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:
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.
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:
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.
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.