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Safety Recommendation Details

Safety Recommendation M-11-004
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: Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 2/16/2017
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Alternate Action)
Keyword(s): Distraction

Safety Recommendation History
From: NTSB
To: USCG
Date: 2/16/2017
Response: Although we are disappointed that you will not pursue the regulatory action requested in Safety Recommendation M-11-3, we note that you have committed to continue stressing the importance of posting alert lookouts and standing diligent watches as part of your standard public outreach, which includes publishing safety alerts, marine safety information bulletins, and entries on the Coast Guard Maritime Commons blog. You will also continue to garner maritime industry input on the issue at periodic meetings with organizations such as the Passenger Vessel Association, the American Waterway Operators, and the Offshore Marine Services Association, and with your federal advisory act committees. Because these combined efforts address the intent of Safety Recommendation M-11-4, it is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

From: USCG
To: NTSB
Date: 10/18/2016
Response: -From Charles W. Ray, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Although the Coast Guard does not plan to develop new regulations, we will continue to stress the importance of posting alert lookouts and standing diligent watches as part of our standard public outreach including safety alerts, marine safety information bulletins, and entries on our Coast Guard Maritime Commons blog. We will also continue to garner maritime industry input on the issue during periodic meetings with maritime organizations (e.g., Passenger Vessel Association, American Waterway Operators, Offshore Marine Services Association) and our Federal Advisory Act (FACA) committees. We consider our ongoing actions on this recommendation to meet the intent of the Board’s recommendation and request that it be closed.

From: NTSB
To: USCG
Date: 3/11/2016
Response: This letter concerns 40 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Coast Guard between 2002 and 2015. For several years, the NTSB received an annual update on all open safety recommendations issued to the Coast Guard; however, for 25 of the 40 recommendations listed, we have received no update in over 2 years regarding the status of action either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Please respond to this letter electronically at correspondence@ntsb.gov regarding your progress in addressing these safety recommendations, and do not submit both an electronic and a hard copy of the same response. To assist with your response, enclosure (1) is a list of the 40 recommendations highlighting the recommendation number, current status, source of the recommendation, and date of the last Coast Guard update; enclosure (2) is a print-out from our database with the complete correspondence history of each open recommendation.

From: NTSB
To: USCG
Date: 5/13/2014
Response: We are disappointed that you have not made any progress in addressing this recommendation since December 2012. Nevertheless, because the Coast Guard was actively working with the Ship Operations Cooperative Program and with the American Waterways Operators to address this issue, Safety Recommendation M-11-4 remains classified OPEN—ACCEPTABLE RESPONSE. Please provide a detailed description of your progress as soon as possible.

From: USCG
To: NTSB
Date: 1/28/2014
Response: -From Peter V. Neffenger, Vice Admiral, Deputy Commandant for Operations: Enclosed is our semiannual report of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board. There are currently 39 safety recommendations with an "open" status issued to the Coast Guard. Of those, I am providing our initial response to six new recommendations, proposing that seven recommendations be closed as acceptable, and updating five previously issued recommendations. At this time, there are no significant changes in action to be reported for the remaining 21 recommendations. These recommendations include: M-02-5, M-07-6, M-09-4, M-09-10, M-09-14, M-09-15, M-09-16, M-10-5, M-10-6, M-11-4, M-11-13, M-11-15, M-11-16, M-11-23, M-11-24, M-11-25, M-11-26, M-11-27, M-12-1, M-12-2, and M-12-3.

From: NTSB
To: USCG
Date: 7/8/2013
Response: Thank you for the April 5, 2013, letter signed by Vice Admiral Peter V. Neffenger, Deputy Commandant for Operations, to the National Transportation Safety Board (NTSB) containing your semiannual update regarding actions to address 42 safety recommendations that the NTSB issued to the US Coast Guard. To assist with future updates and to align our records, we are enclosing a copy of the NTSB’s safety recommendation database history for these 42 recommendations. This response letter will be divided into four parts: • Part 1 – Evaluation of actions to address Safety Recommendations M 09 15 and 16 and M-10-2, recommendations for which Admiral Neffenger provided a substantive update. • Part 2 – List of 6 safety recommendations previously closed. • Part 3 – List of 7 safety recommendations that were the subject of a recent Coast Guard update and that the NTSB is currently evaluating; these recommendations will be addressed in detail in separate correspondence. • Part 4 – List of 26 safety recommendations for which the Coast Guard did not provide a substantive update or for which status has not changed since the last update. Part 1 – Safety Recommendations Updated in the April 5, 2013, Letter: We issued Safety Recommendations M-09-15 and -16, stated below, to the Coast Guard on October 20, 2009, as a result of a review of the involvement of obstructive sleep apnea (OSA) in several accidents investigated by the NTSB. M-09-15 Implement a program to identify licensed mariners subject to the Navigation and Vessel Inspection Circular on Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (NVIC 04-08) and who are at high risk for obstructive sleep apnea, and require that those mariners provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. M-09-16 Develop and disseminate guidance for mariners, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that mariners who have OSA that is effectively treated are routinely approved for continued medical certification. We are encouraged that the Merchant Mariner Medical Advisory Committee is planning to review and revise Navigation and Vessel Inspection Circular 04-08, including Enclosure (4), Guidance on Specific Medical Conditions, which details the medical decision making criteria for common conditions (including sleep disorders such as OSA) as they relate to determining merchant mariner fitness for duty. Pending completion of these efforts, Safety Recommendation M-09-15 is classified “Open—Acceptable Alternate Response” and Safety Recommendation M 09-16 is classified “Open—Acceptable Response.” We issued Safety Recommendation M-10-2, stated below, to the Coast Guard on August 11, 2010, as a result of two recent maritime accidents involving Coast Guard patrol boats: the December 5, 2009, collision of the CG 25689 with the small passenger vessel Thriller 09 in Charleston, South Carolina, and the December 20, 2009, collision of the CG-33118 with a 24 foot recreational vessel in San Diego, California. M-10-2 Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. The Coast Guard’s recent revision of Coast Guard Boat Operations and Training (BOAT) manual, volume I, COMDTINST M16114.32C, section F.2, prohibits the use of cellphones/texting devices and phone applications aboard all boat force assets without the permission of the coxswain, which will only be granted on a case-by-case basis and only when operational safety is not compromised. Because this action satisfies Safety Recommendation M 10-2, it is classified “Closed—Acceptable Action.” Part 2 – Safety Recommendations Previously Closed: M-06-5 (Closed—Acceptable Action, March 14, 2011) Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. M-06-6 (Closed—Acceptable Action, March 14, 2011) Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. M-06-7 (Closed—Unacceptable Action, March 14, 2011) Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. M-06-8 (Closed—Unacceptable Action, March 14, 2011) Until such time as you revise the passenger weight standard as requested in Safety Recommendation M-06-5 and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation M-06-7, develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations. M-06-9 (Closed—Unacceptable Action, March 14, 2011) Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection. M-11-11 (Closed—Acceptable Action, November 13, 2012) Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. Part 3 – Recommendations Recently Updated and Under Evaluation by the NTSB: M-10-5 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders that meet the international performance standard on new ferry vessels. M-10-6 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders on ferry vessels built before the enactment of voyage data recorder carriage requirements that will record, at a minimum, the same video, audio, and parametric data specified in the International Maritime Organization’s performance standard for simplified voyage data recorders. M-12-1 (Open Initial Response Received; USCG Update February 12, 2013) Require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-2 (Open Initial Response Received; USCG Update February 12, 2013) Where technically feasible, require existing U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be retrofitted with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-3 (Open—Initial Response Received; USCG Update February 12, 2013) Require all operators of U.S.-flag passenger vessels to implement safety management systems, taking into account the characteristics, methods of operation, and the nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. M-12-6 (Open—Initial Response Received; USCG Update March 21, 2013) Develop and implement a policy to ensure adequate separation between vessels operating in the Bayport Channel and Bolivar Roads Precautionary Areas and any other similarly configured precautionary areas in the Houston Ship Channel. M-12-7—(Open Initial Response Received USCG Update March 21, 2013) Graphically delineate precautionary areas on appropriate Houston Ship Channel nautical charts so they are readily identifiable to mariners. Part 4 – Safety Recommendations Not Substantively Updated in the April 5, 2013, letter: M-02-5 (Open—Acceptable Response, February 4, 2013) Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. M-07-1 (Open—Acceptable Response, February 4, 2013) 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 enginerooms. M-07-6 (Open—Acceptable Response, February 4, 2013) Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. M-08-2 (Open—Acceptable Response, February 4, 2013) Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-4 (Open—Acceptable Response, February 4, 2013) Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. M-09-10 (Open—Unacceptable Response, February 4, 2013) Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-14 (Open—Acceptable Response, February 4, 2013) Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-09-17 (Open—Unacceptable Response, February 4, 2013) Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 (Open—Acceptable Response, February 4, 2013) Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety. M-11-4 (Open—Acceptable Response, February 4, 2013) Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue. M-11-8 (Open—Acceptable Response, November 13, 2012) Develop and implement procedures for your special purpose craft–law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. M-11-9 (Open—Acceptable Response, November 13, 2012) Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. M-11-10 (Open—Acceptable Response, November 13, 2012) Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. M-11-12 (Open—Acceptable Response, November 13, 2012) Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. M-11-13 (Open—Acceptable Response, November 13, 2012) Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, determine from that whether the risk is unacceptable, and if so, develop risk mitigation strategies. M-11-14 (Open—Acceptable Response, November 13, 2012) Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. M-11-15 (Open—Acceptable Response, November 13, 2012) Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. M-11-16 (Open—Unacceptable Response, November 13, 2012) Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. M-11-23 (Open—Unacceptable Response, June 12, 2012) Establish standards for new and existing commercial fishing industry vessels of 79 feet or less in length that (1) address intact stability, subdivision, and watertight integrity and (2) include periodic reassessment of the vessels’ stability and watertight integrity. M-11-24 (Open—Unacceptable Response, June 12, 2012) Require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use of vessel stability information regardless of plans for implementing the other training provisions of the 2010 Coast Guard Authorization Act. M-11-25 (Open—Unacceptable Response, June 12, 2012) Require each person on deck of a commercial fishing industry vessel to wear a flotation aid at all times. M-11-26 (Open—Unacceptable Response, June 12, 2012) Require owners of commercial fishing industry vessels to (1) install fall overboard recovery devices appropriate for the vessel, (2) periodically ensure the functionality of such equipment, and (3) regularly conduct drills in which crewmembers demonstrate their competence in the use of such devices. M-11-27 (Open—Unacceptable Response, June 12, 2012) Require all crewmembers to provide certification of completion of safety training before getting under way on commercial fishing industry vessels, such training to include both prevention of and proper response to emergency situations as well as actual use of emergency equipment. M-12-8 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard military personnel with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-9 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard civilian personnel, seeking appropriate legislative authority if necessary, with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-10 (Open—Await Response) Disseminate guidance within the Coast Guard so that commanding officers have unambiguous instruction detailing the requirements for timely drug and alcohol testing of Coast Guard military and civilian personnel whose work performance may be linked to a serious marine incident. Thank you for your commitment to marine safety. We look forward to receiving further updates on the action being taken to implement the following safety recommendations: M-02-5 M-07-1 M-07-6 M-08-2 M-09-4 M-09-10 M-09-14 M-09-15 M-09-16 M-11-3 M-11-4 M-11-8 M-11-9 M-11-10 M-11-12 M-11-13 M-11-14 M-11-15 M-11-16 M-11-23 M-11-24 M-11-25 M-11-16 M-11-27 M-12-8 M-12-9 M-12-10

From: USCG
To: NTSB
Date: 4/5/2013
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Please find enclosed our agreed upon semiannual update of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board and are awaiting Coast Guard response. There are currently 42 safety recommendations with an "open" status issued to the Coast Guard. Of those, we attest that our actions are complete for six, six are pending resolution, and five require long-term agency action. Updates for the remaining 25 have been or will be provided in separate correspondence. Enclosure (1) provides specific information for each recommendation. There has not been a change in the status since the last update for the following four recommendations: M-07-6 Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. (Supersedes M-00-10) M-08-2 Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-14 Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-11-4 Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue.

From: NTSB
To: USCG
Date: 2/8/2013
Response: We understand that the Coast Guard continues outreach efforts with the Ship Operations Cooperative Program and with the American Waterways Operators to develop a framework to disseminate information to the maritime industry. Once established, similar outreach frameworks will be utilized through the Coast Guard’s advisory committees and other safety partnerships. Pending completion of these actions, Safety Recommendation M-11-4 is classified OPEN—ACCEPTABLE RESPONSE.

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. As mentioned in your letter, we issued marine Safety Advisory 01-10, Distracted Operations - Don't let it be you, which warned mariners of the danger and potential for distraction from duty caused by the use of cell phones or other wireless devices. Our outreach continues through other efforts, including the Ship Operations Cooperative Program (SOCP) and our safety partnership with the American Waterways Operators (AWO), where we are developing a framework to disseminate information to its members. Once established, similar outreach frameworks will be utilized through the Coast Guard's advisory committees and other safety partnerships. I will keep the Board informed of the Coast Guard's action on this recommendation.