In closing, I want to recognize the NTSB staff for their hard work in
developing and presenting this excellent safety report. Investigator-in-Charge
Morgan Turrell and his team did a terrific job. I want to also thank my fellow
Board members for their participation today.
In his book Outliers, Malcolm Gladwell says that to truly master a
skill, from archery to playing the violin, one needs 10,000 hours of practice.
That's 5 years of 40-hour weeks. By all accounts, the accident captain was
qualified, experienced and conscientious. He was the number one captain, he'd
delivered this vessel for the company and trained other company captains, and he
was a man that other crew members looked up to.
Yes, our report identified that the final error was made by the Captain on
the day of the accident, but the first vulnerabilities were designed into the
system years before. Accidents, like a fraying rope, are always a series of
missed opportunities, but the blame typically falls on the final strand in a
rope that breaks – often it is the human being.
The value of training must be maximized within a holistic safety management
system, or SMS. Strong and relevant instructional design, robust maintenance
procedures, manuals that can guide operators through real-world occurrences,
recognition that newer equipment demands new procedures and training, and many
other factors must support every person whose duties affect vessel safety.
Just as important, a robust safety management system means investigating
seemingly minor incidents: procedures for noting and investigating the causes of
minor failures that could lead to major ones.
But these are both cases of SMSs developed after an accident.
By requiring SMSs on all passenger vessels, we may prevent the next accident,
or mitigate its effects – rather than meet again in this Board room to adopt a
major accident investigation report.
Finally, requiring a Voyage Data Recorder or VDR on every passenger vessel
will help all who pursue vessel safety.
The VDR may be one tool for the operator to investigate an incident, so that
an accident never occurs; for the NTSB, a VDR greatly amplifies the lessons we
can learn from an accident, to help prevent similar accidents in the future.
Safety is indeed a voyage, not a destination. I would add that the voyage is
no solitary adventure. Rather, it is a continuous effort from the shipyard to
We stand adjourned.