Remarks of Jim Hall, Chairman
National Transportation Safety Board
International Marine Transit Association
Vancouver, Canada, September 23, 1996
Good afternoon ladies and gentlemen.
I am pleased to be here at the International Marine Transit Association
to address you concerning safety in marine transportation.
As you may be aware, the United
States National Transportation Safety Board is charged with improving
the safety of the public by recommending changes in government
and industry transportation policies, practices, and systems through
independent accident investigations.
The CHALLENGER accident; the
EXXON VALDEZ; the derailment of Amtrak's Sunset Limited in Mobile,
Alabama; the nation's worst drunk driving accident that killed
27 schoolchildren and adults in Carrollton, Kentucky; and the
recent ValuJet and TWA tragedies. All of these accidents captured
the attention of the nation and the world, all of them were investigated
by the National Transportation Safety Board.
Since its inception 29 years
ago, the NTSB has investigated more than 100,000 aviation accidents
and thousands of surface accidents as the world's premier transportation
accident investigation agency. We maintain a list of Most Wanted
Safety Accomplishments, which we update every year. These are
recommendations that, in the Board's estimation, would accomplish
the most safety benefits to the traveling public. For example,
currently on the 18-item list are the safety of small passenger
ships and fishing vessels, fatigue in transportation, and issues
regarding youth highway crashes.
On call 24 hours a day, 365 days
a year, Safety Board investigators travel throughout the country
and to every corner of the world to investigate significant accidents,
developing a factual record that often leads to the issuance of
safety recommendations aimed at ensuring that such accidents never
Transportation accidents kill
tens of thousands of Americans a year and cost our economy hundreds
of billions of dollars annually. We oversee the safety responsibilities
of all the DOT modal agencies, yet to give you an idea of our
relative sizes, the Safety Board's annual budget would fund the
Department of Transportation for just nine hours.
And just recently, the Board
has been given a new role, that of coordinator of federal services
to families of victims of aviation accidents. This is a new challenge
for my agency, but one that I think we all agree needs to be met.
The traditional way that family members were dealt with in the
past has proven unworkable today.
Under a directive issued by President
Clinton two weeks ago, and under legislation passed by both houses
of Congress, my agency will coordinate services provided by federal
agencies like the State and Defense Departments and FEMA, and
by private groups like the Red Cross. We've learned from recent
accidents that there has to be a central authority that family
members can turn to when they feel they are not getting the information
I bring this up only as a note
of caution to you. No one expects to have a catastrophic accident,
and therefore it seems no one is fully prepared for one. I urge
your companies to draw up plans for how you would handle not just
the media onslaught, but the needs of potentially hundreds of
family members who will descend upon your city and your company.
I expect that once we have geared
up to fulfill this new responsibility, my agency will be happy
to meet with your personnel to share our experiences and describe
potential pitfalls you should avoid.
Returning to our investigative
role, the Safety Board attempts to determine first what happened
in an accident and then, by establishing a "probable cause,"
why it happened.
The Board has increasingly found
the answer to that question in what is termed "human error."
This is because over the years the machinery has become more reliable
and many of the obvious "hardware" fixes have been made.
Concepts unheard of years ago, like "corporate culture,"
now illuminate for us how some human error problems are made inevitable
by the context established for the human operator long before
the accident scenario begins.
Individual human errors do not
occur in a vacuum. They take place within a cultural, social and
organizational context. That is, there are underlying causes and
conditions that shape, facilitate or even nurture the behavior
and actions of an accident-causing individual. These causes and
conditions arise from government, industry, or individual company
policies, procedures and programs that either do not exist or
do not properly address the issues at hand. The Safety Board often
cites such underlying contextual factors as precursors to human
error accidents. The Mobile accident that I'll talk about shortly
was such a case.
When our investigations identify
human errors and the factors that help facilitate them, we recommend
changes, corrections, and mitigating strategies to the government
and industry entities best able to affect change and enhance safety.
Our process though, does not end with a recommendation. The Safety
Board is also proactive and seeks to disseminate information to
a wide audience to facilitate safe transportation and protection
of the public.
The impact of transportation
accidents on American society is significant. More than 44,000
people died in all modes of transportation in 1995, 900 in marine
accidents. Monetary cost estimates run as high as $100 billion.
The costs to individual companies can be staggering. The EXXON
VALDEZ has cost billions to date.
I'll take a moment to remind
you that while the Safety Board listed several elements in its
probable cause of that accident, the first was an individual human
error. The third mate was cited for his failure to properly maneuver
the vessel because of fatigue and excessive workload.
Three other elements of the probable
cause were contextual, in that they provided the environment in
which the first could occur. Personnel and manning policies encouraged
employees to work long hours, particularly during cargo handling
operations. The Coast Guard Vessel Traffic Service was ineffective
because of inadequate equipment and manning levels, inadequate
personnel training and deficient management oversight. And, the
Board cited a lack of effective pilotage service. Consequently,
in its simplest terms, the accident was the result of individual
human errors within an organizational context that allowed them
The impact of such accidents,
of course, extends far beyond the individuals or organizations
involved. They have an effect on U.S. public policy and government,
and thus can affect you.
The same is true of accidents
in other modes of transportation. A 1987 collision between an
Amtrak train and Conrail freight engines in Chase, Maryland resulted
in the tragic deaths of sixteen people. The monetary cost for
Amtrak alone was $82 million.
I mention this particular railroad
accident because it had ramifications for all modes of transportation,
including the marine industry. If you recall, that accident involved
a train crew who had been smoking marijuana on duty. The public
and Congress were outraged, and the accident became a catalyst
for producing the federal drug testing regulations under which
the marine industry operates today.
Given this backdrop of accident costs and implications, and the pervasive nature of human errors, it is vitally important to recognize and address the interrelationship between the two.
To illustrate the types of human
errors we see, how they lead to an accident and what preventive
measures might be taken to preclude their future occurrence, I
will touch on a few more recent accidents.
Errors resulting from the lack
of training and sufficient experience came to the forefront in
1993 as a result of the nighttime collision of the towboat MAUVILLA
and its nearly 400-foot barge flotilla with a railroad bridge
over the Big Bayou Canot near Mobile, Alabama. The impact displaced
a bridge girder, causing the derailment of an Amtrak train eight
minutes later. Forty seven people died.
The cause of the accident was
a tow boat operator who became lost and disoriented in dense fog.
He had no experience operating in fog, and though he had radar
aboard his boat, he had no formal training in the use and interpretation
The enabling context included
the towboat, itself, and the training of the operator. The boat
was not equipped nor was it required to be equipped with a compass
or charts that may have helped the operator correct his error.
Likewise, the radar could certainly have been of assistance if
the operator's knowledge had been more than rudimentary. Formal
radar training was not required by either the company or the Coast
The MAUVILLA accident cost 47
lives and nearly $20 million in equipment damage, not to mention
the unknown amount of civil liability. Such a cost to society
is unacceptable. However, the accident could have been prevented
if regulators and overseers of safety, both in government and
the private sector, had realized the need to more fully equip
and train the operator, and recognized the vulnerability of bridges.
Three years ago in Tampa Bay,
the nature of communications played into an accident involving
three vessels, two carrying petroleum products. The collisions
resulted in a fire and explosion on one ship and an ocean clean-up
cost of $25 million.
The Safety Board identified a
contributing cause to that accident as the failure of the pilots
and masters of the vessels to adequately communicate their intentions
to each other. The vessels had talked to one another, but had
not supplied all the pertinent information, with everyone assuming
what the others would do, rather than working it out ahead of
Which brings me to the subject
of Bridge Resource Management, or BRM. BRM is a direct outgrowth
of cockpit resource management, or CRM, from the aviation industry,
and is a shining example of transportation modes being willing
to learn from successes in other modes. In 1978 a United Airlines
DC-8 crashed, with multiple fatalities, about 6 miles short of
the runway when it ran out of fuel.
From the flight data recorder,
our investigation revealed that the pilot and co-pilot were preoccupied
with a hydraulic anomaly while they circled the airport. The flight
engineer was aware of the fuel situation and mentioned it, but
not forcefully enough to shift the pilot's focus. As a result
of that accident, we recommended that the FAA review its flight
training program and place more emphasis on participative management
for captains and assertiveness training for the other members
of the flight team. That was the beginning of CRM.
BRM has somewhat varying definitions,
but in general it is the utilization of all available resources
-- equipment, information, and personnel -- to achieve safe vessel
operation. It involves a sense of shared responsibility. The master
must integrate the resources available at any given time through
his or her leadership and command authority while at the same
time indicate a willingness to accept operating information from
Using BRM methods and skills
is not new. Many effective mariners use them intuitively. But,
of course, others do not.
A final human performance issue that deserves attention is a modern one. It involves society's need to adapt itself to the electronic age, the faith we put in these systems and how easily we can confuse accuracy and ease of use with dependability.
Automation can provide great
benefits to all modes of transportation, provided it is properly
designed to incorporate human strengths and compensate for human
As the level of automation increases,
the role of the human in the system becomes increasingly supervisory.
This brings human frailties such as maintaining alertness and
vigilance to the forefront.
Humans bear the ultimate responsibility
for recognizing, interpreting, compensating for, and correcting
or mitigating the consequences of deficiencies and malfunctions
in the hardware and software, and ironically in their own performance.
Because the human retains responsibility for the system, regardless
of its level of automation, human/machine system failures are
often reported as human error.
But system failures can result
from contextual factors masked as human failure. To illustrate
my point, I will cite a current Safety Board investigation. On
June 10, 1995, the Panamanian passenger ship ROYAL MAJESTY
grounded about 10 miles east of Nantucket Island, Massachusetts.
There were no injuries but lost revenue and damage to the vessel
The ROYAL MAJESTY was fitted
with an integrated bridge system designed to assist bridge officers
with voyage planning, navigation, shiphandling and collision avoidance
The autopilot portion using programmed
information and position data from the vessel's Global Positioning
System (GPS) and LORAN-C units, was capable of automatically steering
the vessel along a predetermined route. The autopilot was engaged
and operating in this mode for the 32 hours preceding the accident.
During the investigation, the
Safety Board learned that the shield wire component of the GPS
antenna cable had separated from the connection at the antenna,
causing the unit to transmit inaccurate position data to the integrated
bridge system. Neither the system nor the bridge watchstanders
detected the failure before the accident, nor were the alarm systems
adequate to the task. The ship grounded 17 miles off course.
By the way, finding yourself
miles from where you thought you were is not an embarrassment
left solely to mariners. Last September we learned of a transatlantic
jetliner that landed in Brussels, Belgium, rather than where the
crew thought they were going, Frankfurt, Germany.
Another major factor in many
human performance accidents is fatigue -- a subject the Safety
Board addressed in a proactive effort. In November 1995, the Board
and NASA sponsored a multimodal symposium titled "Managing
Fatigue in Transportation." In our almost 30-year history,
we have investigated accidents in every mode of transportation
in which the effects of fatigue, circadian factors and sleep loss
have been found to be causal or contributory. The Safety Board
has issued nearly 80 fatigue-related safety recommendations since
1972 to the modal administrations in the Department of Transportation,
transportation operators, associations and unions. Yet, these
issues continue to permeate our society and place a heavy burden
on safety and productivity.
The Safety Board and NASA produced
a Fatigue Resource Directory that provides a wealth of available
resources to help you tailor a fatigue reduction program for your
company's operation. The directory can be found on NASA's home
page on the internet. I would encourage you to use it.
The 4 ferry vessel accidents
we've investigated since 1981 were all collisions in fog and resulted
in no deaths, 100 injuries and almost $1 million in damages. They
all were attributed to speed in fog and the improper use of radar.
Following the ESTONIA disaster
in 1994, the Society of Naval Architects and Marine Engineers
in the United States empaneled a committee, which included the
Safety Board, to study the broad area of Roll On/Roll Off ferry
safety. The panel conducted model tests of various hull forms
and delved into the technical aspects of damage stability and
watertight integrity and reviewed human performance issues.
In the fall of 1995, their recommendations
were forwarded to the Coast Guard, the U.S. representative to
the International Maritime Organization. As a result, important
amendments to the Safety of Life at Sea regulations were made
concerning damage stability, phasing out of the one-compartment
standard on RO-RO ferries for existing vessels by 2010, evacuation
arrangements, and lifesaving systems.
In closing, it is clear that
accidents have broad implications. They can have a catastrophic
impact on lives and the environment, and effect public policy,
regulators, ship users and ship owners. We must work diligently
to prevent them. We must educate ourselves about human capabilities
and frailties, design our ships and their systems to accommodate
those human abilities, effectively equip and train personnel to
safely operate ships, and progressively refine the process until
we get it right.
I commend you for recognizing
the importance of safety by inviting me to keynote this conference
and for your attention to my remarks. Thank you.