St. George, Staten Island, New York
October 15, 2003
NTSB Number: MAR-05-01
NTIS Number: PB2005-916401
Adopted March 8, 2005
About 1520 on October 15, 2003, the Staten Island Ferry Andrew J. Barberi, owned and operated by the New York City Department of Transportation, was near the end of a regularly scheduled trip from Manhattan to Staten Island when it allided with a maintenance pier at the Staten Island Ferry terminal. Fifteen crewmembers and an estimated 1,500 passengers were on board. Ten passengers died in the accident and 70 were injured. An eleventh passenger died 2 months later as a result of injuries sustained in the accident.
Hundreds of emergency personnel and dozens of emergency vehicles, including several vessels, responded to the accident, dispatched by the New York City Police Department, the New York City Fire Department (including emergency medical services), the U.S. Coast Guard, and the U.S. Army Corps of Engineers. Damages totaled more than $8 million, with repair costs of $6.9 million for the Andrew J. Barberi and $1.4 million for the pier.
The National Transportation Safety Board determines that the probable cause of this accident was the assistant captain's unexplained incapacitation and the failure of the New York City Department of Transportation to implement and oversee safe, effective operating procedures for its ferries. Contributing to the cause of the accident was the failure of the captain to exercise his command responsibility over the vessel by ensuring the safety of its operations.
The Safety Board's investigation of this accident identified safety issues in the following areas:
As a result of its investigation, the Safety Board makes recommendations to the New York City Department of Transportation, the U.S. Coast Guard, the States that operate public ferries, and the Passenger Vessel Association.
As a result of its investigation of the Andrew J. Barberi allision, the National Transportation Safety Board makes the following safety recommendations.
To the New York City Department of Transportation:
Require your licensed pilots to provide proof of compliance with the Coast Guard medical certification requirements. (M-05-01)
Adhere to your October 2005 target for implementation of a comprehensive safety management system, incorporating all matters recommended by the Global Maritime and Transportation School assessment, and ensuring medical fitness oversight (requiring, minimally, assurance of compliance with Coast Guard requirements). (M-05-02)
As part of your response to the Global Maritime and Transportation School assessment, fully comply with the technology-related recommendations of the Global Maritime and Transportation School, and establish a recurrent evaluation process to assess the use of navigation technology. (M-05-03)
To the U.S. Coast Guard:
Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations. (M-05-04)
In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers. (M-05-05)
Seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so. (M-05-06)
To the States Operating Public Ferries:
Encourage your public ferry operators to voluntarily request application of the Federal requirements at 33 CFR 96 for implementing a safety management system, if they have not already done so. (M-05-07)
To the Passenger Vessel Association:
Encourage your member ferry operators to voluntarily request application of the Federal requirements at 33 CFR 96 for implementing a safety management system, if they have not already done so. (M-05-08)