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Keynote Remarks at the Puget Sound Harbor Safety Committee Meeting, Seattle, Washington
T. Bella Dinh-Zarr, PhD, MPH
Seattle, Washington

​Good morning!  I appreciate the invitation to come here today to meet all of you.  Thank you to John Lauber and John Veentjer for introducing me to this group.  It is a pleasure and an honor to be here with all of you - maritime leaders who are working together towards the common goal of safety. I am joined today by Brian Curtis, our Acting Director of Marine Safety, Sharon Bryson our Director of Safety Recommendations and Communication, who also created our Family Assistance Program, and John Brown, my Confidential Assistant.  They are just three examples of the fine professionals we have working at the NTSB.

I have always had a deep personal appreciation for the work you do, here on Puget Sound, because although I grew up on the Gulf Coast, I have family in this area.  It has been very interesting to learn more professionally, first-hand, over the past few days about Puget Sound.  Since arriving in Seattle last week, we have had the privilege of meeting some of your dedicated maritime community here in Seattle – we visited the Puget Sound VTS and Joint Harbor Operations Center, we met with Holland America and took a bridge tour of the Westerdam, we toured the Washington State Ferries and rode to Bainbridge Island, and we had the pleasure of meeting Rear Admiral Mark Butts and the other dedicated men and women from the US Coast Guard.

Today I hope to give you a glimpse into the work that my colleagues and I do every day at the NTSB.  Some of you are very familiar with the NTSB and others less so, but regardless, many of you probably know John Lauber, who was an NTSB Board Member for nearly a decade and someone, I should add, who is still considered the epitome of a truly great NTSB Board Member.  First, I would like to provide an overview of our NTSB investigative process, especially as it relates to maritime accidents.  As John Lauber says, it is good to hear about our process under benign conditions and we will all hope that this will never amount to anything more than information for you.  Then, I will briefly discuss our 2016 Most Wanted List of Transportation Priorities.  Finally, I would like to provide factual information about our upcoming VTS safety study and the EL FARO investigation.  But I also would like to leave plenty of time for questions, especially since we have Brian Curtis and Sharon Bryson here.  They have a wealth of knowledge and many years of experience at the NTSB.

The NTSB is unique because we are an independent federal agency solely dedicated to transportation safety.  We are charged by Congress with investigating every civil aviation accident in the United States – historically, the public is most familiar with our investigations of airplane crashes - but as you know, we also investigate major transportation accidents in marine, rail, and highways, as well as pipeline and hazardous materials disasters.

In addition to beinh independent of all other federal agencies, 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 disaster.

Unlike many government agencies, the NTSB does not have regulatory authority and we also 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 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 this credibility by conducting very thorough investigations that touch on every single aspect of an accident from engineering to human performance to weather.  We value this scientific and investigative rigor because our credibility lies in our reports and recommendations.  As for transparency, our work and deliberations and votes are all done in the public eye, usually 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 a privilege and a responsibility for a Board Member.  We debate publicly not for any political gain, but in order to come to the best resolution for the sake of safety.



Let’s turn to our authority to investigate marine casualties.  Under 49 USC Section 1131, the NTSB is authorized to investigate any major marine casualty occurring on or under the US navigable or territorial waters, or involving a US vessel in foreign waters, or involving a US public vessel and any other vessel.  However, the NTSB’s authorization overlaps in many instances with that of the US Coast Guard.  Therefore, the NTSB and the Coast Guard have a memorandum of understanding (an MOU) which determines which agency will lead a given accident investigation.  The agencies agree to provide each other mutual assistance in marine casualty investigations.  The MOU establishes that the NTSB will investigate “significant marine causalities” and defines those events in the MOU.

To give you an example – the NTSB will serve as lead agency to investigate a casualty involving the loss of 3 or more lives on a commercial passenger vessel or the loss of 12 or more lives on a commercial vessel.  The US Coast Guard may still conduct a separate marine board for the purposes of their safety investigation and any potential enforcement actions.  Both agencies share the factual findings from their investigations, but we always conduct separate analyses.

During the on-scene phase of our investigations, if a Board Member travels to an accident scene, we serve as the on-scene spokesperson to the family members, elected officials, and press.  The NTSB sends an investigator-in-charge (or IIC) who leads the investigation.  We offer party status to those companies, government agencies, and organizations that have employees, activities or equipment involved in the accident.  The reason we offer party status to those groups is because they provide the technical expertise and relevant information so that we can develop the best possible factual record.

Parties may not release information about the investigation to the media or anyone outside the investigation without approval of the IIC.  On scene, we form investigative groups in subject areas such as: Operations, Engineering, Survival Factors, and Human Performance.

Once we leave the scene, usually after 7 to 10 days, our investigation continues with the assistance of our party members.  In certain cases, we may hold an investigative hearing well before the board meeting.  The party participation in our process ends at the technical review of factual information and the completion of these group chairman reports.

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, recommendations, and a probable cause determination, all of which must be voted on by the Board Members.



Another way to advance the safety information in our reports is through the 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 by the NTSB and our colleagues.  This year, 5 of the 10 issue areas we selected relate to marine safety.  Specifically those issues involve:

  • Use of Recorders
  • Medical Fitness for Duty
  • Ending Substance Impairment
  • Distraction and
  • Fatigue

Just two weeks ago, we published our 2015 Safer Seas publication.  Although I know many of you have seen it online, we have brought copies to share with you today.  In this publication, you will find lessons learned from our marine investigations in 2015 and see how many of these relate specifically to our Most Wanted List.  Additionally, this year, Brian Curtis and his staff are working on 50 major marine casualties.  In many of these investigations, they are finding issues relating to fatigue and distraction so there is more to come in the 2016 Safer Seas. I think this is a great-looking and very useful publication, which is another example of the good work of Brian’s and Sharon’s offices, and I hope you will find it helpful, too.



The VTS safety study is something that many of you have helped us on.  In September, the NTSB will be meeting to discuss this safety study.  Although I cannot give you the findings and recommendations because the Board must deliberate and we vote on the final report at the public meeting, I can share a little factual background that might be of interest to you.

NTSB has a long history of interest in the Coast Guard VTS system dating back to its 1971 investigation of the collision involving the tankers Arizona Standard and Oregon Standard in San Francisco Bay.  NTSB first made recommendations supporting the Coast Guard’s establishment of VTS centers in the early 1970s and we have continued to investigate safety issues related to VTS centers.  We have made numerous recommendations supporting the Coast Guard’s use of VTS to promote the safe and orderly movement of commercial vessel traffic.

  • The goal of the study was to: evaluate the effectiveness of the Vessel Traffic Service (VTS) system by assessing its ability to:
  • detect and recognize traffic conflicts and other unsafe situations;
  • provide mariners with timely warning of such situations; and
  • control vessel traffic movements in the interest of safety.

The study received extensive support from the Coast Guard’s VTS program in Washington, DC, and from the VTS directors and Sector Commanders at the 12 VTS centers.  NTSB was granted access to personnel and the watch floor at each of these facilities.  Our staff used a combination of quantitative and qualitative data sources and analytical methods, including:

  • analysis of accident, vessel movement, and VTS activity data;
  • review of procedures, documents, and training;
  • a VTS watchstander survey;
  • VTS center visits and interviews;
  • stakeholder comments (among these were comments from the Puget Sound Harbor Safety Committee); and
  • a comparison with international guidelines and foreign counterparts.

I would like to take a moment to say thank you to all of you, who took the time to provide us with information for this study.  The comments and feedback received from the Puget Sound area were invaluable.  Also, the Puget Sound Harbor Safety Committee Chair, John Veentjer, provided a very helpful summary of this committee’s perspectives and experiences related to the VTS system.  Mr. Veentjer also provided comments on VTS from his position as the executive director of Puget Sound’s Marine Exchange.

Other stakeholder comments from the area included individuals representing:

  • Puget Sound Pilotage District,
  • Washington State Ferries,
  • harbor tug operations,
  • local charters, and
  • recreational boating interests
  • Thank you again and I hope you will find the study useful when it is complete.



I know many of you know the facts about El Faro, but I want to give you an overview and go into further detail in the Q&A. On October 4, 2015, the National Transportation Safety Board launched a go-team to Jacksonville, FL, to investigate the loss of the cargo ship El Faro, which was last heard from on October 1. Our team was led by the NTSB’s Tom Roth-Roffy as investigator-in-charge and I served as the Board Member on-scene.  We worked closely with the Coast Guard as this accident changed from a search and rescue mission to an investigation and I cannot emphasize enough the importance of our excellent working relationship which made it easier for us to do our jobs, both in collecting factual information and in providing assistance to families.  Thank you to the Coast Guard.

On October 23, the United States Naval Ship (USNS) Apache with Navy and NTSB personnel on board arrived at the last known position of the El Faro, and began searching for the vessel with a Towed Pinger Locator (TPL).  The search area consisted of 10 nautical miles by 15 nautical miles.  On October 31, 2015, we located the wreckage of El Faro in more than 15,000 feet of water.  During that first mission, we completed video documentation of the ship and the associated debris field, but the vessel’s Voice Data Recorder (VDR) was not located.

During a second mission, the VDR was located on April 26, 2016, in 15,000 feet of water, about 41 miles northeast of Crooked Islands, Bahamas, by a team of investigators and scientists using remotely operated undersea search equipment.

On August 8, 2016, during a third mission, the VDR from El Faro was recovered from the ocean floor and taken back to NTSB’s labs in Washington, DC.  Investigators examined the VDR, found it to be in good condition, and downloaded its memory module data in accordance with the manufacturer’s recommended procedures.  Information from the VDR was successfully retrieved August 15th and the NTSB convened a VDR group.  Approximately 26 hours of information was recovered from the VDR, including bridge audio and navigational data.

Numerous events leading up to the loss of the El Faro are heard on the VDR’s audio, recorded from microphones on the bridge.  The quality of audio contains high levels of background noise.  There are times during the recording when the content of crew discussion is difficult to determine, and at other times the content can be determined using advanced audio filtering.

The recording began about 5:37 a.m., September 30, 2015 –8 hours after the El Faro departed Jacksonville, with the ship about 150 nautical miles southeast of the city.  The bridge audio from the morning of October 1st, captured the master and crew discussing their actions regarding flooding and the listing of the vessel.  The vessel’s loss of propulsion was mentioned on the bridge audio at approximately 6:13 a.m.  Also captured was the master speaking on the telephone, notifying shoreside personnel of the vessel’s critical situation.  He also informed them he was going to send out an emergency distress signal.  The master sounded the abandon ship alarm at 7:30 a.m., on October 1st.  The recording ended approximately 10 minutes later.  These times are preliminary and subject to change and final validation by the VDR group.

The VDR group, comprised of technical experts, will continue reviewing (called “auditioning”) the entire recording, including crew discussions regarding the weather situation and the operation and condition of the ship.  Families of the El Faro crew were briefed about the results before the NTSB’s public release of the information about the audition.

We do not know exactly how long it will take to develop the final transcript of the VDR.  As you can imagine, this is a time consuming process, both because of the length of the recording (which has high levels of background noise) and the care we want to take in transcribing the information to ensure it is as accurate as possible.

Before we take questions, I would like to thank you again for inviting me and even more, for giving me a chance to meet you and learn more about your work.  I will meet with some highway and aviation professionals while I am here, but in my short time in Seattle, I can already see that the maritime community is an integral and beloved part of this city and this part of the country.  In addition, you play an important role for our country and the world.  I hope today is just the start of our conversations about the important work that you do and the work we do to help keep our country safe.

Thank you.

Now I would like to ask Brian Curtis and Sharon Bryson to come up and join me.  We would be happy to answer your questions.