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Speeches

Remarks at American Institute of Marine Underwriters (AIMU)
T. Bella Dinh-Zarr, PhD, MPH
New York, NY
5/10/2017

Good morning!  Thank you, John (Miklus, AIMU President), for that very kind introduction.  I appreciate the invitation to speak today.  It is a pleasure and an honor to be here with all of you – marine underwriters, who have the common goal of preventing accidents.  I am joined by my colleague, Captain Mike Kucharski, who not only is a premier NTSB investigator and an experienced master, but he also is an attorney.  Mike is just one example of the fine professionals we have working at the NTSB.
 
I always have lived in areas with a strong maritime tradition.  I was born in Da Nang, Vietnam.  I grew up in Galveston, Texas, and I studied at the University in Valparaiso, Chile.  So, I appreciate your tight bonds.  Since arriving at the NTSB, thanks to our excellent Office of Marine Safety, I have had the opportunity to get to know the maritime community a little better.  I traveled along with the Virginia Pilot’s Association; operated a simulator at the Maritime Institute of Technology and Graduate Studies (MITAGS); visited the Puget Sound Vessel Traffic Service and Joint Harbor Operations Center; met Holland America executives and took a bridge tour of the Westerdam; toured Staten Island with Captain DeSimone here (in New York) and the Washington State Ferries.  I also have visited Kings Point Merchant Marine Academy (and I hope to visit Fort Schuyler, of course!); and launched with the NTSB go-team after the sinking of El Faro, where I had the privilege of meeting some of the families. 
 
Today Mike and I would like to give you a glimpse into the work that we do every day at the National Transportation Safety Board.  Many of you know us, or have even taken a class at our Training Center, but I would like to give you a brief overview of the NTSB so you can know more about who we really are and how we work.  Then, I will briefly discuss our work as it relates to our 2017-2018 Most Wanted List.  Mike will cover the specifics of how we conduct marine investigations and discuss the importance of voice data recorders (VDRs) to our marine investigations.
 
The NTSB is an independent federal agency dedicated to transportation safety.  We are charged by Congress with investigating every civil aviation accident in the United States (US) – historically, the public is most familiar with our investigations of airplane crashes - but we also investigate major transportation accidents in rail, marine, and highways, as well as pipeline and hazardous materials disasters. 
 
We are independent of all other federal agencies and we have 5 independent Board Members nominated by the President and confirmed by the Senate.  Since our creation in 1926, our agency has one simple but noble purpose: to prevent transportation-related deaths and injuries.   At the NTSB, we are on call 24 hours a day, 365 days a year to investigate accidents, assist the families of victims, and develop factual records and safety recommendations to make our transportation system safer.  Currently there are 4 Members on the Board (one spot is vacant) so Board Members like myself are “on call” every 4 weeks, ready to launch as part of a Go Team, in case of a major transportation disaster. 
 
Unlike many government agencies, the NTSB does not have regulatory authority and we have no financial incentives to promote our safety recommendations.  We fiercely protect our values of independence, credibility, and transparency because these are the values that define our agency.  We are truly independent so we do not report to anyone and we can make recommendations to anyone, such as the US Department of Transportation, state governments, associations, and private companies. 
 
We maintain our credibility by conducting very thorough investigations that touch on every single aspect of an accident from engineering to human performance to weather.  We value scientific and investigative rigor because our credibility lies in our reports and recommendations.  Also, as for transparency, our work and deliberations and votes are all done in public, in webcast meetings in compliance with what is known as the Government in the Sunshine Act.  As you can see if you ever watch our accident investigation and other board meetings, we sometimes do not agree – but that is the beauty and strength of the NTSB, we debate publicly not for any political gain, but in order to come to the best resolution for the sake of safety.
 
Mike will discuss marine investigations in greater detail in his part of the presentation but during the on-scene phase of our investigations, if a Board Member travels to an accident scene, they serve as the on-scene spokesperson to the family members and press.  After the on-scene phase, investigators work independently until the final product is presented to the Board for a vote.
 
During our final report development, the NTSB may issue a Board Accident Report after a public meeting or may issue a brief report format.  The board report contains analysis of factual information, conclusions, a probable cause determination, and safety recommendations. 
 
Yet, we cannot do it without your help.  I am here today to ask you to participate in our Marine Safety Listening Sessions, which provide invaluable information.  Mike will give you the details on how to do this.  Also, please support our Most Wanted List which I will discuss next.
 
MOST WANTED LIST
 
Every year, the NTSB releases our “Most Wanted List” of transportation priorities for the year.  For over 25 years, the NTSB has chosen ten issues – covering all modes of transportation - that represent safety challenges; challenges which have a strong chance of being advanced if given some good hard pushes.  Each Board Member is assigned to take the lead on 2 to 3 issue areas.  This year, 5 of the 10 issue areas we selected relate to marine safety.  Specifically, those issues involve:
 
       Eliminate Operator Distraction
       Reduce Fatigue-Related Accidents
       Require Medical Fitness
       End Alcohol & Other Drug Impairment in Transportation
       Expand Recorder Use to Enhance Safety
 
Last August, we published our 2015 Safer Seas publication.  We have brought copies to share with you today, but if we run out or you need more, please get in touch and we will send you more.  In this publication, you will find specific lessons learned from our marine investigations in 2015 and see how many of these relate specifically to our Most Wanted List.  Additionally, this year, the Marine Safety staff is working on over 50 major marine casualties.  In many of these investigations, they are finding issues relating to fatigue and distraction so more to come in the 2016 Safer Seas. 
 
I am going to briefly review the first 4 issues and then will discuss recorders.  Recorders is one of my 3 Most Wanted List issues. 
 
Over the past several years, we have found distractions have caused many marine accidents.  For example, in 2010, the NTSB found the probable cause of a barge with a DUKW boat in Philadelphia was, in part, caused by the failure of the mate to maintain a lookout because he was distracted by his personal electronic devices. 
 
Can anyone guess what happened here ? [image featured in the slide presentation.]  “The National Transportation Safety Board determined that the probable cause of the grounding ……. was the vessel straying off course and entering shallow water because the captain fell asleep, while navigating, due to fatigue.” 
 
This [another image featured in the slide presentation] is one of Captain Mike’s investigations so he can tell you every detail. 
 
Fatigue has been on the list for several years.  We have found that it is involved in accidents like the fishing boat found in the previous slide.  Yet, we have found fatigue has been involved in accidents involving public vessels, too.
 
Medical fitness for duty also has been on the list for several years.  We have seen this issue on the rise across all the modes.
 
One of my Most Wanted List issues is ending impairment in transportation.  I have spent time this year working on safety recommendations we have made to help reduce alcohol impairment in highway transportation, such as the .05 BAC (blood alcohol concentration) laws.  This is a subject I could talk to you all about for hours so I am going to save that for future discussions with you.
 
Today, I would like to talk with you about another of my Most Wanted List issues, recorders, because they are the “unsung heroes” of safety.  Even though the “black box” always gets a great deal of media attention after an accident, ensuring that crash resistant recorders are installed (in any mode) is not an easy task.  Over the decades, recorders have provided information that would be unobtainable otherwise and this information has been vital to preventing future accidents.  No single tool has helped the NTSB determine what went wrong more than recorders. 
 
Mike is going to talk to you specifically about VDRs and our recommendations related to them.  But our recommendations in this area involve federal rulemaking and as we all know, rulemaking can take years.  So, I would like to talk about a success story involving voluntary compliance by way of an aviation example in hopes that you might think of ways you can encourage voluntary compliance in the marine community as well.
 
In aviation, the NTSB recommends that all existing turbine-powered, non-experimental, non-restricted category aircraft contain or be retrofitted with a crash-resistant flight recorder system that records cockpit audio and images with a view of the cockpit environment.  On a more basic level, our general aviation accidents many times involve a single pilot and yet a complex system.  When that pilot dies, and even when the pilot survives, important data is lost without some type of recorder.
 
Last June, the NTSB met in a sunshine meeting to hear about the accident involving an Embraer 500’s aerodynamic stall and loss of control that took place in Gaithersburg, MD.  The plane crashed into a home in a residential neighborhood.  Sadly, the pilot, two passengers, and three people in one of the houses died as a result.  It was a general aviation, not commercial flight.  Data from the CVDR (cockpit voice and flight data recorder) provided information that demonstrated that the pilot did not use the de-ice system during the approach which led to ice accumulation and aerodynamic stall.  This aircraft was not required to have a CVDR.
 
Yet, because of the manufacturer’s decision to install a CVDR in this fleet, our investigators were able to access critical information to determine the sequence of events in order to identify actions to prevent a similar accident in the future.  Without that recorder, most information would have been lost, as has happened in countless other accidents. 
 
We always follow up on our recommendations with federal agencies, but we also seek out opportunities to talk about recorders to anyone, who may effect some changes – manufacturers, private pilots, flying clubs, companies with fleets.  In the maritime community, it is vessel owners, builders, and insurers like you.  Sometimes they do listen—one Chief Pilot of a Fortune 500 Company recently told me after listening to me twice that he decided to check out whether and what recorders were included in the next order of business jets he was buying for his company (perhaps so that he would not have to listen to me a third time!).  So, even before crash resistant recorders are required in all planes, this gentleman’s company will probably have recorders in their planes.
 
Perhaps all of you in the maritime insurance community have ways to encourage installation of recorders in the vessels you insure.  Installing recorders would be invaluable to helping prevent future accidents.  In my past life, I often worked with car insurance companies, some of the same companies I see here today, so I know you are powerful voices for safety.
 
As I turn the presentation over to Mike to tell you about marine investigations, I ask for your advice on ways to encourage your clients to voluntarily install these much-needed devices on their vessels.  If there is anything I can do, please do not hesitate to get in touch. 
 
Thank you for inviting me here today and for your commitment to your work which is so vital to preventing accidents and ultimately, to preventing injuries and saving lives.