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
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.
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.
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.
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.
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
Expand Recorder Use to Enhance Safety
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
am going to briefly review the first 4 issues and then will discuss recorders. Recorders is one of my 3 Most Wanted List
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.
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.”
[another image featured in the slide presentation] is one of Captain Mike’s
investigations so he can tell you every detail.
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.
fitness for duty also has been on the list for several years. We have seen this issue on the rise across
all the modes.
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.
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
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.
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.
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.
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
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.
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.
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
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