Remarks of Mark V. Rosenker
Acting Chairman, National Transportation Safety Board
44th Annual National Association of Marine Surveyors
April 10, 2006
Good afternoon ladies and gentlemen. I am pleased to have the opportunity to be with you at the National Conference of the National Association of Marine Surveyors.
I would like to talk about three things today. First, I would like to tell you a little about the Safety Board, especially its mission and role in maritime safety. Next, I would like to summarize the importance of some recent marine investigations as they relate to your profession. And, finally, I would like to talk about the importance of professional organizations in safeguarding our nation's transportation system.
The National Transportation Safety Board was established by statute in 1967. In 1974, the Safety Board became a completely independent agency. The Board's mission is to determine the probable cause of selected transportation accidents and "... to promote transportation safety by conducting independent accident investigations and by formulating safety improvement recommendations." In plain language, the Board exists for the sole purpose of making transportation safer.
The Independent Safety Board Act of 1974 gave the Board authority to investigate major marine casualties, but it did not define the term "major marine." When Congress set up the Safety Board, it recognized that the Coast Guard had been investigating marine accidents for years, going all the way back to the Steamboat Inspection Service, which was established before the Civil War. Congress, in effect, allowed the Safety Board and the Coast Guard to decide how they would work together. The result was the development of joint regulations, which are set forth in 49 CFR part 850, providing for Safety Board participation in Coast Guard investigations, and for the Safety Board to conduct investigations completely independent from the Coast Guard under Safety Board regulations. The joint regulations define major marine accidents as those resulting in:
These criteria are under continual review and, in fact, we have initiated discussions with the Coast Guard to see how we can set our respective priorities to have the biggest impact on marine safety consistent with our agency missions and increasing pressure on our already strained resources. The public gets its money's worth from the Coast Guard and the Safety Board.
Loss of six or more lives; Loss of a mechanically propelled vessel of 100 or more gross tons; Property damage initially estimated at $500,000 or more; or Serious threat to life, property, or the environment from hazardous materials.
Under the regulations, the Coast Guard makes an initial investigation of each accident to determine if it is a major marine accident, then notifies the Safety Board. This usually results in timely notification of a major marine accident. However, the Safety Board's communication center, which is staffed 24/7, sometimes finds out about accidents even before Coast Guard headquarters.
In September 2002, the Chairman of the Safety Board and the Commandant of the U.S. Coast Guard worked out an arrangement to determine which agency would take the lead in any particular investigation. The arrangement was formalized in a memorandum of understanding. If the Safety Board takes the lead, the Coast Guard participates in the investigation as a party. Our MOU with the Coast Guard is also under review.
Major marine accidents the Safety Board might choose to investigate include the following:
When a major marine accident is reported, the Safety Board decides whether to investigate, depending upon the issues involved. At current staffing levels, the Board is able to investigate about 20 percent of the 20 to 40 major marine accidents that are reported annually.
The Safety Board has investigated more than 200 major marine accidents and has issued nearly 2,000 marine safety recommendations. The recommendations have been addressed to various maritime organizations, including vessel operating companies, marine associations, classification societies, the International Maritime Organization, and the U.S. Coast Guard. Although the Safety Board does not have authority to regulate or to require recipients to implement our recommendations, we enjoy an acceptance rate of about 83%.
Two accident investigations that we have recently completed that may be of interest to you are the Lady D and the Express Shuttle. The Board adopted the final reports on both accidents within the past month.
The Lady D was a pontoon water taxi that capsized in Baltimore Harbor in March 2004. Five people died, four were seriously injured, and 12 suffered minor injuries. The major safety recommendations issued included determining safe loading conditions, revising stability criteria for pontoon vessels, revising passenger weight standards, and establishing limiting environmental conditions for operating pontoon boats.
The United States has the best marine safety regime in the world-through robust laws and regulations, good industry standards, competent inspectors and surveyors, good cooperation among all players involved in promoting and assuring marine safety, and most importantly, a commitment by our great American society that safety and quality of life are of paramount importance. I cannot emphasize that enough.
Because of this comprehensive safety regime, it is extremely rare that an accident can be traced back to a single cause. I am not talking about deliberate events, such as flying an airplane into a building or foolhardy accidents caused by carelessness or negligence, but those events that are truly accidents-unforeseen, most likely preventable, tragic to those involved. We study those and determine what went wrong and what can be done to keep them from happening again.
Again, because of our comprehensive safety regime and culture, accidents are almost never from a single cause, but rather the result of a chain of multiple things gone wrong. In the case of the Lady D, the first boat in the series, the Fells Point Princess, was certificated for 25 persons based on a stability test for monohull vessels, even though it was a pontoon vessel and a stability protocol for pontoon boats was available and should have been used. That was clearly a mistake.
Subsequently, three other similar pontoon boats were built by a different builder and with some differences in design and configuration. They should have had their own stability assessments, but instead, they were called sister vessels and certificated for the same number of passengers as the Fells Point Princess. We now had four vessels out there carrying too many people. If a stability test had been done on even one of those boats, it is very likely that the original mistake would have been identified and corrected, and the Lady D might never have capsized.
And it wasn't just the number of people - it was also their weight. Fifty years ago, when the Coast Guard developed the standards for small passenger boat stability, maybe the average person, including children, weighed 140 pounds. I don't know, but I do know they're a lot heavier today. The average weight of the people on board the Lady D was 168 pounds, and that included three children. All this extra weight further reduced the margin of safety on stability. In December 2004, we recommended to the Coast Guard that they revise and update their passenger weight standards, and they are working on that now.
The final major thing that went wrong was the weather on the day of the accident. The National Weather Service saw the cold front coming through, but because of the way the Weather Service processed information and issued warnings, it missed an opportunity to alert boaters in the Chesapeake Bay and Baltimore Harbor area that a storm was coming. The National Weather Service has since revised its procedures so warnings are now getting out a lot quicker.
And on the water the master of the Lady D and others in his company saw the front approaching, and they thought it wouldn't affect them too much, so the Lady D left the dock, with a completely full load of people, who were heavier than the Coast Guard stability standards assumed. The result was catastrophic, ending the lives of five people and forever changing the lives of many more.
So you see in this accident at least three things had to go wrong before the accident occurred. If even one of them had been avoided, I probably wouldn't be here talking to you about this today. This is why each of us, who has a role in the marine industry, must be constantly vigilant in our duties and responsibilities to ensure the safety of the system. Had anyone questioned the allowable load, the suitability of the stability standards applied, or the appropriateness of granting sister status to a vessel that had substantial design differences, this accident may have been prevented.
Although a similar accident on Lake George, New York, in October 2005, involving the Ethan Allen is still being investigated, I anticipate that similar issues may arise. One thing naval architects know is that increased weight, especially if it is up high, will have a deleterious effect on stability. We are presently looking into the possibility of that on the Ethan Allen. However, this is something you can also be alert for. If you survey a vessel that has been modified, and the weight or center of gravity might have changed, ask yourself the question and alert the vessel's owner about possible consequences on the boat's stability. It may not be obvious, but it is certainly worth looking into.
Another investigation that we have recently concluded involves the Express Shuttle II. On October 17, 2004, a fire broke out in the engine room as the vessel was returning to Port Ritchey, Florida, after having ferried passengers to a casino boat moored offshore. Only the master and two deckhands were onboard when the fire broke out. The crew attempted to fight the fire with portable extinguishers but quickly realized the fire was out of control and abandoned ship. None of the crew activated the vessel's fixed carbon dioxide fire suppression system. Fire fighters from Port Ritchey and Pasco County fought the fire. Although no one was seriously injured, the vessel, which was valued at $800,000, was a total loss. The major safety issues associated with this accident were preventive maintenance, crew response to the fire emergency, and fire detection systems.
The Express Shuttle II's starboard engine had been having a high rate of fuel line failures, which was not proactively addressed by the owners. Company maintenance was sloppy. In replacing the fuel line, the crew did not follow procedures as outlined in the engine maintenance/operation manual. Fuel line clamps were not in place or tightened.
When the engine room fire broke out, no alarm was received on the fire detection panel in the pilothouse. In the course of our investigation, we learned that the fire detection system should not have been approved in the first place, and it was also improperly installed.
The crew members efforts were ineffective in fighting and controlling the fire. The deckhands had no formal firefighting training and had participated in no drills in their brief time with the company. Further, the master made no attempt to activate the vessel's fixed carbon dioxide fire-extinguishing system, and for awhile appeared to not even realize it was there.
Training materials are available. The Passenger Vessel Association, for example, has instructional videotapes available to its members and others that cover firefighting practices and procedures and could be included in small passenger vessel crew training.
The probable cause of the fire was a fractured, improperly installed fuel-injection line that allowed diesel fuel to spray onto the engine and ignite. Contributing to the cause of the fire was the failure of the owner to have a preventive maintenance program, which could have identified the company's ongoing problem with the vessel's fuel lines. Also contributing were the vessel's faulty fire detection system and the crew's failure to use proper marine firefighting techniques. Again, good business practices may have prevented this accident.
The financial benefits of a corporate safety culture for safety equipment, trained and qualified individuals, good crew work-rest cycles, and reliable equipment far outweigh the financial losses of an accident. An accident results not only in damage costs, lawsuits, and lost revenues, but also in the distrust of the public.
As traffic increases on our waterways, so will the potential hazards. The possibility of mechanical failure, hostile environmental conditions, human error, and organizational failures affecting safety must be anticipated, and safeguards must be developed and implemented. The better this is done, the safer the carrier will be, and the accident statistics will reflect it.
Professional organizations that promote education, provide certification programs, and develop standards, are an important part of the marine transportation industry. You play an important role in maintaining safety. By promoting quality and professionalism, you are safeguarding the integrity and safety of our nation's transportation system and enhancing the competitiveness of U.S. businesses.
As you may surmise, I am proud to be a part of the Safety Board and I could speak longer, but I believe I have covered most of the points I wanted to mention. Again, I thank you for the opportunity to be with you today.