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Safety Recommendation Details

Safety Recommendation M-11-001
Details
Synopsis: The National Transportation Safety Board (NTSB) has completed its investigation of yet another marine accident in which crewmember distraction resulting from nonoperational use of a cell phone or other wireless device has been identified as a causal factor. The findings from the investigation of this fatal accident suggest that Coast Guard actions thus far, with regard to wireless device use by crewmembers engaged in vessel operations, have been inadequate in addressing this critical safety risk and that additional, more effective measures are needed. On Wednesday, July 7, 2010, the empty 250-foot-long sludge barge The Resource, being towed alongside the 78.9-foot-long tugboat Caribbean Sea, collided with the anchored 33-foot-long amphibious passenger vehicle (APV) DUKW 34 in the Delaware River at Philadelphia, Pennsylvania. DUKW 34 carried 35 passengers and 2 crewmembers. On board the Caribbean Sea were five crewmembers. As a result of the collision, DUKW 34 sank in about 55 feet of water. Two passengers were fatally injured, and 26 passengers suffered minor injuries. No one on the Caribbean Sea was injured.1 The NTSB determined that the probable cause of this accident was the failure of the mate of the Caribbean Sea to maintain a proper lookout due to (1) his decision to operate the vessel from the lower wheelhouse, which was contrary to expectations and to prudent seamanship, and (2) distraction and inattentiveness as a result of his repeated personal use of his cell phone and company laptop computer while he was solely responsible for navigating the vessel. Contributing to the accident was the failure of Ride The Ducks International maintenance personnel to ensure that DUKW 34’s surge tank pressure cap was securely in place before allowing the vehicle to return to passenger service on the morning of the accident, and the failure of the DUKW 34 master to take actions appropriate to the risk of anchoring his vessel in an active navigation channel.
Recommendation: TO THE UNITED STATES COAST GUARD: Develop and implement an investigative protocol that directs your investigation officers to routinely check for nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions involved in marine accidents.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Philadelphia, PA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10MM025
Accident Reports:
Collision of Tugboat/Barge Caribbean Sea/The Resource with Amphibious Passenger Vehicle DUKW 34
Report #: MAR-11-02
Accident Date: 7/7/2010
Issue Date: 8/26/2011
Date Closed: 2/8/2013
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s): Distraction

Safety Recommendation History
From: NTSB
To: USCG
Date: 2/8/2013
Response: We understand that, on September 7, 2012, the Coast Guard’s Office of Investigations and Casualty Analysis satisfied this recommendation by publishing investigative protocol CG INV Policy Letter 1-12. Accordingly, Safety Recommendation M 11 1 is classified CLOSED—ACCEPTABLE ACTION.

From: USCG
To: NTSB
Date: 12/20/2012
Response: -From J.A. Servidio, Rear Admiral, U.S. Coast Guard, Assistant Commandant for Prevention Policy: I concur with this recommendation. On September 7, 2012, the Office of Investigations and Casualty Analysis published policy that provides guidance and instructions to Coast Guard Investigative Officers to identify and document any instances where the use of cell phones or other wireless electronic devices by on-duty crewmembers in safety-critical positions may be a causal factor in a marine casualty. The procedures are to be utilized for all vessel navigation incidents and for those other marine casualties whenever it appears the use of wireless electronic devices may have played a role in the marine casualty. The procedures include collecting the following information for each crewmember who was on duty in the period of time leading up to and including the marine casualty: 1. Whether the crewmember had cell phone or other wireless electronic device in their possession while they were on duty in the period of time leading up the casualty, and if so, whether it was a personal device or one provided by their employer. 2. For those that had a device, a record of all communications made using the device(s) while they were on duty leading up to the marine casualty will be generated. For each communication, it is to be determined whether it was work-related or personal. I consider the Coast Guard's action on this recommendation complete and asked that it be closed.