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Safety Recommendation Details

Safety Recommendation M-06-005
Details
Synopsis: On March 6, 2004, the small passenger pontoon vessel M/V Lady D, a 36-foot-long by 8-foot-wide enclosed water taxi, was carrying 23 passengers and 2 crewmen en route from Fort McHenry National Monument to Fells Point, Inner Harbor, Maryland, when it encountered a rapidly developing storm with high winds. As the wind and wave intensity increased, the vessel capsized. Most of the water taxi’s occupants were able to escape from the vessel, and all but 3 occupants of the Lady D were rescued within an hour of the capsizing. The bodies of the remaining victims were recovered from the waterway on March 14 and 15. As a result of this accident, 5 passengers died; 4 passengers suffered serious injuries; and 12 people sustained minor injuries.
Recommendation: TO THE UNITED STATES COAST GUARD: Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. (Supersedes Safety Recommendation M-04-004)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Harbor, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA04MM015
Accident Reports:
Capsizing of U.S. Small Passenger Vessel Lady D
Report #: MAR-06-01
Accident Date: 3/6/2004
Issue Date: 3/27/2006
Date Closed: 3/14/2011
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 7/8/2013
Response: Thank you for the April 5, 2013, letter signed by Vice Admiral Peter V. Neffenger, Deputy Commandant for Operations, to the National Transportation Safety Board (NTSB) containing your semiannual update regarding actions to address 42 safety recommendations that the NTSB issued to the US Coast Guard. To assist with future updates and to align our records, we are enclosing a copy of the NTSB’s safety recommendation database history for these 42 recommendations. This response letter will be divided into four parts: • Part 1 – Evaluation of actions to address Safety Recommendations M 09 15 and 16 and M-10-2, recommendations for which Admiral Neffenger provided a substantive update. • Part 2 – List of 6 safety recommendations previously closed. • Part 3 – List of 7 safety recommendations that were the subject of a recent Coast Guard update and that the NTSB is currently evaluating; these recommendations will be addressed in detail in separate correspondence. • Part 4 – List of 26 safety recommendations for which the Coast Guard did not provide a substantive update or for which status has not changed since the last update. Part 1 – Safety Recommendations Updated in the April 5, 2013, Letter: We issued Safety Recommendations M-09-15 and -16, stated below, to the Coast Guard on October 20, 2009, as a result of a review of the involvement of obstructive sleep apnea (OSA) in several accidents investigated by the NTSB. M-09-15 Implement a program to identify licensed mariners subject to the Navigation and Vessel Inspection Circular on Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (NVIC 04-08) and who are at high risk for obstructive sleep apnea, and require that those mariners provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. M-09-16 Develop and disseminate guidance for mariners, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea (OSA), emphasizing that mariners who have OSA that is effectively treated are routinely approved for continued medical certification. We are encouraged that the Merchant Mariner Medical Advisory Committee is planning to review and revise Navigation and Vessel Inspection Circular 04-08, including Enclosure (4), Guidance on Specific Medical Conditions, which details the medical decision making criteria for common conditions (including sleep disorders such as OSA) as they relate to determining merchant mariner fitness for duty. Pending completion of these efforts, Safety Recommendation M-09-15 is classified “Open—Acceptable Alternate Response” and Safety Recommendation M 09-16 is classified “Open—Acceptable Response.” We issued Safety Recommendation M-10-2, stated below, to the Coast Guard on August 11, 2010, as a result of two recent maritime accidents involving Coast Guard patrol boats: the December 5, 2009, collision of the CG 25689 with the small passenger vessel Thriller 09 in Charleston, South Carolina, and the December 20, 2009, collision of the CG-33118 with a 24 foot recreational vessel in San Diego, California. M-10-2 Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. The Coast Guard’s recent revision of Coast Guard Boat Operations and Training (BOAT) manual, volume I, COMDTINST M16114.32C, section F.2, prohibits the use of cellphones/texting devices and phone applications aboard all boat force assets without the permission of the coxswain, which will only be granted on a case-by-case basis and only when operational safety is not compromised. Because this action satisfies Safety Recommendation M 10-2, it is classified “Closed—Acceptable Action.” Part 2 – Safety Recommendations Previously Closed: M-06-5 (Closed—Acceptable Action, March 14, 2011) Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. M-06-6 (Closed—Acceptable Action, March 14, 2011) Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. M-06-7 (Closed—Unacceptable Action, March 14, 2011) Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. M-06-8 (Closed—Unacceptable Action, March 14, 2011) Until such time as you revise the passenger weight standard as requested in Safety Recommendation M-06-5 and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation M-06-7, develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations. M-06-9 (Closed—Unacceptable Action, March 14, 2011) Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection. M-11-11 (Closed—Acceptable Action, November 13, 2012) Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. Part 3 – Recommendations Recently Updated and Under Evaluation by the NTSB: M-10-5 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders that meet the international performance standard on new ferry vessels. M-10-6 (Open—Unacceptable Response, May 24, 2012; USCG Update February 12, 2013) Require installation of voyage data recorders on ferry vessels built before the enactment of voyage data recorder carriage requirements that will record, at a minimum, the same video, audio, and parametric data specified in the International Maritime Organization’s performance standard for simplified voyage data recorders. M-12-1 (Open Initial Response Received; USCG Update February 12, 2013) Require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-2 (Open Initial Response Received; USCG Update February 12, 2013) Where technically feasible, require existing U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be retrofitted with alarms that audibly and visually alert the operator to deviations between the operator’s propulsion and steering commands and the actual propeller response. M-12-3 (Open—Initial Response Received; USCG Update February 12, 2013) Require all operators of U.S.-flag passenger vessels to implement safety management systems, taking into account the characteristics, methods of operation, and the nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. M-12-6 (Open—Initial Response Received; USCG Update March 21, 2013) Develop and implement a policy to ensure adequate separation between vessels operating in the Bayport Channel and Bolivar Roads Precautionary Areas and any other similarly configured precautionary areas in the Houston Ship Channel. M-12-7—(Open Initial Response Received USCG Update March 21, 2013) Graphically delineate precautionary areas on appropriate Houston Ship Channel nautical charts so they are readily identifiable to mariners. Part 4 – Safety Recommendations Not Substantively Updated in the April 5, 2013, letter: M-02-5 (Open—Acceptable Response, February 4, 2013) Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. M-07-1 (Open—Acceptable Response, February 4, 2013) Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. M-07-6 (Open—Acceptable Response, February 4, 2013) Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. M-08-2 (Open—Acceptable Response, February 4, 2013) Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. M-09-4 (Open—Acceptable Response, February 4, 2013) 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. M-09-10 (Open—Unacceptable Response, February 4, 2013) Seek legislative authority to require that all commercial fishing vessels be inspected and certificated by the Coast Guard to ensure that the vessels provide an appropriate level of safety to those on board. M-09-14 (Open—Acceptable Response, February 4, 2013) Modify Form 719K (Merchant Mariner Physical Examination Report) to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. M-09-17 (Open—Unacceptable Response, February 4, 2013) Require that out-of-water survival craft for all passengers and crew be provided on board small passenger vessels on all routes. M-11-3 (Open—Acceptable Response, February 4, 2013) Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety. M-11-4 (Open—Acceptable Response, February 4, 2013) Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue. M-11-8 (Open—Acceptable Response, November 13, 2012) Develop and implement procedures for your special purpose craft–law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. M-11-9 (Open—Acceptable Response, November 13, 2012) Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. M-11-10 (Open—Acceptable Response, November 13, 2012) Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. M-11-12 (Open—Acceptable Response, November 13, 2012) Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. M-11-13 (Open—Acceptable Response, November 13, 2012) Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, determine from that whether the risk is unacceptable, and if so, develop risk mitigation strategies. M-11-14 (Open—Acceptable Response, November 13, 2012) Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. M-11-15 (Open—Acceptable Response, November 13, 2012) Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. M-11-16 (Open—Unacceptable Response, November 13, 2012) Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. M-11-23 (Open—Unacceptable Response, June 12, 2012) Establish standards for new and existing commercial fishing industry vessels of 79 feet or less in length that (1) address intact stability, subdivision, and watertight integrity and (2) include periodic reassessment of the vessels’ stability and watertight integrity. M-11-24 (Open—Unacceptable Response, June 12, 2012) Require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use of vessel stability information regardless of plans for implementing the other training provisions of the 2010 Coast Guard Authorization Act. M-11-25 (Open—Unacceptable Response, June 12, 2012) Require each person on deck of a commercial fishing industry vessel to wear a flotation aid at all times. M-11-26 (Open—Unacceptable Response, June 12, 2012) Require owners of commercial fishing industry vessels to (1) install fall overboard recovery devices appropriate for the vessel, (2) periodically ensure the functionality of such equipment, and (3) regularly conduct drills in which crewmembers demonstrate their competence in the use of such devices. M-11-27 (Open—Unacceptable Response, June 12, 2012) Require all crewmembers to provide certification of completion of safety training before getting under way on commercial fishing industry vessels, such training to include both prevention of and proper response to emergency situations as well as actual use of emergency equipment. M-12-8 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard military personnel with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-9 (Open—Await Response) Align your standards for postaccident toxicological testing of Coast Guard civilian personnel, seeking appropriate legislative authority if necessary, with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-10 (Open—Await Response) Disseminate guidance within the Coast Guard so that commanding officers have unambiguous instruction detailing the requirements for timely drug and alcohol testing of Coast Guard military and civilian personnel whose work performance may be linked to a serious marine incident. Thank you for your commitment to marine safety. We look forward to receiving further updates on the action being taken to implement the following safety recommendations: M-02-5 M-07-1 M-07-6 M-08-2 M-09-4 M-09-10 M-09-14 M-09-15 M-09-16 M-11-3 M-11-4 M-11-8 M-11-9 M-11-10 M-11-12 M-11-13 M-11-14 M-11-15 M-11-16 M-11-23 M-11-24 M-11-25 M-11-16 M-11-27 M-12-8 M-12-9 M-12-10

From: USCG
To: NTSB
Date: 4/9/2013
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Please find enclosed our agreed upon semiannual update of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board and are awaiting Coast Guard response. There are currently 42 safety recommendations with an "open" status issued to the Coast Guard. Of those, we attest that our actions are complete for six, six are pending resolution, and five require long-term agency action. Updates for the remaining 25 have been or will be provided in separate correspondence. Enclosure (1) provides specific information for each recommendation. The Coast Guard published its Final Rule, “Passenger Weight and Inspected Vessel Stability Requirements,” on December 14, 2010. Under these new requirements, the “Assumed Average Weight Per Person” (AAWPP) is required to be periodically updated based on the most recent report released by the Centers for Disease Control and Prevention (CDC) through the National Center for Health Statistics (NCHS), or any successors to those centers. Each time the CDC releases a report containing mean weights of United States adult males and females, the Coast Guard will apply the formula in 46 CFR 170.090(e) to that data. The resulting value will become the new AAWPP if the sum equals or exceeds 10 pounds more than the AAWPP then in effect. We consider our action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
Date: 3/14/2011
Response: The Coast Guard has established a formula for calculating the average weight per person, currently 185 pounds, at 46 Code of Federal Regulations (CFR) 170.090 and 171.045. The formula relies on the most recent mean body weight data, obtained through the National Health and Nutrition Examination Survey; such data are expected to be released periodically by the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). Further, as the CDC periodically updates weight data for the U.S. population, the formula will compute the latest, statistically representative, assumed average weight per person, which will then be used to evaluate the stability of passenger vessels. Because this action satisfies Safety Recommendation M-06-5, the recommendation is classified CLOSED -- ACCEPTABLE ACTION.

From: NTSB
To: USCG
Date: 6/26/2009
Response: The Coast Guard’s proposed rulemaking sets forth a formula for calculating the average weight per person (currently 185 pounds), which was published in the Federal Register on April 26, 2006. The formula relies on the most recent mean body weight data resulting from the National Health and Nutrition Examination Survey; such data are expected to be released periodically by the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC). As the CDC periodically updates the U.S. population weight data, the formula proposed in the new rule would compute the latest, statistically representative, assumed average weight per person, which would then be used to evaluate the stability of passenger vessels. The NTSB supports the Coast Guard’s rule but noted in its November 18, 2008, letter to the docket that the text of the NPRM is inconsistent with the document’s preamble and that the rule itself may be difficult to administer because it will rely on the marine community to track updates to the average weight figures published in the Federal Register. Pending publication of the final rule rule, Safety Recommendation M-06-5 is classified OPEN -- ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 2/13/2009
Response: Letter Mail Controlled 2/20/2009 11:16:05 AM MC# 2090085: - Walter D. Rabe, United States Coast Guard: Status: On Aug. 20,2008, we published a Notice of Proposed Rulemaking (NPRM) on Passenger Weight and Inspected Vessel Stability Requiremcnts (73 FR 49244). ‘The NTSB submitted comments on the NPRM to the docket on Nov. 18,2008 and stated thercin that the proposed rule for increased assumed passenger weight that would be used in stability tests and calculations is responsive to this Safety Recommendation. The NPRM comment period will close in March 2009. Based on comments received, we will evaluate the next regulatory action to be taken. We will kcep the Board informed of our progress on this rccornmendation.

From: NTSB
To: USCG
Date: 11/18/2008
Response: Safety Recommendation M-06-5 is currently classified OPEN -- ACCEPTABLE RESPONSE. In April 2006, the Coast Guard published a notice (71 Federal Register 24732) recommending an assumed weight per person of 185 pounds for men and women. In April 2007, the Coast Guard informed the Safety Board that it concurred with Safety Recommendation M-06-5. The NPRM proposes adding new provisions to 46 CFR subchapter S concerning the calculation of assumed per-person weight. The new provisions would replace the weight standard currently found at 46 CFR 178.330. The proposed formula, at 5 170.090(e), would use the most recent mean weight data for males and females aged 20 and over (mean weight of males plus mean weight of females, divided by 2, plus 7.5 pounds for clothing). The Coast Guard expects that the weight data, which will come from the National Health and Nutrition Examination Survey (NHANES), will be periodically updated and released by the IIrJational Center of Health Statistics of the Centers for Disease Control and Prevention (CDC). Using the CDC updates, the proposed formula would "compute the latest, statistically representative, assumed average weight per person," which would then be used to evaluate passenger vessel stability. The Safety Board notes that the age range (20 and over) given in $ 170.090(e) is inconsistent with the range (between 20 and 74) stated in the NPRM preamble. According to the NHANES mean weight data for 1999-2002, the average weight of males and females aged 75 years and older is about 20 pounds less than the figure for adults aged 20 to 74. Using the data for people over 75 would thus bias downward the weight value used to evaluate passenger vessel stability. The Safety Board believes that proposed $ 170.090 is responsive to Safety Recommendation M-06-5 but urges the Coast Guard to amend the text of $ 170.090(e) to specify the age range as 20 to 74 for both males and females. The Safety Board also notes that if the rule is adopted, administration and compliance will present challenges both to the Coast Guard and to passenger vessel owners and operators. According to the NPRM, the appropriate average passenger weight to be used for stability tests and calculations will no longer be included in the regulations. Rather, when the CDC publishes new average-weight data, the Coast Guard, "without fbrther rulemaking," intends to publish a Federal Register notice that the new data are available. The notice would include revised calculations of average per-person weight in the United States. The Safety Board is concerned that owners and operators not accustomed to tracking Coast Guard notices in the Federal Register could remain unaware of the latest published value of average passenger weight or not realize that the value has changed. The Safety Board therefore urges the Coast Guard to develop procedures that will keep the marine industry and Coast Guard field offices informed of the latest average passenger weight value to be used for stability tests and calculations. Possible vehicles for conveying the information include navigation and vessel inspection circulars and postings on the Coast Guard's public website. Current regulations require masters to verify, "after loading and prior to departure and at all other times necessary to assure the safety of the vessel," that their vessels comply "with all applicable stability requirements."' As the Safety Board observed in its report on the Lady D capsizing, even if the number of passengers permitted on a vessel is based on a higher weight standard, a vessel could still be overloaded if enough passengers exceed the standard weight. To give vessel masters an easy way of identifying whether a particular passenger load could compromise a vessel's stability, the Safety Board urged the Coast Guard to take the following action: Notation 7679B: The National Transportation Safety Board has reviewed the U.S. Coast Guard's notice of proposed rulemaking (NPRM), "Passenger Weight and Inspected Vessel Stability Requirements," published at 73 Federal Register 49244-49275 on August 20, 2008. The Coast Guard is proposing to amend regulations at 46 Code ofFederal Regulations (CFR) subchapter H (passenger vessels), subchapter K (small passenger vessels carrying more than 150 passengers or with overnight accommodations for more than 49 passengers), subchapter S (subdivision and stability), and subchapter T (small passenger vessels carrying 150 or fewer passengers or with overnight accommodations for 49 or fewer passengers). The stated purpose of the proposed amendments is to update the passenger vessel regulations "to more accurately reflect today's average weight per person" and to "clarify and update" the regulations regarding intact stability, subdivision, and damage stability. The Coast Guard's proposed rulemaking comes in response to an accident on March 6, 2004, in which the U.S. small passenger vessel Lady D capsized in the Northwest Harbor of Baltimore, Maryland, with loss of life. The Safety Board investigated the capsizing and concluded that errors in determining the allowable number of occupants had permitted the Lady D to operate in an overloaded condition that, combined with the strong wind and waves the boat encountered, significantly reduced its intact stability.2 The Safety Board's accident report raised issues concerning passenger weight standards, vessel stability standards, and policies and procedures related to weather operations. After the Lady D accident and before the Safety Board issued its report, the Coast Guard undertook an action plan designed to evaluate and improve the process of assessing passenger vessel stability. The plan included evaluating the stability standards and assessing the impact on the marine industry of increasing the passenger weight and size standards used to calculate the stability of domestic passenger vessels. The NPRM reflects the results of those studies, as well as addressing recommendations the Safety Board made as a result of its investigation of the Lady D accident. While the Safety Board supports the intent of the rulemaking, it has also identified opportunities to strengthen the proposed regulations, as detailed below. The Safety Board's comments address only proposed regulations that affect small passenger vessels-the vessels addressed in the Board's safety recommendations resulting from the Lady D accident investigation. Passenger Weight Criteria for Stability Assessment Preliminary results from its investigation ofthe Lady D accident persuaded the Safety Board that the Coast Guard was not using a realistic average occupant weight (140 pounds for vessels operating in protected waters and carrying a mix of men, women, and children) in calculating the number of people that could safely be carried on pontoon vessels. Accordingly, on December 20, 2004, the Safety Board issued the following safety recommendation to the Coast Guard in advance ofthe final report: M-04-4 Revise your guidance to Officers in Charge, Marine Inspection, to determine the maximum occupant capacity of small passenger pontoon vessels either (1) by dividing the vessel's simplified stability proof test weight by the per-person weight allowance for an average adult stipulated in Federal Aviation Administration Advisory Circular 12027D (174 pounds per person, assuming summer clothing and a 50-50 gender mix), or (2) by restricting (at the time of loading) the actual cumulative weight of passengers and crew to the vessel's simplified stability proof test weight. In its final report on the Lady D capsizing, the Safety Board superseded Safety Recommendation M-04-4 with the following recommendation to the Coast Guard: M-06-5 Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative passenger weight standard that is periodically updated. Safety Recommendation M-06-5 is currently classified "Open-Acceptable Response." In April 2006, the Coast Guard published a notice (71 Federal Register 24732) recommending an assumed weight per person of 185 pounds for men and women. In April 2007, the Coast Guard informed the Safety Board that it concurred with Safety Recommendation M-06-5. The NPRM proposes adding new provisions to 46 CFR subchapter S concerning the calculation of assumed per-person weight. The new provisions would replace the weight standard currently found at 46 CFR 178.330. The proposed formula, at § 170.090(e), would use the most recent mean weight data for males and females aged 20 and over (mean weight of males plus mean weight of females, divided by 2, plus 7.5 pounds for clothing). The Coast Guard expects that the weight data, which will come from the National Health and Nutrition Examination Survey (NHANES), will be periodically updated and released by the National Center of Health Statistics of the Centers for Disease Control and Prevention (CDC). Using the CDC updates, the proposed formula would "compute the latest, statistically representative, assumed average weight per person," which would then be used to evaluate passenger vessel stability. The Safety Board notes that the age range (20 and over) given in § l70.090(e) is inconsistent with the range (between 20 and 74) stated in the NPRM preamble. According to the NHANES mean weight data for 1999-2002, the average weight of males and females aged 75 years and older is about 20 pounds less than the figure for adults aged 20 to 74. Using the data for people over 75 would thus bias downward the weight value used to evaluate passenger vessel stability. The Safety Board believes that proposed § 170.090 is responsive to Safety Recommendation M-06-5 but urges the Coast Guard to amend the text of § 170.090(e) to specify the age range as 20 to 74 for both males and females. The Safety Board also notes that if the rule is adopted, administration and compliance will present challenges both to the Coast Guard and to passenger vessel owners and operators. According to the NPRM, the appropriate average passenger weight to be used for stability tests and calculations will no longer be included in the regulations. Rather, when the CDC publishes new average-weight data, the Coast Guard, "without further rulemaking," intends to publish a Federal Register notice that the new data are available. The notice would include revised calculations of average per-person weight in the United States. The Safety Board is concerned that owners and operators not accustomed to tracking Coast Guard notices in the Federal Register could remain unaware of the latest published value of average passenger weight or not realize that the value has changed. The Safety Board therefore urges the Coast Guard to develop procedures that will keep the marine industry and Coast Guard field offices informed of the latest average passenger weight value to be used for stability tests and calculations. Possible vehicles for conveying the information include navigation and vessel inspection circulars and postings on the Coast Guard's public website. Current regulations require masters to verify, "after loading and prior to departure and at all other times necessary to assure the safety of the vessel," that their vessels comply "with all applicable stability requirements.,,3 As the Safety Board observed in its report on the Lady D capsizing, even if the number of passengers permitted on a vessel is based on a higher weight standard, a vessel could still be overloaded if enough passengers exceed the standard weight. To give vessel masters an easy way of identifying whether a particular passenger load could compromise a vessel's stability, the Safety Board urged the Coast Guard to take the following action: M-06-6 Identify a method for detennining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. The current classification of Safety Recommendation M-06-6 is "Open-Acceptable Response." The NPRM proposes adding new sections, titled "Stability Verification," to the subchapters that address the inspection of passenger vessels. The new sections would require owners or operators to demonstrate the method masters use to avoid overloading their vessels, based on the most recent stability calculations. Among possible methods cited in the NPRM is "the competent reading of loading or draft marks." The proposed new requirements for small passenger vessels are found at §§ l15.505(a) and l76.505(a). The Safety Board believes that the proposed additions to the small passenger vessel regulations are responsive to Safety Recommendation M-06-6 and urges the adoption of §§ 115.505(a) and 176.505(a). The proposed rules also require verification that a vessel still meets applicable stability requirements "as soon as practicable" after the vessel or its loading is modified, and the use of the latest data on average per-person weight in the verification procedure. The Safety Board supports the Coast Guard's proposal to require immediate revisions to a vessel's stability information that will reflect the latest assumed average weight per person, and that vessels undergoing modification or loading changes will also receive immediate stability verification. Paragraph (b) of the proposed rules would require a vessel's stability to be verified at 10-year intervals. The Safety Board supports this proposed rule. The Safety Board notes, however, that the preamble to the NPRM states that the proposed rules require all vessels to meet the latest stability weight standards "immediately upon the effective date of this rule," no matter when a vessel's stability requirements were issued. The proposed regulations contain no specific provision to this effect. Pontoon Vessel Stability Standards Intact stability standards are found in subchapter T, part 178, subpart C. The NPRM proposes extensive revisions to the intact stability requirements at §§ 178.320 and 178.330 and to the stability standards for pontoon passenger vessels at § 178.340. The Safety Board has concerns about a number of the proposed revisions. Intact Stability Requirements. The Coast Guard's multiphase pontoon stability project launched after the Lady D capsizing included an evaluation of the current stability process and an analysis of alternate stability standards. On April 28, 2005, a Coast Guard study team published its Study on the U.S. Domestic Intact Stability and Subdivision Requirements for Twin Hull Pontoon Passenger Boats Less Than 65 Feet in Length, which reviewed the pontoon vessel simplified stability test (PSST) variables found in subchapter T regulations, as well as industry and international standards. Among other results, the study recommended restricting the applicability of the PSST to defined parameters related to full load submergence (percentage of pontoon diameter underwater when carrying a full load), pontoon diameter, and distance between pontoon centers. The study concluded that the PSST's margin of safety (conservativeness) was questionable if pontoon vessels with characteristics falling outside the restrictions were tested using the PSST. Based in part on the Coast Guard's 2005 study, the NPRM proposes a new subsection, § 178.320(g), which contains nine restrictions on when a multihull vessel "may undergo" a PSST. As recommended by the study, two provisions, §§ 178.320(g)(8) and (9), restrict the applicability of the PSST to vessels that meet criteria for the distance between pontoon centers and the diameter of each pontoon. The study also recommended a full load submergence of not more than 50 percent as a boundary condition for the application of the PSST. The proposed regulations do not include such a restriction, despite the safety concerns raised by the Coast Guard study. The Safety Board's report on the capsizing of the Lady D, which referred to the 2005 Coast Guard study, found that the Lady D capsize condition was 56 percent submergence of the pontoon.4 The Safety Board urges the Coast Guard to include the 50 percent full load submergence criterion in the proposed restrictions on the application of the PSST. The Safety Board believes that the regulations should require the stability of pontoon vessels that do not meet the nine criteria in § 178.320(g) and the 50 percent submergence criterion to have their stability evaluated under the provisions of subchapter S. According to the NPRM preamble, the revisions to § 178.320 are intended to clarify which passenger vessels are subject to the PSST and which to the subchapter S stability requirements. In the Safety Board's opinion, the proposed rules have little potential for clarifying the stability standard applicable to pontoon passenger vessels. Not only do the proposed rules contain technical errors, they are difficult to follow, in large part because of the multitude of cross-references. For example, § 178.320(b) states: "Except as provided by paragraph (i) of this section, each vessel must comply with paragraph (c), (d), (e), (t), (g), or (h) of this section." Paragraph (c) sends readers to part 170 subparts G and H and part 171 subparts A and B. Paragraph (g) sends them to § 178.340. Paragraph (i) provides an exception to paragraph (b) that mayor may not apply to pontoon vessels. In comparison, current regulations at § 178.320 are clear and easy to follow. It is unlikely that the stability standard applicable to pontoon vessels would be misunderstood, inasmuch as current regulations at § 178.320(b) clearly state that "a pontoon vessel operating in protected waters must undergo a simplified stability proof test" unless the owner chooses to comply with subchapter S requirements. The potential for confusion about the standards for pontoon vessels is compounded by the absence of the limiting condition, "operating in protected waters," from the text of the proposed regulations (it appears only in Figure 178.320). The Safety Board believes that the limiting condition is critical and urges the Coast Guard to make it clear in proposed § 178.320(g) that the regulation applies only to pontoon passenger vessels operating on protected waters. The Safety Board is particularly concerned that proposed § 178.320(i) appears to give the cognizant officer in charge, marine inspection (OCMI) the authority to develop his own stability test or to dispense with stability requirements altogether. Current standards at § 178.320(c) allow OCMIs to dispense with a simplified stability test (SST), but that relaxation of the rules has until now been extended only to monohull vessels, not to pontoon vessels. The Safety Board believes that the stability of all pontoon passenger vessels should be evaluated, whether by PSST or through subchapter S calculations, for the loading and environmental conditions under which they are intended to operate. The Safety Board therefore urges the Coast Guard to clearly state that proposed § 178.320(i) applies only to monohull vessels. The NPRM proposes adding Table 178.320 to the regulations as a summary of the intact stability requirements. To make it clear that proposed § 178.320(i) applies only to monohull vessels, as the Safety Board believes it should, Note 2 should be removed from the "Non-sailing" doublehull column of Table 178.320. In addition, the Safety Board notes that an entry for number of passengers seems to be missing from the column for double-hulled sailing vessels (rightmost column). Pontoon Simplified Stability Test. The Coast Guard's NPRM states that in revising § 178.340, it seeks to "codify existing policy on pontoon vessel intact stability, clarify those requirements, and improve consistency of application." The Safety Board believes that the proposed changes do not meet the stated objectives. The proposed revisions involve reorganizing § 178.340 to "align with" § 178.330, which gives the procedures for administering an SST to monohull vessels. The Safety Board finds that the proposed changes would, contrary to the stated objectives, introduce inconsistencies between the PSST and the SST. For example: • The SST includes the weight of personal effects and excludes crew weight in calculating total test weight. The PSST includes both passenger and crew weight but does not address the weight of personal effects. The Safety Board believes that the weight of crew, passengers, and personal effects should be consistently accounted for in the tests. • The PSST includes the weight of sewage tanks, whereas the SST is silent about them. • The current SST procedure requires fuel and water tanks to be "approximately three quarters full." The NPRM proposes to require that fuel and water tanks on pontoon vessels be filled to 100 percent capacity when a PSST is performed. The Safety Board believes that the proposed change does not reflect actual operating conditions for pontoon vessels and could reduce safety margins because it does not account for the negative effects of free surface on stability. The Safety Board urges the Coast Guard to remove the requirement for filling tanks to 100 percent capacity. The Safety Board has serious concerns about the proposed regulations regarding the formulas used to calculate a vessel's stability. Evaluating whether a vessel has the minimum stability for its proposed operation involves calculating the wind heeling moment and the passenger heeling moment.5 The passenger heeling moment is based on the beam of the vessel and the number of passengers carried. The wind heeling moment is based on the projected lateral surface of the vessel exposed to wind pressure. The larger of the two heeling moment calculations is used in conducting a stability proof test on the vessel that involves shifting weights on the deck until that heeling moment is reached. The formulas for calculating heeling moments are found in the current regulations applicable to monohull vessels (§ 178.330). Seven months after the Lady D capsizing, the Coast Guard issued guidance for conducting stability tests that included formulas for calculating heeling moments specifically for pontoon passenger vessels. 6 The formulas are incorporated in the proposed regulations at § 178.340(b). However, a critical change has been made to the formula given in the guidance document for calculating passenger and crew heeling moment. The Safety Board is concerned that the change would reduce the safety margins for pontoon passenger vessels. The proposed formula contains a factor, K, that was not part of the formula given in the Coast Guard's guidance document. K reduces by 2 feet the maximum transverse distance of the deck area accessible to passengers. The consequence of the change in the formula is to reduce the magnitude of the passenger heeling moment in the PSST. There is no discussion in the NPRM preamble justifying this reduction, nor does the public docket contain information supporting a reduction in the passenger weight shift test. If the proposed formula had been applied to the Lady D, it would have reduced the passenger heeling test moment applied to the vessel during a PSST by 25 percent.8 The result would have been to allow a corresponding increase in the number of passengers the Lady D was permitted to carry. The preamble to the NPRM refers to the "overall good safety record of the passenger vessel industry" that "reflects safety factors inherent in the stability requirements applied to passenger vessels." The effect of introducing K into the stability formula would be to reduce the safety factors in the stability requirements for pontoon passenger vessels. Such a change could very well negate the effect of increasing the assumed passenger weight for stability calculations. Any attempt to reduce the safety factors inherent in the PSST is contrary to the interests of safety. The Safety Board does not support such a reduction in safety and urges the Coast Guard to reconsider the proposed change. As part of the proposed revisions to § 178.340, the NPRM has revised the figures intended to illustrate the PSST procedures. The Safety Board considers that the general readability of Figures 178.340(d)(1) and 178.340(d)(2) has been improved. However, inconsistencies between the illustrations could mislead those conducting a PSST as to the positioning of the test weights. Figure 178.340(d)(2) shows the weights raised to meet a vertical center of gravity (VCG) of 30 inches above the deck, while Figure 178.340(d)(1) shows the test weights positioned on the deck. The Safety Board suggests modifying Figure 178.340(d)(1) to show the weights positioned to meet a VCG of 30 inches above the deck. The Safety Board also notes an inconsistency between the text of proposed § 178.340(c) and Figure 178.340(d)(1). The text specifies the following: With the appropriate heeling moment applied to the most adversely affected side of the vessel, the remaining exposed cross sectional area of the hull, without consideration of the cross-structure area on that side, must be equal or greater than-( l) The cross sectional area submerged due to the load shift (for an example, see Figure l78.340(d)(1); and, (2) One-quarter of the cross-sectional area on one hull. For consistency with the text, the Safety Board suggests revising the box in Figure 178.340(d)(1 ) to read, "With load in outboard positions (Position 2), Area A must be equal to or greater than Area B and at least 1/4 of the cross-section area of one pontoon." Finally, the NPRM proposes changing the title of § 178.340 from "Stability Standards for Pontoon Vessels on Protected Waters" to "Pontoon Simplified Stability Proof Test (PSST)." The Safety Board believes that this section should apply only to pontoon passenger vessels operating on protected waters, as specified in the existing regulation, and urges the Coast Guard to modify the section heading to read, "Pontoon Simplified Stability Proof Test (PSST)-Protected Waters." Policies and Procedures Pertaining to Weather Conditions Stability Criteria. As a result of its investigation of the Lady D accident, the Safety Board issued the following safety recommendation to the Coast Guard: M-06-7 Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. The Safety Board classified Safety Recommendation M-06-7 as "Open-Acceptable Response," pending the results of the Coast Guard's review of the subchapter S stability criteria and PSST procedures and its proposed corrective action. The Coast Guard's proposed rulemaking does not include a standard for pontoon vessel dynamic stability that, if met, might have prevented the Lady D capsizing. The Coast Guard has maintained that dynamic stability standards for pontoon passenger vessels are unnecessary because pontoon vessels have an acceptable accident record. The Lady D accident cannot be considered as part of an acceptable safety record, and the stability of pontoon vessels is not comparable to that of monohull vessels in bad weather. The Safety Board is unaware of any rigorous effort by the Coast Guard to analytically evaluate the dynamic stability ofpontoon vessels operating in wind and waves and is disappointed that the Coast Guard has not indicated actions in the NPRM that would meet the intent of Safety Recommendation M-06-7. Environmental Conditions. In response to the Lady D accident, the Coast Guard announced on April 26, 2006, voluntary interim measures for owners and operators of all small passenger vessels certificated for operation only on protected waters (71 Federal Register 24732). The voluntary measures included operating only in "reasonable operating conditions," defined as not including times when (1) a small craft advisory is in effect, (2) wind gusts are over 30 knots (35 mph), (3) waves exceed 2 feet, or (4) sustained winds are above 18 knots (21 mph). On November 2, 2006, the Coast Guard issued updated guidance (71 Federal Register 64546) that clarified the scope of voluntary measures published in April. The updated guidance defined "reasonable operating conditions" and addressed pontoon boats separately from other passenger vessels under 65 feet that operate on protected routes. Owners and operators of pontoon passenger vessels were advised to voluntarily operate in "reasonable operating conditions" that do not include wind gusts over 30 knots (35 mph), waves over 2 feet, sustained winds over 18 knots (21 mph), or conditions associated with a small craft advisory. Other small passenger vessels were advised to "give special consideration" to the reasonable operating conditions defined above. The updated guidance was consistent with the following safety recommendation, which the Safety Board issued to the Coast Guard after the capsizing of the Lady D: M-06-9 Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel's certificate of inspection. In its comments on the Federal Register notices, the Safety Board supported the language used in the notices and the guidance offered to operators of both pontoon passenger vessels and small passenger vessels under 65 feet. However, in the Safety Board's opinion, the revisions proposed in the NPRM at 46 CFR 185.304, "Navigation Underway," do not meet the intent of Safety Recommendation M-06-9. Section I85.304(a) specifies eight conditions that masters must pay "special attention" to while under way. Although the NPRM proposes changing condition 3 from "prevailing visibility and weather conditions" to "prevailing and forecasted visibility and environmental conditions, including wind and waves," it also would add paragraph (b) to the regulations, as follows: Masters of vessels not greater than 65 feet (19.8 meters) in length must have means available, satisfactory to the OeMI, to obtain or monitor the latest marine broadcast in order to comply with the requirements of paragraph (a) of this section. The Safety Board is disappointed that the Coast Guard has retreated from its earlier position to specify limits on environmental conditions, such as wind speed and wave height, in which pontoon passenger vessels may safely operate. The proposed rule would require the operator only to obtain the latest marine weather forecast and plan his voyages accordingly. That is nothing more than good marine practice. The Safety Board is particularly disappointed that the proposed regulations would continue to rely on the undefined phrase "reasonable operating conditions" on a pontoon vessel's certificate of inspection rather than providing definitive operational guidance to the vessel's operator. Strong winds and waves challenge pontoon vessels to a greater degree than they do monohull vessels. Without specific environmental limitations on a vessel's certificate of inspection, the operator may place passengers at unnecessary risk. Simply having access to a marine weather forecast, as was the case for the operator of the Lady D, would not significantly reduce the risk of capsizing in strong winds and waves. The recommendation to "establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel's certificate of inspection" was also made by the Coast Guard study team in its review of pontoon passenger vessel stability for vessels operating in conditions approaching Beaufort force 4 (1.5-foot wave heights, 29-knot wind gusts). The Safety Board believes that to assist pontoon boat operators in planning a voyage, the Coast Guard should provide guidance on weather conditions that may be hazardous, based on the stability characteristics of the boat. The Safety Board is disappointed that the Coast Guard has not indicated actions in the NPRM that would meet the intent of Safety Recommendation M-06-9. The Board urges the Coast Guard to reconsider its position in this matter and continues to believe that limiting environmental conditions should be explicitly listed on a pontoon vessel's certificate of inspection. Editorial Corrections • In proposed § l70.170(a)(2), the term f in the formula for P (ocean service) should be ft2, • In proposed § l78.330(b), in the formula for Mp, the term W, defined as the total test weight, should be in pounds (kilograms), not pounds (meters). • In proposed § l78.340(a), citing the applicability requirements of § l78.330(b) and (e) appears to be an error; those sections do not contain applicability requirements. Other Considerations As noted earlier, the Coast Guard conducted an impact study to determine the effect on the marine industry of increasing the standard allowance for passenger weight and size used to calculate the intact stability of domestic passenger vessels. As stated in the Coast Guard's announcement,10 the study was also intended to "identify the regulations potentially requiring change." The study was published in March 2007. The subject NPRM focuses on the effects of increased average passenger weight on vessel stability but does not address the effects of increased average passenger size. The impact study identified other areas in 46 CFR that would be affected by increased passenger weight and size-weight loads for structural design; passenger loading based on deck area or rail length; passenger seating widths; sizing of means of escape; window and aisle widths; spacing of seat fronts to seat fronts; buoyancy and strength calculations related to lifejackets, liferafts, and buoyant apparatus; and loading and seaworthiness of liferafts, life boats, and survival capsules. The NPRM does not indicate whether the Coast Guard plans further work related to the effects of increased passenger weight and size on regulations found in 46 CFR. The Safety Board appreciates this opportunity to comment on the Coast Guard's proposed rulemaking regarding passenger weight and vessel stability requirements. The Safety Board urges the Coast Guard, however, not to lose sight of other regulations that could be affected by increased passenger weight, girth, and height.

From: NTSB
To: USCG
Date: 1/22/2008
Response: On July 26, 2005, in reply to the Coast Guard’s April 7, 2005, response to Safety Recommendation M-04-4, which was superseded by Safety Recommendation M-06-5 in the final Lady D report, the Safety Board noted that the Coast Guard had chartered a work group to analyze the passenger weight issue and to assess the potential impacts of regulatory changes in pontoon boat stability calculations. The work group was tasked with reviewing background material and determining the potential impacts of changes to the regulations regarding passenger weight, simplified stability proof tests, and other small passenger vessel stability requirements. The work group completed its report on May 1, 2005, and the Coast Guard continues to review it to determine the best means to address the issues raised by the Lady D accident. On May 22, 2006, the Safety Board submitted comments to the docket for the Coast Guard’s announcement, Domestic Vessel Passenger Weights Voluntary Interim Measures, published in the Federal Register on April 26, 2006. The purpose of the notice was to advise owners and operators of small passenger vessels of prudent actions to take to address potentially unsafe operating conditions that had been identified by the Board in its Lady D investigative report. The Board notes that the Coast Guard evaluated various weight studies and found that, currently, 185 pounds appears to be the most accurate and appropriate average weight of occupants to use in evaluating small passenger vessel stability. We agree that increasing the weight value used in stability assessments is a prudent action and that the measures outlined in this document, if adopted by vessel owners and operators, will help safeguard passengers. The Board is aware that the Coast Guard intends to incorporate these measures into regulatory changes; we encourage you to complete this action expeditiously. As we indicated in our report and safety recommendation to the Coast Guard, the average passenger weight value used for vessel stability assessments should be periodically reviewed and updated as necessary to ensure its suitability. As the Coast Guard has taken interim action to address this issue, Safety Recommendation M-06-5 is classified OPEN -- ACCEPTABLE RESPONSE, pending completion of high-priority regulations to require that a realistic average passenger weight standard is used to determine vessel stability and passenger capacity.

From: USCG
To: NTSB
Date: 4/10/2007
Response: Letter Mail Controlled 4/18/2007 1:29:30 PM MC# 2070167: - From Brian M. Salerno, Rear Admiral, U.S. Coast Guard, Director of Inspections and Compliance: We concur with this recommendation. In a letter to the Board dated April 7, 2005, the Coast Guard agreed that the standard weight per person used in determining passenger vessel capacity needs to be updated to account for the increase in the average weight of Americans since 1960. Given the extended time necessary to revise related regulations, and in light of the rapidly approaching summer 2006 recreation/vacation season, the Coast Guard took interim actions responsive to the general recommendation stated at the March 6, 2006 NTSB meeting. Among these actions was the expedited publication, in an April 26, 2006 Federal Register notice (71 FR 24732), of voluntary interim measures, for use by owners and operators of certain domestic vessels, to account for increased passenger and vessel weight when determining the number of passengers permitted. In addition, we committed to a high priority rulemaking that will amend our regulations to address stability issues involving increases in passenger and vessel weight. A method to periodically update the average passenger weight standard will be considered in the upcoming rule. We will keep the Board informed of our progress on this recommendation.

From: NTSB
To: USCG
Date: 6/5/2006
Response: During the week of June 5, 2006, Jack Spencer, while at IMO FSI 14, discussed the dynamic analysis of the Lady D with Doug Rabe (USCG). Mr. Rabe advised that his staff believed that the computer program AQWA, used by the NTSB contractor, Alion Science & Technology, JJMA Maritime Sector, was inappropriate for this type of analysis. The USCG was considering questioning the NTSB findings. Mr. Spencer said that he believed the analysis was appropriate and the results were reasonable, and suggested that USCG and NTSB staff meet with the contractor to discuss the analysis before taking any positions in writing. Subsequently, Mr. Spencer contacted JJMA to discuss the program AQWA and to arrange a meeting. A meeting is tentatively scheduled for November 21, 2006.