Thank you for inviting me to speak with you today. I am very interested in your efforts to improve safety and it is gratifying to see involved people being proactive and getting together to identify the risks and come up with strategies to ensure passenger ship safety in this very busy waterway. I know you have a lot planned for this afternoon, so I will not take much of your time. I’d like to cover three things: our mission, our ongoing marine safety activities, and recent marine safety recommendations directed at improving passenger vessel safety.
The NTSB is an independent Federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation – railroad, highway, marine, and pipeline – and issuing safety recommendations to prevent future accidents. The NTSB also oversees the assistance to victims and their families during commercial aviation accidents and also acts as the Court of Appeals for airman, mechanics and mariners whenever certificate action is taken by the Federal Aviation Administration (FAA) or the U.S. Coast Guard Commandant, or when civil penalties are assessed by the FAA.
The NTSB promotes transportation safety by conducting independent, objective, precise accident investigations and safety studies, and by advocating and promoting NTSB safety recommendations. The scope of NTSB maritime responsibility is to determine the probable cause of:
- Major marine accidents and marine accidents involving a public and a nonpublic vessel;
- Releases of hazardous materials in all forms of transportation; and
- Selected transportation accidents that involve problems of a recurring nature or where a Coast Guard mission may have some involvement.
You are aware that the NTSB sends investigative “Go-Teams” to major accidents. Last month, we were in Cape May, New Jersey, investigating a tragic fishing vessel accident where the vessel owner lost his two sons, a brother, and three other crewmen. Earlier in the year, the NTSB launched to New York City when US Airways flight 1549 ditched in the Hudson River. The Go-Team included two investigators from the Office of Marine Safety who looked into the waterborne emergency response, which was handled exceptionally well. What you may not know is that the NTSB, despite a staff of fewer than 400 people, covers the entire United States and also sometimes sends teams abroad. And our investigators don’t just respond to commercial accidents. In mid-April, we sent a Go-Team, including one of our Board Members, to Palm Valley, Florida, to investigate a marine accident involving a 22-foot pleasure boat that struck a moored workboat in the Intracoastal Waterway. That accident resulted in several fatalities and numerous injuries. Three years ago we also investigated the capsizing of a small passenger vessel in which 20 elderly people died – that boat was not inspected by the Coast Guard because it operated on the state waters of Lake George, New York.
Our Office of Marine Safety is the smallest of the NTSB’s modal investigation groups, having at present 11 investigators. Accidents currently under investigation, in addition to the recreational boat just mentioned, include the sinking of a commercial fish processing vessel in the Bering Sea, an allision between a dredge and an orange juice tank vessel in New Jersey, an engineroom fire on a passenger vessel in Oregon, and the collision between a passenger ferry and a Coast Guard cutter on Rhode Island Sound.
Examples of recent marine accidents that the NTSB has investigated and released final reports on include the following:
- Kition – The Kition investigation was recently completed and involved an 800-foot tanker that departed its berth on the Mississippi River immediately above the I-10 bridge in Baton Rouge and struck the bridge. The critical safety issue identified in this accident was lack of an effective master/pilot exchange; specifically, the pilot not informing the master about how he intended to depart the berth and head the vessel downriver.
- Empress of the North – This investigation was completed last year and involved a passenger vessel that struck a charted rock during a nighttime transit through an Alaskan strait. The master had assigned an inexperienced, newly licensed third mate to the watch but did not remain on the bridge to supervise him, nor did any other licensed officer.
- Cosco Busan – The Cosco Busan was one of our higher profile accidents and was just considered by the Board at our public meeting some 3 months ago. The Cosco Busan made for a very interesting investigation and report. There was probably not a single dynamic in that accident that wasn’t analyzed by our staff. From prescription drugs, vessel traffic service, company safety management systems, training, language complications, and cultural differences, the Cosco Busan will likely be discussed in training schools and professional classrooms for some time to come.
There are three lessons learned from our recent marine investigations that will benefit this conference in managing and mitigating risk; bridge resource management, communication, and medical oversight of licensed mariners. Please permit me to share with you the NTSB’s perspective on theses topics.
- Bridge Resource Management
A shipmaster is the ultimate authority at sea. In many cases this individual is the most experienced and knowledgeable person on board when it comes to vessel operations. Historically, because of a master’s position, some junior officers and unlicensed crew were reluctant to report issues pertaining to safety. Crewmembers often regarded the reporting of information on an issue to fall into the category of something the master probably already knew or anticipated, and therefore, not something that required bothering the master with.
Bridge resource management (BRM) training was envisaged as a means to bring about a change in culture whereby masters would expect and be receptive to subordinates’ reporting safety issues. The crewmembers were therefore trained that reporting was their obligation. The rationale was that, should the master fail to recognize a problem, timely reporting by subordinate officers and crewmembers would ensure that problems were recognized and that timely corrective action was taken. BRM, in other words, could help identify safety problems and establish procedures to prevent accidents.
Today, international requirements adopted by the International Maritime Organization mandate that officers on oceangoing vessels undergo BRM training. The principals of BRM are now part of the safety management system that each oceangoing vessel and its operating company are required to have. However, despite the apparent universal acceptance of the required training, we still encounter cases where BRM is not practiced. In recent accidents we have seen a trend of navigation crew standing meekly by while the individual with the ‘conn’ placed the vessel in danger.
Language barriers, cultural differences, and lack or improper use of marine terminology have also contributed to many marine accidents investigated by the NTSB. With increasing numbers of foreign-flagged vessels and non-English-speaking crew, we must be sensitive to the importance of clear unambiguous communications. Moreover, because verbal dialogue only makes up part of how people communicate, how much are we missing if we don’t understand and appreciate the cultural diversity that we encounter every day?
Clearing a mariner as medically fit should entail more than checking a box during the periodic licensing renewal. The Coast Guard has made great strides to close loopholes on unfit mariners but more is needed. Mariners need to be physically fit whenever they are carrying a license, not just at the renewal period.
Along those lines, postaccident drug- and alcohol testing must be timely and must include all individuals involved in the accident, not just the master or the pilot. However, in almost every accident that the NTSB investigates, we find that this is not the case – either testing was not timely, or not all relevant persons were tested.
NTSB safety recommendations are our primary mechanism for improving transportation safety. Since 1967, we have issued over 2,300 marine safety recommendations, over half of them addressed to the Coast Guard. The following safety recommendations, issued since 2000 to the Coast Guard, seek to reduce risk to passenger vessel operations.
- Revise passenger regulations to require that passenger capacity be calculated based on statistically representative average passenger weight standards that are periodically updated.
- Seek legislative authority to require all US-flag ferry operators to implement safety management systems.
- Establish firefighting training requirements for crewmembers on board all small passenger vessels and improve the effectiveness of firefighting drills.
- Evaluate the procedural effectiveness of the [cruise vessel] crew in crowd control, crisis management, life jacket distribution and passenger accountability. (M-01-1, Ecstasy)
- Require that companies operating passenger vessels develop and implement a preventative maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems.
- Require that all small passenger vessels certificated to carry more that 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.
We are working closely with the Coast Guard to have a favorable outcome for these safety recommendations.
In closing, let me say that our nation’s transportation system is very safe. People like you, who work hard every day to operate the transportation system and keep it safe, have our sincere admiration and appreciation. I applaud your proactive efforts to reduce the risks associated with the movement of passenger vessels in and out of your port and waterways in restricted visibility. I realize it is no small feat to plan, execute, and maintain timely schedules for high-passenger-capacity cruise vessels along with all other marine traffic on the Mississippi River. I'm sure there’s constant pressure to maintain scheduled ship departures and arrivals, and for your efforts to do so safely – today and in the future – I commend you.
The NTSB is committed to the idea that there is always room for safety improvements. For this reason, we will continue to conduct careful, scientific investigations of transportation accidents to determine how our transportation system can be made even safer.
Thank you for inviting me.