Remarks of Mark V. Rosenker
Vice Chairman, National Transportation Safety Board
Before the River Pilots' Association
June 26, 2003 and July 17, 2003
Good morning ladies and gentlemen. I am very pleased to be speaking to you today and congratulate your efforts to make the pilotage system safer through your Pilot Education Series.
The Piloting profession is vitally important to the safety of marine transportation, the protection of the marine environment, and to the commerce of our nation.
About 2 weeks ago Captain Douglas Grubbs invited me to take a trip aboard a ship with a Crescent River pilot, from about 20 miles upriver from New Orleans to a point just below New Orleans giving me a firsthand view of what a pilot is faced with when maneuvering downriver. It was a fascinating educational and most valuable experience and I want to thank Captain Grubbs for showing me this major part of our transportation system.
What I am going to talk to you about today is the National Transportation Safety Board - who we are, what we do, and why we do it. I will also discuss a few of our marine investigations which resulted in recommendations on Bridge-to-Bridge Radiotelephones, Bridge Resource Management, and Voyage Data Recorders.
The National Transportation Safety Board (NTSB) is an independent Federal agency that reports directly to Congress. Created through the Transportation Act of 1966 the NTSB's mission is to promote transportation safety by conducting cause finding investigations of major transportation accidents, and, most importantly, formulate safety improvement recommendations. These recommendations go to government entities or various industries to help prevent a recurrence of these accidents in the future.
The Safety Board consists of five governing Members - each appointed to a five-year term by the President, "with the advice and consent of the Senate." The terms are staggered so that only one five-year term expires each year. Two of the members are designated by the President to serve as Chairman and Vice Chairman for 2-year terms. No more than three members of the Board may be of the same political party, and at least three must be appointed on the basis of their technical qualifications, professional standing. A professional staff of about 420 supports the Board Members.
The Safety Board is neither a law enforcement nor a regulatory agency. NTSB investigations are not intended to be adversarial in nature and do not attempt to establish fault or liability in the legal sense.
Our federal charter states that the Board shall investigate or cause to be investigated an accident to determine the facts, conditions, circumstances and the cause or probable cause. This applies to any major marine commercial vessel casualty, occurring on the navigable waters or territorial seas of the United States, regardless of the nationality of the ships involved. The NTSB also handles accidents anywhere in the world when U.S. registered commercial vessels are involved. The Act also requires that the Safety Board investigate or cause to be investigated any other accident which occurs in connection with the transportation of people or property which, in the judgment of the Board, is catastrophic, involves problems of a recurring nature or would otherwise be in the public interest. This section of the Act gives the Board wide discretionary authority to investigate transportation accidents, and the Board has routinely exercised this authority in the marine mode.
When a marine casualty occurs the Coast Guard conducts a preliminary investigation and determines whether it is:
U.S. regulations define a major marine casualty as one involving a vessel, other than a public vessel, that results in:
In September 2002, the NTSB Chairman and the Commandant of the Coast Guard signed a Memorandum of Understanding to (1) clarify the standards used to determine when the National Transportation Safety Board will lead an investigation, and (2) to develop new standards to determine when a major marine accident involves significant safety issues related to USCG safety functions. USCG and NTSB agree that NTSB may elect to lead the investigation of major marine casualties that risked or threatened high loss of life to innocent third parties, under the following conditions:
In each marine instance where the NTSB elects to lead the investigation, the Coast Guard shall participate as a party. I'll explain more about the party system in a moment.
A small agency, with limited resources, the NTSB has 8 marine accident investigators. These specialists include former shipmasters, former chief engineers, and human performance and survival factors specialists. When one considers that an average of 60 major marine accidents are reported to the Safety Board each year, it becomes apparent that the Board does not have the manpower resources to investigate them all in an in-depth manner.
If the accident meets any of the criteria for a major marine accident, the Coast Guard is required to notify the NTSB. If the major marine accident has catastrophic consequences or which has the potential for such consequences and wide public interest, one of the five Safety Board members may be present on-scene to oversee the initial phase of the investigation. An NTSB staff member known as the Investigator-in-Charge (IIC) is in charge of the on-scene investigation. The IIC, normally a marine expert from the Board's Office of Marine Safety, is authorized to issue subpoenas, and to administer oaths. Except for proprietary information, all facts collected in Safety Board investigations are available to the public. After factual reports are developed and before being available to the public, they are forwarded to the parties to make corrections and make sure that the factual reports are accurate and complete.
The size and make up of a NTSB investigation team will vary from accident to accident depending upon the needs of the investigation, and the resources available. An investigative team could consist of the IIC alone for relatively minor accidents, or include a marine engineer, an operations specialist, a metallurgist, a fire scientist, a human performance specialist, or a survival factors specialist for more complicated accidents. Each Safety Board technical specialist forms an investigative group and would be in charge of investigating the particular aspect of the accident that falls under their expertise. Parties to the investigation are then asked to participate in the investigative group or groups where his or her knowledge will enhance the fact gathering. Normally companies, government agencies, organizations, or unions, rather than individuals are designated as parties in an NTSB investigation. Parties are designated because they have special knowledge, expertise, and/or resources, which will assist the Board in the development of factual and pertinent information. Wreckage parts or machinery components can be selected for further testing at NTSB or other laboratory. Parties are invited to be present whenever such testing is scheduled. Typically, organizations such as the Coast Guard, the ship's classification society, steamship companies, and sometimes pilot associations are designated as parties. Thus, if one of your members is involved in an accident investigated by the Safety Board, your association may be invited to participate as a party to the investigation. Periodically, the Safety Board offers industry and other government agencies training in the Board's Party system. If anyone is interested, Party training is scheduled for July 21 and 22 (at a cost $100) and there are still some seats available for this upcoming class.
Board Meeting. Sometime, generally about 12 months after the accident, the investigative team presents the draft report of the accident before the Safety Board in public session as required by federal sunshine laws. Parties to the investigation and the public are invited to attend, but are not allowed to participate in the Board's deliberations. The Board Members discuss the safety issues, make any necessary changes to the report and then usually adopt the amended report with a finding of probable cause. It is at that point, that the Board's report of the accident is made available to the public. It should be noted that the Congress has prohibited the use of any part of an NTSB accident report to be used as evidence in a legal suit or action for damages for that accident.
Post Board Meeting. Adopting the Board's accident report does not close the investigation. The Safety Board never considers an investigation closed and stands ready to receive new evidence concerning an accident at any time.
Preventing accidents is a difficult task to perform when one considers the fact that the Safety Board has no statutory authority to require remedial action. The Safety Board can only issue safety recommendations, and the parties to whom such recommendations are addressed are free to act upon them as they see fit. Safety Recommendations are made to federal government agencies, state and local governments, domestic and foreign commercial organizations, to the International Maritime Organization (IMO) through the U.S. Coast Guard, and if appropriate to foreign governments through the Department of State.
The National Transportation Safety Board's impact upon marine transportation safety has been significant. Three examples that you, as pilots, might be familiar with are: the requirements for bridge-to-bridge radiotelephones, bridge resource management, and voyage data recorders.
The Safety Board utilized collision research to determine the need for bridge-to-bridge radiotelephones. They then urged the DOT to vigorously support legislation requiring the technology - it took another 3 years for the law to be passed. The need was there and I believe that the use of the bridge-to-bridge telephone has proven its worth and has been instrumental in avoiding collisions. I'm sure that you will agree that it has proven to be an invaluable tool to maneuvering around blind bends in channels and for making meeting or passing agreements.
The Safety Board has also actively supported bridge resource management (BRM) because of its importance to marine safety. BRM was an outgrowth of aviation's cockpit resource management and is an excellent example of exchanging safety ideas between transportation modes. BRM effectively uses all available resources to achieve safer operation. A master or pilot must integrate the resources for any given passage or watch using leadership skills and command authority. At the same time they must indicate their willingness to accept operating information from subordinates to avert operating errors. Intercultural or language differences can often be circumvented by deliberate, clear master-to-pilot briefings, and by providing expectations of job performance for multi-national crews.
We first recommended the BRM to the U.S. Navy after an investigation of an allision between the aircraft carrier Dwight D. Eisenhower and an anchored foreign freighter in 1988. In this accident, the captain was distracted and vital information was not exchanged between navigation and conning personnel. The NTSB later investigated a series of accidents involving commercial pilots in which we discovered similar problems. In 1991 and 1993 we recommended that the Coast Guard require BRM for deck watch officers and federal pilots. We also proposed the need for BRM training to the IMO. BRM training was adopted by the IMO and was effective on February 1, 2002. The rule, however, applies to licensed deck crews on commercial vessels over 200 gross tons operating domestic or foreign voyages. I am pleased to see that your agenda for this educational series includes a section on crew utilization and situational awareness, both of which are part of BRM.
On October 5, 1993, the American Pilots' Association (APA) recommended that all APA member pilots take a BRM course with refresher courses at least every 3 years. In 1997, the APA adopted a resolution regarding the respective roles of the pilot and the master. The NTSB commends your Association and the APA for realizing the need for BRM and taking the necessary steps, without regulation, to improve safety.
The 3rd NTSB accomplishment I will briefly comment on relates to Voyage Data Recorders (VDRs). The Safety Board has promoted the use of event recorders on ships since the 1970s to the Coast Guard and to the IMO through the Coast Guard. The Chairman of the Safety Board recently emphasized the growing importance of vehicle recorders to safety in all modes of transportation, stating that "For the Board to draw sound conclusions on vital safety issues, we need to evaluate a great deal of data." VDRs will provide hard-line facts and data to help us reconstruct accidents. I'm sure you will all agree that VDRs will be of great assistance in helping to determine the factors of a marine accident and will help the Safety Board to develop meaningful safety recommendations to prevent future accidents.
The IMO requires that all new ships above 3,000 gross tons must be fitted with a VDR. Roll-on, roll-off (Ro-ro) passenger ships and other passenger ships constructed before July 1, 2002, have until July 1, 2004 to have them installed. Existing cargo ships are being studied to determine the feasibility of retrofitting VDRs.
In closing, I want to commend your Association for your innovative continuing education program. New ideas or different approaches to your activities on the river are necessary to maintain your professional skills. I encourage you to continue with your efforts to increase your safety awareness through education.
Thank you again for inviting me to speak today.