Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation M-11-006
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 K-SEA TRANSPORTATION PARTNERS, L.P.: Review K-Sea Transportation’s existing safety management program and develop improved means to ensure that the company’s safety and emergency procedures are understood and adhered to by employees in safety-critical positions.
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: 12/22/2011
Addressee(s) and Addressee Status: K-Sea Transportation Partners, L.P. (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: K-Sea Transportation Partners, L.P.
Date: 12/22/2011
Response: The NTSB is pleased that K-Sea senior management reviewed the company’s existing safety management program, certified by the American Bureau of Shipping in July 2010 to meet International Safety Management Code and International Standards Organization standards. We commend K-Sea for the numerous safety improvements, detailed in Mr. Sullivan’s letter, to ensure that its employees understand and follow company safety and emergency procedures, including internal and external audits to be conducted, memoranda to be issued, seminars to be held, training to be offered, and other actions taken and planned. Because these combined actions satisfy Safety Recommendation M-11-6, it is classified CLOSED—ACCEPTABLE ACTION. Thank you for your commitment to marine safety and for your prompt action to address this recommendation. We appreciate your cooperation.

From: K-Sea Transportation Partners, L.P.
To: NTSB
Date: 11/28/2011
Response: -From Thomas Sullivan, Chief Operating Officer, K-Sea Transportation: K-Sea Transportation is in receipt of Safety Recommendation M-11-6. We believe the NTSB investigation into the collision of the tug/barge combination Caribbean Sea/The Resource with Ride the Ducks International amphibious passenger vehicle (APV) DUKW 34 was comprehensive and insightful. In response to Safety Recommendation M-11-6, K-Sea Transportation senior management reviewed the existing safety management program which was implemented July 1, 2010 and is certified to ISM and ISO standards by the American Bureau of Shipping (ABS). We developed the following improved means to ensure our employees understand and follow our safety and emergency procedures: 1. Our SMS has been audited internally by company representatives aboard K-Sea vessels and shore side offices and externally by ABS representatives at shore side offices and aboard a representative sampling of vessels. 2. Fleet Memo FN10.02.010 titled "Personal Electronic Equipment" was distributed on August 16, 2010 to all vessels and shore side employees. The memo reinforces our policy against duty distractions. 3. October and November 2010, a two day Captain Seminar was held in Seattle, New Jersey and Hawaii for our senior licensed deck officers. Presentations included training and reinforcement of the Company's safety management system and related emergency procedures. These presentations included a review and discussion of the DUKW incident by the company's Chief Operations Officer and/or the Executive Vice-President. 4. A Document of Compliance (DOC) and Certificate of Company Compliance (CCC) for our SMS were both issued by ABS on March 17, 2011. The certification process included a third party auditor confirming our employees' understanding of and compliance to our safety and emergency procedures. K-Sea is the first U.S. flag tug and barge operator to achieve ABS HSQE certification; the highest achievement for safety management systems certification. Our management system meets the standards of the ISM Code, ISO 9001, ISO 14001, OHSAS 18001 and the AWO Responsible Carrier Program. 5. Fleet Memo FN11.03.013 titled "NTSB Findings-Tug Caribbean Sea" was distributed on June 22, 2011 to all vessels and shore side employees. This memo included the probable cause of the DUKW incident identified by the NTSB investigative team. 6. A fleet-wide Safety Stand Down was initiated in June 2011 whereby all company vessels held a "Time Out for Safety" meeting. Each vessel scheduled a period when all vessel operations were coordinated to be safely stopped to conduct the 1-2 hour meeting with all vessel personnel in attendance. The meeting was structured to focus attention on our critical bridge operation and management procedures, including discussions on our Duty Distraction Prevention policy. 7. The Company established a goal for fiscal year 2012 (July 2011 - June 2012) with a target to "Demonstrate that Company has taken initiatives each month to improve awareness and prevent incidents due to Duty Distractions". We consider every crewmember aboard our vessels to be serving in a safety-sensitive position. Periodic training through seminars, audits, fleet instructions vessel drills and safety meetings will ensure these employees are cognizant of our safety and emergency procedures and compliant in their application. Additionally, we have shared the details and lessons learned from the incident with various industry stakeholders, such as the AWO Safety Committee and the National Safety Council's Marine Section. In closing we would like to compliment and thank the NTSB staff for their work on this investigation.