor 23 21 20 20 20 20 17 17 16 15 15 15 15 Pacific Princess Sapphire Princess Regal Princess Noordam Sojourn Odyssey AIDAmar Crown Princess Star Princess Encore Carnival Ecstasy Aurora Carnival Elation Grand Princess 2 2 2 2 2 2 2 1 1 1 1 1 1 1 EVALUATION OF THE TPA A. Engagement with the TPA One aspect of the CAM’s work under the ECP is to oversee the TPA. See ECP §§ VI.F.1-3. The goal of this oversight is to confirm that the TPA acts with independence and performs adequate ECP-required audits. Id. The CAM Team has undertaken a number of efforts to oversee the work of the TPA. As an initial matter, since the start of the monitorship, the CAM Team has reviewed the selection of TPA auditors. For each auditor the TPA proposed to use, the TPA sent the proposed auditor’s resume to the CAM Team for review. If it was determined that the auditor appeared to be qualified and did not face any known conflicts of interest, then the CAM would approve the auditor to serve on the TPA team. The CAM Team is in regular contact with the TPA. The CAM Team has in-person meetings and weekly calls with the TPA to coordinate efforts and to address issues as they arise. 58 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 62 of 205 CONFIDENTIAL June 21, 2018 The CAM Team and the TPA also share information from their respective activities. In addition, the CAM Team worked with the Company to access Company databases, and then set up a knowledge management platform that the TPA can access. The CAM Team also conducts oversight of the TPA’s work. This includes accompanying the TPA on shoreside and vessel audits, as well as visiting vessels that the TPA previously audited. These visits help inform the CAM’s assessment of the independence and rigor of the TPA audits and auditors. The CAM Team also reviews all of the TPA audit reports and tracks these findings to look for any issues related to the TPA’s methods or analysis, or with individual auditors. B. TPA Audit Process During ECP Year One, the CAM Team has not identified any significant shortcomings with the TPA’s audit process. Based on the CAM Team’s direct observations during vessel and shoreside visits, follow-up visits after TPA audits, and discussions with Company personnel, the TPA teams are highly qualified, well-organized, methodical, and thoughtful. TPA auditors confer with a cross-section of the officers and crew, from the Captain to ratings. Auditors explore the Company’s processes, do not merely check boxes, and take the time needed for each inquiry. The TPA auditors show respect for crew members’ schedules and the operational demands of the ship. The TPA has an extensive checklist to guide the performance of the audit. The TPA’s checklist and report format reflect the elements of the ECP that the TPA is tasked with auditing. These include all twenty-six elements of ECP Section VIII.B, as well as elements from ECP Sections IX and X. 59 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 63 of 205 CONFIDENTIAL June 21, 2018 The TPA teams have demonstrated the technical ability and maritime experience to identify a wide range of issues during their vessel and shoreside audits. The TPA has documented findings of varying degrees of severity (ranging from Observations to Major NonConformities). The CAM Team has seen no indications that the TPA is dissuaded from its independent judgment regarding these findings, even when the findings are met with disagreement. For example, during one CAM Team ride-along with the TPA, the TPA identified as a finding that sampling procedures were not consistent with ECP requirements. Company representatives questioned the basis of this finding, noting that the vessel was cooperating with a necessary retrofitted modification of the sample location. TPA auditors acknowledged the response and again explained the basis for the finding. The finding ultimately was included in the audit report. One concern the CAM Team has raised with the TPA relates to the difficult role of an auditor. Occasionally, the TPA representatives slide into the role of consultants rather than auditors, providing advice rather than observing. The CAM Team raised this issue to the TPA, and the TPA concurred on the importance of acting as an auditor only and instructed its auditors accordingly. C. TPA Audit Reports The TPA’s finalized reports track their checklist and templates. The reports are clear, cover the necessary areas, and document the TPA’s findings. 60 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 64 of 205 CONFIDENTIAL June 21, 2018 D. TPA Receptiveness to CAM Feedback As noted above, CAM Team feedback to the TPA has been via in-person meetings and teleconferences, weekly and as needed. TPA representatives have been receptive to the CAM Team’s feedback. VII. EVALUATION OF INTERNAL AUDIT FUNCTION A. Overview of Internal Audit Process The Company’s internal audits are conducted by RAAS.51 RAAS is an independent department that reports directly to Carnival Corp.’s Board of Directors. ABSG, Carnival Corporation & PLC Environmental Compliance Audit Report: Carnival Corporate Office 14-18 August 2017 at 7 (Aug. 25, 2017). These audits occur annually for each vessel and operating line shoreside facility and assess compliance with applicable codes (e.g., the ISM Code), regulations, and internal policies. See HMP-1301 Internal Audits (Dec. 13, 2016). In 2013, the internal audit function was restructured to establish teams of auditors at each operating line that report to RAAS. ABSG, Carnival Corporation & PLC Environmental Compliance Audit Report: Carnival Corporate Office 14-18 August 2017 at 8 (Aug. 25, 2017). During the course of an audit, RAAS auditors generate findings that carry an associated category and severity (e.g., environmental medium non-conformance). After the audit is complete, RAAS generates a score for each finding based on its severity and risk. See HMP1301-A3 Finding Risk Matrix (May 7, 2015). These scores are deducted from 1000 (the starting vessel score) to generate the overall audit grade. For example, in 2017, the Ruby Princess received an audit grade of 756 for zero Major Non-Conformities, one High Non-Conformity, 51 The RAAS audit function is distinct from its investigation function, discussed above in Section III.G and in Section IV.C. 61 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 65 of 205 CONFIDENTIAL June 21, 2018 five Medium Non-Conformities, seventeen Low Non-Conformities, and three Observations. RAAS Final Maritime Presentation & Audit Report Cover Sheet, Ruby Princess (Mar. 11-18, 2017). In the spectrum of audit grades from excellent (950-1000) to below average (below 250), 756 is classified as above average. See HMP-1301-A3 Finding Risk Matrix (May 7, 2015). In general, each RAAS audit team consists of three auditors. The audit team typically remains onboard a vessel for seven days. The duration of a shoreside audit visit varies based on the facility site. Draft audit schedules are sent to the ship or office at least fifteen days prior to an audit. The audit beings with a RAAS team introduction to the Captain (or, if on shore, to the CEO or other senior manager), followed by an opening meeting to discuss the scope, methods, and objectives of the audit. The audit then proceeds with interviews of various crew members, document review, and physical inspection of the deck, engine, and hotel spaces and equipment. A closing meeting is held at the completion of the audit during which all findings are discussed. Shipboard personnel are given ten days to review the report and/or discuss it with shoreside management. If shipboard personnel do not agree with a RAAS audit finding, they are to tell the lead auditor during the closing meeting the reasons why they disagree. If they cannot agree, then the shipboard personnel can involve the relevant operating line’s Audit Review Committee. Similarly, if either the Designated Person Ashore52 or Audit Review Committee does not concur with any findings in the audit report, then the head of RAAS or the Vice President of RAAS will be advised, and these findings will be sent to the Chief Maritime Officer for clarification or interpretation. 52 A Designated Person Ashore is a shoreside-based person designated by a Company under the ISM Code to provide a link between shoreside and shipboard personnel. The Designated Person Ashore’s duties should include monitoring the safety and pollution prevention aspects of the operation of each vessel and ensuring that adequate resources and shore-based support are supplied. Joint Glossary of Terms at 4-5. 62 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 66 of 205 CONFIDENTIAL June 21, 2018 Within three weeks of completing any shipboard audit, the chair of the Audit Review Committee holds a post-audit committee meeting where the Audit Review Committee members present and agree on final action plans and implementation dates. The agreed action plans should be based upon a root cause analysis, and all action plans are to include an implementation date. Although not part of the Audit Review Committee, the head of RAAS is invited to attend all post-audit meetings, as is the lead RAAS auditor for the audit and the shipboard senior management of the ship under audit. B. CAM Assessment of Internal Audits and Audit Reports The ECP requires the CAM to “conduct a review of [the Company’s] internal environmental audits with respect to Covered Vessels and Covered Personnel . . . The CAM’s review shall assess the ability of [the Company’s] internal audit process to accomplish the objectives of this ECP, including any inadequacies with respect to [the Company’s] performance, whether personnel-based or related to any of its Covered Vessels, systems, equipment, or components.” ECP § VI.F.4. 1. Shipboard Audits During ECP Year One, the CAM Team conducted two ride-alongs of RAAS vessel audits: the Carnival Pride in December 2017 and the Carnival Victory in February 2018. The majority of the visit was spent with the auditor responsible for the environmental component of the audit. The RAAS auditors were knowledgeable about the HESS system, conducted themselves professionally, and had the technical expertise required for the audit. It appeared that the auditors were provided with full access to relevant aspects of the vessel and given complete cooperation from the crews. 63 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 67 of 205 CONFIDENTIAL June 21, 2018 2. Audit Reports The CAM Team reviewed the environmental component of RAAS audit reports for 2017 and 2018 (to date) for seventy-three Covered Vessels and four shoreside office locations. The RAAS audit reports cover a wide variety of environmental issues, including policies and procedures, training, recordkeeping, and the physical condition of the vessels. There were several common findings, regardless of operating line or brand, including findings related to Oil Record Book entries, Environmental Officer training, and critical spare parts. Below is a more detailed summary of repeat findings: Vessels • Oil Record Book incorrect or missed entries – ENV-1201 • Vulnerability Assessments needing additions – ENV-1204 • Bilge arrangement drawings posted – unapproved – DER-2002 • MARPOL samples not sealed – TEC-1402 • Portable pump either not logged out or not controlled – ENV-1203/1204 • Critical spares not standardized or below minimum levels – ENV-1201 • Minimum quantity of spare within the planned maintenance system can be modified by shipboard personnel – ENV-1201 • One scrubber not on ship’s operational manual – ENV-1202 • No audible and visual alarms on bridge for Oil Record Book overboard valve – DER2002 • Secondary containment for chemicals not provided – OHS-1102 • No instruction on how Environmental Officer is to check for proficiency of training or means, procedure for other training – ENV-1008 • Environmental Officer’s role and responsibility is for monitoring only – ENV-1008 • Oil-to-sea interface log improper filled out – ECR-1.1 • Environmental aspects/impacts of Ship Energy Efficiency Management Plan (“SEEMP”) not up to date, completed with targets – ENV-1404 • Shipboard Oil Pollution Emergency Plan – amendments to the plan & inventory – EMR1801 • Reefer equipment instruction manuals/calibration not found – ENV-1402 64 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 68 of 205 CONFIDENTIAL June 21, 2018 • Fuel bunker checklists (bunker delivery note) logs not completed in full – TEC-1402 • Gas bottle monthly inspection and ten-year hydro not carried out – ENV-1402 • No fuel test kits; tests not carried out, test kits cannot meet bunkering instruction – TEC1402 • Fuel change over guidance not ship/class specific – TEC-1404 • Wash water analysis results for EGCS not provided by shoreside – ENV-1102 • Boiler blow down valve, no verification as to when and where operated – ENV-1001 Shoreside • Company incident investigation process doesn’t meet ISM (SOLAS Ch. 9) and internal Company procedures – HMP 1302 and 1303 • Management Corrective Action plan does not meet ISM (SOLAS Ch. 9) and internal Company procedures – HMP 1301 • Environmental Officers & EGCS officers have not had EGCS training at CSMART – TRG-2101/2104 • ECP Monitoring System – several spare (critical) spare parts not maintained as minimum stock – ENV-1014-2.1.2 • No shoreside waste vendor assessments - ENV-1004-4.1 • Annual review of SEEMP was not conducted – ENV-1404-4.3 3. Employee Interviews During CAM Team vessel visits, the CAM Team asked crew members, including Captains, Environmental Officers, Chief Engineers, and others, for their perspectives on the Company’s internal audit process. Similarly, during shoreside office visits, the CAM Team solicited interviewees’ opinions on the auditing process. The responses have been mixed. Positively, many interviewees indicated that the internal audit process has improved over the past few years and that “having another set of eyes” is helpful. See Employee Interview Notes. Criticisms, though, were more common and generally can be categorized as addressing (i) auditor competency; (ii) the substance of audit findings; and (iii) the impact of audit findings on compensation and bonuses. See id. 65 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 69 of 205 CONFIDENTIAL June 21, 2018 Relatedly, as noted above in Section VII.A, there is an extensive internal process before a RAAS audit is finalized. Concerns have been raised that this process leads to a focus on obtaining a good audit score rather than addressing the learning opportunities raised by the substantive findings identified during the audit. i. Auditor Competency Multiple crew members across several brands indicated that the value of an internal audit largely depends on the experience and knowledge of the auditors. See id. One Safety Officer observed that the audit can vary depending on the “personality” of the auditor, while a Chief Engineer suggested that the process could be improved by hiring former Captains and Chief Engineers as auditors, indicating that auditors with more relevant engineering and environmental experience would improve the overall auditing process. See id. ii. Substance of Audit Findings Crew members criticized the substance of audit findings, which sometimes are perceived as unfair or “nit-picky.” See id. At one extreme, a shoreside interviewee described the system as “absolute crap,” while a Captain observed that the auditors issue findings for unimportant details. See id. In one instance, a shoreside interviewee reported that a ship was issued a finding for not following incinerator ash sampling procedures even though the vessel’s incinerator was not functional (and, therefore, no ash was available to sample). Similarly, a Captain referred to an audit finding issued for not having markings for a helicopter landing pad, although such a pad is not required on passenger ships. The finding later was retracted. See id. A broader criticism is that RAAS audit findings do not address the root causes of issues. Id. 66 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 70 of 205 CONFIDENTIAL June 21, 2018 iii. Impact of Audit Findings on Compensation and Bonuses Multiple shoreside interviewees raised concerns with how audit findings and grades can impact compensation and bonuses. See id. It appears that this is a matter of discussion and review, at least at some operating lines. Id. This discussion reflects a legitimate concern, for example, that vessels would try to “game” or “win” internal audits by masking or superficially addressing issues in advance of an audit. The CAM will examine this issue further in the future. See infra, § VIII.D. C. TPA Assessment of Internal Audit Function The TPA assesses the internal audit process during audits of the Company’s shoreside offices. See ECP § VIII. The TPA has made favorable assessments of the Company’s RAAS auditing function. For example, the TPA noted in the Holland America Group shoreside office report that “procedures for RAAS Auditing are well defined, and the process is mature and consistent across all brands and groups and yield overall excellent audits that result in meaningful [corrective actions and preventative actions].” ABSG, Holland America Group Environmental Compliance Audit Report, Holland America Group Offices Seattle/Santa Clarita 15-24 January 2018 at 21 (Feb. 23, 2018). D. Overall CAM Observations Overall, the CAM Team has observed that the RAAS audit function has experienced and hardworking auditors who follow a comprehensive review process. Further work is required to better understand how the RAAS group supports a sustainable compliance culture, including: whether RAAS requires additional auditors to focus on environmental compliance; whether auditors require additional opportunities for training; and how attitudes towards the audits might impact the development of a strong compliance culture. 67 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 71 of 205 CONFIDENTIAL June 21, 2018 VIII. AREAS OF FOCUS FOR YEAR TWO Much of ECP Year One was spent in an effort to understand the Company’s complex operations and organization. These efforts—which included CAM Team visits to shoreside facilities, visits to at least one of the vessels for each of the eight Covered Vessel cruise brands, and oversight of the TPA and RAAS auditors—required more time and resources of both the CAM Team and the Company than was anticipated. Some significant areas that will receive attention and review going forward are described below. A. Culture Survey The CAM, with the support of the Company, is retaining a consultant to conduct an environmental compliance culture assessment. This survey, conducted during ECP Year Two, is designed to provide a baseline of the current corporate compliance culture. A follow-up survey is to be conducted before the completion of the five year probationary period. Following a Request for Proposal and referral review process that evaluated multiple culture consultant candidates, the CAM has selected Propel AS (“Propel”), based in Oslo, Norway, to help the CAM survey the Company’s compliance culture. Propel was chosen based on its approach to survey design and its maritime expertise. The survey instrument will be developed by Propel, with input from the Company— though the CAM has final control. It is planned that the survey will be administered to shipboard and shoreside employees. The survey population will be determined by the CAM in consultation with the Company.53 Propel also will conduct focus groups and one-on-one interviews to clarify and further explore observed survey trends and responses. 53 The CAM notes that a relevant population of approximately 45,000 was identified; however, the Company asked to expand the population scope to include employees who are not Covered Personnel and who may not have work duties directly related to environmental compliance. 68 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 72 of 205 CONFIDENTIAL June 21, 2018 B. Investigations All parties recognize that internal investigations are a particular area of challenge for the Company. See supra, §§ III.G and IV.C. The CAM will evaluate the Company’s actions in response to the recommendations of DNV GL in the coming year. C. Training During the April 2017 Sentencing Hearing, the Court emphasized the importance of training, noting that “training needs to be for everyone and it needs to be on an annual basis and it needs to be training similar to that in the military where it becomes instinctive that there is a call and a response; it is so ingrained in the individuals, each member of the crew is committed to the environment.” Sentencing Hr’g Tr. at 13 (Apr. 19, 2017). The ECP has numerous training requirements, and the Company invested significant resources in this training. Going forward, the CAM will continue to examine the environmental and ECP-related training for all personnel. In June 2017, the CAM visited the Company’s CSMART training facility in Almere, The Netherlands. The Company’s ECP-required Environmental Officer training was just beginning. The Company reports that it is employing a third party to review and revise the substance of its Environmental Officer and other trainings. The Company also reports that it is integrating environmental requirements and related issues into the existing training for its deck and technical officers. See Appendix B. In October 2017, the TPA conducted an audit of the CSMART Environmental Officer training course. The TPA found that the course met ECP obligations, but made the following observations: • The course did not have written objectives for the students during the introduction of the course. • The course did not have written objectives for the simulator exercise or a brief prior to entering the engine room simulator. 69 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 73 of 205 CONFIDENTIAL June 21, 2018 • The group in the simulator (full class) appeared to be too large for the exercise. • Similar naming exercise that is done with OWS’ systems [should] be done on the white box. • Pre‐requisite requirements for the course was not met by a majority of students. Reasons were varied; “couldn’t open files”, “a lot of information to look at”, “no internet access”. • No written procedures [were] developed for course review and revision that meets the Company’ standards. • No written audit/evaluation [were] developed for the EO training manager’s ECP’s ship visits. ABSG, Carnival Corporation & PLC Environmental Compliance Audit Report, CSMART Environmental Officer Course 25-30 September 2017 at 4 (Oct. 9, 2017). The TPA also found several factors that adversely impacted the effectiveness of the course, including variation in the level of student maritime and engineering experience, variation in the applicable shipboard procedures between the operating lines, and variation between pollution prevention equipment used in the course and that in operation on certain vessels. Id. at 5. The CAM will track how and the extent to which Company has addressed these factors. In addition, the CAM plans to examine the training of ratings, which primarily is conducted by third-party manning agencies.54 D. Resources for Operations and Compliance The CAM Team has not yet determined how budget-development and financial goals have, or have not, impacted compliance efforts. Personnel report tension between maximizing revenues and support for ship operations. See Employee Interview Notes. Personnel also report that they continue to face the “excessive frugality” identified by Chief Maritime Officer Burke in 54 Manning agencies are “companies that act as an employment agency for seafarers. Seafarers use them to find employment at sea and shipping companies use them to source crew.” http://sea-jobs.net/encyclopediaen/163. 70 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 74 of 205 CONFIDENTIAL June 21, 2018 his analysis of the Caribbean Princess incident. In contrast to these statements, senior management can point to the funding of initiatives beyond the enumerated requirements of the ECP, and they assert that no reasonable requests related to environmental compliance are being denied. See id. During ECP Year Two, the CAM will seek to better understand how the Company addresses long-term plans for compliance within the context of strategic plans for achieving financial objectives. In addition, the CAM will seek to better understand the bonus structure across the operating lines. The Company’s bonus structure has changed over the years and varies by operating line. Notably, a respondent to the Fleet engineering survey reported “that bonuses incent people to not follow procedures (bonuses linked to reduction of discharges of sludge and bilge, reduction of spare parts expense, faster port visits).” DuPont Sustainable Solutions, Environmental Compliance Survey Final Results (Feb. 2018) at PCL ECP00042053. E. Shoreside Support for Vessels The CAM intends to further examine shoreside support for vessels. Shoreside operations play a critical role in vessel compliance obligations. Shoreside personnel establish and manage: HESS policies and procedures; training programs; budgets for vessel operation, maintenance, and repairs; internal audits; and incident investigations. They also develop, implement, and train employees on information technology systems and applications, such as training tracking, incident reporting, and financial systems. Shoreside environmental responsibilities include supporting ships with the management of waste, garbage, ballast water, oily bilge water, and critical environmental equipment, including critical spare parts for pollution prevention equipment. 71 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 75 of 205 CONFIDENTIAL June 21, 2018 Ships depend on support from shoreside to provide human resources as well as supplies. If parts do not arrive on time, the ship is in a no-win position where it must either “make do” or risk losing revenue and disappointing customers due to a departure delay. Unlike an airline company that can, at times, provide a replacement for a plane with a problem, or call up a standby pilot, cruise ships are not quickly repositioned, and qualified mariners may be across the globe from where they are needed. The CAM Team has received mixed responses from vessel personnel concerning shoreside support. Complaints focus on maintenance delays, budgetary constraints, and the lack of centralized information technology systems for tasks such as tracking training or incident reporting. Others complain about a tidal wave of communication from shore, including uncoordinated and unprioritized email inquiries. See Employee Interview Notes. On the other hand, the CAM Team has heard from shoreside personnel that they are committed to supporting the vessels. See id. The CAM will seek to explore these issues in ECP Year Two. F. Personnel The CAM will review several areas related to personnel going forward. These include the Environmental Officer position, staffing of engineers, and hiring and training of ratings. 1. Environmental Officers The Environmental Officer plays a key role in the implementation and verification of ECP requirements. In ECP Year One, the Company reports that it lost a total of 20 out of approximately 200 Environmental Officers across all operating lines. The Company cited several factors for these mostly unwanted departures, including salary, dissatisfaction with changes in job duties, and inability to pass the newly required Environmental Officer training course. However, the Company reports that this attrition rate appears to have decreased in the 72 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 76 of 205 CONFIDENTIAL June 21, 2018 second half of ECP Year One. The Company recognizes that the ability to retain a sufficient number of competent Environmental Officers is a challenge for several reasons, including the lack of a clear path of upward mobility from the Environmental Officer position and frustrations on the part of some Environmental Officers regarding workload. 2. Engineers Some personnel have raised concerns about the availability of a sufficient number of engineers qualified for the roles needed on the ships. Following the events on the AIDAvita, the Company’s consultant observed that a lack of availability of senior engineers was not an isolated incident on the AIDAvita. Investigation Memo No. 11/2018 AIDAvita – Alleged Tampering with the Bilge Control Discharge Box (BCDB) at PCL_ECP00046689. 3. Ratings Ratings perform important duties related to environmental compliance such as tank soundings, maintenance operations, and repairs. The CAM will seek to understand more about the recruitment and training of these employees. G. Company Vessel Visit Programs During ECP Year One, two vessel visit programs came to light. The first program was one where individuals or teams were deployed to inspect and correct ECP issues onboard vessels approximately a week prior to a scheduled TPA audit. See Employee Interview Notes. This program was not disclosed to the CAM or the TPA, and, as far as is known, the teams left no reports or documentation as to their observations and corrective actions, if any. During the December 2017 Status Conference, the Company’s pre-audit review of its vessels was described as “one or two people who have gone to try to get the ship in a position where they prepared or 73 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 77 of 205 CONFIDENTIAL June 21, 2018 are ready for the audit.” Status Conf. Tr. at 69 (Dec. 4, 2017). The Company committed to the Court that “to the extent that we’ve done that, we will do it no more.” Id. at 23-24. At the April 3, 2018, Status Conference, another vessel visit program was revealed to the Court. The government has issued document requests to understand the nature of both the first and second vessel visit programs. The CAM has informed the Court that it will review these programs and report back to the Court and the Interested Parties. Respectfully Submitted, STEVEN P. SOLOW Court Appointed Monitor June 21, 2018 74 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 78 of 205 CONFIDENTIAL APPENDIX A June 21, 2018 APPENDIX A: CAM’S METHODOLOGY AND ACTIVITIES The CAM and the Company entered into a Monitor Agreement that provides: “By no later than the 1st of August of each year of the monitorship, and commencing on August l, 2017, the Monitor shall provide the Company with a comprehensive, written annual work plan that reflects the work expected to be undertaken by the Monitor Team in the forthcoming year. This work plan will include, among other things, the expected maximum total number of Monitor Team visits to Covered Vessels and shore side facilities (including attendance at Third Party Auditor audits of Covered Vessels and shoreside facilities, as well as Covered-Vessel and shoreside facility visits the Monitor Team may conduct separately from the Third Party Auditor), and the estimated fees and expenses for that work.” During the first year of the monitorship, on August 1, 2017, the CAM submitted a “First Annual Work Plan and Budget of the Court Appointed Monitor.” The Company objected both to the scope and to the cost of the CAM’s planned work. The CAM and the Company subsequently entered into negotiations that resulted in the presentation, on October 20, 2017, of a “Superseding First Annual Work Plan and Budget of the Court Appointed Monitor.” This Superseding Work Plan is attached and describes the CAM’s methodology and activities during ECP Year One. The CAM will prepare a work plan that reflects the CAM’s planned work for ECP Year Two on or before August 1, 2018. Page 1 of 1 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 79 of 205 CONFIDENTIAL APPENDIX B June 21, 2018 APPENDIX B: COMPANY INITIATIVES BEYOND ENUMERATED ECP REQUIREMENTS I. Policy In 2013, the Company began a process to unify and standardize policies and procedures across its brands through the implementation of a computer-based, corporate-wide HESS Management System, known as Global HESS. See e.g., INT-1001 Introduction to Global HESS (Jan. 6, 2017); Global HESS Project Status Update (June 6, 2017), PCL_ECP00025134-155. Deployment of the system began in May 2017, and was made available to each of the brand fleets by September 2017. Id. at PCL_ECP00025137. As part of this effort, and following sentencing in this matter, the Company focused significant resources, estimated at 1,764 hours or 220 full-time employee days, to review and revise the Global HESS policies to incorporate the requirements of the ECP. See Letter from John Haeflinger, Vice President, Maritime Policy & Analysis, Carnival Corporation & plc to Steven Solow, CAM (June 5, 2017), PCL_ECP00020299. The Company also continues to implement the Fleet Captain and Fleet Chief Engineer program, which allows Captains and Chief Engineers to step away from their normal duties for a period of two years and serve as compliance mentors across the fleets with respect to Global HESS implementation. II. Training The Company has made several improvements to its training programs both in accordance with the ECP, and outside of the enumerated ECP requirements. In July 2016, the Company opened a $90 million state-of-the-art training center in Almere, The Netherlands to provide deck and engine room officers with simulated instruction on bridge and deck resource management, which is focused on safe marine operation, communication, and decision-making. See Carnival Corporation’s Arison Maritime Center and CSMART Academy (Jan. 2017), Page 1 of 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 80 of 205 CONFIDENTIAL APPENDIX B June 21, 2018 PCL_ECP00040937; see also CSMART, https://www.csmartalmere.com/. CSMART is the home to the ECP-required technical training course for Environmental Officers, which allows the Environmental Officers to observe full-size, operational Oily Water Separators and Oil Content Meters. See CSMART, Environmental Officer Training, PCL_ECP00040945. The facility also provides environmental training to all engineers and deck officers attending the facility. See March 2018 USPO Supervision Report, Attachment 3; Module 1, Workshop Introduction, Compliance 2 Commitment (C2C) Workshop, PCL_ECP00040941. This training is designed to refresh personnel knowledge of regulatory requirements, Company policies, and particular job duties for key compliance tasks. Id. Additionally, the Company has made several technological improvements to its overall training management and dissemination. This includes the launch of a new corporate-wide electronic learning management system called the Global Learning and Development Information System (“GLADIS”). See March 2018 USPO Supervision Report, Attachment 3. GLADIS currently allows for the completion and tracking of basic environmental training for shoreside employees and pre-learning training for Environmental Officers, and eventually will be used for all HESS trainings. Id. To facilitate remote access to training, the Company is finalizing the development of an application for smart phones and tablets, called “CrewTube,” which be launched in two phases during 2018. See ECP Corporate Compliance Manager Annual Report (2017-2018) at PCL_ECP00046501-502. Phase 1 of the CrewTube launch will provide HESS information and some HESS training to crewmembers before they embark on a vessel. Id. Phase 2 of the CrewTube launch will allow personnel to receive HESS notifications and report potential compliance issues. Id. Page 2 of 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 81 of 205 CONFIDENTIAL III. APPENDIX B June 21, 2018 Communication The Company has sought to improve its corporate messaging related to compliance over the course of ECP Year One. The Company’s Chief Maritime Officer launched a monthly newsletter to communicate incidents, initiatives, and lessons learned through implementation of the ECP. See March 2018 USPO Supervision Report, Attachment 3; see also January 2018 ECP Newsletter, PCL_ECP00041008. The Company also has begun sharing cross-brand incidents and near misses reported in the weekly Flash Reports across the brand fleets. See ECP Corporate Compliance Manager Annual Report (2017-2018), PCL_ECP00046501. The Company is rolling out signage near pollution prevention equipment designed to remind engineering officers of environmental regulatory requirements. See February 2018 USPO Supervision Report, Attachment 4. The Company has launched the Operation Oceans Alive campaign, which it describes as an effort to “promote in each employee a higher consciousness of environmental stewardship by instilling a sense of personal commitment to the environment.” ECP Corporate Compliance Manager Annual Report (2017-2018) at PCL_ECP00046436-437, 497, 567. The campaign includes several other initiatives including its “Top 5” compliance priorities, and environmental and HESS performance awards. Id. The “Top 5” initiative is an effort to identify high-risk areas of environmental compliance, which then are communicated as compliance priorities to shipboard personnel. Id. at PCL ECP00046437, 572. The current list is: 1. No non-compliant discharges at sea and in port; 2. No unauthorized modifications to pollution prevention equipment; 3. Properly identify and control all vulnerable valves and fittings; 4. No use of non-compliant fuel; and Page 3 of 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 82 of 205 CONFIDENTIAL APPENDIX B June 21, 2018 5. Minimize bilge water accumulation. February 2018 ECP Newsletter, PCL_ECP00052353 at PCL_ECP00052353. The Company has launched an Environmental Excellence Awards program, which honors shipboard team members on the vessel with best compliance record in each operating line, as well as a HESS Employee of the Month Program, which honors employees for their commitment to HESS compliance. See ECP Corporate Compliance Manager Annual Report (2017-2018) at PCL_ECP00046497. IV. Technology Before and after the start of the ECP, the Company launched Fleet Operations Centers to track its ships and serve as a single point of contact for ships in the fleet for operational and safety support. These centers, which are located in Miami, Florida, Hamburg, Germany, and Seattle, Washington, can track a ship’s location in real-time and track the operational status of onboard equipment. The centers are staffed 24 hours a day, seven days a week. The employees of the Fleet Operations Centers have the ability to mobilize an emergency response should an incident occur. The Company also is looking to new technology to improve vessel voyage plans. Such voyage plans identify where certain discharges or emissions are allowed or prohibited, based on a ship’s location and the applicable restrictions. As noted in the CCM’s Annual Report to the HESS Committee, over the first year of the ECP, the Company has made multiple discharges of treated sewage, grey water, food waste, and ballast water in prohibited locations. See ECP Corporate Compliance Manager Annual Report (2017-2018) at PCL_ECP00046434. One cause of these discharges appears to be a failure to develop and follow effective voyage plans. Id. The Company is evaluating software programs designed to improve voyage planning, including an Page 4 of 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 83 of 205 CONFIDENTIAL APPENDIX B June 21, 2018 electronic discharge matrix that would provide coordinates of areas with discharge limits and the related restrictions. Id. at PCL_ECP00046434, 502. Finally, the Company is considering moving to a single planned maintenance system for use across the fleet and is developing a new software program to assist with environmental checklists and reporting items. See April 2018 USPO Supervision Report, Attachment 3. V. Equipment The Company is upgrading its fleets’ Oily Water Separators and White Boxes so that they are Marine Environmental Protection Committee (“MEPC”) 107(49) compliant devices, a newer and more efficient technology authorized under MARPOL. See April 2018 USPO Supervision Report, Attachment 3; ECP Corporate Compliance Manager Annual Report (20172018), PCL ECP00046437-438. The Company is completing the installation of CCTVs in the engine room to record operation of the oily water separation equipment. Id. These equipment upgrades and installations are scheduled to be complete by January 31, 2019. Id. The Company also is testing and seeking approval under Flag State requirements for a new, advanced onboard wastewater treatment system. Id. VI. Incident Investigation and Reporting The Company hired DNV-GL to review the Company’s investigation process, policies, and structures, and to provide recommendations for improvement. See ECP Corporate Compliance Manager Annual Report (2017-2018), PCL_ECP00046434. In early May 2018, DNV GL provided a report on their review and findings. See DNV GL, Towards improving Carnival’s incident investigation process, Report No. 2018-0209, Rev. Final (May 8, 2018), PCL_ECP00052001-52050. For additional detail, see Section III.G and Section IV.C. The Company also is working to develop a corporate-wide incident and near miss reporting system, Page 5 of 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 84 of 205 CONFIDENTIAL APPENDIX B June 21, 2018 called SEAevent, which is scheduled for implementation by the end of 2019. See April 2018 USPO Supervision Report, Attachment 3. Page 6 of 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 85 of 205 CONFIDENTIAL APPENDIX C June 21, 2018 APPENDIX C: ORGANIZATIONAL CHARTS Holland America Group Corporate Structure. The above chart was prepared by the CAM Team based on interviews with Company employees. The colored dotted lines represent the CAM’s understanding of reporting lines. Page 1 of 2 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 86 of 205 CONFIDENTIAL APPENDIX C June 21, 2018 Carnival Corp. Chief Maritime Officer Corporate Structure (as of April 1, 2018). The above chart was provided to the CAM Team by the Company. PCL_ECP00046950. Page 2 of 2 CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 87 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status CCM is responsible for developing and implementing a tracking mechanism to ensure that CARNIVAL takes corrective action on Audit Findings made by the TPA and makes timely reports to Interested Parties within the timeframes provided in the ECP. This tracking system shall be established no later than thirty (30) days after sentencing. The OLCMs shall be responsible for ensuring actual corrective action is taken on Audit Findings made by the TPA related to their respective Operating Lines. III.A.7 Complete Within thirty (30) days of sentencing, the CCM and OLCMs shall ensure that notification is given to all Covered Vessels regarding the prohibition against using unauthorized stub pipes, cross connections, or piping on engine room waste systems. IX.C.3 Within thirty (30) days of sentencing, the CCM and OLCMs shall ensure that notification is provided to all Covered Vessels regarding the prohibition against the non-emergency usage of cross connections from engine room bilge mains to the suction piping of larger pumps, which may be referred to as the “fire and general service pump” or “fire, bilge and ballast” pump. The notification shall state that such usage is similar to bypassing the OWS equipment and is strictly prohibited. Cross connections to eductor systems or any other system capable of pumping out bilge and wastes will also be referenced, with the exception of Classification Society and/or Flag Administration-approved food waste eductor systems. Any method to discharge overboard via the soot collection tank and soot educator must be disabled and locked out. IX.D.1 ECP Requirement Verification 30-Day Requirements • CCM Annual Report, Attachment E (Quarterly Issue Tracker – TPA Final Audit Findings) • OLCM Quarterly Reports Complete • ECP Videos • Environmental Compliance Notices Complete • Environmental Compliance Notices • Company policies and procedures 1 60-Day Requirements 1 Within sixty (60) days of sentencing, CARNIVAL will submit to the Government a list of three (3) qualified candidates for the CAM position, from which the Government will select a candidate to serve. In the event that none of the candidates are found acceptable, or if the work of the CAM is unsatisfactory at any time, the Government may request that CARNIVAL supply additional candidates VI.A Complete • Government selected Steve Solow as the CAM Within sixty (60) days of sentencing, CARNIVAL shall submit to the Government a list of three (3) qualified candidates for the TPA position, from which the Government will select a candidate to serve. VII.A Complete • Government selected ABSG as the TPA ENV-1204: Environmental Control System Page 1 of 9 CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 88 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status Within three (3) months after sentencing, the OLCMs shall be responsible for developing a ship-level annual budget process to ensure that each Covered Vessel is provided adequate funding for shore-side disposal of wastes, including solids, bilge water, oily wastes, and sludge; the minimization and management of waste streams; the maintenance, technical upgrade, or replacement, as appropriate, of environmental equipment; and funding necessary to meet the other requirements of this ECP. Such budgets shall include a methodology to estimate quantities to be sent ashore and/or processed by the Covered Vessels, based on historical data and expected itinerary or equipment changes. III.A.9 Complete Within three (3) months of sentencing, the OLCMs will create a system to tally and track on a quarterly basis the tons of waste solid and liquid sent ashore for each Covered Vessel. The OLCM will record quarterly waste volumes by tracking daily quantities offloaded from Covered Vessels. III.A.9 ECP Requirement Verification 90-Day Requirements • Company Policies and Procedures 2 • CCM Annual Report, Attachment D (OLCM Annual Budget Certifications) • ECP CCM Quarterly Reports Complete • Company Policies and Procedures 3 • CCM Annual Report, Quarterly Machine Space Waste Volumes and Tank Capacities • ECP CCM Quarterly Reports Within three (3) months of the date of sentencing, the CCM shall be responsible for establishing a CARNIVAL policy and message that is communicated to all shipboard Covered Personnel that they shall not follow illegal orders that violate international law, the laws of the United States, or CARNIVAL policy, and that any such orders involving this ECP, the EMS, or other Marine Environmental Protection Requirements can and shall be reported immediately to the respective OLCM, CCM, Master, or Environmental Officer, or through the Open Reporting System. III.A.13 Within three (3) months of sentencing, the OLCMs shall be responsible for ensuring the development and maintenance of a system to track and report each Covered Vessel’s machinery space waste quantities and capacities. The CCM shall provide the Interested Parties with this data on a quarterly basis. III.A.16 CARNIVAL shall, within three (3) months of sentencing, develop an EO Competency Framework that will detail the relevant knowledge and skills (including technical proficiency) required of EOs. IV.A.3 In addition to the training for EOs prescribed in ECP Attachment 3 and elsewhere in the ECP, CARNIVAL shall, within three (3) months of sentencing, adopt and implement a training and IV.A.4 Complete • Environmental Compliance Notices • Environmental Compliance Policy 4 Complete • CCM Annual Report, Quarterly Machine Space Waste Volumes and Tank Capacities • ECP CCM Quarterly Reports Complete • Company Policies and Procedures 5 • Documents Produced to CAM Complete 2 ENV-1009: Operating Line Compliance Manager 3 ENV-1003: Environmental Performance Monitoring 4 POL-1010: Environmental Compliance Plan (adoption of the ECP as a company policy) 5 ENV-1008: Environmental Officer Role and Responsibilities; TRG-2306: Environmental Officer Training Course at CSMART 6 TRG-2306: Environmental Officer Training Course at CSMART Page 2 of 9 • ECP Training Videos • Company Training Requirements 6 • CCM Annual Report CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 89 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section ECP Requirement Completion Status Verification • Documents Produced to CAM assessment program designed to ensure EOs meet the requirements of the EO Competency Framework. Within three (3) months of sentencing, CARNIVAL shall hire an EO training manager, who shall have an Engine Officer license, will have prior experience having sailed and served at the level of 2nd Engineer or higher, and has demonstrated knowledge of and experience with the Marine Environmental Protection Requirements. IV.A.5 Within three (3) months of the date of sentencing, CARNIVAL will adopt and implement a training program to educate the Covered Personnel on the environmental impact of operations and to be aware of the policies and procedures that form the basis of this ECP and the EMS, and which otherwise meets the specific requirements of this section. Attachm ent 3 Unless otherwise stated, all of the Engineering Requirements set forth below shall be implemented on Covered Vessels as soon as is reasonably practicable, but in any event not later than three (3) months from the date of sentencing. IX.A Complete • CCM Annual Report • Documents Produced to CAM Complete • Company Training Requirements 7 • ECP CCM Quarterly Report 8 • Notices of Violation CARNIVAL shall implement an Environmental Control System (“ECS”) to help prevent unauthorized usage or connections within the engine room and machinery spaces. Under the ECS, CARNIVAL shall require crew members to use numbered seals, locks, or welds (on flanges) to prevent the unauthorized connection to, and discharge through, piping systems that are or may be connected to the oily bilge system or overboard discharge connections. IX.B.1 Seals used as part of the ECS seals shall be non-reusable and uniquely numbered. An ECS Seal Log shall be maintained by the Chief Engineer that records each time a seal is affixed or removed, including IX.B.2 Substantially Complete 9 • ECP CCM Quarterly Report 10 • TPA Audits Substantially Complete 11 • Company Policies and Procedures 12 Substantially Complete 13 • Company Policies and Procedures 14 • TPA Audits • Notices of Violation 7 TRG-2302: Environmental Awareness Induction; TRG-2303: Environmental Technical Awareness Induction; TRG-2304: ECP Awareness Video for All Crew; TRG-2305: ECP Awareness Video for Technical Crew 8 CCM Q3 2017 Report (“Per Attachment 3 of the ECP, the updated environmental training course was reported as completed by all applicable personnel by October 19, 2017.”) 9 The Company reported that all Engineering Requirements (see footnote 10, infra) were completed by July 19, 2017, but the CAM identified some discrepancies between the ECP requirements and the Company’s implementation as noted in footnotes. 10 CCM Q2 2017 Quarterly Report (HAG, CCL, CMG, and CUK have “fully implemented all ECP engineering requirements by 19 July 2017.”) 11 TPA audits identified Section IX.B.1 non-conformities on the P&O Aurora (Oct. 2017), Crown Princess (Nov. 2017), Royal Princess (Dec. 2017), and Star Princess (Jan. 2018). 12 ENV-1204: Environmental Control System 13 Notice of Violation #10-2017 reports that a Section IX.B.2 violation was identified on August 15, 2017, on the AIDALuna; Notice of Violation #16-2018 reports that a Section IX.B.2, IX.B.3, and IX.B.4 violation was identified on March 14, 2018, on the Carnival Conquest. 14 ENV-1204-A1: Critical Valves, Fittings, Tank Hatches Lists, Lock Log, and Seal Log Page 3 of 9 CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 90 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status To prevent unauthorized manipulation of waste management systems within the engine room and machinery spaces, vessels shall maintain Classification Society-approved drawings that reflect all approved modifications made to waste management systems. IX.C.1 Complete • Company Policies and Procedures 15 Vessels shall implement corporate approval procedures for any modifications made to waste management tanks or their systems. Those procedures shall require prior Operating Line approval for all non-emergency modifications and shall require prompt approval or removal of modifications after an emergency. Any emergency modification must be reported to the TPA and CAM promptly after work is performed. IX.C.2 Complete • Company Policies and Procedures 16 To prevent unauthorized usage of bilge water tanks or oily waste tanks, CARNIVAL shall require that ECS seals or locks be placed on tank hatches, valves, or flanges that could allow for an external connection to the system. The ECS Seal Log or Lock Log shall track any time a processed bilge water tank is opened. IX.C.6 The deck plates above or near the locations of these cross connections or other interconnected systems and the valve bodies and associated hand wheels shall be painted international orange. A brightly colored sign with three inch letters shall be permanently fixed nearby, stating – “Bilge System Piping Crossover – Emergency Use Only.” To prevent unauthorized usage of those valves, CARNIVAL shall require that ECS seals be placed on such valves. IX.D.2 The ECS Seal Log shall track any time a crossover to the bilge main is opened. If a valve is remotely operated from the engine control room, the associated push button or switch must be unable to be used without breaking an environmental seal. Except that where a seal cannot be affixed to either the valve or associated push button or switch, the EO must review the valve position history to determine if the valve has been opened, and if it has, make a record in the ECS Seal Log. IX.D.3 ECP Requirement Verification the date, time, seal number removed, seal number affixed, personnel involved, and reason for any seal removal/replacement. The keys used to open locks utilized as a part of the ECS shall be controlled. • OLCM Quarterly Reports Complete 17 • Company Policies and Procedures 18 • TPA Audits Substantially Complete 19 • Company Policies and Procedures 20 Complete • Company Policies and Procedures 21 • TPA Audits 15 ENV-1011: Chief Engineer Environmental Responsibilities 16 Id. 17 The log requires tracking of “all critical valves and tank hatches that are controlled by locks,” but does not specifically reference bilge water tanks. 18 ENV-1204-A1: Critical Valves, Fittings, Tank Hatches Lists, Lock Log, and Seal Log 19 DER-2002 indicates that valve bodies, hand wheels, and nearby deck plates can be painted international orange or bright green. Additionally, a TPA audit identified a Section IX.D.2 non-conformity on the P&O Arcadia (Jan. 2018). 20 DER-2002: Oily Bilge System Operation Monitoring Equipment; ENV-1204: Environmental Control System 21 ENV-1204-A1: Critical Valves, Fittings, Tank Hatches List, Lock Log, and Seal Log Page 4 of 9 CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 91 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status All other bilge suction valves not connected to the bilge main, and independent emergency suctions to the vessel’s engine room bilges like those which may be connected to sea water circulating pumps, shall be painted international orange on all vessels and labeled in a manner similar to “Emergency Bilge Suction – Emergency Use Only.” The valve wheels will also have a numbered and logged ECS seal capable of breakaway during emergencies, testing, and maintenance. IX.E Substantially Complete 22 • Company Policies and Procedures 23 To prevent unauthorized connections within the engine room and machinery spaces of vessels, every blank flange connected to overboard piping, on systems such as salt water service, main engine raw water cooling, or other systems, shall be permanently secured, removed, or fitted with numbered ECS seals through the flange bolts that will break when such bolts are removed to prevent unauthorized connections and discharges. The ECS seals used shall be numbered and records kept in the ECS Seal Log. Alternative sealing methods, such as numbered foil-coated sticker seals for flanges, may also be used. IX.F.1 Substantially Complete 24 • Company Policies and Procedures 25 The blank flange securing the bilge and sludge transfer system shore connection discharge valve at the discharge stations shall also require controls as part of the ECS. IX.F.2 Complete • Company Policies and Procedures 26 The samples will be collected by an engineer designated by the Chief Engineer and be taken in the presence of the EO. Sample points shall be identified by the Chief Engineer. The sample procedure shall include the use of tamper-evident containers and uniquely numbered seals. With respect to tank samples, no attempt should be made to collect a clean sample only. IX.G.2 Substantially Complete 27 • Company Policies and Procedures 28 In consultation with the TPA, CARNIVAL shall contract with a company providing sampling and analysis services. IX.G.3 Complete • Company Policies and Procedures 29 ECP Requirement Verification • TPA Audits • TPA Audits • Correspondence between CAM and Company 22 DER-2002 indicates that bilge suction valves and independent emergency suctions to the ship’s engine room bilges can be painted international orange or bright green. 23 DER-2002: Oily Bilge System Operation Monitoring Equipment 24 A TPA audit identified a Section IX.F.1 non-conformity on the P&O Arcadia (Jan. 2018). 25 ENV-1204: Environmental Control System 26 Id. 27 A TPA audit identified a Section IX.G.2 non-conformity on the Sapphire Princess. Additionally, TPA audits identified Section IX.G non-conformities on the Carnival Inspiration (Oct. 2017), Diamond Princess (Aug. 2017), Grand Princess (Sept. 2017), and Queen Mary 2 (Oct. 2017). 28 POL-1010-A2: ECP TPA Sampling Protocol 29 Id. Page 5 of 9 CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 92 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status CARNIVAL shall work cooperatively with OWS manufacturers to verify the equipment’s capability to process fluids that may enter the bilges. CARNIVAL will work with the manufacturer in this verification process and to develop ways to improve the performance of existing equipment, or it may explore other separation technologies capable of handling the fluids. IX.G.5 Ongoing The sample line from the OWS discharge connection to the sample/flush line control valve will be painted a bright color to distinguish it from other tubing and piping in the area. The line must be routed so it is clearly visible to the extent possible for its entire length. No additional connections or tees of any kind may be added to the line. IX.H.1 Substantially Complete 30 • Company Policies and Procedures 31 The sample line connecting to the OWS discharge pipe shall be fitted with a manual valve or petcock, or tamper proof automatic valve. The tube end fittings and the valve handle must be fitted with a numbered seal that will break if the valve is closed, removed, or if the tubing connection nuts are loosened. The end nearest the sample/flush line control valve and any tubing in between the control valve and the OCM will be similarly protected to prevent any disassembly of the sensing system. OCM sample water outlet piping or tubing will not include any operational valves that are not sealed. IX.H.2 Substantially Complete 32 • Company Policies and Procedures 33 CARNIVAL shall employ the OCM manufacturer or contracted distributor to perform annual testing that ensures the OCM requires a sample flow for normal operation and control. Any OCM that allows the OWS to function normally without sample flow is prohibited unless all valves from the OWS discharge to the sample/flush line control valve are removed. CARNIVAL shall ensure that every vessel’s OWS is configured and capable of being fully operationally tested in port with the overboard valve closed. IX.H.3 Complete • Company Policies and Procedures 34 Every vessel shall perform monthly operational tests of the OWS and OCM in the presence of the Chief Engineer, the EO, and one other engineer. The test shall be logged in the vessel’s Oil Record Book (Part I) and co-signed by the EO and all present. The Chief Engineer shall send a report to the cognizant OLCM. IX.H.4 Substantially Complete 35 • Company Policies and Procedures 36 ECP Requirement 30 TPA audits identified Section IX.H.1 non-conformities on the Carnival Sunshine (Sept. 2017) and Diamond Princess (Sept. 2017). 31 DER-2002: Oily Bilge System Operational and Monitoring Equipment 32 TPA audits identified Section IX.H.2 non-conformities on the P&O Arcadia (Jan. 2018). 33 ENV-1204: Environmental Control System 34 ENV-1201: Oily Bilge Water Management; ENV-1014: Shore Management Environmental Responsibilities 35 TPA audits identified Section IX.H.4 non-conformities on the Diamond Princess (Aug. 2017) and Carnival Inspiration (Oct. 2017). 36 ENV-1201: Oily Bilge Water Management Page 6 of 9 Verification • TPA Audits • TPA Audits • TPA Audits CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 93 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status Every vessel shall conduct an annual operational test of the OWS system under actual operational conditions. This test shall include one (1) full hour of continuous processing of the contents of the Bilge Holding Tank without dilution, and without dilution of the sample line leading to the OCM conducted by the Chief Engineer in the presence of a CARNIVAL shore-side representative, Chief Engineer, the EO, and any other engine room personnel assigned responsibility for the operation and/or maintenance of the OWS. If an actual discharge is not feasible due to the location of the vessel or the levels of the Bilge Holding Tanks, then the discharges shall be through a recirculation line, in accordance with the procedures approved by the vessel’s Classification Society and provided further that soundings of the Bilge Holding Tanks shall be made before and after the test and shall be made a part of the test record and providing that any alarms shall be recorded and made part of the test record. All of the above shall be recorded in the Oil Record Book (Part I). In the event that the assessment determines the OWS is not operating as designed, then an immediate report shall be made to the cognizant OLCM, the Interested Parties, the TPA, and the CAM, with a copy of the engine room alarm printout to be retained and appended to the Oil Record Book page documenting the test. IX.H.5 Complete or Substantially Complete 37 • Company Policies and Procedures 38 Every vessel shall clean the OWS source tanks and remove any accumulated oil at least once every six (6) months. Such cleaning shall be logged in the PMS. IX.H.6 Complete • Company Policies and Procedures 39 Anytime an OCM is subject to maintenance, including flushing, cleaning, or calibration, such actions shall be logged in the ORB. IX.H.7 Complete • Company Policies and Procedures 40 A log shall be maintained of any instance where a pneumatic or portable pump is used on board. The log shall include a description of the fluid pumped, its source, and the tank or location where the fluid was transferred. The log shall include the date and time the pump was used and shall identify the person(s) who checked out the pump and operated it. IX.I.2 Complete • Company Policies and Procedures 41 ECP Requirement 37 Depending on the vessels’ schedules for annual testing, there may be vessels that did not conduct an annual test by April 19, 2018. 38 ENV-1201: Oily Bilge Water Management 39 Id. 40 Id.; ENV-1201-A3: Codes to be Used for Oil Record Book (ORB) Entries 41 ENV-1203: Use of Portable Pumps; ENV-1203-A2: Portable Pump Log Page 7 of 9 Verification CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 94 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Section Completion Status Entries made into the Oil Record Book (Part I) shall be made and signed by the officer or officers in charge of the operation, and each completed page shall be reviewed and signed by the EO, Chief Engineer, and Master. At the beginning of each contract, engineers responsible for Oil Record Book entries will acknowledge by signature their obligation to make true and accurate entries in the Oil Record Book for the next U.S. port of call. IX.J Substantially Complete 42 • Company Policies and Procedures 43 CARNIVAL shall provide each vessel with a standard format tank sounding log that includes, for each sludge and bilge tank associated with bilge water and/or oil residues (sludge), the tank name/designation, tank capacity, sounded quantity and time and method of sounding. Soundings from each tank shall be taken at least daily. The individual taking the tank sounding shall make entries in the tank sounding log and initial each entry. IX.K Complete • Company Policies and Procedures 44 CARNIVAL shall have a standard system for monitoring fuel oil and lube oil management, including the operation of the fuel oil and lube oil purifiers. CARNIVAL shall ensure that hour meters are installed on the related motor controllers if not currently available. IX.L.1 More Information Required 45 Any extraordinary operations (such as frequent draining of fuel oil service and settling tanks, draining engine lube oil sump tanks of excessive water, or other problems such as waxing, compatibility, stratification or contamination) shall be recorded in the Oil Record Book (Part I). Explanations shall be provided in the Oil Record Book for the abnormal volumes of unburned oil residues (sludge), oils, oily wastes, and anomalies in filter cleaning or replacement. IX.L.2 Complete • Company Policies and Procedures 46 All oil leaks exceeding manufacturer or historical volumes, including any fuel and/or lubricating oil leaks resulting from mechanical failure shall be reported to CARNIVAL’s MP&A department per CARNIVAL incident reporting policy. IX.L.3 Complete • Company Policies and Procedures 47 CARNIVAL shall have a standard system for monitoring equipment having oil-to-sea interfaces that relies on mechanical tension, hydrostatic pressure on the seal, and the surface tension between water and oil to minimize oil releases to the sea. Such interfaces may include stern tube bearings, stabilizers, controllable pitch propeller systems, maneuvering thrusters, propulsion pods, and similar IX.M.1 Complete • Company Policies and Procedures 48 ECP Requirement Verification • Notices of Violation 42 Notice of Violation #08-2017 reports that two instances of Section IX.J violations occurred between April 19, 2017, and August 18, 2017, on the AIDALuna and Costa Deliziosa. 43 ENV-1201: Oily Bilge Water Management; ENV-1201-A2: Oil Record Book (ORB) Statement Signature Recognition Sheet 44 ENV-1201: Oily Bilge Water Management; ENV-1201-A1: Daily Sounding Log 45 A TPA audit identified a Section IX.L non-conformity on the Carnival Inspiration (Oct. 2017). 46 ENV-1201-A3: Codes to be Used for Oil Record Book (ORB) Entries 47 ENV-1011: Chief Engineer Environmental Responsibilities 48 ENV-1202: Oil-to-Sea Interfaces Page 8 of 9 CONFIDENTIAL Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 95 of 205 June 21, 2018 APPENDIX D: STATUS OF ECP YEAR ONE REQUIREMENTS ECP Requirement ECP Section Completion Status IX.M.2 Complete • Company Policies and Procedures 49 IX.N.1 Complete • Documents Produced to CAM, including Survey Instrument and Results Verification equipment whereby the leakage of a sealing component may cause a loss of operating medium into the waters surrounding the vessel. Any replenishment of oil into the head tanks, operating systems reservoirs, or other receivers associated with this equipment shall be logged, regardless of the quantity involved. Ingress of water or drainage of water into or from these systems must also be logged, as far as practicable. An explanation of the loss of oil or the need to replenish the oil in this equipment shall be provided in the log, along with the date, time, and signature. Any losses of oil from this equipment that exceed manufacturer specifications or historically logged data must also be logged and promptly reported to the OLCM. 6-Month Requirements Within six (6) months of the date of sentencing, CARNIVAL shall issue a survey to all shipboard engineering officers and all Environmental Officers on its vessels for information on how to improve MARPOL compliance, to include what new equipment, maintenance, parts, and procedures would be beneficial. An assessment requesting the frank opinions of the vessels’ engineers as to their ability to adequately maintain the vessels’ systems, equipment, and components will be included. The survey will emphasize non-retaliation for open and honest opinions and reports of current non-compliant circumstances. • ECP CCM Reports 1-Year Requirements OLCMs shall be responsible for annually certifying in writing to the CCM to the adequacy of Covered Vessel operating budgets, including costs related to the operation, maintenance, and repair of pollution prevention equipment, use of shore-side reception facilities, labor costs relating to maintenance of machinery spaces, and other related costs necessary to meet the objectives of this ECP. III.A.10 Complete • Company Policies and Procedures 50 • CCM Annual Report • CCM Annual Report, Attachment D (OLCM Annual Budget Certifications) CCM shall submit the OLCM certifications [on operating budget adequacy] to the HESS Committee of the BOD of Carnival as part of the CCM’s annual report to the Committee, which will in turn be provided to the Interested Parties. 49 Id. (Note that, unlike the ECP, ENV-1202 qualifies the loss: “Any external losses of oil from this equipment that exceed manufacturer specifications or historically logged data must be promptly reported to the OLCM.”) 50 ENV-1009: Operating Line Compliance Manager (OLCM) Page 9 of 9 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 96 of 205 Appendix E: ECP Year One Incidents Tracked by the CAM CONFIDENTIAL Reference No. 03-2017.1 Date of Event 9/1/15 Brand/Vessel HAL - Various Vessels 03-2017.2 9/18/16 PCL Grand Princess 013_2017-FA 11/7/16 Carnival Fantasy CAM-00313 2/9/17 PCL Emerald Princess 01-2017 4/9/17 Costa Deliziosa Event Description Between September 2015 and October 2016, vessel discharges in contravention of NOAA's marine sanctuary regulations were identified on 4 PCL ships and 1 HAL ship. Discharges were within the expanded boundaries of the Greater Farallones National Marine Sanctuary. Discharges were food waste, processed permeate, untreated grey water, membrane bioreactor sludge (not oil), advanced wastewater treatment system permeate, exhaust gas cleaning system ("EGCS") wash water, and treated sewage. June 21, 2018 CAM Incident Category EGCS Voyage Planning On December 2, 2016, while making preparations for the Grand Princess' voyage, the EO and the Voyage Planning Officer held a voyage planning meeting. During this meeting it was discovered that an "Environmental Limit Marker" on the planned track, similar to ones used for the 4 NM and 12 NM limits, was within the boundaries of the Cordell Bank National Marine Sanctuary. There were no "Environmental Limit Markers" around the boundaries of the expanded Cordell Bank and Greater Farallones Not Applicable Marine Sanctuaries. This discovery led to an investigation into whether the "Environmental Limit Marker" had been used during the 2016 summer season when the ship was sailing between San Francisco and Alaska. The initial internal investigation, conducted by the EO, confirmed that the ship had been discharging various waste streams as detailed in Annex 1 between May 11, 2016, and September 18, 2016, within the expanded boundaries of the Greater Farallones National Marine Sanctuary. 1,620 kg of refrigerant gas leaked from the ship's refrigeration systems in November 2016. Due to the lack of communication and awareness of record keeping, entries were not made in the refrigerant or oil record books. The missing entries have been added to the Refrigeration Record Book, incident reports have been completed, and the Oil Record Book was updated. Oil Record Book Recordkeeping Refrigerants Shore side was informed that on November 29, 2017, Maritime New Zealand filed criminal charges against PCL for two alleged violations of New Zealand’s Maritime Transport Act 1994 in connection with a fatal accident on board the Emerald Princess while docked in Port Chalmers, New Zealand on or about February 9, 2017. A high-pressure nitrogen cylinder burst while being reNot Applicable pressurized, which resulted in the death of an Emerald Princess crew member standing nearby. The Transport Accident Investigation Commission (TAIC) in New Zealand investigated the incident and issued an interim report on May 10, 2017, concluding that the burst nitrogen cylinder had suffered significant corrosion at the point of failure. A metallurgist’s initial assessment also concluded that the failure had occurred as a result of overload caused by corrosion thinning. On April 9, 2017, two Italian Coast Guard Petty Officers boarded the vessel for routine collection of MARPOL marine gas samples. The MARPOL samples of marine gas oil bunkered in Port Everglades on March 18, 2017, could not be found onboard, despite their recordation in the corresponding Bunker Delivery Note. This violated MARPOL Annex VI, Regulation 18.3.8.1 Not Applicable 08-2017.1 4/19/17 AIDAluna The ORB was not signed by an EO from April 19, 2017, to May 5, 2017, and from June 27, 2017, through August 18, 2017. Both the Captain and the Chief Engineer continued to sign each page during this period. There was an EO handover during this period, which may have been a contributing factor. The departing EO explained that he forgot to sign the completed ORB pages the referenced time periods. The boarding EO expected further clarification of the significance of her signature, so she did not sign the Recordkeeping completed ORB pages from July 11, 2017 to August 18, 2017. The AIDA Environmental Manager was onboard at the time the Oil Record Book issue was discovered. He discussed it with the current EO, who then signed all completed ORB pages from July 11, 2017, to August 18, 2017. The prior EO visited the ship on August 19, 2017, to sign the completed ORB pages and did so for those from June 27, 2017, to July 11, 2017, but forgot to sign the pages from April 19, 2017 to May 5, 2017. Shore side management was informed and arranged for the ORB pages from April 19, 2017, to May 5, 2017, to be signed. CAM-00071 4/24/17 Carnival Triumph The ORB had a missing entry for maintenance of the OCM performed on April 24, 2017. An 'I' entry was made in the ORB Oil Record Book indicating the missing maintenance operation and the Captain, Chief Engineer, OLCM, and Director of Environmental Operations Recordkeeping were informed. Page 1 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 97 of 205 Appendix E: ECP Year One Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description During a review of the ORB, it was identified that a BCDB OCM cleaning operation was recorded in the PMS system but not in the ORB. The OLCM and shore side management were notified. During a review of the ORB, it was identified that a BCDB OCM cleaning operation was recorded in the PMS system but not in the ORB. The OLCM and shore side management were notified. Ship discharged Ballast water early May while alongside in Hawaii without use of the installed Ballast Water Treatment System. The request to do so was made by the Staff Captain. Ballast water was initially treated on the way into the ship through the Hyde Guardian BWT system, but also needed to be treated on the way out, which it was not. The EO sent an email to the HR department, with a copy to technical operations, providing notification that the Chief Engineer discovered that the solenoid valve on one of the OWS had been replaced with piping. The Chief Engineer noticed the missing solenoid valve sitting next to the OWS, and he replaced the piping with the valve. Based on AMOS maintenance records, the Chief Engineer believes that he identified the Engineer that implemented the piping. AMOS records indicate that the solenoid valve was due to be cleaned on routine basis (monthly), and the most recent AMOS record for such maintenance indicated that the cleaning had recently been performed/completed by the engineer in question. The engineer, however, went on leave two days prior to the Chief Engineer’s discovery of the piping. The HAG Safety Env. and Regulatory Services (SERS) group – Paul McClelland (the OLCM) and Kelly Clark (Senior VP) – received word of the issue via the technical operations group. SERS directed Jeanne Grasso (Blank Rome) to fly to Australia and board the ship on June 29, conduct an investigation into the issue, and disembark on July 1. The Carnival Ecstasy was alongside port of Charleston operating on Heavy Fuel Oil for a number of hours without use of the EGCS. It appears the EGCS tripped out earlier in the day. It is unclear if the system failed to alarm upon trip or if the watch-keeper failed to respond. 156 kg of refrigerant gas leaked from a line connected to a provision system due to deteriorating materials and ship vibration. The line was repaired and system was put back in place. 102 kg of refrigerant gas leaked from an air conditioning compressor due to a cracked gasket. The gasket was replaced and the system was put back in service. A sample pump on the EGCS stopped working but the system did not alarm or indicate a fault on the control panel. The pump was reset and no further issues have been reported. On May 15 and 16, 2017, PCL self-reported two separate test results of samples taken from the Star Princess on May 9, 2017, which indicated that the vessel's Biological Oxygen Demand ("BOD") levels exceeded the daily maximum allowed. PCL had the vessel's Membrane Bioreactors (the "MBR") inspected and discovered that blown gaskets created air leaks that caused the devices to become insufficiently aerated. To rectify the problem, PCL cleaned and sanitized the tanks, serviced the system, increased aeration in the buffer tank, added an additional 0.5 liters of Heeburn Bio ET to each jet, and revised the MBRs' desludging frequencies. On July 13, 2017, PCL received a Notice in response to these self-reported violations, plus three additional violations regarding daily and monthly BOD exceedances. While underway, approximately 15 liters of MGO leaked overboard from a lifeboat due to a corroded fuel tank. The drain was plugged and the excess MGO was contained. The incident was also recorded as a Potentially Significant LSA Failure. While alongside in Ketchikan, Alaska, a grey sheen was observed in the water on the starboard side of the area of the EGCS overboard discharge. A blocked filter was found to be the cause of the contamination. A pressure transducer on the forward OWS failed. The sensor was replaced and the OWS returned to service. June 21, 2018 CAM Incident Category CAM-00106 4/25/17 Carnival Ecstasy CAM-00107 4/25/17 Carnival Ecstasy CAM-00015 5/1/17 PCL Sea Princess ECP 17-07-02 5/1/17 PCL Sun Princess CAM-00016 5/8/17 Carnival Ecstasy CAM-00003 5/9/17 Carnival Glory CAM-00004 5/9/17 Carnival Inspiration CAM-00005 5/9/17 P&O Azura CAM-00424 5/9/17 PCL Star Princess CAM-00006 5/10/17 Carnival Elation CAM-00007 5/10/17 HAL Eurodam CAM-00011 5/13/17 Cunard Queen Mary 2 CAM-00010 5/13/17 HAL Westerdam The BCDB (whitebox) data recorder has an intermittent fault resulting in lapses of data recording. An investigation is ongoing. Not Applicable CAM-00009 5/15/17 Costa Luminosa The BCDB (whitebox) was taken out of service due to a data recorder failure. An urgent external service was arranged to determine the root cause of the failure and the necessary corrective actions. Not Applicable Page 2 of 94 Recordkeeping Oil Record Book Recordkeeping Voyage Planning OWS/Whitebox EGCS Refrigerants Refrigerants EGCS Not Applicable Lifeboat/Tender EGCS OWS/Whitebox Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 98 of 205 Appendix E: ECP Year One Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00012 5/15/17 HAL Veendam CAM-00031 5/20/17 Carnival Inspiration 02-2017 5/22/17 HAL Shore Side 2017-R0637-40-0001 5/22/17 PCL Ruby Princess CAM-00020 5/26/17 Carnival Fascination CAM-00062 6/1/17 Carnival Valor CAM-00081 6/1/17 Carnival Fantasy CAM-00021 6/2/17 Carnival Ecstasy CAM-00022 6/3/17 Carnival Conquest 005_2017-EL.1 6/4/17 Carnival Elation 005_2017-EL 6/4/17 Carnival Elation 04-2017 6/8/17 PCL Diamond Princess Event Description 2 pH sensors on the EGCS systems failed their calibration tests resulting in higher consumption of MGO. 156 kg of refrigerant gas leaked from an air conditioning system due to a faulty compressor. The system was repaired and put back in service. On May 22, 2017, Holland America Line and Princess Cruises entered into Settlement Agreements with the State of Alaska for alleged violations of the State’s visible emissions standards. The alleged violations spanned the period 2009 to 2014. A MBR sample taken that same day from the Ruby Princess, which indicated an ammonia discharge that exceeded the daily maximum. The vessel's onboard sampling results were within allowable parameters, so PCL concluded that the MBRs were not properly processing effluents prior to discharge, which caused ammonia levels to be too high in the overboard samples measured by the ADEC. Following discovery of this issue, PCL cleaned the MBR tanks onboard the Ruby Princess and revised the vessel's desludging frequency requirement based on the vessel's itinerary. PCL received a Notice in response to this self-reported violation on July 13, 2017. While checking the Bahamas Annex VI record book for fuel oil and ozone-depleting substances, the EO noted that the Chief Engineer's signature was missing for six entries between March 31, 2017, and May 26, 2017. The EO could not locate the original copies of bunker delivery notes for fuel oil (HFO and MGO) bunkered between August 2014 and January 2015 as required by MARPOL Annex VI. Scanned copies of the missing delivery notes are available in the InfoShip system. Flag administration was informed. As a preventive action, all current bunker delivery notes are now being secured in a controlled location. EGCS SO2/CO2 compliance data was found to be missing from April 22, 2017, through May 1, 2017 due to a computer malfunction. A technician successfully attempted to retrieve the data but was able to reset the computer to restore normal operations. The ship discharged food waste and treated black water within 12 NM of Bahamas Archipelagic Baselines on four occasions due to misinterpretation of company policy. Recorded as a water discharge and solid waste discharge. The ship discharged food waste and treated black water within 12 NM of Bahamas Archipelagic Baselines on four occasions due to misinterpretation of company policy. Recorded as a water discharge and solid waste discharge. Meeting with all Deck and Engine Officer was done and EN000011 discussed with all involved and all Officers understand that discharge of black water and food waste inside Bahamas Archipelagic waters is not permitted. First Officer was aware of requirement but, by mistake, believed that the vessel used BW#14 for grey water and BW#15 for black water and gave an order for flushing of BW#14 once outbound 12 mls from nearest shore. On change of watch at 00:10, OOW, who take over the watch, realized the issue and immediately stopped flushing. Approximately 1,270 cubic meters of treated black water and 22 cubic meters of comminuted food waste were discharged inside Bahamian waters in violation of MARPOL and company procedures between June 4, 2017, and June 16, 2017. Discharge was also recorded as a "Other Discharge: Solid Waste." Diamond Princess sailed for more than 7 days (11th – ETA 23rd June) without an EO onboard due to employment termination and challenges finding a replacement on short notice. On June 8th, 2017, the Captain of the Diamond Princess informed HAG OLCM of a shipboard investigation relating to the performance of the EO. Training required by ECN4 (watch the CEO ECP video) was not conducted per company instruction by the EO, and the resulting attendance records may also have been improperly recorded. EO’s employment was terminated as a result and disembarked June 11, 2017 on Jeju Island, South Korea. Normally the first resort is to reach out to the EO scheduled to relieve the disembarking EO to fill the gap however, the current EO had already extended his time on board because the relieving EO had resigned shortly before he was scheduled to join the Diamond Princess. Thus the first choice for relieving the EO was not available. 11 potential EO replacements were contacted, none of whom were available to embark the ship on short notice. Page 3 of 94 June 21, 2018 CAM Incident Category EGCS Refrigerants Not Applicable Not Applicable Recordkeeping Recordkeeping EGCS Voyage Planning Voyage Planning Voyage Planning Voyage Planning Training Falsification Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 99 of 205 Appendix E: ECP Year One Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00017 6/8/17 HAL Nieuw Amsterdam CVL-17-06-0029 Env Open Report #012017 6/9/17 CCL Shore Side CAM-00023 6/12/17 Carnival Ecstasy CAM-00024 6/12/17 Carnival Ecstasy 024_2017-FD 6/13/17 Carnival Freedom 005_2017-EL.5 6/15/17 Carnival Conquest 005_2017-EL.4 6/15/17 Carnival Liberty 005_2017-EL.3 6/15/17 Carnival Magic 005_2017-EL.2 6/15/17 Carnival Vista CAM-00425 6/16/17 Seabourn Sojourn CAM-00014 6/17/17 Costa - CSMART CAM-00025 6/20/17 Carnival Magic CAM-00026 6/21/17 Carnival Imagination CAM-00018 6/23/17 P&O Arcadia CAM-00027 6/23/17 Carnival Conquest CAM-00028 6/23/17 Carnival Dream Event Description During ship construction (2009), a drain line from a galley dishwasher was inadvertently connected to an overboard scupper and not to the ship's grey water collection system. This was discovered mid-June 2017 by the ship’s crew. Piping has now been corrected. Anonymous caller raised issue regarding Richard Miller, VP CCL. Caller states that he/she has been with the Company for over 17 years as a shipboard employee and that he/she is concerned with Mr. Miller's knowledge of MARPOL, environmental regulations, Corporate procedures, and environmental leadership and stewardship. Caller also stated that this is a concern to other shipboard and shore side team members. 156g of refrigerant gas leaked form an air conditioning system due to the failure of the shaft seal compressor. The system was taken out of service. 104 kg of refrigerant gas leaked from a refrigeration system due to a cracked expansion valve fitting. The fitting was replaced and the system put back in service. Approximately 467 cubic meters of treated black water/sewage and 6.2 cubic meters of comminuted food waste was discharged inside Bahamian Archipelagic Baseline between June 13, 2017, and June 15, 2017, due to misinterpretation of Bahamas baselines listed in ENV 1001. Comminuted food waste and treated black water from several CCL ships was improperly discharged inside the 12 mile base line of the Bahamas. The cause of these events is not yet clear, although it appears to be associated with the interpretation of procedure ENV1001 (Worldwide Environmental Standards). Comminuted food waste and treated black water from several CCL ships was improperly discharged inside the 12 mile base line of the Bahamas. The cause of these events is not yet clear, although it appears to be associated with the interpretation of procedure ENV1001 (Worldwide Environmental Standards). Comminuted food waste and treated black water from several CCL ships was improperly discharged inside the 12 mile base line of the Bahamas. The cause of these events is not yet clear, although it appears to be associated with the interpretation of procedure ENV1001 (Worldwide Environmental Standards). Comminuted food waste and treated black water from several CCL ships was improperly discharged inside the 12 mile base line of the Bahamas. The cause of these events is not yet clear, although it appears to be associated with the interpretation of procedure ENV1001 (Worldwide Environmental Standards). June 21, 2018 CAM Incident Category Not Applicable Training Refrigerants Refrigerants Voyage Planning Voyage Planning Voyage Planning Voyage Planning Voyage Planning On July 13, 2017, Seabourn self-reported in connection with the Seabourn Sojourn's June 2017 Discharge Monitoring Report that the vessel's BOD levels exceeded the monthly average allowed, and a sample on June 16, 2017, exceeded the daily maximum. To Not Applicable remedy the exceedance, the Company engaged Wartsila, the manufacturer of the Seabourn Sojourn 's sewage treatment system, to conduct a service visit. Seabourn received a Notice in response to this self-reported violation on August 16, 2017. Costa EO failed CSMART proficiency assessment 350 kg of refrigerant gas leaked from a refrigeration system due to an evaporator failure and loose expansion valves. The evaporator was repaired, the valves were tightened and the system was put back in service. 1 kg of refrigerant gas leaked from a refrigeration system due to a corroded service valve. The valve was replaced and the system put back in service. A page was found missing in the ORB onboard Arcadia. CUK stated it was a blank page. 167 kg of refrigerant gas leaked from an air conditioning system due to Conquest loose evaporator inlet flange. The flange was tightened and the system was put back in service. 104 kg of refrigerant gas leaked from a provision system due to a failed welded joint. The joint was repaired and the system was put back in service. Page 4 of 94 Training Refrigerants Refrigerants Oil Record Book Recordkeeping Refrigerants Refrigerants Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 100 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00029 6/23/17 Carnival Freedom CAM-00043 6/24/17 P&O Azura CAM-00030 6/25/17 P&O Ventura CAM-00032 6/25/17 PCL Sun Princess CAM-00033 6/26/17 Carnival Liberty 08-2017.2 6/27/17 Costa Deliziosa CAM-00034 6/28/17 Carnival Dream CAM-00035 6/28/17 Carnival Imagination 004_2017-VE 6/29/17 HAL Veendam CAM-00036 6/30/17 Carnival Conquest 006_2017-LI 6/30/17 Carnival Liberty CAM-00037 6/30/17 Carnival Sunshine CAM-00038 6/30/17 HAL Maasdam CAM-00039 6/30/17 P&O Britannia Event Description 161 kg of refrigerant gas leaked from a provision system due to a failed pipe connection. The pipe was replaced and the system put back in service. The ship used HFO for 16 hours while transiting the Icelandic Environmental Protection Zone where Sulphur max is 1.5%, due to a misinterpretation of regulations. Once noted, the EGCS was put online to bring the ship into compliance. During routine maintenance, the calibration certificate of the BCDB oil content monitor (OCM) was noted to have expired. The OCM was checked and found to be within calibration limits. A new certificate was issued. A bypass solenoid and valve were reported missing from the Centrifugal Oily Water Separator (COWS). Investigations found a watch keeping engineer had removed the parts and made a false entry on maintenance into AMOS. The missing parts were replaced and the COWS system was put back in service. There was no overboard bilge water discharge. 201 kg of refrigerant gas leaked from a refrigeration system due to a faulty gasket. The gasket was replaced and the system put back in service. The EO onboard the Costa Deliziosa prior to June 27, 2017, believed the requirement to sign the ORB began on July 19, 2017, based on the ship’s interpretation of the relevant ECP section and corresponding HESS procedure. When the relief EO arrived on June 27, 2017, he began signing the ORB, as required. The prior EO was advised of the error and returned to the Costa Deliziosa to sign the ORB pages completed from the date of sentencing through June 27, 2017. 260 kg of refrigerant gas leaked from a refrigeration system due to a faulty pipe. The pipe was repaired and the system was put back in service. 1.4 kg of refrigerant gas leaked from a provision system due to a faulty valve. The valve was replaced and put back in service. On June 29, 2017, Captain advised HAG shore side of an apparent maintenance mistake on the ship’s Bilge Control Discharge Box (white box). The Captain advised that, during recent maintenance on the ship’s white box, an air pressure regulator/filter was replaced. The replacement was not made in-kind. As a result, the three-way valve in the white box was not operating correctly. The ship tested the calibration of the upstream OCM on the Serep OWS, which was within tolerance for legal discharges. A 4th Engineer noticed the problem and reported up the shipboard chain of command, which was then reported ashore via normal reporting channels. 264 kg of refrigerant gas leaked from an air conditioning system due to a faulty pipe. The pipe was repaired and the system was put back in service. During the EGCS Wash Water Filtration System (WWFS) testing, soot was observed into the water. The system was stopped and the WWFS was inspected. It was discovered that one of the eight filtration bags had ruptured causing the soot to be discharged overboard. 208 kg of refrigerant gas leaked from a provision room due to a faulty fitting. The fitting was repaired and put back in service. During tendering operations in Bar Harbour, USA, a small amount of oil was detected by the bridge near the exhaust of one tender. Further investigation revealed that there was no leak. The discoloring in the water was caused by incomplete combustion from the tender engine. During dirty bilge water transfer ashore, the officer in charge of the operation Grease / Soot / Chemical (UK) noted the tanker overflowing and immediately stopped the transfer pump using the emergency stop button. The operator was not in the tanker during the incident. Approximately 20 liters overflowed during the transfer with some entering the water. The port agent was contacted and attended the scene with the local authorities. A full investigation was conducted. Page 5 of 94 June 21, 2018 CAM Incident Category Refrigerants EGCS Voyage Planning OCM OWS/Whitebox Falsification Refrigerants Recordkeeping Oil Record Book Refrigerants Refrigerants OWS/Whitebox OCM Refrigerants EGCS Refrigerants Lifeboat/Tender Not Applicable Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 101 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category Majestic Princess made her maiden call to Taiwan on June 30, 2017. On July 5, shore side management was notified of news accounts that appeared to indicate that balloons were released from the ship that could land in the marine environment. After investigation, it was confirmed that the balloons were released shore side and not from the ship. The balloons were arranged by the Not Applicable local PR agency representing PCL. The balloons are reportedly “biodegradable latex” that disintegrates in 2-4 weeks. The release of the balloons required approval of local authorities. We have asked to see proof of the approval. 001_2017-MJ 6/30/17 PCL Majestic Princess CAM-00040 7/1/17 Carnival Glory 208 kg leaked from a refrigeration system due to a cracked pipe. The line was repaired and put back in service. Costa Atlantica During an overboard discharge performed through newly installed oil coalescent filtering equipment, the BCDB stopped the overboard discharge due to the OCM showing 18 ppm of oil. The pressure on the delivery side of the OWS was also higher than expected. A test was performed by filling the reading cell with drinking water; however, the oil content still showed 18 ppm of oil. OCM Since previous days, it was also noted that the pressure of the delivery side of the oily water separation circuit of both OWS OWS/Whitebox [coalescent and centrifugal] was higher than expected, causing abnormal noisy working conditions for the pump and consequent line's vibrations. On 18th July, a third-party vendor identified the root cause in a malfunction of the OMD of the BCDB connected to the Westfalia OWS. Therefore, the issue was finally considered as solved. 007_2017-AT 7/1/17 Refrigerants On July 2, 2017, while alongside in Vancouver, Canada, and during the pre-departure motorman checks on board the Golden Princess, it was discovered that the level of the starboard stabilizer header tank was below the level of the sight glass of the lowered header tank on deck 3. Further investigation revealed no sign of an internal leak. The stabilizer housing box venting arrangement was removed and sea water was allowed to enter the vessel and then drained. The quantity of fluid removed was approximately 200 liters of sea water and approximately 5 liters of oil. At no time was an oil sheen observed around the vessel during the evolution. The stabilizer was not in use for a long time. 008_2017-NP 7/2/17 PCL Golden Princess 009_2017-AP 7/2/17 PCL Grand Princess CAM-00044 7/3/17 Carnival Splendor 010_2017-FA 7/3/17 Carnival Fantasy CAM-00041 7/4/17 Carnival Elation A diver team and Class Representative (Lloyd’s Register) attended in San Diego, CA on July 8, 2017, and completed an external inspection of the starboard side stabilizer. At around 15:00 hrs, the divers reported that there was a dripping of the oil in the starboard side stabilizer housing box. They confirmed that the oil was being contained in the box and not leaving the box into the harbor. The stabilizer housing box venting arrangement was removed and sea water was allow to enter the vessel, the quantity was approximately 200 liters and approximately 2-3 liters of which was oil (oil type: “Mobile SHC aware 68). An oil sheen was not observed around the ship. The Master informed the office and then he reported to the USCG (report number 1183497). A “G” entry in the ORB was made. The quantity of oil discharged into the sea (if any) is unknown. On July 2, 2017, while Grand Princess was departing Glacier Bay, AK, it was reported that the Oasis port side Jacuzzi was empty. The equipment was switched off and the valves were visually checked. No alarms were activated during the event. Approximately 7.5m3 of water was discharged with bromine content of 4.3ppm and pH 7.4SU. Further investigation revealed that cause of the accidental discharge was due to a failure of the valve automatic timer which is used for pool cleaning purposes. 267 kg of refrigerant gas leaked from an air conditioning system due to a faulty flange. The flange was repaired and the system was put back in service. During a routine inspection, the EO found several broken seals on the sewage treatment plant. An investigation revealed that 12 seals were broken during monthly routine maintenance but the seals were not replaced. Nine seals were found and replaced; however three, seals could not be found. Approximately eight cubic meters of treated black water was discharged from a ballast water tank inside the Bahamian archipelagic baseline. The incident was caused due to a misunderstanding by the officer on watch who mistakenly thought that the tank contained grey water and not treated black water. Page 6 of 94 Not Applicable Not Applicable Refrigerants Seals or Locks Voyage Planning Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 102 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00045 7/4/17 Carnival Ecstasy CAM-00046 7/5/17 Carnival Splendor CAM-00042 7/6/17 Carnival Elation 011_2017-QM 7/6/17 Cunard Queen Mary 2 05-2017.2 7/7/17 HAL Koningsdam Event Description June 21, 2018 CAM Incident Category 312 kg of refrigerant gas leaked from an air conditioning system due to a faulty pipe. The pipe was repaired and the system was Refrigerants put back in service. 260 kg of refrigerant gas leaked from various provision systems due to general age-related deterioration. The systems were refilled Refrigerants and was put back in service. On July 6, 2017, the United States Coast Guard issued an inspection report detailing a deficiency relating to MARPOL 1973/78 Annex 1, Regulation 14.7. The ship’s crew were unable to demonstrate the proper operation of the alarm arrangement on the OCM OCM (TD170) fitted to the OWS that is used to indicate when the oil content exceeds 15 parts per million. Additionally, the inspection Training report requires that the ships IOPPC "Form A" be amended to reflect a maximum throughput of 2.0m3/hour in the event that we can’t demonstrate that the crew are trained and able to show the proper operation of the alarm during the next US port of call. The bowl on the forward OWS failed. The equipment was stopped and isolated. The root cause of the failure is under OWS/Whitebox investigation. Two ships in the Holland America Line fleet, Koningsdam and Noordam, were requested to temporarily assign EO duties to a second engineer (non-watch standing) with the onboard EO. Both Engineers were planned to attend the EO training when they disembarked. The temporary assignment was made on each ship on July 2, 2017, to cover an unplanned gap in EO coverage until a Training replacement could be sent onboard. This was approved shore side without reference to the applicable requirements of the ECP or the internal procedure, ENV-1008. The ships were directed on July 7, 2017, to reassign the EO duties to the Staff Captain, Chief Engineer, or another senior non-watch standing officer, as required pursuant to the ECP. EO Issues: While conducting our end of month ECP implementation & compliance verification checks, we became aware of the below issue. Per Section IV.A.1 of the ECP, all Vessels must have an EO onboard at all times. In the event of a gap, the EO duties must be assigned to the Staff Captain, Chief Engineer or another senior non-watch standing officer. Among the qualifications for an EO is the training required in Section IV.A.4.b, which requirement is fulfilled through the training we provide at our maritime training facility located in the Netherlands (CSMART). EO’s appointed after the implementation of this training (22 May 2017) must complete the training prior to assigning their duties. 05-2017.1 7/7/17 HAL Noordam Two ships in the Holland America Line fleet, Koningsdam and Noordam, were requested to temporarily assign EO duties to a second engineer (non-watch standing) with the onboard EO. Both Engineers were planned to attend the EO training when they disembark. The temporary assignment was made on each ship on July 2, 2017 to cover an unplanned gap in EO coverage until a replacement could be sent onboard. This was approved shore-side without reference to the applicable requirements of the ECP or the internal procedure, ENV-1008. The ships were directed on July 7, 2017 to reassign the EO duties to the Staff Captain, Chief Engineer or another senior non-watch standing officer, as required pursuant to the ECP. Efforts are ongoing to send EO’s as soon as possible to those ships, although it is likely replacements will not be onboard until after July 9, meaning that the ships will not have met the seven-day requirement to replace the EO. We will let you know when these issues have been resolved. Page 7 of 94 Training Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 103 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 17-R0720-40-0001 7/7/17 PCL Island Princess 012_2017-OR 7/8/17 P&O Oriana 002_2017-TP 7/8/17 PCL Star Princess CAM-00048 7/9/17 Carnival Dream CAM-00049 7/9/17 PCL Caribbean Princess CAM-00050 7/10/17 HAL Zuiderdam CAM-00051 7/10/17 Carnival Magic CAM-00052 7/11/17 Carnival Fantasy CAM-00053 7/13/17 Carnival Paradise 025_2017-PR 7/13/17 Carnival Pride CAM-00082 7/13/17 Carnival Splendor 003_2017-AD 7/14/17 P&O Adonia 023_2017-OR 7/14/17 P&O Oriana Event Description June 21, 2018 CAM Incident Category On July 7, 2017, the Island Princess's smoke emissions exceeded the 20% opacity limit imposed by the applicable Alaska Air Quality Control Regulations while the vessel was moored in Ketchikan. Princess Cruise Lines actively cooperated and conferred Not Applicable with the ADEC during the weeks following this incident and concluded that the exceedance was caused by the vessel's burning marine oil gas while the EGCS was not properly running. There were no upsets with the combustion sources. Princess Cruise Lines received a Notice related to this occurrence on December 1, 2017. While alongside in Palermo, Italy, an unknown quantity of chlorinated recreational pool water was discharged due to a faulty Not Applicable pump valve. Two ships in the Holland America Line fleet, Koningsdam and Noordam, were requested to temporarily assign EO duties to a second engineer (non-watch standing) with the onboard EO. Both Engineers were planned to attend the EO training when they disembarked. The temporary assignment was made on each ship on July 2, 2017, to cover an unplanned gap in EO coverage until a Not Applicable replacement could be sent onboard. This was approved shore side without reference to the applicable requirements of the ECP or the internal procedure, ENV-1008. The ships were directed on July 7, 2017, to reassign the EO duties to the Staff Captain, Chief Engineer, or another senior non-watch standing officer, as required pursuant to the ECP. 260 kg [sic] leaked from a provision system due to a cracked pipe. The pipe was repaired and was put back in service. During tendering in South Queensferry, Scotland, a tender engine in operation had a defective fuel pump resulting in a minor oil sheen on the water. The engine was stopped, the tender was recovered, and the fault was repaired. A hydraulic oil leak was found on the forward davit arm of a lifeboat. The lifeboat has been taken out of service pending the investigation and repair. 413 kg of refrigerant gas leaked from a refrigeration system due to a crack in the main line. The pipe was repaired and the system put back in service. 307 kg of refrigerant gas leaked from an air conditioning system due to a corroded pipe. The pipe was repaired and the system put back in service. While underway, after exiting US Vessel General Permit waters but within the North America ECA area, the ship burned HFO for approx. 40 minutes until the changeover to MGO was completed. While anchored at Half Moon Cay (within the Bahamas Archipelagic Baseline), a plastic bin containing a plastic bag and noncomminuted food waste fell into the sea due to it being not properly secured to a pallet. Incident occurred when one local tender was transferring back to ship the food waste generated on the island. Half Moon Cay does not have a waste facility and hence all food waste that is generated on the island by the ships guest are brought back on board to be disposed of by the ship. The plastic bin, waste bag, and some food waste was recovered but approximately 15 pounds of food waste could not be recovered. 260 kg of non-ODS refrigerant gas leaked from an air conditioning system due to a failure of a discharge valve. The valve was replaced and the system put back in service. While alongside in Southampton, UK, discharging sludge, the hose connected to the tanker failed causing approx. 20 liters of oil sludge to spill onto the ship and into the harbor. Absorbent booms, pads, and other materials were used to clean up the oil and prevent the oil from spreading. The Port Authority was notified and the waste vendor assisted with the cleanup. Refrigerants Lifeboat/Tender Lifeboat/Tender Refrigerants Refrigerants Voyage Planning Not Applicable Refrigerants Not Applicable A COWS was out of service due to the feed pump stator being damaged. The second COWS was functional but the ship had reduced bilge treatment capacity. The COWS feed pump consists of two parts: a chrome-vanadium rotor and a rubber stator. The OWS/Whitebox rubber stator is designed to be the sacrificial element of the pump and wears at a faster rate to the rotor. The stator was worn as per expectation by manufacturer. This item has already been identified as a critical spare part as defined by the ECP. Page 8 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 104 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 019_2017-SL 7/15/17 Carnival Splendor CAM-00054 7/16/17 Carnival Valor 020_2017-FS 7/17/17 Carnival Fascination CAM-00055 7/17/17 Carnival Glory CAM-00056 7/17/17 PCL Star Princess 014_2017-VI 7/18/17 Carnival Victory 028_2017-NA 7/18/17 HAL Nieuw Amsterdam CAM-00019 7/19/17 PCL - Various Vessels 021_2017-MA 7/19/17 HAL Maasdam 016_2017-EC 7/21/17 Carnival Ecstasy 037_2017-CB 7/21/17 PCL Caribbean Princess Event Description Treated black water was potentially discharged inside Bahamas baseline due to accidentally opening the overboard discharge valve. The valve was closed within 10 minutes. Compliance verification was done with the fleet in June 2017 regarding the proper understanding of the Bahamian baseline and associated discharge restrictions. This incident was caused by a separate human error and not a fundamental misunderstanding of the baseline restrictions. 260 kg of refrigerant gas leaked from a refrigeration system due to ship vibrations. The system was repaired and put back in service. During the review of the bilge system, a discrepancy was found between the actual and the approved design layout of the system. An actual design layout drawing will be completed. A missing seal was found on the vacuum line of the sewage treatment plant. An investigation revealed the seal was accidently broken but not noticed by engine personnel. The seal was replaced and the system put back in service. While underway, recreational water was discharged overboard due to electrical failure. During maintenance checks, it was noted that the ship was missing original hardcopy fuel bunker delivery notes between July 2014 and January 2017. Ship has electronic copies of the bunker notes contained in InfoShip. Search on board to find missing folder has not recovered the original documents. While alongside in Skagway, Alaska, a full blackout occurred during an emergency shutdown system test. Incorrect procedural instructions were found in the job description of AMOS. Power was recovered quickly. 2 PCL ships that likely won’t meet the July 19, 2017, deadline to have accurate and class approved drawings onboard. June 21, 2018 CAM Incident Category Voyage Planning Refrigerants Not Applicable Seals or Locks Not Applicable Recordkeeping Not Applicable Not Applicable The ship sailed in an air emission control area for 45 minutes running an engine on HFO due to the EGCS being accidentally stopped. Three DGs running during the approach and arrival into Charlottetown. Two DGs were running on MGO (DG1 and DG3) and one generator was running on HFO (DG5) with EGCS in operation. Although not required, in order to keep the system running and flushing, the EGCS on DG 3 was also running. Shortly before ‘red manning’ status for arrival, the scrubber of DG 3 EGCS was shut down to enable cleaning of the sea chest. Due to an internal communication error, the scrubber of DG5 (on HFO) was Voyage Planning accidentally shut down as well. Between 07:44 and 08:26, DG 5 was running on HFO without the scrubber in operation. DG1 and DG3 were in operation on MGO at all times. As soon as it was identified that the EGCS for DG5 had been shut down (DG5 still on HFO) the ship changed over from DG5 to DG4. DG4 was already operating on MGO. As soon as the DG4 was on the board, DG5 was stopped. That all happened while maneuvering on arrival in Charlottetown. The ship sailed in an air emission control area for nearly two hours with an engine running on HFO. The EGCS had automatically shut down due to water in the sensor. The Engineer On Watch acknowledged the alarm, but did not realize the significance of the issue and did not investigate. Subsequently, email was received from MST2 Marcus Thompson, USCG Sector Charleston EGCS Prevention, asking for relevant info about the issue, so he was replied back with all detailed info about the same. Thereafter, on July 22, 2017, around 12:30 pm, USCG MST1 Dan Mitchell, boarded the vessel and enquired about the same. The Master, Chief, Voyage Planning and EO provided the same information. Mr Mitchell gave a Port state control inspection report Form A and Form B, indicating the following: Action taken: 16 (a,c). The report requests an audit from Recognized Organization ( Lloyd’s ) for this issue with given time frame of 14 days from today. While the ship was at anchor in South Queensferry, Scotland, a tender was lowered into the water for testing following maintenance performed by a Service Technician. When the engine was started an area of discoloration approximately 2-3 square Lifeboat/Tender feet in size appeared. The tender was immediately recovered and local authorities were notified. The cause of the incident was found to be a mechanical failure of the diesel-cooler caused by wear and tear. The diesel cooler was replaced and the engine tested with satisfactory results. All other tenders were checked for similar issues. Page 9 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 105 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 06-2017 7/22/17 Costa Luminosa 018_2017-SP 021_2017-SP 07-2017 7/22/17 Carnival Spirit 027_2017-VE 7/22/17 HAL Veendam 015_2017-VITA 7/23/17 AIDAvita 017_2017-VS 7/23/17 Carnival Vista 032_2017-MI 7/23/17 Carnival Miracle 029_2017-VI 7/24/17 Carnival Victory CAM-00063 7/24/17 Carnival Dream CAM-00059 7/26/17 HAL Zuiderdam Event Description On July 22, 2017, the OLCM for Costa Group (Costa Crociere and AIDA Cruises), Alessandro Bertorello, was informed by his Environmental Compliance Manager, Alessandro Pugliaro, that there may be an issue with recent training records on the Costa Luminosa. When Alessandro Pugliaro embarked the Costa Luminosa on July 22, 2017, for a one week visit he was informed by the disembarking EO (EO), Giulia Facelli, and her replacement, Stefano Incao, that records of a training session that allegedly took place on June 6, 2017 may have been falsified. The training in question was allegedly held by the EO onboard at the time, Marcio Goncalves. The training session records showed several pages of signatures confirming attendance. Since notification of this issue, multiple interviews have been conducted with those onboard, who have confirmed that they never took part in the alleged training and that the signatures are not theirs. On July 22, 2017, it was brought to the attention of the shore side environmental operations team via email from the EO that the Carnival Spirit had not been recording the periodic maintenance of the OCMs in the ORB since April 19, 2017. Periodic maintenance of the OCMs is recorded and visible in PMS, but not in the ORB. All PMS Entries are available in infoship The critical control units of the OCMs and waste water treatment plants are displaying error messages and need repair or replacement. There are currently no spare units on the ship. During routine, reoccurring maintenance, the spare PLC was inspected and found to be malfunctioning (60 monthly, AMOS job #TESTPLC001). The PLC currently installed is operational and functioning correctly. While underway, the flow pressure rate of the OWS was low due to the outlet piping being too small in diameter. The Chief Engineer of AIDAvita reported that the newly installed Westfalia oil filtering equipment worked at a lower flow rate (2m³/h) than the one the system should work at (5m³/h) when discharging overboard. Flow rate in recirculation mode was not affected; therefore, the issue was attributed to the overboard piping diameter. No pollution or MARPOL violation involved Carnival Vista while returning to Miami sailing through Bahamas Channel accidently discharged Comminuted Food Waste and Treated Black Water (AWPS) inside Bahamas Base Line. Approximate quantity of the Food Waste discharge was 4.0 m3 and Black Water from AWPS was 100 M3. Crew was aware of baseline issue, properly planned and briefed multiple times; human error by watch officer in authorizing discharge. When the Officer on Watch realized the mistake, he immediately stopped all discharge operations and self-reported. Compliance verification was done with the fleet in June regarding the proper understanding of the Bahamian baseline and associated discharge restrictions. This incident was caused by a separate human error and not a fundamental misunderstanding of the baseline restrictions. During a review of the ORB, it was noted that entries for periodic maintenance were not recorded. A meeting was held to discuss and clarify the requirements with the Engineer Officers. Entries for performed maintenance to bilge equipment were not recorded in ORB as per company procedures and ECP requirements. PMS was performed and recorded in InfoShip; however, additional entries in the ORB as required by the ECP were not made. Hydraulic oil drops fell from a lifeboat while the ship was in the Port of Miami due to a gasket failure in the hydraulic station. Upon noticing the leak, the hydraulic pump was immediately stopped. The pump was repaired and the pollution team cleaned up the oil. The EO could not locate the original copies of bunker delivery notes for fuel oil (HFO and MGO) bunkered between January 2015 and June 2015 as required by MARPOL Annex VI. Scanned copies of the missing delivery notes are available in the InfoShip system. Flag administration was informed. As a preventive action, all current bunker delivery notes are now being secured in a controlled location. While underway in North Sea ECA, the ship burned HFO for 3 hours and 30 minutes without an EGCS online as the EGCS did not start automatically when the associated DG was started. Page 10 of 94 June 21, 2018 CAM Incident Category Training Recordkeeping Falsification Oil Record Book Recordkeeping OCM OWS/Whitebox Voyage Planning Oil Record Book Recordkeeping Lifeboat/Tender Recordkeeping EGCS Voyage Planning Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 106 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00060 7/26/17 PCL Ruby Princess 030_2017-IM 7/27/17 Carnival Imagination CAM-00072 7/28/17 Carnival Pride CAM-00061 7/29/17 HAL Zaandam CAM-00064 7/29/17 Carnival Miracle CAM-00073 7/29/17 Cunard Queen Mary 2 CAM-00065 7/30/17 Carnival Glory 021_2017-SP 032_2017-MI 7/31/17 Carnival Spirit 031_2017-AT 7/31/17 Costa Atlantica 040_2017-SU 7/31/17 PCL Sun Princess Event Description While underway in North Americas ECA, the EGCS shut down and the ship burned HFO for 7 minutes. The Engineer On Watch responded to the alarm and promptly restarted the EGCS. Approximately 0.004 m3 (4 liters) of pre-treated oily bilge water from clean bilge tank (LO5) was discharged overboard while inbound 12NM but outside 4NM. EOOW did not ask for a confirmation from the Bridge to commence the discharge. This was not a MARPOL violation, but did violate corporate procedure. This was a mistake of the EOOW and possibly miscommunication with 3rd EOOW. As soon as the Second Engineer realized the mistake, he immediately stopped the operation and informed the CE and EO. The ORB was found to be missing entries for flushing/cleaning of the OCM between April 19, 2017, and July 28, 2017. The responsible engineer was completing all necessary weekly maintenance on the OCM and was updating the planned maintenance system but he did not make entries in the ORB because he was not completely familiar with the updated corporate policy. An 'I' entry was made in the ORB indicating the missing maintenance operations and a copy of the incident report was attached to the front page of each affected ORB. While underway in North Americas ECA, the EGCS shut down and the ship burned HFO for 1 hour and 45 minutes. The EO on watch acknowledged the alarm, but did not realize the significance of the issue and did not investigate. During a check of the ORB, the EO discovered that the ship had not been following the revised HESS ENV-1201 and ENV-1204 procedures by not accurately maintaining the Critical Bilge Valves and Fitting Lock Log and not recording periodic maintenance of the OCM. The Captain conducted an investigation, which revealed that a third engineer who had prepared the log entries had performed the cleaning of the OCM without retrieving the key from the Chief Engineer to open the valve. Additionally, the EOOW had not been making an entry in the ORB for week maintenance of the OCM. The forward OWS shut down due to abnormal vibration. The OWS was isolated while a faulty pump was replaced with a spare unit held on board. The system was fully tested before placing back in service. There was no impact on operations as the ship remained below 50% of total bilge holding capacity at all times. The EGCS was operated inside the North American ECA with a non-compliant SO2/CO2 ratio for approx. 1 hour beyond the maximum permissible company troubleshooting period of 6 hours, resulting in a violation of MARPOL Annex VI. The engine was shut down when troubleshooting efforts during the previous watch were unsuccessful, but the oncoming watch restarted the engine and exceeded the troubleshooting period. The cause of exceeding the maximum troubleshooting period was inadequate watch handover between the EOOWs. The watch keeper's handover checklist did not include notes regarding the EGCS troubleshooting. The Chief Engineer reviewed the incident with all EOOWs and the Captain shared the incident with all OOWs stressing the importance of effective communication during handover. During a review of the ORB, it was noted that entries for periodic maintenance were not recorded. A meeting was held to discuss and clarify the requirements with the Engineer Officers. While underway, it was noted that the BCDB recorder had not properly recorded data for a period of approximately five minutes. The issue was identified by the EO during the periodic BCDB record check, when he found out that a 5 minute period of data was missing. The oil filtering equipment was not in operation and, therefore, no overboard discharge occurred during that period. While the issue was being investigated by on board personnel, a second identical event occurred when 5 minutes of data were lost on August 13 while trying to download data from the White Box Data Recorder via the USB pen drive. In particular, it was noted that when the USB key is inserted in the Data Recorder, the software starts an automatic reboot, causing the loss of data until the reboot is complete. Also during this second event, the oil filtering equipment was not in operation and therefore no overboard discharge occurred during that period. Several emergency bilge suction valves are failing. The ship is planning repair on all valves using parts scheduled to arrive by September 34, 2017. Page 11 of 94 June 21, 2018 CAM Incident Category EGCS Voyage Planning Voyage Planning Oil Record Book Recordkeeping EGCS Voyage Planning Oil Record Book Recordkeeping OWS/Whitebox EGCS Voyage Planning Oil Record Book Recordkeeping Not Applicable Not Applicable Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 107 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00088 7/31/17 AIDAluna 034_2017-EP 8/1/17 PCL Emerald Princess 039_2017-OS 8/1/17 HAL Oosterdam ENV 1201.16 8/1/17 Carnival Breeze ENV 1201.15 8/1/17 Carnival Conquest ENV 1201.14 8/1/17 Carnival Dream Event Description The 'Critical Valves, Fittings, and Tank Hatches List and Seal Log' required as per ENV-1204 Annex 2 was found to be not fully implemented. Overboard system vulnerable points where seals had been used as an interim solution prior to being replaced by a welded permanent solution were not logged. While in the North American ECA and Alaskan State waters, the EGCS shut down for nine minutes with no associated audible alarm. Upon noticing the visual alert, the EOOW restarted the system. However, the EGCS sensor tripped again resulting in HFO being used for a further 11 minutes without the EGCS in operation. The system trips were found to be due to dilution line low pressure caused by a partially blocked sea chest. The sea chest was cleaned and issues have been resolved. A software patch to correct the audible alarm issue has been tested and is expected to be installed on all EGCS ships by the end of August. This was not a non-compliance event based on USCG CSNCOE Field Notice 01-2017. While underway, the ship discharged approximately 270 cubic meters of ballast water. The discharge occurred due to a miscommunication between the bridge watch officer and the engineering watch officer. The National Ballast Information Clearinghouse was notified. The company received a warning in lieu of a penalty from the U.S. Coast Guard. An investigation is underway and additional training and maintenance actions have been undertaken. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. Page 12 of 94 June 21, 2018 CAM Incident Category Seals or Locks Recordkeeping EGCS Voyage Planning Training Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 108 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel ENV 1201.13 8/1/17 Carnival Elation ENV 1201.12 8/1/17 Carnival Fascination ENV 1201.11 8/1/17 Carnival Freedom ENV 1201.10 8/1/17 Carnival Glory Event Description A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. Page 13 of 94 June 21, 2018 CAM Incident Category Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 109 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel ENV 1201.9 8/1/17 Carnival Imagination ENV 1201.8 8/1/17 Carnival Legend ENV 1201.7 8/1/17 Carnival Liberty ENV 1201.6 8/1/17 Carnival Magic Event Description A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. Page 14 of 94 June 21, 2018 CAM Incident Category Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 110 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel ENV 1201.5 8/1/17 Carnival Paradise ENV 1201.4 8/1/17 Carnival Sensation ENV 1201.3 8/1/17 Carnival Splendor ENV 1201.2 8/1/17 Carnival Sunshine Event Description A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. Page 15 of 94 June 21, 2018 CAM Incident Category Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 111 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel ENV 1201.1 8/1/17 Carnival Valor CAM-00066 8/2/17 Carnival Legend CAM-00067 8/3/17 PCL Ruby Princess CAM-00083 8/4/17 Carnival Splendor CAM-00068 8/5/17 Carnival Fantasy Event Description A focused investigation found that the ORB on 20 total ships in the Carnival fleet were missing entries between April 2017 and July 2017 for flushing/cleaning of the OCM as required by the procedure ENV 1201 and the ECP. The focused review was conducted after the initial ship reported missing this compliance issue and a fleet-wide review was ordered. All ships were directed to submit incident reports and make proper administrative corrections if similar errors were found. These reports are a result of that direction. The cause of the omissions is related to a lack of awareness/oversight of the ENV 1201 procedural requirements. On all ships, the Captain, Chief Engineer, and EO have reviewed the planned/unplanned maintenance records in order to verify which ORB entries were missing and held a meeting with the engine officers to reinforce the procedure. 'I' entries were made in the ORBs to indicate which maintenance operations were not recorded and a copy of the incident report was attached to the front page of each ORB involved. Topping up of the refrigerant gas in standalone refrigerators was not reported as leaks in the Refrigeration and Ozone Depleting Substances (ODS) record book for the last four years. A total of 135kf of R404a gas were used to top up standalone refrigerators during this period. This was noted by the EO during a review of the Refrigeration and ODS record book when he noted that three empty cylinders were offloaded to shore and no corresponding leads had been reported. The centrifugal OWS on board is out of service due to a faulty mother board. The remaining static OWS is fully functionally and the ship is not experiencing any constraints processing bilge water. A new mother board is expected to arrive onboard during this week’s turnaround. An entry has been made in the ORB and the OCLM has been notified. 267 kg of non-ODS refrigerant gas leaked from an air conditioning system due to a failure of a shaft seal. The seal was replaced and the system put back in service. 255 kg of refrigerant gas leaked form an air conditioning system due to a corroded shaft seal. The seal was replaced and the system put back in service. June 21, 2018 CAM Incident Category Oil Record Book Recordkeeping Recordkeeping Refrigerants OWS/Whitebox Refrigerants Refrigerants 033_2017-DE 8/5/17 Carnival Sunshine While underway approximately 60 nautical miles outside the Bermuda Baseline, approximately 20 liters of hydraulic oil went overboard due to a broken lifeboat launching station manometer in violation of MARPOL Annex I. Upon noticing the spill, crew members blocked the drains with rags, the valve on the hydraulic oil line to manometers was closed, and the broken manometer was replaced. The system is now back in service. The incident was reported to the DPA and local authorities via the Port Agent. CAM-00070 8/6/17 PCL Ruby Princess While underway more than 12 nautical miles from the Alaskan coast and in the North American ECA, the EGCS shut down due to a failure of the high pressure pump switch. This resulted in one DG to run on HFO for 12 minutes and another for 20 minutes EGCS before both EGCS tower systems were re-started. The ADEC has been informed. CAM-00074 CAM-00100 8/6/17 8/7/17 Lifeboat/Tender Carnival Fantasy Approx. 798 kg of refrigerant gas was used to refill/top up various small capacity standalone refrigerators during routine maintenance between the years 2011 and 2017. However, the refills were not reported in the Refrigeration and Ozone Depleting Substances (ODS) record book. This was noted by the EO during a review of the Refrigeration and ODS record book when he noticed that one cylinder of non-ODS refrigerant gas was off loaded but no leak was recorded in the respective log. Recordkeeping Refrigerants Carnival Freedom During a routine check of critical valves in the garbage room, two ECP seals on the food waste vacuum system were found to be missing. The seals were not recovered and prevented the Chief Engineer maintaining the inventory of broken seals. After a detailed investigation, including questioning all concerned environmental team members under the supervision of the Chief Engineer, it was concluded that the seals may have been damaged during the garbage transportation work in the area. It was confirmed that no unauthorized access had taken place, new seals were installed and the seal log was updated. Seals or Locks Page 16 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 112 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00075 8/8/17 Carnival Imagination CAM-00076 8/8/17 Carnival Valor 054_2017-FD 8/8/17 Carnival Freedom 035_2017-AP 8/9/17 PCL Grand Princess 036_2017-VO 8/9/17 HAL Volendam CAM-00077 8/9/17 P&O Britannia CAM-00079 8/11/17 Costa Luminosa CAM-00080 8/13/17 Costa Atlantica CAM-00084 8/15/17 PCL Grand Princess CAM-00089 8/15/17 P&O Azura Event Description June 21, 2018 CAM Incident Category The Westphalia OWS was placed out of service due to a malfunctioning unit. With the Sanitec OWS also out of service, the ship was unable to process bilge water. The ship confirmed sufficient bilge holding capacity and was advised of no restrictions of OWS/Whitebox offloading bilge water ashore. Flag Administration and the USCG were informed. On August 13, 2017, the ship received a replacement control unit and the Westfalia OWS was assembled, tested, and is back in service. An entry was made in the ORB. A technician is scheduled to repair the Sanitec OWS on August 30, 2017. 312 kg of non-ODS refrigerant gas leaked from a refrigeration system due to leaks caused by corroded pipes and ship vibration. Refrigerants Four pipes were repaired and the system was put back in service. During a routine check of critical valves in the engine room, an ECP seal on the jet food waste vacuum system were found to be missing. The seals were not recovered and prevented the Chief Engineer maintaining the inventory of broken seals. After a detailed investigation, including questioning all concerned environmental team members under the supervision of the Chief Engineer, it was concluded that the seals may have been damaged by a plumber during routine maintenance on the system. It was Seals or Locks confirmed that no unauthorized access had taken place, a new seal was installed and the seal log was updated. A corporate initiative is in progress to evaluate new stronger seal designs to prevent inadvertent breakage during the routine operations and maintenance. The Grand Princess arrived in Ketchikan, Alaska today with a dead humpback whale on the bow. The Grand is the vessel that was implicated in the NOAA violations (i.e., the discharges into the NOAA marine sanctuary off the west coast that were reported to NOAA earlier this year). In addition, Carnival corporation brand ships have experienced prior whale strikes in this area. While conducting maintenance on the starboard propeller in Vancouver, Canada, a small oil leak of two or three drops was observed that created a light oil sheen in the water. Divers isolated the oil leak and the sheen disappeared shortly after. The Vancouver Harbormaster, Transport Canada, and the Canadian Coast Guard were notified. While alongside in Bergen, Norway, a diesel generator was tested for approximately 4 minutes while using HFO in violation of MARPOL Annix VI. Engineers have been re-briefed regarding fuel sulfur requirements and the Chief Engineer has been given Voyage Planning clear instruction on compliance with reference to planned and unplanned events. During sludge offload operations in Dubrovnik, Croatia, it was realized that there was a leak in a pipe connection provided by the external vendor. Approximately 10 liters of sludge oil spilled on the pier and into the water. Absorbent brooms and cloths were used to collect the sludge. The Port Authority was notified via the Port Agent. Five minutes of data was lost while downloading data from the BCDB recorder. The system restarted during the download resulting in the loss of data. The Ship Superintendent is in contact with the manufacturer to avoid reoccurrence by installing a direct connection between the BCDB and the ship’s server. During a changeover of a provision compressor, it was discovered that the unit being placed in service did not contain any refrigerant gas. The compressor system has a capacity of 260 kg of non-ODS refrigerant. A leak test identified the source of the Refrigerants leak and a repair is being undertaken. While alongside in Alesund, Norway, and testing the EDG breakers, the EGCS sea water and dilution pumps tripped. This resulted in a DG running on HFO for 21 minutes without a running EGCS in the port area. A standby DG was started on MGO to take the EGCS load. The EGCS was brought back online within 30 minutes. The response to the event was as per the EGCS Compliance Plan and did not constitute a MARPOL Annex VI violation. Local authorities were not notified. Page 17 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 113 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 10-2017 8/15/17 AIDAluna CAM-00085 8/16/17 Carnival Freedom 041_2017-EU 8/16/17 HAL Eurodam CAM-00087 8/18/17 PCL Coral Princess 043_2017-OR CAM-00091 8/18/17 8/19/17 Event Description June 21, 2018 CAM Incident Category A Fleet Chief Engineer visiting the AIDAluna from August 15-19, 2017, raised questions concerning whether the vulnerability assessment implementation onboard was completed correctly. We requested a review of the matter by our internal investigators. The review concluded that the vulnerability assessment requirements had been implemented across the ship. However, the review also concluded that the ECS Log had not been implemented onboard per Section IX.B.2 of the ECP. Following this discovery, the Recordkeeping ship’s Chief Engineer implemented and began maintaining an ECS Log. Also, the ship’s Master instructed the Chief Engineer on the importance of ECP compliance and required that a working group be assembled, including an engineer appointed to focus exclusively on ECP compliance, and that the EO provide a daily report regarding the working group. During an inspection of a refrigeration system it was noticed that the relief valve was open, probably due to ship vibration. A total Refrigerants of 315 kg of non-ODS refrigerant gas had leaked. The valve was replaced, the system was refilled, and put back in service. The mechanical seals of the sewage transfer pumps were changed but started leaking within three days of operation. It is unknown why the seals failed and the manufacturer is assisting with the investigation. New seals have been ordered, which may resolve the issue if the old seals were degraded and/or from a bad batch. While the ship was underway, a hydraulic oil spill from a lifeboat was reported to the bridge. Most of the oil was contained on the promenade deck and cleaned up by the spill response team; however, an estimated quantity of one liter spilled overboard. Upon Lifeboat/Tender investigation, the cause of the spill was found to be a failed isolation valve gasket. All other lifeboats were checked for similar issues. The incident was reported to the Victoria Coast Guard and an entry was made in the ORB. P&O Oriana During crew drills while in Akureyri, Iceland, the rescue boat experienced engine issues and an oil sheen, approximately three meters long, was noted on the water. When the boat was recovered, a second oil sheen was visible on the water directly beneath Lifeboat/Tender the boat. No oil was found within the boat. An investigation identified that, due to the cold ambient conditions, more throttle than usual had been used on the rescue boat and the sheens were likely caused by unburnt fuel carrying over into the exhaust. Carnival Fascination During a routine check of the critical valves in the engine room, the EO noticed an ECP seal on the open valve on the discharge line of the engine room cooling system was missing. The seal was not recovered and prevented the Chief Engineer from maintaining the inventory of broken seals. After a detailed investigation, including questioning all concerned engine team under Seals or Locks supervision of the Chief Engineer, it was concluded that the seal may have been damaged and broken during the maintenance work carried out on a system cooler. It was confirmed that no unauthorized access had taken place, a new seal was installed and the seal log was updated. During routine daily cleaning of grey water filter, it was noted that 2 adhesive seals on the filter were missing from point ID 466. The 2 missing seals were installed the previous day. It is presumed that the seals were fitted to a wet surface and subsequently fell off (area was being cleaned at the time). It was confirmed that no pollution had occurred during the period in which the seals were Seals or Locks missing as removal of the filter cover with the overboard in an open position would flood the engine room. The investigation also highlighted that the affected grey water filter may be controlled by the use of portable pumps and that seals are not required. CAM-00092 8/19/17 Costa Luminosa CAM-00101 8/19/17 Carnival Freedom CAM-00093 8/20/17 Carnival Magic CAM-00094 8/21/17 Carnival Pride During a routine Chief Engineer handover, an unused ECP seal was found to be missing. As a preventive action, all new and used Seals or Locks seals are now secured in the Chief Engineer’s office. During an inspection, a non-ODS refrigerant leak was noted coming from a provision system. The leak was located in the upper part of a pipe and appeared to have been caused by ship vibration. The pipe was repaired, the system was refilled with 515 kg of Refrigerants R407c refrigerant gas, and the system was put back in service. During an inspection, a non-ODS refrigerant leak was noted coming from an air conditioning system. The leak was located in a Refrigerants condenser. The system was repaired, refilled with 570 kg of R134a refrigerant gas, and put back in service. Page 18 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 114 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category CAM-00095 8/23/17 HAL Eurodam During maintenance work on a tender platform while alongside in Sikta, Alaska, approximately one liter of hydraulic oil spilled into the sea when the platform was opened. The oil originated from a leaking hydraulic connection on the forward ram of the platform, which could not be seen prior to opening the platform. The spilled oil could not be recovered or contained but the oil leaking from the hydraulic hose connection of the ram was contained and cleaned up. CAM-00096 8/24/17 HAL Rotterdam While alongside in Liverpool, UK, a hydraulic fluid leak was observed dripping from a tender platform into the river. It is estimated that approximately five milliliters of biodegradable hydraulic fluid entered the water. An investigation found that the Lifeboat/Tender cause was a leaking valve connection. This was in violation of MARPOL Annex I and the Liverpool Port Authority were notified. CAM-00102 8/24/17 Carnival Fantasy 052_2017-ZU 8/24/17 HAL Zuiderdam CAM-00097 8/25/17 Costa Deliziosa 044_2017-QV 8/25/17 Cunard Queen Victoria CAM-00098 8/26/17 Carnival Magic 09-2017 8/26/17 HAL Odyssey CAM-00099 8/27/17 HAL Amsterdam Lifeboat/Tender During an inspection it was identified that the Bunker Delivery Notes (BDN) for 2014 were missing in violation of MARPOL requirements to maintain records for three years. Copies of the missing BDNs are available in Infoship. All BDNs for the 2015, Recordkeeping 2016 and 2017 to date are archived in a secure cabinet in the Chief Engineer's Office. An entry was made in the ORB by the Chief Engineer and notification of Flag Administration is in progress. While underway in the North Sea ECA, the gas analyzer for the EGCS was placed in standby mode during routine maintenance. On completion of the maintenance, the gas analyzer did not return to full operation as designed due to a software issue, which caused it to 'freeze' and not operate correctly. There was no alarm or indication that the gas analyzer was still in standby mode. The EGCS EGCS was subsequently in operation for over seven hours without the correct gas monitoring in violation of Company procedure ENV-1102 and MARPOL MEPC 259 (68). One of 2 plastic seals securing the flange on the bilge discharge shore connection was found to be missing and could not be located. After an investigation, it was concluded that the seal may have been broken and lost during painting work carried out in Seals or Locks the area. It was confirmed that no unauthorized access and discharge took place as the bunker station shell door was closed and disabled from the bridge. A new seal was installed and the seal log was updated. The ship bunkered fuel in Trieste, Italy, on August 19, 2017. The Bunker Delivery Note (BDN) indicated the fuel had a Sulphur content of 1%. On August 23, 2017, the ship received the results of the independent fuel sample analysis that showed the Sulphur content was actually 1.6%. The ship had used the fuel in regulated areas of Greek waters requiring fuel with a Sulphur content of less of 1.5%. Authorities were not notified as the legally recognized Sulphur content value is the one on the BDN. The remaining fuel will be used where allowed. The ECP seal on an OWS flowmeter viewing screen was found to be missing and could not be located. After a detailed investigation, it was concluded that the seal may have been broken and lost during cleaning work carried out in the area. There was Seals or Locks no apparent damage or tampering with the flowmeter itself. A new seal was installed and the seal log was updated. The EO onboard the Seabourn Odyssey had to disembark due to compassionate leave to tend to his wife. During his absence, the Senior First Officer was appointed to take over his role and an exception request was issued to shore side and approved. The EO returned to the ship on September 5, 2017. Per Section IV.A.1 of the ECP, if a vessel must operate without an EO on board, a qualified replacement must join within seven calendar days. Although best efforts were made, the seven day requirement could not be met. The ship's incinerator is out of operation due to requiring replacement parts to be fitted. Waste is being stored in the garbage room and the marshaling area as there is no available space in the cold room to store any waste. The ship only has nine cubic meters of cold storage space and no designed storage space outside of the garbage room. Solid waste offloads are being conducted but the garbage builds up rapidly when the incinerator is not functioning. The current estimated time to repair and recommission the incinerator is unknown. Page 19 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 115 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 053_2017-SE 8/28/17 Carnival Sensation CAM-00103 8/28/17 HAL Prinsendam 051_2017-ZU 8/28/17 HAL Zuiderdam 046_2017-LU 8/29/17 Costa Luminosa CAM-00104 8/29/17 HAL Maasdam CAM-00113 8/29/17 Carnival Inspiration 055_2017-LUNA 8/30/17 AIDAluna CAM-00114 8/30/17 Carnival Valor Event Description During an internal grey water transfer operation while alongside in the Port of Miami, deck personnel reported an overboard discharge from an air vent. A tank level sensor had malfunctioned allowing the tank to fill and resulted in the overflow through the vent. An estimated 1.5 cubic meters of grey water were discharged into the sea. A non-critical solenoid of an OWS three-way valve developed an electrical short. The failure affected the control unit for the associated OCM. A spare OCM control unit was on board and confirmed to be operational. A purchase order was raised for two replacement non-critical solenoids. The replacement parts are scheduled to be delivered on September 7, 2017. The bilge water processing system remains fully functional. While underway in Icelandic waters, the ship discharged 80 cubic meters of untreated sewage outside 12 nautical miles above the maximum permitted discharge rate of 32 cubic meters per hour in violation of MARPOL Annex IV. The untreated sewage had been stored in a dual-use tank and the discharge pumps exceeded the maximum permitted flow rate. The rate of discharge can be monitored in the automation system to ensure it is within compliant parameters but the operator had not been trained prior to the incident. While alongside in Katakolon, Greece, it was noted that the control panel of the centrifugal OWS was in failure. Following consultation with a Classification Society surveyor, the equipment was placed out of service. The required spare part, which is not on the critical spares list, has been ordered from the manufacturer. The expected delivery date is September 9, 2017, including technical support for installation. The ship is equipped with a static OWS which is fully operational and therefore remains in compliance with statutory requirements. June 21, 2018 CAM Incident Category OCM OWS/Whitebox Voyage Planning OWS/Whitebox During departure from Sydney, Canada, the ship was unable to start any EGCS systems due to a communication failure between the EGCS software and the engine automation system. The vessel departed with one DG running on HFO and 2 running on MGO. Following departure, the ship flushed the fuel system of the engine running the HFO to enable the changeover to MGO. EGCS Authorities were not notified as the ship was within the permitted 6 hour troubleshooting period. An entry was made in the EGCS log. The cause of the failure was identified as a software communications problem between the software programs for the EGCS and the engine automation. The failure has been remotely rectified and the EGCS system is fully operational. During a routine inspection of the machinery spaces, the EO noted several metal drums in the sewage room. One drum was fitted with a device, later identified as a pneumatic vacuum, and a hose. There were no other personnel present in the area at that time. An investigation found that the Chief Motorman had been using the vacuum pump to transfer bilge water from the bilge wells into the drums. The contents of the drums were later transferred into a sludge tank and appropriate entries made in the ORB. The vacuum pump was not controlled as per ENV-1203 and the Chief Engineer was not aware of its use. The pump had been ordered prior to implementation of the procedure. When the device was received on board in June 2017, the procedure had been fully implemented, but it was not recognized that the device should be controlled. The pump was of a different style and shape from other controlled pumps on board and apparently not recognized by watch standers. During a routine inventory check, the MARPOL samples of the MGO bunkered in New York on October 8, 2016, were noted as missing in violation of MARPOL regulation. Investigations are ongoing regarding the root causes of the unavailability of the requested samples but no reason for the loss has been identified. The weekly entry for the quantity of oil residue in the sludge tanks was found to be missing for the week commencing August 27, Oil Record Book 2017, in violation of MARPOL regulation. The omission was due to a lack of attention regarding the ORB completion process. Recordkeeping The Director of Environmental Operations was informed. While entries were not recorded in the ORB, a copy of the incident report was stapled to the respective ORB to document the missing entries. Page 20 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 116 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. 2017-R0805-40-0001 050_2017-CO Date of Event 8/30/17 8/31/17 Brand/Vessel Event Description HAL Eurodam The Eurodam's August 2017 Discharge Monitoring Report indicated that an August 30, 2017, sample of the vessel's mixed grey and black water exceeded the daily maximum level of fecal coliform. The Company believes that this exceedance was an aberration without a specific root cause because an inspection confirmed that all of the vessel's ultraviolet bulbs were in working order and the Eurodam 's next sample taken just a few days later on September 4, 2017, met all specifications and confirmed that no additional remedial measures were necessary. The Holland American Line received a Notice concerning this testing sample on November 7, 2017. PCL Coral Princess While underway in Alaskan waters with three DGs running on HFO and the EGGS systems in operation, the gas analyzer alarm for one DG activated indicating that the system was exceeding the regulatory limits for S02/C02 (Sulphur Dioxide/Carbon Dioxide) ratio. The EOOW acknowledged the alarm but did not take any further actions and the issue was not addressed until the change of watch. The emissions and discharges exceeded compliance thresholds for six hours and 39 minutes. CAM-00108 9/1/17 P&O Britannia CAM-00140 9/1/17 Carnival Freedom 062_2017-WE 9/3/17 HAL Westerdam 061_2017-AC 9/3/17 P&O Arcadia 056_2017-MA 9/6/17 HAL Maasdam 059_2017-KP 9/6/17 PCL Crown Princess CAM-00110 9/6/17 PCL Golden Princess The static OWS has been taken out of service due to its three way valve remaining open when the oil content is above 15ppm. The valve is new and had been fitted recently due to repeated failures of the previous unit. It was confirmed that no overboard discharge greater than 15 ppm had occurred. The OWS will remain out of service while the manufacturer assists with an analysis of the system and resolution of the issue. The ship's ability to manage bilge water is not currently impacted. During a monthly check, it was noticed that two MARPOL bunker samples from September 1, 2017, were missing in violation of MARPOL Annex VI. An investigation did not identify a cause for the missing samples and it is believed the supplier omitted the two missing items from a batch of samples. The incident is being reported to all relevant authorities. The OCM for an OWS developed a cooler water leak resulting in the potential to dilute sample water with cooling water. The cause of the leak is not yet confirmed but is likely to be related to internal clogging of the cooler. The OWS remains operational as the temperature is low enough to operate without the cooler. A replacement cooler is scheduled to be delivered to the ship by September 20, 2017. Options to fit similar OCMs with improved coolers are being investigated. During off-loading operations in Southampton, UK, a bulk bag of crushed glass toppled from a pallet as it was being lifted from a baggage platform. The majority of the glass remained inside the bag on the platform but approximately 5 kg spilled from the platform into the water. While underway in Canadian waters, the emission monitoring system failed. Consequently, a system communication fault caused the EGCS to stop. The ship changed over to MGO before reaching the six hour permissible troubleshooting time limit and therefore remained compliant with Company procedure. An investigation found the EGCS Engineer had inadvertently reset the control system back to factory settings. Measures to prevent a system reset were in place but not followed. During oily sludge discharge ashore in Akureyri, Iceland, the shore side-provided hose began leaking. The discharge was immediately stopped and the EO was informed. All spilled sludge was contained within the ship. After disconnecting the hose, the shore operator inverted the hose and some oily sludge residue spilled onto the dock and into the water. Oil absorbent pads were provided by the ship to the shore operator. It was estimated that approximately 1.5 liters of oily sludge spilled on the dock with approximately 0.3 liters entering the water. The ship experienced a large loss of lubricating oil from a stabilizer head tank. 80 liters of sea water was drained from the tank and it was concluded that the missing quantity of oil was lost at sea with the sea water ingress replacing it. The system was taken out of service and drained pending repair at the next dry-dock scheduled in April 2018. Page 21 of 94 June 21, 2018 CAM Incident Category EGCS Training Voyage Planning OWS/Whitebox OCM OCM OWS/Whitebox EGCS Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 117 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00134 9/6/17 PCL Island Princess CAM-00111.7 9/7/17 Carnival Ecstasy CAM-00111.6 9/7/17 Carnival Freedom CAM-00111.5 9/7/17 Carnival Glory CAM-00112 9/7/17 Carnival Inspiration CAM-00111.4 9/7/17 Carnival Legend CAM-00111.3 9/7/17 Carnival Paradise CAM-00111.2 9/7/17 Carnival Sensation Event Description While alongside in Whittier, Alaska, the Senior First Engineer informed the Chief Engineer of a large quantity of water coming out of a diesel generator's (DG) turbocharger. The DG was isolated. A valve had been closed on the EGCS as a safety precaution to allow cleaning of the sea water filter for the EGCS. The overboard valve is connected to the general service water pump, which also supplies the static mixer for the EGCS. With the valve closed, sea water filled the exhaust duct and overflowed into the engine casing. Approximately 120 tons of seawater entered the bilges prior to being transferred into the double-bottom and bilge settling tanks. The new volumes for those tanks were entered into the stability computer with the free surface effect being accounted for in the revised stability calculations. The updated volumes/calculations were submitted to the FOC/Company as required prior to departure. The bilge water was untreatable due to the soot content and approximately 60 tons of bilge water was offloaded via trucks at the next two port calls. Island Princess is the only ship with this overboard valve arrangement and is due to be modified during the drydock scheduled for November 2017. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. Page 22 of 94 June 21, 2018 CAM Incident Category EGCS Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 118 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 058_2017-SL 9/7/17 Carnival Splendor CAM-00111.1 9/7/17 Carnival Triumph 057_2017-KP 9/7/17 PCL Crown Princess CAM-00123 9/9/17 Carnival Liberty CAM-00115 9/10/17 Cunard Queen Mary 2 CAM-00116 9/11/17 Carnival Dream CAM-00124 9/11/17 Carnival Fascination 083_2017-EL 9/11/17 Carnival Elation 064_2017-QU 9/12/17 Seabourn Quest Event Description While docked in Isla Roatan, Honduras, an oil leak was reported to be coming from a lifeboat. A high pressure hydraulic pipe was found to have failed, spilling oil down the ship's hull. Operation of the affected davit system was halted, which immediately stopped the leak. Approximately 0.5 liters of oil was estimated to have been spilled with a small proportion of this volume entering the water. No oil sheen was observed. The Port Authority was notified via the Port Agent and permission was granted to repair the failed pipe prior to departure. The pipe was welded and successfully tested. The davit system and lifeboat were put back in service. A 'G' entry was made in the oil record book. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During reviews of ORB, several ships identified pages missing the signature of the EO, ranging from 1 to 13 pages. The OLCM and shore side management were notified and the Chief Engineer conducted a meeting with the EO and the Captain. A copy of the incident report was added to the ORB and an 'I' entry made to address the issue. Administrative checks with the EO will reinforce that they correctly fulfill their responsibilities. During routine checks of a provision system, a leak of non-ODS R407c refrigerant gas was detected coming from a crack in a pipe line. The pipe was welded and 304 kg of refrigerant gas were added. The ship experienced issues with the recently installed forward OWS unit where the OCM reported an error. Attempts to clean the OCM were unsuccessful and it appeared that the self cleaning function was faulty. The manufacturer’s commissioning engineer was requested to undertake a follow-up visit during which he resolved the issue and provided additional training to the ship’s team. The OWS is now fully functional. While fitting new ECP seals to a grey water tank, it was noted that two old seals were missing. An investigation found the Deck Department had removed the seals prior to transferring grey water to an alternate holding tank in order to inspect a sounding pipe. Due to a lack of awareness, the bosun had failed to deliver the seals to the EOOW in the ECR. While the grey water transfer was authorized by the Chief Engineer, the ECR watch was busy with other tasks and also forgot to ask the bosun to deliver the seals. The broken seals were then likely to have been removed during cleaning. It was confirmed that no unauthorized access to the system had taken place. While undertaking a routine operation, the Staff Chief Engineer noted that a chemical and associated injection tubing on a static OWS had been removed during a prior maintenance task and not reinstated. The initial review concluded no illegal discharge occurred. The system has been returned to its approved arrangement. A manufacturers service visit verified the entire system was fully restored to specification. Approximately four liters of treated oily bilge water was discharged within 12nm of land due to an error by the engineer on watch. The engineer on watch failed to stop the overboard discharge of treated bilge water before the ship entered the 12nm boundary. The operation was stopped after five minutes and the Chief Engineer was informed. The volume of discharge was determined using the flow meter. The discharge was in violation of company procedures but not MARPOL. While alongside in Montreal, Canada, seven empty carbon dioxide (CO2) cylinders were dropped into the water by stevedores while the cylinders were being offloaded. The cylinders sank immediately. The ship’s agent and the Harbour Master were advised. Divers recovered all cylinders the following day. Page 23 of 94 June 21, 2018 CAM Incident Category Lifeboat/Tender Oil Record Book Recordkeeping Refrigerants OCM Training OWS/Whitebox Voyage Planning Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 119 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. 075_2017-TP; NOV #2017-R856-40-0001 073_2017-NO CAM-00118 Date of Event 9/12/17 9/13/17 9/13/17 Brand/Vessel PCL Star Princess Event Description June 21, 2018 CAM Incident Category Preliminary results of the sampling conducted on the Membrane Bio-Reactor's (MBR) indicated that the ship exceeded the daily Biochemical Oxygen Demand (BOD) limit of 60 mg/I and was anticipated to exceed the monthly average limit of 30 mg/I. The ship was instructed to inspect, clean and replace diffusers in the MBRs if necessary. The ship was not restricted in it abilities to discharge in accordance with IMO and Company standards and there was no impact on operations. The preventive maintenance program was reviewed by the shore side technical team. The Alaska Department of Environmental Conservation and U.S. Coast Guard were notified. HAL Noordam While alongside in Juneau, Alaska, a public complaint was made via the Alaskan Department for Environmental Conservation (ADEC) regarding the opacity of the ship’s smoke emissions. At the time of the complaint, the ship was running on a single Diesel Generator (DG) with its attached EGCS online. The EGCS and DG were operating within all required parameters. The issue was discussed with shore side management, and a decision was made to switch over to a DG running Marine Gasoil (MGO). All relevant data logs were submitted to the ADEC who declared satisfaction with the situation with no additional follow-up. P&O Ventura The COWS was selected to discharge overboard, but its OCM read 20 ppm and both oil content alarms activated. The COWS still indicated overboard discharge and the BCDB flow meter showed 1.65 cubic meters of water were discharged before the operation was stopped. The OCM reading in the automation system for the COWS was erratic throughout the discharge and, when the OCM operation was stopped, was significantly different from the local reading on the OCM (17 to 23 ppm versus 42 to 46 ppm). The OWS/Whitebox BCDB maintained readings of 7 to 10 ppm throughout the discharge. It was subsequently confirmed that no violation had occurred. An inspection found the COWS OCM control unit was badly corroded and full of water. 063_2017-FS 9/14/17 Carnival Fascination 072_2017-GL 9/14/17 Carnival Glory CAM-00119 9/14/17 Costa Atlantica During the transfer of oily sludge to a truck while alongside in Saint Lucia, approximately 18 liters of sludge spilled onto the pier and approximately five liters entered the water. All checklists had been completed and agreed with all relevant parties. An initial investigation found that the receiving truck operator had stopped the transfer operation and attempted to adjust the hose while it was still pressurized. The ship responded to the incident. All spilled sludge on the pier and in the water was contained and collected. All cleaning materials were disposed shore side as oily waste. The incident was reported to the Port Authority via the port agent. The Port Authority visited the ship and advised that no further actions were required. The OLCM and shore side management were notified and a ‘G’ entry was made in the ORB. While alongside in Freeport, Bahamas, a normally empty emergency ballast double bottom tank was found to contain 59 cubic meters of grey water. There was no indication of oil contamination. Shore side management were contacted to obtain permission to transfer the flood water to a grey water tank. The water was transferred using a portable pump under the supervision of the Staff Captain. A subsequent inspection of the emergency ballast tank identified a failed grey water suction pipe that had caused the tank to flood. During an inspection of an air conditioning condenser, it was noted that a safety valve had opened due to a failed spring component. A total of 1,485 kilograms of Non-ozone Depleting Substance (ODS) Freon R410A refrigerant gas had leaked. The Refrigerants failed valve was replaced and the system was refilled and put back in service. 074_2017-ZA 9/14/17 HAL Zaandam While alongside in Juneau, Alaska, a public complaint was made via the Alaskan Department for Environmental Conservation (ADEC) regarding the opacity of the ship’s smoke emissions. At the time of the complaint the ship was running on a single Diesel Generator (DG) with its attached EGCS online. The EGCS and DG were operating within all required parameters. All relevant data logs were submitted to the ADEC who declared satisfaction with the situation with no additional follow-up. CAM-00121 9/14/17 P&O Adonia While underway in heavy weather, two light units on the forward mooring deck came loose. The light units remained attached but the two fluorescent tubes and the transparent covers fell into the sea. The fluorescent tubes contained mercury. Page 24 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 120 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 066_2017-EU 9/16/17 HAL Eurodam CAM-00122 9/16/17 HAL Prinsendam 076_2017-VO 9/16/17 HAL Volendam CAM-00125 9/16/17 P&O Arcadia 085_2017-ZU 9/16/17 HAL Zuiderdam CAM-00141 CAM-00142 CAM-00128 9/17/17 9/17/17 9/18/17 Carnival Miracle Carnival Spirit PCL Regal Princess Event Description While underway heading towards Seattle, Washington, the ship discharged nine cubic meters of permeate within four miles of land, in violation of Company policies and the Washington State Memorandum of Understanding. An investigation found that the Bridge team had not checked the discharge matrix prior to discharging the permeate and were therefore unaware of the restriction. Prior to undertaking a subsequent discharge operation, the Bridge team checked the matrix, realized the prior error, and selfreported. The U.S. Coast Guard and Washington State Department of Ecology were notified. The control unit on an OWS developed a fault where it froze during operation of the OWS. The unit was replaced immediately, restoring full OWS functionality. A replacement spare was ordered. Holland America Group has an ongoing OCM / OWS upgrade program, and the Prinsendam is scheduled to be upgraded in May 2018. While opening a tender platform when alongside in Skagway, Alaska, a few drops of hydraulic oil spilled into the water, resulting in a sheen approximately two meters long. Movement of the platform was immediately stopped. The small oil droplets dissipated quickly and no cleanup was possible. An inspection found a hydraulic coupling was loose. The coupling was tightened and the platform was tested with no further leaks found. The shore side technical team followed up with the ship. The remaining tender platforms were subsequently checked for similar defects. The Alaska Department of Environmental Conservation and National Response Corporation were notified and an entry was made in the ORB. The COWS was taken out of service due to a vibration issue. The static OWS remained in service to process bilge water. The COWS was overhauled, rebuilt, and tested before it was put back in service. While underway, the ship discharged 35 cubic meters of pool water in EPA regulated waters. The water was not de-chlorinated as required by EPA and Vessel General Permit (VGP) limits, resulting in a violation of EPA and VGP Section 5.1.1.2. The Bridge and the Engine Control Room team did not correctly read the discharge matrix and thought that it was a permissible discharge. They had inadvertently read the general requirements and country-specific requirements, missing the VGP requirements. The discharge was discovered while reviewing the ship’s eLog the next day. The incident was reported to EPA via email, and they acknowledged receipt of the notification with no further inquiries raised. The incident was recorded in the ship's VGP logbook and will be included as a non-compliant event in the vessel's annual VGP report. A Corrective Action Assessment will be prepared and sent to EPA as required by the VGP. While reviewing ORB entries for fuel oil changeovers, the EO noted that the time and position for entering and exiting restricted Californian waters did not correspond with those recorded in the navigational records. The matter was discussed with the Captain and all corresponding records were reviewed. It was found that the ship used compliant fuel while navigating through these waters, but the recording requirements were not met. Deck and Engine Officers were not familiar with the recording requirements and the previous ORB checks were not effective. The system times were not synchronized and personnel turnover with inexperienced engineers contributed to the incident. The Bridge and Engine officers were advised and have started to record the entries correctly. June 21, 2018 CAM Incident Category Voyage Planning OWS/Whitebox Lifeboat/Tender OWS/Whitebox Voyage Planning Oil Record Book Recordkeeping Voyage Planning Training While conducting a routine check on September 24, 2017, the EO discovered the IOPP weekly entry in the ORB was not recorded Oil Record Book on September 17, 2017. It was concluded this omission was due to procedural oversight. All appropriate personnel were informed Recordkeeping of the missing entry and a late entry was subsequently made in the ORB. A standard guide sheet was developed to serve as a Training reminder of what items to check when reviewing the ORB. While underway, the ultraviolet (UV) sensor on the Ballast Water Treatment System (BWTS) gave an incorrect signal. The ship did not have a spare UV sensor. The UV sensors are an ECP critical spare. The original UV sensor became faulty during an Atlantic crossing. A spare UV sensor was fitted but didn't fully function and was found to have an expired calibration certificate. An urgent purchase order was approved and the manufacturer was requested to attend the ship as soon as possible. With the BWTS inoperable, the ship is not able to de-ballast within U.S. waters. The issue is not currently impacting ship operations as there is limited ballast water on board and the itinerary provides opportunity for deep sea exchanges as needed. Page 25 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 121 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00129 9/20/17 Carnival Miracle CAM-00130 9/21/17 Cunard Queen Mary 2 CAM-00176 9/21/17 Carnival Ecstasy CAM-00131 9/22/17 P&O Arcadia CAM-00135 9/22/17 Carnival Paradise CAM-00132 9/24/17 Costa Atlantica CAM-00133 9/24/17 HAL Zuiderdam CAM-00136 9/24/17 Carnival Pride CAM-00137 9/25/17 Carnival Freedom Event Description June 21, 2018 CAM Incident Category An unknown quantity of non-ODS R410A refrigerant gas leaked from an air conditioning system due to a failed safety valve. The system was isolated pending delivery of a replacement valve. The quantity of refrigerant lost was expected to be determined once Refrigerants the new valve is fitted and the system was refilled. During a bilge water discharge, an internal cooler fault was suspected to have the potential to dilute the OCM sample. The BCBD, which is included on the IOPP certificate, ensured no discharge above 15 ppm took place. The failed cooler was isolated and OWS/Whitebox removed pending replacement. The cooler was expected to be landed on October 13, 2017 for further investigation. During a routine service of the BCBD digital recording device (DRD), the manufacturer's technician inadvertently left one connection loose. During overboard bilge discharges the following day, the flow counter was not incrementing. The issue was reported and, following initial remote troubleshooting, technicians visited the ship twice before identifying and correcting the fault OWS/Whitebox on October 6, 2017. During the intervening period, the ship was in violation of Company procedures requiring sounding data to be compared other to volumetric measurements. The initial retest was inadequate because there was no method of conducting a test until the next discharge was required, which was the following day. While alongside in Halifax, Canada, a shaft seal leak on the starboard podded propulsion unit was identified and reported to authorities. The ship remained alongside overnight while ship staff completed the manufacturer’s recommended actions to stop the leak. The ship’s Classification Society granted a Condition of Class which was accepted by the Flag Administration and Transport Canada allowing the ship’s itinerary to continue. During routine checks of an air conditioning system, a leak of non-ODS R410 refrigerant gas was found coming from a faulty service valve and pipe. The valve was changed, the pipe was welded, and 313 kilograms of refrigerant gas was added to the Refrigerants system. During routine rounds, it was noted that a seal installed on the emergency bilge suction was missing. The seal could not be found in the immediate area. A new seal was immediately installed and the corresponding log was updated. The quantity of bilge retained Seals or Locks onboard was checked and all expected quantities confirmed as being onboard. An initial investigation was unable to identify why the seal was missing. It is presumed to have been broken during maintenance and subsequent cleaning. During lifeboat maintenance while alongside in Sydney, Canada, a few drops of non-biodegradable hydraulic oil leaked from a davit into the water. At the time of the incident, there was a strong current that prevented a sheen from forming. The current also Lifeboat/Tender prevented any cleanup operation. The leak was repaired and the port authorities were informed. While the ship was underway inside the North American Emission Control Area (ECA) with five Diesel Generators (DG) online, the ship commenced fuel changeover from Marine Gasoil (MGO) to Heavy Fuel Oil (HFO). An engineer officer of the watch accidently shut down the ECGS on one DG, resulting in the ship burning HFO fuel for approximately three hours in violation of MARPOL Annex VI. The EGCS alarm sounded only on the EGCS panel and was not noticed. Once the engineer on watch EGCS realized that the EGCS was not running, he immediately informed the Chief Engineer and the EGCS engineer and started the EGCS. The system will be modified to also show an alarm on the main automation system The incident was reported to the U.S. Coast Guard and port authorities in Baltimore, and a record was made of the incident. A review is being conducted into the crew's understanding of the EGCS system. During a routine inspection of critical valves, it was noticed that three ECP seals were missing and could not be found. It was concluded that the seals may have been unintentionally damaged by a crew member. New seals were installed. The missing seals Seals or Locks were from the propulsion motor room, forward tunnel suction, and the jet system in the provision compressor room. It was confirmed that no unauthorized access was made in the areas. The incident is in violation of ECP and corporate HESS procedures. The missing seals was recorded in the seals log. Page 26 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 122 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00201 9/25/17 Carnival Liberty CAM-00143 9/26/17 Cunard Queen Elizabeth 084_2017-IM 9/27/17 Carnival Imagination CAM-00138 9/27/17 HAL Volendam CAM-00139 9/27/17 P&O Oriana CAM-00144 9/28/17 Carnival Breeze CAM-00145 CAM-00146 9/29/17 10/1/17 Event Description During a routine test of an oily water treatment system, an electrical component of the filter was found to be burned out due to water ingress from a nearby system. The filters are listed on the IOPP certificate; however, they are part of an extra filtration unit on the pre-treatment delivery lines. The system remains fully functional with the additional filtration unit bypassed. The treatment system was expected to soon be replaced with a new OWS and BCDB. A significant discrepancy between the overboard discharge entries in the ORB and the BCDB flowmeter counter reading was identified. An investigation confirmed that tank soundings matched the ORB entries, indicating either a BCDB counter malfunction or an internal leak in the COWS. The COWS was put out of service for overhaul and further investigation. The static OWS remained operational. Approximately four liters of pre-treated oily bilge water from the clean bilge tank was discharged within 12 nautical miles of land due to a miscommunication between the second and third engineer on watch. The operation was immediately stopped and the Chief Engineer was informed. An entry was made in the ORB. The volume of discharge was determined using the flow meter. The discharge was in violation of company procedures but not MARPOL. An investigation was initiated. June 21, 2018 CAM Incident Category OWS/Whitebox OWS/Whitebox Recordkeeping Oil Record Book Voyage Planning While alongside in Vancouver, Canada, a few drops of hydraulic oil spilled into the water from the side doors of a tender platform creating a sheen and resulting in a violation of MARPOL Annex I. The oil leaked from a seal on the shaft of a cylinder which opens the shell door. The small oil droplets dissipated quickly in the water. The cylinder was wrapped in absorbent material and a bucket was placed under the door during the recovery of the tender platform. The Harbor Master was informed and an entry was Lifeboat/Tender made in the ORB. The cylinder was replaced in the next port on September 29, 2017. Following the incident, the shore side technical team conducted a review of the issue with the ship and found that the cylinder was not included in the planned maintenance of the tender doors. The planned maintenance job was updated accordingly and the ship planned to check all other tender platforms. All cylinders were expected to be replaced or overhauled. During routine checks, an OWS was taken out of service due to a bearing pressure ring failure. Replacement parts were ordered OWS/Whitebox and the ship continued to operate with one OWS. The part was added to the ship's critical spares list. While conducting a routine check of ORBs, it was found that six ORBs were missing from the Chief Engineer's office. A subsequent search was unsuccessful and it is believed that the ORBs may have been removed during a past audit/inspection but Oil Record Book not returned. A form has been created to control the movement of ORBs kept in the Chief Engineer's office. The missing ORBs Recordkeeping were also documented in the Chief Engineer and EO's handover notes. A best practice plan for handling and storing of older ORBs was expected to be finalized and circulated fleet-wide. Carnival Miracle The ship reported that two GRBs were missing, in violation of MARPOL Annex V and Company procedure. A search was unsuccessful. It was concluded that the GRBs may have been filed with other Bridge documents that had subsequently been disposed at the end of the retention period. All officers were advised by the Captain to be more careful with document control and Recordkeeping retention. A Compliance Management Notice is being sent to the fleet to confirm ships have full accountability of GRBs. This was expected to standardize control and storage of older GRBs in a similar fashion to the procedure for older ORB retention. HAL Volendam The incinerator is working but could not be used because the coupling of the hydraulic power pack was worn and needed to be replaced. Two coupling sets were onboard the ship but were found to be the incorrect type. The correct part was ordered with a lead time of 14 days, plus approximately five days shipping to Asia. At the time of the report, the incinerator had been out of service for ten days. Page 27 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 123 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00147 Date of Event 10/2/17 Brand/Vessel Event Description P&O Ventura While underway, the smell of fuel was reported in the main laundry area and in passenger areas. An investigation identified a fuel leak from the top of a HFO settling/service tank which had spilled fuel behind bulkhead panels in the laundry. Laundry operations were shut down and ventilation of the spaces was adjusted to stop the smell of fuel from spreading. Bulkhead panels were dismantled to allow oil soaked lagging to be removed and fuel to be cleaned. All spilled oil was offloaded ashore. During the repairs, some internal scuppers were identified as contaminated. This included one scupper leading to a laundry drain tank. It was isolated and the associated pumps and valves locked shut. At the time of the report, repairs were ongoing, including cleaning and repairing the damaged HFO tank. A Classification Society surveyor was scheduled to attend the ship on October 15, 2017. June 21, 2018 CAM Incident Category CAM-00148 10/2/17 PCL Ruby Princess While underway in the Olympic Coast National Marine Sanctuary, the ship operated an EGCS system in violation of Company requirements. Marine sanctuary regulations prohibit discharging EGCS wash-water irrespective of the type of fuel being used. An EGCS investigation identified that the ship correctly changed over to MGO, but the engineer officer of the watch did not request that the Voyage Planning EGCS be stopped. At the time of the report, a preliminary notification had been made to the Olympic Coast National Marine Training Sanctuary. Retraining was given to the watch keepers to remind them of the requirements in this region. CAM-00149 10/2/17 Seabourn Sojourn An OWS was taken out of service for approximately three hours to fit a spare OCM. The ship had sufficient spare OCMs onboard OCM to complete the repair and a replacement OCM was ordered to replenish the onboard inventory. CAM-00155 CAM-00150 CAM-00151 CAM-00152 10/4/17 10/5/17 10/5/17 10/5/17 Carnival Dream Following fleet-wide direction to check MARPOL samples and associated records, the ship found that fuel samples for October 2016 had been disposed, in violation of MARPOL Annex VI and Company procedures. An engineer misunderstood the procedures and disposed of the records. All older fuel sample records were checked to ensure records were available. The issue Recordkeeping was reported to the Chief Engineer who explained the correct procedures to the engineer. In the future, the Chief Engineer will be Training the only person who will have the key to access the fuel oil sample records and will be contacted when record access is required. All engineering crew were reminded of MARPOL and Company procedures and training was planned with all engine officers. A fleet-wide procedure was expected to be implemented to control access to sample location and associated records. Carnival Magic During an inspection, it was noticed that a seal installed on the OWS flow switch cage was missing. The missing seal could not be found. An investigation concluded that the seal could have been damaged unintentionally while cleaning the area. It was Seals or Locks confirmed by the Chief Engineer that no unauthorized access was made and there was no sign of tampering. A new seal was installed and an entry was made in the seal log. Carnival Paradise While alongside in Tampa, Florida, the ship's only online Diesel Generator (DG) shut down. Another DG started automatically, but failed to synchronize in time and a full blackout occurred. A third DG was brought online which restored normal power nine minutes after the blackout occurred. The third DG burned HFO without its associated EGCS running for approximately 40 minutes, resulting in violations of the North American ECA requirements and MARPOL Annex VI. An investigation determined that a cooling system valve malfunctioned and caused high cooling water temperature, triggering the initial DG shutdown. At the time of the report, a review of valve history and overhaul frequency was in progress to determine if a maintenance change or a more predictive method was possible. The ship recorded the incident as a full blackout and non-refrigerant air emission. EGCS Carnival Triumph During a routine check, eight seals were discovered missing from tank hatches in engine room spaces. The seals were broken during maintenance, chipping, and painting of the engine room spaces. There was no evidence of tampering or illegal transfers. The seals were replaced, a corresponding entry was made in the seal log, and all appropriate parties were informed about the incident. There is now a program to replace vulnerable seals with padlocks where possible. Additionally, ship personnel will monitor future maintenance in these areas to ensure install control devices are quickly replaced if disturbed. Seals or Locks Page 28 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 124 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00157 10/6/17 Carnival Fantasy CAM-00154 10/7/17 HAL Zaandam CAM-00243 10/7/17 Carnival Elation CAM-00158 10/8/17 HAL Amsterdam CAM-00159 10/9/17 Carnival Freedom CAM-00160 10/9/17 Carnival Miracle CAM-00161 10/10/17 Carnival Breeze CAM-00162 10/10/17 Carnival Conquest Event Description A total of 311 kilograms of non-ODS refrigerant gas leaked from an air conditioning system due to a faulty shaft seal, cracked filter pipe, loose connections, and a faulty service valve. The air conditioning compressor was shut down and put out of service while the shaft seal was replaced. The system was tested, oil filters were replaced, and the system put back in service. While topping up the system, the dry filter pipe cracked and the main shut off valve started leaking due to loose connections. The system was shut down, the cracked pipe was welded, the connections were tightened, and the system was put back in service. The next day, the system started leaking again due to a faulty service valve on the evaporator. The air conditioning compressor was shut down, the service valve was replaced, and the system was put back in service. 300 kilograms of non-ODS R134 refrigerant gas were added to an air conditioning system. The system had been out of service to re-tube the condenser bundle. After starting the chiller, it was found that the suction pressure was too low and required the system to be refilled. A review of historical ORB entries revealed that a technical issue during an oil transfer had not been noted correctly. A faulty valve had resulted in approximately three cubic meters of oil being transferred into a sludge tank. No ORB entries had been made for the quantity retained or the quantity incorrectly transferred. The mistakes were brought to the attention of the Chief Engineer and engineer officers of the watch. An appropriate correction entry was made in the ORB. The port side grey water overboard valve had reduced flow and the starboard valve was out of service. The ship was able to discharge via the port side valve at reduced flow. An underwater inspection was arranged to inspect and repair both valves. Following the inspection, the port side valve was repaired and put back in service. The starboard valve could not be repaired due to a corroded valve and a seized shaft. At the time of the report, a purchase order had been issued and the part was being sourced, but estimated time of receipt and repair was unknown. June 21, 2018 CAM Incident Category Refrigerants Refrigerants Oil Record Book Recordkeeping While reviewing ORB entries for fuel oil changeovers, the EO noticed entries were missing signatures from the previous EO on October 6, 2017. The entries were reviewed and corrected. The missing signatures were due to the previous EO being disembarked Oil Record Book due to a medical emergency. Due to the medical disembarkation, there was no physical handover. However, the EO disembarked Recordkeeping on the same morning when handover of duty would have taken place. As a result, there was no EO gap. Following fleet-wide direction to check MARPOL samples and associated records, the ship found 26 fuel oil samples were missing, in violation of MARPOL Annex VI and Company procedures. After further investigation, it is believed that either the samples were not taken or the records were accidently discarded. All older fuel sample records were checked to ensure records were available. In the future, the Chief Engineer will check all fuel oil samples and records before they are stored. As further preventative actions, all engineering crew were reminded of MARPOL and Company procedures and training was held with all engine officers. A fleet-wide procedure was expected to be implemented to control access to sample location and associated records. Following fleet-wide direction to check MARPOL samples and associated records, the ship found two fuel oil samples dated October 16 and October 23, 2017 were missing, in violation of MARPOL Annex VI and Company procedures. Further investigations also identified records that were missing details of broken seals and missing labels. It was concluded that the omission of the missing seals and labels was due to changing record storage locations. All older fuel sample records were checked to ensure records were available. In the future, the Chief Engineer will check all fuel oil samples and records before they are stored. As further preventative actions, all engineering crew were reminded of MARPOL and Company procedures and training was held with all engine officers. A fleet-wide procedure was expected to be implemented to control access to sample location and associated records. 310 kilograms of non-ODS refrigerant gas leaked from a refrigeration system due to a faulty section valve. The valve was replaced and the system was put back in service. Page 29 of 94 Recordkeeping Training Recordkeeping Training Refrigerants Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 125 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description CAM-00163 10/10/17 Carnival Ecstasy While underway to Princess Cays, Bahamas, the EGCS shut down while in an ECA area. The ship burned HFO for three hours and 24 minutes without the EGCS, resulting in a violation of the North American ECA requirements and MARPOL Annex VI. Four alarms related to the EGCS were activated but were not acknowledged due to a lack of situational awareness to call for assistance. The engineer officer of the watch stated there were too many alarms sounding at the same time, and he misjudged the importance of the EGCS alarm. The incident occurred and was rectified in a single watch duty. The EGCS record book was updated. CAM-00164 10/10/17 Carnival Sensation During a routine check, four seals were discovered missing from the sludge leakage tank and jet system. The seals were broken during contractor maintenance. The missing seals could not be found, so they were replaced with padlock seals. All seals were checked and secured. The missing seals were logged in the seals log. The ship planned to implement a seal maintenance process. CAM-00165 10/10/17 Carnival Splendor CVL-17-10-0037 Env Open Report #022017 10/10/17 Carnival Triumph CAM-00194 CAM-00282 CAM-00167 10/11/17 10/11/17 10/12/17 Carnival Valor June 21, 2018 CAM Incident Category EGCS Voyage Planning Training Seals or Locks 272 kilograms of non-ODS refrigerant gas was added to a compressor system after two leaks were found on the refrigerant pipe system. One of the leaks was due to a broken pipe line and the other was the result of a loose expansion valve nut connection. The Refrigerants leaks were repaired and the system was put back in service. A report was submitted anonymously through the hotline on October 10, 2017 reporting gas fumes in the vent of a cabin. The reporter also indicated that reports were made onboard with either no action taken or the reporter being advised to “keep quiet” or they would “be in trouble.” It was determined that there was fuel contamination of at least five ballast tanks. The tanks were secured. It was believed that the ballast pipes running through the fuel tanks were weakened, permitting fuel to leak into the pipe and thus contaminate the tanks. Class was notified. The ship did not inform the OLCM that an operational test was conducted, as required by the ECP. ENV-1201 requires every operational test of the OWS and OCMs to be reported to the OLCM. A shore side manager preparing a tracking report for the OLCM noticed there was no notification from the ship on this specific occasion and followed up with the Chief Engineer to validate and correct the mistake. A scanned copy of the ORB and the Chief Engineer's confirmation was provided. PCL Pacific Princess In accordance with the ECP Section VIII.C.4, a Major Non-Conformity was noted onboard the Pacific Princess during a TPA audit from October 7 through 11, 2017. While conducting the engineering space review of pollution prevention equipment, it was noted that the port side Membrane Bioreactor (MBR) for the treatment of sewage was not operational. The port side MBR system had been out of commission for over a year. The space apparently flooded on October 14, 2016 because of hull damage that occurred when the vessel ran aground in Nice, France. The starboard MBR was fully operational with 125% of the capacity required for vessel operations. All required spare parts were verified on board for the MBR in case of failure of the starboard side MBR. In addition, there are three holding tanks for the blackwater. The port side MBR is expected to be replaced during the next dry dock. Cunard Queen Victoria While the ship was alongside in Rhodes, Greece, the ship was conducting routine testing of reverse power trips on all Diesel Generators (DG). The EGCS was online prior to arrival into the port. The port authorities advised the ship that an unquantifiable amount of visible soot deposits were spotted in the water. The ship stopped the EGCS and changed over to MGO to reduce the discharge in the water. The cause of the soot discharge was due to the stopping and starting of the DGs during testing. The EGCS computer confirmed that the ship was within limits. The local environmental agency requested a fast rescue boat be launched to check any remaining soot particles. The ship liased with port authorities, the Harbor Master, and the local environmental agency. At the time of the report, a review was being conducted into EGCS in port operations during engine testing. Page 30 of 94 EGCS Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 126 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00166 10/12/17 HAL Zaandam 11-2017-2 10/12/17 HAL Prinsendam CAM-00168 10/13/17 Carnival Conquest CAM-00169 10/14/17 Carnival Dream CVL-17-10-0048 Env Open Report #032017 CAM-00171 10/14/17 10/14/17 Event Description The flow switch on the OCM for an OWS stopped operating. The flow switch could not be repaired and the cause was determined to be corroded internal elements. There was no spare on board because the part was not listed as an ECP critical spare part in AMOS. This has now been amended in AMOS. The vessel has two 50 ppm facets for internal cascading processing, so oily water processing was unaffected by one facet being out of service. The flow switch was ordered. The ship estimated the part would arrive by October 27, 2017. During a Port State Control inspection while alongside in Venice, Italy, the Italian Coast Guard requested the ship produce bunker samples as required by MARPOL. Samples from bunkering operations in Copenhagen, Denmark, on 16 September 2017 could not be found. The Coast Guard issued a 5000 euro fine. An investigation found the ship had received three samples but not an official MARPOL sample due improper documentation processing of one of the samples by the ship's bunkering team and the delivery barge. The recent Environmental Compliance Notice addresses this issue and should preclude future occurrences. (Appears to be a duplicate entry). 311 kilograms of non-ODS refrigerant gas leaked from a refrigeration system due to a faulty valve. The valve was replaced and the system put back in service. 311 kilograms of non-ODS refrigerant gas leaked from a provision system due to a loose connection near the expansion valve caused by ship vibrations. The connection was tightened and tested, the system was refilled, and the system was put back into service. Carnival Triumph A report was submitted anonymously through the hotline on October 14, 2017 reporting the observation of oil on the surface of the water near the ship in New Orleans, Louisiana. The reporter also indicated that reports had been made onboard with either no action taken or the reporter being advised to “keep quiet” or the they would “be in trouble.” It was determined that there was fuel contamination of at least five ballast tanks. The tanks were secured. It was believed that the ballast pipes running through the fuel tanks were weakened, permitting fuel to leak into the pipe and thus contaminate the tanks. Class was notified. Carnival Conquest While alongside in Fort Lauderdale, Florida, the Staff Chief Engineer reported that water from a pool deck was leaking into a lower cabin. The risk was identified of flooding in other cabins if the pool water was not drained. The Captain was informed and received written notification from shore side to proceed with a minimum release of pool water. It was estimated that four cubic meters of pool water were discharged. The U.S. Coast Guard and the National Response Center were notified and requested further information of the discharge. The chlorine level was checked and determined to be at 2.8 ppm; the U.S. Coast Guard confirmed the level was below the reportable threshold. The cause of the pool water leak was a hole in an outflow channel due to ship vibrations and fatigue. The hole in the pool outflow channel was drained and repaired with no further leaks. CAM-00172 10/14/17 Carnival Fantasy CAM-00173 10/16/17 Cunard Queen Mary 2 June 21, 2018 CAM Incident Category OCM Recordkeeping Refrigerants Refrigerants During the OWS and OCM maintenance tests, it was noted that the BCDB was not allowing overboard discharges due to the threeway valve being in the recirculation position. The cause was believed to be a faulty flow switch; therefore, the switch was replaced with a new spare on board. However, overboard discharges were still impeded by the three-way valve returning to the recirculation OWS/Whitebox OCM position. The OLCM was notified via email. The ship has another BCDB, thus the ability to discharge treated bilge water overboard was not affected. A technician was scheduled to board the ship on October 16, 2017, but was delayed therefore the BCDB was still out of service as the time of the report. An internal leak was found in the sample cooler of the aft BCDB. No water was being processed overboard at the time the internal leak was identified. The Bridge took control of the BCDB and access was only be allowed following authorisation from the Chief Engineer. The bilge overboard discharges were locked and the key will be held by the EO. The cooler was replaced with new spares on board and the BCDB was put back in service. The cooler was sent to the supplier for analysis to determine the cause of the fault. Page 31 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 127 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category While the ship was within the Greek Exclusive Economic Zone ("EEZ"), a Diesel Generator (DG) was run with the EGCS online for approximately 11 hours. A water rack on the system was isolated so the required data recording did not occur, in violation of MARPOL Annex VI. Upon discovery, the water rack was immediately de-isolated. The SO2/CO2 ratios showed that the ship was EGCS compliant with air emissions. The EGCS log has been updated to include flow rate columns for the water racks. The ship concluded an investigation and contingency plans have been implemented. Part of the contingency plan includes a Chief Engineer standing order to double-check water racks are online when the EGCS is in operation. In addition, alarms will be fitted on isolation valves to indicate when they are closed. While the ship was underway and experiencing 65-knot winds, a plastic painting raft that was secured to the forward open deck fell into the sea, in violation of MARPOL Annex V. The heavy weather was anticipated and all checks were completed. The paint raft was not recovered. The flag state was notified and an entry was made in the GRB. Oil Record Book During a corporate investigation, it was identified that the OCM on an OWS was recorded in the ORB as having been cleaned Recordkeeping when the engineering team had not cleaned it. The OWS had not been used since the previous cleaning operation. A warning was OCM issued to the relevant engineer to ensure all OCM cleaning operations are correctly recorded in the ORB. Falsification While underway in Greek waters approximately nine nautical miles from land, the ship's food waste system valves were opened and approximately 0.4 cubic meters of food waste were discharged, in violation of MARPOL Annex V. At the time of the incident, other compliant operations were being undertaken, while the ECR status board was erroneously reading "Not inside 12 [nautical Voyage Planning miles]." An investigation identified a combination of communication issues, a lack of experience by the acting EO, and other operational distractions. During a lifeboat exercise in Aomori, Japan, a crew member accidentally dropped a portable ultra high frequency (UHF) radio from a tender into the sea, in violation of MARPOL Annex V. The radio could not be recovered. An entry was made in the GRB and ship log book. While underway towards Port Everglades, Florida, the ship discharged permeate waste outside 12 nautical miles at a speed below six knots, in violation of Company procedures. The ship's speed dropped to 2.7 knots for approximately 20 minutes following a loss of propulsion. The discharge was not stopped before the ship's speed dropped below six knots. The incident was not a violation of MARPOL or U.S. VGP, so no notifications to external agencies were required. CAM-00174 10/16/17 Cunard Queen Victoria 110_2017-ZU 10/16/17 HAL Zuiderdam CAM-00178 10/16/17 Carnival Valor CAM-00179 10/16/17 Cunard Queen Elizabeth 111_2017-DI 10/19/17 PCL Diamond Princess CAM-00180 10/19/17 HAL Veendam CAM-00170 10/20/17 CCL Shore Side Hotline complaint against Rabih Aboudargham alleging harassment and bullying of team members. CAM-00181 10/20/17 Carnival Dream 311 kilograms of non-ODS R407c refrigerant gas were discovered to have leaked from a provision system due to a corroded evaporator. The system was stopped, isolated, and the evaporator was replaced. After pressurizing and testing for further leaks, the Refrigerants system was put back in service. CAM-00182 10/20/17 Cunard Queen Mary 2 While alongside in New York, New York, a spill occurred while discharging sludge oil to a truck. Oil spilled onto the pier, the ship's hull, and into the water, in violation of MARPOL Annex I. The ship followed standard operating procedures and emergency stations were called to implement a containment response, including deployment of a spill kit. The U.S. Coast Guard (USCG) was notified and permission was granted for the ship to depart approximately four hours late following completion of the clean-up. The cause of the spill was a failure on the receiving truck. This was acknowledged by the USCG. Page 32 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 128 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00183 10/21/17 Carnival Conquest 121_2017-GP 10/21/17 PCL Regal Princess CAM-00184 10/22/17 Carnival Conquest CAM-00185 10/22/17 Carnival Liberty CAM-00186 10/22/17 Carnival Liberty CAM-00187 10/22/17 Carnival Liberty CAM-00188 10/23/17 Carnival Conquest CAM-00189 10/23/17 Carnival Ecstasy Event Description While underway, the ship unintentionally discharged 50 cubic meters of treated sewage and five cubic meters of comminuted food waste within 12 nautical miles of the Bahamas Archipelagic Baseline, in violation of MARPOL Annex IV, MARPOL Annex V, and Company requirements. The non-compliant discharge was identified by the incoming officer of the watch during watch handover. The discharges were immediately stopped, and the Captain and the EO were informed. The initial investigation identified watch officer confusion with the electronic chart lines and associated annotation. In addition, the Captain's standing orders were not followed, a "four-hour ahead" discussion was not conducted after taking over the watch, and the Environmental Schedule was not followed. Flag Administration and Bahamian authorities were notified. Several specific training steps were reviewed with the officers involved, as well as fleet-wide training steps associated with lessons learned from this event. In addition, the updated corporate baseline matrix in a revision to ENV-1001 was expected to address not only Bahamas, but other coastal states with unique baseline concerns as well. While loading stores in New York, New York, a shore side forklift driver caused some boxes of food to fall into the water, in violation of MARPOL Annex V. Shore side staff assisted in recovering the boxes, however five boxes with an approximate total volume of 1.5 cubic meters were lost. Local authorities were informed and an entry was made in the GRB. Per port operations, the precautions taken were adequate. Port operations also liaised with the stevedore company to reinforce the need to maintain safe operations. An OWS was found not working due to a damaged transmission belt and O-ring. The EO, Captain, and Ship Manager were informed. U.S. Coast Guard officers who were on board conducting the annual Port State Control Inspection were also advised. The failed OWS had been routinely tested the previous day with satisfactory results. The OWS was placed out of service for approximately five hours while repairs were completed. It was re-tested in the presence of a U.S. Coast Guard officer and a Classification Society inspector. Drive belts and O-rings were not part of the ECP critical spare parts list, but the ship did have spares on board. Both items were added to the critical spare parts list. During a review of the key log, no evidence was found for the unlock / lock operation of a number of valves. An investigation found a lack of monitoring and control by engineers. All affected valves were included in the ENV-1204-A1 Lock Log, and the ship planned to control the keys. June 21, 2018 CAM Incident Category Voyage Planning Training OWS/Whitebox Seals or Locks Recordkeeping During a review of fuel samples and bunker delivery notes (BDN), it was identified that 14 fuel samples were missing, in violation of MARPOL requirements. An investigation found that the cabinet used to hold the fuel samples was not controlled. The ship's Recordkeeping Flag Administration was notified. All fuel oil samples were secured and will be controlled. A log will be used to track all MARPOL fuel oil samples. The process of controlling the fuel oil samples was also being rolled out fleet-wide. During a review of waste landing sludge receipts, it was noticed that receipts from October 2015 to December 2015 and from November 2016 to December 2016 were not available, in violation of MARPOL requirements. An investigation found the receipts Recordkeeping were archived in the engine locker and could be accessed by multiple personnel. The vendor was contacted to obtain copies of lost receipts. In response, the ship planned to keep receipts under the Chief Engineer’s control. 310 kilograms of non-ODS R407c refrigerant gas leaked from a walk-in refrigerator system due to a cracked pipe connection. The Refrigerants connection was replaced and the system was put back in service. During drydock, a number of ECP critical seals were broken due to contractors working in various locations of the engine room. Most of the seals were recovered and replaced, but four seals could not be traced. The areas where the seals were missing were Seals or Locks thoroughly searched, but the seals were not found. Upon completion of the drydock, all broken and missing seals were replaced and the Critical Valves, Fittings, Tank Hatches List, Lock and Seal Log was updated. Page 33 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 129 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00190 10/24/17 Carnival Inspiration CAM-00191 10/24/17 HAL Oosterdam 117_2017-VO 10/25/17 HAL Volendam 120_2017-KP 10/25/17 PCL Crown Princess CAM-00195 10/25/17 PCL Sapphire Princess CAM-00192 10/26/17 Carnival Sensation CAM-00193 10/27/17 Carnival Valor 119_2017-CB 10/27/17 PCL Caribbean Princess CAM-00196 10/28/17 HAL Veendam Event Description During routine checks while anchored in Catalina, Catalina, the starboard stern tube header tank was found to have lost approximately 20 liters of non-biodegradable oil. No evidence of an internal leak could be found and it was initially assumed that this volume was lost overboard due to a blocked drain line. Two dive inspections were unable to confirm an external leak, but a manufacturer service found a valve set in the wrong position and cleared the blocked air drain lines. A corresponding ORB entry was made and the National Response Corporation and U.S. Coast Guard were been notified. The sewage treatment system was taken out of service. The Vice President of Environmental approved an Exception Request to discharge stored untreated sewage, as permitted by MARPOL regulations. The issue was caused by an electronic failure in the controller. It required multiple technical visits to determine the failure and the correct part to replace. The system was repaired and put back online. A newly-installed OWS system controller developed an internal water leak. There were no further spare units on board because a similar OMD-21 unit was fitted to the BCDB two weeks previously. The ship was unable to process bilge water until it received a new spare three days later. The manufacturer also repaired and calibrated another unit to provide an additional spare. The ship was scheduled to replace all similar OMD-21 units in drydock at the end of November 2017. While alongside in Quebec, Canada, a metal rat guard placed on a forward mooring line fell into the water due to the ship's tidal movement, in violation of MARPOL Annex V. The ship's crew were unable to recover the guard. The local agent and authorities were informed and an entry was made in the GRB. The bosun reminded his crew to make sure all rat guards were secured properly. All other rat guards were checked and re-secured. While underway and in the process of responding to a list caused by strong winds, the ship discharged approximately eight cubic meters of grey water inside four nautical miles of Taiwan. An investigation found that, prior to the discharge, the junior officers of the watch (JOOW) discussed a rock identified on the charts and reviewed the associated Electronic Chart Display and Information System notes. They concluded that the rock was a tidal object only exposed at low tide and proceeded within four nautical miles. Approximately 20 minutes later, the senior officer of the watch questioned the two JOOWs about the rock and it was subsequently determined to be a very small piece of land. All overboard discharges were immediately closed and the incident was reported to the EO. The discharge was not a MARPOL violation, but did violate Company Standard ENV-1001-F1. An investigation was initiated. 331 kilograms of ODS R22 refrigerant gas leaked from an air conditioning system due to leaks on an oil pump and a non-return valve in the liquid line. The system was repaired and put back in service. All units on the ship are scheduled to change to nonODS by the end of 2018. 260 kilograms of non-ODS R407c refrigerant gas leaked from a main galley refrigerator system due to corroded evaporator pipes. The pipes were repaired and the system was put back in service. While docking in Port Limon, Costa Rica, a plastic safety helmet fell into the water from the aft mooring station, in violation of MARPOL Annex V. The helmet sank immediately and was not recovered. The incident was reported to the Port Authority and an entry made in the GRB. June 21, 2018 CAM Incident Category OWS/Whitebox Voyage Planning Training Refrigerants Refrigerants Two EGCS systems were taken out of service pending temporary repair due to the bellows on the demister drain lines leaking badly and causing seawater to enter the boiler rooms. New bellows were ordered with expedited delivery. At the time of the report, one EGCS had been temporarily repaired and placed back into service. The other EGCS was being temporarily repaired by the EGCS manufacturer and was expected to be back in service on November 8, 2017. To prevent recurrence, the technical team was considering substitute parts within the EGCS with a different metal composition to prevent future galvanic corrosion issues. Page 34 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 130 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00197 10/30/17 Cunard Queen Mary 2 130_2017-NP 10/30/17 PCL Golden Princess CAM-00336 CAM-00202 10/30/17 11/1/17 Event Description June 21, 2018 CAM Incident Category Approximately one cubic meter of HFO sludge leaked from a section of pipe common to both starboard and port bunker stations. Sludge transfer ashore was terminated and the crew commenced clean-up and repair. The oil spill was contained within a provisions compressor save-all in a low fire risk machinery space. The cause of the incident was age-related deterioration of the piping. The pipe was repaired and the system put back in service. During tender operations while at anchor in Port Arthur, Australia, a member of the ship's security department accidentally dropped a radio into the water, in violation of MARPOL Annex V. The radio sank immediately and could not be recovered. The local agent was informed and an entry was made in the GRB. Cunard Queen Mary 2 In a letter dated January 4, 2018, the TPA notified the CAM and other Interested Parties of a Major Non-Conformity finding under ECP Section VIII.D on the Queen Mary 2 during an audit from October 27 through 30, 2017: “While conducting an operational test of the OWS, the aft Bilge Control Discharge Box (BCDB) or also known as the “Whitebox,” a part of the pollution prevention OWS/Whitebox equipment, was not functioning as intended. There are currently two BCDB installed on the Queen Mary 2; the forward whitebox and the aft whitebox. The operational test of the two OWS was discharged only through the forward BCDB as the aft whitebox was not in operation. The company should repair the aft whitebox system as soon as practical." AIDAmar Prior to bunkering operations in New York, New York, the Declaration of Inspection (DOI) was signed by onboard personnel but the bunker supplier did not handover a copy to be retained onboard. On November 5, 2017, during a subsequent routine check of documents by the EO, it was identified that the DOI was missing. The bunker supplier was contacted and a duplicate copy of the Recordkeeping DOI was provided. The Chief Engineer was reminded to keep a copy of this document after every future bunker operation. As a preventative action, all ships calling into the U.S. will be reminded of this requirement. CAM-00199 11/2/17 HAL Westerdam CAM-00205 11/2/17 Seabourn Odyssey CAM-00206 11/3/17 Carnival Dream An internal leak was discovered on a fuel tank of a tender boat. The leak was significant enough to saturate adjacent buoyancy foam which now needs to be replaced. A similar issue occurred previously on another tender boat on board, prompting the creation of a plan to replace all tender boat fuel tanks. The ship's Flag Administration has been informed, and the ship requested a shortLifeboat/Tender term reduction in lifesaving capacity. Work on the affected tender boat is expected to be completed on November 11, 2017. A tender fuel tank inspection job was created in the planned maintenance system to address potential issues on similar tenders across the fleet. A tender replacement program was also underway. While at anchor in Cap Cana, Dominican Republic, a heavy swell caused a ship's fender to fall from its securing point and into the sea, in violation of MARPOL Annex V. The 70 kilogram galvanized metal and rubber fender immediately sank and could not be immediately recovered. The local ship's agent was informed and an entry was made in the GRB, prior to the fender being subsequently recovered by divers. The fender had been secured for sea as per the ship's design. The pin securing the fender worked itself loose in the seaway and failed. The holding pins for the fenders do not contain securing devices to prevent them from working their way loose. The ship was expected to install cotter pins to prevent further incidents and other ships in the fleet were instructed to do the same. The ship did not inform the OLCM that the operational tests of the OWS and OCMs for September and October were completed, as required by the ECP. ENV-1201 requires every operational test of these items to be reported to the OLCM. After identifying the situation, scanned copies of the relevant records were provided. Page 35 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 131 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00207 11/3/17 Cunard Queen Mary 2 CAM-00208 11/4/17 P&O Britannia CAM-00200 11/5/17 PCL Sun Princess CAM-00209 11/5/17 Carnival Conquest CAM-00210 11/6/17 Cunard Queen Mary 2 CAM-00211 11/6/17 PCL Sea Princess Event Description June 21, 2018 CAM Incident Category While alongside in Hamburg, Germany, a Diesel Generator (DG) was started on MGO. The EGCS for this DG started automatically and EGCS wash-water was discharged for approximately nine minutes, in violation of Company requirements. Local authorities were not notified. The EO found that the option to automatically start the EGCS had not been de-selected in the EGCS EGCS control system. The Tier 3 pre-arrival and departure checklists were found to not include the removal of the EGCS auto-start. A Voyage Planning proposed amendment to ensure that the automatic start option is only selected for those ports/areas where EGCS operation is permitted was expected to be drafted. At the time of the report, the ship was confirming if both watch standers reviewed the procedure. While the ship was discharging overboard from a bilge settling tank, the EO attempted to download an archived data-set from the system data recorder as allowed by the manufacturer. The data recorder software froze and would not respond. The discharge was stopped while the data recorder was reset and restarted. The data recorder was subsequently found to be functioning correctly but with six minutes of data missing. A corresponding entry was made in the ORB. A corrupt memory stick is believed to have caused the anomaly. The data recorder will be monitored by the EO and, it any further issues become evident, the manufacturer will be contacted for assistance. In addition, the procedure was expected to be amended to ensure data downloads are not actioned during discharge operations. In accordance with ECP Section VIII.C.4, a Major Non-Conformity was noted onboard the Sun Princess during a TPA audit from November 5 through 9, 2017. In review of the GRB, it was noted in Attachment “A” that “Operational Waste” was being discharged while the vessel was moored in port. This operational waste entry as presented by the EO were deck cleaning chemicals. The deck cleaning chemicals, Deck Clean NP and Metal Brite HD, were being used on board to clean decks and were being discharged directly overboard through deck scuppers while in port and underway. The manufacturer, Wilhelmsen Chemicals, states in Attachment “B” the cleaning agents meet the criteria for being harmful to the environment. However, in reviewing the Material Safety Data Sheets in Attachment “C” it states the material is corrosive and must be disposed of as “Hazardous Waste,” and the product should not to be discharged into drains or the environment, and that disposal should be in accordance with local, state or national legislation. No documentation was provided from government authorities stating these deck chemicals are safe for discharge into the environment while in port or underway. The company should cease using the deck cleaning chemicals until proper documentation is provided stating these chemical are accepted for use by a government authority in the port of which the chemical are being discharge are safe for the environment. While alongside in Port Everglades, Florida, the ship experienced a drive belt failure of an OWS. At the time of the failure, the affected OWS was the only operational separator because a second OWS was in the process of being commissioned. The second OWS/Whitebox OWS was fully operational later the same day. At the time of the report, the failed OWS remained out of service pending manufacturer assistance confirmed for November 16, 2017. The failed belt was expected to be replaced during the service and was added to the list of critical spares. A fuel leak of approximately 40 liters occurred within the hot box of a Diesel Generator (DG). The DASPOS hydrocarbon detection system did not alarm. The DG was immediately stopped and a gas turbine was put online. The fuel leak was caused by a failed accumulator which was subsequently replaced. The DG was put back in service. While underway from Sembawang Shipyard, Singapore to the Marina Bay Cruise Centre, Singapore, the ship experienced a full loss of propulsion due to the activation of a distribution transformer protection trip. The propulsion motors (PEMs) were put back in service after one hour and 40 minutes following a thorough inspection of the involved transformer. For the duration of the incident, the ship had four thrusters available and in use with two tugs standing by, so it was able to maintain a safe position without dropping anchor. A manufacturer’s representative was onboard at the time of the incident and confirmed the cause of trip was the loss of port engine room distribution transformer with consequent loss of the propulsion auxiliaries and excitation supplies. At the time of the incident, the exciters of the port and starboard PEMs were fed from the port engine room switchboard. Page 36 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 132 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00214 11/8/17 Carnival Dream CAM-00215 11/8/17 Carnival Fascination CAM-00216 11/8/17 Carnival Magic CAM-00217 11/9/17 AIDAvita CAM-00218 11/9/17 Carnival Splendor CAM-00219 11/9/17 Carnival Sunshine CAM-00220 11/9/17 P&O Ventura CAM-00761 11/9/17 Carnival Imagination Event Description June 21, 2018 CAM Incident Category During a weekly review of the Critical Valve and Tank Hatch Lock Log, it was noted that seven entries relating to the bunker station sludge delivery line were missing between September 24 and November 4, 2017, in violation of Company requirements. It Recordkeeping was confirmed by the Chief Engineer that no sign of tampering was found. The engineers of the watch were reminded of the importance to record in the Critical Valve and Tank Hatch Lock Log any time a key is used. The ship also evaluated options to introduce a shorter period of review. While alongside in St. Croix, U.S. Virgin Islands, and pumping grey/black water to the local sewer, the shore-supplied hose failed, causing approximately 500 liters of mixed grey water and treated black water to spill onto the dock and into the sea, in violation of MARPOL Annex IV. The hose failure was caused by the detachment of a new hose connection which had been run over by a garbage truck just prior to the incident. The discharge was stopped, hoses were repositioned to minimize further vehicle risk, and the damaged hose was replaced. The spill was cleaned by ship personnel and the incident was reported to the port authorities and the U.S. Coast Guard. No further action was requested. During a weekly review of the Critical Valve and Tank Hatch Lock Log, it was noted that seven entries relating to the bunker station sludge delivery line were missing from 24 to 30 September 2017 in violation of Company requirements. An investigation found that the keys were not recorded because the person in charge forgot to update the Log. It was confirmed by the Chief Engineer that no sign of tampering was found. The EOOW's were reminded of the importance to record in the Critical Valve and Tank Hatch Lock Log any time a key is used. Options to introduce a shorter periodicity of review are being evaluated. During a routine check, it was found that four adhesive seals were missing. The seals could not be found in the surrounding area and it was concluded that all four missing seals were unintentionally removed during maintenance work. Two new seals of the same type were immediately installed and the corresponding log was updated. Two non-mandatory seals were not replaced. No signs of tampering and no anomalies on the tanks quantities were noted. During a routine check, the EO discovered two seals were missing from the food waste vacuum system. It is suspected that the seals were broken during maintenance/cleaning of the garbage room. New plastic seals of the same type were installed and the log was updated. The importance of ECP seals was emphasized to crew members. During a routine check, it was noted that the seal on the overboard food line in the garbage room was missing. It is suspected that the seal was accidentally broken and mixed with the garbage. A Classification Society surveyor who was on board to check seal effectiveness reported that the seal was broken involuntarily. No violations of the flange were noted and, as a preventative action, the flange was welded with bars. A failure on the COWS BCDB monitor required discharges to be suspended until a faulty control signal isolator was replaced. No discharges over 15 ppm occurred. The COWS was placed in a re-circulation mode and a replacement isolator is being transferred from another ship in the fleet. On November 9, 2017, the ship offloaded hazardous waste to a third-party contractor. Both the number of containers and the quantity of waste were recorded incorrectly by both ship and vendor personnel. Upon discovering the error, both the manifests held by the ship and the contractor were corrected. However, a manifest was sent to the California Department of Toxic Substances Control (DTSC) before the error was corrected. The corrected manifest with an updated quantity for “oily/bilge sediments” drums (four instead of one) was sent to DTSC for their records. The final signed manifest was received in time confirming the correct quantity disposed. The root cause was human error as the crewmember failed to cross-check the actual quantities of drums of oily/bilge rust sediments offloaded against the quantities listed on the manifest. Unfortunately, the vendor did not detect this either. Page 37 of 94 Recordkeeping Seals or Locks Seals or Locks Seals or Locks OWS/Whitebox OCM Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 133 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00221 Date of Event 11/10/17 Brand/Vessel Carnival Sensation CAM-00222 11/10/17 Costa Atlantica CAM-00223 11/10/17 PCL Golden Princess CAM-00224 11/10/17 P&O Azura CAM-00225 11/11/17 HAL Veendam CAM-00261 11/11/17 Costa Atlantica CAM-00226 11/12/17 HAL Amsterdam Event Description June 21, 2018 CAM Incident Category During a routine check, the Ballast Water Record Book archive between December 2015 and July 2016 and the GRB archive from January 2013 to March 2013 were noted as missing, in violation of Company requirements. The OLCM, Ship Manager, and Environmental Manager were informed of the missing archives. The check was part of a fleet-wide review of archived Recordkeeping environmental-related record books to ensure all records were being maintained as required. Missing old books would be logged and noted. A new fleet-wide procedure was being implemented that would require secure storage of all archived record books, a single person to be accountable for control of the key to storage, and a signing procedure if older books must be reviewed. During overboard discharge operations while underway, it was noted that the OCM of the BCDB was showing an error alarm indicating the oil content reading was incorrect. After cleaning and flushing the cell, the OCM was still indicating an incorrect oil content reading. The cell was replaced with a spare and calibrated. An entry in the ORB was created. The failed cell was sent back to the supplier and a new unit was expected to be received onboard. While alongside in Lautoka, Fiji, a white discoloration was observed in the water near the forward gangway. A few drops of oilbased paint and a few paint flakes had been spilled into the water in violation of MARPOL Annex I as deck ratings painted the starboard side anchor. The job was immediately stopped and the Port Authority was notified by the local agent. No further action was requested. The paint was not cleaned up as it quickly dissipated with the wind. The crew were counselled by the Captain and retrained in the use of drop cloths and other preventative measures to prevent recurrence. The COWS failed. The ship was still able to process bilge water via the static OWS. The ship had multiple sets of all spares and the failed OWS was repaired and returned to service the following day. The cause of the failure was a build up of dirt in the purifier bowl which prevented the bowl from closing correctly and subsequently activating an alarm. While alongside in Naples, Italy, during the recovery of a fuel transfer hose from the ship by the chemical shore side vendor, approximately 10 milliliters of oil dripped into the water, in violation of MARPOL Annex I. The oil formed a small sheen, but dissipated very quickly with the current and was unrecoverable. Prior to recovery, the hose had been vacuumed and emptied; however, no end cap was provided by the vendor. Local port authorities were advised by the ship's agent and an accidental discharge entry was made in the ship's Log Book and ORB. The EO planned to work with the Chief Engineer to ensure the fueling team did not accept hoses without end caps to prevent a spill from residual fuel in the hose either before or after the scheduled transfer. During a review of the ORB, it was noted that an EO did not sign an entry, although the completed page was countersigned by the Chief Engineer, the EO, and the Captain. Preventative training was immediately planned. While alongside in Benoa, Indonesia, a shell door was opened to check the operation of the tender chemical platform. A small amount (less than five milliliters) of biodegradable hydraulic oil dripped into the water, in violation of MARPOL Annex I. A very small sheen was observed but dissipated quickly and was unrecoverable. It was assessed that during maintenance on the hydraulic hoses some oil spilled into the gutter of the recess and, due to the restrictive location and design of the arrangements, the oil was not seen and thus not cleaned up at the time. The other shell doors were not checked as the cylinder exchange was only performed on the affected door. The ship planned to cover recesses and surrounding areas to ensure that if any oil spilled during future maintenance actions, it would be captured and easily cleaned up, preventing any spills into the water. Page 38 of 94 OCM OWS/Whitebox Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 134 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00227 11/12/17 PCL Ruby Princess CAM-00228 11/13/17 AIDAdiva CAM-00229 11/13/17 Carnival Freedom CAM-00232 CAM-00233 11/13/17 11/13/17 Event Description June 21, 2018 CAM Incident Category After cleaning the starboard aft sea chest filter, the lockout / tagout procedures were not properly followed to bring the system back online and one drain valve was accidently left open. A total of 110 tons of water accumulated in the bilge over a 12 hour period through the poor execution of watch standing procedures, as well as not properly investigating a high level bilge alarm. The bilge water was transferred to a double bottom bilge water tank and processed through the ship's OWS prior to being discharged overboard. An entry was made in the ORB detailing the origin of the bilge water. The flood water affected the ship's stability due to the free-surface effect although the ship continued to surpass all intact stability requirements, including the weather criterion. The engineer officer in charge of overseeing the cleaning was responsible for ensuring the valves were in the correct position. The water ingress was caused by only one open valve. Cleaning of the sea chest filter is a weekly task performed by the technical team. The ship planned to develop a checklist to cover the procedure. During a routine check, two ECS adhesive seals were discovered to be detached from the sensor connections of the EGCS washwater overboard pipeline. The seals were found on the floor below their respective vulnerable points. The vulnerable points remained covered by other seals. An initial investigation presumed that the seals detached due to the high temperature or humidity Seals or Locks present on site. At the time of the report, the ship was still assessing how to replace adhesive seals with plastic ones on this particularly challenging vulnerable point where no welding is possible. A shore side working group tasked with aligning and simplifying the Vulnerability Assessment and ECS planned to consider this issue and assess whether this is a point that needs to be controlled at all. 252 kilograms of non-ODS R407A refrigerant gas leaked from the thread of the shut-off valve on the liquid line of a provision system. The leak was due to corrosion and vibration. The valve was replaced and the system was put back in service. Refrigerants P&O Azura While the ship was in Guadeloupe, France, a discharge pump for the crew pool was placed in manual mode to remove between five and ten liters of rainwater which had accumulated and had not drained. The crew member involved did not inform the ECR or the Bridge of their intention to use the pump. All relevant parties were notified. The pump in question was a permanently installed automatic pump controlled by the Bridge which was taken into manual control locally in order to remove the rainwater from the pool in preparation for cleaning/painting. It was identified that there was no ship-specific written control procedure for the local Voyage Planning operation of the pump and it was not padlocked. The ship planned to implement a new control procedure with the pump padlocked in the automatic position, not compromising emergency Bridge control. The ship planned to incorporated the switch into the onboard environmental vulnerability list and controlled via padlock. This padlock would require authorization to operate manually. Training was planned pump operation control procedures and new padlock arrangements. PCL Royal Princess While en route to Princess Cays, Bahamas, the ship passed within 12 nautical miles of Turks and Caicos. As a result of the engine room watch stander not reviewing the Environmental Schedule, as well as a miscommunication between the Bridge and engine room watch standers, 8.2 cubic meters of grey water and treated sewage were discharged over a 12-minute period. The mistake was recognized by the oncoming engineering watch stander. The resulting discharge was in violation of local regulation and Company policy. The voyage plan had been reviewed and briefed and an Environmental Schedule prepared by the EO in Voyage Planning conjunction with the First Officer. The Environmental Schedule indicated that all overboard discharges were to be closed from Training 12:30LT on the day of the incident. The ship was ahead of schedule but the Bridge adapted to this and gave the ECR proper notification. The engineering officer misunderstood the directions from the Bridge and opened the overboard discharges inappropriately. The engineering officer in question completed the Environmental Assessment at Almere and completed the required onboard environmental training before the incident. He had not sailed in the area before and did not understand the restrictions around the Turks and Caicos Islands. Page 39 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 135 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00234 11/14/17 Carnival Breeze CAM-00235 11/14/17 Costa Luminosa CAM-00236 11/14/17 HAL Rotterdam CAM-00245 11/14/17 Carnival Liberty CAM-00237 11/15/17 HAL Maasdam CAM-00239 11/17/17 Carnival Freedom CAM-00240 11/18/17 Carnival Paradise CAM-00248 11/18/17 P&O Oceana Event Description June 21, 2018 CAM Incident Category While alongside, a fuel oil feeder pump seized and caused a gasket to fail producing a fuel spray. Crew in the area activated the high pressure water mist system locally, closed the fire screen door, and alerted the ECR. DASPOS detectors alarmed. Approximately 80 liters of fuel was expelled before the pump was shut down. A standby pump was manually started, which avoided a Diesel Generator (DG) shut down and subsequent blackout. The failed pump was installed in July 2017. It was opened and found destroyed. Pumps of the same type were inspected for similar issues. The manufacturer assisted with an investigation. While alongside in Piraeus, Greece, a plastic sliding entrance door fell from a lifeboat into the seam in violation of MARPOL Annex V after the sliding guide stopper broke. The door could not be recovered and the Port Authority was notified. The door was Lifeboat/Tender replaced prior to departure and the lifeboat was available for use. A new OWS was installed while the ship was in drydock. Due to the timing in ordering spares, they were not initially available when the installation was completed. Critical spares are being expedited to the ship. A spare OCM was delivered on November 19, OWS/Whitebox 2017 and the ship now has two spares. This spares issue was rectified and all future new installations will have the needed spares OCM immediately. There was no impact to the ship processing bilge water. During a routine inspection, the Environmental Technician (ET) noted cooking oil in the main galley pulper. The following day, the pulper system tank was inspected by the ET and EO and cooking oil residues were found. An investigation concluded that approximately a quarter of a gallon of water contaminated with cooking oil had been collected following cleaning of the galley grills and poured into the pulper by a new crew member. The oil-contaminated food waste had subsequently been discharged, in violation of MARPOL Annex I and MARPOL Annex V. The ship's Flag Administration was notified. The crew member had received training covering proper handling, segregation and disposal of all galley-related waste streams. In addition, the galley supervisor had reviewed these requirements with him. All relevant crew members were given refresher training as a result. Training While the ship was at anchor in Penneshaw, Australia, a number of passengers had their headwear blown into the sea due to the strong winds. In addition, a crew member's plastic helmet without a fitted chinstrap was also blown into the water and not recovered, in violation of MARPOL Annex V. An entry was made in the GRB and the local agent was informed. During an inspection of record books, the Ballast Water Record Books could not be located. Company policy requires records to be maintained on board the ship for a minimum period of two years after the last entry has been made. The inspection was part of a Recordkeeping fleet-wide review. All relevant historical records are now required to be stored in a secure location with accountable control and access. While alongside in Cozumel, Mexico, approximately 500 liters of grey water were unintentionally discharged from a multi-use grey/ballast tank air vent. An investigation found that both the sounding method and the sensor reading were inaccurate. The sensor was last calibrated in 2012 and the sounding pipe was last used two days earlier. The overboard discharge was in violation Voyage Planning of local regulations and Company policy. Reports were made to the local authorities. The manual sounding pipe was found blocked and it was suspected that the level sensors were out of calibration. The tank was placed out of service until further calibration checks could be done. The sounding pipe was unblocked. At the time of the report, further investigation was in progress to determine if any other procedural issues existed and appropriate crew follow-up. While underway, with three Diesel Generators (DG) online, a significant cooling water leak was detected on a heat exchanger in the port cooling system. The heat exchanger was isolated and the affected DG was temporarily cooled via an evaporator in order to maintain required speed. The affected DG was subsequently taken offline and the full port cooling system was isolated. Two plate gaskets in the heat exchanger were found damaged and were replaced, restoring full propulsion. The ship's itinerary was not impacted. Page 40 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 136 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00249 11/18/17 PCL Emerald Princess CAM-00241 11/19/17 Carnival Victory CAM-00250 11/19/17 P&O Ventura CAM-00300 11/19/17 Carnival Valor CAM-00252 11/21/17 HAL Zuiderdam CAM-00262 11/21/17 PCL Star Princess CAM-00263 11/22/17 Cunard Queen Victoria Event Description June 21, 2018 CAM Incident Category While at anchor off Catalina Island, California, a crewmember accidentally lost a handheld very high frequency (VHF) radio overboard, in violation of MARPOL Annex V, while stationed on the tender platform. The radio slipped out of the crewmembers hand while he was taking it off his belt. An entry was made in the GRB and the local agent was advised. The radio was not fitted with a retaining strap. To prevent recurrence, the Marine Department would be looking into alternative means to secure the radio while facilitating safe operations, instead of just having the radio clipped to the belt and possibly losing the radio when taking it off to use it. Possible alternatives include using a microphone on a lanyard along with a securing holster for the radio on the belt. 468 kilograms of non-ODS R407C refrigerant gas leaked from an air conditioning system. The leak was the result of a broken solenoid valve. The solenoid valve was replaced and the system was put back in service. During a lifeboat launching exercise while in Cartagena, Spain, oil was observed coming from the engine of the starboard rescue boat. An oil sheen was observed on the surface of the water, in violation of MARPOL Annex I. The quantity of spilled oil was estimated to be less than 0.5 liters and the rescue boat was recovered to prevent further discharge. The ship's emergency oil spill response was activated and an oil boom was deployed to retain the sheen prior to a full clean-up. The ship's agent was made aware and instructed to advise the appropriate local authorities. Poor combustion when starting the engine, together with some residual oil in the bilge well, was believed to have contributed to the incident. The second rescue boat was inspected but not found to have similar issues. To prevent recurrence, the ship planned to ensure that the bilge is dry before launching the rescue boats and continue regularly inspecting the engines. The ship planned to have oil booms available for immediate deployment during the next testing of the starboard rescue boat. While checking the critical valves and seals, it was noted that an ECS seal was missing from a flange. After an investigation and questioning all concerned engine team members, the seal was not found. It was concluded that no unauthorized transfer was conducted as a second seal still remained intact on the flange. A new seal of the same type was installed and the Seal Log was updated. During a routine abandon ship drill while alongside in Cartagena, Columbia, part of the training life raft container shell fell into the water, in violation of MARPOL Annex V. The shell had been secured as required but the metal fastener holding the line to the shell parted/failed during inflation, allowing the shell to fall into the water. The crew attempted to recover the shell but were unable to reach it before it sank. The local agent was informed and an entry was made in the GRB. While approaching Nawiliwili, Hawaii, a drain blockage resulted in the accidental spill of recreational water from a hot tub onto the deck and into the scuppers. Approximately one cubic meter of water with a bromine content of 5.4 ppm was discharged overboard inside three nautical miles of land, in violation of EPA and VGP requirements. The hot tub was taken out of service and the remaining water content was discharged when the ship was outside 12 nautical miles from land. The blockage was found to have been caused by paint flakes from the tub lining breaking free and flowing into the drain and accumulating. The incident was reported to the EPA and the Hawaii Department of Health. A corrective action report was sent to the authorities and the ship planned to include the event in its annual VGP report. Following completion of waste offload operations, palleted waste containers were being loaded onto a truck. A 200 liter drum containing galley grease trap waste fell off a pallet and onto the pier where it split open. Approximately five liters of grease spilled onto the pier with some waste entering the water. Booms were deployed onto the pier by the vendor to prevent any further liquid from running into the water. Absorbent material was used to soak up the waste liquid from the water. The drum had been secured to the pallet as per standard procedure with cling film and there were no issues with the pallet or previous pallets being offloaded, as all the precautionary measures had been exercised. The ship's agent was on the pier at the time and the vendors took full responsibility for causing the incident. The incident was a violation of MARPOL Annex V and the port agent was instructed to inform the relevant authorities. Page 41 of 94 Refrigerants Lifeboat/Tender Seals or Locks Lifeboat/Tender Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 137 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00253 11/23/17 HAL Volendam CAM-00254 11/24/17 Carnival Dream CAM-00255 11/24/17 Carnival Magic CAM-00256 CAM-00264 CAM-00265 CAM-00258 11/24/17 11/25/17 11/25/17 11/26/17 Event Description While en route to Singapore, the ship lost 12 pieces of plywood deck covering which had been stored on the bow area in preparation for container loading the next morning during the upcoming drydock. During the evening, the ship experienced a passing squall with a wind speed of 40 knots, causing the 24-square foot plywood panels to be blown overboard, in violation of MARPOL Annex V. At the time of the incident the ship was approximately 39 nautical miles from the Malaysian coast. An entry was made in the GRB and the ship's Flag Administration was notified. Due to human error, the panels were laid down too soon without being properly secured. The Marine Department planned to work with the Technical department to ensure proper coordination occurs while preparing for a drydock and that materials like this are either secured on deck to prevent going overboard or are not laid out until needed. 285 kilograms of non-ODS R134A refrigerant gas leaked from an air conditioning compressor due to a failed O-ring. The O-ring was replaced and the system was put back in service. 359 kilograms of non-ODS R407c refrigerant gas leaked from a provision system due to loose pipe fittings. The system was repaired and put back in service. Carnival Spirit While underway, a single-walled fuel inlet hose failed and leaked between 200 and 300 liters of fuel into the bilges. The engineer of the watch acted immediately by activating the high pressure water mist system, closing the quick closing valves, and requesting the Bridge to reduce speed. The hose was replaced with a spare. The failure appeared to be in the material of the conventional hose. The ship planned to install double-walled hoses in early 2018 and to re-pipe sections of the fuel system to have straight length hoses to avoid any further similar failures on these engines. It was recorded as a partial loss of propulsion. HAL Oosterdam While alongside in Corinto, Nicaragua, an environmental near-miss occurred when between 300 and 500 liters of MGO spilled in the aft purifier room. At the time of the incident, ship's power was being supplied by a single Diesel Generator (DG) located in the aft engine room. The forward engine room had no DGs running as the fixed high pressure water mist system was isolated due to ongoing hot work in the area. Later in the day, low pressure alarms were activated in the aft fuel system. Simultaneously, the high pressure water mist and the hydrocarbon detector system activated in the aft purifier room indicating that a fuel leak had occurred. A DG in the forward engine room was put online so that the running DG could be shut down and relieve the pressure on the aft fuel system. The fixed high pressure water mist system automatically started at the start of the incident and then stopped. It was later activated again to lower the temperature of the room. It was determined that the outlet valve on a fuel filter located in the aft separator room was left open during routine maintenance, due to incorrect/improper lockout / tagout of the equipment. At the time of the report, investigations were ongoing and actions were being taken to prevent recurrence. It was recorded as a fuel leak. P&O Azura Carnival Victory A fuel leak was detected on a Diesel Generator (DG) via the clean and dirty fuel leakage alarms. A crew member identified the source of the leak as a small drip on a fuel pump high pressure pipe. The fixed suppression system was not activated due to the small drips presenting a minimum of risk. The DG was shut down and the fuel supply was isolated. Approximately 0.5 liters of fuel leaked into the hotbox. The affected fuel pipe was repaired. While discharging grey water after departing from Nassau, Bahamas, the engineer of the watch noticed that the quantity of treated sewage in another tank was also falling. Approximately 15 to 20 cubic meters of treated sewage was discharged inside the Bahamas Archipelagic Baselines, in violation of MARPOL Annex IV and Company requirements. The Port Authority of Nassau and the ship's Flag Administration were notified. An investigation identified a failed valve in the double bottom which the automation system indicated was closed but was actually partially open. When the ship started pumping grey water, the partially open black water valve allowed both grey and black water to be discharged. The ship planned to develop a comprehensive corrective plan. The location of the valve does not allow easy or effective manual verification for each operation. Page 42 of 94 June 21, 2018 CAM Incident Category Voyage Planning Refrigerants Refrigerants Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 138 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00259 11/26/17 HAL Oosterdam CAM-00267 11/27/17 Carnival Freedom CAM-00268 11/27/17 Carnival Paradise CAM-00269 11/27/17 Carnival Sensation CAM-00270 11/27/17 Carnival Vista CAM-00273 11/27/17 HAL Prinsendam CAM-00274 11/27/17 PCL Grand Princess Event Description June 21, 2018 CAM Incident Category While alongside in Puerto Quetzal, Guatemala, an oily sheen was observed in the water underneath the gangway. An investigation identified that a small amount (less than 20 milligrams) of biodegradable hydraulic oil had dripped into the water, in violation of MARPOL Annex I, from the scupper located on the starboard side tender platform. The spill of oil was due to an internal leak Lifeboat/Tender which was stopped and isolated. The oil was unrecoverable and dissipated. The local port facilities authorities were notified by the ship’s agent. The other tender platforms were checked and no leaks were noted. All fittings on the affected platform were replaced and tightened to prevent recurrence. The GRB in use on the Bridge was found to be missing the Captain's signature on a single page. The shore side environmental department was notified. The cause of the incident was an oversight by crew. To prevent recurrence, the ship planned to check Recordkeeping signatures on a voyage basis. While alongside in Mahogany Bay, Isla Roatan, a utility barge was rented to facilitate painting of the ship's hull. During the painting operation some drops of paint spilled into the water. Tarpaulins were not being used and the wind conditions made it difficult to keep the barge in position. A Mahogany Bay Cruise Centre Supervisor identified the spill and informed the ship. The incident was in violation of MARPOL Annex I. A meeting was conducted with deck personnel to prevent recurrence. The ship had not followed established fleet protocols for painting operations. It was stressed to report any future paint spills. Port Authorities were notified and an entry was made in the ORB. A shore side investigation was initiated. While underway, the officer of the watch ("OOW") informed the ECR to close the black water overboard valves but failed to request the grey water overboard valves also be closed as per local restrictions. This was despite the local environmental restrictions being reviewed and discussed during the voyage overview meeting. The environmental schedule was available in the voyage plan portfolio, however the OOW did not consult the environmental schedule and the engineer of the watch failed to crosscheck the instruction with the environmental schedule. The ship discharged 8.8 cubic meters of grey water within 12 nautical miles Voyage Planning of Turks and Caicos, in violation of local and Company requirements. An investigation was undertaken. The incident root causes were reviewed and the corrective actions to be taken with immediate effect were discussed. A conference call was scheduled with all EOs to discuss lessons learned. Additionally, a new environmental schedule format detailing relevant information was sent fleetwide and shore side environmental managers planned to increase engagement with assigned ship's environmental schedule on a voyage basis. The ship used MARPOL-approved chemicals to wash the open decks and balconies within 12 nautical miles of the Bahamas, in violation of Company requirements. At the time of the event, the ship was sailing through the old Bahamas channel, outside four Voyage Planning nautical miles from nearest land, but inside 12 nautical miles. The incident occurred due to a misinterpretation of territorial waters. Approximately five liters of chemicals entered the water. Entries were made in the GRB. The ship had a suspected external non-biodegradable oil leak from a stern thruster, in violation of MARPOL Annex I. An internal leak started several months ago and, until the end of October 2017, the quantities of oil used to top up the thruster system matched the amounts removed from the bilge. The amount was estimated using general purpose cups to scoop the oil out of the bilge. Between November 2 and November 27, 2017, the system was refilled with 30 liters of oil while the volume removed from the bilge was approximately six liters. The external leak was estimated to be one liter a day. The leak was not initially considered reportable and was overlooked. Reporting requirements were reinforced. The stern thruster could not be inspected while in the Amazon due to the river visibility/turbidity. An underwater inspection was scheduled to be performed when diving conditions allowed on December 15, 2017. Local authorities were informed by the EO. The ship planned to not use the stern thruster unless required in an emergency and tugs would be obtained as needed. The ship could not monitor the exhaust smoke density on one Diesel Generator (DG). The cause was a part failure, as well as a subsequent missing spare part. The part was ordered and was scheduled to be delivered onboard on December 8, 2017. The monitor was properly maintained and the filters regularly replaced. Page 43 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 139 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00275 11/29/17 Carnival Fantasy CAM-00276 11/29/17 Carnival Splendor CAM-00277 11/29/17 Cunard Queen Victoria CAM-00284 11/30/17 PCL Caribbean Princess CAM-00279 12/1/17 Carnival Freedom CAM-00280 12/2/17 Carnival Pride Event Description June 21, 2018 CAM Incident Category During a lifeboat drill while in Costa Maya, Mexico, an oily sheen was noticed on the surface of the water. The oil was found to be coming from a lifeboat. The ship's crew initiated a response by lowering the rescue boat and cleaning up the sheen. The incident was a violation of MARPOL Annex I, an entry was made in the ORB, and the ship's agent confirmed that the port authorities were Lifeboat/Tender notified. At the time of the report, the incident was still under investigation and a full investigation report was anticipated by the end of the week. During a review of the Vulnerability Assessment, an environmental near-miss was identified when a pipe that was part of the clean bilge system was found without orange markings on the welds. There is no ECP requirement for this line to be painted orange but painting of the welds is good practice to assist in correct identification. The Chief Engineer and Staff Chief Engineer were not aware that the pipe had been replaced. At the time of the report, investigations were in progress to identify where the breakdown in records took place. The ship planned to interview all previous engineering staff to check if they are aware of anything related to the pipe replacement. Initial perceptions indicated that the previous Engineer Officer did not verify that the welds were in place during weekly checks. The ship planned to discuss lessons learned. While the ship was alongside in Fort-de-France, Martinique, the ECR received an instruction to fill a ballast tank with 150 cubic meters of sea water. The engineer of the watch (EOOW) ballasted the tank with approximately 300 cubic meters of water and then Voyage Planning began de-ballasting to correct the error. The officer of the watch observed the de-ballasting operation and instructed the EOOW to Training stop because de-ballasting was prohibited by the port authority. Approximately 40 cubic meters of water was discharged in the port, in violation of local requirements only. At the time of the report, an investigation was in progress. While alongside in Fort Lauderdale, Florida, 77 cubic meters of ballast water were inadvertently discharged overboard in violation of the U.S. Coast Guard (USCG) regulations on ballast water management because it had been treated with a UV intensity below the 70% minimum threshold. The incident was reported to the USCG and the EPA. The manufacturer assisted with the installation of audible alarms to ensure operators are aware if certain parameters are out of compliance. The respective crew members were retrained on the use of the ballast water treatment system. While checking the critical valves, it was noted that two ECS seals were missing. After an investigation and questioning all concerned engine team members, the seals were not found and it was concluded that they could have been unintentionally Seals or Locks damaged by a team member on duty while working and cleaning the bilge spaces. A new seal of the same type was installed. A more robust seal was ordered. During an inspection of environmental records the following entries were found missing: in the ORB, 17 MGO bunkering operations not made since July 9, 2017; several pages not signed by the Chief Engineer (CE); monthly operational test footnote not signed by CE or EO (EO); and no entry made for using a portable pump during a sludge transfer. In the GRB, several entries not made; signatures missing; several ECS seals missing and not reported. It is believed that personnel were not aware of the Flag Administration requirement to record bunkering of MGO. Involved personnel were not fully aware of the requirement to record the monthly operational test. The missing sludge transfer entry was due to an oversight of the recording requirements. Seals or Locks Requirements were not followed or enforced and entries were not properly reviewed. The CE was not informed that seals were Oil Record Book missing and engine personnel were not aware of corporate reporting requirements. Compliance Management System (CMS) Recordkeeping notices were sent earlier to check relevant records; closed by the ship confirming compliance; however, it is evident that the checks were not performed diligently and the EO failed to exercise meticulous checks. As a part of the investigation, the CE, Captain and EO were interviewed as to what checks were done before the compliance notices were closed. A formal investigation by shore side environmental operations was initiated to identify the root cause. To prevent recurrence, the actions taken include increasing Environmental Manager ship visits, travelling EO ship visits, sharing lessons learned during monthly EO conference calls and reviewing current ORB and GRB training materials to evaluate their effectiveness. Page 44 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 140 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00281 12/2/17 Carnival Sensation CAM-00426 12/2/17 Carnival Splendor CAM-00285 12/3/17 Carnival Paradise CAM-00286 12/3/17 Carnival Pride CAM-00287 12/3/17 Seabourn Odyssey CAM-00551 12/3/17 PCL Sea Princess Event Description The overboard bilge discharge status monitor in the ECR is not functioning, in violation of Company requirements. The Chief Engineer and EO could review the data through their computers; however, the ship was holding all bilge water on board and did not conduct any overboard discharge until the system is repaired. A technician attended the ship on December 4, 2017 and the system was put back in service. 326 kilograms of non-ODS R407c refrigerant gas leaked from a provision system from a number of locations. All leaks were repaired and the system was put back in service. While reviewing the Seal Log, a number of discrepancies were noted. Further investigation identified a total of five seals were missing from fittings and a number of fittings controlled by seals that were not recorded in the Log. It is believed that the issue was caused by a lack of awareness by crew members together with a lack of oversight. All missing seals were replaced with seals of the same type and training with all concerned technical team was conducted. Environmental manager ship visits were used to reinforce the importance of ECS compliance. All involved EOs were expected to be counseled. During a routine check, a seal was noted missing on the emergency bilge suction. The suspected cause is that it was accidentally broken during painting operations by engine personnel not aware of Company requirements. The missing seal was replaced with a seal of the same type and the incident report included in the log to account for the missing seal. The incident appeared to be a breakdown in effective communication. The ship planned to retrain all crew will by the Chief Engineer (CE) and Staff CE regarding the correct actions following discovery of a broken seal. While the ship was underway, an intoxicated crew member threw four lifejackets and a lifebuoy over the side of the ship, before making an attempt to jump overboard. The crewmember was brought to the onboard medical center where he was held under medical and security supervision until the ship's arrival in Miami on December 5th. A report regarding the discarded lifebuoy and life jackets was made to the U.S. Coast Guard in Miami and the Bahamian Coast Guard, as well as to the ship's Flag Administration. The items discarded overboard and not recovered constitute a MARPOL Annex V violation and a corresponding entry was made in the GRB. [02/16/2018 letter from ABS to company] In accordance with the Environmental Compliance Plan (ECP), Section VIII.C.4, Major Non-Conformities were noted onboard the Sea Princess during an audit from December 3-8, 2018. These findings are listed as follows: 1. As the auditor walked around the vessel during the first day of the audit, on deck 7 starboard side (lifeboat deck) the crew was performing a fresh water wash down of the deck. The auditor noticed a sheen on top of the pooling water on deck. Auditor questioned the crewmember about the sheen and the reply was that the sheen was most likely from grease or oil from the life boats but continued to wash the deck allowing the water to flow into the deck drains and into the water while in port. The staff captain was notified of the incident. 2. During the audit, in the garbage handling room on deck 4, the auditor found 4 paper cups of used motor oil in a plastic trash can for paper and plastic waste. The paper cups filled with oil was from the result of weekly oil samples being taken from the engines on main generators. The Third Engineer improperly disposed of the oil after taking the samples. 3. It was also noted in the garbage handling room that the food waste containers had other items such as plastic straws, corn on the cob plastic holders, wooden stir stick, and other miscellaneous items mixed in the food waste ready to be discharged down the chute and then overboard while at sea. Page 45 of 94 June 21, 2018 CAM Incident Category Refrigerants Seals or Locks Recordkeeping Training Seals or Locks Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 141 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00288 Date of Event 12/4/17 Brand/Vessel Costa Atlantica CAM-00292 12/6/17 Cunard Queen Mary 2 CAM-00293 12/6/17 Cunard Queen Mary 2 CAM-00295 12/7/17 P&O Azura CAM-00296 12/8/17 Carnival Pride CAM-00301 12/8/17 Carnival Fantasy CAM-00297 12/9/17 HAL Eurodam CAM-00298 12/9/17 HAL Oosterdam CAM-00299 12/9/17 HAL Veendam Event Description June 21, 2018 CAM Incident Category While alongside in Fukuoka, Japan, the reference number on an ECS seal fitted to a vulnerable point valve was found to not match the corresponding entry in the Seal Log. There was no record in the Seal Log indicating why the original seal was replaced or who replaced it. The original seal was also not found during the check of the used seals kept in the Chief Engineer's office. It is Seals or Locks assumed the original seal was broken and replaced without being reported correctly. The area around the affected valve was Recordkeeping inspected. No oily residues were visible, there were no signs of tampering, and no anomalies on the related tank quantities were noted. The last inventory was completed in September and,, at the time of the report, an investigation was ongoing. While outside the North American ECA and burning HFO with the EGCS systems off, a loss of power to the aft switchboard caused a partial blackout, shutting down the EGCS compliance computer. The computer was restarted when the loss of power to the computer was highlighted by the EGCS Engineer. The incident resulted in no compliance data being recorded for over three hours and constituted an environmental near-miss. To prevent recurrence, a dedicated uninterruptible power supply for the EGCS compliance computer was ordered and tracked in the business risk register. Fuel was found leaking within three rocker boxes of a Diesel Generator (DG), resulting in the contamination of lubricating oil. An investigation found three leaking injector seals which were subsequently changed. The manufacturer pressure tested the system and renewed the lubricating oil. The affected DG was returned to service with no further issues. While underway, the sludge pump on an OWS failed. Processing of bilge water was not impacted due to the availability of an alternate OWS. The failed pump internals were found to be in a dirty condition, causing intermittent operation of the pump. The pump was disassembled, cleaned, and put back in service with no subsequent issues and was fully operational. Following a major repair in February 2017, a Diesel Generator (DG) oil sump was leaking into the bilge due to the sump tray not being completely sealed with the engine frame. The temporary repairs carried out by the manufacturer and shipboard team were ineffective. The manufacturer was scheduled to visit the ship before the end of the month to clean and fully repair the mating surfaces of the affected seam. The DG was held in standby but was fully operational for emergency use. Following completion of an overboard treated bilge discharge operation, the engineer of the watch failed to notice that the overboard discharge valve was not closed by the Third Engineer. The error was identified during the change of watch. A review of the BCDB data recorder confirmed that the BCDB valve remained closed. The ship was confirmed as being outside 12 nautical miles during the entire time the overboard discharge valve was open. The EO was notified and the environmental near-miss was reported to the Captain and shore side management. The Chief Engineer reiterated the importance of ensuring that the overboard discharge valve is closed after completion of all overboard discharge operations. A new overboard valve alarm was scheduled for January 2018. While the ship was departing Key West, Florida, a crewmember lost a plastic safety helmet into the water from the starboard forward mooring deck platform. The helmet, which was not fitted with a chin strap, was not recovered. The incident, which was a violation of MARPOL Annex V, was reported to the Port Agent and an entry was made in the GRB. While the ship was at anchor in Lahaina, Hawaii, a passenger accidentally lost his walking stick overboard. The stick fell between the tender and the tender platform when the passenger was disembarking from the tender to the ship. The violation of MARPOL Annex V was recorded in the GRB and the local agent was advised. While underway, a leak in a ballast line caused approximately 0.4 cubic meters of grey water to enter the bilge. In a separate incident, approximately 0.2 cubic meters of processed food waste spilled onto the deck plates in the incinerator room due to a food water tank pipe rupture. Both spills were contained and cleaned up and the leaks in the pipes were repaired. The grey water and food waste were stored in steel drums for subsequent offload ashore. Corresponding entries were made in the GRB. Page 46 of 94 EGCS OWS/Whitebox OWS/Whitebox OCM Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 142 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00304 CAM-00283 Date of Event 12/9/17 12/10/17 Brand/Vessel Event Description PCL Sea Princess Two pressure transmitters on the ship's ballast water treatment system (BWTS) are currently not operational. The need to have the pressure differential within a certain range is a U.S. Coast Guard requirement within U.S. waters. The IMO ballast water treatment performance standard does not include a requirement for continuous monitoring of the pressure differential. The ship was outside U.S. waters and was not scheduled to return until April 2018. The necessary spare parts were ordered. UV dosing was not affected and the BWTS still treated processed ballast water. AIDAvita CAM-00305 12/10/17 P&O Oriana CAM-00306 12/11/17 Carnival Glory CAM-00315 12/12/17 Carnival Ecstasy CAM-00308 12/13/17 Carnival Fantasy CAM-00309 12/13/17 Costa Atlantica June 21, 2018 CAM Incident Category An attempt to tamper with the BCDB needle valve through the cage was identified by the Chief Engineer and EO. The incident was communicated to various shore side stakeholders including the OLCM, CCM, CAM, and DOJ. The event was investigated by OCM onboard personnel and a responsible person identified through CCTV footage. An external legal consultant acting on behalf of OWS/Whitebox Carnival Corporation and representatives of the CAM and TPA joined the ship to conduct interviews with all involved. No evidence that an overboard discharge occurred was found. At the time of the report, the matter was under investigation. While underway, a flexible hydraulic oil hose supplying the port controllable pitch propeller ruptured, spilling 1300 liters of oil into the bilges. The spilled oil was transferred to the sludge tanks. The port propulsion shaft was taken out of service for three hours while repairs were completed. The ship's speed was reduced during this time. The hose was replaced by the ship's crew and the port shaft was put back in service restoring the ship's required speed. There was no impact on the ship's itinerary. It was recorded as a partial loss of propulsion. While alongside in Nassau, Bahamas, deck personnel were noted using rags sprayed with "Metal Brite" chemical to clean the ship's hull, in violation of Company requirements. The deck personnel incorrectly believed their actions were permitted as the chemical was sprayed onto the rags and not directly onto the hull. No deck washing was undertaken and it was not believed any chemical entered the water. The ship received written approval for fresh water cleaning from the Nassau Port Authority. As the cleaning activity was in violation of the written approval, local authorities were notified of the incident via the Port Agent. The chemical used has internal applications and, at the time of the report, the ship was awaiting results of a full review before making changes to the inventory of solvents and cleaners. Five cubic meters of pool water was discharged inside 12 nautical miles of the Bahamas Archipelagic Baseline in violation of brand-specific requirements to limit all discharges outside 12 nautical miles from baselines. The pool was filled with sea water at the time. As per the environmental schedule of the ship, the plan was to discharge the water outside 12 nautical miles from the nearest land. The discharge was caused by a broken spindle on an automatic butterfly valve. There had been no indication of the spindle failure prior to the incident. The manual overboard valve was closed to prevent further release. As the incident did not violate any external regulations, authorities were not notified. The automatic butterfly valve was replaced. Two ECS seals were broken in order to action the authorized use of two portable pumps during routine drills. However, the broken seals were misplaced and not found during a subsequent search for them. The portable pump log and list was updated Seals or Locks appropriately. After being advised that two ECS seals on a sludge tank needed to be removed, the EO noted that the serial numbers were different from the last recorded numbers in the Seal Log. The EO was then informed that the sludge tank had been opened on December 9 and December 11, 2017. The engine officer who removed the seals advised that he surrendered the seals to the engineer officer of the watch to allow the Seal Log to be updated. The two missing seals removed on December 11, 2017 were subsequently found Seals or Locks with a corresponding note. The seals removed on December 9, 2017 were not found. The area around the sludge tank was Recordkeeping inspected. No evidence of tampering was found and there were no anomalies regarding bilge and sludge quantities. The affected tank was secured and fitted with a new seal. A meeting was held with the Captain, EO, and all engine officers to reinforce the seal management and control procedure. An investigation by the Environmental Department to identify the dynamics behind the incorrect ECS seal management was ongoing at the time of the report. Page 47 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 143 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00310 12/14/17 Carnival Triumph CAM-00001 12/14/17 Carnival Vista CAM-00316 CAM-00317 CAM-00318 CAM-00319 12/14/17 12/14/17 12/14/17 12/15/17 Event Description June 21, 2018 CAM Incident Category During the loading of luggage while alongside in New Orleans, Louisiana, four passenger bags fell into the Mississippi River. Two of the bags were recovered. An inquiry with the embarkation staff revealed that during the loading process, the uncontrolled actions of the stevedore forklift operator caused the bags to fall. The local Coast Guard, National Response Corporation, and local port authority were informed of the violation of MARPOL Annex V. 375 kilograms of non-ODS R134a refrigerant gas leaked from an air conditioning system due to a loose filter connection. The Refrigerants system was repaired and put back in service. HAL Zuiderdam Due to a suspected discrepancy, the EO conducted a review of disposal records for used cooking oil. It was found that between September 20 and December 2, 2017, approximately 500 liters of cooking oil were unaccounted for when compared to the historic daily average of waste cooking oil produced. The issue was brought to the attention of shore side management and an investigation was initiated. The Provisions Room grease trap was opened for inspection and found to have captured over 100 liters of cooking oil. A galley drain tank was inspected and a thick film of cooking oil was noted on the surface of the liquid in the tank. An investigation identified clerical errors in the log books that also contributed to the error in the estimated volume of oil disposed. Training The contaminated tanks were taken out of service for cleaning. Galley staff were retrained on the correct procedures for disposal of Recordkeeping used cooking oil and informed of the importance of correct record keeping. The ship's Classification Society and Flag Administration were notified of the potential discharge of up to 500 liters of cooking oil in violation of MARPOL Annex V. An entry was made in the GRB. The incident was caused by complacency and a lack of supervision resulting from failures at several levels. The new EO implemented a tool to elevate visibility on oil disposal to encourage proper reporting. Additionally, extensive training was conducted on board. The implementation of this new tool was recommended fleet-wide. Details of the incident and the need to be attentive and follow correct procedures was sent to the Hotel Teams on all ships in the fleet. P&O Oceana During post-drydock sea trials, approximately 104 cubic meters of mixed black water (treated sewage) and grey water were discharged over a 30-minute period within 12 nautical miles of the U.K., in violation of Company requirements. During the recent refit, a blank between a grey water tank and a black water tank was removed to facilitate inspection. On completion of the refit, the blank was not replaced, allowing the contents of the two tanks to mix. It was not recognized that the tanks remained connected and Recordkeeping contained mixed waste streams because there was nothing entered in the ECR log regarding the change of tank use. This information appears to have been lost during the handover of successive watches in a busy period of post-refit sea trials. The ship intended to replace the blank and return the two tanks to dedicated separate black and grey water use. At the time of the report, root cause determination and corrective action plans were being developed and expected to be communicated to the Chief Maritime Officer by January 3, 2018. PCL Sun Princess During tendering operations while at anchor in Akaroa, New Zealand, the officer on watch spotted a black oily sheen in the water coming from the starboard engine of a tender. The tender was taken out of service and recovered on board. The Port Authorities were informed of the violation of MARPOL Annex I via the agent and it was confirmed that no further action was required as Lifeboat/Tender long as the tender remained out of service. An external contractor attended to inspect the starboard engine of the affected tender and found that worn piston rings had allowed lubrication oil to pass into the cylinder, causing increased smoke and soot in the combustion process. The ship’s staff overhauled the pistons and piston rings and the engine was scheduled to be tested on December 29, 2018. The tender remained available and no further reporting to external authorities was required. Carnival Legend While approximately 60 nautical miles from the Australian Coast, ship security was notified that several pieces of furniture had been thrown overboard from the open decks, in violation of MARPOL Annex V. Three plastic tables, five metal tables and 13 cushions/pillows were found to be missing. All remaining items were secured and an extra guard was placed on watch. The ship's agent was advised to notify the Sydney Port Authority. The ship's Flag Administration was also notified of the incident. An investigation was unable to identify the passenger that threw the furniture overboard. Page 48 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 144 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00320 12/15/17 Cunard Queen Elizabeth CAM-00321 12/15/17 P&O Ventura CAM-00322 12/15/17 Seabourn Encore CAM-00337 12/16/17 AIDAluna CAM-00338 12/16/17 AIDAluna CAM-00339 12/16/17 HAL Maasdam CAM-00312 12/17/17 Carnival Elation Event Description June 21, 2018 CAM Incident Category A significant hydraulic oil leak was identified on the davit of a tender. An inspection found a section of the hydraulic line had been cross threaded and could no longer be fully tightened. This resulted in a significant leak whenever the davit was moved. A Lifeboat/Tender temporary repair was made and the ship's Flag Administration granted permission to sail. No hydraulic oil was lost overboard and the tender remained available as a Life-Saving Applicable (LSA). While cleaning the bilges in an engine room, a rating noted a leak from a main lubricating oil pipe in the bilge. The leak was reported to the ECR and identified to be associated with a Diesel Generator (DG) which was running at the time. A standby DG was started and the affected DG was stopped. The spilled oil was removed and an investigation found a cracked pipe weld which was subsequently repaired. Measurements of the sump showed around 200 liters of oil had leaked into the bilge. The DASPOS hydrocarbon detection system did not activate as the leak was initially contained within insulation which channeled the oil directly into the bilge. It was reported as a fuel leak. While the ship was at anchor in Kaikoura, New Zealand, a plastic bucket and sponge were accidentally dropped overboard from a suite by the steward. The Bridge was advised of the incident but it was not possible to recover the items. The Port Authorities were notified of the MARPOL Annex V violation by the port agent and it was confirmed that no further action was required. An entry was made in the GRB. The Housekeeping Department held a meeting to prevent recurrence where all stewards were advised not to place buckets on the railings while they are washing the balconies. Following completion of sludge transfer ashore, it was noted that the engine automation IMACS system indicated over 17 cubic meters of sludge remained in a sludge tank. A manual sounding confirmed that the actual quantity of sludge in the tank was significantly less. The pressure sensor used to indicate the volume of sludge in the affected tank was removed, purged, and reinstalled. The IAMCS volume reading dropped to 0.4 cubic meters, matching the manual sounding value. An entry was made in to the ORB to justify the previous difference of the soundings. Prior to the incident, the affected sensor was last serviced in April 2017. 372 kilograms of non-ODS R134a refrigerant gas leaked from an air conditioning system. Failed components were replaced and Refrigerants the system was put back in service. Upon conducting the weekly back-up of CCTV footage covering the exhaust stack, BCDB and OWS equipment, the EO identified that there were no recordings between December 16 and December 22, 2017. The cause of the missing footage is under investigation. The CCTV manufacturer was contacted to provide remote support to prevent recurrence. The environmental data recorders were reviewed and no indication of improper discharge during the period that the CCTV recording function malfunctioned was identified. At the time of the report, the investigation was ongoing to determine whether the issue relates to the downloading or the recording of the data. While underway, the starboard podded propulsion motor (PEM) tripped, resulting in the ship's speed being reduced. A ruptured high pressure hydraulic oil pipe was discovered in the pod room. Approximately 400 liters of oil had spilled to bilge. The ruptured pipe caused the starboard steering system's hydraulic oil pressure to drop, followed by a loss of steering control on the starboard side, which in turn caused the starboard podded PEM to trip. The pipe was repaired onboard and was reinstalled approximately 3 hours and 20 minutes after the initial incident occurred. The starboard podded PEM was then put back in service. The ship's itinerary was not impacted. It was recorded as a partial loss of propulsion. Page 49 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 145 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00323 12/17/17 Carnival Vista CAM-00340 12/18/17 Cunard Queen Mary 2 CAM-00325 12/19/17 Carnival Fantasy CAM-00326 12/19/17 HAL Rotterdam CAM-00342 12/20/17 Costa Luminosa Event Description June 21, 2018 CAM Incident Category While the ship was alongside in the Port of Miami, a small volume (few drops) of oil-based paint spilled into the water, in violation of MARPOL Annex I. The paint dissipated and could not be recovered. A bucket being used on a cherry-picker platform had not been properly secured and was overturned. The canvas tarpaulin placed under the cherry picker platform was not sufficient to contain all the paint, allowing some to fall into the water. Port Authorities, U.S. Coast Guard, and the National Response Corporation were notified. The Staff Captain and EO reviewed painting procedures and best management practices with concerned deck team members. While there are procedures for painting and side shell maintenance and all deck department ratings undergo Training on the job training covering all their tasks, the procedures were not followed by the crew. The current procedures also do not mandate that an officer verifies compliance. The ship planned to share lessons learned from this incident across the fleet, reinforcing the Staff Captain’s duty to ensure that procedures and oversight are maintained during such maintenance. The associated procedures were expected to be revised January 5, 2018 to ensure that the proper focus on training for these precautions was in place and to mandate that an officer designated by the Staff Captain review the precautions/preparations before commencing work. While underway and 630 nautical miles from land, approximately four cubic meters of untreated sewage were discharged overboard, in violation of Company wastewater management requirements. The discharge was identified following a review of the Sewage and Greywater Log by the EO. The black water EVAC tank had backed up due to a loss of air supply to the sewage screen press. The failed screen press and the Membrane Bioreactor (MBR) system were bypassed in order to fix the issue. With no tank Training available to divert flow to/from the EVAC tank in case of malfunction, the overboard discharge occurred. The MBR system was not on the planned maintenance system and was waiting processing by the AMOS team. The engineer officer of the watch (EOOW) actioned the bypass without raising an Exception Request (ER) in order to investigate/repair the issue. There was no alarm in the ECR. Further clarification on untreated sewage discharge requirements and the need to raise ERs for this type of situation was conducted with all EOOWs. While garbage was being processed, a hydraulic hose on the garbage compactor ruptured. The compactor was stopped and the drains in the garbage room were covered to prevent any oil entering the drain. An initial investigation indicated the hose ruptured due to high pressure caused by excess oil in the system. The compactor was repaired and put back in service. A newly commissioned OWS, installed during drydock in October 2017, had an issue with a faulty valve. Once the valve was replaced, the OWS was put back in operation. The OWS has the capacity to address the bilge water processing needs. The spares for both new OWS systems were on order and the order was expedited with the manufacturer. The parts were expected in several OWS/Whitebox batches, between mid-January 2018 to March 2018. The manufacturer was aware of the issue with the valve, but was not required as a Company Project Engineer attended the ship and was able to resolve the issue. While discharging grey water at sea, it was noted that the grey water pump ejector was blocked, resulting in a loss of vacuum in the grey water line. The discharge was stopped, the blockage on the pump ejector was cleared and the grey water pump was put back in service. At the time of the report, the cause of the blockage was being confirmed. A new grey water pump was scheduled to be installed in a new grey water line, providing two grey water pumps and therefore redundancy on the system. Page 50 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 146 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00343 CAM-00344 CAM-00314 CAM-00327 CAM-00345 CAM-00346 Date of Event 12/20/17 12/20/17 12/22/17 12/22/17 12/22/17 12/23/17 Brand/Vessel Cunard Queen Elizabeth HAL Eurodam Event Description June 21, 2018 CAM Incident Category The Bridge gave 30 minutes notice to the ECR for closing all discharges and turning off the incinerator. The ECR confirmed to the Bridge that all discharges were closed and the incinerator was off, ready for entering inside 12 nautical miles off the Portuguese coast. The time, position, and permitted discharges (in this case none) were confirmed by email from the Bridge to the ECR. 28 minutes later the ECR called the Bridge to check whether the ship had crossed the 12 nautical mile line as, contrary to the earlier Voyage Planning report, the incinerator was still running. The ECR then confirmed to the Bridge that the incinerator was off and the ship crossed the 12 nautical mile line 13 minutes later. The incident occurred due to a communication break down between the ECR and the incinerator operator. While the statutory requirement is for incinerators to be stopped one hour prior to arrival in Lisbon, the ship had taken the decision to stop all discharges and the incinerator prior to entering within 12 nautical miles from the coast. During the ship's arrival into Falmouth, Jamaica, a crewmember dropped his plastic safety helmet into the water from the port forward mooring deck platform and it was not able to be recovered resulting, in a violation of MARPOL Annex V. The helmet was not fitted with a chin strap and was lost as a result of a strong wind gust. The incident was reported to the Port Agent and an entry was made in the garbage record book. The ship planned to replace helmets as they became unserviceable with models fitted with integrated chin straps. Training HAL Amsterdam While at anchor in Cabo San Lucas, Mexico an apparent violation of the ECP occurred concerning the handling of oily water, however, the ship believed there was not an improper discharge. A wiper was observed by the staff chief engineer using a bucket to empty the contents of a 55 gallon drum into a sink that typically drains into a drain tank and ultimately into a grey water tank for overboard discharge. The crew member was stopped from continuing, but approximately three buckets of this oily water was poured down the drain. The drum contained oil contaminated water that had been used to clean parts during an engine overhaul. It seemed that the wiper was acting on his own initiative and believed his conduct was appropriate. The relevant tanks were isolated and were not discharging at the time of the event. No discharge of this oily water occurred. HAL Amsterdam While the ship was at anchor in Cabo San Lucas, Mexico, a crew member poured approximately 30 liters of water contaminated with soot, hydrocarbons, and rust into a hand wash sink connected with the grey water system. The related grey water tank was isolated and the contents discharged ashore. No discharge of the contaminated water occurred. The affected tanks were subsequently decontaminated. The crew member involved in the incident was relieved of his duties, but remains on board. Internal and external counsel were notified. An investigation was initiated into the environmental near-miss. HAL Amsterdam During tender operations while at anchor in Cabo San Lucas, Mexico, a hydraulic hose coupling came loose on a tender platform. A few drops of biodegradable hydraulic oil spilled into the water in violation of MARPOL Annex I and were not recovered. The Lifeboat/Tender coupling was tightened and the dripping stopped. Port Authorities were informed and an entry was made in the ORB. An oil absorbent pad was placed under the coupling as an additional safeguard. All other tender platforms were checked and no leaks were found. Cunard Queen Elizabeth During the annual COWS operational test, the alarm activated when the oil content exceeded 15 ppm, however the OCM indicated zero ppm throughout test. No processed bilge has been discharged overboard via the COWS since July 2017. It has been used OCM routinely for recirculating the bilge retention tanks prior to discharge overboard using the static OWS. The OWS systems are OWS/Whitebox tested monthly with no deficiencies were reported on the COWS after the previous test on November 8, 2017. All critical spares were onboard. The OCM on the COWS was replaced and tested and the OWS was returned to service on December 26, 2017. Page 51 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 147 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00347 Date of Event 12/23/17 Brand/Vessel PCL Pacific Princess CAM-00328 12/24/17 Carnival Pride CAM-00348 12/24/17 Carnival Valor CAM-00349 12/24/17 Carnival Valor CAM-00351 12/24/17 PCL Emerald Princess CAM-00352 12/25/17 PCL Emerald Princess CAM-00329 12/26/17 Carnival Pride CAM-00331 12/26/17 HAL Eurodam Event Description June 21, 2018 CAM Incident Category During a crew drill while alongside in Fort Lauderdale, Florida, a black strap from a life raft shell fell overboard. The strap broke free from the shell when its connector failed during the inflation of the life raft. An entry was made in the GRB and the Deck Log Book. Port Authorities were informed of the MARPOL Annex V violation via the Port Agent and it was confirmed that no further Lifeboat/Tender action was required. Other life rafts on the ship do not have similar connectors as the affected life raft was a training device and the connector was to facilitate collection, deflation, and return of the device to the manufacturer. During provision loading while alongside in Baltimore, Maryland, a number of boxes of cream were accidentally punctured by a shore side forklift operator resulting in approximately 12 liters of cream spilling into the sea. The cream could not be recovered. The forklift operator had mistakenly pushed the forks into the pallet instead of underneath. The Port Authority and National Response Corporation were informed. While no food containers entered the water, the ship planned to confirm with the stevedore supervisor that filed a report of the incident with the correct authorities. Following completion of a bilge discharge operation, the engineer officer of the watch noted that the three-way valve was showing as open in the ECR data recorder while physically closed in the BCDB. The EO was informed and the manual bilge overboard discharge valves were closed. The BCDB was opened by the Chief Engineer and EO and the three-way valve indicator switch was found corroded. The switch was cleaned and lubricated before being reinstalled and tested. The switch was then found to operate normally and with the valve position correctly indicated in the ECR. The BCDB was locked by Chief Engineer and EO and a corresponding entry was made in the ORB. An inspection identified that the automatic delivery valve on the emergency fire/bilge pump discharge side had continuously leaked while in a closed position, allowing a total volume of 46 cubic meters of sea water to enter the oily bilge tank. The valve was disassembled and the sealing rubber ring was found broken allowing the valve to leak in the closed position. The valve was repaired and appears to have been an isolated issue. Prior to identifying the issue, the bilge water was treated and processed overboard via the OWS. After the issue was identified, all bilge water was offloaded ashore. The line in question has a non-return valve, as well as the automatic valve. It also has a constant sea water head pressure between the sea and the oily bilge water tank. There was no other valve that should have been closed as that would compromise the damage control function of the line. The combination of the non-return valve, head pressure and the automatic valve was sufficient to prevent oily water from releasing into the sea. At the time of the report, the investigation was expected to conclude that the EO and the watch standers should have detected the anomaly in the normal tank level pattern. A meeting was held with the Engine crew to reinforce the importance of attention to detail. While maneuvering at Amalia Glacier, Chile, a passenger dropped an umbrella into the water from the promenade deck, which could not be recovered. An entry was made in the Garbage Record Book. The port authority was notified of the MARPOL Annex V violation via the ship's agent. While the ship was at anchor in Punta Arenas, Chile, a waterproof canvas lifeboat-hook cover was blown overboard by strong wind and could not be retrieved.. An entry was made in the Garbage Record Book and the local agent was informed of the violation of MARPOL Annex V. All similar covers were checked for secure fitment and the need to properly secure covers and other items on deck was reiterated to the deck hands. A double bottom fuel tank was noted to have leaked approximately three liters of diesel into the bilge due to corroded material. The leak was temporarily sealed with cement. A Classification Society surveyor was scheduled to inspect the tank on January 7, 2018, and plans are being made for a permanent repair. While the ship was alongside in Grand Turk, Turk and Caicos Islands, a passenger's hat was blown into the water and could not be recovered. The local agent was notified of the MARPOL Annex V violation and an entry was made in the garbage record book. Page 52 of 94 OWS/Whitebox Training Lifeboat/Tender Training Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 148 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00353 12/26/17 Carnival Dream CAM-00332 12/27/17 Carnival Victory CAM-00355 12/27/17 Carnival Triumph CAM-00356 12/27/17 PCL Diamond Princess CAM-00357 12/27/17 Seabourn Odyssey CAM-00333 12/28/17 Carnival Glory CAM-00358 12/28/17 Carnival Legend CAM-00359 12/28/17 PCL Star Princess CAM-00334 12/29/17 Cunard Queen Mary 2 CAM-00335 12/29/17 P&O Oceana Event Description June 21, 2018 CAM Incident Category Approximately three cubic meters of recreational water from the water park tank was discharged inside 12 nautical miles from nearest land in violation of brand-specific requirements. The discharge is believed to have been caused by a failure of the software that automatically controls the discharge valve. The manual overboard valve was closed to prevent further release. No external authorities were notified. Both of the ship's OWSs were taken out of service on the same day. The OCM on one OWS was showing an error message and the glass of the cell was cracked. The second OWS had no flow through the flow switch causing the system to alarm. A manufacturer's OWS/Whitebox technician completed repairs on December 28, 2017, and both OWS systems were returned to service. The ship had a requisition OCM in place for spares pending delivery and there were no spares on board at the time. Shore side management is following up to expedite delivery of spare OCMs. During maneuvering in the entrance to the Mississippi River, the ship listed to approximately 3.5 degrees and caused five cubic meters of recreational water to overflow from a pool and drain overboard. The pool water had a residual chlorine level of 2.6 ppm and the spill was therefore a violation of Vessel General Permit requirements. The incident was reported to the local Coast Guard office and the National Response Coordination Center. The company is evaluating whether to lower the pool water levels. While the ship was alongside in Picton, New Zealand, the sight glass of a tender winch broke, causing a hydraulic oil spill of approximately 50 liters on deck and an estimated five liters into the harbor in violation of MARPOL Annex I. No visible sheen was sighted on the water so no attempt at cleanup was made. Authorities were notified via the local agent and an entry was made in the Oil Record Book. The incident was under investigation. While alongside in Bridgetown, Barbados, a metal garbage bin cover was blown into the water by strong winds experienced in the port. The EO notified the local port agent and port authorities of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. Two ECP seals installed on a fuel oil overflow tank hatch were noted missing that could have been accidently broken. A replacement seal of the same type was installed and the Seal Log was updated. The ship was replacing all hatch seals with iron bars and locks. Additionally, when alongside in Baltimore, MD, a number of boxes of cream were accidentally punctured by a shore side forklift operator resulting in approximately 12 liters of cream spilling into the sea. The Port Authority and National Response Corporation were informed. While the ship was underway approximately 19 nautical miles from the Australian coast, two passengers threw a balcony chair and coffee table overboard. The Australian Maritime National Co-ordination Centre and the ship's Flag Administration were informed of the violation of MARPOL Annex V. The event was determined to not meet the requirements to include a corresponding entry in the Garbage Record Book. While the ship was underway, the EO was informed that the static OWS was not functioning properly and was out of service for maintenance due to inability to operate the three way valve. The static OWS was put back in operation after a modification was made. The ship's vessel’s centrifugal OWS was used to process the bilge during the period the static OWS was not in operation. There were sufficient critical spare parts on board. An entry was made in the ORB. While alongside in Bridgetown, Barbados, a offloading hose split and approximately half a litre of unprocessed bilge water spilled into the bunker station. The operation was stopped and the hose disconnected. All water was contained and none spilled overboard. The local vendor was requested to hold valid hose certificates in the future. Following the ship's last discharge of bilge water ashore in Lisbon, Portugal on December 26, 2017, the pre-separation tank was emptied, cleaned and refilled with clean bilge water. But there was no discharge to the BCDB when the bilge separator was set to overboard, so the ship had no functioning bilge treatment system to discharge overboard. The issue was resolved and the ship was able to discharge overboard at three cubic meters per hour. Shore side management expedited the commissioning of the aft separator, which caused the problem, with the manufacturer. Page 53 of 94 Lifeboat/Tender Seals or Locks OWS/Whitebox Training OWS/Whitebox OCM Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 149 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category CAM-00360 12/29/17 Carnival Breeze During a weekly check, three ECS seals were noted to be missing in the forward purifier room. Training was given to engine personnel to remind them that all broken seals must be submitted to the Chief Engineer. The Seal log was updated and the ship requested delivery of a more robust type of seal. CAM-00361 12/29/17 Carnival Liberty During a round in the machinery space, nine ECS seals were noted missing. The Seal Log was log updated and the Chief Engineer Seals or Locks reviewed ECS requirements with all engine team members. The ship requested delivery of a more robust type of seal. Training CAM-00362 12/29/17 Carnival Magic CAM-00363 12/29/17 P&O Oceana CAM-00366 12/30/17 PCL Star Princess CAM-00367 12/31/17 AIDAvita CAM-00391 12/31/17 AIDAluna CAM-00369 1/1/18 Carnival Pride CAM-00370 1/1/18 HAL Volendam CAM-00392 1/3/18 HAL Eurodam CAM-00762 1/3/18 PCL Star Princess 310 kg of non-ODS R407c refrigerant gas leaked from a refrigeration system due to loose fittings and a failed solenoid valve seal. All fittings were tightened and the valve seal was replaced before putting the system back in service. During a watch handover, the incoming EO on watch noticed that the main rule bilge direct overboard remote controlled valve's environmental seal was broken. The ship side manual valve was closed and no discharge overboard could have taken place. The control card believed to cause the problem has been replaced. The manufacturer assisted in the investigation regarding the valve opening without manual intervention. While underway in international waters, a small aluminum and wood table was thrown overboard by a passenger, a 10 year old boy with learning difficulties, and not recovered. The MARPOL Annex V violation was recorded in the deck log book and in the garbage logbook. 270 kg of non-ODS R404a refrigerant gas leaked from a provision system due to a cracked pressure relief valve. The valve was replaced and the system put back in service. During a review of ORB entries, it was noted that records for the November operational tests of all oily water separators and oil content monitors were missing, the PMS record showed the tests were acknowledged as completed by the 2nd Engine Officer. The ORB was updated to correctly record the operational tests for the month of December. Preventative training was provided to all involved crew members by the current Chief Engineer and EO. Including the PMS an alert for the monthly operational tests was discussed with the system provider. Seals or Locks Training Refrigerants Seals or Locks Refrigerants Training Oil Record Book Recordkeeping Approximately 225 cubic meters of grey water were discharged over a six day period between four and 12 nautical miles of land in violation of brand requirements. A meeting was conducted by the Captain on the Bridge with the entire deck team to review all Voyage Planning environmental restrictions, and calls with the entire fleet were conducted to review this incident and reinforce the requirements. The oil content monitor (OCM) cell for the clean bilge overboard pump lost communication with the OCM computer. The function of the clean bilge overboard pump was not required as all bilge water could be processed via an intermediate bilge tank. OCM A replacement was scheduled for delivery on January 16, 2018. During the ship's arrival into Grand Turk, Turks and Caicos Islands, a crewmember accidentally dropped his identification card into the water from the forward mooring deck. The port agent was informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. In a letter dated March 1, 2018, ABSG notified the CAM and Interested Parties of a Major Non-Conformity finding on the Star Princess during an audit from January 3-8, 2018: The OWS was modified to perform the one hour operational test as required by the ECP, but the static OWS would not fully process oily water due to the operating parameters being out of sync. The Chief Engineer noted the back pressure was higher than the required manufacturer maximum pressure. The Chief Engineer and company representative received approval from the OLCM to install a pressure regulator valve which corrected the problem. The company recommended the manufacture and their respective classification society approve the modification. Page 54 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 150 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00376 1/4/18 Carnival Magic CAM-00377 1/4/18 Carnival Sunshine CAM-00379 1/4/18 HAL Rotterdam CAM-00380 1/4/18 HAL Zuiderdam CAM-00382 1/4/18 PCL Crown Princess CAM-00763 1/4/18 HAL Amsterdam CAM-00383 1/5/18 Carnival Magic CAM-00384 1/5/18 Carnival Pride CAM-00385 1/5/18 PCL Royal Princess CAM-00386 1/6/18 Carnival Liberty CAM-00387 1/6/18 HAL Amsterdam Event Description Food waste and plastic were found inside a main galley drain pipe, which collects waste from the main galley, lido galley, room service, bars and restaurants. The blockage occurred at the grey water screen installed to stop debris from entering the waste water tanks. A meeting was held with all Department Heads to reinforce the requirement to properly segregate plastics from food waste and waste waters. Following a lifeboat drill while alongside in Port of Roatan, Honduras, a lifeboat davit hydraulic pipe spilled a few drops into the water in violation of MARPOL Annex I, creating a visible sheen which was dissipated by the current. Operation of the affected davit was immediately stopped and the failed hydraulic hose was replaced. Shore side Environmental Operations and the local Port Authority were notified by the EO and an entry was made in the ORB. During the ship's arrival into Mahogany Bay, Honduras, a crewmember dropped his plastic safety helmet into the water in violation of MARPOL Annex V. The incident was reported to the Port Agent and an entry was made in the Garbage Record Book. The company decided to replace the helmets with ones fitted with chin straps. While underway towards Puerto Limon, Costa Rica, a signal light fell from the radar mast onto the deck below and shattered. An estimated one kg of plastic was lost overboard in violation of MARPOL Annex V. An entry was made in the Garbage Record Book. No authorities were informed as the incident occurred outside 12 nautical miles. While alongside in Kralendijk, Bonaire, the EO noted the manual bilge overboard valve was open and unlocked. No discharge of bilge water occurred inside 12nm from land. In an audit report dated January 12, 2018, ABSG notified the CAM and Interested Parties of several Major Non-Conformities on the Amsterdam during an audit from January 4-9, 2018: The black water vacuum manifold piping, in way of treatment tank #3, was modified, including a secondary containment box around the vent pipe to treatment tank #3. The vacuum piping was also modified by adding a branch line into the containment box to assist in removal any blackwater accumulating in the containment box and returning it back to the blackwater tank. Flexible hoses and hose clamps were used in the modification leaving the system vulnerable to unauthorized disposal of oily waste. 258 kg of non-ODS R407c refrigeration gas leaked from a provision system due to a cracked expansion valve. A new expansion valve was installed and the system was put back in service. June 21, 2018 CAM Incident Category Training Lifeboat/Tender Training Refrigerants During bunkering while alongside in Freeport, Bahamas, approximately 200 liters of HFO was found to have leaked from the HFO transfer line onto the tank top. No fuel drained into the bilge well . The cause of the leak was found to be the failure of a gasket. While the ship was underway, approximately two cubic meters of grey water overflowed into the bilges and was pumped from the bilges into the dirty bilge tank. The relatively small amount of grey water was within the processing capacity of the oily water Training separation system. The engineer involved was reminded to investigate alarms to ensure proper corrective actions are undertaken. The actuator on a black water valve has failed due to a faulty solenoid, and there was no spare on board. In normal operations, the valve was open as it is a damage control isolation valve on the bulkhead in case of emergency. There were therefore no immediate operational limitations. Following repairs to a tender gearbox cooler while the ship was in George Town, Grand Cayman, the repaired tender was being tested. Approximately two minutes after the test run was started, an oil sheen was sighted from the Bridge. The tender was immediately returned to the blocks and hoisted back on board. The sheen rapidly dissipated due to high winds and no cleanup Lifeboat/Tender actions were possible. An inspection determined that approximately three liters of biodegradable oil was lost overboard. The internal seals in the new gearbox cooler had failed and the oil was discharged into the sea along with the cooling water of the engine. Local authorities and the port agent were informed of the MARPOL Annex I violation and entries were made in the Oil Record Book and the Deck Log. Page 55 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 151 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description CAM-00390 1/6/18 HAL Amsterdam While the crew was conducting an operational check for repairs done on tender #9, it released approximately 3 liters of il into the waters of Georgetown, Grand Cayman. The Amsterdam was anchored in the harbor. Tender was taken out of service. The ship made proper notification to authorities. The light sheen rapidly dissipated and no clean up actions were necessary. CAM-00395 1/6/18 AIDAluna While underway, a passenger reported that he had seen a chair falling into the sea in violation of MARPOL Annex V. Preventative actions were taken, including lashing the furniture on these cabin balconies when poor environmental conditions are expected. CAM-00396 1/6/18 P&O Azura CAM-00397 1/6/18 P&O Britannia CAM-00398 1/6/18 PCL Sapphire Princess CAM-00388 1/7/18 HAL Koningsdam CAM-00399 1/7/18 AIDAluna CAM-00400 1/7/18 Carnival Pride CAM-00401 1/7/18 Costa Deliziosa CAM-00402 1/7/18 Costa Luminosa CAM-00403 1/8/18 Carnival Breeze CAM-00404 1/8/18 Cunard Queen Mary 2 June 21, 2018 CAM Incident Category Lifeboat/Tender The glass fiber cover of the hatch access to the GPS dome was noted missing, believed to be lost on January 6, 2018. A temporary hatch was fitted by a carpenter and the ship ordered a replacement hatch. Authorities in Grenada were notified of the violation of MARPOL Annex V and an entry was made in the Garbage Record Book. During offloading of sludge to a truck while alongside in Barbados, the hose transferring the sludge to the truck split and some sludge spilled onto the quayside. An estimated volume of less than one liter of oily water spilled into the water in violation of MARPOL Annex I. The port staff and the ship's clean up operation removed all traces of sheen. The port authorities were notified by the port agent and an entry was made in the ORB. While alongside in Penang, Malaysia, the ship experienced a blackout which resulted approximately 12 cubic meters of fresh water from Jacuzzis being discharged overboard. The discharge violated corporate requirements. The local agent has been informed and an entry was made in the ship's log. The configuration of the Jacuzzi dumping valves has now been changed from a 'fail open' to a 'fail closed' arrangement. Also recorded as a Full Blackout. During the arrival mooring operation in Castries, St Lucia, the forward section of an extendable boat hook fell over the side in violation of MARPOL Annex V. The ship's agent and local authorities were informed and an entry was made in the Garbage Record Book. During daily rounds in the engine room, it was noted that a single ECS seal installed on a cross connection valve was broken. An investigation identified that the seal was broken while conducting a weekly inspection and test of the bilge pump. No signs of Seals or Locks tampering and no anomalies on the tank quantities were noted. Preventative training has been arranged by the Chief Engineer and Training EO with all personnel involved. While investigating the incident, it was also noted that the valve had been opened for testing reasons and a second seal was broken. Two new seals were immediately installed and the corresponding log was updated. During ballast water discharge operations while alongside in Baltimore, MD, approximately three cubic meters of sea water contaminated with grey water were discharged overboard in violation of local regulations. The National Response Coordination Center and U.S. Coast Guard were notified of the violation of VGP and Company requirements. The EOOW was re-trained by the Chief Engineer and a notice was issued to instruct ships to flush all ballast water lines related to black/grey discharge lines before entering restricted areas. The recently installed ballast water treatment system was out of order due to a computer system failure. The manufacturer assisted with replacement of the defective part and the system returned to service. Before repair, the ship avoided discharging ballast water in US waters and reported no issues with observing this constraint. During a daily round in the engine room, three ECS seals were noted to be missing from the sewage vacuum line of two collecting units. New seals were installed and the corresponding log updated accordingly. A preventive discussion on the best practices was arranged with all the personnel involved. During a routine inspection, it was noted that one ECS seal was missing from a main sea water cooler drain valve. A new seal of the same type was installed and the Seal Log was updated. After the system monitor showed a communication, a failed OCM cell was found in the aft BCDB. This resulted in a brief reduction in treated oily bilge discharge capacity while the affected BCDB was out of service. The faulty cell was returned to the manufacturer for repair and an entry was made in the ORB. Page 56 of 94 Voyage Planning Training Seals or Locks Training Seals or Locks OCM Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 152 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00405 1/8/18 P&O Ventura CAM-00406 1/8/18 P&O Ventura CAM-00407 1/9/18 Carnival Freedom CAM-00408 1/9/18 Carnival Pride CAM-00411 1/9/18 Seabourn Odyssey CAM-00412 1/10/18 Carnival Dream CAM-00413 1/10/18 Cunard Queen Mary 2 CAM-00414 1/10/18 P&O Ventura CAM-00428 1/11/18 Carnival Miracle CAM-00435 1/11/18 Carnival Conquest CAM-00417 1/12/18 Carnival Fantasy CAM-00418 1/12/18 HAL Koningsdam Event Description June 21, 2018 CAM Incident Category Approximately two cubic meters of water had entered the bilge through the emergency direct bilge suction valve for the ballast system. The ballast system was isolated and the ingress of water stopped. The suction valve was found to be heavily corroded. The valve was overhauled and rebuilt with parts held on board. After starting an additional diesel generator ("DG") ready for arrival into Madeira, Portugal, a fuel leak occurred for about five minutes from a double-wall fuel return hose gasket. The engine was stopped and isolated. Approximately 500 liters of HFO entered the bilge. All spilled fuel was manually cleaned by the engine crew and transferred to sludge tanks, and a fuel leak was recorded. An investigation found the gasket on the fuel hose had failed. While checking the integrity of all ECS seals, it was noticed that one of the two seals on a food waste vacuum system were Seals or Locks missing. The flanges of two food waste vacuum systems were welded to remove the need to use ECS seals. During an engine round, it was noticed that a seal was missing from a low temperature cooling water line. The missing seal was Seals or Locks replaced and the Seal Log was updated. Training While alongside in Basseterre, Guadeloupe, a sack containing 0.5 cubic meters of crushed glass was dropped into the water during garbage offload operations. The port agent and local authorities were informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. The ship determined to put less glass in the bags until cargo nets that are capable of handling the weight of full bags are received. During a routine check of critical valves and seals, it was noted that one ECS seal was missing from a flange on the crossover valve of a grey water tank. The missing seal was replaced with a new seal of the same type and the Seal Log was updated. Seals or Locks While offloading bilge water alongside Southampton, UK, the bilge transfer pumps were unable to gain suction from the clean oily bilge tank. This resulted in a reduction in the amount of bilge water which could be offloaded to the reception facility until the Captain authorized transfer from clean oily bilge tank to the dirty oil bilge tank using salvage pumps. The Seal Log and ORB were updated. At the start of a treated bilge water discharge operation through the BCDB, the OCM was noted to be reading a high PPM value OWS/Whitebox with cloudy water coming from cell despite the sample valves being closed due to problems with the sample cooler. After a new cooler was installed, the treated bilge discharge operation was completed without further incident. An entry was made in the ORB. OCM The Company considered a planned maintenance amendment to replace the coolers every 12-18 months. While en route to Long Beach, CA, a low level lubricating oil alarm activated on the seal tank of a podded propulsion motor (PEM) propeller. The manufacturer advised that approximately 15 liters of biodegradable oil likely leaked to sea due to a faulty seal. The violation of MARPOL Annex I was reported to the National Response Coordination Center and the U.S. Coast Guard, and an entry was made in the ORB. The header tank valve to the seal was kept closed while the ship was in port. The company decided to have divers inspect the seal for signs of defects, leaks or foreign objects. The replacement of the seal will occur during the next dry dock in 2020. While the ship was underway in international waters, a crew member's lanyard and identification card were blown overboard. The MARPOL Annex V violation was not reported to any authorities. To mitigate flooding in the bow thruster room and maintain the stability of the ship, ten cubic meters of water from the bilge spaces of the bow thruster room was transferred into the nearest black water tank. The leak that caused the flood was stopped and repairs were completed the following day while alongside in Mobile, AL. The Pump Log and NAPA log were updated and relevant entries were made in the ORB. The black water content was transferred on January 23, 2018. While the ship was underway, the BCDB displayed a continuous error message and would not measure any sample water due to a OCM malfunctioning measuring cell. The cell was replaced, tested and confirmed to be accurate. An entry was made in the ORB. Page 57 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 153 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description CAM-00419 1/12/18 HAL Oosterdam During the rigging of the portside tender platform while at anchor in Cabo San Lucas, Mexico, two metal stanchions accidentally fell into the water and sank. The local ship's agent was advised of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. CAM-00436 1/12/18 Carnival Ecstasy Four new and unused ECS seals were found missing and reported. CAM-00420 1/13/18 Carnival Elation CAM-00422 1/13/18 PCL Emerald Princess CAM-00429 1/13/18 Carnival Fascination CAM-00437 1/13/18 HAL Noordam CAM-00423 1/14/18 Carnival Liberty CAM-00438 1/14/18 PCL Pacific Princess CAM-00430 1/15/18 Costa Atlantica CAM-00431 1/16/18 AIDAvita CAM-00432 1/17/18 Carnival Miracle CAM-00433 1/18/18 AIDAvita CAM-00439 1/18/18 Carnival Miracle CAM-00441 1/19/18 Carnival Ecstasy June 21, 2018 CAM Incident Category Seals or Locks While the ship was at the port of Jacksonville, FL, it was determined a discharge had occurred of approximately 20 cubic meters of pool water with a residual chlorine level of 3.67 ppm. The violation of VGP and Company requirements was reported to the U.S. Voyage Planning Training Coast Guard, National Response Coordination Center and the port authority. The automatic overboard valve was removed and replaced. While en route to Amalia Glacier, Chile, in heavy weather, a glass panel on an open deck shattered, resulting in pieces of glass falling into the water. The glass panel was replaced on arrival into Puerto Montt, Chile on January 15, 2018. At the time of the incident the ship was approximately five nautical miles from the nearest land. The local agent was informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. An ECP seal on the open delivery line valve from a grease tank was found missing. A replacement seal of the same type was Seals or Locks installed and the Seal Log was updated. During routine painting operations while the ship was alongside in Napier, New Zealand, a crewmember accidentally dropped drops of oil‐based paint into the water. The estimated quantity lost overboard and recovered was two milliliters. While the ship was alongside in Port Canaveral, FL, a hot water pipe in the starboard stabilizer room failed and approximately ten cubic meters of fresh water leaked into the engine room bilges. All leaked fresh water in the bilge was transferred to the oily bilge tank and treated as bilge water. While the ship was at anchor in San Juan Del Sur, Nicaragua, a passenger's cotton hat was blown into the sea. The violation of MARPOL Annex V was reported to port authorities via the local agent, and an entry was made in the Garbage Record Book. While the ship was in dry dock in Shanghai, China, six plastic ECS seals were found loose in the engine room. The seals have not yet been replaced. Appropriate logs were updated accordingly. The importance of the ECS seals was discussed in a meeting with crew and contractors, and specific instruction on the protocol to follow in case of seals being broken or found broken was provided. While the ship was underway in waters off the Canary Islands, Portugal, two sunbeds were blown overboard due to the strong wind in violation of MARPOL Annex V. Instruction was given to the involved crew to undertake all necessary precautions to avoid recurrence. Authorities were not notified and no entry was made in the Garbage Record Book. While the ship was en route to Puerto Quetzal, Guatemala, the bottom part of a cabana was blown overboard in violation of MARPOL Annex V. At the time of the incident, the ship was in international waters. The ship's Flag Administration were notified but an entry was not required in the Garbage Record Book. During an ECS seal inventory, it was noted that a used seal was missing. The Seal Log was updated and preventive training was arranged with all personnel involved. While the ship was alongside in Puerto Quetzal, Guatemala, a crew member reported that he had accidentally dropped his identification card into the sea. The MARPOL Annex V violation was reported to the port authority via the local agent. During an audit, the ORB was reviewed and it was noted that incorrect codes had been used to indicate missed operational entries for operations related to bilge and sludge operations. The engineers were advised about the correct codes to use for future missed operational entries. Page 58 of 94 Seals or Locks Training Seals or Locks Training Training Oil Record Book Recordkeeping Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 154 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00442 1/19/18 Carnival Liberty Event Description June 21, 2018 CAM Incident Category Following the completion of a grey water overboard discharge operation, the EOOW failed to ensure that the grey water overboard Training discharge valve was closed. No non-compliant discharges had occurred. The EOOW was disciplined and a near miss was reported. CAM-00443 1/19/18 P&O Oceana Grey water pipe leaked from a pipe into the bilges in the main engine pump room, and the ship was unable to process this contaminated bilge water with the onboard OWS. The ship could not process 59 cubic meters of contaminated bilge water from previous leaks. The ship offloaded contaminated bilge water in January and February, and planned to restore full bilge system functionality on February 11, 2018. A single tank was used for non-contaminated bilge water and there was no impact on the ship's ability to process this bilge water. CAM-00444 1/20/18 Carnival Liberty While the ship was underway, sea water was found inside a void space which is normally empty. Approximately seven cubic meters of water were transferred from the void space to the forward engine room bilges leading to an increase in the daily bilge load. The cause, a damaged pressure level transmitter, was replaced and an entry for the transfer was recorded in the ORB. CAM-00445 1/20/18 Carnival Liberty CAM-00446 1/20/18 Cunard Queen Elizabeth CAM-00447 1/20/18 Cunard Queen Mary 2 CAM-00448 1/20/18 HAL Zuiderdam CAM-00451 1/20/18 P&O Arcadia CAM-00452 1/20/18 P&O Aurora CAM-00479 1/20/18 PCL Diamond Princess CAM-00552 1/20/18 PCL Ruby Princess CAM-00453 1/21/18 Carnival Ecstasy CAM-00454 1/21/18 Carnival Imagination While underway, the OOW discovered a total of 39 cubic meters of grey water inside ballast tanks which are normally empty. The water was offloaded to a port reception facility the following day. Entries corresponding to the transfer and offload operations were made in the Oil Record Book. Permanent repairs were planned. During routine rounds, the EO (EO) found the vent lock on the suction strainer lid of a black water collecting tank unlocked and the ECS padlock next to the lid. No evidence of unauthorized use was discovered. All technical ratings were briefed on the importance of securing all vulnerabilities upon completion of work and the implications of not doing so. The ship required ratings to check all padlocks before returning the key. The sample flow solenoid valve installed on the forward OWS was found to be leaking, leading to instability in ppm readings. A new solenoid valve was taken from the second OWS as there were no spares on board and the solenoid had not been identified as a critical spare. While the ship was alongside in Oranjestad, Aruba, a passenger's hat fell into the sea due to a gust of wind. The violation of MARPOL Annex V was reported to port authorities via the local agent. The oil content monitor (OCM) on a new centrifugal OWS was providing a reading error, due to failure of the sample cooler. The OCM measuring cell was replaced for a spare calibrated cell. The manufacturer agreed to supply a replacement cooler to the ship under guarantee. Sealing faces of the closed suction valve on the second bilge double-bottom tank were found to leak, causing the OWS to transfer bilge water to the first tank while it was discharging in violation of Company procedure. All recirculation and discharge operations were stopped. The faulty suction valve was repaired immediately and the system returned to service. While the ship was en route to Lautoka, Fiji, approximately 25 cubic meters of treated permeate was unintentionally discharged overboard when suction was taken from the wrong tank during routine maintenance. At the time of the incident the vessel was outside of four nautical miles of the Fiji coast and therefore not a violation of MARPOL Annex IV. An internal investigation determined that it had been intended to discharge grey water. A Major Non-Conformity was noted onboard the Ruby Princess during a TPA audit from January 20-24, 2018. It was witnessed that other items such as plastic straws, corn on the cob plastic holders, wooden stir stick, steak identifiers, paper and other miscellaneous items are mixed in the food waste for discharge down the chute and then overboard while at sea. 468 kg of non-ODS R407c refrigerant gas leaked from a provision system due to pipe corrosion. The affected pipe was replaced and the system put back into service. While alongside in Long Beach, CA, an OWS was placed out of order due to an internal leak of cooling water inside the oil content monitor cell cooler. There was no spare cooler on board. The OWS was placed out of service and bilge water was offloaded to a reception facility in Ensenada, Mexico. Page 59 of 94 Seals or Locks Training OWS/Whitebox OCM OWS/Whitebox OWS/Whitebox Refrigerants OWS/Whitebox OCM Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 155 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00455 1/21/18 Carnival Triumph CAM-00456 1/21/18 Carnival Victory CAM-00457 1/21/18 Carnival Victory CAM-00480 1/21/18 PCL Crown Princess CAM-00460 1/22/18 AIDAvita CAM-00461 1/22/18 Carnival Spirit CAM-00462 1/22/18 P&O Arcadia CAM-00463 1/22/18 P&O Oriana CAM-00481 1/22/18 Costa Luminosa CAM-00482 1/22/18 PCL Royal Princess CAM-00464 1/23/18 Carnival Elation CAM-00466 1/23/18 P&O Aurora CAM-00467 1/24/18 Carnival Triumph CAM-00469 1/24/18 HAL Zuiderdam CAM-00470 1/25/18 Carnival Breeze Event Description June 21, 2018 CAM Incident Category The ship had no functional OWS while a new OWS was installed. The ship decided to offload bilge to a shore side reception facility in New Orleans, LA. An entry was made in the ORB. The U.S. Coast Guard, ship's Classification Society and ship's Flag OWS/Whitebox Administration were informed. The new OWS was commissioned on January 25, 2018. While the ship was in drydock, 780 kg of non-ODS R407c refrigerant gas leaked from the freezer compressor system. No cause for Refrigerants the leak could be identified. During dry dock, a total of 17 ECS seals went missing. New seals were installed and the Seal Log updated accordingly. While the ship was underway, failures to a gasket and a bellows piece on an air conditioning (AC) heater steam line resulted in approximately 24 cubic meters of water leaking into the bilge over a period of approximately eight hours. The excess bilge water was treated through an oily water separator and discharged overboard as permitted by regulation via the BCDB. Entries were made in the ORB. While the ship was alongside in Praia da Vitoria, Azores, the duty Fire Patrol accidentally dropped his portable UHF radio overboard in violation of MARPOL Annex V. Local authorities were notified. Preventive actions included instructing the involved crew member in taking greater care. While the ship was alongside in Suva, Fiji, a crew member dropped her identification card as she was crossing the gangway to board the ship. The MARPOL Annex V violation was reported to the port authority via the local agent. A leak occurred on the grey water main pipe in the aft engine room. Approximately ten cubic meters of grey water entered the tank top area and bilge wells resulting in the potential contamination of bilge water and an inability to process. Temporary repairs were made to the failed pipework and permanent repairs to the pipework were planned. During daily checks of critical valves, fittings and hatches, the ECS seal on a grease trap deck penetration cover was found broken. Technical teams will be re-briefed on the need to take care when working in the vicinity of these seals. While alongside in Bridgetown, Barbados, an increase of grey water was detected by the EOOW due to a malfunction of an overboard valve. No grey water was released into the port. The defective overboard valve was replaced and put back in service, and the non-return flap type at issue was subjected to more regular inspections. The sample water cooler of the centrifugal OWS was found to be leaking. Repairs were completed the following day and the system was tested successfully. Bilge water was not discharged overboard at any time while the OWS was out of service. An entry was made in the ORB. While the ship was underway, two male passengers threw a restaurant chair overboard. The MARPOL Annex V violation occurred while the ship was outside 12 nautical miles from the nearest land. During offload of grey water to a shore facility in Montevideo, Uruguay, leaks were discovered on the greywater line in two compartments causing approximately 28 cubic meters of bilge water to transfer to a bilge holding tank from where it was subsequently processed via the recently commissioned oily water separator and discharged normally. Operation of the bilge system was not compromised. While maneuvering on the Mississippi river, the ship listed to two degrees, causing approximately nine cubic meters of pool water to spill overboard. The residual chlorine level of the pool water was 3.2ppm. The incident was reported to the U.S. Coast Guard and the National Response Coordination Center. While the ship was alongside in Puerto Limon, Costa Rica, a four foot long wooden dowel from a lifeboat canvas fell into the water during lifeboat maintenance. The port authority was notified of the MARPOL Annex V violation via the local agent and an entry was made in the Garbage Record Book. While the ship was alongside in Mahogany Bay, Isla Roatan, a passenger accidentally dropped her purse into the sea from the pier. The MARPOL Annex V violation was reported to the port authority. Page 60 of 94 Seals or Locks Training Seals or Locks Training OWS/Whitebox Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 156 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description CAM-00471 1/25/18 Carnival Fascination While the ship was alongside in St. Croix, U.S. Virgin Islands, a bucket fell into the sea while a crew member was taking a sea water sample for to test for water density. The MARPOL Annex V violation was reported to the port authorities via the port agent. CAM-00472 1/25/18 Carnival Legend CAM-00473 1/25/18 Cunard Queen Mary 2 CAM-00483 1/25/18 PCL Emerald Princess CAM-00476 1/26/18 P&O Britannia CAM-00484 1/26/18 Carnival Victory CAM-00485 1/27/18 AIDAdiva CAM-00486 1/27/18 Carnival Miracle CAM-00487 1/27/18 Carnival Pride CAM-00488 1/27/18 Carnival Splendor CAM-00489 1/27/18 HAL Oosterdam CAM-00490 1/27/18 HAL Zuiderdam June 21, 2018 CAM Incident Category After a fitter was observed taking transformer coolant from a drum to use to refill the hood washing stations in the galleys, the ship found that approximately 100 liters of the incorrect MIDEL 7131 fluid had been used over a period of one month. The fluid is Training biodegradable, non-toxic and not harmful to aquatic life. During a de-ballasting operation the bilge/ballast pump was unable to gain suction on the ballast tank being discharged as it was drawing in air. After closing the bilge/ballast crossover valve, the bilge/ballast pump was able to take suction and the de-ballasting operation was completed. During tender operations while the ship was at anchor in Stanley, Falkland Islands, a handheld UHF radio was accidentally dropped into the water. The local agent was informed of the MARPOL Annex V violation and an entry was made into the Garbage Record Book. During a routine operation of the centrifugal oily water separator, it was noted that the sample water flow to the oil content monitor was very low due to the pipework becoming restricted by contaminants. New ECS seals were fitted and accounted for in OWS/Whitebox the Seal Log before returning the OWS to service. Entries were made in the ORB. 350 kg of non-ODS R407c refrigerant gas leaked from an air conditioning system due to pipe corrosion. The pipe was repaired Refrigerants and the system put back in service. Two adhesive ECS seals were found missing from a food waste tank and a grey water filter. The Seal Log was updated. The ship determined to reassess all vulnerable points in February with adhesive seals to be replaced with a more robust seal design. Seals or Locks While alongside in Tampa, FL, divers identified an oil leak coming from a bolt hole in a rope guard cover plate of approximately 12 drops every 3-4 seconds. The divers installed a plug in the bolt hole and subsequently confirmed no further oil was leaking. The violation of MARPOL Annex I was reported to the National Response Coordination Center and the U.S. Coast Guard. An entry was made in the ORB. During a routine check of the critical valves and tanks hatches, the EO noted that one ECS seal was missing from the EGCS line. A new seal of the same type was fitted and the Seal Log was updated. The incident report was filed with the used seals to account Seals or Locks for the missing item. While the ship was alongside in Long Beach, CA, ballast water was discharged in violation of California 'Marine Invasive Species Program' regulations. The required ballast water reporting forms were also not sent on time to the National Ballast Information Clearinghouse and the California State Lands Commission due to an administrative oversight. The initial investigation found there Voyage Planning was inadequate voyage planning for the relocation cruise, including that the Ballast Water Management Plan was not updated to reflect the relocation voyage or subsequent voyages. During painting operations while alongside in Nawiliwili, Hawaii, a bucket containing oil-based paint was kicked over and 50 milliliters of paint fell into the water. All visible paint was recovered. The incident was a violation of MARPOL Annex I and Environmental Protection Agency (EPA) VGP requirements. The EPA, National Response Coordination Center and U.S. Coast Guard were notified . An entry was made in the ORB and a report was sent to the EPA. While the ship was underway, a mechanical failure in the sewage purification system caused a bellows piece to burst, resulting in three cubic meters of raw sewage to enter the bilges. The sewage system was repaired and an entry was made in the Sewage Record Book. The spilled sewage was collected in the sludge tank and subsequently offloaded to a shore side reception facility on February 4, 2018. No wastewater was lost overboard. Page 61 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 157 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description While the ship was underway, a water leak occurred in a pool machinery room due to a filter failure resulting in approximately four cubic meters of water leaking into the bilge. The bilge water was treated and discharged overboard as permitted by regulation. An entry was made in the Oil Record Book. CAM-00491 1/27/18 PCL Golden Princess CAM-00492 1/27/18 PCL Sun Princess CAM-00494 1/28/18 Carnival Conquest CAM-00495 1/28/18 Carnival Liberty CAM-00496 1/28/18 Costa Deliziosa CAM-00498 1/28/18 P&O Arcadia CAM-00499 1/29/18 Carnival Fantasy CAM-00501 1/29/18 HAL Eurodam CAM-00502 1/29/18 PCL Golden Princess CAM-00503 1/30/18 Carnival Pride CAM-00504 1/30/18 P&O Arcadia CAM-00505 1/30/18 P&O Oriana CAM-00506 1/31/18 Carnival Legend CAM-00507 1/31/18 P&O Aurora CAM-00513 1/31/18 HAL Eurodam June 21, 2018 CAM Incident Category During tender operations while the ship was at anchor in Bay of Islands, New Zealand, a tender's Plexiglas window pane became loose and fell in the water. An inspection of all tender windows was added to the routine maintenance checklist. The local agent and port authorities were notified of the MARPOL Annex V violation. An entry was made in the Garbage Record Book. While underway, approximately seven cubic meters of grey water leaked into the bilge due to the failure of a grey water pipe. The leak was temporarily repaired using clamps and replaced on January 31, 2018. The water was processed through an oily water separator and discharged overboard via the BCDB. The incident was recorded in the ORB. While the ship was alongside in Port Canaveral, FL, approximately seven cubic meters of sea water was found inside a coffedam due to a faulty sounding sensor. The water was processed through an oily water separator and discharged overboard via the BCDB. The faulty sensor was replaced and the ORB was updated. During a routine check, four ECS seals were noted missing from two vacuum units. The corresponding logs updated. The vessel Seals or Locks Chief Engineer and EO arranged preventive training for all Engine Department personnel. Training The newly commissioned ballast water treatment system (BWTS) was taken out of service for approximately 18 hours. The faults were cleared and the system was returned to service. During a drill while the ship was alongside in Progreso, Mexico, a ship telephone fell from a crew member's pocket into the water and was not recovered. The Port Authority was notified of the Marplot Annex V violation. During departure from Half Moon Cay, Bahamas, a plastic hard hat was lost overboard. The violation of MARPOL Annex V was reported to the island Manager. An entry was made in the Garbage Record Book. While the ship was underway, the inlet pipe of the sea water general service cooler failed due to corrosion, resulting in a sea water leak into the bilge of the aft general service room. No overboard discharge occurred. Approximately three cubic meters of sea water were transferred into a bilge settling tank. The water was subsequently processed and discharged overboard. The corroded pipe was repaired on February 2, 2018. Entries were made in the ORB. The fire watch noted a slow fuel leak from a double walled fuel hose on the return side of a main engine. Approximately two liters of oil leaked into the bilge. A pulsation damper failure had caused a sudden pressure increase in the hose. Approximately 22 cubic meters of seawater was found to have entered the bilge tank via a closed cross-connection valve which is suspected to have lifted under pressure during operation of the ballast water treatment system. Between January 31, 2018 and February 6, 2018, 69 cubic meters of bilge have been processed through the oily water separators and discharged overboard via the BCDB. A galley pot wash heater was found to overflow into bilge water tank. The excess bilge was offloaded to a shore side reception facility on February 6, 2018. Watch keepers were provided with a file to track additional bilge source production in an effort to reduce the volume of bilge water. Improper sorting and loading of garbage was determined to cause a fire in the incinerator room, triggering the automatic high pressure water mist suppression system and manual activation of the steam system. Workplace operations and fire safety training was completed with all the relevant staff. Approximately 16 cubic meters of grey water leaked into the bilge due to the failure of a rubber coupling on a suction line. It was subsequently discharged to a reception facility, and the pipe coupling was repaired. While the ship was departing Georgetown, Grand Cayman, a crew member accidentally dropped a metal rod used for tightening turnbuckles on the deck. The violation of MARPOL Annex V was noted in the Garbage Record Book and the local agent was informed. Page 62 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 158 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category While the ship was en route to Nha Trang, Vietnam, 2.5 cubic meters of galley grey water overflowed into the bilges from a collecting tank due to a delivery filter blockage resulting from accumulated deposits on the bottom of the tank. At the time of the incident, several galley washing operations were in progress and there was insufficient time to react to the high-level alarm before the spill occurred. The bilge water was transferred to a sludge tank and will be offloaded to a shore side reception facility. No overboard discharge occurred. The grey water tank has been cleaned to avoid further occurrence and will be inspected monthly. An entry was made in the Oil Record Book. A starboard rescue boat was taken out of service due to a leak in the davit accumulator. A lifeboat tender has been temporarily Lifeboat/Tender designated as a rescue boat until repairs were completed in the next port on February 5, 2018. While preparing for tender operations in Waitangi, Bay of Islands, a 40 kg steel and rubber pontoon fender was dislodged by the swell and fell into the water. The violation of MARPOL Annex V was recorded in the Garbage Record Book and the local Harbormaster was informed. CAM-00514 1/31/18 PCL Sapphire Princess CAM-00508 2/1/18 PCL Island Princess CAM-00515 2/1/18 HAL Maasdam CAM-00809 2/1/18 PCL Diamond Princess While the ship was underway towards Port Chalmers, New Zealand, approximately one cubic meter of sewage overflowed from the sewage evacuation system into the bilges. The ship determined to transfer the sewage to a sludge tank and offload it ashore. An entry was made in the Oil Record Book. All sewage evacuation systems were scheduled to be upgraded in March 2018. CAM-00516 2/1/18 PCL Sapphire Princess The ship experienced an internal leakage on both sea water lubricated propulsion shafts of approximately one cubic meter per day, causing an internal leak of seawater and no external discharge. Replacement of the internal and external seals was scheduled for dry dock in March 2018. The water was processed through an oily water separator and discharged via the BCDB. CAM-00509 2/2/18 Carnival Liberty CAM-00510 2/2/18 Carnival Magic CAM-00517 2/2/18 HAL Noordam CAM-00518 2/2/18 HAL Prinsendam CAM-00511 2/3/18 Carnival Glory CAM-00512 2/3/18 Carnival Splendor CAM-00519 2/3/18 Cunard Queen Elizabeth CAM-00520 2/3/18 Cunard Queen Mary 2 The EO noted an emergency portable damage control pump was not fitted with a plastic ECS seal as listed in the Seal Log. A new seal was installed and a preventative review of relevant procedures was carried out with all personnel with access to the pump cabinet. The discharge of treated water in a clean bilge tank could not be started due to a high ppm reading on an oil content monitor, recirculating the water into the oily bilge tank. The ship stopped operation of the discharge and determined to check and clean the associated tanks and piping system at the next opportunity. While the ship was en route to Melbourne, Australia, the primary burner fuel pump of the ship's incinerator seized, severely damaging the pump shaft and rendering the incinerator inoperable. Spare parts were on board and the incinerator was returned to service the following day. While the ship was en route towards Punta Arenas, Chile, the plastic top cover of the stern light was lost overboard. The ship was outside 12 nautical miles from land. The violation of MARPOL Annex V was recorded in the Garbage Record Book. The cover was replaced with a spare. While the ship was alongside in Miami, FL, a deck hand dropped a cleaning brush into the water. The Port Authority was notified of the violation of MARPOL Annex V via the port agent. All deck hands were advised to be more cautious. During hull maintenance while alongside Long Beach, CA, approximately 200 milliliters of paint spilled from a bucket that was tied to a floating platform. The MARPOL Annex I violation was reported to the U.S. Coast Guard, National Response Coordination Center and the Port Authority. The crew members involved were advised to exercise caution when completing similar operations and the lessons learned were incorporated into a revision of painting procedures. The EO identified that the flushing of the BCDB OCM was not being recorded on the ECR display, Bridge recorder or BCDB data recorder. As a precautionary measure, flushing of the OCM Meter on the BCDB was conducted by the Chief Engineer and witnessed by the EO. The manufacturer attended the ship on February 10, 2018 and resolved the issue. The OCM in the forward BCDB was unable to be zeroed and the ship was unable to discharge treated bilge water through the forward BCDB. The faulty OCM was replaced and the BCDB put back in service. The ORB was updated. Page 63 of 94 Seals or Locks Training Training OCM OCM Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 159 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00521 CAM-00810 Date of Event 2/3/18 2/3/18 Brand/Vessel P&O Oceana PCL Golden Princess CAM-00523 2/4/18 Carnival Pride CAM-00524 2/4/18 Carnival Triumph CAM-00526 2/4/18 PCL Crown Princess CAM-00527 2/4/18 Seabourn Odyssey CAM-00528 2/5/18 PCL Caribbean Princess CVL-2018-2-108 2/6/18 PCL Caribbean Princess Event Description June 21, 2018 CAM Incident Category During a routine check, one of the two ECS seals attached to the dry dock sea water connection in the starboard bunker station was Seals or Locks found broken. A new seal of the same type was fitted and the Seal Log was updated. While the ship was en route to Wellington, New Zealand, a malfunction of the discharge pump of a grey water collecting tank caused four cubic meters of galley grey water to overflow into the bilge well. No overboard discharge occurred. The broken mechanical seal on the discharge pump was replaced. The grey water from the bilge was transferred into a sludge tank and offloaded to a shore side reception facility on February 6, 2018. Relevant entries were made in the Oil Record book. While underway within three nautical miles of the U.S. coast, approximately 27 cubic meters of pool water with a 3.6 ppm chlorine level was discharged due to the malfunction of a pool control system in violation of VGP requirements. The National Response Coordination Center and local U.S. Coast Guard were advised. The company reviewed the possibility of diverting recreational water facility discharge to the grey or ballast water systems while vessels are inside environmentally restricted areas. 860kg of non-ODS refrigerant gas R134a leaked from an air conditioning (AC) compressor due to a corroded condenser. The AC Refrigerants system remains out of service pending repair in second quarter 2018. While the ship was en route towards St. John's, Antigua, crew were setting up a party in a stairwell when a passenger opened a door and eight unsecured balloons were blown overboard. The ship was outside of 12 nautical miles at the time of incident and authorities were not notified. The violation of MARPOL Annex V was recorded in the Garbage Record Book. While the ship was at anchor in Saline Bay, Saint Vincent and the Grenadines, a trainee cabin steward dropped a plastic window wiper as she was cleaning glass on a balcony. The MARPOL Annex V violation was recorded in the Garbage Record Book and the local agent informed the port authorities. During life raft party preparation training while the ship was en route to Port Everglades, FL, a manual hydraulic system isolation valve failed, causing a leak of approximately 0.2 liters of biodegradable hydraulic fluid that spilled into the sea. At the time of the Lifeboat/Tender incident, the ship was outside 12 nautical miles from the nearest land. The failed valve was replaced and the area was cleaned. The MARPOL Annex I violation was recorded in the ORB. On February 6, 2018 in the morning, a caller reported to the hotline observing leakage of gray water from the ship’s drainage system that was sent overboard. The caller believed this gray water came from the bar upstairs. The caller also believed this polluting was done intentionally and wants the company to be aware of this incident. On the same day at approximately 1645, the Caribbean Princess’ 2nd Ventilation Officer informed the ship’s EO that there was an improper catchment set-up under a grey water pipe that was improperly being diverted to an Air Conditioning condensate drain inside Air Conditioning space 14.5. The notification by the 2nd Ventilation Officer was made as the ECP TPA audit was beginning and the CAM was onboard. The next day, February 7, 2018, the Staff Engineer and the 2nd Ventilation Officer inspected AC space 14.5 and found a temporary repair made to a grey water drain, under which was a catchment with a connected hose that was reported to run to the AC condensate drain. The catchment was dry with dust and dirt inside and the temporary pipe patch showed no evidence of leakage. They removed the catchment. They and the Chief Engineer and Captain notified the OLCM, TPA, and CAM. There was no evidence MARPOL, Vessel General Permit, or other regulatory discharge violations occurred. Around Thursday, 8 February, a Hotline Report was received concerning this same catchment. The Final Investigation report was made on April 6, 2018. Page 64 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 160 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00530 Date of Event 2/6/18 Brand/Vessel Event Description Carnival Triumph While departing Progreso, Mexico, a change of course combined with a 32-knot wind caused the ship to list approximately one degree to port. Approximately eight cubic meters of water with a 1.2 ppm chlorine level overflowed from the main pool and discharged overboard through the scupper drains in violation of Company requirements. At the time of the incident, the pool was filled to beach / harbor level. The Port Authority was notified via the local agent. A procedural revision under review was expected to lower the level of all pools where overflow and / or discharge inside areas subject to discharge restrictions is foreseen. CAM-00531 2/6/18 Costa Atlantica CAM-00532 2/6/18 Cunard Queen Elizabeth CAM-00533 2/6/18 Cunard Queen Mary 2 CAM-00811 2/6/18 HAL Zuiderdam CAM-00535 2/6/18 P&O Britannia CAM-00536 2/7/18 Carnival Breeze CAM-00538 2/7/18 HAL Amsterdam June 21, 2018 CAM Incident Category During a routine inspection, 16 ECS seals were noted to be missing from 11 vulnerable points. The missing seals were from sea chests (6), a vacuum collecting unit (2), sludge tank (1), sea water cooling pump (1), and a bilge suction valve (1). It is presumed that the seals were removed / broken due to work performed during the recent drydock. The nearby area was observed as being Seals or Locks clean with no visible oily residues. No signs of tampering or anomalies on the tanks quantities were noted. New seals were Training immediately installed and the corresponding Seal Log updated accordingly. A meeting with all engine officers, the Captain, and EO was held to re-discuss the importance of ECS seals. A reassessment of all vulnerable points was scheduled to be completed in February 2018. The ship expected that this reassessment would define sealing methods to remove as many adhesive seals as possible. A domestic hot water pipe failed, filling a void space with approximately 21 cubic meters of fresh water. The water was transferred to the bilge system and subsequently processed through an OWS and discharged overboard via the BCDB. The failed pipe was isolated and repaired. The ship planned to monitor the void space for any further leaks. During planned maintenance on the ship's Membrane Bioreactor (MBR) system, the MBR was isolated from the sewage collection system to allow cleaning of the mixing tanks. A fault in the discharge arrangements caused approximately two cubic meters of raw sewage to overflow into the bilges. The sewage in the bilge was transferred directly into bulk liquid containers for offload at the next port. An investigation found the discharge pipework was blocked. This was cleared and the MBR maintenance was completed. While the ship was en route to Fort Lauderdale, Florida, one of the ship's sewage treatment systems was running an automated cleaning cycle when the compartment's bilge alarm activated. Sewage was found to have overflowed from the cleaning tank and into the bilge. An initial review identified that the manual suction valve was open, causing low suction to the feed pump and resulting in the line backing up and subsequently overflowing the cleaning tank. The suction valve was closed and all valves were labeled to prevent recurrence. Two cubic meters of sewage were transferred from the bilge into drums for offload on February 18, 2018. An entry was made in the ORB regarding the event. The ship produced 27 cubic meters of bilge water over a 24-hour period due to a combination of a leaking exhaust gas boiler safety valve and contractors washing the bilges in two compartments in preparation for painting. The faulty safety valve was replaced. The bilge water was processed through an OWS and discharged via the BCDB. While the ship was approaching Freeport, Bahamas, a crew member dropped his identification card into the water due to negligence. The crew member was advised to be more careful. The violation of MARPOL Annex V was reported to the Port Training Authority via the local agent. While the ship was en route towards Flordland National Park, New Zealand, gale-force winds and heavy seas were encountered. The next morning, it was noted that the waterproof canvas cover was missing from the Long Range Acoustic Device (LRAD) plinth. The cover could not be found on the ship and was presumed to have been lost overboard, in violation of MARPOL Annex V. The incident occurred inside 12 nautical miles of land in a New Zealand no-discharge area. Authorities were notified via the local agent and an entry was made in the GRB. To prevent recurrence, additional lashings were fitted to the replacement LRAD cover. Page 65 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 161 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00539 2/7/18 HAL Westerdam CAM-00540 2/7/18 PCL Golden Princess CAM-00554 2/7/18 HAL Rotterdam CAM-00541 2/8/18 Cunard Queen Mary 2 CAM-00542 2/8/18 Cunard Queen Mary 2 CAM-00543 2/8/18 P&O Oriana CAM-00544 2/8/18 P&O Ventura CAM-00545 2/9/18 Carnival Conquest CAM-00546 2/9/18 Carnival Liberty CAM-00547 2/9/18 Carnival Sensation CAM-00548 2/9/18 Carnival Triumph Event Description While the ship was en route to Cartagena, Colombia, maintenance was being conducted on a blocked oily-sludge tank vent line. The engineer in charge washed sections of sludge-coated pipeline in the garbage room bin washing station, which drains into the grey water tank servicing the passenger galleys. This grey water tank was being discharged at the time, resulting in sludge residue being discharged overboard, in violation of MARPOL Annex I. As soon as the situation was recognized, the discharge pumps were stopped, the grey water tank pumps were isolated, and the galley drains were rerouted to a different grey water tank. One kilogram of sludge residue was collected from the contaminated tank, with an estimated 0.5 kg being lost overboard. The incident occurred outside 12 nautical miles. The shipped planned to discharge the contents of the contaminated tank ashore and the empty tank was decontaminated and cleaned. The ship’s engineers were counselled on the matter. A corresponding entry was made in the ORB. While the ship was departing Tauranga, New Zealand, a passenger reported seeing unattended 'Wet Paint' signs being blown overboard. The paper signs had been secured with adhesive tape. Five signs were lost overboard due to the wind in violation of MARPOL Annex V. The ship was inside four nautical miles of land at the time of the incident and the Port Authority was notified via the local agent. The Bosun was briefed regarding the incident and the ship started using laminated signs secured with rope to prevent recurrence. 330 kilograms of non-ODS R134a refrigerant gas leaked from an air conditioning system due to a cracked discharge pipe. The pipe was repaired and the system was put back in service. While fitting a new titanium sample cooler to the aft BCDB, pipes and fittings were found corroded and the non-return valve threaded pipe connection was found sheared. The BCDB was repaired, tested, and put back in service. At the time of the report, a manufacturer annual service and technical upgrade inspection was being expedited. The three-way valve on the forward BCDB was not changing over to the overboard discharge position when all prerequisite conditions were met. An inspection of the valve identified a faulty pneumatic solenoid actuating coil. The coil was replaced, the valve as tested, and the BCDB was returned to service. An ORB entry was made to record the failure. A water leak was found coming from a flange on the pump discharge line to a main pool. The pool was taken out of service. Approximately five cubic meters of water leaked to the bilge. The flange has been repaired and the pool put back in service. The bilge water was offloaded to a shore side reception facility. June 21, 2018 CAM Incident Category Training Refrigerants OWS/Whitebox OWS/Whitebox While the ship was en route to Ponta Delgada, Portugal, bilge alarms activated in a compressor room. Approximately five cubic meters of pool water leaked from a main pool machinery space into the bilges due to a failed valve on a pump discharge. The pool was closed. The accumulated water was processed through an OWS and subsequently discharged via the BCDB. While a crew member was conducting maintenance in the forward mooring station, a gust of wind blew his identification card and cabin key into the water. The items were not retrieved. The ship was outside 12 nautical miles from the nearest land and, therefore, the violation of MARPOL Annex V was not reported to any authorities. While the ship was alongside in Nassau, Bahamas, a crew member working on a catwalk dropped a window wiper blade into the water. The item was not recovered. The Port Authority was notified of the MARPOL Annex V violation via the local agent. The crew member was briefed to secure all loose items before starting work over the side of the ship. During a man overboard drill pre-inspection while alongside in Key West, Florida, the training officer dropped a UHF radio into the water. The radio could not be recovered. All other radios were properly secured. The violation of MARPOL Annex V was reported to the Port Authority via the local agent. Two ECS seals fitted to a valve in the forward sewage room were found missing. They were replaced with two new seals. The original seals were not found in the surrounding area. No signs of tampering were found. The seals were believed to have been damaged during maintenance work. Crew members were retrained regarding the procedure for broken seals. Page 66 of 94 Training Training Seals or Locks Training Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 162 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00549 2/9/18 PCL Emerald Princess CAM-00553 2/10/18 Carnival Freedom CAM-00555 2/10/18 Carnival Triumph CAM-00556 2/11/18 Carnival Victory CAM-00558 2/11/18 HAL Zuiderdam CAM-00559 2/11/18 P&O Oceana 14-2018 2/12/18 AIDAdiva CAM-00860 CAM-00561 2/12/18 2/12/18 Event Description June 21, 2018 CAM Incident Category During tender operations while the ship was at anchor in Punta Arenas, Chile, a wooden flagpole and flag were detached from a tender by the wind and fell into the water. The incident was not initially noticed by the tender's crew. Once identified, recovery of the flag and pole was not possible. Securing was not sufficient in the weather conditions and flags were removed from all other tenders for the remainder of the tender operations. The securing issue was addressed and standardized across the fleet. The local agent was advised of the MARPOL Annex V violation and an entry was made in the GRB. In accordance with the ECP Section VIII.C.4 and guidance from U.S. Coast Guard / Department of Justice, a Major NonConformity finding was noted onboard the Carnival Freedom during an audit from February 10 to 14, 2018. The number 1 incinerator, a pollution prevention equipment, was found not in service due to a defective frequency converter since January 3, 2018. A new part for the incinerator was ordered and delivered on January 25, 2018; however, the new part was not compatible with the system. A new converter was ordered, but the incinerator remained out of service. While the ship was en route to New Orleans, Louisiana, two passengers who were minors threw a golf ball and two golf clubs overboard. Both were identified by Security and were advised of environmental law and Company policies in the presence of their parents. At the time of incident, the ship was 15 nautical miles from the Mexican coast and, therefore, the MARPOL Annex V violation was not reported to authorities. While the ship was underway, an automation reading fault resulted in a sludge tank in the fuel oil purifier room overflowing into the bilge. It is estimated 23 cubic meters of sludge overflowed into the bilge. The contents of the bilge were pumped into the overflow tank and the bilge was cleaned. The faulty level transmitter was cleaned and calibrated. During the closure of a forward tender platform while the ship was alongside in Willemstad, Curacao, a hydraulic coupling failed and approximately two fluid ounces of biodegradable oil spilled into the water. The sheen dissipated quickly and no cleanup was Lifeboat/Tender possible. The damaged coupling was replaced and all other couplings were checked. The violation of MARPOL Annex I was reported to the Port Authority via the local agent and an entry was made in the ORB. During a routine check while alongside in Southampton, U.K., an ECS seal was found broken but still in position. No evidence of tampering was identified. It was suspected that the seal broke due to it being fitted too tightly when initially attached. The seal was Seals or Locks replaced with one of the same type and the Seal Log was updated. The ship planned to monitor the new seal during future inspections. During tests in preparation for a Passenger Ship Safety Certificate renewal inspection, it was noted that the engine automation system had not stored any data since February 3, 2018. The omission meant that bilge alarm notifications to comply with ECP Recordkeeping recordkeeping requirements were not available. An investigation determined that a server was replaced by the manufacturer on February 3, 2018 but was defective. In response, the manufacturer was scheduled to complete an upgrade and synchronization of data. Carnival Legend After responding to a high bilge level alarm in the aft sewage room, the engineer officer of the watch discovered that the failure of a black water overboard spool piece had resulted in a significant leak of sea water into the space. The damage control code was activated. A temporary repair reduced the flow of water to approximately three liters of water per minute. Approximately 30 cubic meters of sea water had flooded the space. The ship's stability was not affected and the bilge water was transferred into a sludge tank and offloaded to a tank truck. The spool failure was due to corrosion and was replaced by divers on arrival at the next port. Carnival Triumph During provision loading operations while the ship was alongside in New Orleans, Louisiana, some oil was noted in the water. It was found that a stevedore had punctured a cooking oil container on the berth and proceeded with the loading. Approximately three liters of cooking oil was spilled into the Mississippi River and could not be recovered due to the current. The violation of Annex V was reported to the National Response Coordination Center and the U.S. Coast Guard. The Port Authority was notified via the local agent. The stevedore supervisor was requested to ensure his staff take additional care to prevent recurrence. Page 67 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 163 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00562 2/12/18 Costa Atlantica CAM-00564 2/12/18 HAL Maasdam CAM-01220 2/12/18 HAL Noordam CAM-00565 2/13/18 Carnival Conquest CAM-00566 2/13/18 Carnival Glory CAM-00567 2/13/18 Carnival Glory CAM-00568 2/13/18 Carnival Glory CAM-00569 2/13/18 Carnival Glory CAM-00570 2/13/18 Carnival Paradise Event Description June 21, 2018 CAM Incident Category While the ship was en route to lshigaki, Japan, an incinerator was unable to start. An investigation determined that during a recent drydock, a complete renewal of the fire detection system was performed and a new release of software had been implemented. A false alarm signal in the fire detection system was found to be blocking the incinerator start sequence. The ship planned to address the issue with the installation of an updated version of the software. A technicians service on board was scheduled on March 3, 2018. While the ship was en route to Honolulu, Hawaii, a passenger dropped his cell phone overboard. The passenger reported the incident and was consequently interviewed by the Security Officer. At the time of the incident, the ship was outside 12 nautical miles from land. The MARPOL Annex V violation was entered in the GRB. While the ship was en route to Akaroa, New Zealand, the sewage treatment system was reported to be leaking. The system was stopped and a vent was opened to drain the pressure in the system. Approximately one cubic meter of sewage leaked into a secondary containment area. An investigation found that the overpressure in the system was caused by a vent line blockage resulting from a number of partially seized drain valves. As a result, the system was not completely drained on a daily basis as required. Overtime, this condition caused the overpressure in the system. All valves on the vent line drains were overhauled and the system was put back in service. The technical team has been instructed to report any issues in a timely manner to prevent recurrence. The ship made an entry in the ORB and the sewage has been pumped into drums for offloading to a shore side reception facility. The daily draining PMS was not signed off as complete because there is no AMOS job in the system for this and it is not covered in the daily watch routine. The ship's technical team planned to review and adjust AMOS / the daily watch routine. While the ship was alongside in Amber Cove, Dominican Republic, a crew member dropped his identification card and cabin key into the water. The cards could not be retrieved. The violation of MARPOL Annex V was reported to the Port Authority via the local agent. Excess water accumulation was noted in the bilge wells of both stabilizer rooms. An investigation found grey water had overflowed from a ballast water tank. Approximately three cubic meters of accumulated grey water was transferred to a sludge tank using a portable pump. The bilge water was transferred into a sludge tank and offloaded to a tank truck. An ORB entry was made. The incident occurred during a maneuvering operation. At the time of the grey water high level alarm, a fixed water mist suppression system level alarm also triggered. While one engineer responded to the water mist alarm, the rest of the operational team continued to focus on the maneuver operation and the grey water alarm was missed. Once the water mist issue was cleared, the engineer officer of the watch recognized and responded to the grey water alarm, limiting the volume of overflow. While the ship was approximately 10 nautical miles from the coast of Belize, a passenger threw his partner's cell phone overboard . The passenger was counseled by Security Officers. The MARPOL Annex V violation was reported to the Port Authority via the local agent. 460 kilograms of non-ODS R410a refrigerant gas leaked from an air conditioning system due to a loose automatic check valve. The valve was tightened and the system was put back in service. During a routine check, the EO noted one of two ECS seals fitted to a blind flange on a grey water shore connection was missing. No evidence of intentional tampering was observed and the second seal was in place and intact. The flange is located at the entrance of the aft bunker station and the ship believed that the missing seal may have been broken as crew entered / exited the compartment. Arrangements were made to weld the flanges. 602 kilograms of non-ODS R410a refrigerant gas leaked from an air conditioning system due to failed fitting bolts. The bolts were replaced and the system was put back in service. Page 68 of 94 Refrigerants Seals or Locks Training Refrigerants Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 164 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category During maintenance on a sewage discharge pump while the ship was en route to Nassau, Bahamas, an ECS seal installed on a suction pump valve was determined to be missing. The seal could not be found in the area. Initial onboard investigations confirmed that no unauthorized discharge took place. The area around the involved valve was observed as being clean with no oily Seals or Locks Training residues visible. No signs of tampering and no anomalies on the tanks' quantities were noted. A new seal was installed and the corresponding logs updated accordingly. The ship arranged preventive training by the Chief Engineer and EO with all the engine department personnel. The bellows on a hot water circulation pump developed a leak resulting in an elevated daily bilge volume production. The associated pump was stopped and isolated but the valves were found to be leaking. The valves were replaced and the leak was stopped. A bobbin piece was inserted pending replacement of the flexible coupling. Approximately 10 to 15 cubic meters of bilge water was added to the bilge tank. At the time of the report, the ship was processing bilge water via an OWS and discharging via the BCDB. The remainder was being offloaded ashore. CAM-00571 2/13/18 Costa Deliziosa CAM-00861 2/13/18 Cunard Queen Mary 2 CAM-01221 2/13/18 HAL Volendam During maintenance on a grey water drain line while the ship was alongside in Singapore, the drain line split and three cubic meters of grey water spilled into the bilge. The contaminated bilge water was pumped into drums and offloaded to a shore side reception facility in Singapore. The offload receipt was attached to the ORB. CAM-00573 2/14/18 Carnival Magic While the ship was alongside in San Juan, Mexico, a sun umbrella was blown overboard by a strong wind and could not be recovered. There is a procedure in place for securing deck furniture in heavy weather forecasts; however the strong weather was not expected therefore the umbrella was not secured. The Port Authority was notified of the MARPOL Annex V violation. CAM-00574 2/14/18 HAL Amsterdam While the ship was en route to Kangaroo Island, Australia, 57-knot winds blew a metal and plastic deckchair overboard. At the time of the incident, the ship was outside 12 nautical miles from land. The violation of MARPOL Annex V was reported to the local agent. The ship investigated how to improve securing arrangements to prevent recurrence. CAM-00582 2/14/18 Carnival Spirit While the ship was alongside in Hobart, Australia, a total of 28 sun lounger cushions were blown overboard due to strong winds. The cushions could not be retrieved. It was not anticipated that large furniture would be blown overboard. The remaining furniture was removed to prevent further incident. The Port Authority was informed of the MARPOL Annex V violation via the local agent. While the ship was in Isla of Roatan, Honduras, a crew member accidentally dropped a UHF radio into the sea while deck personnel were pulling a water hose onto the pier. The radio could not be recovered. The crew member was advised to be more careful. All concerned parties were notified of the MARPOL Annex V violation. The ship planned to incorporate a suitable directive into the current project to eliminate items going overboard. A fleet-wide email reminding crew of their obligations to prevent these incidents and to protect company property was expected to be circulated. While the ship was underway from Nassau, Bahamas to Charleston, South Carolina, a passenger threw a plastic cup overboard. A sale of alcohol restriction was placed on the passenger's account. As the ship was outside territorial waters, no authorities were notified. The EO was notified of the MARPOL Annex V violation. CAM-00576 2/15/18 Carnival Breeze CAM-00577 2/15/18 Carnival Ecstasy CAM-00862 2/15/18 Carnival Triumph During a crew drill while the ship was alongside in Progreso, Mexico, a lifejacket and a safety helmet were dropped overboard by a new crew member who was not being properly supervised. The items were dropped overboard while the crew member was Training securing his safety harness. Both items were later recovered by lifeboat crew. The Port Authority was notified via the local agent. CAM-00578 2/15/18 Carnival Victory 350 kilograms of non-ODS R407c refrigerant gas leaked from an air conditioning system due to a cracked suction line. The pipe was repaired and the system was put back in service. Page 69 of 94 Refrigerants Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 165 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00580 2/15/18 P&O Azura CAM-00584 2/15/18 Cunard Queen Victoria CAM-00586 2/16/18 Carnival Conquest CAM-00587 2/16/18 Carnival Fascination CAM-00588 2/16/18 Cunard Queen Victoria CAM-00590 2/16/18 P&O Oriana CAM-00591 2/16/18 PCL Crown Princess Event Description June 21, 2018 CAM Incident Category The COWS was taken out of service as it was directing water to the sludge tank. The ship had sufficient capacity in the bilge water holding tanks to manage the situation. An intermediate service was completed which resolved the issue of the system bowl not OWS/Whitebox closing correctly. The COWS was tested and returned to service later that day. Whilst the ship was at anchor in Punta Arenas, Chile, a deck officer dropped his VHF radio overboard. The radio sank and was not recovered. The radio was not fitted with a lanyard. The local authorities were notified of the MARPOL Annex V violation via the Port Agent. The deck officer was reminded of his environmental responsibilities and instructed to take greater care when working near the water. While the ship was alongside in Freeport, Bahamas, a crew member dropped his identification card and cabin key as he conducted a maintenance operation. The items, which had not been secured to his overalls, were not recovered. The MARPOL Annex V violation was reported to the Port Authority via the local agent. The Staff Captain organized a meeting with all Deck Department personnel who were instructed to secure all similar objects inside the pockets of their clothing. Following a drydock period, four ECS seals were found missing from a lubricating oil filter and a food waste overboard check valve. Contractors had been advised during vessel familiarization about the ECS seal requirements including the need to not Seals or Locks dispose of any seals. All missing seals were replaced with new seals of the same type and the Seal Log was updated. While the ship was positioned off the Amalia Glacier, Chile, a crew member who was taking photographs with his cell phone, accidentally dropped it over the side. The crew member was reminded of his environmental responsibilities. The authorities were not notified of the MARPOL Annex V violation. While discharging grey water en route to La Palma, Canary Islands, grey water suction was lost. An investigation found grey water leaking into the bilge from the tank suction line. The discharge was stopped and a temporary repair was completed. Approximately seven cubic meters of grey water which leaked into the bilge was offloaded to a shore side reception facility. The source of the leak was a grey / ballast suction line. At the time of the report, a permanent repair was being scheduled. While the ship was underway to Port Everglades, Florida, approximately three cubic meters of grey water overflowed from a collecting tank into the bilges due to a fouled level switch. The contaminated bilges were transferred to a sludge tank and subsequently offloaded to a shore side reception facility. An entry was made in the ORB. The level switch was repaired and put back in service. CAM-00593 2/17/18 P&O Oriana Shortly after the ship's arrival alongside in Tenerife, Canary Islands, the EO was informed by the Bridge of an oily sheen in the water off the ship's bow. An investigation confirmed discoloration of the water where a bunker barge had waited for the ship to complete its arrival maneuver. From the port bunker station, it was possible to see discoloration in the water between the bunker barge and ship's hull as the barge came alongside. The EO confirmed with the ECR that no discharges were taking place. The local agent was informed and requested to advise the Port Authorities. Deployment of absorbent materials was determined to not be necessary as the discoloration dispersed rapidly. The crew of the barge was advised of the discoloration, but they did not take any action. All control forms were signed off by the Captain of the barge and the bunkering operation was closely monitored. The barge departed following completion of the operation and no further discoloration was identified. CAM-00594 2/17/18 PCL Caribbean Princess While the ship was anchored in Princess Cays, Bahamas, an identification card was dropped overboard by a passenger. The card, which was not on a lanyard, was not recovered. The MARPOL Annex V violation was reported to the port authority via the local agent. An entry was made in the GRB. Page 70 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 166 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00595 2/17/18 PCL Royal Princess CAM-00597 2/18/18 HAL Zaandam CAM-00599 2/19/18 Cunard Queen Victoria CAM-00600 2/19/18 HAL Noordam CAM-00601 2/19/18 HAL Noordam CAM-00602 2/19/18 HAL Zuiderdam CAM-00604 2/19/18 PCL Sea Princess CAM-00605 2/20/18 Carnival Breeze Event Description June 21, 2018 CAM Incident Category During a routine check, an ECS seal was noted missing on a vent drain next to an EVAC overflow tank valve in the Membrane Bioreactor (MBR) room. There was no sign of any tampering and, as a precaution, the portable pump logs were reviewed. None had been used in the vicinity in the previous 48 hours. The Chief Engineer and EO reviewed the situation and interviewed all Seals or Locks technical personnel assigned to the EVAC Units and MBR Room. The plumber assigned to the unit confirmed that the seal had been intact and present the day before. The valve is located on a main alleyway and maintenance was being conducted on a line directly above the valve. The ship believed the seal was accidentally damaged and lost. A replacement seal was installed and appropriate notations were made in the Seal Log and inventory. While the ship was alongside in Buenos Aires, Argentina, a deck officer dropped his VHF radio into the water while a lifeboat was being lowered for maintenance. The radio sank and could not be recovered. The radio was not fitted with a lanyard. The violation of MARPOL Annex V was reported to authorities via the local agent and an entry was made in the Garbage Record Book. To prevent recurrence, all ships have been sent a reminder to use lanyards and cases when there is a risk of dropping radios overboard. Watch keepers opened a line drain from the dirty condensate system to ensure a representative sample was taken. The drain valve was not closed after the sample was drawn allowing the sample line to drain into an intermediate bilge tank. The line drained approximately 20 cubic meters of condensate over a period for eight hours before the error was noted. The mistake was not initially identified as the line drains directly into the bilge tank and the increasing tank level was not noticed. The condensate was added to the existing contents of the bilge / sludge tanks. Part of this content was offloaded to a shore side reception facility with the remainder processed through an OWS and discharged via the BCDB. This condensate system is completely closed with no visible sign of water flowing when the sample valve is closed. The line drains directly to a bilge tank and the increasing tank level was initially viewed as an error. Additional signage has been produced and the ship investigated the option of locking the drain valve with key access controlled by the ECR. Passengers in two separate cabins were observed throwing used cigarette ends overboard while smoking on their balconies. The passengers were informed of company and international regulations as well as the safety risks involved with throwing lit materials overboard. Additional announcements were made by the Captain asking passengers to refrain from throwing anything overboard and to reinforce the "no smoking on cabin balconies" policy. The MARPOL Annex V violations were recorded in the Garbage Record Book. While the ship was en route to Gisborne, New Zealand, the ram of the ship's only incinerator seized due to apparent deformation, which rendered the incinerator inoperable. The ram was repaired on board and returned to service three days later. Critical spares were on board the ship. During a Man Overboard exercise while the ship was at anchor in Half Moon Cay, Bahamas, a support bracket fitted to a rescue boat detached and fell overboard while the boat was being lowered. The five pound stainless steel and rubber bracket sank Lifeboat/Tender immediately and could not be recovered. The Safety Officer briefed his teams to be more vigilant when deploying the rescue boats. The MARPOL Annex V violations were recorded in the Garbage Record Book. The authorities were notified. During routine painting maintenance while alongside in Tauranga, New Zealand, a crewmember spilled a few drops of oil-based paint into the water. Upon noticing the paint drops in the water, the maintenance was immediately suspended. The paint could not be recovered. A tarpaulin was in place to prevent paint entering the water but was not correctly positioned. The MARPOL Annex I violations were recorded in the Garbage Record Book. The authorities were notified. While the ship was alongside in Key West, FL, a passenger reported that he had dropped his identification card and driver's license into the sea. Ship security were unable to recover the items due to the strong current. The violation of MARPOL Annex V was reported to local authorities. Page 71 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 167 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-01222 2/20/18 Carnival Imagination CAM-00606 2/20/18 Carnival Triumph CAM-00607 2/20/18 HAL Zuiderdam CAM-00608 2/20/18 P&O Oriana CAM-00609 2/20/18 P&O Oriana CAM-01223 2/20/18 PCL Diamond Princess CAM-00610 2/21/18 HAL Veendam CAM-00612 2/22/18 AIDAluna CAM-00613 2/22/18 Carnival Conquest Event Description June 21, 2018 CAM Incident Category During an internal transfer of grey water, a PVC pipe fitting in the air conditioning plant room failed, which caused a leak of approximately nine cubic meters of grey water into the bilges. The grey water pump was stopped to minimize the leak volume. A corresponding entry was made in the ORB. While the ship was en route to Yucatan, Mexico, a passenger threw three china plates, napkins, and cutlery overboard. The passenger was advised about environmental regulations. Relevant authorities were notified of the MARPOL Annex V violation via the Cozumel agent. While the ship was en route to Oranjestad, Aruba, the static OWS was taken out of service due to high system backpressure. It was determined that the filters were blocked. Changing the filters did not resolve the pressure issue. The OWS was tested in recirculation mode without the filters in place and no overpressure alarms were noted. The OWS may not be operated fully without OWS/Whitebox the filters fitted. Bilge water was being processed via the ship's centrifugal OWS, which had sufficient capacity to process the bilge content. The manufacturer assisted with faultfinding and ordered a new set of spare filters. The static OWS was resolved by cleaning the filters for a longer duration as per the manufacturer recommendations. During a routine check of critical valves, fittings and hatches, the EO identified a sewage reclaim tank was overflowing into the bilge. Approximately one cubic meter of sewage had entered the bilge. The submersible pump in the tank was found disconnected, Training the return valve from the reclaim tank had been closed, and the pumps were in manual. The situation was resolved and the power to the submersible pump was reconnected. The sewage was offloaded to a shore side reception facility. At 0500, while the ship was underway, the Bridge instructed the ECR to close all overboard valves in preparation for entering within 12 nautical miles. The ECR confirmed the grey and black water overboard discharge valves were closed and a corresponding entry was made in the discharge log. At 0936, during pre-watch checks, the second EO identified that the control system was indicating that the forward and aft black water overboard discharge valves were still in the open position. The valves Voyage Planning were closed immediately and the Chief Engineer and EO were advised. The control system does not monitor the operation of pumps and there is no indication to confirm whether any overboard discharge took place. Local port authorities were informed of the possible discharge. While the ship was en route to Port Chalmers, New Zealand, approximately three cubic meters of biomass overflowed from the sewage treatment system into the bilges. An investigation found the overflow occurred due to the malfunction of a level sensor. The biomass was transferred to a sludge tank for subsequent offload to a shore side reception facility. The faulty sensor was replaced and an entry was made in the ORB. While the ship was alongside in Fort Lauderdale, FL, a crewmember dropped his VHF radio into the water. The radio sank and could not be recovered. The crewmember had a lanyard but the radio fell into the water when the lanyard slipped off the crewmember's hand. The violation of MARPOL Annex V was reported to authorities via the local agent and an entry was made in the Garbage Record Book. While the ship was en route to Catalina Island, Dominican Republic, a sun lounger, a chair and a footrest were reported missing from passenger balconies. The items could not be found on board and it was concluded that they had been blown overboard by strong winds. All other items in the weather-affected areas were secured or removed. At the time of the incident, the ship was outside 12 nautical miles and no authorities were informed of the MARPOL Annex V violation. During connection of a fresh water hose to a shore connection while the ship was alongside in San Juan, Puerto Rico, a small wooden ship platform/bench was accidentally knocked off the pier and into the water. The bench could not be recovered as it moved under the ship and was not visible. The violation of MARPOL Annex V was reported to the port authority via the local agent. All other wooden benches were properly secured to avoid recurrence. Page 72 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 168 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00614 2/22/18 P&O Azura CAM-00615 2/22/18 P&O Ventura CAM-00616 2/22/18 PCL Island Princess CAM-01224 2/22/18 PCL Island Princess CAM-00618 2/22/18 P&O Azura CAM-01225 2/23/18 P&O Ventura CAM-00619 2/24/18 Carnival Glory Event Description June 21, 2018 CAM Incident Category While the ship was alongside in Kingstown, St. Vincent, a grey water leak in an engine room caused approximately three cubic meters of grey water to spill into the bilge. Hot and cold water supplies were isolated to galleys on two decks while a temporary repair was actioned. The grey water was discharged to a shore side reception facility. The water leak was from the galley grey water main return line. A centrifugal OWS tripped due to low pressure and bowl leakage alarms, resulting in an inability to process bilge water. Bilge offload had already been arranged while in New Orleans, LA, due to the ship's scheduled duration inside 12 nautical miles. The OWS/Whitebox OWS was stripped down and a piston gasket was found damaged. The gasket was replaced and the OWS was tested and put back in service. During the ship's arrival into Puerto Madryn, Argentina, a gust of wind blew a crewmember’s plastic safety helmet overboard and into the water from the forward mooring station. The helmet sank immediately and was not recovered. The helmet was fitted with a chinstrap, which was not being used. The crewmember was in the habit of not using the chinstrap and should have used it given the conditions. The crewmember was counseled on his oversight/lack of understanding. The violation of MARPOL Annex V was reported to the local agent and an entry was made in the Garbage Record Book. While the ship was en route to Cape Horn, Chile, 22 cubic meters of pool-water overflowed into the bilge from a collection tank. An investigation found a recirculation pipe in a pool machinery room was damaged. Heavy weather affected the level in a compensation tank, resulting in the continuous start and stop of a recirculating pump and the subsequent failure of the pipe at a weak joint. The bilge water was transferred to two bilge-settling tanks and subsequently offloaded to a shore side reception facility in Ushuaia, Chile. The damaged pipe has been replaced and an additional bracket installed to support the pipeline and prevent recurrence. Relevant entries were made in the ORB. No overboard discharge occurred during the incident. While processing bilge water for discharge, the static OWS failed due to a low sample flow alarm. While subsequently cleaning the affected orifice to improve the sample flow, the seal for the Oil Content Monitor (OCM) inlet was damaged. The OCM was replaced before returning the OWS to service. As the U.S. Coast Guard (USCG) were disembarking the ship in New Orleans, LA, they observed an oily sheen on the quay underneath the hose stowage area of a sludge receiving truck. The source of the oil was noted as a drainage hole on the truck stowage area, which had been flushed with rainwater. No oil entered the sea. The USCG confirmed their satisfaction with the ship's precautions and response. The USCG identified the contractor was not in possession of the appropriate emergency procedures as required by U.S. regulation and ordered the ongoing sludge discharge operation to be stopped. The ship had used a company-approved vendor and had presumed all required documentation would be in order. The USCG attended the ship the following day to check all corresponding paperwork, check sheets and bunker stations. All were found satisfactory. OWS/Whitebox OCM Following departure from Miami, FL, the Bridge informed the ECR through talk-back communication that the ship was outside three nautical miles. The EOOW misheard and replied back stating that the ship was outside 12 nautical miles. The Bridge did not identify the error and replied "Yes.” Approximately ten minutes later, the EOOW informed the Bridge that black and grey water discharges were about to commence. The Bridge instructed the EOOW to stop immediately. The EOOW followed the Bridge's Voyage Planning instructions and cancelled the operation. At this point, the overboard discharge valve was open but no other valves were open and Training no discharge pumps had been started. No overboard discharge of black or grey water took place. The Captain, Chief Engineer and EO reviewed the VDR records and subsequently reported the near miss event. The cause of the near miss incident was miscommunications between the Bridge and the ECR which also resulted in the EOOW not correctly following procedures. Page 73 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 169 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00620 2/24/18 Costa Atlantica CAM-00621 2/24/18 Costa Deliziosa CAM-00622 2/24/18 Cunard Queen Mary 2 CAM-00624 2/24/18 P&O Azura CAM-00625 2/24/18 P&O Azura CAM-00626 2/24/18 P&O Azura CAM-00623 2/24/18 P&O Oceana CAM-00627 2/24/18 P&O Oriana CAM-00628 2/25/18 Carnival Triumph Event Description While opening a sludge tank in preparation for a manual transfer of sludge operation, it was noted that a plastic ECS seal on the tank-accessing hatch was missing. The second seal on the same hatch was present and intact. The missing seal could not be found in the nearby area, which was observed as being clean with no visible oily residues. No signs of tampering or anomalies on the tank quantity were noted. It is presumed that the missing seal was accidentally broken during routine cleaning operations. On completion of the manual sludge transfer, two new plastic seals of the same type were fitted to the hatch and the corresponding log was updated accordingly. While bilge water was being processed, the Oil Content Monitor (OCM) on an OWS was noted to be reading an abnormally high ppm content, closing the three-way valve and continuously recirculating the bilge. The OWS was isolated and the OCM was replaced. The OWS was tested and put back in service. The OCM failure was recorded in the ORB and the faulty OCM unit has been returned to the manufacturer for repair. While the ship was alongside in Sydney, Australia, the lubricating oil sludge tanks were noted to contain an additional 13.5 cubic meters of sludge. It is believed that the increase in sludge volume was due to the bowl of the centrifugal OWS not sealing properly, allowing oil to pass down the sludge discharge chute from the OWS to the sludge tank. The OWS was taken out of service. As the ship was departing from Barbados, a grey water leak was reported in the aft auxiliary room. An investigation identified a failure in the grey water line before the overboard valve. A watch keeper error had resulted in a tank filling valve being closed and the main line becoming pressurized. Approximately 10 cubic meters of grey water spilled into the bilge before the pipe was isolated. A temporary repair was applied prior to completing a permanent repair, which was witnessed by a Classification Society surveyor. The grey water in the bilge was offloaded to a shore side reception facility on 26 February. June 21, 2018 CAM Incident Category Training OCM OWS/Whitebox Training During Passenger Ship Safety Certificate tests while alongside in Barbados, the hydraulic return line for a lifeboat davit failed. No oil entered the water. A replacement pipe was manufactured onboard and installed. Five crewmembers were inside the lifeboat for Lifeboat/Tender approximately five hours. The Bridge was in continuous communication with the lifeboat and the crew were transferred back onboard safely. The ship's departure was not delayed and the lifeboat was put back in service prior to departure. During preparations for cleaning strainers while the ship was alongside in Barbados, an ECS seal was noted missing from a sea chest drain line. A search of the bilge area did not locate the missing seal. The blanking plug and securing bolt were still in place and an examination of the portable pump log indicated no unauthorized use. The strainer was cleaned and the seal was replaced with one of the same type. All technical staff were briefed on the importance of reporting. While offloading garbage in Castries, St Lucia, a towel was blown from a bale of garbage into the water. The towel could not be retrieved. The incident was witnessed by the EO. A net was in place during the offloading but the wind blew the towel beyond the net limits. The MARPOL Annex V violation was reported to the port authority via the local agent. An entry was not made in the Garbage Record Book. The garbage team was reminded to ensure there are no loose items during offloads. During the ship's arrival into Zeebrugge, Belgium, a deck officer's plastic safety helmet was blown into the water. The helmet could not be recovered due to the weather conditions and the fact that the ship was under pilotage. The port authority was notified of the MARPOL Annex V violation via the port agent and an entry was made in the Garbage Record Book. The deck team were reminded to ensure safety helmets are worn as securely as possible. Helmet chinstraps have been ordered. While the ship was approaching New Orleans, LA, and inside three nautical miles from land, the ship listed by approximately one degree, causing four cubic meters of water to overflow from the main pool and spill overboard through the scuppers. At the time of the violation of company requirements, the pool had been in 'Beach Mode' with a chlorine content of 3.47 ppm. The U.S. Coast Guard and National Response Coordination Center were notified. Page 74 of 94 Seals or Locks Training Training Training Voyage Planning Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 170 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-01226 2/25/18 Cunard Queen Mary 2 CAM-00629 2/25/18 Carnival Fantasy CAM-00630 2/25/18 Carnival Pride CAM-00693 2/25/18 HAL Veendam CAM-00631 2/25/18 HAL Volendam CAM-00692 2/25/18 PCL Island Princess CAM-00632 2/26/18 Carnival Elation CAM-00633 2/26/18 Carnival Legend CAM-01227 2/26/18 Cunard Queen Mary 2 CAM-00634 2/26/18 P&O Oriana Event Description June 21, 2018 CAM Incident Category While the ship was underway, 1.2 cubic meters of sewage overflowed into the incinerator room bilge from a sewage treatment system tank. The spill was caused by foaming in the treatment tank. The spilled waste was transferred into drums for landing ashore and the space was washed and sanitized. The automation and control of the sewage treatment discharge pump, tank level transmitter, and de-foaming system will be addressed. 57kg of ODS R22 refrigeration gas leaked from an air conditioning compressor due to a failed shaft seal in violation of MARPOL Annex VI. The seal was replaced and the system was put back in service. A corresponding entry was made in the Refrigeration Refrigerants Record Book and Oil Record Book. During a Refrigeration Engineer handover review of the Refrigeration Record Book (RRB), the following discrepancies were identified: 24 cylinders of R410a 45kg (versus 26 cylinders on board), one cylinder of R134a 13.6 kg (zero on board), four Recordkeeping cylinders of R404a 10.9 kg (zero on board), and three cylinders of R404a 45 kg (two on board). Improper recording of offload/onload cylinder quantities is believed to be the cause of the discrepancies. The RRB was updated with the correct cylinder quantities and notes were placed on the relevant pages to reflect the updates. During a weekly lifeboat drill while the ship was alongside in Cozumel, Mexico, a boat hook was used to move a fall block towards the lifeboat. The boat hook slipped out of the hands of a crewmember and fell into the water. The hook was made of aluminum and rubber and could not be recovered. The loss is a violation of MARPOL Annex V. The port agent was informed and an entry was made in the Garbage Record Book. While the ship was en route to Singapore, approximately half a cubic meter of grey water overflowed to the ship's bilge from a grey water collecting tank. The automatic discharge pumps for the tank were found off resulting in the overflow. When switched back to automatic, the overflow stopped and the tank level lowered. On reviewing the ECR alarm list, it was found that the highlevel alarm on the grey water tank had not been activated. The high-level sensor has since been tested and found in good working order. The grey water from the bilges was collected into drums for off-loading in Singapore. The affected bilge section was cleaned. No overboard discharge occurred during this event. An entry was made in the Oil Record Book. During maintenance of the lifeboat davits while the ship was at anchor in Punta Arenas, Chile, the Senior First Officer was descending the maintenance ladder when his UHF radio accidentally fell into the water and sank. The loss is a violation of MARPOL Annex V. The port agent was informed and an entry was made in the Garbage Record Book. 260 kg of non-ODS R407c refrigerant gas leaked from an air conditioning system due to a damaged valve gasket. The gasket was Refrigerants replaced and the system put back in service. While the ship was en route to Dunedin, New Zealand, a passenger dropped a ball overboard from a cabin balcony. Security advised the passenger not to repeat the activity leading to the MARPOL Annex V violation. The ship was outside 12 nautical miles of land so no authorities were notified. During a ballast exchange operation, a leak of approximately 60 cubic meters of ballast water was identified in the bow thruster compartment. The source was believed to have been a leaking gasket on a ballast tank lid. The ballast exchange operation was halted and the water ingress stopped. The water was transferred using portable pumps into the machinery space bilges for subsequent processing and discharge via the bilge treatment system. The bow thruster space was checked and no evidence of leaks from any source above the tank top was identified, including the bow thruster door mechanisms. During a routine review of CCTV footage, the security team noted the canvas shroud for the starboard bridge wing console had become detached and subsequently been blown overboard. The ship was in international waters at the time of the incident and so the MARPOL Annex V violation was not reported to authorities. An entry was made in the Garbage Record Book. Page 75 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 171 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00635 2/26/18 HAL Noordam CAM-00637 2/27/18 Carnival Dream CAM-00638 2/27/18 Carnival Miracle CAM-00639 2/27/18 Carnival Sunshine CAM-00640 2/27/18 Costa Atlantica CAM-00641 2/27/18 P&O Aurora CAM-00642 2/27/18 Carnival Miracle CAM-00643 2/27/18 PCL Coral Princess CAM-00645 2/28/18 Carnival Glory CAM-01228 2/28/18 Carnival Legend Event Description While the ship was entering the channel towards the port of Melbourne, Australia, a crewmember dropped his identification card into the water. The accident occurred while the crewmember was working on the mooring deck with winds gusting up to 39 knots. The loss is a violation of MARPOL Annex V. During a routine check, the EO noted three ECS seals missing from a sludge tank manhole cover plate and a grey water drain valve. The areas around the two involved vulnerable points were observed as being clean with no traces of oil and no evidence of intentional tampering was identified. The second sets of seals on both vulnerable points were in place and intact. It was concluded that the missing seals were unintentionally broken and lost during cleaning and maintenance works performed in the area. A new set of seals of the same type was installed and the corresponding logs updated accordingly. During painting operations while the ship was alongside in Mahogany Bay, Roatan, a Security Officer reported paint chips in the water. A tarp was in place to contain any spilled liquid paint. Knowledge of the correct painting procedures was confirmed and initial preparations followed company policy. The tarp size was inadequate and could not have prevented the dry paint from falling into the water. Local authorities were notified. A flexible hydraulic oil hose on a lifeboat davit arm failed and approximately 1.5 liters of hydraulic oil spilled onto the deck. No oil reached the scuppers. The spill was contained and cleaned. The hose was replaced and subsequently found to have failed due to corrosion. While opening a sludge tank in preparation for a manual transfer of sludge operation, it was noted that one plastic ECS seal on the tank-accessing hatch was missing. The second seal on the same hatch was present and intact. The missing seal could not be found in the nearby area, which was observed as being clean with no visible oily residues. No signs of tampering or anomalies on the tank quantity were noted. It was presumed that the missing seal was accidentally broken during routine cleaning operations. On completion of the manual sludge transfer, two new plastic seals of the same type were fitted to the hatch and the corresponding log was updated accordingly. During gangway recovery operations in St. John's, Antigua, a UHF radio was dropped into the water. The radio sank immediately and was not recovered. The MARPOL Annex V violation was reported to the port authority and an entry was made in the Garbage Record Book. The Chief Engineer was notified that an erasable pen was being used to make entries in the Oil Record Book (ORB). The Chief Engineer verified that the pen being used was erasable and immediately informed the Captain. The involved EOOW was interviewed. No evidence of records falsification was identified. The EOOW was instructed to stop ordering and using erasable pens with immediate effect. June 21, 2018 CAM Incident Category Seals or Locks Training Training Lifeboat/Tender Seals or Locks Oil Record Book Recordkeeping During tender operations while the ship was at anchor in San Juan Del Sur, Nicaragua, it was necessary to make unplanned repairs to a tender's starboard engine. While the rocker arm cover was open, the engine was accidentally started and some oil was sprayed Lifeboat/Tender into the engine bay. A small non-quantifiable amount went overboard in violation of MARPOL Annex I. The oil created a sheen Training on the water, which quickly dissipated. An entry was made in the ORB and the ship's agent was informed over the phone. While cleaning the anchor during preparations for departure from Belize, a crewmember dropped a small plastic brush into the water. The brush was not recovered. The brush did not have a lanyard. The MARPOL Annex V violation was reported to the port authority via the local agent. After responding to a high level bilge alarm in the aft engine room, the EOOW found a main sea water pipe in-board of the overboard valve had failed, resulting in a 6.4 cubic meters leak of sea water into the space. The pipe was isolated to allow personnel to perform a temporary repair prior to fitting a concrete box. The water was contained on board in a bilge tank. There was no operational or stability impact. A temporary repair was made using rubber and metal clamps. Page 76 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 172 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00648 Date of Event 2/28/18 Brand/Vessel Event Description HAL Oosterdam During a Man Overboard drill while the ship was alongside in Mazatlan, Mexico, a crewmember on the boat deck accidentally lost his UHF radio overboard. The radio had been attached to the crewmember's clothing with a velcro strap, which opened under the weight of the radio when the crewmember looked over the rails. The radio sank immediately and could not be recovered. The loss was a violation of MARPOL Annex V. The port agent was informed and an entry was made in the Garbage Record Book. CAM-00650 3/1/18 Carnival Dream CAM-00651 3/1/18 Carnival Fascination CAM-00764 3/1/18 Carnival Spirit CAM-00655 3/2/18 Carnival Fantasy CAM-00656 3/2/18 Cunard Queen Mary 2 CAM-01229 3/2/18 Cunard Queen Mary 2 CAM-00657 3/2/18 Cunard Queen Victoria CAM-01230 3/2/18 P&O Aurora CAM-00658 3/2/18 P&O Azura June 21, 2018 CAM Incident Category During a routine check, the EO noted an ECS seal was missing from a food waste back flush valve. The area around the vulnerable point was observed as being clean with no traces of oil and no evidence of intentional tampering was identified. It was concluded Seals or Locks that the missing seals were unintentionally broken and lost during cleaning and maintenance works performed in the area. The seal Training will be replaced with a padlock and the corresponding logs updated accordingly. While the ship was alongside in Castries, St. Lucia, a crewmember dropped her plastic identification card and it was subsequently blown overboard. It was not possible to recover the card. The MAR POL Annex V violation was reported to the port authority via the local agent. A routine check of the records revealed that since 1 October 2015, during arrivals and departures from Sydney, Australia, the ship did not always complete fuel changeovers within the timeframe required by regional/local regulations. This occurred over almost 3 years and even in the aggregate was a little over 3 hours total at departure and a little over an hour on arrival as this did not happen Training every call. The correct guidance is shown in company policy, however, the terms “arrival” and “departure” were misinterpreted to have meant “Finished with Engines” and “Standby Engines” instead of “first securely moored” and “untied from mooring.” While a service technician was performing a routine check of lifeboat winches, he noted a minor oil leak. The Safety Officer assisted with an inspection and a failed seal was identified. The oil below the affected winch was immediately cleaned after liaising with the EO to confirm that no overboard spill had occurred. The incident was recorded as a Potentially Significant LSA Failure. Low output flow was noted when discharging overboard via the aft centrifugal OWS. The OWS was shut down and the suction strainer was cleaned. The flow rate did not improve and the OWS was stopped again for the feed pump to be overhauled. The OWS is back in service with no further issues. During a sludge offload operation while alongside in Wellington, New Zealand, a minor leak occurred from the contractor's truck on the quayside. Approximately one liter of oil spilled onto the berth and a very small volume of oil sprayed onto the ship's hull. There was no indication that any oil entered the water. Ship staff attempted to clean the ship's hull with dry cloths but were unsuccessful. The Port Authority granted permission for the use of deck cleaning chemicals to complete the cleanup operation. The port authority later inspected the area and confirmed satisfaction with the ship's actions. While flushing the Oil Content Monitor (OCM) of the static OWS, the OCM failed to indicate 0 ppm +/- 2ppm as per manufacturer instructions. The OCM was replaced and the OWS was tested and returned to service. During an inspection of stub pipes, the Chief Engineer noted that one of the two ECS seals on the BCDB overboard flange was missing. The seal was found in the bilge below the BCDB. The seal is believed to have been knocked off when locking/unlocking the overboard valve, which was very close to the affected flange. The seal was replaced with one of the same type and the duty to report any missing or disturbed ECS seals was reinforced with the engine room team. During an inspection of stub pipes, the Chief Engineer noted that one of the two ECS seals on the BCDB overboard flange was missing. The seal was found in the bilge below the BCDB. The seal is believed to have been knocked off when locking/unlocking the overboard valve which is very close to the affected flange. The seal was replaced with one of the same type and the duty to report any missing or disturbed ECS seals was reinforced with the engine room team. Page 77 of 94 Lifeboat/Tender OWS/Whitebox OCM Seals or Locks Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 173 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00661 3/3/18 HAL Nieuw Amsterdam CAM-00663 3/3/18 P&O Aurora Event Description June 21, 2018 CAM Incident Category While the ship was en route to Key West, FL, the ship unintentionally discharged fully exchanged ballast water in violation of Federal regulations. It was determined that the intended discharge was from a permeate tank. Closed loop communications between the Bridge and ECR were correctly conducted to discuss the intended discharge but through human error and inattention to detail, the Senior Watch Engineer opened the incorrect valve. The OOW observed that a ballast tank was being discharged in Voyage Planning error and informed the ECR. The process was in operation for 22 minutes, during which 96 cubic meters of ballast water were Training discharged. The U.S. Coast Guard was informed and an amended Ballast Water Management Report was sent to the National Ballast Information Clearinghouse. It was confirmed with the Environmental Protection Agency (EPA) that the discharge was not a violation of Vessel General Permit requirements since the discharge occurred at seven nautical miles from land. During a game on an open deck, a quoit made of rope and plastic was lost overboard. The ship was underway and so the quoit could not be recovered. The incident occurred outside 12 nautical miles and so no authorities were advised of the MARPOL Annex V violation. An entry was not made in the Garbage Record Book. CAM-00664 3/4/18 Cunard Queen Elizabeth While the ship was transiting the Great Barrier Reef Marine Park, oil was noted on the promenade deck adjacent to a lifeboat. Approximately half a liter of hydraulic oil was noted to have leaked from a stainless steel cabinet containing a pressure gauge and charging point. A small amount of oil had reached a nearby scupper. The oil was quickly removed from the scupper grating and deck. When the cabinet was opened, it was determined that the leak was from the gauge fitting. The gauge valve was isolated and absorbent sheeting was placed under the fitting and recharging point. The grating on the affected scupper was lifted and approximately 20 milliliters of oil were found inside indicating that a MARPOL Annex I violation had occurred. The scupper was cleaned using oil absorbent sheeting. The defective gauge and all corresponding seals were replaced. CAM-01231 3/4/18 Cunard Queen Victoria While flushing the Oil Content Monitor (OCM) of the static OWS, the OCM failed to indicate 0 ppm +/- 2 ppm as per manufacturer instructions. The OCM was replaced and the OWS was tested and returned to service. With the ship alongside in New Orleans, LA, a crewmember reported that his plastic nametag had fallen into the sea while he was working on the ship's catwalk. It was not recovered. The nametag had been worn correctly, but became detached due to contact with the crewmember's protective safety harness. The crewmember was advised to place his nametag in a secure pocket when performing future operations. The port authority was notified of the MARPOL Annex V violation. While checking ECS seals in the engine room, the EO noted one seal missing from a bilge/fire pump. The seal could not be found. After questioning all concerned team members under the supervision of the Chief Engineer (CE), it was concluded that the seal Seals or Locks might have been unintentionally broken while transferring materials in the engine spaces. It was confirmed by the CE that no unauthorized access had been made. A new seal was applied and the Seal Log was updated. 506kg of non-ODS R407c refrigeration gas leaked from a refrigeration system due to the failure of a fitting on a suction line. The Refrigerants system was repaired and put back in service. CAM-00666 3/4/18 Carnival Dream CAM-00667 3/4/18 Carnival Freedom CAM-00668 3/4/18 Carnival Magic CAM-01232 3/4/18 P&O Ventura The discharge isolating valve for a grey water tank corroded through and leaked. Approximately 200 liters of grey water leaked into the bilge. The grey water was processed through onboard equipment and discharged. There was no spare valve on board the ship. Temporary repairs were undertaken to stop the grey water leak. An urgent order was raised for a replacement valve. CAM-00670 3/5/18 Carnival Elation One of the ship's incinerators has been out of service due since Jan 2017 due to a damaged silo screw. Incinerator waste is being processed via the ship's second incinerator or landed ashore as needed. No repair was made because the incinerator was being considered for decommission. Page 78 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 174 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-01233 CAM-00671 Date of Event 3/5/18 3/5/18 Brand/Vessel Event Description P&O Ventura While the ship was en route to Southampton, UK, the motorman reported a lubricating oil leak from pipework forward of a Diesel Generator (DG). The affected DG was stopped and isolated. Approximately 500 liters of lubricating oil leaked into the bilge. The ship's speed was reduced to match the available power. The spilled oil was removed and transferred into the sludge system. The lubricating oil leak was repaired and the DG was put back in service. Also recorded as a Fuel Leak and a Partial loss of propulsion. Seabourn Encore CAM-00672 3/6/18 AIDAluna CAM-00674 3/6/18 Carnival Pride CAM-00675 3/6/18 Cunard Queen Mary 2 CAM-00696 3/6/18 HAL Maasdam CAM-00694 3/6/18 PCL Diamond Princess While the ship was alongside in Darwin, Australia, a cabin steward reported that she had dropped her window cleaning blade overboard. The blade had come loose from its handle while being used. The blade sank immediately and could not be recovered. The port agent and port authority were advised of the violation of MARPOL Annex V and an entry was made in the Garbage Record Book. June 21, 2018 CAM Incident Category Training While underway with four Diesel Generators (DG) on line, two DGs were being operated through exhaust gas cleaning systems (EGCS), while the other two were being changed from HFO to MGO before entering the U.S. Caribbean ECA. During the changeover, a fuel leak was discovered on one of the DGs at a connection piece on a low pressure inlet pipe. The involved DG was immediately shut down and the ship's speed was reduced. Approximately one hour later, another fuel leak was discovered on the other DG undergoing fuel changeover, with the leak occurring in the same location as the previous DG. Additionally, on the same DG, a leak occurred on a high pressure fuel pipe creating fuel spray. The involved DG was shut down and ship's speed was further reduced. It was determined that activation of the fixed high pressure water mist system was not required. Failed 0-rings were found to have caused each of the leaks and are believed to have failed prematurely due to the differences in temperatures experienced during multiple fuel changeovers. Approximately 10 to 15 liters of fuel leaked from each of the affected DGs during this incident. The fuel was collected by the fuel drainage system. The involved 0-rings were replaced allowing all DGs to be put back online. Plans were made to change additional 0-rings on the other DGs while in the next port of call. The ship's speed was fully restored approximately six hours after the initial event occurred. Also recorded as a Partial loss of propulsion. An ECS seal was noted as missing from the second stage of an OWS. There was no suspicion of tampering with the equipment or of any illegal discharge. The subject OWS was being decommissioned by a team of technicians and the seal was likely to have Seals or Locks been accidentally broken and lost during this operation. The equipment was subsequently decommissioned. While investigating a faulty pool buffer tank level indication sensor in preparation for maintenance while the ship was in the Bay Of Islands, New Zealand, loose connections were noted on an alarm and control transducer terminal connection box. Tightening these connections triggered the automation system to discharge approximately 500 liters of pool water via the buffer tank overflow in violation of company requirements. The discharge was immediately identified as the overflow was close to the pontoon where tendering operations were underway. The 'stop and close' function for the affected pool was activated, which stopped discharge. The pool was closed and netted. Pool circulation was reinstated and the pool was re-opened once the ship had departed and was beyond four nautical miles. Local authorities were advised via the port agent. While dismantling a tender platform, following completion of tender operations in Fuerte Amador, Panama, the locking pin of a fender was removed and accidentally dropped into the water. The steel pin sank immediately and could not be recovered. The Port Lifeboat/Tender Authority was informed of the MARPOL Annex V violation via the ship's local agent. An entry was made in the Garbage Record Book. While the ship was at anchor in Port Arthur, Australia, a crewmember dropped his identification card into the sea. The crewmember was sitting on a tender upper deck and, as he tried to retrieve his card from his pocket, it slipped from his hands and was blown overboard. The local agent was notified of the MAR POL Annex V violation and an entry was made in the Garbage Record Book. Page 79 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 175 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00695 3/6/18 PCL Emerald Princess CAM-00698 3/6/18 PCL Ruby Princess CAM-00676 3/7/18 Carnival Dream CAM-00677 3/7/18 Carnival Freedom CAM-00678 3/7/18 Carnival Sunshine CAM-00679 3/7/18 P&O Arcadia CAM-00680 3/7/18 P&O Azura CAM-00699 3/7/18 PCL Island Princess Event Description June 21, 2018 CAM Incident Category While the ship was at anchor in Stanley, Falkland Islands, one of the "Keep 50 meters Clear" plastic tarpaulin banners was blown into the water where it sank immediately. The security team had previously removed the banner, folded it, and placed it on a storage box near the rails. The wind lifted the banner off the storage box and into the water. The Port Agent was informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. While the ship was en route to Mazatlan, Mexico, approximately 22 cubic meters of sewage overflowed into the bilges. The ship was discharging treated sewage but a Membrane Bioreactor {MBR) de-sludge tank inlet valve was left open, causing it to overflow with a mixture of treated and untreated sewage. The high-level alarm activated and the discharge operation was stopped. The sewage was transferred from the bilges to the sludge tank and subsequently offloaded to a shore side reception facility. No overboard discharge of the mixed treated/untreated sewage occurred during the incident. An entry was made in the Oil Record Book. During a routine check of critical valves and tanks hatches, the EO noted two ECS seals missing from the manhole cover plate on Seals or Locks a grey water tank. The areas around the involved vulnerable point were observed as being clean with no traces of oil and no Training evidence of intentional tampering. The missing seals could not be found. New seals of the same type were immediately installed and the corresponding logs updated accordingly. While connecting water hoses in Ocho Rios, Jamaica, a crewmember dropped his ship telephone into the water. The telephone, which was not fitted with a lanyard, was not recovered. The port authority was notified of the MARPOL Annex V violation via the local agent and no further action was requested. During routine rounds in the aft pool machinery pump room, an electric submersible pump was discovered by the floor's drain well. The submersible pump can only be switched locally by plugging or unplugging the relevant socket. The pump's delivery was cross-connected with the pool drain manifold to the grey water holding tanks and consequently with the same pool drain. No additional information could be found regarding the cause of this installation. The pump was dismantled and removed including the related delivery line. The connection to the grey water manifold was also subsequently blind flanged, welded, and listed in the Critical Valves/Fittings List. Shortly after departure from Manila, Philippines, passengers reported seeing items being thrown from a cabin balcony by a male passenger. The items were described as possibly being fruit and paper. The passenger witnesses and cabin stewards were interviewed and CCTV footage was reviewed. While the ship was en route to Kingstown, Jamaica, the centrifugal OWS tripped due to a sludge tank high level alarm, which resulted in reduced capacity to process bilge water. It was believed that the increase in sludge volume was due to the bowl of the OWS/Whitebox centrifugal OWS not sealing properly, which allowed oil to pass down the sludge discharge chute from the OWS to the sludge tank. The OWS was taken out of service and opened for overhaul. A damaged seal was identified and replaced with an onboard spare before testing and putting the OWS back in service. While the ship was en route to San Martin, Peru, the BCDB was taken out of service for approximately 10 hours. The three-way valve was stuck in the recirculation position and was identified prior to a planned discharge. The failure was due to a corroded coil OWS/Whitebox in a solenoid that was subsequently replaced before putting the BCDB back in service. An entry was made in the Oil Record Book. Page 80 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 176 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. CAM-00681 Date of Event 3/8/18 Brand/Vessel Cunard Queen Elizabeth CAM-00700 3/8/18 Seabourn Odyssey CAM-00682 3/9/18 Carnival Fascination CAM-00683 3/9/18 Costa Atlantica CAM-00684 3/9/18 Costa Luminosa CAM-00685 3/9/18 Cunard Queen Victoria CAM-00686 3/9/18 P&O Azura Event Description June 21, 2018 CAM Incident Category A plumber signed out all keys required to complete maintenance on a toilet evacuation system. After completing the maintenance, all locks were refitted and secured correctly. The ship then carried out a full crew drill where the plumber took up his emergency response role. On completion of the drill, the plumber changed and took his boiler suit to the ship's laundry. The following day, a different plumber went to sign out the same keys and found that they were missing from the key locker. The plumber from the Training previous day was called who realized the keys were in his boiler suit pocket in the ship's laundry. The keys were recovered and returned to the key locker. The portable pump log was checked and the use of all pumps during the time the keys were not under control was accounted for. The key log was annotated to reflect the control system violation. While the ship was alongside in St. George's, Grenada, an aluminum rat guard attached to a mooring line was dropped into the water. The rat guard had become stuck between a mooring rope and the side of the ship. A crewmember attempted to free the guard but was unable to maintain his grip. The port agent and local authority were notified of the MARPOL Annex V violation and it was confirmed that no further action was required. During a routine check of damage control equipment, the ECS seal on an emergency portable pump was noted as missing. The area was thoroughly checked but the missing seal was not recovered. It was concluded that the seal was likely to have been broken Seals or Locks while the fire patrol team was cleaning the locker and conducting the monthly inventory. The missing seal was replaced and the Portable Pump Log and Seal Log were updated. While the ship was en route to Naha, Japan, the strong wind detached a stainless steel panel that had been mounted under the starboard bridge wing. The panel was installed during recent dry-dock works and was secured with rivets. The panel fell into the sea and could not be recovered. No authorities were informed of the MARPOL Annex V violation. The ship was temporarily detained by the Australian Maritime Safety Authority (AMSA) during her call in Cairns, Australia. The AMSA Port State Control inspector found a number of deficiencies involving the ship's previous voyage plan and execution, Voyage Planning ECDIS symbology knowledge, and a tender operations risk assessment. The ship, in consultation with a Classification Society surveyor and shore side management, submitted proof to resolve all deficiencies to the satisfaction of the Port State Control. The Lifeboat/Tender ship was released by AMSA and the onward itinerary was not expected to have been substantially affected by the three-hour delay in departure. During routine propeller polishing dive maintenance in Port Everglades, FL, divers noted an oil leak from the starboard podded propeller. The leak was confirmed as coming from the propeller seal and not the slewing arrangement. The leak was described as one droplet every 20 seconds with an occasional flurry of additional oil droplets being dispersed. No visible sheen was seen on the water surface. The Harbor Master and the U.S. Coast Guard (USCG) were advised of the MARPOL Annex I violation. The Harbor Master confirmed he was satisfied for the ship to depart as scheduled. The oil within the propeller bearing and seal system is certified as an environmentally acceptable lubricant by the Environment Protection Agency. The USCG attended the ship and were advised that the manufacturer's guidance was that an oil consumption of 0.6 liters per day was within normal operational parameters. While food supplies were being loaded in Barbados, a forklift driver accidentally hit the platform and 13 boxes of frozen meat dropped into the water. The boxes sank and were not recovered. Witnesses stated that the MARPOL Annex V violation occurred when the forklift driver failed to account for the ship's vertical movement during the loading. The forklift driver and the person overseeing the operation were advised to take additional care to avoid recurrence. The port authority was notified via the port agent. There was no long-term environmental impact as all packaging was recovered and the meat was not wrapped in plastic. Ship supervision of the loading operation was in place at the time of the incident but staff were unable to anticipate or prevent the momentary judgement error by the stevedore crew. This was also acknowledged by the stevedore supervisor. Page 81 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 177 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 15-2018 3/9/18 P&O Adonia CAM-00687 3/10/18 Carnival Elation CAM-00688 3/10/18 Cunard Queen Mary 2 CAM-00689 3/11/18 Cunard Queen Mary 2 CAM-00690 3/11/18 P&O Azura CAM-00691 3/11/18 P&O Britannia CAM-00701 3/11/18 AIDAmar CAM-00702 3/11/18 Carnival Magic CAM-00704 3/12/18 Carnival Breeze CAM-00705 3/12/18 P&O Azura CAM-00706 3/12/18 PCL Diamond Princess Event Description June 21, 2018 CAM Incident Category On February 20, 2018, the EO (EO) onboard the Adonia was admitted to the onboard hospital with appendicitis. He was subsequently disembarked for surgery on February 21, 2018. His EO duties were split between the Chief Engineer and Deputy Captain until a replacement EO was sent to the ship within 7 days. Due to operational needs elsewhere in the fleet, the replacement EO left the ship on the March 9, 2018. That EO was replaced by an experienced EO who missed his scheduled CSMART EO course in 2017 due to a long-term medical leave of absence. Per Section IV.A.4.b of the ECP, the EO should have participated in 5 contiguous days of in person training (i.e., CSMART EO course). Due to EO availability and scheduling constraints, the decision was made to provide the ship with experienced, albeit not ECP-qualified, EO coverage for the period of March 9-14, 2018 rather than sail with no EO onboard. During this period, the ship was traveling from Barbados to Freeport to transfer the ship to Azamara Club Cruises. During provision loading while the ship was alongside in Jacksonville, FL, a pallet broke as the shore side stevedore was placing it on the loading platform. A plastic container containing 30 lbs. of egg yolks fell overboard and could not be recovered. The port authority was notified of the MARPOL Annex V violation via the local agent. The aft centrifugal OWS was taken out of service due to no discharge pressure, which resulted in a reduced capacity to treat bilge OWS/Whitebox water. The OWS separator bowl was overhauled and the system was tested and returned to service. A wooden pallet loaded with 12 steel kegs of beer collapsed while it was being offloaded from a stores platform in Brisbane, Australia. One keg fell clear of the platform, entered the water, and could not be recovered. The EO witnessed the event and Training coordinated the clean-up including recovery of the kegs that were caught in the cargo net. The port authority was notified of the MARPOL Annex V violation via the local agent. No entry was made in the Garbage Record Book. A leak was found coming from the centrifugal OWS sample cooler. The OWS was taken out of service, which resulted in a reduction in the ability to process bilge water. There was no spare cooler onboard and an urgent request was submitted for a OWS/Whitebox replacement unit. Bilge water was offloaded to shore side reception facilities. As the ship's forward gangway was being assembled in preparations for arrival into St. George's, Grenada, a one-meter long piece of handrail fell into the water when a securing pin failed. The handrail was not recovered as the ship was moving and completing the arrival procedure. The port authority was notified of the MARPOL Annex V violation via the local agent. During preparations for overboard discharge while the ship was en route to Georgetown, Grand Cayman, it was noted that the flow switch installed on the BCDB was flashing when there was no flow through the device. The flow switch was checked, replaced OWS/Whitebox with a spare, and the BCDB was put back in service. The failure of the flow switch was recorded in the Oil Record Book. A replacement flow switch was ordered. No unplanned discharge was caused at any time during the malfunction. 360 kg of non-ODS R407c refrigerant gas leaked from a refrigeration system due to a cracked line. The failed line was repaired Refrigerants and the system was put back in service. While the ship was underway and outside 12 nautical miles from land, a crewmember reported that she had dropped her identification cards into the sea. The cards had been clipped to her trouser pocket but had become detached while on the open deck and subsequently been blown overboard in violation of MARPOL Annex V. The crewmember was advised to be more careful in the future. The measuring cell three-way valve in the Oil Content Monitor (OCM) of the ship’s centrifugal OWS failed. The three-way valve OWS/Whitebox OCM was replaced and the OWS was put back in service. While the ship was en route to Auckland, New Zealand, a piece of plastic was found in a galley dishwasher pulper during the EO's rounds. The machine was off and the food waste discharges were closed. An additional inspection was conducted in the food waste Training tank to check for the presence of plastic debris. No plastic was found. The previous discharge of the food waste tank took place the day before of the incident and a previous inspection of the pulper had been completed earlier in the day with no findings. Page 82 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 178 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00707 3/12/18 PCL Ruby Princess CAM-00725 3/12/18 Costa Atlantica CAM-00708 3/13/18 Carnival Ecstasy CAM-00709 3/13/18 Carnival Fantasy CAM-00711 3/13/18 P&O Aurora CAM-00712 CAM-00765 CAM-00727 3/13/18 3/13/18 3/13/18 Event Description June 21, 2018 CAM Incident Category While the ship was alongside in San Francisco, CA, a passenger was observed throwing his cigarette overboard. The violation of MARPOL Annex V was entered into the Garbage Record Book and the Port Authority was informed. A meeting was held with the passenger to reinforce company policy. During a routine check round it was noted that two plastic ECS seals were missing from the suction lines of an oily water separator and a clean bilge water pump. The missing seals could not be found in the nearby area, which was observed as being clean with no visible oily residues. No signs of tampering or anomalies on the tanks quantities were noted. It was presumed that the missing seals Seals or Locks were accidentally broken during routine cleaning operations. Two new plastic seals were put in place on the flanges and the corresponding log updated accordingly. A security officer noted a passenger throwing a plastic drinking cup overboard in violation of MARPOL Annex V during a party on the open deck. The passenger was briefed on regulations related to environmental laws. While the ship was docked in Cozumel, Mexico, the EO was advised that a lifeboat was missing an access hatch. It was confirmed that the hatch had been in place following departure from Progreso, Mexico, the day prior. It is believed that the orange fiberglass hatch detached from the lifeboat during the transit due to strong winds and was lost in violation of MARPOL Annex V. The hatchclosing handle may have been left open during lifeboat checks and operations. All relevant crew were advised to confirm correct Lifeboat/Tender closing of all hatch handles upon completion of lifeboat operations/maintenance and to report any malfunction or damage in a timely manner. All other lifeboats were inspected and 19 issues with similar handles were identified for subsequent replacement or repair. The issue was forwarded to the shore side LSA asset team for review. While the ship was alongside in Andalsnes, Norway, a piece of paper was blown overboard. The port agent was informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. PCL Emerald Princess While the ship was outside 12 nautical miles from land and en route to St. George's, Grenada, a food tray and plate were thrown from an upper balcony onto an open deck. The incident was reported to a security officer who questioned the occupant of the passenger cabin from which the items were believed to have been thrown. The passenger denied any involvement. A review of CCTV footage subsequently showed an unidentified object also going overboard at the same time that the tray and plate were found. The Port Agent was informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. PCL Royal Princess While the ship was outside 12 nautical miles from land and en route to St. George's, Grenada, a food tray and plate were thrown from an upper balcony onto an open deck. The incident was reported to a security officer who questioned the occupant of the passenger cabin from which the items were believed to have been thrown. The passenger denied any involvement. A review of CCTV footage subsequently showed an unidentified object also going overboard at the same time that the tray and plate were found. The Port Agent was informed of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. AIDAluna While the ship was en route to Cozumel, Mexico, a small plastic ball fell into sea in violation of MARPOL Annex V during a game in the youth facility. No authorities were informed. Preventative actions were not feasible as the construction of the ship could not be changed and ball games in the youth facility would not have been suspended. There was netting in this area but the ball was lost through an access opening. Page 83 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 179 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel 16-2018 3/14/18 Carnival Conquest CAM-00713 3/14/18 Carnival Spirit CAM-00728 3/14/18 Event Description While the ship was at anchor in Isle of Pines, New Caledonia, a passenger's hat was blown into the water as he stepped onto the pier from a tender. The hat could not be retrieved. The Port Authority was informed of the MARPOL Annex V violation via the local agent and it was confirmed that no further actions were required. Carnival Liberty CAM-00714 3/15/18 Carnival Triumph During a routine check, the EO noted that the ECS seals for a critical bilge line suction valve were missing. The surrounding area was checked for the missing seals but they could not be located. The Chief Engineer and EO conducted an investigation and did not find any evidence of tampering. It was concluded that the missing seals were unintentionally broken and lost during cleaning performed in the area. New seals were installed on the valve and the Seal Log was updated. CAM-00715 3/15/18 HAL Noordam As the ship was departing Sydney, Australia, a deck officer on the mooring deck noted a polythene catering glove falling into the water. The glove was blown overboard by a gust of wind and could not be recovered. The MARPOL Annex V violation was caused by carelessness of an unidentified crewmember. An entry was made in the GRB and the local authority was informed. 3/15/18 Costa Deliziosa CAM-00716 3/16/18 HAL Maasdam CAM-00718 3/16/18 Seabourn Sojourn CAM Incident Category From March 9 to March 14, 2018, the EO and traveling Environmental Superintendent aboard the Carnival Conquest conducted a thorough inventory of all unused, used, and currently installed Environmental Control System (ECS) seals. It was discovered that 336 seals were missing. Initial inquires revealed that most this was likely due to a procedure interpretation issue that took place from May 2017 to September 2017. The former Carnival Cruise Line Environmental Director provided guidance to the ship regarding the April 2017 version of the associated procedure in which he failed to correctly recognize and advise that all seals must be accounted for, including those from locations where two or more seals were linked together to secure a valve/fitting. The Seals or Locks practice aboard was to keep and record only one seal number tab from each location where multiple seals are linked together to secure a valve/fitting. All other used seal number tabs were cut off and disposed of. This practice was followed from May 2017 until September 18, 2017, when the requirement was clarified. On August 17, 2017, the ship’s EO reported the removal of seal number tabs to the Environmental Manager as non-compliance, but the former Environmental Director failed to address the report or allow for proper follow up. The ship completed a dry dock in October 2017, during which time it was likely that a number of seals were misplaced by workers. A new seal inventory was conducted to identify all fitted seals. While the ship was underway, a leak of 15 cubic meters of seawater into the port propulsion motor room bilges was reported. An emergency unscheduled sludge truck was requested for subsequent offload. Some of the seawater was processed via the oily bilge system and discharged overboard. The incident did not affect the ship's operation. The seawater leak was traced back to a damaged valve seat on the daily bilge suction valve in the same space combined with a failed valve on an evaporator room seawater crossover valve. The valves were overhauled and tested before putting them back in service. CAM-00729 June 21, 2018 Seals or Locks Training While the ship was en route to Santa Cruz de Tenerife, an OWS was noted to be showing a "water pocket breakage" failure alarm, which indicated a potential O-ring failure. The OWS was subsequently fitted with a new bowl spare part kit before testing and OWS/Whitebox returning to service. No discharge to sea occurred during the system malfunction. The failure was recorded in the Oil Record Book. During a crew safety drill while the ship was alongside in Puntarenas, Costa Rica, a life raft hard shell cracked at its retaining lanyard fixing point and one half of the plastic shell broke free and dropped into the water. A tender was immediately lowered into Lifeboat/Tender the water but it was not possible to recover the shell. The local agent advised the Port Authority of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. While the ship was en route to Penang, Malaysia, the OCM in the Bilge Control Discharge Box (BCDB) suffered a failure. The OCM was constantly reading above 15ppm and the operation of the three-way valve correctly remained in the recirculation OCM position. The unit was replaced with a spare and the system was put back in service. No discharges occurred during the period when the BCDB was out of operation. An entry was made in the ORB. Page 84 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 180 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00730 3/16/18 Carnival Inspiration CAM-00731 3/16/18 Cunard Queen Mary 2 CAM-00732 3/16/18 P&O Azura CAM-00733 3/16/18 PCL Royal Princess CAM-00719 3/17/18 HAL Zuiderdam CAM-00734 3/17/18 P&O Ventura CAM-00721 3/18/18 Carnival Triumph CAM-00723 3/18/18 Seabourn Odyssey CAM-00735 3/18/18 HAL Koningsdam CAM-00766 3/18/18 Costa Atlantica CAM-00737 3/19/18 Carnival Elation Event Description June 21, 2018 CAM Incident Category The Chief Engineer signed off the ship at 06:30LT and the new Chief Engineer signed on at 10:30LT the same day. The final page of the Oil Record Book was subsequently found to not have been signed off by the departing Chief Engineer. The page also Oil Record Book contained an operational entry completed at 06:35LT during a time gap when no Chief Engineer was onboard. Shore management Recordkeeping did not properly address an emergent manning issue and left a ship without a Chief Engineer and no handover. The ship's forward centrifugal OWS feed pump was noted as not achieving the expected discharge pressure, which resulted in a reduction in bilge water treatment capacity. The pump was replaced and the OWS was returned to service later the same day. While the ship was underway, the Oil Content Monitor (OCM) on the centrifugal OWS would not read below 20 ppm following completion of flushing and cleaning maintenance. The issue appeared to have resolved itself after a while, possibly indicating that some moisture present inside the unit had dried out. No overboard discharge occurred while the OCM was providing a high reading. A spare OCM was fitted and the OWS is back in service. While the ship was alongside in Kralendijk, Bonaire, a metal barrier fell into the water due to the strong wind that was blowing at the time. An entry was made in the Garbage Record Book. The local agent subsequently confirmed that the barrier was recovered from the water the following day. During tender operations while the ship was at anchor in Gatun Lake, Panama, a crewmember reported a small amount of oil leaking from a tender davit. A clean up kit was deployed, covering the area with absorbent pads. It was confirmed that the leak originated from the pressure gauge on the davit. No oil went into the scuppers or overboard. The pressure gauge was isolated and repaired. All oil was removed. During maintenance on the ship's only incinerator in dry dock, it was identified that steelwork in the incinerator chambers is in poor condition and requires replacement. Repairs were scheduled. While the ship was en route to Cozumel, Mexico, 52 nautical miles from land, a security officer noted that one life ring was missing from an open deck. The plastic life ring could not be found. CCTV footage was reviewed but a suspect could not be identified as the subject life ring was distantly located behind a stack of chairs placed in the same area. It was assumed to have been thrown overboard by an unidentified passenger. The local agent advised the Port Authority of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. The life ring was replaced with a spare. While the ship was alongside in St John's, Antigua, an OWS was taken out of service. The OWS monitor indicated that the Oil Content Monitor (OCM) sensor was defective and providing out of range readings. The OCM was replaced with a spare and the OWS was put back in service approximately one hour after the initial incident. No discharges occurred during this period. Corresponding entries were made in the ORB. During hull maintenance while the ship was alongside in Fort Lauderdale, FL, a crewmember dropped a few drops of oil-based paint from his paint roller into the water. Upon discovering the paint drops in the water, the maintenance was immediately suspended and oil absorbent pads were dispatched. All paint was successfully recovered from the water. The incident was reported to the Environmental Protection Agency (EPA) who acknowledged receipt of the notification with no further inquiries raised. The Incident was recorded in the Vessel General Permit (VGP) logbook. The National Response Coordination Center was informed and an entry was made in the Oil Record Book. Approximately 400 kg of non- ODS R410a refrigerant gas leaked from an air conditioning compressor due to the mechanical failure of a seal. A new seal was requested. During a review of corresponding records by the EO, a one-ppm discrepancy was noted between the readings of a BCDB Oil Content Monitor (OCM) and the ECR digital data recorder. The BCDB OCM was replaced. The new BCDB OCM and data recorder readings were confirmed to be corresponding and the BCDB was put back in service. An ORB entry was completed. Page 85 of 94 OWS/Whitebox OCM Training Lifeboat/Tender OWS/Whitebox OCM Refrigerants OCM Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 181 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00738 3/19/18 Carnival Legend CAM-00739 3/19/18 Carnival Liberty CAM-00740 3/19/18 Costa Atlantica CAM-00741 3/19/18 PCL Regal Princess CAM-00742 3/20/18 Carnival Fantasy CAM-00743 3/20/18 Carnival Imagination CAM-00744 3/20/18 HAL Noordam 17-2018 3/21/18 PCL Island Princess CAM-00745 3/21/18 HAL Noordam Event Description June 21, 2018 CAM Incident Category While the ship was alongside in Melbourne, Australia, the assistant housekeeping manager reported part of a window cleaning blade had fallen into the sea. The handle of the blade had been secured with a rope but the lower part had become detached due to wear and tear. The MARPOL Annex V violation was reported to the port authority via the local agent. While the ship was alongside in Nassau, Bahamas, the assistant housekeeping manager reported part of a window cleaning blade had fallen into the sea. The handle of the blade had been secured with a safety strap but the lower part had become detached due to Training a loose screw fitting. The MARPOL Annex V violation was reported to the port authority via the local agent. During a visit on board, the Environmental Manager and the EO noted unusually low figures for the volumes of used cooking oil landed ashore during 2017. After having discussed the matter onboard with the ship's management team, an internal investigation was initiated to determine whether a violation of MARPOL Annex V had occurred. While the ship was underway, the Bridge advised the SEOOW that the ship was outside four nautical miles from shore and greywater discharge was permissible. The SEOOW instructed the motorman to open the greywater overboard valve (SB/601VF). The motorman opened the greywater valve SB/601VF as instructed but also opened greywater / permeate overboard valve (SB/600VF). Both were manual lockable valves with the keys for the padlocks on the same key ring. The report back to the ECR Voyage Planning did not indicate both valves had been opened. As the valves are manual and not on the automation system, the SEOOW in the Training engine control room could not see the status of valve SB/600VF. The motorman of the next watch noticed that valve (SB/600VF) was opened by checking the valve locally in the engine room and noting that the valve was registered closed and locked in the ECR. It was confirmed that no overboard discharges had taken place during the time frame involved. While the ship was underway and outside 12 nautical miles from land, a passenger was noted throwing a non-plastic drinking glass overboard into the sea in violation of MARPOL Annex V. A security officer approached the passenger and advised him of environmental policy. The passenger apologized and admitted to throwing the empty glass overboard. While the ship was alongside in Ensenada, Mexico, the Bridge was notified that there was water being discharged close to the gangway. The Bridge called the ECR and the discharge was stopped. Approximately 100 liters of treated black water had been discharged overboard. It was found that the high-level alarm for a black water tank had been acknowledged during the ECR departure briefing but no action had been taken to divert the effluent to another tank. This error alone could not have caused the overflow. It was suspected that a tank level transmitter also malfunctioned. The port authority was notified of the MARPOL Annex IV violation via the ship's local agent. The port authority granted permission for the ship to depart on schedule. The highlevel sensor transmitter was replaced and adjusted to provide earlier notification of a high tank level. During bunkering of water while the ship was alongside in Port Vila, Vanuatu, a potable water tank overflowed overboard. A review identified that the remote level indication device was behaving erratically and there was no reliable remote measurement of the amount of potable water present in the tank. When the tank became full, there was no alarm on the automation system and approximately five cubic meters overflowed. An Equipment Failure Report was issued by the ship to have the gauge repaired. The incident was recorded as a Pollution Prevention Equipment Issue summary. On March 21, 2018, Princess Cruise Lines, Ltd. and the State of Alaska entered into a Settlement Agreement to resolve concerns about insufficient sampling that were pending from the 2016 operating season. The agreement was to have been signed last year, but the signature ready version was not provided to Princess until earlier this year. To resolve the alleged violations, Princess agreed to pay $12,565.00 in civil penalties. While the Noordam was en route to Lautoka, Fiji, a crewmember accidentally dropped a metal screwdriver overboard. The crewmember stated that the screwdriver fell out of his breast pocket while he was leaning on the side railing. The violation of MARPOL Annex V was entered into the Garbage Record Book. At the time of the incident, the ship was approximately 161 nautical miles from the nearest land. Page 86 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 182 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00767 3/21/18 Costa Deliziosa CAM-00749 3/22/18 Carnival Freedom CAM-00752 3/22/18 P&O Oriana CAM-00769 3/22/18 HAL Prinsendam CAM-00770 3/22/18 PCL Coral Princess CAM-00753 3/23/18 Carnival Inspiration CAM-00754 3/23/18 Cunard Queen Victoria CAM-00756 3/23/18 PCL Grand Princess CAM-00772 3/24/18 Carnival Freedom Event Description June 21, 2018 CAM Incident Category While the ship was underway to Marseille, France, three sun beds were observed being lifted by the wind from an external deck and blown overboard, in violation of MARPOL Annex V. The sun beds were not recoverable. Initial on board investigations identified that the rope securing the sunbeds was broken by the severe gale wind (gusts up to 55 Knots). All equipment was lashed, however the wind gusts were stronger than expected. Authorities in Barcelona were informed of the incident via radio, as the vessel was inside the Spanish territorial waters. An entry in the Garbage Record Book was made. An engine room potable water distribution line failed and released potable water under high pressure into the engine room bilges. The engine team responded to the situation, stopping the leak and replacing the pipe. An estimated volume of 48 cubic meters of potable fresh water leaked into the bilges. The leak was found to have been caused by vibration-induced fatigue of the pipe structure. All spilled water was processed via the ship's bilge system and discharged overboard. Following departure from Southampton, UK, the Bridge issued an 'Exit of 12nm' notification email allowing food, bilge and sewage discharges to commence. At 22:16LT the Bridge issued a 75-minute “Notice to Enter 12nm” notification. At 23:00LT the Bridge issued a 'Vessel Closed for 12nm' notification. All discharges were closed. At approximately 00:00LT a garbage operator requested permission from the ECR to begin discharging food waste. The EOOW on watch incorrectly referred to the 'Exit of Voyage Planning 12nm' email and gave permission to begin discharging food waste. Approximately four cubic meters of comminuted food waste was discharged within 12 nautical miles of the French coast and within the North Sea MARPOL Annex V Special Area. The error was identified by the EOOW, the discharge was stopped immediately, and the MARPOL Annex V violation was entered in the Garbage Record Book. During the ship's call at Mindelo, Cape Verde, Portugal, while conducting a crew safety drill, half of a life raft hard shell made of plastic and fiberglass resin broke from its retaining lanyard and dropped in the water. A tender was immediately lowered into the Lifeboat/Tender water, but the attempt to recover the life raft shell was unsuccessful because it sunk shortly after. This accidental loss is a violation of MARPOL Annex V. An entry was made in the Garbage Record Book. The port agent and port authority have been informed. While underway to Oranjestad, Aruba, and 14NM from the nearest land, ship's crew were performing internal chipping and painting of the engine casing. During this process, some paint chips were blown out of the engine casing and onto external decks. There was no evidence that any of the paint flakes went overboard, but it was not a certainty. If some did go overboard, it would have been a MARPOL Annex V violation. An entry was made in the Garbage record Book. While the ship was alongside in Long Beach, CA, a crewmember reported that she had dropped her plastic cabin key into the water as she was ascending some stairs on the pier. The key could not be recovered. The port authority was notified of the MARPOL Annex V violation via the local agent. During provisions loading while the ship was alongside in Southampton, UK, stevedores struck a pallet of beer against a mooring bollard next to the loading platform. The contents spilled onto the stores platform and into the stores net, with two cases of beer entering the water. The beer was not recovered. The port authority was notified of the violation of MARPOL Annex V and an entry was made in the Garbage Record Book. During garbage offload operations while the ship was alongside in San Francisco, CA, a pallet of dry mixed garbage was spilled while it was being moved with a pallet truck on the pier. A cardboard box containing mixed linens, shoes, plastic bags and cardboard boxes fell into the water. Some of the items were recovered but some remained in the water in violation of MARPOL Annex V. The port authority was notified via the local agent and an entry was made in the Garbage Record Book. While the ship was within the North American ECA with the EGCS in operation, the SO2/CO2 sensor alarm activated. Troubleshooting was started and fuel was changed over to MGO within 80 minutes. A communication fault between the gas EGCS analyzer and EGCS computer was subsequently identified. Page 87 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 183 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description June 21, 2018 CAM Incident Category While the ship was alongside in Fort De France, Martinique, a crewmember accidentally dropped his plastic identification card into the water as he was walking along the pier. The card sank and could not be recovered. The port authority was notified of the Training MARPOL Annex V violation via the local agent. An entry was made in the Garbage Record Book. While underway to Zeebrugge, Belgium, a member of the Bridge Team observed a beer can and a cigarette being thrown overboard from a passenger cabin balcony, in violation of MARPOL Annex V. Ship's security identified the cabin but could not speak with the occupants who had already left. When the Security Officer spoke to the passenger and advised throwing items overboard was strictly prohibited, the passenger apologized. The incident occurred in international waters, so the authorities were not informed. An entry was made in the Garbage Record Book. CAM-00757 3/24/18 PCL Caribbean Princess CAM-00773 3/24/18 P&O Oceana CAM-00758 3/25/18 HAL Koningsdam While the ship was alongside in Oranjestad, Aruba, the Assistant Bosun dropped his UHF portable radio into the sea. The crewmember was signaling to the shore side linesman that all lines were fastened, when he lost his grip on the radio and it fell into Training the sea in violation of MARPOL Annex V. An entry was made in the Garbage Record Book and the local authority was informed. HAL Prinsendam During a full crew drill while the ship was alongside in Mindelo, Cape Verde Islands, a fabric hat was blown into the sea by a gust of wind. The incident occurred while the crewmember was walking on an open deck to perform his stairway guide duties. It was not possible to recover the hat. The ship's local agent was advised of the MARPOL Annex V violation and an entry was made in the Garbage Record Book. While the ship was en route to Hobart, Australia and outside 12 nautical miles from the nearest baseline, a full loss of propulsion occurred. At the time of the incident, the ship was discharging grey water, permeate, and bilge water in accordance with company policy. The ship's technical team were unable to secure all overboard valves before the ship's speed fell below six knots, resulting in an unintended discharge of grey water, permeate, and bilge water in violation of company policies. All overboard discharges were confirmed closed two minutes after the ship's speed dropped below six knots. Noncompliant discharge volumes were estimated at 800 liters of grey water and 400 liters of permeate. The BCDB counter recorded that 120 liters of <15 ppm processed bilge water was discharged. The incident did not result in any MARPOL violations. Also recorded as full loss of propulsion. CAM-00759 3/25/18 CAM-00760 3/25/18 PCL Sea Princess CAM-00775 3/25/18 Cunard Queen Mary 2 CAM-00776 3/25/18 PCL Star Princess CAM-00777 3/26/18 Carnival Sunshine CAM-00778 3/26/18 HAL Koningsdam The sample shut off solenoid and the flushing solenoid on a new OWS were found leaking past when closed. The OWS was taken out of service, both solenoid valves and OWS were replaced with a spares and the system returned to service. An entry was made OWS/Whitebox in the Oil Record Book. This was the second shut off solenoid valve to fail since installation of this new type of centrifugal OWS. While the ship was alongside in Honolulu, Hawaii, during the routine washing of an economizer, dark steam was noted coming from the funnel. The opacity percentage was not dropping below permissible limits, so the operations were stopped. It exceeded the hourly emission time limit by less than one minute. Local authorities were informed and an entry was made in the Engine Record Book. 445 kg of non-ODS R134a refrigerant gas leaked from a refrigeration system due to a leaking shaft seal on an A/C compressor. Refrigerants The seal was replaced and the system was tested and put back in service. While the ship was underway to Fort Lauderdale, Florida, the Engine Officer of the Watch reported a malfunction of the Oily Water Separator #2 sludge pump. The pump was cleaned, tested, and found to be functioning correctly. It failed again the next OWS/Whitebox day. The pump was subsequently replaced with the new one and the OWS was put back in service. The Operating Line Compliance Manager was notified of the failure of OWS/OCM system and subsequent repair, and two separate entries were made in the Oil Record Book. Page 88 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 184 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description CAM-00779 3/26/18 P&O Azura While en route to Alicante, Spain, the Bridge was notified by port authorities (UK) that pollution has been recorded in the wake of the ship by helicopter. Port authorities did not give any specific details. Initial investigations show no discharges took place inside 12 nautical miles of land. Officials from the Harbor Master's Office in Barcelona boarded the ship to investigate the incident. At the time of the alleged incident, the ship was discharging grey water and treated sewage. Prior to being notified by port authorities, the ship had discharged comminuted food in accordance with MARPOL and Global HESS. The ships logs were shown to the investigating officer, who was then satisfied that no illegal discharges took place. The officer issued a standard PSC certificate closing the investigation and showing that no deficiencies were found. CAM-00780 3/27/18 Carnival Fantasy While alongside in Cozumel, Mexico, a bamboo hat flew off the head of a passenger on the gangway and fell into the water, in violation of MARPOL Annex V. The hat could not be recovered. The incident was reported to port authorities by the ship's agent. CAM-00782 3/27/18 PCL Caribbean Princess During a routine inspection, the EO found a broken ECS seal installed on the vertical hatch of the intermediate sludge tank. During previous rounds, the same seal has been observed intact. An inspection of hatch bolts showed no signs of tampering. It is suspected that the seal was accidentally broken due to its proximity to a stepladder. CAM-00813 3/27/18 HAL Amsterdam CAM-00783 3/28/18 Carnival Freedom CAM-00784 3/28/18 Carnival Pride CAM-00785 3/28/18 Carnival Triumph CAM-00786 3/28/18 Costa Deliziosa CAM-00788 3/28/18 Cunard Queen Elizabeth June 21, 2018 CAM Incident Category Seals or Locks Training While the ship was alongside at Reunion Island, France, a monthly inspection of a ballast water tank identified a crack in a fuel oil tank and evidence of fuel oil seepage therefrom. The previous inspection was undertaken on February 13, 2018, at which time the tank was confirmed sound and clean. The leak from the crack was monitored and estimated at one drop every 10 minutes. The ballast water tank was isolated. Between February 13 and March 27, 2018, the ballast tank had been discharged in international waters on seven occasions. Entries were made in the ORB for every discharge and the ship's Classification Society and Flag Administration were informed. A temporary Passenger Ship Safety Certificate and a Condition of Class were issued. Temporary repairs were made with a structural brace and steel putty, which repairs were observed and approved by Class. The tank was scheduled to have been repaired at the subsequent dry-dock. In the interim period, it was monitored for leakage. While alongside in Mahogany Bay, Isla Roatan, a crewmember was painting the ship's hull from the pier. The pole of the paint roller accidentally hit the ID card that was clipped to the crewmember's coverall and the card fell into the water, in violation of MARPOL Annex V. The card could not be retrieved. The harbormaster was informed via the ship's agent. While the ship was alongside in Grand Turk, a passenger was reported to have dropped his driver's license into the sea due to windy conditions. The driver's license was not recovered. Port authorities were informed of the MARPOL V incident by the port agent. While the ship was alongside in Cozumel, Mexico, a crewmember accidentally dropped his ID card into the sea, in violation of MARPOL Annex V. The card could not be recovered. This incident occurred due to negligence and strong winds. The incident was reported to the harbormaster and documented in the ship's log. During routine provisions loading operations, while alongside in Venice, Italy, cardboard that was located on a pallet was observed falling into the sea between the pier and the shipside, in violation of MARPOL Annex V. The item could not be recovered as it sank immediately. The local port agent was immediately informed and requested to notify local authorities. An entry was made in the Garbage Record Book. During discharge of oily sludge ashore, while alongside in Xiamen, China, a weld crack was observed on the locking device of the sewage discharge to shore valve (welded flat steel bar) located in the starboard bunker station. The crack was suspected to have Seals or Locks been due to improper welding technique of two metals types. No unauthorized operation of the valve in question had taken place. The item was re-welded and repainted the following morning while the ship was at sea. Page 89 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 185 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00790 3/28/18 P&O Ventura CVL-2018-3-254 3/29/18 PCL Caribbean Princess CAM-00792 3/29/18 Carnival Magic CAM-00793 3/29/18 Carnival Magic CAM-00794 3/29/18 Carnival Splendor CAM-00795 3/29/18 Carnival Splendor CAM-00797 3/29/18 PCL Star Princess CAM-00816 3/29/18 AIDAluna CAM-00798 3/30/18 Carnival Elation Event Description While in port in Southampton, U.K., the ship was preparing to offload bilge water to a barge, however the key to unlock the discharge valve was missing. A thorough search for the key was conducted, which included a review of the key log and cabin searches. Despite all efforts, the key could not be found but no suspicious circumstances were observed. To avoid further delays to bilge offload the padlock to the bilge discharge valve was broken and the offloading operation was conducted. The broken padlock was replaced by a new ECP numbered padlock. The broken lock is being held by the Chief Engineer together with other broken seals. The ship could not establish why the key was missing, but was confident no unauthorized operation took place. The key compartment was locked and under CCTV surveillance. An individual who purported to have been a Carnival employee, made a telephonic report that he or she had observed certain other Carnival employees dumping "oil water with seawater" off the ship. The caller said that management was not aware of the incident. The caller identified it as a one-time environmental violation. While checking a fault alarm in the EGCS monitoring system, it was discovered that the UTC clock built into the system had been inoperative for 55 days, beginning on February 3, 2018. The issue was corrected two days later by ship personnel. Two ECP seals were found missing in the incinerator room. Upon inspection, one of the two missing seals was found broken and the other could not be recovered. Both seals were replaced with new numbered seals. The matter was immediately reported to the Captain, Chief Engineer, and Engine Team. The Chief Engineer confirmed that no unauthorized access was gained and the system was not improperly used. No sign of tampering was noted. An entry was made in the ship's seal log. Upon receiving an unexpected bilge alarm, it was discovered that a BCBD overboard valve located in the Evaporator Room starboard had a hole of approximately 3mm in diameter. The hole allowed sea water to enter the Evaporator Room. The leak was temporarily stopped by using a cement box. There was approximately 500 liters of sea water intake. The water was transferred into the bilge tank dirty side. While the ship was underway, sailing 90NM from the nearest land, a plastic life ring was noted missing from an open deck location. It is suspected that the life ring was thrown overboard by unidentified individuals, in violation of MARPOL Annex V. The missing ring was replaced with a spare. The incident was reported to the USCG (Long Beach sector) and was recorded in the ship's log. While transiting from Lahaina, Hawaii to Ensenada, Mexico, the crew received a complaint from passengers who observed the discharge of "dark water" at approximately 10:00 local time. The passengers stated that they had taken photographs and a video recording and indicated to an Assistant Maitre D' that they would report the Company to authorities. A review of the ship's operations showed that membrane bioreactor was being de-sludged between 08:34 and 10:22 local time. The initial assessment shows that these operations were in compliance with MARPOL and company guidelines as the ship was travelling over six knots (no less than 16.5 knots during the time in question) and well outside of 12 nautical miles from the nearest land (over 580 NM during the time in question). Following the manual sounding of a sludge tank, a discrepancy of approximately three cubic meters was noted between the sounding and the quantity indicated in the automation system. The initial assessment could not identify a root cause. It was presumed that the automation pressure sensor indicating the volume of sludge was not working properly. The sensors were purged but no different reading was obtained. While the ship was alongside in Freeport, Bahamas, a crewmember loaded a trolley with two cushioned plastic chairs and one plastic table. He left them unattended on the pier because he needed to return to the ship to retrieve additional items. The strong wind caused the trolley and the items on it to fall into the water, in violation of MARPOL Annex V. Crewmembers were able to retrieve the table and two cushions from the water. The chairs and the trolley sank and could not be retrieved. The incident was reported to local authorities. Page 90 of 94 June 21, 2018 CAM Incident Category Seals or Locks EGCS Training Seals or Locks OWS/Whitebox Training Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 186 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00799 3/30/18 Carnival Legend CAM-00800 3/30/18 Carnival Liberty CAM-00801 3/30/18 HAL Noordam CAM-00803 3/30/18 P&O Oceana CAM-00804 3/30/18 PCL Pacific Princess CAM-00819 3/30/18 Costa Atlantica CAM-00820 3/30/18 P&O Britannia CAM-00821 3/31/18 P&O Azura Event Description June 21, 2018 CAM Incident Category While at anchor in Lifou Isle, New Caledonia, an Engineer reported dropping a metal spanner into the sea while performing maintenance on a lifeboat, in violation of MAR POL Annex V. The Engineer stated that the tool accidentally slipped from his hand. The incident was reported to local authorities. While underway, a passenger reported to have dropped his cell phone overboard while leaning on the handrail of his cabin's balcony, in violation of MARPOL Annex V. At the time of the incident, the ship was sailing at more than 12 nautical miles from shore, but inside Bahamas Baseline. The incident was reported to local authorities via the port agent. While the ship was preparing for departure from Hobart, Tasmania, a crewmember accidentally dropped a plastic rat guard (40cm diameter) from the pier into the water while removing the rat guard from a line, in violation of MARPOL Annex V. The rat guard sank immediately and was not recovered. The local ship's agent was informed, and an entry was made in the garbage record book. The OCM of a centrifugal OWS was found to be unable to read values below 12 ppm when flushed with fresh water. The ship cannot process bilge water due to high ppm content. The OCM was replaced with a new OCM, but the ship was unable to test the OCM until the COWS was run. The bilge tank was discharged to shore. While the ship was alongside in Ancona, Italy conducting a crew drill, a life raft was inflated for training purposes and three plastic securing straps fell overboard and into the water, in violation of MARPOL Annex V. A Fast Rescue Boat was already in the water and was instructed to retrieve the straps, but they had already sunk. An entry has been made in the Garbage Record Book. The ships agent was informed and advised the local authority. During a system test while the ship was en route to Shenzhen, China, the OCM installed on an OWS was found in alarm and reading 20 ppm when flushed with clean water. The affected OCM was replaced and the OWS was put back in service. The subsequent monthly operational tests were successfully completed. The failure of the OCM was recorded in the Oil Record Book and the failed cell was to be sent ashore for cause analysis and repair. No bilge water was discharged to sea at any time as a result of the incident. During bunkering while the ship was alongside in Southampton, UK, a Process Application Controller (PAC) card went into alarm. The PAC card controls a number of valves including heeling valves needed for the bunkering operation. A decision was made to reset the PAC on completion of bunkering. When resetting the PAC, a number of valves closed, including the overboard valves for the EGCS system of the Diesel Generator (DG) that was online. The online DG operated on HFO with the EGCS offline for 60 minutes before the EOOW noticed. The EGCS system was then restarted. At the time of the incident, an upgrade to the EGCS system had replaced the control unit and associated software. This new system was not yet linked to the automation and there was no visible or audible alarm to alert the EOOW. The EGCS control panel was scheduled to have been connected with the automation system on April 15. Port Authorities were not notified. While alongside in Civitavecchia, Italy, winds in the morning had been in excess of 20 knots and a tug had been assisting the ship to remain on the berth. Around midday, the weather conditions improved, as forecasted, and the tug was stood down. Approximately four hours later watch keepers sighted a squall line approaching the ship and requested thrusters. The use of thrusters kept the ship initially alongside. However, approximately three to four minutes later as the wind increased further, tugs were requested as the wind strength started to exceed the thrusters’ and mooring lines’ capability. The ship started parting lines and lifting off the berth. The PEMS were made available as the ship lifted off the berth. The forward mooring station was closed up and the anchors were used to reduce the ship's movement across the harbor. Tugs and pilots were quickly on the scene to assist. Once conditions had improved, with tugs support and gangways recovered, the ship was berthed. Once alongside, passengers who were ashore were able to rejoin the ship. Assessments following the incident found 16 metal rat guards were lost, a bent fluke on the port anchor and a broken fluke on the starboard anchor. Mooring lines were recovered. The 16 metal rat guards and one fluke of the starboard anchor fluke were not recovered. Local port authorities were advised. There were no reported injuries. Also reported as other event of note. Page 91 of 94 OCM Lifeboat/Tender OWS/Whitebox OCM EGCS Training Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 187 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel CAM-00806 4/1/18 Carnival Legend CAM-00808 4/1/18 PCL Diamond Princess CAM-00822 4/1/18 HAL Maasdam CAM-00823 4/1/18 HAL Zuiderdam CAM-00825 4/1/18 P&O Oriana 18-2018 4/2/18 PCL Shore Side CAM-00827 4/2/18 Carnival Dream Event Description June 21, 2018 CAM Incident Category A passenger reported that while the ship was underway to Sydney, Australia, and more than 200 nautical miles from the nearest land, another passenger threw a cell phone and a small speaker overboard, in violation of MARPOL Annex V. The passenger who threw the items overboard was reminded of the Company's environmental policy and was issued a GSAR letter (Guest Status Advisory Report), which prohibits them from sailing with the operating line. While the ship was underway, the OCM on the Alfa Laval bilge separator was found to be defective. It was noted that upon flushing the OCM with fresh water, the reading did not fall below 13 ppm even after the cell was cleaned. The failure occurred OCM while the Alfa Laval bilge separator was recirculating a pre-separation tank. During this event, bilge overboard discharges were closed. A new OCM was installed and the separator was placed back in service. During the closing of the starboard aft tender platform following completion of tender operations in Lahaina, HI, a hydraulic hose burst and spilled approximately 50 milliliters of non-biodegradable hydraulic oil onto the deck. No hydraulic oil was spilled Lifeboat/Tender overboard and the spill was cleaned up with absorbent pads. The faulty hydraulic hose was replaced and all other hoses were checked and found in good condition. As a precaution, all the hydraulic hoses on the starboard forward platform were replaced. Following completion of bunkering operations while the ship was alongside in Port Everglades, FL, an internal bunker transfer was started from the ECR. Shortly after the transfer pump was started, oil was noted to have been pouring into the starboard bunker break. The transfer of fuel was immediately stopped and it was found that a sample valve had been left open, allowing the Training oil to leak. The main bunker valve was confirmed closed and the blind flange was secured. It was also verified that the scupper drain was plugged and were no traces of oil to the bunker break door or any indications of any discharge to the sea. A spill response team was sent to clean the area. An intoxicated passenger threw a potted plant overboard. The incident was witnessed by another passenger who reported it to housekeeping. The passenger was escorted to his cabin and the Bridge was notified. The MARPOL Annex V violation incident was recorded in the Garbage Record Book. On behalf of Princess Cruise Lines, Ltd. and Carnival Corporation & plc, I write to inform you of information that recently came to our attention concerning a prohibition on de-ballasting in Port Everglades that is included as a term of a port tariff (Tariff No. 12, Item No. 1015). We were previously unaware of the tariff provision, and as a consequence a number of Covered Vessels have de-ballasted in Port Everglades in contravention of the tariff provision. As part of our review of this issue, we learned that other customers of the port were similarly unaware of the tariff provision. A meeting was held on April 2, 2018 with the Port Everglades Deputy Port Director to discuss the discharge prohibition, as it is inconsistent with federal ballast water regulatory requirements. Also in attendance at the meeting were representatives from Royal Caribbean Cruises, Ltd., Crowley Maritime, and Kirby Offshore, who were similarly situated. The port is open to reviewing this issue and has agreed to research the Vessel General Permit and USCG Ballast Water Management program requirements in advance of considering a modification of the tariff to reflect an approach that is more consistent with federal requirements. The Deputy Port Director also stated he was open to reviewing case by case ballast water discharge waiver requests if needed for ship stability/safety reasons. We are currently reviewing the facts and will provide additional information once we have completed our review. We have notified the Deputy Port Director of the violations of which we are aware and will provide him with any information he requests. We will update you accordingly. During a routine check of ECS seals installed on critical fittings, the EO noted that one seal was missing from the manometer delivery line of a sewage treatment plant. No signs of tampering were found around the location or on the sewage plant itself. Maintenance and cleaning of the sewage plant had been completed two days prior to the seal being found missing. It is suspected Seals or Locks that the seal was broken during the maintenance of the sewage plant as the manometer is located at shoulder height and adjacent to the passageway. A new seal was fitted and the Seal Log was updated to reflect the change. Page 92 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 188 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description 4/2/18 HAL Nieuw Amsterdam CAM-00829 4/2/18 HAL Westerdam CAM-00831 4/3/18 HAL Volendam CAM-00833 4/3/18 PCL Diamond Princess While the ship was en route towards Kota Kinabalu, Malaysia, a passenger dropped his cell phone overboard. At the time of the incident, the ship was outside 12 nautical miles. The violation of MARPOL Annex V was entered in the Garbage Record Book. CAM-00834 4/4/18 Carnival Elation A ship's plastic life ring was reported missing by the Safety Officer. It is unknown when the life ring was lost. No emergency was associated with the loss. The area was searched and the life ring was assumed to have been lost overboard in violation of MARPOL Annex V. The U.S. Coast Guard was informed of the loss. Carnival Sunshine While the ship was underway within the Bahamas Baseline, two minor passengers were observed throwing two yellow plastic caution cones overboard. A Security Officer spoke with the parents of the minors, who apologized for their misconduct. The Security Officer reminded the parents about company environmental policy and the consequences of violation. The Bahamas Port Authority was notified of the MARPOL Annex V violation and it was confirmed that no further action was required. PCL Coral Princess During sludge offload to a barge while alongside in Cartagena, Colombia, the duty wiper reported that sludge was spraying from sludge hose. He activated the emergency stop button. There was no indication of a discharge/spill into the sea. Most of the sludge was collected in second containment barriers with the rest on the floor of the bunker station. The total amount spilled was approximately 40 liters. The incident occurred because the pressure had blown the rubber end of the hose from its nozzle. The hose had been pressure tested on February 27, 2018, and the pressure during the offload was monitored from the ship's side by the motorman. The Harbor Master was informed of the near miss via the local agent. Seabourn Odyssey While the ship was alongside in Fort-de-France, Martinique, a leaking black water pipe was identified in the aft engine room. Approximately a third of a cubic meter of sewage had leaked into the bilge well. The sewage was transferred to a dirty lubrication oil tank and subsequently processed via the ship's sludge tank. An entry was made in the Oil Record Book. The leak was internal with nothing discharged overboard. Corrosion created a pinhole in the pipe. A new pipe was fabricated and installed. HAL Koningsdam During tendering operations in Tabuaeran, Kiribati, two temporary buoys used to indicate the safe passage for tenders, started to drift away due to the current. The Port Authority, who had approved the temporary buoys, were informed. One plastic buoy was recovered by a local boat after three hours of searching but the second buoy was lost in violation of MARPOL Annex V. It had been necessary to use temporary buoys to mark the safe channel as no official buoys were in place. An entry was made in the Garbage Record Book. CAM-00839 CAM-00840 CAM-00844 4/4/18 4/4/18 4/4/18 4/5/18 CAM Incident Category During an abandon ship drill while the ship was alongside in Grand Turk, Turks and Caicos Islands, a life raft was inflated for training purposes. The life raft's upper shell fell overboard and into the water due to the failure of the container tie lines connection Lifeboat/Tender to the shell. The shell was recovered using a ship's tender. While the ship was approaching Puerto Quetzal, Guatemala, a leak of non-biodegradable oil was observed on the deck below a lifeboat. The leak originated from the hydraulic pressure control box for the davits. There was no spill of oil into the sea. Prior to Lifeboat/Tender clean up of the spill, the scuppers were blocked off and absorbent pads were used to collect the oil. The ship departed Tianjin, China, approximately three hours late due to delays in the immigration departure clearance. As the authorities were not able to predict the delay, the ship burned HFO in violation of local regulations for one hour as the fuel change over from MGO to HFO was completed for the scheduled departure time. The fuel was changed back to MGO to limit the violation. The ECR was advised of the delay at the scheduled time of departure of the delay. The immigration clearance process Voyage Planning was projected not to take a long time. After an hour of continued delays by immigration officials, the ship commenced to shift back to MGO and completed it within 30 minutes. The ship was not fined and the local authority was informed. The ship's arrival at the next port was not affected. The ship operated in an efficient manner to minimize the use of HFO in port while properly managing their overall fuel consumption and mix. CAM-00828 CAM-00835 June 21, 2018 Page 93 of 94 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 189 of Appendix E: ECP Year One 205 Incidents Tracked by the CAM CONFIDENTIAL Reference No. Date of Event Brand/Vessel Event Description CAM-00845 4/5/18 HAL Noordam CAM-00846 4/5/18 HAL Veendam CAM-00848 4/5/18 PCL Crown Princess CAM-00849 4/6/18 Carnival Vista CAM-00850 4/6/18 Costa Deliziosa CAM-00851 4/6/18 HAL Noordam CAM-00853 4/7/18 Carnival Freedom CAM-00854 4/7/18 Carnival Freedom CAM-00855 4/7/18 Carnival Freedom CAM-00856 4/7/18 HAL Noordam During a routine check, the EO noted that an ECS seal was missing from a wet food waste tank vent in the garbage room. The missing seal was not found. No signs of tampering could be identified. It was determined that the seal was most likely removed during cleaning which had been conducted in the area in the previous week. The seal was replaced and recorded in the Seal Log. CAM-00857 4/7/18 PCL Grand Princess The ship departed from San Francisco, CA, approximately one hour later than scheduled due to faulty flow meter readings on the Ballast Water Treatment Systems, which resulted in slow de-ballasting operations. The ship's arrival into the next port was not affected. June 21, 2018 CAM Incident Category While the ship was alongside in Picton, New Zealand, a communication error between the BCDB data recorder and the ECR data recorder was identified. An Oily Water Separator discharge operation was found not to have been recorded in the ECR system. OWS/Whitebox The Oil Content Monitor and the three-way valve in the BCDB were checked and confirmed to be functioning correctly. While the ship en route to Georgetown, Grand Cayman, a ship's sun umbrella was blown overboard. The MARPOL Annex V violation was recorded in the Garbage Record Book. At the time of the Incident, the ship was more than 12 nautical miles from the nearest land. While the ship was en route to Funchal, Madeira, a fault was identified with the automatic ballast overboard valve. The valve, which is also designated as an emergency bilge discharge, was taken out of service and an alternate valve was designated as a temporary emergency bilge discharge. It is believed that the affected automatic ballast overboard valve may have been installed the wrong way around during the recent dry-dock period. The fault was identified when the ship attempted to de-ballast. The ship's Flag Administration has been informed. All other bilge/ ballast pumps and overboard valves have been checked and found in good working order. While the ship was en route to Miami, FL, and 32 nautical miles from land, a Security Officer witnessed a passenger throwing a golf club overboard in violation of MARPOL Annex V. The passenger was spoken to regarding company environmental policy and the consequences of violation. During a routine check of the portable pumps, two ECS seals were noted missing from an air-driven portable pump in the damage control equipment cage. An assessment determined that the pump had not been used to transfer any liquid and the seals were likely Seals or Locks to have been broken during the preparation of luggage cages prior to the ship's turnaround. The portable pump was relocated to a Training more protected position, a new seal was attached, and the Seal Log was updated. While the ship was alongside in Wellington, New Zealand, a passenger's hat was blown into the water as he proceeded ashore. The hat was not recovered. The MARPOL Annex V violation was recorded in the Garbage Record Book. The Port Authority was notified via the ship's local agent. During loading of provisions in Galveston, Texas, a shore side worker placed a pallet of watermelons on the ship's platform. Due to the pallet not being correctly positioned on the platform, the pallet tilted causing a number of watermelons to fall. All the watermelons were recovered from the netting placed below the ship's loading platform. During provision loading in Galveston, Texas, a shore side worker punctured a one gallon bucket of paint hardener. The ship's bosun immediately separated the punctured can and deployed absorbent materials from the bunker station. No spilled chemical entered the water. While alongside in Galveston, Texas, as a passenger was boarding the ship, he dropped his paper boarding pass, which was blown overboard and into the water in violation of MARPOL Annex V. The Harbor Master was informed by the ship's local agent. No additional actions were requested. Page 94 of 94 Seals or Locks Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 190 of 205 CONFIDENTIAL June 21, 2018 ATTACHMENT 1: SUPERSEDING FIRST ANNUAL WORK PLAN AND BUDGET OF THE COURT APPOINTED MONITOR [See following pages] Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 191 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS Superseding First Annual Work Plan and Budget of the Court Appointed Monitor United States v. Princess Cruise Lines, Ltd., 1:16-cr-20897-PAS (S.D. Fla.) For the Period April 19, 2017 – April 18, 2022 Submitted October 20, 2018 Pursuant to the status conference before the Hon. Patricia A. Seitz (U.S. District Court) on October 18, 2017, in the matter of United States v. Princess Cruise Lines, Ltd., 1:16-cr20897-PAS (S.D. Fla.), the Court Appointed Monitor (“CAM” or “Monitor”) submits this Superseding Annual Work Plan and Budget, dated October 20, 2017 (“Superseding Work Plan”). This document supersedes the First Annual Work Plan and Budget, dated August 1, 2017, and the Addendum, dated August 30, 2017, and constitutes the Work Plan and Budget of the Court Appointed Monitor for the duration of the monitorship unless the parties agree to modifications. As to budget, the parties agreed that the CAM will conduct up to 15 vessel visits and up to 5 shoreside visits per year. The parties further agreed that for those vessel visits and shoreside visits the fees of the CAM Team, as defined below to include the CAM, CAM attorneys, and CAM advisors will not exceed $3,000,000 for the first year of the monitorship. In subsequent years, this cap on fees will be adjusted in accordance with Section 4.5 of the Monitor Agreement, entitled “Fee Increases.”1 Associated costs and expenses are not subject to this cap.2 As to the amount of fees to be charged for work other than vessel visits and shoreside visits, the parties anticipate that the annual fees for the CAM Team, as defined below, are anticipated to fall between $3,000,000 and $4,000,000 in the first year. In subsequent years, this amount shall be adjusted in accordance with Section 4.5 of the Monitor Agreement, entitled “Fee Increases.” The following categories of work, however, shall not be counted towards the anticipated fee amount: (1) fees associated with any Monitor Work Plan and Budget (such as work plan drafting, the preparation of explanatory letters or documents, the preparation of addenda, or work plan negotiation); (2) fees incurred in preparation for the October 18, 2017, court status conference; (3) fees associated with Carnival’s contest of CAM bills; and (4) major contingencies that may arise during the course of the monitorship. As noted above, costs and expenses are also not 1 Section 4.5 of the Monitor Agreement provides: “Fee Increases. From time to time, rates for members of the Monitor Team, other than the Monitor, may increase, for among other reasons, to keep pace with the market for such services. When Katten rates are raised, the rates for Katten attorneys will increase accordingly, but such increases shall be reasonable and shall not result in a rate that exceeds the lowest hourly rate charged to any Katten client with comparable annual billings. As part of the engagement of any advisor by the Monitor, as set forth in Section 4.2, the Monitor will instruct the advisor that any increase in the advisor’s rate shall likewise be reasonable and not result in a rate increase that exceeds the lowest hourly rate charged to any client of that advisor with comparable annual billings. Any rate increases for members of the Monitor Team will be communicated to the Company at least sixty days in advance of their implementation. Rate increases will not apply retroactively.” 2 In order to reduce travel expenses, for travel booked on or after September 27, 2017, the CAM Team agrees to use the Company’s travel service, except for unannounced visits. 1 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 192 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS included in this amount anticipated for fees. Carnival retains the right to contest any bill by asking the court to review the bill in question. I. Introduction On May 15, 2017, the Company and Mr. Solow entered into a Monitor Agreement that provided that, effective March 21, 2017, Mr. Solow would serve as the Monitor as required by the Environmental Compliance Plan (“ECP”) prepared pursuant to the plea agreement in United States v. Princess Cruise Lines, Ltd., 1:16-cr-20897-PAS (S.D. Fla.). Retention of the CAM is a special condition of the defendant’s five-year period of probation. Mr. Solow was retained by the Company to perform the CAM role in accordance with both the ECP and the Monitor Agreement. The Company has over 120,000 employees operating on vessels and at locations around the globe and utilizes a complicated corporate structure. In addition to an overall “all brands” group, the Company is segmented into four groups: Carnival, Costa Group, Carnival UK, and Holland America Group. Each of these groups has its own executive structure and all but Carnival operate more than one cruise ship brand. Eight of the Company’s ten brands operate “Covered Vessels” as defined in the ECP. See ECP § I.D. Currently, there are 75 Covered Vessels, which are flagged in seven different countries. Policy-making and systems across groups are not uniformly integrated, resulting in varying policies and procedures across brands. Due to the complex organizational structure of the Company and the requirements under which they operate, the Company uses a variety of systems to implement some of the requirements of the ECP. For example, there appear to be ten different computer-based training systems utilized by the Company, in addition to training conducted at a Company-owned facility in Almere, Netherlands. The Court, at the sentencing and the October 18, 2017, status conference, made clear that the CAM’s mandate was broad and citied the Judgment and Commitment entered, as well as ECP Section VI.F.4. which provides: During years one (1) through four (4) of the probationary period, conduct a review of CARNIVAL internal environmental audits with respect to Covered Vessels and Covered Personnel, as well as the trends analysis overseen prior to the end of year three (3) by the CCM. The CAM’s review shall assess the ability of CARNIVAL’s internal audit process to accomplish the objectives of this ECP, including any inadequacies with respect to CARNIVAL’s performance, whether personnel-based or related to any of its Covered Vessels, systems, equipment, or components. Accordingly, the ECP requires the CAM to oversee that the Carnival entities fully comply with all “applicable marine environmental protection requirements established under applicable international, flag state, port state, coastal state law, and United States laws including, but not limited to, the International Convention for the Prevention of Pollution from Ships 2 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 193 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS (‘MARPOL’), and all applicable Federal and state statutes and regulations including, but not limited to the Ports and Waterways Safety Act (’PWSA’), the Act to Prevent Pollution from Ships (‘APPS’), the Clean Water Act (‘CWA’), and [the Oil Pollution Act of 1990 (‘]OPA 90[’)], (MARPOL, APPS, CWA, and OPA 90, collectively, ‘Marine Environmental Protection Requirements’),” as well as the requirements and policies established by the ECP itself. See ECP § I.C. The Company has agreed to fully fund and implement these requirements for all “Covered Vessels” and “Covered Personnel,” as those terms are defined in the ECP. See ECP § I.D. The CAM’s rights, powers, and responsibilities arise out of the ECP (the “CAM mandate”). Pursuant to Section VI. of the ECP, the CAM’s mandate broadly comprises the following categories: 1. Monitoring the Company’s compliance with the ECP. See ECP § VI.A. This includes: a. Assessing whether the Company has adequate systems in place, particularly human and fiscal resources, to ensure regulatory compliance, correct noncompliance, and prevent future non-compliance. See ECP § VI.B.2. b. Reviewing the Company’s internal audits and audit processes as they relate to the objectives of the ECP and assessing “the ability of CARNIVAL’s internal audit process to accomplish the objectives of this ECP, including any inadequacies with respect to CARNIVAL’s performance, whether personnelbased or related to any of its Covered Vessels, systems, equipment, or components.” See ECP § VI.F.4.-5. c. Identifying and analyzing violations of the ECP identified during the term of probation. See ECP §§ III.A.11. III.D.6., III.E.3.-5., VI.A., VI.F.6.-7. 2. Confirming that the Third Party Auditor (“TPA”), retained by the Company pursuant to ECP Section VII., acts with independence and performs adequate ECP-required audits. See ECP §§ VI.F.1.-3. 3. Evaluating the effort and commitment of the Company in satisfying the requirements of the ECP and its Environmental Management System (“EMS,” as defined in ECP § I.D.), including assessing and making recommendations with respect to a culture of compliance.3 See ECP § VI.B.3. 3 During the sentencing hearing conducted on April 19, 2017, Judge Patricia A. Seitz stated “it concerns me that the culture really needs to be changed and [I’m] looking to Mr. Solo[w] to assist.” Transcript of Sentencing at 13, United States v. Princess Cruise Lines, Ltd., 1:16-cr-20897-PAS (S.D. Fla.). Later in the hearing, Mona Ehrenreich, Senior Vice President and General Counsel of Holland America Group stated “we’re committed to working with the court-appointed monitor and the third-party auditor over the next five years to continue to enhance our compliance program even more, and our focus is a culture of compliance.” Id. at 36. 3 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 194 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS In addition, the ECP identifies a number of specific written submissions and reports required of the CAM, as follows: 1. An annual report prepared for submission to the Company and Interested Parties4 regarding: (a) the audits conducted by the TPA; (b) any other information pertaining to the Company’s capabilities to meet the objectives of the ECP; and (c) the Company’s internal audits and trends analyses. See ECP § VI.F.3-5. 2. Reports to Interested Parties regarding: (a) any Environmental Open Report, which covers a credible allegation of a violation of any Marine Environmental Protection Requirement or ECP requirement, (b) information regarding a Major NonConformity, or (c) information regarding a failure of the Company to consider and act on, as appropriate, an Audit Finding or TPA recommendation. ECP §§ III.D, VI.F.6. 3. Additional reports to the Company and Interested Parties, as requested by the Court or as appropriate, concerning any of the issues related to the Monitor’s duties outlined in the ECP. ECP § VI.F.7. This includes quarterly status updates requested by the Court during the October 18, 2017, status conference. As contemplated by Section 4.2 of the Monitor Agreement, Mr. Solow has engaged advisors, including the marine consulting firm of Martin, Ottaway, van Hemmen & Dolan, Inc. (“Martin & Ottaway”), to assist him in the implementation of the monitorship. In addition, Katten serves as counsel to Mr. Solow in his role as CAM, and Katten attorneys will assist Mr. Solow in the execution of his role. The CAM, his counsel, and his advisors shall be collectively described as the “CAM Team.” This Work Plan and Budget outlines the activities the Monitor plans to complete during the term of the monitorship. The work streams contemplated by this Work Plan have been discussed extensively with the Company. This precise nature of the work, however, will necessarily remain flexible to allow the Monitor to adjust planned activities in response to issues that may arise during the course of this work. II. Background The CAM Team began the work of the monitorship by undertaking a series of phone interviews and discussions with key personnel from Carnival Corporation and plc, as well as from each of the four operating lines as follows: 4 The Government, the U.S. Probation Office for the Southern District of Florida, the Seventh Coast Guard District, and the U.S. Coast Guard Office of Investigations & Analysis. ECP § I.D. 4 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 195 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS • from Carnival Corporation and plc, four (4) people were interviewed with responsibilities for Health Environmental Safety and Security (“HESS”) system policy implementation and training5; • from Carnival UK, seven (7) people were interviewed with responsibilities for operations, compliance, resourcing, and deployment6; • from Carnival Maritime Group, five (5) people were interviewed with responsibilities for governance, compliance, human resources, operations, and training7; • from Holland America Group, eleven (11) people were interviewed, including the Operating Line Compliance Manager and others with responsibilities including environmental compliance, ethics and compliance, operations, technical services, workforce management, personnel, and engineering8; • from Carnival Cruise Lines, eleven (11) people were interviewed with responsibilities for compliance, operations, human resources, marine planning/budgeting, and technical assets9. 5 Discussions were held May 15-16, 2017 with the following Carnival Corporation and plc representatives: (1) John Haeflinger, Vice President, Maritime Policy and Analysis; (2) Paul Morgan, Vice President Maritime Compliance, Maritime Quality Assurance; (3) John Allen, ECP, Corporate Training Manager; and (4) Maria Rodriguez, Manager, Training and Communication. 6 Discussions were held May 16, 2017 with the following Carnival UK representatives: (1) Adrian Box, Vice President Fleet Operations (2) Nigel Stewart, Fleet ISM Support Manager, Operating Line Compliance Manager (“OLCM”); (3) Martin Thomas, Senior Manager, Maritime Safety Training; (4) Adam Shelmerdine, Fleet Resourcing Manager; (5) Lynn Cossey, Senior Manager, Vetting & Compliance; (6) Stacey Marlow, Director, Deployment & Partnerships; and (7) Jacqueline Floyd, Shore Resourcing Manager. 7 Discussions were held May 17, 2017 with the following Carnival Maritime Group representatives: (1) Ernesto Gori, Vice President Fleet Governance; (2) Alessandro Bertorello, OLCM; (3) Tino Hensel, Vice President Marine Human Resources; (4) Andre Trommler, Head of Marine Human Resources, Fleet Operations; and (5) Bernd Migeod, Head of Marine Training. 8 Discussions were held May 17, 2017 with the following Holland America Group representatives: (1) Paul McClelland, Vice President Environmental, OLCM; (2) Angela Wagner, Director, Ethics and Compliance; (3) Ed Ramaekers, Vice President, Technical Operations, Princess Cruise Lines; (4) Rob Boksem, Senior Vice President, Technical Services; (5) Eric Visser, Director, Workforce Management; (6) Lance Camarena, Director, Fleet Training; (7) Tina Stotz, ECP Manager; (8) Jim Peschel, Senior Director, Environmental; (9) Federico Cozzani, Director, Shipboard Marine Personnel; (10) Peter Paisley, Fleet Director of Engineering; and (11) Konstantin Konstantinov, Manager, Environmental Operations. 9 Discussions were held May 18, 2017 with the following Carnival Cruise Lines representatives: (1) Domenico Rognoni, Vice President Compliance and Occupational Safety, OLCM; (2) Martin Landtman, Senior Vice President Marine Operations (3) Richard Miller, Vice President Marine, Nautical, & Safety Operations; (4) Rabih Aboudargham, Director of Environmental Compliance; (5) Jose Hernandez, Director of Compliance; (6) Scott Nelson, Vice President, Shipboard Human Resources; (7) Adrian 5 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 196 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS These interviews were conducted to gain information about the Company’s structure, operations, and processes that are implicated by the terms of the ECP. The CAM sought visibility into how the Company as a whole and each operating line individually, approaches key issues relevant to the monitorship including: recruiting, hiring, training, maintenance, budgeting, and HESS policy implementation. The CAM also participated in in-person meetings with the Operating Line Compliance Managers (“OLCMs”) of each operating line and the Corporate Compliance Manager (“CCM”) to discuss ECP implementation and the process of conducting audits aboard vessels.10 In addition to these meetings and discussions specifically identified above, the CAM and his Team have regular calls with the CCM, with corporate personnel to discuss document and information management, and with the TPA to discuss implementation and feedback from the TPA audit activities, as well as numerous ad hoc conversations with Company representatives. On July 7-11, 2017, at the request of the Company, the CAM Team participated in an orientation visit to the Ruby Princess on a voyage from Seattle, Washington to Juneau, Alaska. The purpose of this visit was to discuss and walk through the audit process. These foundational and ongoing discussions, various meetings with the Company, and site visits have informed the scope and nature of this Work Plan. III. Monitorship Methodology and Work Streams This Work Plan is tailored to meet the CAM’s mandate. It was developed after extensive consultation and negotiation with the Company. The CAM, with assistance and support by members of the CAM Team , will discharge the CAM mandate during the term of the monitorship through seven primary work streams: (1) management and contingencies; (2) document and data review; (3) interviews and site visits; (4) vessel visits; (5) shoreside facility visits; (6) compliance culture assessment; and (7) reporting. Greystroke, Vice President, Crew & Travel Operations; (8) Silvio Gentile, Marine Operations; (9) JP Kost, Compliance Data Manager; (10) Jessica Cespedes, Director, Marine Planning/Budgeting; and (11) Kevin Blake, Director, Technical Assets. 10 Meetings were held May 22-23, 2017 with the following Company representatives: (1) Chris Donald, CCM; (2) Aubrie Brake, Manager, Corporate Environmental Compliance; (3) David Morrison, Vice President Maritime Quality Assurance Fleet Chief Engineers; (4) Domenico Rognoni, Vice President Compliance and Occupational Safety, OLCM, Carnival Cruise Lines; (5) Ernesto Gori, Vice President Fleet Governance, Outgoing OLCM Costa; (6) Alessandro Bertorello, Incoming OLCM Costa; (7) Nigel Stewart, OLCM Carnival UK; (8) Paul McClelland, Vice President Environmental/OLCM. 6 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 197 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS 1. Management and Contingencies Undergirding the successful execution of the CAM’s mandate to monitor the Company’s compliance with the ECP, see ECP §§ III.-V., VI.A., and report on findings to the court, the Company, and Interested Parties, see ECP § VI.F., will be the management and oversight of monitorship work streams. These functions will include: (1) planning, (2) budgeting, (3) coordination, (4) tasking, (5) supervision, (6) knowledge management, and (7) organization. This will also encompass the time spent by the CAM and CAM Team coordinating with the U.S. Probation Office, discussing the monitorship with the Department of Justice (“DOJ”) and other government agencies as needed, and preparing for and appearing in court. With respect to contingencies, this category is an effort to plan for issues that arise that implicate the CAM’s mandate. For example, violations of the ECP may require additional vessel visits, interviews, document review, or other unplanned work. 2. Document and Data Review. An essential element in executing the role of the CAM in accordance with the CAM mandate is the review of records and information to determine, among other things, the extent and nature of the company’s training materials, the compliance baseline of the company, the logistics and methods of corporate operations, and ongoing compliance with the ECP and regulatory requirements by and through such corporate operations. This derives from the ECP’s requirements, inter alia, that the CAM: monitor the Company’s compliance with the ECP, see ECP § VI.A.; review all reports and notifications as established in the ECP, see ECP § VI.E.; review records necessary to perform his duties, see ECP § VI.F.2.; review TPA audit reports and related documents, see ECP § VI.F.3.; review the Company’s internal environmental audits and audit processes, see ECP § VI.F.4.; review “information regarding a Major Non-Conformity” or failure of the Company to “consider and act upon, as appropriate, an Audit Finding or recommendation of the TPA,” see ECP §§ III.A.6., VI.F.6.; review the TPA’s reports, see ECP § VIII.D.10.; and review the Company’s EMS, see ECP § X.A.II. The CAM Team has worked with the Company to implement a streamlined and costeffective review of documents and data. Accordingly, the CAM Team and the Company have developed an agreed-upon protocol for the request of information, the response to information requests, and management of produced information in coordination with designated Discovery Liaisons at the Company. As part of this effort, the Company and CAM Team have agreed to utilize a Relativity-based platform through the Company’s preferred vendor, Strategic Legal Solutions, to process and house the records provided in response to CAM information requests. Access to the platform is being provided to the Company, the CAM Team, and the TPA. The CAM Team has developed and implemented two specific methods for the request and production of records and information pursuant to the Records Management and Production 7 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 198 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS Protocol. The first method involves the submission of formal document requests by the CAM to the Company. These requests are designed to facilitate CAM access to records and information relating to execution of all three categories of the CAM’s mandate. During the term of the Work Plan, formal document requests will cover, but are not limited to, the following types of information related to HESS programs, ethics issues, and general corporate compliance: • • • • • • • • • corporate and brand-specific policies, corporate and brand-specific procedures, corporate and brand-specific training materials, job descriptions of Covered Personnel, personnel records of certain Covered Personnel, technical and other records related to Covered Vessels, internal audit reports and supporting documentation, corporate and brand-specific financial information, and corporate and brand-specific budget documents. In connection with the Company’s financial and budget information, the requests and review of the CAM will focus on the budgeting process for ongoing and capital expenditures connected to the Company’s HESS programs. This will include an assessment of the OLCM budgets required by the ECP, see ECP § III.A.9, and related company budget practices, including the process for development and revision of ECP-related and environmental budgets. As of the date of this Superseding Work Plan, the CAM is not seeking to engage advisors with forensic accounting expertise to assist with this aspect of document review and analysis, but may seek the Company’s consent, as required by the Monitor Agreement, to do so at a later date should it be necessary. As of the date of this Work Plan submission, records have been produced by the Company in response to six formal CAM document requests; this does not include information housed in various corporate databases, including Global HESS, that have been made available to the CAM Team. The second method for the request and production of records and information is designed to facilitate the execution of categories 1.c. and 3. of the CAM’s mandate. The Company has agreed to provide the CAM with the Company’s weekly report of incidents, which is maintained in the general course of business (“flash report”), as well as information regarding Major NonConformities, Non-Conformities, or other Observations reported by employees. See ECP § III.A.11. The CAM will review, assess, and track such information, and will report out to the Interested Parties as required by the ECP. Finally, pursuant to category 1.c. and 2 of the CAM’s mandate and ECP Sections IV.F.2.5, the CAM Team will review and assess the TPA audits and the internal environmental vessel and shoreside audits conducted by the corporate Risk Advisory and Assurance Services 8 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 199 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS (“RAAS”) department. This review will dovetail with the data collected and assessed during the vessel and shoreside visits discussed further below. Interviews and Site Visits During the first year of the monitorship, the Company and the CAM agreed that the CAM should conduct interviews of corporate executives and key personnel from each of the operating groups, brands, and the CSMART training facility. Consistent with the ECP, see e.g., ECP §§ III.-V., VI.A., VI.B.2., VI .F.6-7., the purpose of these interviews has been to facilitate the execution of categories 1.a., 1.c., and 3. of the CAM’s mandate by gathering and assessing information on the structure, management, culture and systems of each operating line; engaging with corporate executives or employees on their role in implementing the ECP and corporate compliance generally; exploring management views on compliance-related issues; and gathering additional information regarding identified concerns or incidents. The interviews also provided insights into the unique management and compliance challenges faced by each of the relevant operating lines. The CAM Team worked closely with Christopher Donald, the Corporate Compliance Manager (“CCM”), and Mr. Donald’s team to organize the logistics of these interviews. The CAM concluded the interviews planned for the first year of the monitorship on October 6, 2017. Should circumstances present a need to do so, the Monitor may elect to conduct additional interviews. The CAM may also seek to conduct additional interviews in the second through fifth years of the monitorship. 3. Vessel Visits To facilitate execution of all three categories of the CAM’s mandate and consistent with the CAM’s obligation to ensure compliance with vessel-related requirements of the ECP, including to assess the work of the TPA, see, e.g., ECP §§ III.D., IV., VI.A.,F., IX., X., XI., the CAM (or CAM designee) and members of the CAM Team will conduct up to 15 vessel visits per year for the duration of the monitorship.11 For the first year of the monitorship, as of October 20, 2017, the CAM Team has conducted 2 vessel visits. Based on consultation with the Company, four separate types of vessel visits will be conducted, as discussed further below: (a) TPA audit ride-alongs; (b) TPA follow-up vessel visits; (c) CAM-specific vessel visits; and (d) RAAS audit ride-alongs. Vessels may be visited more than once. These CAM Team vessel visits are not intended to be redundant or to duplicate audits conducted by the TPA or RAAS. The CAM Team visits are designed to, among other things: (1) assess the adequacy, quality, and value of TPA and RAAS audits; (2) assess whether the Company has adequately and promptly addressed Observations or Non-Conformities previously 11 This maximum number is based on the agreement of the parties with the understanding that should an extraordinary and unanticipated event occur, the CAM may seek to conduct additional vessel visits. 9 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 200 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS identified in TPA or RAAS audits, or by classification societies or others related to environmental pollution control obligations; and (3) assess the overall effectiveness of the Company’s efforts to provide the training, equipment, resources and support to the ships, so that those aboard are in a position to meet the obligations the Company agreed to in the ECP. To do so, we expect that these vessel visits will generally involve opportunities: to speak with shipboard personnel; to review vessel and shoreside actions taken in response to prior audit findings and vulnerability assessments; to review training and supervision efforts and their effectiveness; and to look at machinery spaces and pollution prevention equipment, including key documents related to pollution prevention and ECP compliance. These vessel visits will not, however, track the extensive checklist examinations conducted by TPA and RAAS auditors. The ECP requires the TPA to audit all Princess vessels and 20% of the Covered Vessels from the other operating lines. ECP § VIII.A. In accordance with the ECP, the TPA also developed a list of vessels to be audited during the term of the Work Plan. The Monitor engaged Dr. Scheuren to assist in the preparation of a vessel list for the types of CAM vessel visits, described below, using a cumulative results and risk-based approach. The CAM has developed plans to visit vessels consistent with the categories below. a. TPA Audit Ride-alongs The CAM Team plans to accompany the TPA on some scheduled TPA audits. The purpose of these visits will be to inform the CAM’s assessment of the independence and rigor of the TPA audits and auditors. During these audit ride-alongs, CAM team members will observe the TPA’s audit activities. b. TPA Follow-up Visits The CAM Team plans to perform follow-up visits to vessels previously audited by the TPA during the term of the Work Plan. The purpose of these visits will be two-fold. First, the CAM Team will assess whether the TPA’s prior audit on a particular vessel was independent, rigorous, and in accordance with the TPA’s planned audit process. Second, the CAM Team will assess the Company’s support for and efforts to comply with the ECP, including: (a) whether adequate systems and resources are in place designed to ensure regulatory compliance, correct non-compliance, and prevent future non-compliance; (b) an assessment of the effectiveness of prior RAAS audits; and (c) follow-up regarding identified violations of the ECP, including Maritime Environmental Protection Requirements, if applicable. c. CAM-specific Vessel Visits The CAM Team plans to visit vessels that the TPA did not, or will not, audit during the term of the Work Plan. During these visits, the CAM Team will assess the Company’s support for and efforts to comply with the ECP, including (a) whether adequate systems and resources are in place that are designed to ensure regulatory compliance, correct non-compliance, and 10 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 201 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS prevent future non-compliance; (b) the effectiveness of prior RAAS audits; and (c) follow-up regarding identified violations of the ECP, including Maritime Environmental Protection Requirements, if applicable. d. RAAS Audit Ride-alongs The CAM Team plans to accompany the RAAS auditors on scheduled RAAS vessel audits. The purpose of the CAM Team visits will be to fulfill the requirement that the CAM assess whether the RAAS audit process accomplishes the objectives of the ECP, including any areas for improvement with respect to the performance of RAAS audits. During these ride-along visits, CAM team members will observe the RAAS auditor’s activities. Because the activities outlined above will take place simultaneously in various areas of the ship, the Monitor anticipates that between three to four CAM Team members will attend each visit. Participants will include the CAM or a designee, a CAM attorney, and one or two advisors from Martin & Ottaway. There may be occasions where it may be necessary for additional CAM Team members to attend a vessel visit. 4. Shoreside Facility Visits To facilitate execution of all three categories of the CAM’s mandate and consistent with the CAM’s obligation to ensure compliance with shoreside-related requirements of the ECP and to assess the work of the TPA, see, e.g., ECP §§ III.A., IV.A.5., V.A., B., VI.A, F.2., VIII.A.1., B. D.1., the CAM (or CAM designee) and members of the CAM Team will conduct up to five shoreside visits per year during the term of the monitorship. During at least one of these five annual visits, the CAM Team will accompany the TPA on a scheduled TPA shoreside audit. Pursuant to the ECP, the purpose of this visit will be for the CAM to assess whether the TPA is conducting independent and rigorous audits in accordance with its planned audit process. During this shoreside visit, CAM Team members will observe the TPA’s audit activities. For shoreside visits not conducted with the TPA, the CAM Team’s visit will be conducted after the scheduled TPA audit at the relevant facility. The purpose of these shoreside visits will be two-fold. First, pursuant to the ECP, the CAM Team’s visit will assess whether the TPA’s prior shoreside audit was independent, rigorous, and in accordance with the TPA’s planned audit process. Second, the CAM Team’s visit will examine the Company’s compliance with the ECP, including (a) whether adequate systems are in place to ensure regulatory compliance, correct non-compliance, and prevent future non-compliance; (b) an assessment of the effectiveness and value of prior RAAS audits; and (c) follow-up regarding identified violations of the ECP, including Maritime Environmental Protection Requirements, if applicable. Each shoreside visit will address the resources designated to ensure regulatory compliance, correct non-compliance, and prevent future non-compliance. To supplement information obtained from the documents received and reviewed as part of the formal document 11 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 202 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS request process described above, the CAM Team will confer with relevant personnel and conduct additional information gathering, as necessary. To conduct the shoreside visits efficiently, the Monitor anticipates that between two to four CAM Team members will attend each shoreside visit. Participants will include the CAM or a designee, a CAM attorney, and one or two advisors from Martin & Ottaway, as necessary. There may be occasions where it may be necessary for additional CAM Team members to attend a shoreside visit. 5. Compliance Culture Assessment As directed by the Court, and consistent with discussions held by the CAM with the DOJ and with the Company, the CAM will utilize a culture survey to aid the efforts of all parties in assessing both the strengths and the opportunities for improvement in the Company’s culture related to its compliance obligations. See n.3, supra. This is encompassed by the CAM’s duty under the ECP to monitor the Company’s compliance with the ECP, see ECP § VI.A., and to assess whether the Company has adequate systems in place to ensure regulatory compliance, correct non-compliance, and prevent future non-compliance, see ECP § VI.B.2. As agreed by the government and the Company, the Monitor will retain and oversee the work of a third-party to provide services needed for the implementation of this work. The retention of a consultant by the CAM, as opposed to by the Company, will require the Company’s cooperation with respect to drafting contracting documents and providing the CAM with the necessary permissions, releases, and authorities. The consultant retained by the CAM will be skilled in the delivery of corporate culture surveys and will provide the services needed to develop and deliver an appropriate survey instrument designed to measure compliance culture, including in the areas of technical engineering, human resources (including training), bridge and engine room management, shoreside ship supervision, shared services, and corporate management. An initial survey, conducted early in the monitorship, will provide a baseline for the assessment of corporate compliance culture. A second survey will be conducted before the completion of the five year probationary period for comparison purposes. While safety culture surveys are routinely conducted in the maritime and many other industries, the focus of this culture assessment will seek to encompass the interrelated obligations of safety, health, and environmental compliance. It will also be tailored to account for the issues and challenges particular to maritime operations. The Company and the CAM have agreed to work closely and collaboratively together to facilitate the administration of the survey across relevant company populations in a cost efficient manner. Following administration and receipt of the survey data, focus groups may also be used to clarify observed trends and responses. A final report on the survey will be provided to the Company by the CAM, subject to the non-disclosure and confidentiality agreement in this matter. 12 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 203 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS 6. Reporting In accordance with ECP Section VI.F.3, the CAM will prepare an annual report for submission to the Company and Interested Parties regarding: (a) the audits conducted by the TPA; (b) any other information pertaining to the Company’s capabilities to meet the objectives of the ECP; and (c) the Company’s internal audits and trends analyses. See ECP § VI.3.-5. The report will also capture the work implemented during the Work Plan term to execute the CAM’s mandate, as set forth in the work streams described above. At the October 18, 2017, status conference, the Court also requested quarterly status updates. The CAM plans to submit its first annual report to the Court, which will cover the period of April 19, 2017 to April 18, 2018, on June 17, 2018. In accordance with categories 1.c. and 3. of the CAM’s mandate, as well as the CAM’s affirmative obligation pursuant to ECP Sections III.D. and VI.F.6., to report out to the Interested Parties (regarding Major Non-Conformities, certain Environmental Open Reports, and failure of the Company to act on, as appropriate, an Audit Finding or TPA recommendation), the CAM Team members will assess and track incidents reported in weekly flash reports and other selfreported incidents submitted by the Company. Additional reporting may also be required pursuant to ECP Section V.F.7., which provides for reports to the Company and Interested Parties, as requested by the Court or as appropriate, concerning any of the issues related to the Monitor’s duties outlined in the ECP. IV. CAM Team The CAM Team includes attorneys and advisors with a range of relevant professional experiences. Team members will be deployed based on respective skill sets to manage cost and efficiency. At the direction of the CAM, Katten associates and paralegals will prepare for, and follow-up to, CAM visits and interviews, including document intake and review, witness interview preparation, coordination of logistics, and drafting of interview notes and overviews. At the direction of the CAM, Katten partners will manage and implement work streams (with the support and assistance of Katten associates), while retained advisors, such as Martin & Ottaway, will provide substantive expertise in a cost-effective manner. The primary CAM Team attorneys, listed alphabetically below, have experience in environmental and maritime law, internal investigations, corporate compliance programs, and corporate monitorships: • Matthew Baker. Mr. Baker is a member of the Environmental and Workplace Safety practice who focuses his practice on environmental white collar law, internal investigations, and complex electronic discovery. 13 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 204 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS • Anne Carpenter. Ms. Carpenter is a member of the Environmental and Workplace Safety practice who concentrates her practice on environmental and white collar law, with an emphasis on civil and criminal environmental and maritime enforcement. • Lily Chinn. Ms. Chinn is a former trial attorney in the Environment and Natural Resources Division of the DOJ, the managing partner of the San Francisco Bay Area office, a member of the Environmental and Workplace Safety practice, and the cochair of the Electronic Discovery and Information Governance practice; she focuses on civil and criminal defense. • Nadira Clarke. Ms. Clarke is a former trial attorney in the DOJ Environment and Natural Resources Division, a former Assistant U.S. Attorney in the District of Maryland, a former Special Assistant U.S. Attorney in the Eastern District of Virginia, the head of Katten’s Litigation practice in Washington, D.C., and a member of its Environmental and Workplace Safety practice. She has long provided advice to corporations regarding their compliance programs and protocols, and is providing counsel to a monitor in another matter involving an international company subject to a court-ordered monitorship. • Scott Elliott. Mr. Elliott is a member of the Environmental and Workplace Safety practice and counsels clients on conducting internal investigations and responding to government investigations, as well as on environmental, health, and safety culture. • Mark Farley. Mr. Farley is co-head of Katten’s Environmental and Workplace Safety practice and was one of the lead partners supporting the work of the BP US Refineries Independent Safety Review Panel, which investigated the corporate safety culture and oversight at BP’s North American refineries on behalf of an independent panel of experts chaired by former U.S. Secretary of State James A. Baker III. • William Pericak. Mr. Pericak is a member of the White Collar, Investigations and Compliance practice and the Environmental and Workplace Safety practice. Mr. Pericak is a former Assistant U.S. Attorney in the Northern District of New York and a prosecutor in the DOJ’s Criminal Division. Bill’s work at the DOJ included serving as the Director of the Deepwater Horizon Task Force, overseeing prosecution of criminal violations relating to the 2010 Deepwater Horizon explosion and oil spill in the Gulf of Mexico. • Natalia Sorgente. Ms. Sorgente is a member of the Environmental and Workplace Safety and Litigation practices. She is a former senior DOJ official who served as Chief of Staff for the Environment and Natural Resources Division and later as an Associate Deputy Attorney General; her practice focuses on civil and criminal litigation, internal investigations, and corporate compliance. 14 Case 1:16-cr-20897-PAS Document 105 Entered on FLSD Docket 04/10/2019 Page 205 of 205 CONFIDENTIAL NOT FOR DISCLOSURE BEYOND INTENDED RECIPIENTS The CAM Team attorneys also include seven Katten associates from the Environmental and Workplace Safety practice. Additional Katten attorneys may be added, as necessary. The CAM Team attorneys will be supported by Katten paralegals and project assistants, who have a variety of relevant professional skills and experience. The primary CAM Team advisor is Martin & Ottaway, a maritime consulting firm in operation for over 100 years with experience related to complex technical, operational, and financial problems. The firm has extensive experience in vessel-related regulatory compliance and has served as both a third-party auditor and a CAM in other matters. Martin & Ottaway was retained by the CAM to advise and assist in the execution of the monitorship. The primary Martin & Ottaway consultants are: • Jim Dolan: Mr. Dolan is the President Emeritus of Martin & Ottaway, and has been a member of the firm for over 25 years. Mr. Dolan specializes in ship survey issues, casualty investigations, quality/safety/environmental issues, and vessel appraisals. He has provided expert testimony in maritime legal matters in both U.S. and international disputes. • Pierce Power: Mr. Power is a Partner with Martin & Ottaway and has been a member of the firm for over 20 years. Mr. Power specializes in forensic engineering, mechanical systems, structural and mechanical system surveys, and overhaul and failure analyses. • David Tantrum: Mr. Tantrum is the Managing Director of Martin & Ottaway and has been a member of the firm for over 20 years. Mr. Tantrum specializes in forensic engineering, ship vetting surveys, mechanical systems and ship sales analysis, structural and mechanical system surveys, ship valuations, and failure analyses. 15