Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the Maritime Institute of Technology & Graduate Studies
Linthicum, Maryland, October 1, 1996


Good afternoon ladies and gentlemen. Thank you for inviting me to be part of Training 2000 here at MITAGS to address you concerning safety in marine transportation.

As you are aware, the 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 happen again.


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 they need.

But, 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 to occur.

The Safety Board has investigated numerous groundings, collisions, fires and bridge rammings involving tankships, container ships and passenger vessels where human error was identified as a probably cause item.

For example, human error is being explored as a factor contributing to an accident that happened just last Friday. The Liberian tankship, JULIE N, rammed the Portland Bridge in Portland, Maine. More than 168,000 gallons of oil were discharged lost into the waterway, and the ship sustained substantial damage. The bridge is damaged but open to vehicular traffic. There are reports of extensive ecological damage as a result of this accident.

The man piloting the vessel at the time told NTSB investigators that he inadvertently gave the wrong rudder command as the vessel was approaching the bridge. Although he stated that he immediately corrected the order, the ramming was not avoided. Our investigation continues.

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 all of us.

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 of it.

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 Guard.

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 time.

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 subordinates.

Using BRM methods and skills is not new. Many effective mariners use them intuitively. But, of course, others do not.

Another example of deficient use of resources occurred on November 6, 1993, when the passenger ship NOORDAM collided with the bulk carrier MOUNT YMITOS near Southwest Pass, Louisiana. Fortunately no lives were lost and no oil spilled. However, damage to the two vessels and lost revenue for the NOORDAM amounted to more than $10 million.

Several human errors contributed to the accident. The watch officers assigned to the NOORDAM's bridge that night did not adhere to basic watchkeeping standards and therefore did not identify the MOUNT YMITOS until it was about a mile away and closing at 23 knots.

The master of the MOUNT YMITOS had identified the NOORDAM when it was 5 miles away, but assumed that the passenger ship would soon turn. He made no attempt to confirm this assumption while evasive action was still an option.

On the NOORDAM, a watch change was occurring at the time of the collision. Nine people were on the bridge, but they seemed to have been more occupied with other tasks rather than keeping watch. The departing watch officers did not use their radar; the oncoming watch crew did check the radar, but for some reason did not see any approaching ships.

The bridge officers on the NOORDAM did not recognize the extent to which their performance had deteriorated. If the precepts of BRM training had been employed aboard the NOORDAM, it is likely this accident would not have occurred.

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 weakness.

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 were substantial.

The ROYAL MAJESTY was fitted with an integrated bridge system designed to assist bridge officers with voyage planning, navigation, shiphandling and collision avoidance tasks.

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.

The Safety Board's preliminary investigation into this grounding raised such safety concerns that they warranted the issuance of urgent safety recommendations last year, relating to potential failures of integrated bridge systems.

We also conducted a public forum in March of this year to address these and other safety concerns related to integrated bridge systems aboard ships. It is hoped that information gathered during the forum will lead to effective recommendations and help improve maritime safety.

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.

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 am happy that those of you involved in training recognize the importance of your activities to marine safety. Thank you for your attention and for inviting me here today.

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