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Safety Recommendation Details

Safety Recommendation M-05-004
Details
Synopsis: About 1520 on October 15, 2003, the Staten Island Ferry Andrew J. Barberi, owned and operated by the New York City Department of Transportation, was at the end of a regularly scheduled trip from Manhattan to Staten Island when it allided at full speed with a maintenance pier at the St. George ferry terminal. Fifteen crewmembers and an estimated 1,500 passengers were 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. Damages totaled more than $8 million, including repair costs of $6.9 million for the Andrew J. Barberi and $1.4 million for the pier.
Recommendation: TO THE UNITED STATES COAST GUARD: Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 2/18/2009
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 1/31/2019
Response: The National Transportation Safety Board (NTSB) has reviewed the US Coast Guard’s notification of availability and request for comments regarding its draft Merchant Mariner Medical Manual, which was published in 83 Federal Register 56272, on November 13, 2018. The request seeks comments about the manual’s “readability, clarity, and ease of use” as well as whether the draft Manual adequately addresses safety concerns in situations where the Coast Guard receives information indicating that a medical certificate holder has developed a medical condition that poses a significant risk of sudden incapacitation, or is taking a medication that poses a significant risk of impairment. The NTSB is pleased that the Coast Guard has developed the draft manual and appreciates the opportunity to respond to this request. As a result of its investigation into the 2003 allision of the Staten Island Ferry Andrew J. Barberi, the NTSB found shortcomings in the Coast Guard’s system of medical oversight of merchant mariners and issued the following two safety recommendations to the Coast Guard in 2005.1 M-05-4 Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations. M-05-5 In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers. Over the ensuing years, the Coast Guard took action and created a system that now provides 100 percent review of applications for medical certificates and ensures review occurs before certificates are issued. In addition, the Coast Guard issued Navigation and Vessel Inspection Circular (NVIC) 04-08, “Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials,” and has updated it several times to ensure mariners and health care providers have access to medical guidance regarding adequate treatment of identified medical conditions. As a result, in the NTSB’s 2009 report on the allision of the Cosco Busan with the San Francisco-Oakland Bay Bridge, Safety Recommendation M-05-4 was “Closed?Acceptable Alternate Action” and Safety Recommendation M-05-5 was “Closed?Acceptable Action?Superseded.” The combination of the Coast Guard’s increased oversight of medical certification and development of medical guidance appears to be highly effective at addressing safety concerns regarding medical conditions that pose a significant risk of sudden incapacitation. Since 2009, the NTSB has not found any medical conditions to have contributed to the probable cause of a marine accident. However, the NTSB continues to find effects from impairing substances (alcohol and over-the-counter, prescription, or illicit drugs) to have contributed to the probable cause across all modes of transportation. The NTSB finds that the Coast Guard’s draft Merchant Mariner Medical Manual aptly streamlines the guidance available for mariner medical certification. The information is straightforward. The table of contents and bookmarking make specific information on a given topic easy to find. Further, the manual provides a level of detail that should assist medical personnel during mariner medical certification exams. In addition, the NTSB believes the current effort to separate a medical certificate from a mariner’s credentials is appropriate. A new medical diagnosis may disqualify an individual from serving in certain positions due to safety concerns but does not remove or negate an individual’s skill and experience at sea. The NTSB supports the Coast Guard’s development of the draft Merchant Mariner Medical Manual to continue to ensure merchant mariners are medically fit for duty, and the NTSB also appreciates the opportunity to comment on this important notice.

From: NTSB
To: USCG
Date: 5/1/2013
Response: Notation 8484: The National Transportation Safety Board (NTSB) has reviewed the US Coast Guard’s notice and request for comments titled, “Merchant Mariner Medical Evaluation Program,” published in 78 Federal Register No. 63 (19725–19726) on April 2, 2013. The notice and request for comments concern assessing the relative merits of applying a system similar to that of the Federal Aviation Administration (FAA) or the Federal Motor Carrier Safety Administration (FMCSA) to the Coast Guard’s merchant mariner medical evaluation program. Under the current Coast Guard medical oversight system, which the Coast Guard terms an “open” system, applicants for original or renewed merchant mariner credentials are medically evaluated at regular intervals by licensed physicians, nurse practitioners, or physician assistants. The mariner then submits the evaluation results, documented on Coast Guard form 719K, to the Coast Guard. Coast Guard examiners then review the applications and, based on the information provided on form 719K, either approve or deny them or defer approval or disapproval pending the solicitation and review of additional medical information. The Coast Guard is considering two alternative methods of medical evaluation, one referred to as a “closed” system and the other a “hybrid” system. In a closed system, designated medical professionals would be authorized by the Coast Guard to conduct mariner medical evaluations and, in accordance with Coast Guard guidance, issue or deny mariner medical certificates. In a hybrid system, designated medical professionals would, in accordance with Coast Guard guidance, issue medical certificates when mariners meet certain pre-established criteria, and the Coast Guard would review only those applications for mariners who have certain conditions. The FAA and FMCSA employ systems similar to the hybrid system the Coast Guard describes. The FAA authorizes specially trained and certified physicians to act as aviation medical examiners. These designated physicians perform standardized medical evaluations and then issue or deny a provisional medical certificate to airmen based on agency guidelines. Agency physicians review and ultimately decide on all applications for medical certificates. Pilots whose initial application is denied for failure to meet requirements may apply for a special issuance medical certificate. These certificates typically require pilots to submit additional medical information and may specify follow-up testing and be time limited. Beginning this year, FMCSA authorizes medical examiners who are licensed, certified, and/or registered, in accordance with applicable state laws and regulations, to issue or deny medical certificates to commercial motor vehicle drivers based on agency guidelines and the results of physical examinations. Drivers whose applications are denied can request waivers, which FMCSA personnel review and then recommend final disposition to the Administrator. Both agencies designate only specific health professionals?physicians in the case of the FAA or health practitioners for FMCSA?who receive initial training on the respective medical oversight systems and on medical fitness requirements related to the occupations. To remain certified, the designated health professionals must complete recurrent training at regular intervals. NTSB’s Previous Actions Regarding Coast Guard Mariner Medical Oversight The NTSB previously addressed the Coast Guard’s medical oversight system in its investigation of two accidents in which mariner medical conditions and/or medication use played a role. As a result of its investigation of the 2003 allision of the Andrew J. Barberi, the NTSB issued two safety recommendations to the Coast Guard concerning its merchant mariner medical oversight system: M-05-04 Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations. M-05-05 In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers. In response to these safety recommendations, the Coast Guard modified its mariner medical oversight system and, with the exception of addressing the absence of a requirement for mariners to report changes in medical condition between examinations, the changes the Coast Guard implemented largely met the intent of the recommendations. The current medical oversight system is considerably more capable than was the previous system of identifying mariners with potentially impairing medical conditions or who use impairing medications, thereby enhancing the safety of marine operations. As a result, with the exception of the portion of Safety Recommendation M-05-05 that called for the Coast Guard to require mariners to report changes in their medical condition or medication use, the NTSB, in its investigation of the 2007 allision of the M/V Cosco Busan, classified Safety Recommendations M 05 04 “Closed?Acceptable Alternate Action” and classified Safety Recommendation M 05 05 “Closed?Acceptable Action—Superseded.” Recommendation M 05 05 was superseded by Safety Recommendation M 09 04, which calls on the Coast Guard to: M-09-04 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. The NTSB awaits the Coast Guard’s final action in response to Safety Recommendation M 09 04, which is classified “Open—Acceptable Response.” The Coast Guard’s adoption of an alternative medical evaluation system and use of designated medical examiners would likely result in considerable efficiencies, such as those described below. A system that enables the Coast Guard to more effectively monitor changes in mariners' health and medication use between certifications and, thereby, update medical status when a significant change occurs in the mariner's health or use of potentially impairing medications would enhance marine safety. The NTSB urges the Coast Guard to include provisions for addressing changes in mariner medical fitness as part of its program enhancements. The NTSB believes both alternatives the Coast Guard is considering—a closed system or a hybrid system—would enhance the efficiency of its medical oversight system by restricting the health practitioners who can perform medical evaluations to those who have received specific training in the occupational demands of the marine system and the Coast Guard’s medical fitness requirements for mariners. Under the current system, few medical evaluators are likely to possess such expertise, and those seeking additional information must consult Coast Guard form 719K or the 80+ page Navigation and Vessel Inspection Circular (NVIC) 04-08. For health professionals unfamiliar with merchant mariner medical evaluations, taking the time necessary to gain familiarity with the Coast Guard documents during or preceding a medical evaluation is unrealistic—and often omitted. With fewer health practitioners qualified to administer mariner medical evaluations, the Coast Guard could more quickly and efficiently communicate necessary medical information or guidance regarding the evaluations. Under the current system, the Coast Guard makes such information available through its website in changes to NVIC 04-08 and form 719K. Restricting the number of health practitioners to those with a demonstrated interest in maintaining an awareness of such changes would enable the Coast Guard to more readily communicate with those health practitioners and help to ensure a more effective medical evaluation program. Allowing health practitioners to provide mariners with provisional medical certificates, as the FAA does, will ease the Coast Guard’s administrative burden by limiting medical review to those mariners whose applications warrant additional consideration. Provided that the number and geographic distribution of medical evaluators the Coast Guard designates meets the needs of mariners, a hybrid or closed medical oversight system would ease administrative demands on the Coast Guard and reduce the time needed to provide mariners disposition on their medical evaluations. Further, as both the hybrid and closed system alternatives would authorize only health practitioners with the requisite occupational and medical expertise, errors in completing form 719K should decrease, thereby further reducing the administrative burden on both mariners and the Coast Guard. Designated medical evaluators also could immediately inform mariners of additional information the Coast Guard would need to issue waivers regarding specific medical conditions and/or medication use. Either alternative system the Coast Guard is considering could enhance the quality of the waiver process by reducing the likelihood of erroneous waivers being issued because designated medical practitioners would have considerable input in guiding mariners to the relevant documentation needed to support requests for waivers. Evaluators also could advise mariners of medical conditions and/or medications for which the Coast Guard would not issue waivers. Such guidance could result in fewer waiver applications submitted that warrant denial and less extraneous and unnecessary medical information provided in support of valid waiver applications. To realize these efficiencies, however, the Coast Guard must incorporate measures to ensure that a sufficient number of medical evaluators are designated so that mariners can undergo examinations and their applications for initial and renewed certification can be reviewed, as necessary, and acted upon without undue delay. While both systems would reduce administrative burdens and enhance the efficiency of the medical evaluation process, the NTSB believes a hybrid system would afford the Coast Guard greater program oversight and quality management of health practitioners conducting medical evaluations. A disadvantage of a closed system is that critical decisions related to marine safety?specifically, determining mariner medical qualification and issuing medical certificates?would be outside Coast Guard review. Relying solely upon individual providers’ interpretations of Coast Guard policy may lead to variable medical certification decisions, and the net safety benefits of the system would suffer. By contrast, under a hybrid system, medical evaluators would issue certificates only for mariners who met specific, pre established criteria. This added requirement in the certification process would provide a significant safety advantage by providing final review and approval authority of mariners with complex medical issues to Coast Guard medical authorities. The NTSB further suggests that designated medical evaluators, whether operating under a closed or hybrid system, be limited to health practitioners licensed, certified, and registered to perform physical evaluations and to prescribe medications. In addition to establishing substantial medical qualifications for examiners, this requirement would increase the likelihood that these individuals would possess greater expertise in the nature of possible impairing medications as well as an applicant’s medical condition. Summary Observations The NTSB believes these possible changes to the Coast Guard’s merchant mariner medical evaluation system would improve marine safety by enhancing the relevant medical and occupational expertise of practitioners conducting the evaluations, facilitating communications between the Coast Guard and designated medical evaluators, reducing the administrative burden on the Coast Guard and mariners, and shortening the time needed to provide mariners with approved medical certificates. To provide greater oversight of medical practitioners conducting evaluations and recommending and/or issuing mariner certifications, the NTSB supports changing the current Coast Guard medical oversight system to a hybrid system. Thank you for the opportunity to comment on potential changes to the Coast Guard’s system of mariner medical oversight.

From: NTSB
To: USCG
Date: 5/12/2009
Response: On February 18, 2009, these recommendations were closed when the NTSB adopted its marine accident report of the 2007 Cosco Busan San Francisco/Oakland Bay Bridge allision. Safety Recommendation M-05-4 was classified CLOSED—ACCEPTABLE ALTERNATE ACTION because the exercise of authority that the Coast Guard initiated through the Federal Register has achieved the desired goal of requiring pilots to report the results of their annual medical evaluations. Safety Recommendation M-05-5 was classified Closed Acceptable Action Superseded (by M-09-4, stated below) because, although the Coast Guard centralized its review of medical evaluation results under the supervision of a physician trained in occupational medicine, eliminating inconsistencies that the NTSB found among Coast Guard reviewers and making it possible to track the results of medical evaluations, the changes lacked the requirement for mariners to report changes in their medical status between medical evaluations that the NTSB had requested.

From: NTSB
To: USCG
Date: 2/18/2009
Response: On 2-18-09, the Board adopted the Cosco Busan report, and in doing so, closed M-05-4 & M-05-5 to the USCG. The Safety Board first identified shortcomings in the Coast Guard’s system of mariner medical oversight in its investigation of the 2003 allision of the Andrew J. Barberi. In its investigation of that accident the Safety Board wrote: In attempting to determine the medical status of the assistant captain, the Safety Board found additional shortcomings in the Coast Guard’s system of medical oversight of mariners. For example, headquarters Coast Guard personnel overseeing the medical evaluation process knew little about the quality of regional [examination center] reviews of medical evaluations-the initial, and for most mariners, the final evaluator of the results of medical examinations. Consequently, differences between regions in their reviews and determination of fitness may be present and undetected, potentially having an adverse effect on the reliability of the medical oversight system. To address the shortcomings identified in the Coast Guard’s system of medical oversight of mariners, the Safety Board issued, to the U.S. Coast Guard, the following safety recommendations: The Coast Guard agreed with both recommendations and has made progress in addressing the deficiencies identified in the Andrew J. Barberi accident investigation. For example, it has centralized the initial review of mariner medical documents and has employed a physician qualified in occupational medicine to oversee its medical review of merchant mariners. The Safety Board believes that Exercise of Authority that the Coast Guard initiated through the Federal Register in response to Safety Recommendation M-05-4 has achieved the desired goal of requiring pilots to report the results of their annual medical evaluations. An example of the positive effects of this recommendation is the fact that reports of pilot physicals are now being submitted to the Coast Guard annually. Without this requirement, the pilot’s 2007 form 719K would not have been submitted to the Coast Guard, and important information about the pilot’s fitness for duty would not have been available to Coast Guard reviewers (even though in this case, that information was not appropriately acted on). Because of the Coast Guard’s response to the recommendation, the Safety Board reclassifies Safety Recommendation M-05-4 CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: USCG
To: NTSB
Date: 6/20/2008
Response: Letter Mail Controlled 6/24/2008 11:02:29 AM MC# 2080364: Update: As a direct result of the Board’s recommendation, we published a notice in the Federal Register (71 FR 56999) through which we exercised the existing authority in 46 CFR 10.709 to require all first class pilots on vessels greater than 1600 gross registered tons (GRT), and other individuals who serve as pilots on certain types of vessels greater than 1600 GRT, to provide a copy of their annual physical examination to the Coast Guard. Included in the notice were specific instructions for the submission of the reports of physical examination to be followed to comply with the regulations. We consider our action on this recommendation to be complete.

From: NTSB
To: USCG
Date: 5/23/2008
Response: On August 24, 2005, based on information provided in the Coast Guard’s May 18, 2005, letter, Safety Recommendations M-05-4 and -5 were classified Open Acceptable Response, pending completion of action on these issues. The Safety Board noted that although the Coast Guard had not specifically committed to revising 46 CFR 10.709 as requested in Safety Recommendation M-05-4, the Coast Guard did concur that it needed to be aware of the results of physical exams, especially when medical conditions exist. To this end, the Coast Guard agreed to (1) conduct an analysis to determine the responsibilities and resources required to effectively implement the recommendation and (2) provide guidance on any new medical review requirements to mariners, employers, and mariner medical examiners through a navigation and vessel inspection circular (NVIC), titled Medical and Physical Evaluation Guidelines for Merchant Mariners, that would supercede NVIC 2-98. Regarding Safety Recommendation M-05-5, the Coast Guard agreed to construct a database to track mariner physical exams and to hire a physician or other medical specialist in the field of occupational medicine to review medical waiver requests and mariner physicals. Through attendance at Merchant Marine Personnel Safety Advisory Committee (MERPAC) meetings and from informal staff discussions, the Safety Board has learned that the Coast Guard did assign a physician to the National Maritime Center to review medical waiver requests and mariner physicals. Further, the Coast Guard is completing the centralization of its review of merchant mariner medical evaluations, which it believes should provide consistency in its interpretation of medical policy, enable it to address deficiencies in the storing of merchant mariner medical data, and provide a mechanism to track mariner medical examinations. On November 24, 2006, the Safety Board provided written comments to the Coast Guard docket (USCG 2006-25080) on a proposed NVIC that will replace NVIC 2-98. Board staff is also aware that the Coast Guard is developing a revised mariner physical evaluation form CG-719K, which, when used in conjunction with the pending NVIC, should address deficiencies in application of Coast Guard policy by health care providers performing medical evaluations. The Safety Board is not aware of any action the Coast Guard is taking to address the absence of requirements for mariners to report changes in their medical condition between physical examinations, however. The pending NVIC does not address this issue, and the Board is unaware of other Coast Guard action to address this shortcoming. This deficiency was identified in the Board’s ongoing investigation into the November 7, 2007, allision of the container ship M/V Cosco Busan with the San Francisco Oakland Bay Bridge, in San Francisco Bay, California, and during testimony at the Board’s April 8 and 9, 2008, public hearing on this accident. Beyond the information acquired at MERPAC meetings, from informal discussion with Coast Guard staff, and from testimony at the April public hearing, the Safety Board has not received any further information from the Coast Guard since our 2005 correspondence exchange regarding the status of actions being taken to implement Safety Recommendations M-05-4 and 5. Because these issues have been identified in the Safety Board’s ongoing investigation into the Cosco Busan allision, the Board would appreciate receiving a prompt written update from the Coast Guard on what additional actions it has taken to implement these two important safety recommendations. Copies of the Coast Guard’s May 18, 2005, letter and the Board’s March 18, 2005, August 24, 2005, and November 24, 2006, letters are enclosed for your information.

From: NTSB
To: USCG
Date: 8/24/2005
Response: Although the Coast Guard did not specifically commit to revising 46 CFR 10.709 as requested, the Safety Board is pleased that the Coast Guard concurs with the recommendation and that there is a need for it to be aware of the results of physical exams, especially when medical conditions exist. The Board notes that the Coast Guard will (1) conduct an analysis to determine the responsibilities and resources required to effectively implement the recommendation and (2) provide guidance on any new medical review requirements to mariners, employers, and mariner medical examiners through a Navigation and Vessel Inspection Circular. Because the Coast Guard has initiated action on this issue, Safety Recommendation M-05-04 is classified OPEN—ACCEPTABLE RESPONSE. The Safety Board would appreciate periodic updates on the status of these initiatives, including regulatory actions to require that the results of all physical examinations be reported to the Coast Guard.

From: USCG
To: NTSB
Date: 5/18/2005
Response: Letter Mail Controlled 5/24/2005 8:03:10 AM MC# 2050216 We concur with this recommendation. We agree that there is a need to ensure that we are made aware of the results of all physical examinations, especially when they may identify medical conditions affecting licensed mariners' abilities to safely perform their duties on vessels. We will begin by conducting an analysis to determine the responsibilities and resources required to effectively implement such a requirement. We anticipate providing guidance on any new medical review requirements to mariners, employers, and mariner medical examiners through a Navigation and Vessel Inspection Circular (NVIC) to be drafted once our analysis is complete and an implementation plan has been established. We will keep the Board informed of our progress on this recommendation.