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Safety Recommendation Details

Safety Recommendation M-02-005
Details
Synopsis: On the evening of November 17, 2000, the U.S. small passenger vessel Port Imperial Manhattan, with three crewmembers and eight passengers on board, was en route to Weehawken, New Jersey, from the borough of Manhattan in New York City, New York, when a fire broke out in the engine room. Crewmembers attempted to extinguish the fire with portable extinguishers, with no success. The fire burned out of control, causing the vessel to lose power and forcing the crew and passengers to abandon the interior spaces. The crew and passengers were rescued by another NY Waterway passenger vessel, and the burning vessel was towed to Manhattan, where the New York City Fire Department extinguished the fire. One passenger was treated for smoke inhalation. No deaths resulted from this accident. The estimated cost to repair the vessel was $1.2 million.
Recommendation: TO THE UNITED STATES COAST GUARD: Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Marine
Location: River, NY, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA01MM008
Accident Reports:
Fire on Board the Small Passenger Vessel Port Imperial Manhattan
Report #: MAR-02-02
Accident Date: 11/17/2000
Issue Date: 7/3/2002
Date Closed:
Addressee(s) and Addressee Status: USCG (Open - Unacceptable Response)
Keyword(s): Safety Management Systems

Safety Recommendation History
From: NTSB
To: USCG
Date: 12/20/2018
Response: From the Fire on Board US Small Passenger Vessel Island Lady Pithlachascotee River near Port Richey, Florida, January 14, 2018, Report Number MAR-18-02, adopted on December 11, 2018. 2.3 Insufficient Preventive Maintenance Tropical Breeze Casino Cruz stated that it had implemented a preventive maintenance program for its vessels after receiving Safety Recommendation M-06-12 in response to the 2004 Express Shuttle II fire. However, when investigators interviewed company officials and reviewed maintenance records, they discovered several issues with the program that indicated that it was not adequate or robust. For example, although the engine manufacturer, Caterpillar, provided a preventive maintenance schedule in its manual, investigators found no evidence that Tropical Breeze Casino Cruz followed all components of the program. Instead, the company engineer had created a basic monthly maintenance report, which recorded only completed maintenance and did not take engine hours into consideration for maintenance intervals, nor did it have a maintenance schedule with future dates for inspections and maintenance to be completed. The engineer kept this maintenance report for both company vessels on the company’s computer in the office on the dock. Investigators examined the Island Lady’s maintenance log for the year before the fire, between January 2017 and October 2017. No maintenance records were available before January 2017 and after October 2017. The items listed on the maintenance report were: “Flush, oil change, fuel filter, heat exchanger, air filter, transmission fluid change, thermostat, belts, battery water, and impeller.” Several maintenance items that were identified in the Caterpillar maintenance schedule were not included in Tropical Breeze Casino Cruz’s monthly maintenance reports, such as the zinc rod replacement, crankcase oil analysis, auxiliary water pump inspections, hose and clamp inspections, engine speed/timing sensor inspections, valve lash adjustments, and fuel injector checks, among other items. Several of these maintenance items were critical for proper operation, and the infrequent maintenance and inspection likely resulted in undetected, wear-related damage. Based on the captain’s statement that he believed a hose may have failed, releasing cooling water onto the port bulkhead, investigators considered the hoses associated with the raw-water system as a possible source for this water release. Caterpillar recommended that the hoses and clamps be inspected every 250 service hours. Although the monthly maintenance report (kept on a shoreside computer) did not include an entry for inspection or replacement of hoses, the daily engine room checklist (kept on board the vessel) had a fillable field titled “Hoses ok.” According to the owner, all completed daily checklists retained on board were consumed in the fire; therefore, investigators were unable to determine the quality of any hose inspections. After discussion between investigators and the owners, although the monthly maintenance reports were kept shoreside, there was no evidence that the company had reviewed them or provided guidance regarding engine maintenance to the engineer, indicating a lack of oversight by the company. Caterpillar’s interval for raw-water pump inspections was every 250 hours. Accordingly, the pumps installed on the Island Lady should have been inspected and the results documented at these intervals. However, Tropical Breeze Casino Cruz’s monthly maintenance report did not include an entry for inspection of the raw-water pumps. The only reference to the pumps in a report was in May 2017, when an entry recorded the replacement of both pump impellers. When the Island Lady operated 6 hours a day, 4 days a week, the pumps should have been inspected about every 10 weeks. Once the engines were being operated 7 days a week (when the Island Lady increased the number of trips to the casino boat), the pumps should have been inspected every 6 weeks. After the report entries for the May 2017 impeller replacements, no records were available to show any maintenance or inspections completed on the pumps, nor were there any receipts to show parts purchased for the pumps. Even if the Island Lady had been operating at the more conservative 4 days a week, the port engine would have accumulated about 24 hours a week, which would have amounted to about 840 hours in the 35 weeks between the date when the impellers were replaced and the accident. Based on that estimate, the pumps should have been 43 inspected three times since May 2017, but investigators found no record of inspection or replacement since that date. The NTSB therefore concludes that the company’s lack of inspections and infrequent maintenance likely resulted in undetected, wear-related damage causing the port engine’s raw-water pump to fail. Investigators learned that the starboard engine had been overhauled in March 2017, but the port engine had not, although the engines likely had similar running hours. No details were available about the overhaul; no service reports and no engine hours were recorded. According to company officials, at the time of the fire, the engines had an estimated 13,000 hours on them. In an undated vessel specification sheet, sometime after the year 2000, the previous owner had recorded the port engine’s hours as “2,191.4.” Photos taken during the drydock in April 2017 and video footage of the vessel’s stern on the day of the accident show dark exhaust and soot coating the stern. In an interview, the engineer said that after the vessel was purchased, it started blowing black smoke out of the exhaust. He said several people, including Caterpillar representatives, were unable to determine the source of the smoke. Regardless, the accumulation of soot on the stern indicated that the engines were not operating as designed. A well-developed oversight system for maintenance should include record-keeping and documentation. The Caterpillar manual recommended that accurate maintenance records be kept to determine operating costs, establish maintenance schedules, and show compliance with maintenance practices and intervals. The manual stated that such records were essential to a well-managed engine maintenance program and should include fuel consumption, service hours, and detailed service records. However, Tropical Breeze Casino Cruz did not follow these elements in its maintenance program. If the company had performed scheduled preventive maintenance and overhauls as Caterpillar recommended, the Island Lady’s raw-water pump would have been inspected on a regular schedule. The purpose of a raw-water pump is to cool an engine’s jacket-water system; without the pump functioning, the jacket water temperature rises and an engine overheats. Additionally, in a wet-exhaust system, loss of raw-water supply will cause the temperature of the exhaust gases in the tubing to rise substantially. Any issues with the pump could have been identified and addressed before the engine overheated. No records were available to indicate that the raw-water pump had been inspected from the time the impeller was replaced to the day of the fire?a period more than three times the length of the manufacturer’s recommended interval. The NTSB therefore concludes that if Tropical Breeze Casino Cruz had followed Caterpillar’s recommended maintenance schedule for the Island Lady’s propulsion engines, the failed raw-water cooling pump would have been inspected and likely replaced. The NTSB therefore recommends that Tropical Breeze Casino Cruz develop and apply an oversight system to ensure that its maintenance program complies with the manufacturer’s recommended preventive maintenance program for the engines and associated machinery and systems on board its vessels. Following the two previous fires on board the small passenger vessels Port Imperial Manhattan in 2000 and the Express Shuttle II in 2004, the NTSB issued and then reiterated Safety Recommendation M-02-5 to the Coast Guard to develop and implement maintenance systems on board domestic passenger vessels. However, because of the Coast Guard’s lack of progress on the issue, the recommendation remained “Open—Unacceptable Response” at the time of the Island Lady fire. In correspondence with the NTSB regarding the recommendation, the Coast Guard stated that small passenger vessels are already subject to a comprehensive set of regulations designed to promote vessel safety, and that operators are responsible for maintaining their vessels 44 accordingly. The NTSB replied that it was necessary for companies to develop a preventive maintenance program for all systems affecting the safety of passenger vessels. Preventive or periodic maintenance programs are an integral part of any well-run vessel operation, and a requirement to develop and implement such programs should not be burdensome to vessel operators. With a required, ongoing preventive maintenance program, owners might be less likely to operate substandard vessels that place the public at risk. However, the Coast Guard has yet to require preventive maintenance programs for small passenger vessels. Currently, numerous operators of domestic small passenger vessels have voluntarily implemented SMS, which include integral preventive maintenance programs. The NTSB maintains that companies operating domestic passenger vessels should be required to develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull, mechanical systems, and electrical systems. Had the Coast Guard completed implementation of Safety Recommendation M-02-5, Tropical Breeze Casino Cruz would have been required to have a compliant preventive maintenance program subject to Coast Guard oversight, and the Island Lady fire may have been prevented. Therefore, the NTSB once again recommends that the Coast Guard require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and mechanical and electrical systems. In addition to covering preventive maintenance, SMS also addresses crew training, emergency preparedness, documentation, oversight, and so on. For further discussion, see next section.

From: NTSB
To: USCG
Date: 2/17/2017
Response: We understand that you are developing the necessary regulations to implement the requirements called for in the 2010 Coast Guard Authorization Act, which included a requirement for passenger vessels to have a safety management system (SMS), and we note your agreement that preventative maintenance programs for critical equipment and the vessel’s structure are generally included as part of an SMS. Although progress is being made, we are disappointed that action has not been completed on this 14-year-old recommendation. Accordingly, given the age of the recommendation and pending the final rules, Safety Recommendation M-02-5 is classified OPEN--UNACCEPTABLE RESPONSE. We encourage you to expedite your actions.

From: USCG
To: NTSB
Date: 10/18/2016
Response: -From Charles W. Ray, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: The Coast Guard continues to develop the necessary regulations to implement the requirements called for in the 2010 Coast Guard Authorization Act, which included a requirement for passenger vessels to have a safety management system (SMS). Preventative maintenance programs for critical equipment and the vessel’s structure are generally included as part of a SMS.

From: NTSB
To: USCG
Date: 3/11/2016
Response: This letter concerns 40 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Coast Guard between 2002 and 2015. For several years, the NTSB received an annual update on all open safety recommendations issued to the Coast Guard; however, for 25 of the 40 recommendations listed, we have received no update in over 2 years regarding the status of action either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Please respond to this letter electronically at correspondence@ntsb.gov regarding your progress in addressing these safety recommendations, and do not submit both an electronic and a hard copy of the same response. To assist with your response, enclosure (1) is a list of the 40 recommendations highlighting the recommendation number, current status, source of the recommendation, and date of the last Coast Guard update; enclosure (2) is a print-out from our database with the complete correspondence history of each open recommendation.

From: NTSB
To: USCG
Date: 5/13/2014
Response: We are disappointed that, although you state that you continue to work toward addressing this recommendation, you have made no significant progress since August 2012. We ask that you expedite action to require a safety management system [SMS] on all domestic passenger vessels, regardless of their size or capacity, and that you provide a detailed reply regarding this issue in your next update. Pending our receipt of such a response, Safety Recommendation M 02-5 remains classified OPEN—ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 1/28/2014
Response: -From Peter V. Neffenger, Vice Admiral, Deputy Commandant for Operations: Enclosed is our semiannual report of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board. There are currently 39 safety recommendations with an "open" status issued to the Coast Guard. Of those, I am providing our initial response to six new recommendations, proposing that seven recommendations be closed as acceptable, and updating five previously issued recommendations. At this time, there are no significant changes in action to be reported for the remaining 21 recommendations. These recommendations include: M-02-5, M-07-6, M-09-4, M-09-10, M-09-14, M-09-15, M-09-16, M-10-5, M-10-6, M-11-4, M-11-13, M-11-15, M-11-16, M-11-23, M-11-24, M-11-25, M-11-26, M-11-27, M-12-1, M-12-2, and M-12-3.

From: NTSB
To: USCG
Date: 7/8/2013
Response: Thank you for the April 5, 2013, letter signed by Vice Admiral Peter V. Neffenger, Deputy Commandant for Operations, to the National Transportation Safety Board (NTSB) containing your semiannual update regarding actions to address 42 safety recommendations that the NTSB issued to the US Coast Guard. To assist with future updates and to align our records, we are enclosing a copy of the NTSB’s safety recommendation database history for these 42 recommendations. This response letter will be divided into four parts: • Part 1 – Evaluation of actions to address Safety Recommendations M 09 15 and 16 and M-10-2, recommendations for which Admiral Neffenger provided a substantive update. • Part 2 – List of 6 safety recommendations previously closed. • Part 3 – List of 7 safety recommendations that were the subject of a recent Coast Guard update and that the NTSB is currently evaluating; these recommendations will be addressed in detail in separate correspondence. • Part 4 – List of 26 safety recommendations for which the Coast Guard did not provide a substantive update or for which status has not changed since the last update. Part 1 – Safety Recommendations Updated in the April 5, 2013, Letter: We issued Safety Recommendations M-09-15 and -16, stated below, to the Coast Guard on October 20, 2009, as a result of a review of the involvement of obstructive sleep apnea (OSA) in several accidents investigated by the NTSB. M-09-15 Implement a program to identify licensed mariners subject to the Navigation and Vessel Inspection Circular on Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (NVIC 04-08) and who are at high risk for obstructive sleep apnea, and require that those mariners provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. M-09-16 Develop and disseminate guidance for mariners, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that mariners who have OSA that is effectively treated are routinely approved for continued medical certification. We are encouraged that the Merchant Mariner Medical Advisory Committee is planning to review and revise Navigation and Vessel Inspection Circular 04-08, including Enclosure (4), Guidance on Specific Medical Conditions, which details the medical decision making criteria for common conditions (including sleep disorders such as OSA) as they relate to determining merchant mariner fitness for duty. Pending completion of these efforts, Safety Recommendation M-09-15 is classified “Open—Acceptable Alternate Response” and Safety Recommendation M 09-16 is classified “Open—Acceptable Response.” We issued Safety Recommendation M-10-2, stated below, to the Coast Guard on August 11, 2010, as a result of two recent maritime accidents involving Coast Guard patrol boats: the December 5, 2009, collision of the CG 25689 with the small passenger vessel Thriller 09 in Charleston, South Carolina, and the December 20, 2009, collision of the CG-33118 with a 24 foot recreational vessel in San Diego, California. M-10-2 Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. The Coast Guard’s recent revision of Coast Guard Boat Operations and Training (BOAT) manual, volume I, COMDTINST M16114.32C, section F.2, prohibits the use of cellphones/texting devices and phone applications aboard all boat force assets without the permission of the coxswain, which will only be granted on a case-by-case basis and only when operational safety is not compromised. Because this action satisfies Safety Recommendation M 10-2, it is classified “Closed—Acceptable Action.” Part 2 – Safety Recommendations Previously Closed: M-06-5 (Closed—Acceptable Action, March 14, 2011) Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. M-06-6 (Closed—Acceptable Action, March 14, 2011) Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. M-06-7 (Closed—Unacceptable Action, March 14, 2011) Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. M-06-8 (Closed—Unacceptable Action, March 14, 2011) Until such time as you revise the passenger weight standard as requested in Safety Recommendation M-06-5 and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation M-06-7, develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations. M-06-9 (Closed—Unacceptable Action, March 14, 2011) Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection. M-11-11 (Closed—Acceptable Action, November 13, 2012) Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. Part 3 – Recommendations Recently Updated and Under Evaluation by the NTSB: M-10-5 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders that meet the international performance standard on new ferry vessels. M-10-6 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders on ferry vessels built before the enactment of voyage data recorder carriage requirements that will record, at a minimum, the same video, audio, and parametric data specified in the International Maritime Organization’s performance standard for simplified voyage data recorders. M-12-1 (Open Initial Response Received; USCG Update February 12, 2013) Require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-2 (Open Initial Response Received; USCG Update February 12, 2013) Where technically feasible, require existing U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be retrofitted with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-3 (Open—Initial Response Received; USCG Update February 12, 2013) Require all operators of U.S.-flag passenger vessels to implement safety management systems, taking into account the characteristics, methods of operation, and the nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. M-12-6 (Open—Initial Response Received; USCG Update March 21, 2013) Develop and implement a policy to ensure adequate separation between vessels operating in the Bayport Channel and Bolivar Roads Precautionary Areas and any other similarly configured precautionary areas in the Houston Ship Channel. M-12-7—(Open Initial Response Received USCG Update March 21, 2013) Graphically delineate precautionary areas on appropriate Houston Ship Channel nautical charts so they are readily identifiable to mariners. Part 4 – Safety Recommendations Not Substantively Updated in the April 5, 2013, letter: M-02-5 (Open—Acceptable Response, February 4, 2013) Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. M-07-1 (Open—Acceptable Response, February 4, 2013) Require that all small passenger vessels certificated to carry more than 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. M-07-6 (Open—Acceptable Response, February 4, 2013) Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. M-08-2 (Open—Acceptable Response, February 4, 2013) Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-4 (Open—Acceptable Response, February 4, 2013) Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. M-09-10 (Open—Unacceptable Response, February 4, 2013) Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-14 (Open—Acceptable Response, February 4, 2013) Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-09-17 (Open—Unacceptable Response, February 4, 2013) Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 (Open—Acceptable Response, February 4, 2013) Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety. M-11-4 (Open—Acceptable Response, February 4, 2013) Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue. M-11-8 (Open—Acceptable Response, November 13, 2012) Develop and implement procedures for your special purpose craft–law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. M-11-9 (Open—Acceptable Response, November 13, 2012) Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. M-11-10 (Open—Acceptable Response, November 13, 2012) Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. M-11-12 (Open—Acceptable Response, November 13, 2012) Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. M-11-13 (Open—Acceptable Response, November 13, 2012) Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, determine from that whether the risk is unacceptable, and if so, develop risk mitigation strategies. M-11-14 (Open—Acceptable Response, November 13, 2012) Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. M-11-15 (Open—Acceptable Response, November 13, 2012) Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. M-11-16 (Open—Unacceptable Response, November 13, 2012) Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. M-11-23 (Open—Unacceptable Response, June 12, 2012) Establish standards for new and existing commercial fishing industry vessels of 79 feet or less in length that (1) address intact stability, subdivision, and watertight integrity and (2) include periodic reassessment of the vessels’ stability and watertight integrity. M-11-24 (Open—Unacceptable Response, June 12, 2012) Require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use of vessel stability information regardless of plans for implementing the other training provisions of the 2010 Coast Guard Authorization Act. M-11-25 (Open—Unacceptable Response, June 12, 2012) Require each person on deck of a commercial fishing industry vessel to wear a flotation aid at all times. M-11-26 (Open—Unacceptable Response, June 12, 2012) Require owners of commercial fishing industry vessels to (1) install fall overboard recovery devices appropriate for the vessel, (2) periodically ensure the functionality of such equipment, and (3) regularly conduct drills in which crewmembers demonstrate their competence in the use of such devices. M-11-27 (Open—Unacceptable Response, June 12, 2012) Require all crewmembers to provide certification of completion of safety training before getting under way on commercial fishing industry vessels, such training to include both prevention of and proper response to emergency situations as well as actual use of emergency equipment. M-12-8 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard military personnel with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-9 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard civilian personnel, seeking appropriate legislative authority if necessary, with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-10 (Open—Await Response) Disseminate guidance within the Coast Guard so that commanding officers have unambiguous instruction detailing the requirements for timely drug and alcohol testing of Coast Guard military and civilian personnel whose work performance may be linked to a serious marine incident. Thank you for your commitment to marine safety. We look forward to receiving further updates on the action being taken to implement the following safety recommendations: M-02-5 M-07-1 M-07-6 M-08-2 M-09-4 M-09-10 M-09-14 M-09-15 M-09-16 M-11-3 M-11-4 M-11-8 M-11-9 M-11-10 M-11-12 M-11-13 M-11-14 M-11-15 M-11-16 M-11-23 M-11-24 M-11-25 M-11-16 M-11-27 M-12-8 M-12-9 M-12-10

From: USCG
To: NTSB
Date: 4/9/2013
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Please find enclosed our agreed upon semiannual update of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board and are awaiting Coast Guard response. There are currently 42 safety recommendations with an "open" status issued to the Coast Guard. Of those, we attest that our actions are complete for six, six are pending resolution, and five require long-term agency action. Updates for the remaining 25 have been or will be provided in separate correspondence. Enclosure (1) provides specific information for each recommendation. There has not been a change in the status since the last update for the following five recommendations: M-02-5 Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. M-07-1 Require that all small passenger vessels certificated to carry more than 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 engine rooms (M-07-1) (Supercedes Safety Recommendations M-02-6 and M-02-8.) M-09-10 Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-17 Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety.

From: NTSB
To: USCG
Date: 2/4/2013
Response: Because the Coast Guard has initiated a rulemaking project to exercise the authority provided by Section 610, “Safety Management,” of the Coast Guard Authorization Act of 2010 (Pub. Law 111-281) to implement safety management system (SMS) requirements for domestic passenger vessels and small passenger vessels, Safety Recommendation M-02-5 remains classified OPEN—ACCEPTABLE RESPONSE. However, the NTSB reminds the Coast Guard that, in order to satisfy this recommendation, the final rule should require SMS for all domestic passenger vessels and ferries. The NTSB opposes the 399-passenger threshold specified in the July 2007 Coast Guard legislative change proposal to amend 46 United States Code 3202(a) to cover U.S. flag ferries on domestic voyages. We believe that SMS should be required on all domestic passenger vessels, regardless of their size or capacity.

From: USCG
To: NTSB
Date: 8/15/2012
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: The Coast Guard is beginning a rulemaking project to utilized the authority provided by Section 610, "Safety Management", of the Coast Guard Authorization Act of2010 (Pub. Law 111-281) to implement safety management system requirements for domestic passenger vessels and small passenger vessels. We will keep the Board informed of our progress on this recommendation.

From: NTSB
To: USCG
Date: 11/16/2011
Response: This letter concerns 29 open safety recommendations, enclosed, that the National Transportation Safety Board (NTSB) issued to the U.S. Coast Guard between 1995 and 2010. For some of these recommendations, the NTSB has not received an update in almost 3 years regarding the status of action either taken or planned to address the important safety issue that the recommendation addresses. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. NOTE TO FILE (not in original letter): The 29 safety recommendations are: M-95-013, M-98-033, M-98-037, M-99-001, M-00-004, M-01-001, M-02-005, M-04-003, M-05-006, M-06-001, M-06-002, M-07-001, M-07-006, M-07-007, M-08-001, M-08-002, M-09-001, M-09-002, M-09-003, M-09-004, M-09-009, M-09-010, M-09-014, M-09-015, M-09-016, M-09-017, M-10-005, M-10-002 and M-10-006.

From: NTSB
To: USCG
Date: 3/15/2011
Response: CC# 201100031: The NTSB has reviewed the Coast Guard Authorization Act of 2010 (Pub. Law 111 281), Section 610, “Safety Management,” as it relates to Safety Recommendations M-02-5 and M-05-6. We are pleased that Congress has given the Coast Guard the authority necessary to require implementation of SMS on domestic passenger vessels, including domestic ferries. The authority to require PMPs, as a subset of an SMS, has also been granted by this legislative action. Accordingly, pending the Coast Guard’s completion of the recommended actions, Safety Recommendations M-02-5 and M-05-6 are classified OPEN – ACCEPTABLE RESPONSE. In order to satisfy these recommendations, the Coast Guard should require SMS for all domestic passenger vessels and ferries. The NTSB is opposed to the 399-passenger threshold specified in the July 2007 Coast Guard legislative change proposal to amend 46 United States Code 3202(a) to cover U.S. flag ferries on domestic voyages. In a 2007 letter to the Department of Transportation’s docket responding to the Coast Guard’s notice of availability of a voyage data recorder (VDR) study, the NTSB commented specifically on that threshold, which had been specified in Section 420 of the Coast Guard and Maritime Transportation Act of 2006 (Pub. Law No. 109-241) requiring the Coast Guard to undertake the study for domestic VDR requirements. In the 2005 Andrew J. Barberi accident report, referenced in the section-by-section analysis of the draft Coast Guard Authorization Act of 2008, the NTSB recommended that the Coast Guard “Seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so.” The NTSB continues to believe that the specified threshold is arbitrary and, consequently, we advocate the implementation of SMS on all U.S. ferries, regardless of passenger capacity; this is why Safety Recommendation M-05-6 was reiterated in the Block Island/Morrow Bay report.

From: NTSB
To: USCG
Date: 4/6/2010
Response: NMC# 103397: In addition to placing the above three recommendations on the Most Wanted List, Safety Recommendations M-02-5 and M-07-6 were classified OPEN -- UNACCEPTABLE RESPONSE because of the lack of timely action since they were issued in 2002 and 2007, respectively. Safety Recommendation M-05-6 remains classified Open Unacceptable Response, a designation given in the NTSB’s August 27, 2009, letter because the Coast Guard has sought legislative authority requiring SMS only on vessels carrying more than 399 passengers, rather than on all ferry vessels, as requested. However, the NTSB is aware from discussion and e-mail exchanges between Coast Guard and NTSB staff that the Coast Guard’s long-planned notice of proposed rulemaking (NPRM) for uninspected towing vessels (UTV) has been forwarded to the Department of Homeland Security for review and final approval and that the NPRM proposes that UTVs be inspected, have SMS programs, and have new UTV manning standards. We are also aware that the Coast Guard intends to consider requiring PMP and SMS for ferries and small passenger vessels.

From: NTSB
To: USCG
Date: 2/18/2010
Response: At the February 18, 2010 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations M-02-05, M05-06, and M-07-06 on the MWL under the issue category “Require Safety Management Systems (SMS) for Domestic Vessels.”

From: NTSB
To: USCG
Date: 6/12/2009
Response: NMC# 103284: The NTSB recognizes that enrollment in the Streamlined Inspection Program (SIP), although not required, obligates a participating company to develop and utilize a preventive maintenance system (PMS) program to comply with the intent of the SIP. Although the NTSB is aware of ongoing efforts to make the SIP more attractive to small passenger vessel operators and the NTSB notes that enrollment in the program has increased somewhat, the NTSB believes that, as a voluntary program, it will not attract the operators who need it most: those who seek to comply only with minimum requirements and do not recognize the value of additional safety measures to their operations. Therefore, voluntary enrollment in the SIP has not been shown to be a measure that will satisfy Safety Recommendation M-02-5. Although the NTSB is pleased that the Coast Guard still intends to consult with the small passenger vessel industry regarding the possible development of guidance on the creation of operations and maintenance manuals based on the Passenger Vessel Association’s (PVA’s) model PMP, the NTSB is concerned with the lack of action on this issue since the Coast Guard told the NTSB in 2006 of this intended course of action. Pending receipt of further information regarding additional action being taken, such as incorporating the PVA model by reference in the applicable regulations, Safety Recommendation M-02-5 is classified OPEN -- ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 2/13/2009
Response: Letter Mail Controlled 2/20/2009 11:29:34 AM MC# 2090084: - From Walter D. Rabe, United States Coast Guard: Same response as the 2006 update, the Board should ask the CG to expedite action on this issue. At the 9-9-04 SWAT meeting with CG senior staff to discuss their 11-21-03 response it was apparent that the CG was not and had no intention of changing its position on this matter. However, since our 4-7-05 response to the CG’s 11-21-03 letter, in 2006 and again in this 2009 update, it seems they are now open to discuss PMS on small passenger vessels, although there has been little action since 2006. It is possible that because the Passenger Vessel Association in response to M-02-16, developed a straw man PMS for its membership and has strongly endorsed the concept and value of PMS for all small passenger vessel operators (M-02-16 to PVA was classified CAA on 8-24-05.

From: NTSB
To: USCG
Date: 4/19/2007
Response: The Safety Board recognizes that enrollment in the Streamlined Inspection Program (SIP), although not a requirement, obligates a participating company to develop and utilize a preventive maintenance system (PMS) program to comply with the intent of the SIP. Although we are aware of the ongoing efforts to make the SIP more attractive to small passenger vessel operators, the fact remains that, as a voluntary program, it will not attract the operators who need it most: those who seek to comply only with minimum requirements and do not recognize the value of additional safety measures to their operations. As such, the SIP has not been shown to be an option that will satisfy the Safety Board’s recommendation. The Safety Board is pleased that the Coast Guard intends to consult with the small passenger vessel industry regarding the possible development of guidance on the creation of operations and maintenance manuals. In response to Safety Recommendation M-02-16 from the Port Imperial Manhattan accident, the Passenger Vessel Association (PVA) developed a model PMS for its members. The June 2005 edition of the PVA’s Foghorn magazine explained that the PVA had developed and made available on its Web site (www.passengervessel.com) a PMS that includes checklists, guidance documents and other materials operators can use to create their own PMS. PVA’s June 2005 Foghorn magazine also included a strong endorsement of the PMS in its Letter from the President page. The Safety Board urges the Coast Guard to consider the PVA program in developing its guidance on operations and maintenance manuals. Pending receipt of further information on this issue, Safety Recommendation M-02-5 is classified OPEN -- ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 10/12/2006
Response: Letter Mail Controlled 10/23/2006 1:59:45 PM MC# 2060526: - From Thad W. Allen, Commandant: As noted in our previous response (11-21-03), participation in the Streamlined Inspection Program (SIP) includes incorporation of a preventative maintenance program for all systems affecting the safe operation of a vessel. While participation in the SIP is still relatively low, it has increased since the date of the most recent data cited by the Board (October 2003). In order to further increase participation in the program we are considering the implementation of additional incentives for vessel operators. In addition, we intend to consult with the small passenger vessel industry regarding the possible development of guidance on the creation and implementation of Operation and Maintenance manuals.

From: NTSB
To: USCG
Date: 4/4/2006
Response: On April 4, 2006, in the Express Shuttle II report, the Safety Board reiterated Safety Recommendations M-02-5 and -10.From the accident report Fire on board U.S. Small passenger vessel Express Shuttle II in the Pithlachascotee River near Port Richey, Florida on October 17, 2004 (adopted 4/4/2006): On November 21, 2003, the Coast Guard Commandant responded that his agency disagreed with Safety Recommendation M-02-5: We do not concur with this recommendation. Small passenger vessels are subject to a comprehensive set of regulations that are designed to promote vessel safety. The operators of these vessels are responsible for maintaining the vessel in compliance with all applicable regulations at all times. Additionally, the Coast Guard allows vessel operators to participate in the Streamlined Inspection Program (SIP) that enables the owners to more effectively manage the oversight of inspection requirements. We believe that the recommended requirements would be unnecessarily burdensome and duplicative of existing requirements. We intend to take no further action on this recommendation and request that it be closed. The Safety Board generally agrees that small passenger vessel regulations are comprehensive in that they list the vessel components and devices that are subject to inspections and tests and stipulate the standards with which these devices must comply to allow for the safe operation of a vessel. However, regarding the upkeep of the vessel, the regulations state only that repairs and maintenance must be accomplished in compliance with existing standards. The regulations do not promote or require a vessel owner or operator to develop a systematic program for addressing repairs and maintenance. The continuing occurrence of small passenger vessel accidents that stem from maintenance failures demonstrates the need for vessel owners or operators to develop such programs. Preventive maintenance programs should not be considered .burdensome. to vessel operators but rather a means of improving the quality, reliability, and safety of a vessel and its operation. Such a program would help maintain the safety of a vessel between periodic Coast Guard inspections, which at present are often the only time a vessel’s condition and its safety systems are inspected and tested. The Commandant’s reply states that participation in the Coast Guard’s SIP enables the [vessel] owners to more effectively manage the oversight of inspection requirements.. Under the SIP, vessel owners and operators work with Coast Guard representatives to develop company and vessel action plans. Procedures for developing and approving those plans (46 CFR 8.530) specifically require a description of the company’s safety program, environmental protection program, and training infrastructure. They do not, however, specifically require a description of the company’s preventive maintenance program. Although participating in the SIP has good potential for improving overall vessel safety, it is not clear how the SIP can ensure proper preventive maintenance on safety-critical vessel systems. According to the Coast Guard’s latest figures, only 29 small passenger vessels had enrolled in the program as of October 2003 (representing 0.29 percent of the 10,125 small passenger vessels the Coast Guard inspects). Those figures indicate that the SIP has generally been ignored by the small passenger vessel industry. On April 7, 2005, based on the correspondence received from the Coast Guard, the Safety Board classified Safety Recommendation M-02-5 OPEN -- UNACCEPTABLE RESPONSE. The Express Shuttle II fire further demonstrates the need for vessel owners and operators to develop preventive maintenance programs. The Express Shuttle II's operating company did not follow a regular maintenance schedule, did not keep adequate repair records, did not recognize that the vessel was experiencing a large number of failed fuel lines, did not follow the manufacturer's guidelines for clamping and tightening the fuel lines, and most important, did not recognize that the failing fuel lines exposed the vessel and its occupants to the risk of fire. The Safety Board remains convinced that regulatory requirements addressing the maintenance of safety-critical equipment on small passenger vessels are essential. Moreover, the PVA's action in establishing readily accessible materials that vessel owners can use to establish preventive maintenance programs demonstrates industry acceptance of the importance of preventive maintenance. The Safety Board therefore believes that the Coast Guard should reconsider requiring operators of inspected small passenger vessels to develop and implement preventive maintenance programs for safety-critical vessel systems, including the hull and the mechanical and electrical systems. Consequently, the Board reiterates Safety Recommendation M-02-5.

From: NTSB
To: USCG
Date: 4/7/2005
Response: The Safety Board notes the Coast Guard's position that small passenger vessels are subject to comprehensive regulations designed to promote vessel safety, that operators of these vessels are responsible for maintaining the vessel in compliance with all applicable regulations at all times, that the Coast Guard allows vessel operators to participate in the Streamlined Inspection Program (SIP), and that the Coast Guard believes that the recommended requirements would be unnecessarily burdensome and duplicative of existing requirements. The Safety Board is disappointed with the Coast Guard's response to Safety Recommendation M-02-5. While we generally agree that small passenger vessels are subject to "a comprehensive set of regulations," the Board is concerned that these regulations do not address vessel maintenance and contain no maintenance oversight requirements. It is, therefore, difficult to understand how the recommended action could be considered "duplicative of existing requirements." Shipboard mechanical systems have numerous moving parts that require planned inspections and maintenance to avoid unexpected breakdowns and to ensure the safety of passengers and crew. It is therefore necessary for companies to develop a preventive maintenance program for all systems affecting the safety of passenger vessels. Preventive or periodic maintenance programs are an integral part of any well-run vessel operation, and a requirement to develop and implement such programs should not be "burdensome" to vessel operators. With a required, ongoing preventive maintenance program, substandard operators might be less likely to operate substandard vessels, placing the public at risk. The issue of preventative maintenance was found to be a factor in the Safety Board's investigation of the sinking of the U.S. small passenger vessel Panther near Everglades City, Florida, on December 30, 2002 (NTSB Report MAR-04-01). The issue of preventive maintenance is also under investigation in the fire on the U.S. small passenger vessel Express Shuttle II that occurred on October 18, 2004, near Port Ritchie, Florida. The Assistant Commandant's reply states that the Coast Guard's participation in the SIP "enables the [vessel] owners to more effectively manage the oversight of inspection requirements." Under the SIP, the vessel owner or operator works with a Coast Guard representative to develop company and vessel action plans. The development and approval procedures for those plans, 46 Code of Federal Regulations (CFR) 8.530, specifically require a description of the company's safety program, environmental protection program, and training infrastructure, but they do not require a description of the company's preventive maintenance program. Although it is not clear how participation in the SIP will ensure that proper preventive maintenance is carried out on critical vessel systems, the outcome of the overall program could offer an equivalent level of safety for participants. However, according to the Coast Guard, only 29 small passenger vessels had enrolled in the SIP as of February 2005 (representing only 1/4 of 1 percent of the 10,125 small passenger vessels the Coast Guard inspects). The Safety Board reiterates its belief that the Coast Guard should require companies operating domestic passenger vessels to develop and implement preventive maintenance programs for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. Pending further response from the Coast Guard on this issue, Safety Recommendation M-02-5 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 11/21/2003
Response: Letter Mail Controlled 11/24/2003 12:14:53 PM MC# 2030577 - T.H. Gilmour, Rear Admiral, Assistant Commandant for Marine Safety, Security, and Environmental Protection: We do not concur with this recommendation. Small passenger vessels are subject to a cdmprehensive set of regulations that are designed to promote vessel safety. The operators of these vessels are responsible for maintaining the vessel in compliance with all applicable an analysis of casualty data From 1981 through 1986. While there was sufficient reason to require retrofitting on small passenger vessels with fiberglass reinforced plastic and wooden hulls, the substantial cost was not justified on small passenger vessels with steel and aluminum hulls. Since vessels engaged in commuter and ferry service have accounted for only 8.4% of the fire casualties suffered by small passenger vessels from 1992 through 2000, we do not believe that extending these requirements to those vessels is justified. We intend to take no further action on this recommendation and request that it be closed.