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Safety Recommendation Details

Safety Recommendation M-05-001
Details
Synopsis: The recommendations address safety issues involving operational oversight of the Staten Island Ferry by the New York City Department of Transportation (NYC DOT). The recommendations derive from the Safety Board’s investigation of the allision involving the Staten Island Ferry Andrew J. Barberi at St. George, Staten Island, on October 15, 2003, and are consistent with the evidence we found and the analysis we performed. At the time of the accident, the Andrew J. Barberi was at the end of a regularly scheduled trip from Manhattan to Staten Island, with 15 crewmembers and an estimated 1,500 passengers on board. The assistant captain was at the controls but, for reasons that could not be determined, was unresponsive to cues of the impending allision. Except for one deckhand, the crewmembers also did not recognize that the ferry was in danger. Ten passengers died in the accident and 70 were injured. An eleventh passenger died 2 months later as a result of injuries sustained in the accident.
Recommendation: The National Transportation Safety Board makes the following safety recommendations to the New York City Department of Transportation: Require your licensed pilots to provide proof of compliance with the Coast Guard medical certification requirements.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Bays and Sounds, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA04MM001
Accident Reports:
Allision of Staten Island Ferry Andrew J. Barberi
Report #: MAR-05-01
Accident Date: 10/15/2003
Issue Date: 3/18/2005
Date Closed: 3/29/2006
Addressee(s) and Addressee Status: State of New York, City of New York, Department of Transportation (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: State of New York, City of New York, Department of Transportation
Date: 3/29/2006
Response: The Safety Board is pleased that NYC DOT has established a policy under which all licensed personnel must submit annual written confirmation from a physician (1) advising of the date of the most recent physical, (2) confirming that the physical was carried out according to Coast Guard regulations, and (3) certifying that the individual is in good health and has no physical impairment or medical conditions that would interfere with the individual performing his or her duties. Because this information is part of the safety management system, the NYC DOT is now able to monitor the status of mariner physicals and initiate reminder notices to ensure mariners have their annual physical exams. This new process also provides a mechanism to monitor a mariner's health concerns. Accordingly, Safety Recommendation M-05-1 is classified "Closed-Acceptable Action."

From: State of New York, City of New York, Department of Transportation
To: NTSB
Date: 3/16/2006
Response: Letter Mail Controlled 3/31/2006 2:01:15 PM MC# 2060169 By letter dated November 4, 2005 we indicated, among other things, that based on the criteria described during our meeting in August, 2005 for closing outstanding recommendations, we had complied with NTSB Recommendations M-05-01 and M-05-02 and provided supporting documentation attached thereto, and we looked forward to the NTSB's written confirmation that these NTSB Recommendations would be appropriately closed. We are now inquiring if there has been any progress in this regard. Further, on the matter of NTSB Recommendation M-05-03, we also indicated in my November 4, 2005 letter that a meeting was scheduled for November 7, 2005 with GMATS, U S Coast Guard Activities New York and in-house staff to continue our review of the remaining recommendations contained in the GMATS Report, foremost of which would be the evaluation and use of navigation technology, and following this meeting, we would advise you on how we planned to address those remaining recommendations. I am pleased to report that such meeting was held at which representatives from New York City Department of Transportation, Staten Island Ferry Division ("NYCDOT"), GMATS. US. Coast Guard Sector New York and Safety Management Systems LLC (Safety Consultants) and RADM Robert C. North, USCG (ret), the former Assistant Commandant for Marine Safety and Captain of the Port of New York, were present. We have since received the final comments from all those in attendance and are now prepared to discuss how the outstanding technology related recommendations of GMATS will be addressed. The NYCDOT has, to date, completed the following technology enhancements: AIS (Automated Identification System) Units have been installed on all vessels per USCG requirements GPS (Global Positioning System) Units, with speed indicators, have been installed on all vessels. e Hand-held UHF radios have been issued lo all crew members and their use has been incorporated in the operational procedures specified in the Safety Management System. ECDIS (Electronic Chart Display and informatio System) has been installed on the FIB Andrew J. Barberi on a trial basis and a complete fleet retrofit is planned and will be undertaken as soon as the final regulations governing same are promulgated. Automated Announcing Systems have been installed on the ferry boats Guy V. Molinari, Sen. John J. Marchi, Spirit of America, John F. Kennedy, American Legion, Gov. Herbert H. Lehman, Samuel I. Newhouse, and Alice Austen. The F/B John Noble is now in dry-dock and installation will be completed prior to the vessel's return to service. The FIB Andrew J. Barberi is scheduled for dry-docking later this year and such installation will be performed at that time. As regards the multi-directional speed indicators and integrated bridge systems, we discussed these recommendations at length during our meeting of November 7, 2005 at which representatives from NYCDOT, GMATS, US. Coast Guard Sector New York and Safety Management Systems LLC (Safety Consultants) and RADM Robert C. North, USCG (ret), the former Assistant Commandant for Marine Safety and Captain of the Port of New York, were present. It was the consensus of this group that the multi-directional speed indicators were developed primarily for large ships and had limited utility in our application and, in fact, an opinion was expressed that such technology could actually be distracting to the ferry operator during the most critical periods of docking. This discussion then focused the potential benefit of wind speed and direction indicators, and it was agreed that such technology could be of benefit in our application. We will, therefore, research such installations either on the terminals, and/or on the ferryboats. On the subject of integrated bridge systems, it was agreed that an integrated bridge system could have many interpretations depending on application, and it was agreed that for our application an integrated bridge system should embody several major components, namely: radar, ARPA, ECDIS, GPS, VHF, steering and control systems, and internal and external communications systems, all installed with regard for the ergonomics of the operator. This recommendation will then be satisfied upon the fleet-wide installation of ECDIS units. Finally, on the establishment of a recurrent evaluation process to assess the use of navigation technology, in addition to compliance with regulatory requirements, we will organize a committee comprised of management and licensed deck officers which will meet once each year, in conjunction with the annual safety management system compliance audit, to assess the latest navigation technology and its relevance to our application. This should ensure that NYCDOT stays current with such technologies services and trends, and make recommendations as applicable to ensure the utilization of the most up-to-date and appropriate technology. Further, active participation in industry trade associations such as the Passenger Vessel Association and Interfeny, and attendance at trade shows will ensure our keeping abreast of the latest navigation technology. In conclusion, the outstanding navigation technology recommendations are now confined to (i) the balance of the automated announcing system installations, which should be completed by year end; and (ii) the ECDIS retrofits which will also address the integrated bridge system recommendation. However, given the regulatory dynamics currently associated with ECDIS technology, we do not want to retrofit with technology which may be non-compliant from a regulatory standpoint, so we will continue to research this technology with the objective of developing a bid-specification to acquire and install such technology as soon as practicable. As previously indicated, we have complied with NTSB Recommendations M-05-01 and M-05-02, and we look forward to the NTSB's written confirmation that they may now he appropriately closed. We are also hopeful that the aforementioned update on navigation technology will assist in appropriately closing out NTSB Recommendation M- 05-03, and we welcome any comments or suggestions you may have in this regard.

From: State of New York, City of New York, Department of Transportation
To: NTSB
Date: 11/4/2005
Response: Letter Mail Controlled 11/15/2005 8:45:12 AM MC# 2050528 In my letter of August 30,2005, I indicated that as part of our Safety Management System development and implementation, a database (FLOATS -Ferry Logistics, Operations and Training System) had been created to track and monitor the licensing, certification and training of all employees, and that such database would also include the requirement for an annual physical for all pilots (captains and assistant captains), which was at the time being done manually. FLOATS is now fully operational and I have provided herewith a sample page from the actual database depicting the format and indicating the information included. This system has been subject to both internal and external third-party audits and found to he in full compliance with our Safety Management System.

From: State of New York, City of New York, Department of Transportation
To: NTSB
Date: 9/22/2005
Response: Letter Mail Controlled 9/22/2005 9:41:23 AM MC# 2050442 DOT has implemented a policy (see attached) under which all pilots (captains and assistant captains) are required to submit on an annual basis a letter from a physician 1) advising the date of most recent physical; 2) confirming that the physical was carried out pursuant to the provisions of 46 CFR 5 10.205(d); and 3) certifying that the individual is in good health and has no physical impairments or medical conditions which would render h i d e r incapable of performing assigned duties. Additionally, DOT has established a procedure under which compliance with this policy is monitored. DOT staff currently monitors each captain and assistant captain by the anniversary date of their actual physical, which is kept on a spread sheet. One month prior to the anniversary date, each captain and assistant captain is notified that the aforementioned letter is due. They are then reminded on a weekly basis until received and, in the absence of receiving such letter, the employee is suspended from employment. Going forward, and as part of the Safety Management System development and implementation, a data base (FLOATS -Ferry Logistics, Operations and Training System) has been created to track and monitor the licensing, certification and training of all employees which will automatically initiate a reminder to staff of any renewal due dates six (6) months prior to such dates and then again one (1) week prior to such dates, at which time the particular employee files will be flagged. For all pilots, (captains and assistant captains) the requirement for an annual physical will also be included in this data base. We are currently in the data management and trial phase of the project and hope to fully implement it by the end of September.

From: State of New York, City of New York, Department of Transportation
To: NTSB
Date: 6/17/2005
Response: Letter Mail Controlled 6/24/2005 1:38:36 PM MC# 2050267 6-17-05: The following is a brief summary of what we have accomplished to date with respect to the individual items recommended by the NTSB: COAST GUARD MEDICAL CERTIFICATION REQUIREMENTS On May 21, 2004, DOT issued a directive to all Captains and Assistant Captains requiring that they provide a letter from a physician on an annual basis confirming that they have had the annual physical required by Coast Guard regulations and certifying that the individual is in good health and has no physical impairment or medical conditions which would render the individual incapable of performing his duties. A copy of that directive is attached for your review. 8-3-05: NYC DOT met with Board staff to discuss their action on the recommendations. 8-30-05: As discussed at the 8-3-05 meeting, Capt DeSimone provided amplifying information on the action taken on the recommendations. 10-20-05: Capt. DeSimone confirmed that action on M-05-1 and -2 has been completed.