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Safety Recommendation Details

Safety Recommendation M-05-006
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: Seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so. (Superseded by safety recommendation M-12-003)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Marine
Location: Bays and Sounds, NY, United States
Is Reiterated: Yes
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: 5/24/2012
Addressee(s) and Addressee Status: USCG (Closed - Superseded)
Keyword(s): Safety Management Systems,

Safety Recommendation History
From: NTSB
To: USCG
Date: 5/24/2012
Response: From the greensheet issuing safety recommendations M-12-001 through -003, issued as a result of the allision of the Andrew J. Barberi (Staten Island ferry) with slip No. 5 at St. Georges terminal on Staten Island on 5/8/2010. The NTSB is pleased that the Coast Guard obtained authority through the enactment of Public Law 111-281 to require SMS not only on ferries, but on all passenger vessels based on the number of passengers who could be killed or injured. The NTSB concludes that implementing SMS on all U.S.-flag passenger vessels would further enhance operators’ ability to achieve the higher standards of safety that the Coast Guard requires of U.S. oceangoing vessels in international service. The NTSB therefore recommends that the Coast Guard require all operators of U.S.-flag passenger vessels to implement SMS, taking into account the characteristics, methods of operation, and nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. The NTSB classifies Safety Recommendation M-05-6 “CLOSED—SUPERSEDED.” M-05-6 is superseded by recommendation M-12-3.

From: NTSB
To: USCG
Date: 11/16/2011
Response: This letter concerns 29 open safety recommendations, enclosed, that the National Transportation Safety Board (NTSB) issued to the U.S. Coast Guard between 1995 and 2010. For some of these recommendations, the NTSB has not received an update in almost 3 years regarding the status of action either taken or planned to address the important safety issue that the recommendation addresses. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. [NOTE: included M-05-6]

From: NTSB
To: USCG
Date: 7/7/2011
Response: The NTSB is pleased that, in the Coast Guard Authorization Act of 2010 (P.L. 111-281) Congress authorized the Coast Guard to require the implementation of SMS on domestic passenger vessels, including domestic ferries. Accordingly, pending the institution of such a requirement, Safety Recommendation M-05-6 is classified OPEN—ACCEPTABLE RESPONSE. The NTSB is opposed to the 399-passenger threshold specified in the Coast Guard’s July 2007 proposal to amend 46 United States Code 3202(a) to cover U.S.-flag ferries on domestic voyages. In a 2007 letter to the Department of Transportation docket responding to the Coast Guard’s notice of availability of a voyage data recorder (VDR) study, we commented specifically on that threshold, which had been specified in Section 420 of the Coast Guard and Maritime Transportation Act of 2006 (Pub. Law No. 109-241), which required the Coast Guard to undertake the study for domestic VDR requirements. In the 2005 Andrew J. Barberi accident report, referenced in the section-by-section analysis of the draft Coast Guard Authorization Act of 2008, the NTSB recommended that the Coast Guard “Seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so.” We continue to believe that the specified threshold is arbitrary and, consequently, we advocate the implementation of SMS on all U.S. ferries, regardless of passenger capacity; this is why Safety Recommendation M-05-6 was reiterated in the Block Island/Morrow Bay report.

From: USCG
To: NTSB
Date: 5/27/2011
Response: CC# 201100216: - From Kevin S. Cook, Rear Admiral, Director of Prevention Policy: As noted in your safety recommendation letter, the Coast Guard Authorization Act of 2010 (P.L. 111-281), enacted in October 2010, amended 46 U.S.C. Section 3202 giving us the legislative authority to require safety management systems for US-flag passenger vessels, including ferries. It also directs us to consider the characteristics, methods of operation, nature of the service of passenger vessels and small passenger vessels and, with respect to ferries, the sizes of the ferry systems within which they operate, when prescribing regulations to implement the amended statute. We are in the process of determining the appropriate requirements and applicability for safety management systems for U.S.-flag passenger and ferry vessels. We will keep the Board informed of our progress.

From: NTSB
To: USCG
Date: 3/16/2011
Response: CC# 201100031: The NTSB has reviewed the Coast Guard Authorization Act of 2010 (Pub. Law 111 281), Section 610, “Safety Management,” as it relates to Safety Recommendations M-02-5 and M-05-6. We are pleased that Congress has given the Coast Guard the authority necessary to require implementation of SMS on domestic passenger vessels, including domestic ferries. The authority to require PMPs, as a subset of an SMS, has also been granted by this legislative action. Accordingly, pending the Coast Guard’s completion of the recommended actions, Safety Recommendations M-02-5 and M-05-6 are classified OPEN—ACCEPTABLE RESPONSE. In order to satisfy these recommendations, the Coast Guard should require SMS for all domestic passenger vessels and ferries. The NTSB is opposed to the 399-passenger threshold specified in the July 2007 Coast Guard legislative change proposal to amend 46 United States Code 3202(a) to cover U.S. flag ferries on domestic voyages. In a 2007 letter to the Department of Transportation’s docket responding to the Coast Guard’s notice of availability of a voyage data recorder (VDR) study, the NTSB commented specifically on that threshold, which had been specified in Section 420 of the Coast Guard and Maritime Transportation Act of 2006 (Pub. Law No. 109-241) requiring the Coast Guard to undertake the study for domestic VDR requirements. In the 2005 Andrew J. Barberi accident report, referenced in the section-by-section analysis of the draft Coast Guard Authorization Act of 2008, the NTSB recommended that the Coast Guard “Seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so.” The NTSB continues to believe that the specified threshold is arbitrary and, consequently, we advocate the implementation of SMS on all U.S. ferries, regardless of passenger capacity; this is why Safety Recommendation M-05-6 was reiterated in the Block Island/Morrow Bay report.

From: NTSB
To: USCG
Date: 12/3/2010
Response: From the accident report: Collision between U.S. Passenger Ferry M/V Block Island and U.S. Coast Guard Citter Morro Bay in Block Island Sound, Rhode Island on July 2, 2008: (adopted 12/3/2010) Interstate Navigation Co.'s Block Island ferries travel across a major east-west traffic route for large vessels transiting between New York Harbor and the Atlantic Ocean, often in limited visibility conditions. Had the July 2, 2008, collision been more serious, the consequences of this accident could have been far greater. During postaccident communication with several Block Island passengers, NTSB investigators found that a majority of the passengers thought that the accident response of the Block Island crew could have been better. In particular, passengers generally thought that a collision warning should have been announced over the PA system and that a more prompt advisory announcement should have been made following the collision so that passengers could have had a better sense of what was happening. Only after being prompted did the master ensure that an announcement to the passengers was made following the collision. As previously mentioned, Interstate Navigation Co. declined the state of Rhode Island’s request, based on Safety Recommendation M-05-7, that the company voluntarily develop a safety management system. Interstate Navigation Co. did have documentation that outlined shipboard positions and duties and what was required (qualifications, experience, and education) to perform those. The company also had a training manual, which provided expectations for handling fire and emergencies and for general watch standing. Nevertheless, in reviewing Interstate Navigation Co.’s policies and procedures, investigators found that the company’s safety philosophy was informal and incorporated into on-the-job training. It was not evident whether Interstate Navigation Co. had conducted any internal or management audits. As a result, the company may not have conveyed a consistent safety culture to its crewmembers. Better management oversight of crew operations could have prevented deficiencies such as the master's inadequate sounding of the Block Island’s fog signal, the ineffective posting of a lookout, and the crew’s postaccident, response to passengers. The NTSB therefore concludes that a safety management system at Interstate Navigation Co. could have contributed to more thorough operational procedures on the Block Island and greater oversight by management. Interstate Navigation Co. was responsive in correcting some of the problems that investigators identified during the accident investigation; however, the company still falls short of meeting the functional requirements prescribed for a safety management system. The NTSB therefore recommends that Interstate Navigation Co. comply with the provisions of 33 CFR Part 96 for implementation of a safety management system for its fleet to improve safety practices and minimize risk. In operations such as passenger ferry services, where accidents can lead to catastrophic loss of life, a proactive safety management system can be a chief countermeasure to safety risks. Such a system entails risk assessment appropriate to the vessel and its operation, development of safety-centered practices and procedures for which documents and training are provided, and internal and external audits to ensure consistent performance. A safety management system identifies safety-related procedures for crewmembers during both routine and emergency operations. Duties and responsibilities are specified and supervisory and subordinate chains of command delineated. Each crewmember, as a result, better understands what is expected of him or her in critical phases of operations. In addition, safety management systems call for the creation of plans, with crewmember duties and responsibilities specified, to respond to the range of potential emergency situations the ferry could encounter. Despite the large carrying capacity of individual ferry vessels, such as the Block Island with potentially over 1,000 persons on board, only organizations that operate internationally or that have voluntarily adopted the approach operate under safety management systems in the United States. Given the thousands of passengers who ride ferries on U.S. waterways, the NTSB continues to be concerned that the absence of a requirement to implement safety management systems could result in the type of safety-deficient operations found both on the Block Island and in the 2003 accident involving the Andrew J. Barberi ferry. Although some U.S. domestic ferry systems have voluntarily adopted a safety management system, the NTSB concludes that safety management systems on all passenger ferries would enhance the likelihood that operators will maintain the high standards of safety that the Coast Guard requires of U.S. oceangoing vessels operating from the United States. Therefore, the NTSB reiterates Safety Recommendation M-05-6 and recommends that the Coast Guard seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so.

From: NTSB
To: USCG
Date: 4/6/2010
Response: In addition to placing the above three recommendations on the Most Wanted List, Safety Recommendations M-02-5 and M-07-6 were classified “Open—Unacceptable Response” because of the lack of timely action since they were issued in 2002 and 2007, respectively. Safety Recommendation M-05-6 remains classified OPEN—UNACCEPTABLE RESPONSE, a designation given in the NTSB’s August 27, 2009, letter because the Coast Guard has sought legislative authority requiring SMS only on vessels carrying more than 399 passengers, rather than on all ferry vessels, as requested. However, the NTSB is aware from discussion and e-mail exchanges between Coast Guard and NTSB staff that the Coast Guard’s long-planned notice of proposed rulemaking (NPRM) for uninspected towing vessels (UTV) has been forwarded to the Department of Homeland Security for review and final approval and that the NPRM proposes that UTVs be inspected, have SMS programs, and have new UTV manning standards. We are also aware that the Coast Guard intends to consider requiring PMP and SMS for ferries and small passenger vessels.

From: NTSB
To: USCG
Date: 2/18/2010
Response: At the February 18, 2010 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations M-02-5, M-05-6 and M-07-6 on the MWL under the issue category “Require Safety Management Systems (SMS) for Domestic Vessels.”

From: NTSB
To: USCG
Date: 8/27/2009
Response: The NTSB is aware that in July 2007, the Coast Guard submitted a legislative change proposal to amend 46 United States Code 3202(a) to cover U.S. flag ferries carrying more than 399 passengers and operating on domestic voyages and, thus, require such vessels to implement SMS pursuant to 33 Code of Federal Regulations Part 96 but that the proposed legislation failed to pass before the 110th Congress completed its session. While supporting SMS on passenger vessels, the NTSB questions the 399 passenger threshold. In a February 6, 2007, letter (copy enclosed) to the Department of Transportation’s Docket Management Facility, responding to the Coast Guard’s notice of availability of a voyage data recorder (VDR) study, the NTSB commented specifically on that number. The 399 passenger threshold had been specified in Section 420 of the “Coast Guard and Maritime Transportation Act of 2006” (Pub. Law No. 109-241), which required the Coast Guard to undertake that study for domestic VDR requirements. The NTSB has not been able to determine a reason for that threshold and suggests that a smaller number might be appropriate. Coast Guard regulations do not distinguish between vessels with fewer than 399 passengers and those carrying more. While there are thresholds in Coast Guard safety regulations based on the number of passengers carried, that number is substantially lower than 399. The NTSB articulated in a section-by-section analysis of the 2008 draft authorization a particular concern with the following statement: “Finally, regarding the threshold number carrying more than 399 passengers, there is alignment with the requirement found in the Coast Guard and Maritime Transportation Act of 2006.” The NTSB believes that there is no reason for such an alignment. VDRs and SMS are completely different concepts with different purposes and should not be linked to each other. VDRs are most useful in analyzing accidents; SMSs are most useful in preventing them. The section-by-section analysis also states that 399 passengers “is the universe of ferry vessels where the NTSB and the Coast Guard believe SMS will be most effective.” This statement is incorrect. The NTSB advocates SMS on all U.S. ferries. In the Andrew J. Barberi accident report, which is referenced in the section-by-section analysis, the NTSB recommended that the Coast Guard “Seek legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.-flag ferry operators to do so.” Accordingly, because the Coast Guard appears to seek legislative authority requiring SMS only on vessels carrying more than 399 passengers, in lieu of “all” ferry vessels as recommended, Safety Recommendation M-05-6 is classified OPEN--UNACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 2/17/2009
Response: Letter Mail Controlled 2/20/2009 11:16:05 AM MC# 2090085: - From Walter D. Rabe, United States Coast Guard: In July 2007, we submitted a legislative change proposal to amend 46 USC $3202(a) to cover U.S. flag ferries carrying more than 399 passengers and operating on domestic voyages and, thus, require such vessels to implement safety management system. Pursuant to 33 CFR Part 96. The Coast Guard Authorization Act of 2008 (H.R. 2830) provided language that would implement the NTSB recommendation in toto; however, the proposed legislation failed to pass before the 110 Congress completed its session. We will continue to monitor the legislative action associated with this issue. We will keep the Board informed of our progress on this recommendation.

From: NTSB
To: USCG
Date: 8/24/2005
Response: The Safety Board recognizes that industry studies have shown that safety management systems already attain a higher level of compliance and lower level of casualties caused by human factors when a true safety culture is made part of the company's management processes for all personnel. Because the Coast Guard will propose a legislative change to extend the applicability of 46 United States Code 3202(a) to include U.S.-flag ferries operating on domestic voyages to implement safety management systems, Safety Recommendation M-05-06 is classified OPEN - - ACCEPTABLE RESPONSE, pending publication of the final regulations.

From: USCG
To: NTSB
Date: 5/18/2005
Response: Letter Mail Controlled 5/24/2005 8:03:10 AM MC# 2050216 - From Brian M. Salerno, Accting, Assistant Commandant for Marin Safety, Security, and Environmental Protection: We concur with this recommendation. Industry studies have shown that such systems already attain a higher level of compliance and lower level of casualties caused by human factors when a true safety culture is made part of the company's management processes for all personnel. We will propose a legislative change extending the applicability of 46 USC 3202(a) to include US-flag ferries operating on domestic voyages; this will require compliance with 33 CFR Part 96 to implement safety management systems. We will keep the Board informed of our progress on this recommendation.