Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
Remarks to the Passenger Vessel Association
St. Louis, Missouri February 7, 2011


Thank you Jay [Spence] for your kind introduction. It has been a few years since the NTSB has participated in PVA's annual convention, so I am very pleased to be with you this morning. I would like to introduce Liam Larue, one of our marine safety investigators who is attending the conference this weekend. Liam and the other NTSB investigators are responsible for all of the work that goes into the investigations that I am going to talk about today.

It is my hope that when you leave here this week, you'll take home some information to improve the safety of your operation, whether it is a single vessel family sightseeing business or a high volume fleet.

First, I recognize that, fortunately, very few members of PVA have worked directly with us.

So for those of you not familiar with the NTSB, we are an independent agency charged with investigating transportation accidents, determining their probable cause and making recommendations to prevent future casualties. We have a staff of 400 accident investigators, laboratory scientists and transportation specialists. In many ways, they are like the CSIs of transportation.

Since 1967, the NTSB has investigated thousands of accidents and incidents across all modes of transportation aviation, rail, highway, pipeline and maritime. By investigating why accidents happen, we can prevent future tragedies.

We do not have regulatory authority, which is an important distinction from the U.S. Coast Guard and other maritime authorities.

Over our 40 year history, we have issued 14,000 recommendations, and ultimately it is up to the recipients, whether the PVA, the Coast Guard, or an individual operator, to implement them. Although, we can't compel anyone to comply with our recommendations, I am pleased to report that over 80% of our recommendations have a positive acceptance rate.

The NTSB and the Coast Guard both have investigative responsibilities so when there is a maritime accident, we follow our Memorandum of Understanding to determine which agency will lead the investigation.

Generally the NTSB takes the lead when there are significant casualties; however we may also investigate smaller accidents that involve significant safety issues, and our investigators often are called to assist the Coast Guard with its investigations.

Now that I've identified who we are, I'd like to highlight a few passenger vessel accidents from around the country. As a result of our investigations, we've issued recommendations addressing SMS, on-board fires, out-of-water survival gear and average passenger weights.

You were fortunate to hear from Admiral Papp yesterday afternoon. I have a great deal of respect for the Commandant and the Coast Guard for their complex mission. The Commandant and I talk regularly, and I know there are a number of regulatory activities that were mandated in their authorization passed by the Congress last year.

I understand the Commandant mentioned Safety Management Systems in his speech yesterday. Our investigations demonstrate that an effective SMS can be a valuable tool in addressing safety deficiencies.

SMS is not a new concept. It was pioneered by the maritime industry in the late 1980's following a number of serious international accidents caused by human error, and contributed to by faulty management. These management failures were famously characterized as "the disease of sloppiness."

In 1993, the International Maritime Organization (IMO) adopted the International Safety Management Code. Now, some 20 years later, SMS is on the horizon for domestic passenger operations.

As you try to get your head around what an SMS might mean for your operation, let me begin by telling you that an SMS crafted to simply check the box is not going to help you or your crews: it must be used in order for it to be effective.

Here, I am reminded of launching with our team to the Cosco Busan container ship allision with the San Francisco Bay Bridge, which resulted in a release of 53,000 gallons of fuel. While an SMS is required by the IMO on all international vessels, in the investigation of the Cosco Busan we cited the failure of the operator to train the crew and ensure that the crew understood and complied with the company's safety procedures.

When I visited the bridge of a similar vessel from a different part of the world in the port of San Francisco, they had an SMS too. In fact, a bookshelf on the bridge was crammed full with binder after binder of SMS materials, but it was clear to see that unlike the ship's navigational charts and operating manuals, which were clearly heavily used, the SMS binders were covered with dust and virtually untouched.

But SMS is not a one-size-fits-all approach. As a small operator, your SMS should be tailored specifically for your operations. It does not need to be a complicated plan. But it must be clear regarding your safety policies and more importantly, what each employee's role is.

Every crew member should be familiar with it and understand it. And it should be as used and dog-eared as the charts you use to navigate. The template provided by the Coast Guard and the Passenger Vessel Association is an excellent starting point for customizing an SMS.

So what kinds of things have we seen that cause accidents that an SMS might address? What kind of risk assessment or go/no-go decision-making process do you expect your crews to use? Do you conduct scheduled, preventative maintenance? What is your policy regarding electronic device use? The use of cell phones or texting while on duty is becoming an increasing safety concern for the NTSB - we have recommended that operators in highway, aviation, rail and marine address this distraction.

While SMS is a hot topic, our investigations have also shown that some of the things we have long understood are still important and that safety standards for small vessels need updating too.

Take for example, the 2008 fire on the passenger vessel Queen of the West. Fortunately no one was injured. But what it demonstrated was that small passenger vessels need to carry out-of-water flotation for 100 percent of their passengers.

The good news is because the vessel was equipped with detection and suppression equipment in the engine room even though such a system wasn't required the crew was able to contain the engine fire, so that none of the passengers had to be evacuated. However, with only a slight change in circumstances, the outcome could have been much different.

Because of its river route, the Queen of the West was not required to carry out-of-water survival craft or life floats (which provide flotation but do not keep passengers out of the water). The only rescue craft available was a small boat that could carry no more than 6 passengers at a time.

Had the Queen of the West not been equipped with fire detection and suppression systems, or had those systems and the crew not performed as well as they did in detecting and combating the fire, or had the fire intensified beyond the crew's ability to fight it, the master would have had no choice but to evacuate all 177 passengers, many of whom were elderly and some who were non-ambulatory using one 6-person rescue boat. Under those circumstances, many of the passengers could have ended up in the 44 degree water with only their lifejackets.

You may know that the Coast Guard Authorization Act of 2010 mandates the elimination of life floats by 2015. This supports the Safety Board's concern that survivors should not be immersed in cold water. While our recommendations following the Queen of the West incident focused on out-of-water flotation, we recognized the tremendous benefit of their fixed fire detection and suppression systems.

As Jay Spence knows well, in 2006 there was a ferry vessel fire in Boston Harbor. In that accident, the Massachusetts was operating on a normal afternoon run when a fire broke out in the engine room. Recognizing the hazard, the crew promptly stopped the vessel, and all of the passengers were safely evacuated to another ferry. Ironically, because of its age and hull material, the Massachusetts was exempted from engine room fire protection requirements.

As a result of that investigation, we issued a recommendation to the Coast Guard to require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their engine rooms. Yes, there is a cost for such systems, but Jay can tell you how expensive it was to repair the damaged vessel and how long it was out of service.

The final issue I would like to mention is the importance of using up-to-date passenger weight standards when calculating passenger capacity. We have investigated two accidents where this issue was directly related to the cause of the accident.

The first accident involved the Lady D, a pontoon style water taxi, which capsized in Baltimore harbor with 5 fatalities in 2004. The accident brought to light that Coast Guard stability standards were using an out of date average passenger weight estimate of 140 pounds. The Safety Board recommended that the Coast Guard revise its regulations to require that passenger capacity be calculated using more current average passenger weight standards and that this standard be periodically updated.

The Ethan Allen accident the following year further cemented the importance of this issue when the tour boat on Lake George capsized with 20 fatalities. As you well know, the Coast Guard recently amended its regulations to increase the average passenger weight to 185 pounds, an increase of almost 50 pounds.

We do have an on-going investigation of the DUKW accident that occurred in Philadelphia last July. As you may recall, that DUKW broke down in the shipping channel on the Delaware River and was run over by a tug and barge. There were two fatalities.

There has certainly been a lot of interest in the media in this investigation, but I will caution that although we have previously investigated other DUKW boat accidents, every accident is different, and it would be inappropriate to draw conclusions about the safety of any type of vessel from previous investigations. We will conclude our investigation in the coming months and hold a public Board Meeting to discuss the report, which you can observe via webcast.

Today, Americans enjoy one of the most robust and reliable transportation systems in the world. The safety of today's passenger vessel fleet is a direct result of many PVA initiatives, and we know that work continues at this convention.

But the NTSB's perspective is to always focus on how we can make it safer. We do have high expectations because we know that with every accident we investigate, we learn lessons that can result in lives saved.

St. Thomas Aquinas once said, "If the highest aim of a captain were to preserve his ship, he would keep it in port forever." But we all know, that is not the reality. So make safety your priority and bring every vessel, and every passenger, back to port safe and sound.

Thank you.