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Safety Recommendation Details

Safety Recommendation M-05-002
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: Adhere to your October 2005 target for implementation of a comprehensive safety management system, incorporating all matters recommended by the Global Maritime and Transportation School assessment, and ensuring medical fitness oversight (requiring, minimally, assurance of compliance with Coast Guard 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 Management Systems

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 Staten Island Ferry has (1) implemented the GMATS recommendations, (2) implemented a safety management system, and (3) obtained a Document of Compliance from the American Bureau of Shipping (ABS). Among other things, the safety management system addresses the revised Staten Island Ferry organizational structure, vessel personnel staffing and work load, and technical training and professional development for all vessel personnel. Accordingly, Safety Recommendation M-05-2 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 On October 13, 2005, the New York City Department of Transportation, Staten Island Ferry Division was issued a Voluntary Document of Compliance Certificate ("DOC") by the American Bureau of Shipping ("ABS") (see attached). This document certifies that the City's safety management system has been audited and complies with the requirements of 33 CFR 96, Subpart B. Further, Voluntary Safety Management Certificates ("SMC") were issued by the ABS to all operating ferryboats, namely: Guy V. Molinari (SMC attached), Sen. John J. Marchi, Andrew J. Barberi, Samuel I. Newhouse, The Gov. Herbert H. Lehman, American Legion and John A. Noble. The SMCs certify that the safety management system for each of the above-named vessels has been audited and complies with the requirements of 33 CFR 96, Subpart B. The John F. Kennedy is currently in dry-dock, the Alice Austen is at wet berth undergoing a main engine retrofit and we have not yet accepted the Spirit of America. Once these vessels are placed into service they will go through the certification process for issuance of SMCs in accordance with the SMS system which is in place.

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 is on schedule for an October 2005 target for implementation of a comprehensive safety management system (see attached time-line). This has been a significant undertaking for DOT, in that this effort was begun on July 1,2004 and should be implemented less than 16 months later. It is customary in the industry for such projects to take upwards of three years; such an expeditious timeframe is clearly demonstrative of DOT's commitment to this recommendation. When we have completed our third-party audit and receive a Document of Compliance, we will forward a copy to the NTSB. Further, we have attached hereto copies of the cover pages of our Draft Safety Management System Manual which will give you a clear indication as to the scope of the Safety Management System and its comprehensive manual.

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 2. RECIPIENT'S RESPONSE: 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. SAFETY MANAGEMENT SYSTEM As you know, as a result of the accident, and based on GMATS recommendations, DOT elected to voluntarily establish an ISM Code Safety Management System ("SMS") to supplement DOT'S existing safety program. DOT retained Safety Management Systems, LLC, an industry expert in this field, to work closely with Staten Island Ferry personnel to develop a system specifically geared towards the Staten Island Ferry operation. Significant progress has been made, and many of the proposed SMS enhancements to existing manuals, policies and checklists have either been finalized or are in draft. Given the progress to date, we anticipate that the SMS system will be in place by October of 2005 in accordance with the original target date. Further, we hope to obtain a Document of Compliance from the American Bureau of Shipping (ABS) by December, 2005. Among other things, the SMS system includes the following: Organizational Structure: With the implementation of a safety management system, an entirely new organizational structure has been created. As you know, I became the new Chief Operations Officer, and Margaret Gordon was hired as the Executive Director of Safety and Security. We both have broad experience with safety management systems and management of marine operations. In addition, DOT hired a Senior Port Captain, Senior Port Engineer and Safety Officer. This new management team is committed to the SMS system and continued improvements to the overall operation. Vessel Personnel: GMATS recommended adding 95 new fleet personnel to implement SMS and facilitate the overall changes underway, which include increased manning levels, increased training, and less reliance on overtime. DOT has committed to increasing the manning levels by the recommended complement. Technical Training / Professional Development: DOT is in the process of developing a comprehensive technical training and professional development program for all vessel personnel. Familiarization training is being provided to all new hires and those assigned to new vessels including training in personal survival, personal safety, basic shipboard firefighting, crowd management, and passenger safety, crisis management. 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.