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Safety Recommendation Details

Safety Recommendation M-11-007
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 AMERICAN WATERWAYS OPERATORS: Notify your members of the circumstances of this accident, and encourage them to ensure that their 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: 1/11/2012
Addressee(s) and Addressee Status: American Waterways Operators (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: American Waterways Operators
Date: 1/11/2012
Response: The NTSB appreciates learning that the AWO has taken the following actions to address this issue: • The AWO published a front-page story in the September 2011 issue of its AWO Letter. • At its October 2011 fall convention, the AWO convened a panel of members and staff for a special discussion session, titled Preventing Distracted Operations, which included an in-depth discussion of the NTSB investigation, conclusions, and recommendations, as well as the challenges, experiences, and industry best practices to ensure compliance by employees. • All AWO member companies received a letter informing them of the circumstances of the 2010 DUWK accident and urging them to remind employees of their company’s applicable distracted operations policies and emergency relief procedures. We also note that the issue of preventing distracted operations and creating a robust safety culture will be addressed at the February 2012 Coast Guard-AWO Safety Partnership’s National Quality Steering Committee meeting. Because these actions satisfy Safety Recommendation M-11-7, it is classified CLOSED—ACCEPTABLE ACTION. Thank you for your cooperation and for your commitment to marine safety.

From: American Waterways Operators
To: NTSB
Date: 11/30/2011
Response: -From Thomas A. Allegretti, President and CEO, American Waterways Operators: I am writing in response to the NTSB Safety Recommendation M-11-7, dated August 26, 2011. This recommendation asked AWO to: Notify your members of the circumstances of this accident, and encourage them to ensure that their safety and emergency procedures are understood and adhered to by employees in safety-critical positions. AWO believes that its members can learn valuable lessons from this tragic accident, and has taken the following actions to implement the NTSB’s recommendation and prevent future accidents of this kind: - In the September 16, 2011 issue of the AWO Letter, a biweekly newsletter that is disseminated to 1400 AWO members, AWO published a front-page story titled, “National Transportation Safety Board Issues Safety Recommendation to AWO.” The story described the circumstances of the accident, summarized the findings of the NTSB’s investigation, reviewed the NTSB’s safety recommendation to AWO, and outlined the steps that AWO was planning to take in response to the recommendation. A copy of the story is attached. - On October 6, 2011, at the AWO Fall Convention in New York, which was attended by almost 200 AWO members, AWO convened a panel of members and staff for a special discussion session titled, “Preventing Distracted Operations.” After a presentation on the facts of the collision, the NTSB investigation’s conclusions, and the NTSB safety recommendation to AWO, four AWO members representing a diversity of geographic locations and industry sectors, along with AWO’s Vice President – Safety, discussed the programs and policies their companies have implemented to prevent distracted operations and the challenge of ensuring compliance among their employees. Audience members also participated in the conversation, sharing their experiences and best practices.- - On November 28, 2011, AWO Chairman of the Board Peter Stephaich sent a letter to all 350 AWO member companies to personally inform them of the NTSB’s safety recommendation. In his letter, Mr. Stephaich described the circumstances of the accident and urged members to communicate with their employees and remind them of their company’s applicable distracted operations policies and emergency relief procedures. A copy of the letter is attached. - In addition to these actions, the issue of preventing distracted operations and creating a robust safety culture will be on the agenda at the February 2012 meeting of the Coast Guard-AWO Safety Partnership’s National Quality Steering Committee. The chairmen of AWO’s Interregion and Coastal Safety committees will make recommendations and lead a discussion of these issues for consideration by the senior AWO and Coast Guard officials who comprise the National QSC. Thank you again for the opportunity to respond to the NTSB’s Safety Recommendation M-11-7. AWO is pleased to work with the NTSB to support our mutual goal of improving safety in this important sector of our nation’s transportation system.