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Safety Recommendation Details

Safety Recommendation M-05-005
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: 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. (Superseded by M-09-004)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action/Superseded
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Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action/Superseded)
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: 3/19/2015
Response: CC# 201500095: The National Transportation Safety Board (NTSB) has reviewed the United States Coast Guard’s request for public comments on waiver revisions for certain medications and for suggestions for risk evaluation, published in 80 Federal Register (FR) 4582 on January 28, 2015. The request solicits comments on proposed Coast Guard efforts to clarify policy regarding the criteria for granting medical waivers to mariners who require the use of potentially impairing prescription medications, as well as on effective methods of evaluating the risk posed by mariners who had been granted waivers to use such medications while exercising the privileges of their mariner credential. The NTSB has investigated two major marine accidents in which prescribed medication use played a role. In one, on October 15, 2003, the assistant captain of the Andrew J. Barberi, a ferry with a capacity of 3,672 passengers operating between Manhattan and Staten Island, became incapacitated just as he was about to dock the vessel (NTSB 2005). As a result, the ferry allided with a concrete abutment. Eleven passengers died and 70 others were injured. The NTSB was unable to determine the cause of the assistant captain’s incapacitation; however, it learned that he had been regularly using tramadol, a prescription, narcotic-like analgesic to treat pain. Common side effects of tramadol include dizziness and sleepiness; in addition, seizures are also a potential side effect of the drug. However, neither the assistant captain nor his physician, who had prescribed the medication and assessed the assistant captain’s medical condition as part of his required Coast Guard medical evaluation, acknowledged the assistant captain’s use of the prescribed pain medication on the Coast Guard medical evaluation form, CG 719K. Both were criminally charged as a result of signing a form they knew contained false information. As a result of the investigation of the Andrew J. Barberi accident, the NTSB issued Safety Recommendation M 05 5 to the Coast Guard: 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 this recommendation, on September 15, 2008, the Coast Guard issued Navigation and Inspection Circular (NVIC) 04 08, “Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials.” Because the Coast Guard implemented most of the provisions of Safety Recommendation M 05 5 by issuing NVIC 04 08, the quality and rigor of the Coast Guard’s system of medical oversight of civilian mariners increased considerably. The NVIC listed specific medical conditions and medications that the Coast Guard considered to be counter to mariner fitness for duty. After issuing NVIC 04 08, the Coast Guard began reviewing all merchant mariner medical evaluations, and would no longer grant or renew credentials to mariners with certain specified medical conditions, or to those who were using certain medications that were known to impair or degrade performance without additional medical information. These included benzodiazepines, for which the NVIC stated, “waiver is required if used during, or within 48 hours prior to, acting under the authority of the credential,” and opiates, for which it stated, “no waiver required if not used during, or within 48 hours prior to, acting under the authority of the credential. May be waiverable under exceptional circumstances if used during, or within 48 hours prior to, acting under the authority of the credential.” However, on November 7, 2007, just over 4 years after the Andrew J. Barberi accident and before the Coast Guard could fully implement the necessary changes to its medical oversight system described in NVIC 04 08, the container ship Cosco Busan allided with the fendering system of the Delta tower of the San Francisco–Oakland Bay Bridge during restricted visibility (NTSB 2009). The allision led to the breaching of the vessel’s fuel tanks and the spill of over 53,000 gallons of fuel oil into San Francisco Bay, contaminating about 26 miles of shoreline and killing more than 2,500 birds of about 50 species. The NTSB’s investigation found that the vessel’s pilot had been using multiple prescribed opiates and benzodiazepines over an extended period before the accident and that his cognitive performance was degraded as a result of his use of the medications. Further, the NTSB determined that although the actions of the pilot and the vessel’s master caused the accident, the Coast Guard contributed to the cause of the accident because of its “failure to provide adequate medical oversight of the pilot in view of the medical and medication information that the pilot had reported to the Coast Guard.” That is, several months before the accident, the pilot had reported on his form 719K that he used one opiate “for occasional use” but the Coast Guard had granted him his credential nonetheless.

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 Safety Board has reviewed NVIC 04-08 and has found it responsive to much of what the Safety Board called for in Safety Recommendation M-05-5. Further, the Coast Guard, by centralizing its review of mariner medical evaluation results under the supervision of a physician trained in occupational medicine, has eliminated inconsistencies that the Safety Board found among Coast Guard reviewers and has made it possible to track the results of medical evaluations. The Coast Guard has not, however, taken action with regard to one deficiency noted in Safety Recommendation M-05-5, that is, the lack of a requirement for mariners to report changes in their medical condition between examinations. The Coast Guard has given no indication that it intends to implement such a requirement. The period between medical evaluations for non-pilot mariners is 5 years, during which considerable changes in a mariner’s medical status or medication use can take place. Even pilots, who are required to be medically evaluated annually, can experience significant medical changes or be prescribed medications with potentially impairing side effects between required medical evaluations. The absence of a requirement mandating the reporting of substantive changes in medical condition or medication use can thus allow a mariner with a known potential for cognitive or physical performance degradation to serve in a safety-critical position on a vessel in any U.S. waterway. The Safety Board therefore concludes that the Coast Guard’s system of medical oversight of mariners continues to be deficient in that it lacks a requirement for mariners to report changes in their medical status between medical evaluations. The Safety Board recommends that the Coast Guard 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. Because this recommendation addresses the only element of Safety Recommendation M-05-5 that has not been met, that recommendation is reclassified CLOSED—ACCEPTABLE ACTION/SUPERSEDED, by Safety Recommendation M-09-4.

From: USCG
To: NTSB
Date: 6/20/2008
Response: Letter Mail Controlled 6/24/2008 11:02:29 AM MC# 2080364: Update: As stated in our original response, we have been reviewing our medical oversight process, focusing on those areas identified by the Board. The following is the status of our review and actions to date in each of those areas: Lack of tracking of performed examinations and Deficiencies in the svstem of storing medical data: In December 2006, we centralized the medical evaluation process at the National Maritime Center (NMC). The NMC established workflows to address the processes related with the medical evaluation of mariners. These workflows describe not only how such evaluations are routed throughout the NMC, but also specific times when computer input is required. There are specific requirements for the outcomes of the medical evaluation, which include documenting whether the mariner is deemed medically fit or not, and if not, whether a waiver may be issued to a mariner. There have also been specific changes made to the Merchant Mariner Licensing and Documentation system (MMLD) to improve the electronic tracking of medical evaluations, as well as the results of these evaluations. Potential for inconsistent interpretations and evaluations between medical practitioners: In December 2006, we centralized the medical evaluation process at the National Maritime Center (NMC). In addition, we are drafting a revised Navigation and Vessel Inspection Circular (NVIC) to replace the current NVIC 2-98. We anticipate the new NVIC will include, among other things: 1) a comprehensive list of medical conditions subject to further review by the NMC and the associated evaluation data that is to be submitted for each condition; 2) detailed information about illegal substances and intoxicants; 3) a non-exhaustive list of medications (prescription and over-the-counter) that may result in further review by the NMC; and 4) policy regarding the designation by the Coast Guard of certain medical practitioners who meet criteria specified by the Coast Guard as “trusted agents” to perform physical examinations on mariners. We believe the centralization of the medical evaluation process and the revised guidance and policy provided in the upcoming NVIC will reduce the potential for inconsistent interpretations and evaluations between medical practitioners. We will provide a copy of the new NVIC when it is issued. Absence of requirements for mariners or others to report changes in medical condition between examinations: In the draft Navigation and Vessel Inspection Circular (NVIC) that will replace the current NVIC 2-98, we are proposing new policy associated with our medical waiver process whereby the conditions for granting the waiver would include the requirement to immediately report any deterioration of the waived medical condition to the Coast Guard. In certain cases, such as a progressive medical condition, a condition of the waiver may also include the requirement for the mariner to submit medical examination and/or test results at specified intervals to allow the Coast Guard to track the status of the medical condition. This proposed policy has been vetted through and received concurrence from both the Merchant Marine Personnel Advisory Committee (MERPAC) and Towing Safety Advisory Committee (TSAC). While we believe this to be a significant improvement over our current policy, we acknowledge its limitations as it would only apply to mariners who have been granted a medical waiver. Expanding this policy to require all mariners to report changes in their medical condition would require a regulatory change, which we believe would be met with significant resistance from maritime labor interests. At this time we are still reviewing our options to address this issue and anticipate determining a course of action after the new NVIC has been issued. Limited ability of the Coast Guard to review medical evaluations made by personal health care providers: In December 2006, we centralized the medical evaluation process at the National Maritime Center and established a full time Medical Evaluation Branch, staffed with a physician and medically trained staff. These personnel now conduct/review the evaluations of mariner’s medical fitness.

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: USCG
To: NTSB
Date: 5/7/2008
Response: Letter Mail Controlled 5/22/2008 1:54:44 PM MC# 2080253: We concur with this recommendation. We have been reviewing our medical oversight process, focusing on those areas identified by the Board. As a result, we have already determined to take the following actions: add to the Merchant Manner Licensing and Documentation (MMLD) database the ability to track physical waivers granted by the Coast Guard and the conditions for which they are granted; add to the MMLD database the ability to store the medical history of mariners in a centralized location versus the current hard copy file system; update guidelines for physical examination procedures and conditions which may require a waiver to provide better standards; propose regulations to require mariners to report any change in their medical condition between examinations which would result in the mariner not meeting Coast Guard physical standards, or when a mariner is placed on a new prescription drug; and create a full time position at the National Maritime Center for a physician or other medical specialist in the field of occupational medicine to review medical waiver requests and mariner physicals. We will keep the Board informed of our progress on this recommendation.

From: NTSB
To: USCG
Date: 4/23/2008
Response: Notation 7628C: Following its investigation of the allision of the Staten Island Ferry in New York Harbor in October 2003, the National Transportation Safety Board issued Safety Recommendation M 05-5 to the U.S. Coast Guard, asking it to address inadequacies in its medical oversight of merchant mariners. In partial response to that recommendation, the Coast Guard announced in September 2006 the development of a draft navigation and vessel inspection circular (NVIC) titled “Medical and Physical Evaluation Guidelines for Merchant Mariners.” In November 2006, the Safety Board provided comments on the draft NVIC, noting in part that the draft did not establish adequate guidelines for the certification of mariners diagnosed with substance dependence. Since that time, the Merchant Marine Personnel Advisory Committee (MERPAC) has continued to develop the draft NVIC, and Safety Board staff has monitored its development. The Safety Board regards adoption of the new guidelines as an important means of enhancing marine safety by reducing the chances that mariners covered by the NVIC might experience disqualifying physical or medical conditions while on duty. The Board applauds the dedication of the Medical Working Group tasked to grapple with the complicated issues raised by the draft NVIC and the persistence of MERPAC in identifying and resolving contentious components of the draft as it proceeds toward completion. In particular, the Safety Board is pleased that the draft NVIC includes specific guidance on medication use, as suggested in Safety Recommendations M-00-1 through M-00-3. We look forward to the Coast Guard’s eventual adoption of MERPAC’s final product in a new NVIC and the NVIC’s incorporation into a comprehensive, ongoing process for the medical certification of mariners.

From: NTSB
To: USCG
Date: 11/24/2006
Response: Notation 7628B: The National Transportation Safety Board has reviewed the U.S. Coast Guard’s announcement “Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials,” which was published in 71 Federal Register 188 on September 28, 2006. The notice solicits comments on a draft navigation and vessel inspection circular (NVIC) that will replace the existing NVIC 2-98, “Physical Evaluation Guidelines for Merchant Mariner’s Documents and Licenses.” On October 15, 2003, the commuter ferry Andrew J. Barberi allided with a maintenance pier at the St. George Terminal on Staten Island, New York, while en route between Manhattan and Staten Island. The vessel sustained heavy damage to its starboard side, and 11 passengers lost their lives, while 70 others suffered injuries in the accident. The assistant captain was the conning officer at the time of the accident. He told two witnesses that he lost consciousness before the allision. In determining the probable cause of this accident, the Safety Board found that the assistant captain’s unexplained incapacitation was a causal factor. In addition, the Board identified deficiencies in the Coast Guard’s process for evaluating the physical fitness of merchant mariners for licensure. While these deficiencies were not causal to the accident, they warranted corrective action. As a result, the Safety Board issued the following safety recommendation to the Coast Guard: 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. The Coast Guard indicates in the Federal Register announcement that the actions recommended by the Safety Board are addressed in the proposed NVIC. In the Safety Board’s opinion, the proposed standards, with the modifications proposed below, will enhance marine safety by strengthening the process used to evaluate the physical qualifications of merchant mariners, thus reducing the chances that merchant mariners might experience disqualifying physical or medical conditions while on duty. The modifications suggested by the Safety Board are consistent with the observation that substance dependence, whether drug or alcohol, should not be considered curable, but rather should be regarded as chronic and lifelong, requiring continual follow up. Medical literature has shown that even with successful treatment and abstinence for several months or years, relapse rates of over 50 percent are common. The Safety Board therefore suggests that section Nos. 186 and 186a in enclosure (3), “Potentially Disqualifying Medical Conditions and Medications,” be revised. References to a cure should be deleted in items No. 186, “Substance Dependence–Abuse/Dangerous Drugs,” and No. 186a, “Substance Dependence–Abuse/Alcohol.” The Coast Guard should establish guidance for monitoring substance-dependent mariners and require that mariners who have ever been clinically diagnosed with substance dependence, either drugs or alcohol, be monitored as long as their licenses are valid. With regard to potentially disqualifying medications, the proposed NVIC should be changed to prohibit mariners’ use of antihistamines and anti-motion-sickness agents while on duty. The Safety Board’s position regarding these pharmaceuticals is based on its investigation of several transportation accidents in which sedating antihistamines were found in the systems of operators and on substantial medical literature demonstrating the adverse effects on performance of antihistamines and anti-motion-sickness agents. In addition, the Safety Board suggests that the Coast Guard make the following modifications to the proposed NVIC: • Include conditions that cause impairment as disqualifying, in addition to those that cause incapacitation, as noted in paragraph 5j. • Elaborate, in the evaluation data noted in enclosure (3), No. 113, on the need for a urological consultation after the first finding of renal calculus, even if a single stone. The Safety Board appreciates the opportunity to comment on the proposed NVIC.

From: NTSB
To: USCG
Date: 8/24/2005
Response: The Safety Board is pleased that the Coast Guard is taking action to address these issues, including the employment of a database to track mariner physical exams, and will hire a physician or other medical specialist in the field of occupational medicine to review medical waiver requests and mariner physicals. Accordingly, Safety Recommendation M-05-05 is classified OPEN—ACCEPTABLE RESPONSE, pending completion of this effort.

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 have been reviewing our medical oversight process, focusing on those areas identified by the Board. As a result, we have already determined to take the following actions: add to the Merchant Manner Licensing and Documentation (MMLD) database the ability to track physical waivers granted by the Coast Guard and the conditions for which they are granted; add to the MMLD database the ability to store the medical history of mariners in a centralized location versus the current hard copy file system; update guidelines for physical examination procedures and conditions which may require a waiver to provide better standards; propose regulations to require mariners to report any change in their medical condition between examinations which would result in the mariner not meeting Coast Guard physical standards, or when a mariner is placed on a new prescription drug; and create a full time position at the National Maritime Center for a physician or other medical specialist in the field of occupational medicine to review medical waiver requests and mariner physicals. We will keep the Board informed of our progress on this recommendation.