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Safety Recommendation Details

Safety Recommendation M-11-019
Details
Synopsis: On Saturday, January 23, 2010, about 0935 central standard time, the 810-foot-long oil tankship Eagle Otome collided with the 597-foot-long general cargo vessel Gull Arrow at the Port of Port Arthur, Texas. A 297-foot-long barge, the Kirby 30406, which was being pushed by the towboat Dixie Vengeance, subsequently collided with the Eagle Otome. The tankship was inbound in the Sabine-Neches Canal with a load of crude oil en route to an ExxonMobil facility in Beaumont, Texas. Two pilots were on board, as called for by local waterway protocol. When the Eagle Otome approached the Port of Port Arthur, it experienced several unintended heading diversions culminating in the Eagle Otome striking the Gull Arrow, which was berthed at the port unloading cargo. A short distance upriver from the collision site, the Dixie Vengeance was outbound with two barges. The towboat master saw the Eagle Otome move toward his side of the canal, and he put his engines full astern but could not avoid the subsequent collision. The Kirby 30406, which was the forward barge pushed by the Dixie Vengeance, collided with the Eagle Otome and breached the tankship’s starboard ballast tank and the No. 1 center cargo tank a few feet above the waterline. As a result of the breach, 862,344 gallons of oil were released from the cargo tank, and an estimated 462,000 gallons of that amount spilled into the water. The three vessels remained together in the center of the canal while pollution response procedures were initiated. No crewmember on board any of the three vessels was injured. The National Transportation Safety Board (NTSB) determines that the probable cause of the collision of tankship Eagle Otome with cargo vessel Gull Arrow and the subsequent collision with the Dixie Vengeance tow was the failure of the first pilot, who had navigational control of the Eagle Otome, to correct the sheering motions that began as a result of the late initiation of a turn at a mild bend in the waterway. Contributing to the accident was the first pilot’s fatigue, caused by his untreated obstructive sleep apnea and his work schedule, which did not permit adequate sleep; his distraction from conducting a radio call, which the second pilot should have conducted in accordance with guidelines; and the lack of effective bridge resource management by both pilots. Also contributing was the lack of oversight by the Jefferson and Orange County Board of Pilot Commissioners.
Recommendation: TO 24 STATES, GUAM, AND THE COMMONWEALTH OF PUERTO RICO: Ensure that local pilot oversight organizations effectively monitor and, through their rules and regulations, oversee the practices of their pilots to promote and ensure the highest level of safety.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Marine
Location: Port Arthur, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10FM010
Accident Reports:
Collision of Tankship Eagle Otome with Cargo Vessel Gull Arrow and Subsequent Collision with the Dixie Vengeance Tow
Report #: MAR-11-04
Accident Date: 1/23/2010
Issue Date: 11/4/2011
Date Closed: 8/5/2016
Addressee(s) and Addressee Status: Commonwealth of Massachusetts (Closed - Unacceptable Action - No Response Received)
Commonwealth of Pennsylvania (Closed - Unacceptable Action - No Response Received)
Commonwealth of Puerto Rico (Closed - Reconsidered)
Commonwealth of Virginia (Closed - Reconsidered)
Humboldt Bay Harbor, Recreation and Conservation District (Closed - Reconsidered)
Port of Hueneme, Oxnard Harbor District (Closed - Reconsidered)
San Diego Bay Pilots Association, Inc. (Closed - Acceptable Action)
State of Alabama (Closed - Unacceptable Action - No Response Received)
State of Alaska (Closed - Acceptable Action)
State of California (Closed - Exceeds Recommended Action)
State of California, City of Long Beach, California, Harbor Department (Closed - Reconsidered)
State of California, City of Los Angeles, Harbor Department, Port Pilots (Closed - Acceptable Action)
State of Connecticut (Closed - Reconsidered)
State of Delaware (Closed - Unacceptable Action - No Response Received)
State of Florida (Closed - Unacceptable Action - No Response Received)
State of Georgia (Closed - Unacceptable Action - No Response Received)
State of Hawaii (Closed - Reconsidered)
State of Louisiana (Closed - Acceptable Action)
State of Maine (Closed - Reconsidered)
State of Maryland (Closed - Acceptable Action)
State of Mississippi (Closed - Unacceptable Action - No Response Received)
State of New Hampshire (Closed - Reconsidered)
State of New Jersey (Closed - Reconsidered)
State of New York (Closed - Reconsidered)
State of North Carolina (Closed - Unacceptable Action - No Response Received)
State of Oregon (Closed - Acceptable Action)
State of Rhode Island (Closed - Reconsidered)
State of South Carolina (Closed - Reconsidered)
State of Texas (Closed - Unacceptable Action - No Response Received)
State of Washington (Closed - Reconsidered)
Territory of Guam (Closed - Unacceptable Action - No Response Received)
Keyword(s):

Safety Recommendation History
From: NTSB
To: State of Alabama
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 4, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of Alabama has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 4, 2015, letters requesting information.

From: NTSB
To: State of Alabama
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Alabama’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Alabama’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Alabama
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Alabama’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Alaska
Date: 7/17/2012
Response: The NTSB notes that the State Marine Pilot Statutes, at AS 08.62, and the State Marine Pilot Regulations, at 12 AAC 56, establish the Board, which oversees the Alaska Marine Pilots, LLC (AMP), the Southeast Alaska Pilot Association (SEAPA), and the Southwest Alaska Pilot Association (SWAPA). We also note that the Board actively works to ensure high levels of pilotage safety on the navigable waters of Alaska. Accordingly, Safety Recommendation M-11-19 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Alaska
To: NTSB
Date: 1/31/2012
Response: -From Curtis W. Thayer, Chairman, Alaska Board of Marine Pilots, State of Alaska, Department of Commerce, Community and Economic Development, Alaska Board of Marine Pilots: National Transportation Safety Board Safety Recommendations M-1l-19 through M-1l-21 The Office of the Governor received a Safety Recommendation from the National Transportation Safety Board (NTSB) on November 4, 201 I requesting a response within 90 days addressing the actions the State of Alaska has taken to implement the subject NTSB Safety Recommendations. The recommendations are derived from the NTSB's investigation of the January 23, 2010 accident in which the tankship Eagle Glome collided with the general cargo vessel Gull Arrow at the Port of Port Arthur, Texas. The NTSB determined that the probable cause of the collision was pilot error, and that human fatigue was a contributing factor. The Marine Pilot Coordinator forwarded NTSB's Safety Recommendations to the three state-recognized pilot organizations along with the request that each organization provide response to these recommendations. The responses from three pilot organizations - Alaska Marine Pilots LLC (AMP), Southeast Alaska Pilot Association (SEAPA), and Southwest Alaska Pilot Association (SWAPA) indicate their full compliance with state and federal standards addressing competency, proficiency, fitness for duty, and continuing education. Each organization implements safety and fatigue-avoidance practices appropriate to its respective operational environment, manning, scheduling, and dispatching requirements. All three organizations are proactive advocates of Bridge Resource Management (BRM) concepts, and their respective training programs emphasize current BRM techniques. Each organization's address to the NTSB's Safety Recommendations is included with this response. In several instances our pilot organizations practice proactive fatigue-avoidance measures and BRM training that exceed the NTSB's recommendations. The NTSB advises that our response may be submitted electronically to the following email address: correspondence@ntsb.gov, reference Safety Recommendations M-l 1-19 through M-11-21. The suspense date for reply is February 4, 2012. I will promptly respond to any further questions or concerns through the Marine Pilot Coordinator. -From Captain Richard M. Gurry, President, Southeast Alaska Pilots Association: Before the State of Alaska and Federal Authorities began advocating additional training for Mariners SEAPA developed a comprehensive series of Training standards to qualify as a Marine Pilot in the South East region of Alaska, these have been reviewed and approved by the State of Alaska Board of Marine Pilots and are modeled after recommendations from the American Pilots Association. Additionally there are Continuing Education requirements to maintain a State license. These courses are designed to maintain competency and update the professional knowledge and skills needed to keep pace with changes in operating practices, technology, policy, rules and regulations and to promote pilot proficiency. All courses have been reviewed and recommended by the SEAPA Training Committee. They include Bridge Resource Management courses specifically designed for Pilots (BRM-P) that incorporate various scenarios of bridge procedures including interaction with bridge teams, working with a second pilot to assist the lead pilot while at the conn, VHF radio protocol, and fatigue models. Manned Models and Simulation courses are often separate and then incorporated into Bridge Resource Management. There are no age restrictions to holding a Piloting License but the medical requirements have become increasingly stringent. There is the bi-annual State of Alaska medical exam. The USCG has its own set of requirements for maintaining a federal license, including ARPA and Radar training. In addition the USCG requires a Pilot to submit an annual medical exam which must be cleared by the USCG certificate. SEAPA was the first Association in Alaska to implement physical agility standards which all member pilots (with one exception) and all new SEAPA trainees have attended at the pre-employment and biannual work test Healthforce clinic located in Seattle Washington. SEAPA also use Healthforce when a pilot returns from an extended injury prior to returning to dispatch. SEAPA forwards all documentation to the State Marine Pilot Coordinator while at the same time keeping each Pilots documentation on file in the SEAPA offices where they are reviewed by the Training Chair and/or Officers of the Association to insure all State and Federal requirements are current and up to date. Reviews are done in advance and reminder notices are sent to any Pilots that may be coming upon a deadline for meeting a State or Federal requirement. Furthermore the Association proactively monitors the practices of pilots by, a) Conducting internal investigations. See Article X SEAPA ByLaws. b) Receiving complaints against members in writing by Masters or Companies. c) Forwarding to the MPC / BMP with a copy to the member charged any complaint of misconduct or incompetence. d) Dispatching of Pilots, to promote Opportunity to broaden local knowledge of pilots. e) Require Marine Pilot Continuing Education to maintain competency and update professional knowledge and skills to keep pace with changes in operating practices, technology, policy, rules and regulations and to promote pilot proficiency. -From Captain Michael D. Stone, President, Southwest Alaska Pilots Association: This letter is in response to your correspondence dated November 30th and the request for information following the NTSB Safety Recommendation regarding the Sabine-Neches Canal multi-vessel collision on January 23, 2010. Please be advised that SWAPA complies with State regulations and pilots attend risk assessment and advanced simulator training with industry members, which is in addition to current regulations. We would also like to specifically address the NTSB recommendations as follows: Recommendations M-1l-19 and M-1l-20 As the Board is aware, SWAPA has implemented a "Return to Work Policy" which every pilot, deputy pilot, trainee and observer is required to participate in and adhere to at all times. This policy promotes and ensures the highest level of safety and states: A person required to participate in the Policy MUST notify the Dispatch office, in a timely manner, if they become aware of; • "physical or mental limitations that would hinder or prevent performance of duties' • "any medical or physical condition which will prohibit, obstruct, or negatively effect the full performance of their duty and be free from any medical conditions that pose a risk of sudden incapacitation which would affect transferring to and from and operating or working on vessels. " (State of Alaska MAR Form 08-4560 [rev 09/28/10]). Once notification has been given, the person shall, accordingly, be considered ineligible for dispatch or training until they are able to perform their duties as prescribed by law. The policy promotes and ensures the highest level of safety by confirming that a pilot, as an independent contractor, is confirming that it is his/her responsibility to inform the Dispatch office of any physical or mental limitations or medical or physical conditions that thereby make them ineligible for dispatch or training. Physical, mental and medical can obviously cover limitations or conditions such as stress or fatigue if such condition "would hinder or prevent performance of duties" or "will prohibit, obstruct, or negatively affect the full performance of their duty". As the American Pilots' Association clearly states, marine pilots have been aware of fatigue and ways to mitigate it for many years and "during their multi-year progression from trainees to full branch pilots, learn how to sleep efficiently, how to maximize sleep benefits and when to sleep during a pilot rotation to ensure they are fully prepared for their assignments". As an example, a pilot may ask for a room to be made available on a ship prior to sailing if his dispatched flight time will allow for extra rest before the vessel's departure especially if the transit is expected to be long or conditions are challenging. In addition to this ongoing "Return to Work" policy, pilots are required to submit to USCG physicals on an annual basis and the State of Alaska additionally requires its' own physical exams every two years. The Board, for good cause, may also submit a pilot to a physical or mental exam in addition to the biennial requirement. SWAPA works closely with its' customers to ensure best safety practices and SWAPA pilots also adhere to 12 AAC 56.963 (hours of duty). The following are a few examples of how we implement these practices; Vessels transiting from Homer to Anchorage generally require two pilots due to transit time and always require two pilots when ice rules are in effect. We also carefully monitor conditions, time of day and ship particulars when determining if any vessel transit will require two pilots. For jobs in excess of twelve hours, two pilots are required and if there is a question on the length of a job, two pilots may be assigned. On "two pilot" jobs, only one pilot is required on watch at a time and the other pilot is below resting. Traditionally work assignments are six hours on watch and six hours of rest. Another example of a "two pilot" job is when ice rules are implemented in Cook Inlet. Tankers going to KPL or Drift River are required to have two pilots up-bound and two pilots on standby at the dock whilst the ship is alongside. During the summer cruise season, SWAPA has recently implemented pre-dispatching to ensure effective and best use of our manpower allowing for less travel time for pilots and better preparedness where possible. Generally, vessels cruising Prince William Sound will be a two pilot job, depending on vessel itinerary and accordingly, "on duty" times are carefully monitored. The "Eagle Otome" required two pilots working together; in the South Central region we require two pilots on specific jobs, as described above, to ensure that one rested pilot is available throughout the voyage. SWAPA pilots, as independent contractors, will prepare for each dispatch on a case by case basis taking into account all factors involved, including, but not limited to weather conditions, type of vessel, time of day, length of transit etc. If a pilot assigned to a job determines that the job requires a second pilot, he may request that an additional pilot is dispatched. -From Captain Carter Whalen, President, Alaska Marine Pilots, LLC: Alaska Marine Pilots, LLC has adopted in-House training measures well beyond those required by the state. An example of a proactive measure is our containership training guidelines for pilots already licensed by the state, to undergo a prescribed number of observations and hands on supervised dockings and undockings aboard Horizon D-7, Maersk and APL C-11 Class containerships. This container ship training may take upwards of two years to complete depending on scheduling, and this training is beyond any state requirement. AMP implemented this strict standard of training due to the extreme winds and difficult nature of handling these large box ships in and around Dutch Harbor. Attached to this letter is a copy of our In-house container ship training requirements.

From: NTSB
To: State of California
Date: 1/12/2016
Response: We classified Safety Recommendation M-11-19 “Open?Acceptable Response” on July 19, 2012, pending completion of the BOPC’s review of California’s statutes and regulations to verify whether they complied with our recommendation. We are pleased to learn that the BOPC completed its review of the state pilot regulations in Title 7, California Code of Regulations, beginning in section 201, and that, following our issuance of the Eagle Otome accident investigation report, in 2012 the state legislature added the following authority for BOPC oversight of pilot fatigue: “the enhancement of navigational safety is of the utmost concern in state pilotage,” and, “in order to ensure and promote the highest level of safety in pilotage, the [B]oard is empowered to effectively monitor and oversee the practices of pilots and prevent fatigue resulting from extended hours of service, insufficient rest within a 24-hour period, and disruption of circadian rhythms.” We are pleased California thoroughly reviewed its pilot oversight regulations and authorized the BOCA to monitor pilot practices to prevent fatigue resulting from extended hours of service, insufficient rest within a 24-hour period, and disruption of circadian rhythms. Accordingly, Safety Recommendation M-11-19 is classified CLOSED—EXCEEDS RECOMMENDED ACTION.

From: State of California
To: NTSB
Date: 11/25/2015
Response: -From Allen Garfinkle, Executive Director, Board of Pilot Commissioners for the Bays of San Francisco, San Pablo, and Suisun: This report is issued by the Board of Pilot Commissioners for the Bays of San Francisco, San Pablo, and Suisun (BOPC or Board) in response to a recommendation by the National Transportation Safety Board (NTSB). On November 4, 2011, as a result of the investigation into the January 23, 2010, incident involving the tankship EAGLE OTOME, the NTSB issued Safety Recommendations to the governors of twenty four states and territories in which state and local pilots operate, detailing three recommendations concerned with preventing similar incidents from occurring. On behalf of Governor Brown, Traci Stevens, Acting Secretary of California’s Business, Transportation, and Housing Agency, responded to the three recommendations in some detail on January 12, 2012, closing with, “While it is our assessment that existing statutory, regulatory, and BOPC oversight of the San Francisco Bar Pilots appears to satisfy concerns reflected in the NTSB Safety Recommendation, we will refer the NTSB letter to the BOPC for further review and consideration in light of its established expertise in bar pilot practices.” In consideration of the response from Acting Secretary Stevens on behalf of the Governor, Chairman Hersman responded by closing all recommendations but one, M-11-19, which reads “Ensure that local pilot oversight organizations effectively monitor and, through their rules and regulations, oversee the practices of their pilots to promote and ensure the highest level of safety.” In her decision to not close this recommendation, Chairman Hersman interpreted California’s response to mean that, following review, a report would be issued by the BOPC, and stated that “Although the NTSB is aware that the State of California has comprehensive pilot statutes and regulations, because the BOPC is conducting a review and will be providing confirmation that the statutes and regulations adequately address this issue, Safety Recommendation M-11-19 is classified ‘Open – Acceptable Response’ pending our receipt and review of the BOPC’s report.” On July 19, 2012, the NTSB classified the response from Acting Secretary Stevens as “Open – Acceptable Response” pending completion of the BOPC review of California’s statutes and regulations to verify whether they complied with the NTSB recommendation. The following report is in response to NTSB’s Safety Recommendation M-11-19 and details the comprehensive body of statutes and regulations that are in place to monitor and oversee the practices of pilots within the Board’s jurisdiction, thus promoting and ensuring the highest level of safety. In areas that the state and the Board have identified needing potential improvement, we have detailed those efforts. In summary, to monitor and oversee the practices of the pilots it licenses to promote and ensure safety, the Board does the following: •?The Board employs rigorous standards for the testing and selection of trainees. •?The Board requires that trainees complete a one-to-three-year training program that includes a large number of shiphandling assignments involving various vessel types under a variety of conditions under the supervision of a licensed pilot. •?The Board will deny an application for annual license renewal if the pilot applying for license renewal has not actively piloted vessels for any consecutive period of one year. •?The Board requires pilots to complete periodic continuing education courses. •?The Board requires that pilots and trainees submit to an annual medical assessment and that pilots be evaluated for fitness at more frequent intervals at the instance of either the pilot, physician or the Board, as prescribed in regulation. •?The Board requires toxicological tests at least annually that test for prescription drugs in addition to the dangerous drugs that are included in federal toxicological tests. •?The Board’s Incident Review Committee investigates and makes recommendation to the Board concerning each incident that involves a possible cause for discipline against a pilot’s license, from suspension or revocation down to lesser measures, such as letters of reprimand or special training. •?By direction from the Legislature, the Board is undertaking a study of pilot fatigue, which will lead to regulations governing hours of work and rest for pilots. •?In response to the NTSB report on the allision of the OVERSEAS REYMAR with the Bay Bridge, the Board has undertaken developing a process to evaluate pilots while underway and additional training in navigating in low-visibility in restricted waters. •?By direction of the Legislature, the Board has instituted a “pull-notice” system whereby it is advised by the state Department of Motor Vehicles of violations by pilots of traffic laws, including driving under the influence.

From: NTSB
To: State of California
Date: 5/1/2015
Response: On July 19, 2012, we classified Safety Recommendation M-11-19 “Open?Acceptable Response” pending completion of the Board of Pilot Commissioners’ (BOPC) review of California’s statutes and regulations to verify whether they complied with our recommendation. To date, however, we have received no update from California regarding the outcome of the BOPC’s review. As we normally expect actions to address safety recommendations to be completed within 5 years of a recommendation’s issuance, we would appreciate receiving a prompt reply regarding any actions that you have either taken or planned to address this important safety issue. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendation M-11-19; California’s January 12, 2012, response; and our June 19, 2012, reply are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of California
Date: 6/19/2012
Response: Thank you for the January 12, 2012, letter signed by Ms. Traci Stevens, Acting Secretary, California Business, Transportation and Housing Agency (the State), regarding action taken to implement Safety Recommendations M-11-19 through -21, stated below. The National Transportation Safety Board (NTSB) issued these recommendations to the state of California on November 4, 2011, as a result of our investigation of the January 23, 2010, accident in which the tankship Eagle Otome collided with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. We understand that the Port of San Francisco, the only port over which the state exercises regulatory authority, operates in the bays of San Francisco, San Pablo, Suisun, Monterey, and the tributaries to Sacramento and Stockton. The licensing program for the bays of San Francisco, San Pablo, and Suisun is administered by the Board of Pilot Commissioners (BOPC), a body that is organized under the state’s Business, Transportation, and Housing Agency. Thank you for clarifying that the state of California does not exercise regulatory authority over Humboldt Bay, Port Hueneme, Port of Los Angeles, Port of Long Beach, or the Port of San Diego. We appreciate your forwarding these recommendations to the local jurisdictions having regulatory authority so that all California pilot authorities can be evaluated. Since receiving your letter, the NTSB has officially reassigned the recommendations to each of these entities for direct action. Although the NTSB is aware that the State of California has comprehensive pilot statutes and regulations, because the BOPC is conducting a review and will be providing confirmation that the statutes and regulations adequately address this issue, Safety Recommendation M-11-19 is classified OPEN—ACCEPTABLE RESPONSE, pending our receipt and review of the BOPC’s report.

From: NTSB
To: State of California
Date: 2/29/2012
Response: Correspondence control 201200131 was closed administratively, no response letter from the NTSB was ever sent using this correspondence control number.

From: State of California
To: NTSB
Date: 2/8/2012
Response: -From Pete Wallace, Deputy Executive Director, Maritime Services, Port of Hueneme, Oxnard Harbor District: The Oxnard Harbor District, Harbor Safety Committee is in receipt of a correspondence from the office of the Governor of California the honorable Edmund G. Brown Jr., to which is included the recommendations from the NTSB as referenced above. The letter and recommendations have been shared with the Port Pilots Advisory Committee and they are taking them under advisement. Thank you for your time and consideration in this important matter. -From Traci Stevens, Acting Secretary, Business, Transportation, and Housing Agency, State of California: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation issued on November 4, 2011, directed to governors of states and territories in which state and local pilots operate, including California Governor Edmund G. Brown Jr. We have been directed to forward the NTSB Safety Recommendation to your organization on the Governor's behalf. The NTSB recommends that the Governor require al110cal pilot oversight organizations to implement several NTSB Safety Recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enhance the safety of their waterways. However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of the State Government. Because Maritime Services pilotage ground and pilots are not under the direct oversight and control of the Governor, we are referring the NTSB Safety Recommendation to your oversight organization for review and consideration and to respond to the NTSB directly.

From: State of California
To: NTSB
Date: 1/12/2012
Response: -From Traci Stevens, Acting Secretary, Business, Transportation, and Housing Agency, State of California: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation, relative to recommendations M-II-19, M-1l-20, and M-11-21, issued on November 4, 2011, directed to the governors of states and territories in which state and local pilots operate, including Edmund G. Brown Jr., Governor of the State of California. We have been directed to respond on the Governor's behalf. The NTSB recommends that the Governor require all local pilot oversight organizations in California to implement the subject NTSB recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enhance the safety of their waterways. However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of State Government. The local pilot oversight organizations in California not under the direct oversight and control of the Governor are the following: • Humboldt Bay. Pilots are licensed by the Humboldt Bay Harbor, Recreation and Conservation District, a local government entity. • Port Hueneme. Pilots are member of the Port Hueneme Pilots Association and are under the oversight authority of the Oxnard Harbor District, a local government entity. • Port of Los Angeles. Pilots are employees of the Harbor Department of the City of Los Angeles, a city government entity. • Port of Long Beach. Pilots are employees of the Jacobsen Pilotage Service, Inc., and are under the oversight of the Port of Long Beach, a local government entity. • Port of San Diego. Pilots are members of the San Diego Bay Pilots Association, Inc., and are under the oversight of the Port of San Diego, a local government entity. With respect to these local pilot oversight organizations, we have been directed to forward the NTSB Safety Recommendation for their respective review and consideration and to respond to the NTSB directly. Please see the enclosed copies of letters issued by this office to those entities. In California, there is only one pilot group, the San Francisco Bar Pilots operating in the Bays of San Francisco, San Pablo, Suisun, Monterey, and the tributaries to Sacramento and Stocktonthat is regulated by the State. Their licensing program is administered by a policy-making multimember body, the Board of Pilot Commissioners, for the Bays of San Francisco, San Pablo, and Suisun (BOPC). The BOPC is organized under the Business, Transportation, and Housing Agency. Accordingly, the NTSB Safety Recommendation will be referred to the BOPC for its review and consideration. However, as explained below, we believe that the BOPC and the San Francisco Bar Pilots already meet the safety objectives of the recent NTSB Safety Recommendation. NTSB Safety Recommendation M-11-19 This recommendation calls for ensuring that pilot oversight organizations effectively monitor and, through their rules and regulations, oversee the practices of their pilots to promote and ensure the highest level of safety. In that regard the legislative intent expressed in the pilot statutes for San Francisco Bar Pilots emphasizes safe pilotage of vessels by ensuring qualifications, fitness, personal safety, well-being, and reliability of qualified personnel, as well as safety of the environment of the waterways. (See, generally, California Harbors and Navigation Code sections 1100 and 1101.) Accordingly, several provisions in the governing statutes focus on safety from the perspective ()f qualifications, training, fitness, and license discipline. These provisions are implemented through an extensive body of regulations promulgated by the BOPC governing pilot conduct. (See Title 7, California Code of Regulations sections 201 et seq.) These regulations are enforced along with corresponding oversight activities by the BOPC. The statutory authorities and regulations cover a wide range of subjects relating to pilot practices. Moreover, the BOPC maintains oversight of those subjects through proactive interaction with the San Francisco Bar Pilots. Operational details are reported to the BOPC on a monthly basis and members of the board can initiate further inquiries at any time. Suggestions for improvements by BOPC board members are always considered by the pilots. Having an extensive array of statutes, regulations, and oversight related to pilotage safety, the San Francisco Bar Pilots are subject to effective and sufficient oversight by the BOPC. Letter from Traci Stevens, Acting Secretary, State of California, Business, Transportation, and Housing Agency to the Board of Pilot Commissioners of San Francisco, California: Enclosed you will find the Safety Recommendation of the National Transportation Safety Board (NTSB) dated November 4,2011, sent to the governors of twenty-four states and the territories of Guam and Puerto Rico, including California Governor Edmund G. Brown Jr., urging the governors to ensure and require that local pilot oversight organizations implement several safety recommendations relating to safety, fatigue, and bridge resource management. Also enclosed is our response to the NTSB on behalf of the Governor's Office dated January 11, 2012, summarizing our assessment that existing laws, regulations, and Board of Pilot Commissioners (Board) oversight of the San Francisco Bar Pilots appear to satisfy the safety concerns reflected in the Safety Recommendation. Please note that our response informs the NTSB that we intend to refer the Safety Recommendation to the Board for further review and consideration. It is our intention in making this referral that the Board carefully asses the array of NTSB safety recommendations for purposes of implementing any adjustments, amendments, or modification the Board deems necessary and appropriate in light of its expertise in the area of bar pilot practices. Letter from Traci Stevens, Acting Secretary, State of California, Business, Transportation, and Housing Agency to the Humboldt Bay Harbor Recreation and Conservation District, Eureka, California: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation issued on November 4, 2011, directed to governors of states and territories in which state and local pilots operate, including California Governor Edmund G. Brown Jr. We have been directed to forward the NTSB Safety Recommendation to your organization on the Governor's behalf. The NTSB recommends that the Governor require all local pilot oversight organizations to implement several NTSB Safety Recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enh8l1Ce the safety of their waterways. However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of the State Government. Because the Humboldt Bay pilotage ground and pilots are not under the direct oversight and control of the Governor, we are referring the NTSB Safety Recommendation to your oversight organization for review and consideration and to respond to the NTSB directly. Letter from Traci Stevens, Acting Secretary, State of California, Business, Transportation, and Housing Agency to the Port of Hueneme/ Oxnard Harbor District, Port Hueneme, California: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation issued on November 4, 2011, directed to governors of states and territories in which state and local pilots operate, including California Governor Edmund G. Bro\1,,'11 Jr. We have been directed to forward the NTSB Safety Recommendation to your organization on the Governor's behalf. The NTSB recommends that the Governor require all local pilot oversight organizations to implement several NTSB Safety Recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enhance the safety of their waterways, However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of the State Government. Because Maritime Services pilota.ge ground and pilots are not under the direct oversight and control of the Governor, we are referring the NTSB Safety Recommendation to your oversight organization for review and consideration and to respond to the NTSB directly. Letter from Traci Stevens, Acting Secretary, State of California, Business, Transportation, and Housing Agency to the Port of Long Beach, Long Beach, California: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation issued on November 4, 20 11, directed to governors of states and territories in which state and local pilots operate, including California Governor Edmund G. Brown .Ir. We have been directed to forward the NTSB Safety Recommendation to your organization on the Governor's behalf. The NTSB recommends that the Governor require all local pilot oversight organizations to implement several NTSB Safety Recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enhance the safety of their waterways. However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of the State Government. Because the Port of Long Beach pilotage ground and pilots are not under the direct oversight and control of the Governor, we are referring the NTSB Safety Recommendation to your oversight organization for review and consideration and to respond to the NTSB directly. Letter from Traci Stevens, Acting Secretary, State of California, Business, Transportation, and Housing Agency to the Port of Los Angles, San Pedro, California: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation issued on November 4,20 J 1. directed to governors of states and territories in which state and local pilots operate, including California Governor Edmund G. Brown, Jr. We have been directed to forward the NTSB Safety Recommendation to your organization on the Governor's behalf. The NTSB recommends that the Governor require all local pilot oversight organizations to implement several NTSB Safety Recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enhance the safety of their waterways. However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of the State Government. Because the Port of Los Angles pilotage ground and pilots are not under the direct oversight and control of the Governor, we are referring the NTSB Safety Recommendation to your oversight organization for review and consideration and to respond to the NTSB directly. Letter from Traci Stevens, Acting Secretary, State of California, Business, Transportation, and Housing Agency to the Port of San Diego: We are responding to the National Transportation Safety Board (NTSB) Safety Recommendation issued on November 4,2011, directed to governors of states and territories in which state and local pilots operate, including California Governor Edmund G. Brown Jr. We have been directed to forward the NTSB Safety Recommendation to your organization on the Governor's behalf. The NTSB recommends that the Governor require all local pilot oversight organizations to implement several NTSB Safety Recommendations. The request appears to rest on the premise that all local pilot oversight organizations are under the authority of the Governor who may require them to fully regulate practices that enhance the safety of their waterways. However, in the State of California, local pilot oversight entities are not under the control and direction of the Executive Branch of the State Government. Because the Port of San Diego pilotage ground and pilots are not under the direct oversight and control of the Governor, we are referring the NTSB Safety Recommendation to your oversight organization for review and consideration and to respond to the NTSB directly.

From: NTSB
To: State of Connecticut
Date: 5/26/2016
Response: We understand that, through the Connecticut Department of Transportation (the department), the Connecticut Pilot Commission is the state regulatory oversight organization that, in cooperation with the Connecticut state pilots, monitors and enforces Connecticut Regulations Navigable Waters-Marine Pilots Section 15-15a-1-17. The department ensures the highest level of safety by requiring all pilots to possess a federal master’s license, and a federal first class license of unlimited tonnage issued by the US Coast Guard covering the navigable waters of Connecticut to obtain a Connecticut license. Because these regulations were in place prior to our issuing Safety Recommendation M 11-19, it is classified CLOSED—RECONSIDERED.

From: State of Connecticut
To: NTSB
Date: 2/11/2016
Response: -From James Redeker, Commissioner, State of Connecticut, Department of Transportation: The Department, which is the state regulatory oversight organization in cooperation with the Connecticut State Pilots (CSP), monitors and enforces Connecticut Regulations; Navigable Waters-Marine Pilots Section 15-15a-1-17. The Department ensures the highest level of safety by requiring pilots to possess a federal master's license, and a federal first class license of unlimited tonnage issued by the U.S. Coast Guard covering the navigable waters of Connecticut as a basis for a Connecticut license. CSP work rules enforce a one way traffic scheme during harbor transits. No meeting, passing or overtaking of any vessel in the channel is conducted. Pilot work rules require additional Under Keel Clearance (UKC) above the two foot UKC requirement mandated by Connecticut. Lastly, harbor transits do not occur during extreme weather conditions or reduced visibility.

From: NTSB
To: State of Connecticut
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Connecticut’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Connecticut’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Connecticut
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Connecticut’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Delaware
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 5, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of Delaware has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 5, 2015, letters requesting information.

From: NTSB
To: State of Delaware
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Delaware’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Delaware’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Delaware
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Delaware’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Florida
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 5, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of Florida has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 5, 2015, letters requesting information.

From: NTSB
To: State of Florida
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Florida’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Florida’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Florida
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Florida’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Georgia
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 5, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of Georgia has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 5, 2015, letters requesting information.

From: NTSB
To: State of Georgia
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Georgia’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Georgia’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Georgia
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Georgia’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Hawaii
Date: 8/13/2013
Response: Because the state of Hawaii has a program (Hawaii Revised Statutes §462A-3) through which the DCCA provides safety oversight of the Hawaii Pilot’s Association (HPA), and because the program has been in effect since before the issuance of Safety Recommendation M-11-19, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Hawaii
To: NTSB
Date: 6/14/2013
Response: -From Keali’I S. Lopez, Director Department of Commerce and Consumer Affairs, State of Hawaii: The Department of Commerce and Consumer Affairs (DCCA), State of Hawaii, is charged with licensing and oversight of port pilots in Hawaii (§462A-3, Hawaii Revised Statutes). §462A-15 allows for the formation of a pilot's association and the adoption of any working rules that are not inconsistent with the laws or of the rules of DCCA. The Hawaii Pilot's Association (HPA) was formed to provide arrangements and facilities as may be necessary and desirable for the efficient dispatching of vessels and rendering pilot services. The HPA is required to notify DCCA if a vessel under the direction of a port pilot is involved in any incident of significance, such as a collision, oil spillage or harbor pollution. In addition, the pilot must inform DCCA within seven working days if the incident or collision involved injury, death, extensive damages, or running aground. These procedures have been followed after each incident.

From: NTSB
To: State of Hawaii
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Hawaii’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Louisiana
Date: 9/16/2015
Response:

From: State of Louisiana
To: NTSB
Date: 8/7/2015
Response:

From: NTSB
To: State of Louisiana
Date: 8/22/2012
Response: Closed administrativel, no letter was ever sent using CC# 201200440.

From: NTSB
To: State of Louisiana
Date: 7/17/2012
Response: The NTSB has found from a review of Louisiana’s statutes and website that the state’s marine pilots are regulated by the Louisiana Revised Statutes R.S. 34:991, et seq. These statutes establish the Board as the principal oversight authority, address the safety of pilotage on the Mississippi and Calcasieu Rivers in Louisiana, and provide for disciplinary action as necessary. The statutes and the authority and actions of the Board satisfy the recommendation. Accordingly, Safety Recommendation M-11-19 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Louisiana
To: NTSB
Date: 5/8/2012
Response: -From Captain Craig Andrews, President, Board of River Port Pilot Commissioners, Port of New Orleans, State of Louisiana: By letter dated November 11,2011 the NTSB issued recommendations to the Governor of Louisiana as well as other the Governors of other States and Territories. The recommendations are in response to a collision and release of pollution on the Sabine-Neches Canal on January 23, 2010. The incident involved a state commissioned pilots in service on the EAGLE OTOME. The NTSB asked the States to review it pilotage regulations as follows: Effectively Monitor Regulations Professional Education in the Form of BRM-P Fatigue Management Medical Monitoring The Board of River Port Pilot Commissioners regulate river port pilots operating on the Mississippi River. The Board pursuant to statute enact regulations for safe pilotage. The Board's current regulations are published in the Louisiana Administrative Code. The Board actively regulates pilots. It formulates regulations for safe pilotage, investigates incidents, directs the apprenticeship program, evaluates pilots and apprentices, receives and monitors the pilot's annual physicals, and directs the mandatory professional education. The Board monitors the pilot's work rotation. The pilot's work rotation allows for rest between jobs. Pilots are allowed to withdraw from the rotation for any reason and are allowed relief for jobs extending over a period of time. The NTSB report recommended the need for restorative rest following consistent interruptions of the normal sleep pattern. The Board will initiate a review of the pilot work rotation and determine whether this concern is addressed. Feel free to contact me if you need any additional information.

From: State of Louisiana
To: NTSB
Date: 5/8/2012
Response: -From Captain Craig Andrews, President, Board of River Port Pilot Commissioners, Port of New Orleans, State of Louisiana: By letter dated November 11,2011 the NTSB issued recommendations to the Governor of Louisiana as well as other the Governors of other States and Territories. The recommendations are in response to a collision and release of pollution on the Sabine-Neches Canal on January 23, 2010. The incident involved a state commissioned pilots in service on the EAGLE OTOME. The NTSB asked the States to review it pilotage regulations as follows: Effectively Monitor Regulations Professional Education in the Form of BRM-P Fatigue Management Medical Monitoring The Board of River Port Pilot Commissioners regulate river port pilots operating on the Mississippi River. The Board pursuant to statute enact regulations for safe pilotage. The Board's current regulations are published in the Louisiana Administrative Code. The Board actively regulates pilots. It formulates regulations for safe pilotage, investigates incidents, directs the apprenticeship program, evaluates pilots and apprentices, receives and monitors the pilot's annual physicals, and directs the mandatory professional education. The Board monitors the pilot's work rotation. The pilot's work rotation allows for rest between jobs. Pilots are allowed to withdraw from the rotation for any reason and are allowed relief for jobs extending over a period of time. The NTSB report recommended the need for restorative rest following consistent interruptions of the normal sleep pattern. The Board will initiate a review of the pilot work rotation and determine whether this concern is addressed. Feel free to contact me if you need any additional information.

From: NTSB
To: State of Maine
Date: 11/7/2013
Response: We understand that the Maine State Pilot Commission, directed by Title 38 Maine Revised Statute, Annotated, licenses 14 pilots and oversees their performance through regular Commission planning and oversight meetings and maintains strong violation enforcement authority, which includes license suspension and revocation provisions. In addition, the Commission exercises a robust investigatory and disciplinary system to analyze safety issues and accidents. Because Maine’s comprehensive safety oversight program was in effect before we issued Safety Recommendation M-11-19, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Maine
To: NTSB
Date: 8/19/2013
Response: -From John H. Henshaw, Director of Ports and Marine Transportation, State of Maine, Department of Transportation: As a state licensing authority, the Maine State Pilot Commission is guided by state law in its functions, responsibilities, and duties. The Commission, as directed by Maine Revised Statute, Annotated (MRSAL licenses 14 pilots and oversees their performance through regular commission planning and oversight meetings. Title 38 of the M RSA provides for a robust investigatory and disciplinary system to analyze safety issues and accidents. Further, the Commission also maintains strong violation enforcement authority which includes license suspension and revocation provisions.

From: NTSB
To: State of Maine
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Maine’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Maryland
Date: 10/16/2012
Response:

From: NTSB
To: State of Maryland
Date: 7/17/2012
Response: The NTSB notes that the Maryland General Assembly delegated to the State Board of Pilots (the Board) responsibility for safety in providing pilotage on the navigable waters of the state of Maryland through its licensing function, as specified in the Code of Maryland Regulations 09.26. The nine-member Board, which oversees the safety of pilotage in Maryland, includes the president of the Association of Maryland Pilots, two representatives of the steamship industry who actively employ pilots, one representative of the ship-docking tugboat industry in the Port of Baltimore, a consumer member, three licensed pilots with at least 5 years’ experience providing pilotage, and a designated member of the DLLR. The provisions and practices described in your letter satisfy Safety Recommendation M-11-19, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of Maryland
To: NTSB
Date: 7/3/2012
Response: -From Scott Jensen, Interim Secretary, State of Maryland, Department of Labor, Licensing, and Regulation: In February of this year, former Secretary Alexander M. Sanchez wrote to you regarding the above cited Safety Recommendations (copy enclosed). At that time, former Secretary Sanchez advised you that the Work Rules Committee of the State Board of Pilots would conduct a review of the Maryland Association of Pilots Work Rules, focusing particularly on the issues of rotation and fatigue. The Committee was also asked to discuss with the leadership of the Association the educational materials that are provided to the members on the issues of rest and fatigue. The Committee has conducted a complete review of the Work Rules, with particular attention being paid to Work Rules dealing with rotation, fatigue, and safety. Following this review, the Committee made certain recommendations to the Association concerning proposed amendments that the Committee believed would clarify the meaning and application of the Work Rules to the members of the Association, to ensure their understanding of the Rules, particularly those addressing rotation and fatigue. The Association has now adopted those amendments; a copy of the updated Work Rules, with the amendments highlighted, was distributed to the Board members at their June 8th meeting. . The Work Rules Committee also discussed with the Association's leadership the educational program and materials provided to pilots that deal with rest and fatigue. As former Secretary Sanchez advised you in his letter, the Board adopted a regulation in 1997 that requires every licensed pilot (Le., every member of the Association) to take a continuing education course in Bridge Resource Management every five years. The course, given at the Maritime Institute of Technology and Graduate Studies, provides instruction and course material dealing with fatigue issues, including IMO guidelines relating to the basic concepts, causes~ and effects of fatigue, and specific guidelines dealing with fatigue and the maritime pilot, as well as suggestions as to how a maritime pilot can manage and avoid fatigue. All pilots-in-training must successfully complete this course during the second year of their two-year training period. After conducting the review of the Work Rules, and confirming that the suggested changes had been made, and after meeting with the Association's leadership regarding the educational programs, the Work Rules Committee concluded that the Association Work Rules and the educational programs required for both licensed pilots and pilots-in-training appropriately address the issues of rotation and fatigue, and otherwise promote the safe operation of vessels by Maryland pilots. The Committee provided this report to the Board at the June 8th meeting, and the report was reviewed and accepted by the Board.

From: State of Maryland
To: NTSB
Date: 2/21/2012
Response: -From Alexander M. Sanchez, Secretary: Department of Labor, Licensing, and Regulation, State of Maryland: Thank you for your letter to Governor Martin O'Malley regarding the Safety Recommendations of the National Transportation Safety Board. The Governor received your letter and asked that I respond on his behalf. As Secretary of the Maryland Department of Labor, Licensing and Regulation, I have jurisdiction over the State Board of Pilots. The Governor and I are deeply committed to ensuring that the pilotage provided by Maryland licensed pilots is executed with the highest standard of care. The State Board of Pilots consists of nine members, all appointed by the Governor, with the exception of the President of the Association of Maryland Pilots who is an ex officio member. The remaining eight members are as follows: two representatives of the steamship industry who actively employ pilots, one representative of the ship docking tugboat industry in the Port of Baltimore, a consumer member, three licensed pilots with at least five years' experience providing pilotage, and my designee. The General Assembly has given the Board the responsibility for safety in providing pilotage on the navigable waters of the State of Maryland through its licensing function. At their quarterly meeting on January 13, 2012, the Board reviewed your letter and discussed the Safety Recommendations. As a preliminary matter, the Board noted that in 1997 it first promulgated regulations requiring unlimited license pilots to complete certain education requirements every five years. One of the five required courses is Bridge Resource Management for Pilots (BRMP). The curriculum of that course contains extensive material on the hazards of fatigue and strategies to prevent it. The Board also noted that in 2003 it established by regulation the requirement that all changes in Pilot's Association work rules that affect safe operations of vessels by licensed pilots be brought before the Board for approval. Under the regulations, the Work Rules Committee, which consists of the consumer member, a steamship industry member, and a pilot member, performs au initial review of the proposed change and notifies the Association whether the change has received preliminary approval or is being referred to the Board for its consideration. A preliminarily approved change may be instituted immediately, but must be discontinued at the earliest possible time if it is subsequently disapproved by the Board. Work rules involving the rotation of pilotage assignments and rest periods obviously come within the scope of this Board review. Based on the practices that they currently have in place, the Board members believe that they are in compliance with the recommendations set forth in your letter. However, in light of the seriousness of the concerns that you have raised, the Board voted unanimously to require the Work Rules Committee to conduct another complete review of all of the Association's work rules, focusing particularly on the issues of rotation and fatigue. They will also discuss with the leadership of the Association educational materials that are provided to the members on the issues of rest and fatigue. The Board directed the Work Rules Committee to complete their review in time to submit a full report at the next Board meeting on April 13th. I will send you a follow-up response as soon as I review that report and the Board's subsequent discussion. Thank you again for your letter to Governor O'Malley.

From: NTSB
To: Commonwealth of Massachusetts
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 4, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the commonwealth of Massachusetts has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 4, 2015, letters requesting information.

From: NTSB
To: Commonwealth of Massachusetts
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Massachusetts’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or planned to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Massachusetts’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21, and our April 19, 2013, request for information, are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: Commonwealth of Massachusetts
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Massachusetts’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Mississippi
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 4, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of Mississippi has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 4, 2015, letters requesting information.

From: NTSB
To: State of Mississippi
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Mississippi’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Mississippi’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Mississippi
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Mississippi’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of New Hampshire
Date: 9/3/2015
Response: We understand that the PDA-DPH conducted a review of the applicable administrative rules and met with the three licensed state pilots to review policies and procedures. We note that New Hampshire Revised Statutes Annotated (RSA), 12-G: 42, X, grants the PDA-DPH authority to adopt rules for “Port Captains, Pilots and Pilotage” and that Chapter PDA 300 Port Captains, Pilots, and Pilotage, revised April 1, 2011, authorizes oversight of the three state-licensed pilots. Because these regulations were in place before we issued Safety Recommendation M 11-19, it is classified CLOSED--RECONSIDERED.

From: State of New Hampshire
To: NTSB
Date: 6/26/2015
Response: -From Captain Geno J. Marconi, Director, Pease International Ports and Harbors: The Pease Development Authority Division of Ports and Harbors (PDA-DPH) is in receipt of your letter of May 5, 2015 sent to the Honorable Margaret Wood Hassan, Governor of the State of New Hampshire regarding Safety Recommendations M-11-19 through -21. In accordance with New Hampshire Law, RSA 12-G:42, X, the PDA-DPH has the authority to adopt rules, relative to "Port Captains, Pilots and Pilotage". CHAPTER Pda 300 PORT CAPTAINS, PILOTS, AND PILOTAGE, of the New Hampshire Code of Administrative Rules, for the Pease Development Authority, governs State Licensed Pilots. The full text of these administrative rules is attached and can also be viewed on the PDA-DPH website:www.portofnh.org. Upon receiving your letter, the PDA-DPH immediately conducted a review of the applicable administrative rules and met with the three (3) licensed state pilots to review policies and procedures. In reference to your inquiry regarding steps that the State of New Hampshire, acting through the PDADPH, has taken to address the Safety Recommendations M-11-19 through -21, please accept this letter to report that those recommendations have been addressed as follows: PART Pda 305.06 Minimum Requirements for Pilot Appointment or Reappointment of the Code of Administrative Rules, amended and effective April 1, 2011, requires that the applicant (for Pilot) [shall hold a bridge resource management certificate from a course approved by the Coast Guard in accordance with 46 CFR 11.302(10-1-09 edition) in bridge resource management.] One of the modules in the bridge resource management course addresses fatigue and fatigue management. The PDA-DPH reviewed the work/rest rules and fatigue prevention policies of Portsmouth Pilots, Inc. Those policies indicate compliance with the United States Code of Federal Regulations 46 CFR 15.1111, Title 46 U.S.C. 8104 and STCW Convention and Code section A-VIII/1, as certified in the attached letter from Portsmouth Pilots Inc. All the aforementioned regulations set forth work hours and rest periods for mariners. The Pease Development Authority Division of Ports and Harbors maintains a close working relationship with the state licensed pilots. With business offices and dock facilities within line of sight of each other and almost daily communications between the pilots and the Division of Ports and Harbors, we are confident that the Safety Recommendations M-11-19 through -21 have and are being addressed. -From Captain Peter “PJ” Johnson, Portsmouth Pilots: In response to the recent letter addressed to Gov. Hassan on 5/5/2015 regarding NTSB Safety Recommendations M-11-19 and M-11-20 addressing Pilot fatigue and Prevention; Portsmouth Pilots have been and continue to be in compliance of fatigue mitigation and prevention. In January of 2012, Portsmouth Pilots reviewed and amended its work/rest rules and fatigue prevention policy to comply with United States Code of Federal Regulations 46 CFR 15.1111 , 46 U.S.C. 8104(d) and STCW Code Section A-VIII/1. In addition to the above policy(s) all Portsmouth Pilots are required to fulfill a continuing education requirement by completing an American Pilots Association Approved Bridge Resource Management and Emergency handling course which addresses fatigue and fatigue prevention as part of the course curriculum. This continuing education requirement is not only an association requirement but a requirement set forth by Pease Development Authorities Pilotage Rules. Please feel free to contact us at any time regarding this issue.

From: NTSB
To: State of New Hampshire
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding New Hampshire’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, New Hampshire’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of New Hampshire
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding New Hampshire’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of New Jersey
Date: 9/13/2016
Response: We understand that the New Jersey Maritime Pilot and Docking Pilot Commission, formerly the Board of Commissioners of Pilotage of the State of New Jersey, ensures that the pilots who guide ships into New York/New Jersey harbor are well educated and well trained, and that they demonstrate high levels of professionalism. We are further aware that in 2004, the state pilotage regulations were rewritten and docking pilots were brought into state jurisdiction. Accordingly, because New Jersey had regulations in place prior to the issuance of Safety Recommendation M 11-019, it is classified CLOSED--RECONSIDERED.

From: State of New Jersey
To: NTSB
Date: 8/10/2016
Response: -From Andre M. Stuckey, Executive Director: The Commission requires each New Jersey State licensed pilot and registered apprentice to appear before them annually to review their experiences over the previous year and provide them the opportunity to express any concerns. Our rules are reviewed periodically to ensure that they are up to date and able to respond to the changes that continue to take place within our ports. The Executive Director takes on an active role and attends all meetings of the Harbor Operations and Safety Committee, and visits the pilot Associations regularly to listen to and address any issues. She also rides on vessels unannounced with our licensees to monitor their performance and ensure they are following best practices.

From: NTSB
To: State of New Jersey
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 4, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of New Jersey has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 4, 2015, letters requesting information.

From: NTSB
To: State of New Jersey
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding New Jersey’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, New Jersey’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of New Jersey
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding New Jersey’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of New York
Date: 4/30/2012
Response: We note that, since 1853 when the New York State Legislature created the Board, New York has enacted numerous pilotage statutes. We further note that, over the years, the Board has implemented various regulations addressing a wide range of subjects related to pilotage oversight and safety for three pilot associations: the Sandy Hook Pilots Association, the Hudson River Pilots Association, and the Block Island Pilots Association, as recommended. Accordingly, Safety Recommendation M-11-19 is classified CLOSED—RECONSIDERED.

From: State of New York
To: NTSB
Date: 2/21/2012
Response: -From Richard H. Hobbie, III, President, Board of Commissioners of Pilots of the State of New York: In response to the National Transportation Safety Board's letter to Governor Andrew Cuomo with respect to oversight of state pilotage the following information is respectfully provided. The Board of Commissioners of Pilots of the State of New York ("Board") was created by the New York State Legislature to provide for the selection, training, licensing and regulation of State licensed pilots who navigate regulated vessels entering or departing the waters of New York State and within waters of concurrent jurisdiction in Connecticut and New Jersey. The Board provides oversight of three pilot associations: the Sandy Hook Pilots Association, the Hudson River Pilots Association and the Block Island Pilots Association. The Board continuously monitors the practices of its State Pilots to insure the highest level of safety. The Board reviews safety and technical bulletins issued by the United States Coast Guard, the National Transportation Safety Board and minutes of meetings from other state pilot commissions in order to provide direction on safety and navigational issues to its licensed pilots. The Board also provides annual grants to the three pilot associations to assist with Bridge Resource Management Training, ship handling, continuing education and for laptop navigation computer upgrades which assist the State Pilot during navigation. The Board provides guidance to state pilots detailing the role and responsibility of the compulsory state licensed pilot which is then presented in the form of a "pilot card" to the master of the vessel as part of the Master Pilot Exchange. The Board questions each pilot during their annual renewal interview on general pilotage issues as well as on issues of rest, fatigue and workload to determine if there are any concerns that need to be addressed. With respect to pilot fatigue, specifically, the Sandy Hook Pilots Association's rotation period is four weeks on, two weeks off. During the four week rotation period, a pilot averages two jobs within a 24 hour period, and then has approximately 24 hours off before the next assignment. A pilot, if fatigued, can elect to do only one job then take a rest period prior to his/her next assignment. A pilot also has the option to "knock off' (accept no pilotage assignments) for a three day period without pay. The Hudson River Pilots Association by statute must have two pilots for continuous pilotage of more than eight hours assigned at the beginning ofthe transit. The Association's work rules state no pilot shall sail in and out of Albany on the same day, and that deputy pilots are required to have 36 hours off between the completion of one job and the commencement of another. Block Island Pilots Association procedures require that all Long Island Sound Block Island Sound transits in excess of 12 hours have two pilots. No pilot shall work more than 16 hours in a 24 hour period and no pilot shall pilot more than four vessels in a 16 hour period. A pilot who works four vessels in a 16 hour period must take a mandatory eight hour rest period. All pilots are expected to read and be familiar with "Guidelines on Fatigue for the Maritime Pilot". The Board has implemented fatigue mitigation policies. All state pilots must adhere to a Board Policy and Procedure issued to the pilot associations in 2009 that outlines criteria for reporting to a pilotage assignment properly rested. A copy of the Board's Policy and Procedure is enclosed. The Board acknowledges and thanks the National Transportation Safety Board for its continued role and commitment to maritime safety. TO: SANDY HOOK PILOTS ASSOCIATION HUDSON RIVER PILOTS ASSOCIATION BLOCK ISLAND PILOTS ASSOCIATION POLICY AND PROCEDURE NOTICE # 080409-1 The Board of Commissioners of Pilots of the State of New York ("Board") reminds all New York State Licensed Pilots of their duty and obligation to report to a work assignment properly rested. A pilot must consider all relevant factors in evaluating whether he/she is properly rested including off-duty activities and travel time requirements. Rest is defined in Coast Guard Policy Letter 4-00, Rev. 1 as a period of time during which an individual is off-duty, is not performing work including administrative tasks and is allowed to sleep without interruption. Pilots shall make use of all available technologies to monitor their status on the rotation board with regard to work assignments. Pilots should be aware of all the options available within their respective Associations to remove themselves from the rotation board in the event of fatigue which might impair the pilot's ability to safely perform their assignment. Hudson River Pilots must be aware of Section 89-a of the New York Navigation Law which states "In the event a vessel transiting the Hudson River requires a continuous pilotage of more then eight hours, two pilots shall be assigned at the beginning of such transit." Long Island Sound -Block Island Sound Pilots must be aware of Board Policy and Procedure # 070108 requiring two pilots on all transits in excess of 12 hours on the Long Island Sound. Failure to comply with this Policy and Procedure may result in sanctions. BY ORDER OF THE BOARD

From: NTSB
To: State of North Carolina
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 5, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of North Carolina has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 5, 2015, letters requesting information.

From: NTSB
To: State of North Carolina
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding North Carolina’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, North Carolina’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of North Carolina
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding North Carolina’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: Commonwealth of Virginia
Date: 9/16/2015
Response: We understand that Virginia established the recommended regulations in Code of Virginia Title 54.1 Professions and Occupations, Subtitle II: Professions and Occupations Regulated by the Department of Professional and Occupational Regulation and Boards within the Department, Chapter 9: Board for Branch Pilots, effective July 1, 2007, and established specific oversight regulations for the Virginia Branch Pilots in Title 18 Virginia Administrative Code (VAC) 45-20, revised December 1, 2012 (http://leg1.state.va.us/cgi-bin/legp504.exe?000+reg+18VAC45-20). Because these statutes and associated regulations were in place before we issued Safety Recommendation M-11-19, it is classified CLOSED—RECONSIDERED.

From: Commonwealth of Virginia
To: NTSB
Date: 8/5/2015
Response: -From Kathleen R. Nosbisch, Executive Director, Virginia Board for Branch Pilots: The Virginia Pilot Association, through its rules, oversees the practices of its pilots to promote and ensure the highest level of safety by providing ongoing training, and by striving to ensure mental and physical impairment is minimized to the highest degree. There are work rules in place regarding the number of ships and duration of trips, to guard against pilot fatigue. The Virginia Board for Branch Pilots has been the leader in creating the most demanding pilot chemical testing regulations in the country, which not only includes testing for the use of illegal drugs, but also mind impairing prescription drugs.

From: NTSB
To: Commonwealth of Virginia
Date: 7/2/2015
Response: Secretary Layne explained that the Secretary of Commerce and Trade has jurisdiction over the Board for Branch Pilots, the governing board for state pilots in the commonwealth of Virginia. We appreciate learning that the next Board for Branch Pilots meeting is scheduled for July 30, 2015, and that our letter and recommendations will be on the agenda for discussion. We point out that, for the commonwealth to satisfy Safety Recommendation M-11-20, information we need regarding Virginia’s fatigue mitigation and prevention programs includes— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. Pending our receipt of these details, Safety Recommendations M-11-19 through -21 remain classified OPEN—AWAIT RESPONSE. We encourage you to expedite action and look forward to receiving your reply. Thank you for your assistance in this matter.

From: Commonwealth of Virginia
To: NTSB
Date: 6/3/2015
Response: -From Aubrey L. Layne, Jr., Secretary of Transportation: On behalf of Governor McAuliffe, thank you for your correspondence regarding the above-referenced subject matter. The Secretary of Commerce and Trade has jurisdiction over the Board for Branch Pilots which is the governing board for state pilots in the Commonwealth of Virginia. The board administrator, Ms. Kate Nosbisch, was copied on your letter and she has recently corresponded directly to your office. I have been informed that the next Board for Branch Pilots meeting is scheduled for July 30, 2015, and that your letter and recommendations will be on the agenda for discussion. Thank you for bringing this matter to the attention of Governor McAuliffe.

From: NTSB
To: Commonwealth of Virginia
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Virginia’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Virginia’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: Commonwealth of Virginia
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Virginia’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: Commonwealth of Puerto Rico
Date: 6/7/2016
Response: Safety Recommendations M-11-19 and -20 were classified CLOSED--RECONSIDERED on July 23, 2015, based on the information provided in the May 6, 2015, and May 29, 2015, letters from Captain Daniel Murphy, Interim President, Puerto Rico Pilot Commission (see enclosure). We appreciate receiving a copy of the Puerto Rico Pilots Fatigue Risk Management Plan that includes a pilot rest log and an outlined seminar curriculum that the pilot committee intends to implement. We will retain this document in our records.

From: Commonwealth of Puerto Rico
To: NTSB
Date: 2/19/2016
Response: -From David Aviles, President, Comision de Practicaje de Puerto Rico: The Puerto Rico Pilotage Commission (Commission) is pleased to inform that taking into consideration NTSB Safety Recommendations M-11-19 and M-11-20 further, the Puerto Rico Pilots presented, as required, a "Fatigue Risk Management Plan" (attached), that includes a Pilot Rest Log and an outlined seminar curriculum that will be implemented by the committee. Regarding Safety Recommendation M-11-21, as stated before, at present time, all active P. R. Pilots have Bridge Resource Management (BRM) Training or Basic Bridge Resource Management. The Commission has discussed this matter several times, during its monthly meetings, and we are in the process of revising and evaluating the economic impact on the Pilots' Trust Funds that establishing additional or recurrent BRM training for Pilots will have, and how to adequately identify the funding source for said goal. The Commission expects to formally respond to you regarding M-11-21 during the following months.

From: NTSB
To: Commonwealth of Puerto Rico
Date: 7/23/2015
Response: We understand that, on August 12, 1999, the Puerto Rico Pilot Commission was created by Law 226 to regulate maritime pilotage in Puerto Rico, and that the commission regulates, supervises, and is authorized to impose sanctions on, pilots in Puerto Rico. Because the law granted this authority before we issued Safety Recommendation M-11-19, the recommendation is classified CLOSED—RECONSIDERED.

From: Commonwealth of Puerto Rico
To: NTSB
Date: 5/29/2015
Response: -From Captain Daniel Murphy, Interim President, Puerto Rico Pilot Commission: The Puerto Rico Pilot Commission was created by Law 226 of 12 August 1999 to regulate the profession of Maritime Pilotage in Puerto Rico. The Commission regulates, supervises and may impose sanctions on Pilots in Puerto Rico.

From: Commonwealth of Puerto Rico
To: NTSB
Date: 5/6/2015
Response: -From Captain Daniel Murphy, Interim President, Puerto Rico Pilot Commission: As interim President of the Puerto Rico Pilot Commission I am pleased to acknowledge receipt of your correspondence regarding NTSB's requirements regarding Safety Recommendations M-1 1-19, 20 and 21. The Puerto Rico Pilot Commission will take immediate steps to fulfill the requirements of the Safety Recommendations. Today, we have forwarded your latest correspondence to the Island's Pilot Associations for their input on the issues at hand. The Puerto Rico Pilot Commission is committed to continuous improvement in the pilotage system on our Island and recognize the importance of these recommendations. The Commission will take all steps necessary in order to comply with the NTSB's recommendations as soon as is practicable.

From: NTSB
To: Commonwealth of Puerto Rico
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Puerto Rico’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Puerto Rico’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: Commonwealth of Puerto Rico
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Puerto Rico’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Oregon
Date: 8/2/2012
Response: The NTSB has reviewed Oregon statutes, the OBMP’s administrative rules, and the OBMP website, and we have determined that the OBMP provides effective oversight and promotes a high level of safety for marine pilot operations. We believe that the OBMP’s regulation of pilotage, particularly in the areas of training, continuing professional development, investigations, and discipline, will help to ensure practices that promote safety. We are pleased with the detailed reports from the three local pilot associations that Ms. Duncan provided and with the continued efforts to address fatigue and hours of service (HOS) in the state of Oregon that further attest to the effective oversight by the OBMP and its commitment to maritime safety. Accordingly, Safety Recommendation M 11-19 is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: State of Oregon
Date: 5/1/2012
Response: Because Oregon has initiated the recommended review of the effectiveness of local pilot oversight and compliance with rules and regulations, Safety Recommendation M-11-19 is classified OPEN—ACCEPTABLE RESPONSE, pending completion of these efforts.

From: State of Oregon
To: NTSB
Date: 4/18/2012
Response: -Kim Duncan, Chair: Oregon Board of Maritime Pilots: The Board has received the enclosed responses from our pilot organizations to the recommendations made in your correspondence of November 4, 2011. The Board will be working with the pilot organizations over the next several months to address any deficiencies that have been identified. We will keep apprised of our progress. -From Captain Paul D. Amos, President, Columbia River Pilots: We understand this recommendation to address two functions of the Board: (1) Its monitoring (awareness) of pilot practices, and (2) its oversight of such practices through Board regulations. The comprehensive nature of the Board's regulations is apparent, and their effectiveness in promoting safety is proven by the remarkable safety record compiled by Oregon's pilots. With regard to Board monitoring of pilot practices, we offer the following comments: COLRIP members follow published internal Rules and Regulations. A copy of COLRJP's Rules and Regulations is on file with the OBM and is available for Board monitoring and review. These Rules and Regulations include Operating Rules that address pilot practices such as random drug testing, dispatch procedures and work rotation. COLRIP continually reviews its Rules and Regulations to insure that they are up to date and relevant, and updates are periodically filed with the Board. COLRIP participates in the Lower Columbia River Harbor Safety Committee, which issues and periodically updates a Harbor Safety Plan. COLRIP members generally adhere to operational guidelines in the Lower Columbia River Harbor Safety Plan. A Board representative monitors the work of the Harbor Safety Committee and attends its meetings, and the Board is therefore aware of the operational practices addressed in the Harbor Safety Plan. COLRIP has appointed a Vessel Movement Guideline Committee to develop additional operational guidelines for both pilots and our customers. Specifically, this committee is developing ship assist tug guidelines, traffic management guidelines and pilot assignment guidelines. COLRI P expects to complete a first draft for internal review in September 2012. It is anticipated that the new Vessel Movement Guidelines would go into effect in early 2013. Copies of the Vessel Movement Guidelines will be provided to the Board when they are published, to enable to the Board to further monitor the pilots' practices. -From Captain Gary Lewin, Administrative Pilot, Columbia River Bar Pilots, LLC: This letter responds to your request that the Columbia River Bar Pilots review the recent NTSB fatigue recommendations to state pilotage authorities resulting from the investigation of the Eagle Gtome incident in Texas in 2010. This letter addresses the history of the Bar Pilots' involvement with the fatigue prevention issue, our current working rules and our assessment of the sufficiency of our current practices and recommended future plan of action. History of CRBP Involvement with Fatigue Issues The Columbia River Bar Pilots have been substantially involved in the issue of fatigue management throughout the past decade. In 2004, we commissioned a study by Intelstep, a Canadian firm with expertise in analyzing fatigue issues related to various work schedules in transportation and other industries. Intelstep authored a Fatigue Management Guide for Canadian Marine Pilots which we distribute to all ofour pilots. As a result of that study, it became clear to us that there were significant problems with what had been our historic strict rotational schedule of22 days on and then 22 days off. The biggest problems with that schedule were the unpredictability of the traffic (approximately 60% of which occurred during night hours) and the lack of predictable rest periods in a constantly rotating schedule. Based on these findings, we worked with Intelstep to develop alternative schedules, but that firm's computer technology was limited to two respects: (1) it was designed to evaluate fixed shifts; and (2) it could not predict the correct number of pilot personnel by simulating a hypothetical work force against actual traffic. We then sought the advice of Dr. Charles A. Czeisler, a professor of sleep medicine at the Harvard Medical School and one of the world's most well-recognized experts in fatigue management and work scheduling. Dr. Czeisler, who is NASA's longtime fatigue consultant, examined our 22 days on/22 days off strict rotational schedule, found it to be unsafe and strongly recommended that it be changed. In 2004, Dr. Czeisler worked with computer modeler George Fenn to develop a new work schedule that divided the working Bar Pilots into two equally staffed watches, each with a new schedule dividing a pilot's 20-day on duty work schedule into 10 day cycles that included six days of rapidly rotating shifts and four days of flex-time shifts. The fixed watches assigned to six pilots would have allowed those six personnel to be deployed around the clock with two pilots available every hour except that hour which statistically was the lowest hour of traffic. Five of these watches were eight hours in duration and one was 12. In addition, the five pilots with eight-hour watches were subject to an early call in up to three hours before their designated eight hour watch. The one 12-hour watch was subject to a one hour early call in. For the flex shifts, which were to take up to four days of each ten day cycle, pilots in those positions would be deployed to cover peak traffic and work up to 12 hours followed by 12 hours of rest. In addition, there were to be special rules to avoid fatigue including the following: (I) eleven hours off in any 24-hour period; (2) any pilot who pilots 14 ships in seven consecutive shift rotations must receive 36 hours off; and (3) all pilots must have two 24-hour breaks within each seven day period throughout their on duty watch. The computer modeling showed that this new type of schedule was workable with a complement of 20 pilots. All of this information was presented in detail over the course of nearly two days in the 2004-05 rate proceeding. Unfortunately, despite this evidence, the Oregon Board of Maritime Pilots in its Final Order in that rate proceeding concluded that "the presentation by CREP of evidence tending to show the need for fatigue risk management did not meet CRBP's burden of proof by a preponderance of the evidence for maintaining the current number of Bar Pilots." Final Order 05-01 at 9. Then, without any articulation of its reasoning, the Board reduced the number of working pilots recommended by the administrative law judge from 17 to 15. Following a Petition for Reconsideration, a settlement was ultimately reached tying the number of Bar Pilots to a formula based upon projected vessel traffic and a workload factor of233 transits per pilot. Following that settlement, this formula funded 17 working pilots, which was not a number sufficient to implement the fatigue risk management schedule recommended by Dr. Czeisler. CRBP Current Practices. In 2006 through 2010, the Bar Pilots continued to consult with Dr. Czeisler, who presented another comprehensive report in 2010 in connection with our most recent rate proceeding. With the advice of Dr. Czeisler, we have modified our prior strict rotational schedule and have adopted working rules to reduce the risk of fatigue negatively impacting pilot performance. Those working rules are as follows: 1. The on duty work period is now 15 days on/IS days off plus an additional 30 days per year of work to cover for the impact of the fatigue prevention rules. 2. Every pilot must have nine consecutive hours off (eight hours of rest and up to one hour of commute time) following completion of a working tum performing pilotage assignments with each turn having a maximum number of II consecutive hours. 3. Every pilot has the discretion to decline a pilotage assignment if he or she does not feel sufficiently rested. 4. The above rules can be waived in the event of an emergency or an important safety concern. Sufficiency of Current Practices. At present. we believe that our current working rules provide a reasonable level of fatigue risk management, but it is important to emphasize that this is an area of significant ongoing research and analysis throughout the transportation sector of the U.S. economy and throughout the world. We plan to invite Dr. Czeisler to come to Astoria later this year for two purposes: (1) to bring us up to date on the latest research into fatigue risk management and best practices; and (2) to interview individual pilots, examine our current working rules and to assess the adequacy of those rules. Dr. Czeisler is so well regarded in this field that the Board may wish to consider having him make a presentation to the Board during the course of the trip that he will make to Oregon later this year for his meetings with our pilot group. We are also working with an Australian finn to develop a program for use on an iPad that enables each pilot to track work periods, the timing of that work and rest periods to enable each pilot to monitor his or her levels of fatigue on a color coded basis, thus providing a warning system when any individual pilot should decline an assignment because of a dangerously high level of fatigue. We appreciate the Board's interest in this important issue. We would like to emphasize that our present practices are out of the ordinary for pilot groups throughout the United States, which typically work equal amounts of time on and time off each year. Under this industry standard, U.S. maritime pilots work 184 days per year. In order to accommodate the fatigue rules described above, the Columbia River Bar Pilots work an extra 30 days per year plus whatever days that year are necessary for continuing professional development. As to CPO, most U.S. pilot groups count those days as part of a working pilot’s on duty days. This is an area we hope that the Oregon Board of Maritime Pilots will address in the future as the additional 3S to 40 days per year worked by Bar Pilots compared to most U.S. pilot groups is a factor that can negatively impact our ability to recruit the very best merchant mariners from the candidate pool available to fill open positions in a pilot group that serves one of the most challenging pilotage grounds in the world. -From Captain Charles Yates, Coos Bay Pilots Association: This recommendation is directed at the Oregon Board of Maritime Pilots as the “local pilot oversight organization.” The Board's comprehensive regulation of pilotage, particularly through detailed rules that address training, continuing professional development, investigations, and discipline, assures pilotage practices that result in the highest levels of safety. The Board also requires filing of the internal operating rules by each pilot organization, enhancing the Board's ability to monitor pilot practices.

From: State of Oregon
To: NTSB
Date: 1/23/2012
Response: -From Kim Duncan, Chair, Oregon Board of Maritime Pilots: Since 1846, the Oregon Board of Maritime Pilots has licensed and regulated state pilots who provide service on the designated pilotage grounds of the Columbia & Willamette Rivers, Columbia River Bar, Coos Bay Bar, and Yaquino Bay Bar. The Board offers the following response to the recommendations made in your correspondence of November 4. 2011: M-11-19 Ensure that local pilot oversight organizations effectively monitor and through their rules and regulations, oversee the practices of their pilots to promote and ensure the highest level of safety. M-11-21 Require local pilot organizations that hove not already done so to implement initial and recurring bridge resource management training requirements. The Board has had requirements for Continuing Professional Development (CPD) in place since 2000 for courses in bridge resource management for pilots, manned model simulated ship handling and navigational electronic systems. In 2010, the Board developed and adopted expanded CPD requirements which include a course entitled Fatigue, Sleep, and Medications for Pilots, among several other options. and a minimum of one day of personal safety training annually. The compliance date for the expanded rule was January 1. 2012. Before that date, almost half of Oregon's licensees have completed courses in Fatigue Management or Personal Safety Training. Both courses were developed by Pacific Maritime Institute in Seattle and the Personal Safety Training course also devotes a significant section to fatigue management. The remaining licensees will be required to provide certification of this training with their license renewal applications this year. M-11-20 Require local pilot oversight organizations that have not already done so to implement fatigue mitigation and prevention programs that (1) regularly inform mariners of the hazards of fatigue and effective strategies to prevent it and (2) promulgate hours of service rules that prevent fatigue resulting from extended hours of service, insufficient rest within a 24-hour period and disruption of circadian rhythms. The Columbia River Bar pilots have been working with Dr. Charles Czeisler, a noted professor of sleep medicine, since 2004 to review their work schedules and provide recommendations to mitigate fatigue. Dr. Czeisler's recommendations included working no more than 12 consecutive hours during daytime hours and no more than 8 hours if work includes any of the hours between midnight and 6 a.m. Additionally, he recommended at least 11 consecutive hours off-duty every 24 hours. His recommendation for education on fatigue management has been implemented by the Board as previously noted. The purpose of the education is to heighten awareness about fatigue-related impairment. Following receipt of the NTSB letter, the Board has issued a request to each Oregon pilot organization to review the recommendations Within the context of their current operational working rules and report back no later than 90 days with on assessment of the sufficiency of current practices and initial recommended plans of action should the organization conclude it could benefit from changes. The Board is also reviewing its responsibility in the oversight of pilot operations.

From: NTSB
To: Commonwealth of Pennsylvania
Date: 8/5/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 4, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the commonwealth of Pennsylvania has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 4, 2015, letters requesting information.

From: NTSB
To: Commonwealth of Pennsylvania
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Pennsylvania’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Pennsylvania’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: Commonwealth of Pennsylvania
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Pennsylvania’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Rhode Island
Date: 4/30/2012
Response: The NTSB understands that Rhode Island has the recommended regulatory statutes in place and that, by statute, the Commission exercises an effective oversight process that carefully monitors the effectiveness of both the regulations and policy. We also understand that the Commission regularly reviews input from various sources and circumstances that might indicate a need for change in law or rule to better prevent maritime accidents. Because these statutes, rules, and practices were in place before the NTSB issued Safety Recommendation M-11-19, the recommendation is classified CLOSED—RECONSIDERED.

From: State of Rhode Island
To: NTSB
Date: 1/12/2012
Response: -From Captain E. Howard McVay Jr., Chairman, Rhode Island State Pilotage Commission: The Rhode Island Pilotage Commission, which has regulatory authority over the State Licensed Pilots of Rhode Island, has a long track record of being "pro-active" in the areas of training and safety. All of our pilots have a deep sea experience leading up to obtaining an "Unlimited Ocean Master license". This is the highest license issued by the USCG and is required to apply to be a Rhode Island State Pilot. The Rhode Island State Pilots Apprentices are required to take "Bridge Resource Management for Pilots" (BRMPA) course while undergoing their training to be a pilot. Then once a licensed state pilot, they are required to take a (BRMPA) refresher course every 3 years in order to be in compliance with the requirements. The issue of bridge to bridge communications which was mentioned in the report is dealt with in this course. Many years ago a fatigue policy was implemented which all pilots are required to comply with. This has been in effect for many years. To date, there has not been an accident which might have been related to fatigue. In addition to the items mentioned above, the Rhode Island State Pilots are required to take many other courses to include Manned Model Ship Handling courses, (every 5 years) Portable Pilot Nav Unit Certification and Refresher Tractor Tug for Pilots Training, ECDIS Certification, and Nav Decision Making using Radar and ARPA course. Emergency Ship Handling for Pilots as designed by the Rhode Island State Pilot Chairman. In addition to the above classes, the Rhode Island State Pilots also conduct safety drills aboard the Rhode Island inspected and certified pilot boats with the boat crews on pilot recovery and safety. In closing, the Rhode Island State Pilots are among the highest trained, if not the highest trained pilots in the United States. Our pilots have an excellent training program and as a result, a tremendous safety record.

From: NTSB
To: State of South Carolina
Date: 4/30/2012
Response: The NTSB understands that South Carolina has regulatory statutes in place and that, by statute, the Commissioners of Pilotage for the Lower Coastal Area (Commission) exercise an effective oversight process that carefully monitors the effectiveness of both the regulations and policy. We note that the Commission regularly reviews input from various sources and circumstances that might indicate a need for a change in law or rule to better prevent maritime accidents. Because South Carolina’s statutes and process were in place before we issued this recommendation, Safety Recommendation M¬-11-19 is classified CLOSED—RECONSIDERED.

From: State of South Carolina
To: NTSB
Date: 2/1/2012
Response: -From Nikki R. Haley, Governor: Please consider this response to the National Transportation Safety Board's (NTSB) Safety Recommendations M-II-19 through -21, regarding harbor pilotage for the Port of Charleston in the State of South Carolina. In response, the Commissioners of Pilotage of the Lower Coastal Area are undertaking a fatigue performance evaluation of the Charleston Harbor Pilots to thoroughly study pilot fatigue. The standards are established by state regulation, but the commission agrees with the NTSB's recommendation to review the effectiveness of these regulations. While the commission believes the current policies will prove to be sound, it will reserve final judgment until after the study has been completed. Our office will follow up with the NTSB on the commission's findings and any recommendations.

From: NTSB
To: State of Texas
Date: 8/4/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, your state has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and May 4, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the state of Texas has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and May 4, 2015, letters requesting information.

From: State of Texas
To: NTSB
Date: 7/8/2015
Response: -From Greg Abbott, Governor: Thank you for writing. I appreciate your sharing NTSB 's recommendations regarding pilot oversight. As you may know, my administration began on January 20,2015, and is working on how Texas can best address the issues raised in your letter. In the meantime, I have tasked the Texas Department of Transportation, through its Maritime Division, to coordinate with my office in discussing this matter with the various pilot boards across the state. Once the necessary feedback has been received, my office will provide NTSB with any appropriate updates. I look forward to working with you.

From: NTSB
To: State of Texas
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding North Carolina’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, North Carolina’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: State of Texas
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Texas’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: State of Washington
Date: 4/30/2012
Response: We note that Washington has regulations in place and that, by statute, the Washington State Board of Pilot Commissioners has an oversight process in place to monitor the effectiveness of both the Revised Code of Washington and the Washington Administrative Code as they pertain to pilotage. The Commissioners regularly review input from various sources regarding any circumstance that might indicate a need for a change in law or rule to help ensure maritime safety. As these provisions predate the issuance of the recommendation, Safety Recommendation M-11-19 is classified CLOSED—RECONSIDERED.

From: State of Washington
To: NTSB
Date: 1/31/2012
Response: -From Christine O. Gregoire, Governor: The Washington State Board of Pilotage Commissioners (Board) is tasked by the Legislature (through The Pilotage Act - codified in the Revised Code of Washington as RCW 88.16) to maintain efficient and competent pilotage service in the "pilotage grounds" of our state which include the Washington waters inside the international boundary line east of 123° 24' west longitude and the inland waters of Grays Harbor and Willapa Harbor. Note that pilotage in the Washington waters of the Columbia River is under the control of the State of Oregon. The Pilotage Act mandates and empowers the Board to create and maintain rules under the Washington Administrative Code (WAC) to enforce and administer the Pilotage Act. These rules are codified in WAC 363-116 Pilotage Rules. The Board has specific rules (WAC 363-116-200) which require prompt reporting of marine incidents and near misses to the Board. If an incident involves pilot error, the Board has various remedial measures in its rules ranging from reprimand to license revocation. It has various disciplinary statutes and rules to implement this program, e.g. RCW 88.16.1 00, WAC 363-116-370 (specified corrective actions), and WAC 363-116-420 (emergency suspension of license). The reports submitted by pilots (or any other entity) are reviewed monthly (unless scheduling conflicts require cancellation of a monthly meeting) at an open meeting of the Board and are disseminated to pilots and shipping companies. The Board's analysis of these reports often results in Board action or communication with third parties to address issues that may have been a causal factor in a near miss or incident. The Board also makes sure that all other relevant regulatory bodies have been notified of such events. The Board carefully monitors the effectiveness of both the law (RCW) and rules (WAC) by regularly reviewing input from a variety of sources regarding any circumstance that might indicate that there is a need for a change in law or rule to better prevent incidents that could lead to maritime casualties of any level of significance. Other actions the Board may take as a result of the analysis of feedback regarding situations that involve pilots include, but are not limited to: • Working with the U.S. Coast Guard, the Harbor Safety Committee, local yacht clubs, Native American Tribes, other pilotage authorities including Canadian, shipping companies, etc. to improve communications or other aspects of safe navigation. • Disciplinary sanctions against a pilot (including possible revocation of license) whose performance fails to meet the standards set in the RCW and associated WAC. • Changes to educational requirements for pilots. • The issuance of Safety Advisory Bulletins. • Development of Policy Statements.

From: NTSB
To: Territory of Guam
Date: 8/4/2016
Response: For more than 4 years, the NTSB has worked to gain support for pilot oversight regulations, hours-of-service regulations, education on the hazards of fatigue and effective strategies to prevent it, and initial and recurrent bridge resource management training for pilots. To date, 17 of the 31 addressees (55 percent) have satisfied the recommendations, and 3 others are working to address these issues. Regrettably, Guam has not taken action to implement these important safety recommendations, although we made two additional requests for information on April 19, 2013, and April 30, 2015. Accordingly, Safety Recommendations M-11-19 through -21 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED. We monitor the status of all of our recommendations because we are interested in knowing whether and how they are implemented, both to ensure that the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Should we receive a timely response from you indicating that the territory of Guam has acted to address these recommendations, with details of the actions taken, we may reevaluate our classification. For your convenience, I have enclosed a copy of the November 4, 2011, letter issuing these recommendations and our April 19, 2013, and April 30, 2015, letters requesting information.

From: NTSB
To: Territory of Guam
Date: 4/30/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Guam’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you have either taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Guam’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: Territory of Guam
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Guam’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: Humboldt Bay Harbor, Recreation and Conservation District
Date: 6/23/2015
Response: We understand that, since 1997, the State of California, through the Harbors and Navigation Code, has delegated to the Humboldt Bay Harbor, Recreation and Conservation District (HBHRCD) authority to provide for and supervise pilots aboard vessels in foreign trade. We note that, on February 26, 1997, the Governor of California, the US Coast Guard Assistant Commandant for Marine Safety and Environmental Protection, and the executive directors of the harbors of Humboldt Bay, Port Hueneme, Los Angeles, Long Beach and San Diego signed a Memorandum of Agreement (MOA) requiring a federal pilot license as a condition of employment as a pilot. Federal statute (46 United States Code 8503) authorizes the Coast Guard to regulate individuals’ licenses when piloting vessels in foreign trade. Accordingly, pilots in Humboldt Bay are subject to the jurisdiction of the Coast Guard’s suspension and revocation process when they are piloting vessels in coastwise or foreign trade. In addition, we note that the state delegated authority to HBHRCD in Ordinance #15, Article 6 Oversight and Enforcement, Section 6.1, to issue licenses for pilotage in Humboldt Bay, to monitor pilot performance, and to provide feedback on the effectiveness of qualification and training programs, including legal and administrative procedures for the enforcement of pilotage standards. We are pleased to learn that Ordinance #15 has been updated as of April 9, 2015. However, because the key provisions were in place in 1997, before we issued Safety Recommendation M-11-19, the recommendation is classified CLOSED—RECONSIDERED.

From: NTSB
To: Humboldt Bay Harbor, Recreation and Conservation District
Date: 5/4/2015
Response: Although it has been more than 3 years since these recommendations were issued, we have received no information to date regarding Humboldt Bay’s actions or intentions to address them, even after our April 19, 2013, additional request for information. Accordingly, we would appreciate receiving a prompt reply regarding any actions that you either have taken or plan to take to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Unless we receive a timely reply from you, we may have to classify the recommendations in an unacceptable status. We point out that, to satisfy Safety Recommendation M-11-20, Humboldt Bay’s fatigue mitigation and prevention programs should include— • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it. • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 and our April 19, 2013, request for information are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: Humboldt Bay Harbor, Recreation and Conservation District
To: NTSB
Date: 5/4/2015
Response: -From Captain Tim Petrusha, Director of Harbor Operations. Bar Pilot, Port of Humboldt Bay: We have received your letter dated May 5, 2015. Pilotage in Humboldt Bay is governed by The Board of Directors and Executive Director of the Humboldt Bay Harbor, Recreation and Conservation District. All of our local Pilot requirements, rules and regulations are defined in Ordinance NO. 15 of the Humboldt Bay Harbor District. Oversight and Enforcement are defined in Article 6 of the Ordinance. With the help of the Executive Director and other Staff members, a checklist is in place and monitored that is designed to ensure these requirements and regulations are followed. As stated specifically in Article 5, section 5.1 item c., it is required that all Pilots ”undergo simulator training and Bridge Resource Management training for Pilots at least once every five years.” The current pilots are scheduled to renew this training beginning May 27th of 2015. With less than 12 ships per year that we are currently receiving, we do not currently have a fatigue mitigation and prevention program in place. This is something we will discuss with the local Pilot group and the Board of Directors. Please don’t hesitate to contact me if you have any further questions of me.

From: NTSB
To: Humboldt Bay Harbor, Recreation and Conservation District
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Humboldt Bay’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: Humboldt Bay Harbor, Recreation and Conservation District
Date: 8/2/2012
Response: We understand that the state of California previously forwarded these recommendations to you; for your convenience, a copy of our November 4, 2011, letter issuing these recommendations is enclosed. When responding to these recommendations, please refer to Safety Recommendations M-11-19 through -21 by number.

From: NTSB
To: State of California, City of Los Angeles, Harbor Department, Port Pilots
Date: 5/13/2013
Response: Because (1) Los Angeles pilots are licensed by the US Coast Guard, (2) the Port employs two management pilots to enforce its guidelines and provide oversight and training, and (3) the Port recently reviewed the effectiveness of local pilot oversight and compliance with rules and regulations, made needed changes, and will continue to closely monitor the practices of its pilots, Safety Recommendation M-11-19 is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, City of Los Angeles, Harbor Department, Port Pilots
To: NTSB
Date: 3/5/2013
Response: -From Captain John M. Holmes, Port of Los Angeles, Deputy Executive Director of Operations: These recommendations (M-11-19 through -21) were forwarded to the Port of Los Angeles (Port) as the organization that provides oversight of the Los Angeles Pilots. We have reviewed the recommendations listed above and have addressed each. With respect to Recommendation M-11-19, the Port management and Board of Harbor Commissioners will continue to closely monitor the practices of our pilots, as it has done in the past. With respect to Recommendation M-11-20, we have reviewed pilot hours and dispatch procedures in order to ensure that the issue of pilot fatigue has been addressed. As a pilot organization with an average number of two jobs per day, an average job duration of two hours, and a 12 hour watch rotation, we do not foresee any possibility of fatigue issues. We will continue to closely monitor pilot work hours to ensure that pilot fatigue does not become an issue. Finally, with respect to Recommendation M-11-21, we will continue our Bridge Management Training every other year which has become part of the simulator training required by the Port.

From: NTSB
To: State of California, City of Los Angeles, Harbor Department, Port Pilots
Date: 11/6/2012
Response: We note that the Port of Los Angeles has initiated the recommended review of the effectiveness of local pilot oversight and compliance with rules and regulations; accordingly, Safety Recommendation M-11-19 is classified OPEN—ACCEPTABLE RESPONSE pending completion of that review.

From: State of California, City of Los Angeles, Harbor Department, Port Pilots
To: NTSB
Date: 7/24/2012
Response: -From Geraldine Knatz, Ph.D., Executive Director, The Port of Los Angeles: In addition to federal licensing requirements, pilots are governed by contractual obligations and a comprehensive set of working rules that define the safety and training requirements of the pilots. The contract is currently being reviewed and revised and the working rules were revised in 2010. It is the responsibility of the two fully qualified management pilots to actively enforce these guidelines' and ensure that appropriate oversight and training is being provided.

From: NTSB
To: State of California, City of Los Angeles, Harbor Department, Port Pilots
Date: 6/14/2012
Response: This letter concerns Safety Recommendations M-11-19 through -21, stated below, which the National Transportation Safety Board (NTSB) issued to 26 addressees, including the state of California, on November 4, 2011. These recommendations resulted from the NTSB’s investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. On January 12, 2012, Ms. Traci Stevens; Acting Secretary; California Business, Transportation and Housing Agency, advised the NTSB that the only pilot group regulated by the state is the San Francisco Bar Pilots, which operates in the bays of San Francisco, San Pablo, Suisun, Monterey, and the tributaries to Sacramento and Stockton. Because the state of California does not exercise regulatory authority over Humboldt Bay, Port Hueneme, the Port of Los Angeles, the Port of Long Beach, or the Port of San Diego, and the regulatory authority lies exclusively with each of these local jurisdictions, the following recommendations are also being issued to the individual jurisdictions for action. We understand that the state of California previously forwarded these recommendations to you; for your convenience, a copy of our November 4, 2011, letter issuing the recommendations is enclosed. When responding, please refer to Safety Recommendations M-11-19 through -21.

From: NTSB
To: State of California, City of Long Beach, California, Harbor Department
Date: 7/17/2012
Response: The NTSB understands that pilot oversight in the Long Beach Harbor District is conducted by the Local Pilotage Advisory Council and that federally licensed pilots for the Long Beach Harbor District are provided by Jacobsen Pilot Service. We also understand that, in 2000, Jacobsen Pilot Service voluntarily become certified as ISO 9002 (International Organization for Standardization) compliant, and that Jacobsen Pilot Service has a Quality Management System (QMS) that is reviewed through periodic internal audits as well as by comprehensive, annual, third-party audits. We appreciate the details Ms. Duncan provided regarding the details of the QMS and the audits. Because the pilot oversight program of the Port of Long Beach has been in place since before Safety Recommendation M-11-19 was issued, this recommendation is classified CLOSED—RECONSIDERED.

From: State of California, City of Long Beach, California, Harbor Department
To: NTSB
Date: 4/4/2012
Response: -From Sean C. Strawbridge, Managing Director, Port Operations, Port of Long Beach: The City of Long Beach Harbor Department (commonly referred to as the "Port of Long Beach") has received the National Transportation Safety Board (NTSB) Safety Recommendations distributed to governors of states and territories in which state and local pilots operate. In accordance with a formal Memorandum of Agreement with the State of California, the U.S. Coast Guard, and certain other California ports, the Port of Long Beach acts as the harbor pilot oversight organization for vessel operations within the City of Long Beach Harbor District. Therefore, the State of California has referred the Safety Recommendations to the Port of Long Beach for consideration and response directly to the NTSB. To provide oversight of the pilotage within the Long Beach Harbor District, Representatives of the Port of Long Beach routinely meet, interview, and collaborate with the local pilots via the Local Pilotage Advisory Council ("the Council"), as part of recurring port operations, and as participants of the region's Harbor Safety Committee. The Port of Long Beach is signatory to an agreement which established the Council to assesses the Long Beach pilotage operations and determine the risks as well as best practices associated with safe piloting of vessels within the Long Beach Harbor District. The Council reviews and oversees pilot processes and practices and serves to make recommendations for establishing requirements which, if necessary, are promulgated through the Port of Long Beach Tariff. Representatives from the Port of Long Beach Operations Bureau, Jacobsen Pilot Service (Pilots for the Long Beach Harbor District), and shipping industry leaders are appointed to the Council. Representatives from the Coast Guard and the State Office of Oil Spill Prevention and Response also participate on an "ex officio" basis. Representatives from the local Vessel Traffic Service / Marine Exchange and other industry members participate as invited guests. In accordance with established practice, the Council met most recently on March 27, 2012 to conduct its annual review of Jacobsen Pilot Service's operations during 2011. As a result of these continuous reviews, the Port of Long Beach is confident the processes, policies, practices, and procedures used by Jacobsen Pilot Service provide an exceptionally high level of vessel operational safety within the Long Beach Harbor District. One example of our confidence is the voluntarily effort Jacobsen Pilot Service undertook to become certified as ISO 9002 compliant in 2000. To our knowledge, Jacobsen is recognized as the only piloting organization in the United States to be ISO 9002 Certified. Additionally, Jacobsen Pilot Service has a Quality Management System ("QMS") that is reviewed through periodic audits, including comprehensive annual third party audits. The QMS addresses procedures for the hiring process, initial training, periodic continuation training, daily operations, and working rules. Incident reviews are also conducted by both the internal and third party auditors to identify procedural or systematic problems for correction. The Council regularly receives auditor reports for review. We are confident that this system of oversight is working as intended. In more than 15 years since creation of the Council, Jacobsen Pilot Service has never had a reportable incident. Significantly, Jacobsen Pilot Service has embraced the oversight process as a valuable tool and resource. Already recognized throughout the maritime industry as a leader in providing safe, efficient and professional piloting services, Jacobsen Pilot Service has developed systems and a culture designed to ensure the safety of its operations and to improve and adapt its systems to remain in the forefront of responding to the demands of larger vessels and new technologies. The Council has reviewed the NTSB recommendations and has agreed that the Port of Long Beach Tariff be reviewed and improved upon if necessary, taking into account the Analysis, Conclusions, and Recommendations of the referenced accident report in the NTSB letter. At the March 27, 2012 annual Council meeting, the agenda included an extended discussion of the NTSB report and the actions currently being undertaken by Jacobsen Pilot Service to ensure that its systems and operations are compliant with the NTSB recommendations.

From: NTSB
To: State of California, City of Long Beach, California, Harbor Department
Date: 3/27/2012
Response: Correspondence control #201200172 was closed administratively. No reply was sent using correspondence control #201200172, see correspondence control #201200224, where the reply was sent 7/17/2012.

From: State of California, City of Long Beach, California, Harbor Department
To: NTSB
Date: 3/23/2012
Response: -From Dan Kane, Security Division: The City of Long Beach, California, Harbor Department is in receipt of the National Transportation Safety Board’s Safety Recommendation document of November 04, 2011 made as a result of the subject NTSB accident investigation. In its role as the pilot oversight organization, the Harbor Department is in process of reviewing the accident report and the recommendations as they pertain to vessel operations within the Port of Long Beach. The topic is on the agenda for the next meeting of the Local Pilotage Advisory Council, scheduled for March 27, 2012. It is our intent to develop a response to the NTSB recommendations shortly thereafter. Please contact me if you have any questions or concerns.

From: NTSB
To: San Diego Bay Pilots Association, Inc.
Date: 9/16/2015
Response: We understand that, on September 16, 2014, the San Diego Unified Port District completed work to revise its pilot oversight regulations, issuing Ordinance 2780, which included the implementation of new reporting, training, professional development, and oversight requirements to address our recommendations. We also understand that, on July 29, 2014, the Port of San Diego Pilotage Advisory Council issued the oversight guidance document Training, Professional Development and Oversight Program for Pilots at the Port of San Diego, which contains the council’s recommendations for revision of the apprenticeship, professional growth, and oversight programs for pilots at the Port of San Diego that were originally created in 2004. The San Diego Unified Port District’s revisions to its pilot oversight regulations and the issuance of Ordinance 2780 satisfies Safety Recommendation M-11-19, which is classified CLOSED—ACCEPTABLE ACTION.

From: San Diego Bay Pilots Association, Inc.
To: NTSB
Date: 6/18/2015
Response: -From Joel Valenzuela, Director, Maritime, Port of San Diego: On January 12, 2012 a letter from the State of California Business, Transportation and Housing Agency was addressed and sent to Ms. Deborah A.P. Hersman, Chairman of the National Transportation Safety Board (NTSB) at that time. The Port of San Diego was copied on that letter with a request from the State of California that the local pilot oversight organizations work to address safety recommendations made by the NTSB on November 4, 2011 in regards to port pilotage. Recommendations were designated as M-11-19 through 21 by the NTSB. In summary these three recommendations are as follows: 19. Ensure that local pilot oversight organization effectively monitor and, through their rules and regulations, oversee the practices of their pilots to promote and ensure the highest level of safety. 20. Require local pilot oversight organizations that have not already done so to implement fatigue mitigation and prevention programs that (1) regularly inform mariners of the hazards of fatigue and effective strategies to prevent it and (2) promulgate hours of service rules that prevent fatigue resulting from extended hours of service, insufficient rest within 24-hour period, and disruption of circadian rhythms. 21. Require local pilot oversight organizations that have not already done so to implement initial and recurring bridge resource management training requirements. On May 23, 2013 the Port of San Diego sent a letter to Ms. Hersman informing her that we had created a forum which includes representatives from the San Diego Bay Pilot's Association, Port of San Diego Pilotage Advisory Council, the United States Coast Guard, and the California State Lands Commission to identify areas in need of improvement and develop recommendations to address these weaknesses. Initial recommendations were developed and submitted to the NTSB for review. NTSB feedback requested the Port of San Diego in short provide greater oversight than what was presented at that time to address M-11-20 (fatigue management and oversight). To address recommendations M-11-19 through 21 the Board of Port Commissions adopted a new pilotage ordinance in September 2014 (attached: Ordinance 2780). This ordinance requires San Diego Bay pilots submit a traffic dispatch log on a weekly and quarterly basis. This log is then reviewed by Port of San Diego Maritime staff to ensure pilots are working within safe fatigue standards as set by section 6a in the new ordinance which references and empowers as an oversight document the Training, Professional Development and Oversight Program for Pilots at the Port of San Diego which has been attached for your reference. In this Oversight Program document Section V.B.1 addresses M-11-21 and Sections V.B.3 and Section VI.C address M-11-20. In reviewing in their entirety the new Ordinance and the new Training, Professional Development and Oversight Program document recommendation M-11-19 is addressed.

From: NTSB
To: San Diego Bay Pilots Association, Inc.
Date: 5/12/2015
Response: Your May 23, 2013, letter said that you had created a forum comprising representatives of the San Diego Bay Pilot’s Association, Port of San Diego Pilotage Advisory Council, the US Coast Guard, and the California State Lands Commission. You stated that this forum had proposed changes to your Ordinance 1603 that would require (1) pilots to submit weekly and quarterly traffic dispatch logs to the Port, (2) timely review of these logs to monitor pilot work hours, (3) mandatory recurrent pilot training, and (4) the establishment of the San Diego Pilotage Advisory Council as the oversight body to ensure implementation of these requirements and to perform ongoing process checks and improvements. You further stated that the ordinance would require annual physical examinations to determine pilots’ fitness to perform their jobs, and that the recommended changes would soon be presented to the Board of Port Commissioners for their approval. Based on this information, Safety Recommendations M 11 19 through -21 were classified OPEN—ACCEPTABLE RESPONSE on July 29, 2013. Completing actions to address our safety recommendations usually takes recipients 3 to 5 years or less, and these recommendations are now 3 1/2 years old. To date we have received no additional information from the Port of San Diego regarding whether you have implemented the recommended revisions to Ordinance 1603, and we would appreciate receiving a prompt reply regarding your progress. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. We point out that, to satisfy Safety Recommendation M-11-20, the Port of San Diego’s fatigue mitigation and prevention programs should address the following issues: • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. To satisfy Safety Recommendation M-11-21, the Port of San Diego should require initial and recurring bridge resource management training, similar to what other port pilot associations and commissions require. We look forward to receiving further information on the completion of revisions to the Port of San Diego Ordinance 1603 and on how these revisions address the issues specified in Safety Recommendations M-11-19 through -21. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21, the Port of San Diego’s May 23, 2013, response, and our July 29, 2013, reply are enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/MAR1104.aspx.

From: NTSB
To: San Diego Bay Pilots Association, Inc.
Date: 7/29/2013
Response: The NTSB understands that, in April 2012, the Port of San Diego created a forum that included representatives of the San Diego Bay Pilot’s Association, Port of San Diego Pilotage Advisory Council, the U.S. Coast Guard, and the California State Lands Commission, to evaluate current regulations and practices with respect to pilotage, identify areas of weakness, and develop recommendations for improvement. We note that the forum has proposed changes to the Port of San Diego Ordinance 1603, “Ordinance Regulating Pilotage and Pilots for the Port of San Diego”, to require pilots’ submission of weekly and quarterly traffic dispatch logs to the Port; timely review of the logs to monitor pilot work hours and immediately address any scheduling issues that may cause fatigue and danger to life, property, and environment; mandatory training and professional development for new and current pilots; and the establishment of the San Diego Pilotage Advisory Council as the oversight body to ensure implementation of these recommendations and to perform ongoing process checks and improvements. The NTSB notes that Port Ordinance 1603 also requires annual physical examinations to determine pilots’ fitness to perform their jobs, and that the recommended changes will soon be presented to the Port’s Board of Port Commissioners for approval. Pending implementation of the proposed changes and an explanation of how the changes address each recommendation, Safety Recommendations M 11 19 through -21 are classified OPEN—ACCEPTABLE RESPONSE. We point out that, to satisfy Safety Recommendation M-11-20, the Port of San Diego’s fatigue mitigation and prevention programs should address the following issues: • The frequency and methods used to inform pilots of the hazards of fatigue and effective strategies for preventing it • Specific hours-of-service rules that have been implemented to address the issues specified in element (2) of this recommendation. To satisfy Safety Recommendation M-11-21, the Port of San Diego should require initial and recurring bridge resource management training, similar to what other port pilot associations and commissions require. We look forward to receiving further information on the completion of revisions to the Port of San Diego Ordinance 1603 and on how the revisions address the issues specified in Safety Recommendations M-11-19 through -21.

From: San Diego Bay Pilots Association, Inc.
To: NTSB
Date: 5/23/2013
Response: -From Joel Valenzuela, Director of Maritime, Port of San Diego: This responds to the National Transportation Safety Board’s (NTSB) correspondences to the Port of San Diego (Port) regarding safety standards for bay pilots. The Port is committed to ensure safe and secure operations and is in the process of amending its ordinances to improve oversight of pilotage operations and associated safety issues. On April 18, 2012, the Port created a forum which included representatives from the San Diego Bay Pilot’s Association, Port of San Diego Pilotage Advisory Council, the United States Coast Guard, and the California State Lands Commission. The objectives of the forum are to evaluate current regulations and practices with respect to pilotage, identify areas of weakness, and develop recommendations for improvement. The forum met on April 18 2012, May 2, 2012, June 13, 2012, August 2, 2012 and August 22, 2012. Based on these meetings and consistent with NTSB recommendations M11-19 thru 21, the following changes to the Port Ordinance 1603, Ordinance Regulating Pilotage and Pilots for the Port of San Diego, are being proposed: 1. A requirement for pilots to submit weekly and quarterly traffic dispatch logs to the Port. These logs will include date and time of the commencing of each job, the date and time each job is completed, total number of hours/minutes spent on each job, the name of the vessel/barge, job description, and pilot's name. 2. A requirement for timely review of the logs to monitor pilot work hours and immediately address any scheduling issues that may cause fatigue and danger to life, property, and environment. 3. A requirement for mandatory training and associated training schedule for new pilots. 4. A requirement for professional development and continued training for current pilots. 5. The establishment of the San Diego Pilotage Advisory Council as the oversight body to ensure implementation of the above recommendations and to perform ongoing process check and improvement. Additionally, the current Port Ordinance 1603 already requires annual physical examinations to determine pilots’ fitness to perform job requirements. The recommended changes will be presented to the Port’s Board of Port Commissioners for approval in the near future. We will send you a copy of the revised ordinance once approved. Please do not hesitate to contact me with any questions or concerns.

From: NTSB
To: San Diego Bay Pilots Association, Inc.
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding San Diego’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: San Diego Bay Pilots Association, Inc.
Date: 6/14/2012
Response: This letter concerns Safety Recommendations M-11-19 through -21, stated below, which the National Transportation Safety Board (NTSB) issued to 26 addressees, including the state of California, on November 4, 2011. These recommendations resulted from the NTSB’s investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. On January 12, 2012, Ms. Traci Stevens; Acting Secretary; California Business, Transportation and Housing Agency, advised the NTSB that the only pilot group regulated by the state is the San Francisco Bar Pilots, which operates in the bays of San Francisco, San Pablo, Suisun, Monterey, and the tributaries to Sacramento and Stockton. Because the state of California does not exercise regulatory authority over Humboldt Bay, Port Hueneme, the Port of Los Angeles, the Port of Long Beach, or the Port of San Diego, and the regulatory authority lies exclusively with each of these local jurisdictions, the following recommendations are also being issued to the individual jurisdictions for action. We understand that the state of California previously forwarded these recommendations to you; for your convenience, a copy of our November 4, 2011, letter issuing these recommendations is enclosed. When responding, please refer to Safety Recommendations M-11-19 through -21.

From: NTSB
To: Port of Hueneme, Oxnard Harbor District
Date: 1/28/2019
Response: Safety Recommendation M-11-19 was classified CLOSED--RECONSIDERED on August 13, 2013, based on the information provided in the June 18, 2013, letter from Mr. Pete Wallace, Chief Operations Officer, Port of Hueneme, Oxnard Harbor District (see enclosure). We appreciate receiving your update verifying that you continue to manage an effective pilot safety oversight program. We will retain this information in our records.

From: Port of Hueneme, Oxnard Harbor District
To: NTSB
Date: 8/30/2018
Response: -From Captain Eric W. Ireland, Port Hueneme Pilot and Christina Birdsey, OHD Port Operations: The Port Hueneme Pilots Association and the Oxnard Harbor District meet quarterly to review operations and evaluate procedures to promote the highest level of safety.

From: NTSB
To: Port of Hueneme, Oxnard Harbor District
Date: 8/13/2013
Response: Because the Port of Hueneme/Oxnard Harbor District has had an effective pilot safety oversight program in effect since before Safety Recommendation M-11-19 was issued, the recommendation is classified CLOSED—RECONSIDERED.

From: Port of Hueneme, Oxnard Harbor District
To: NTSB
Date: 6/18/2013
Response: -From Pete Wallace, Chief Operations Officer: The Port of Hueneme, Oxnard Harbor District is in receipt of your stamp dated letter of April19, 2013 in which you state in paragraph three that the NTSB has not had a response to earlier request concerning the above referenced. Attached herewith are copies of the original responses that were emailed per instruction to correspondence@ntsb.gov. Please contact me if you have any further questions or concerns. The Oxnard Harbor District (OHD) exercises pilot oversight of the Port Hueneme Pilots Association (PHPS). With support from the OHD, the PHPA pilots work as a team and are acutely aware of our responsibilities to perform our services safely. We value our close relationship to the OHD. We will continue to work with the OHD to monitor, evaluate our practices and improve our operations when necessary. February 8, 2012 letter from Pete Wallace, Chief Operations Officer: The Oxnard Harbor District, Harbor Safety Committee is in receipt of a correspondence from the office of the Governor of California the honorable Edmund G. Brown Jr., to which is included the recommendations from the NTSB as referenced above. The letter and recommendations have been shared with the Port Pilots Advisory Committee and they are taking them under advisement. Thank you for your time and consideration in this important matter.

From: NTSB
To: Port of Hueneme, Oxnard Harbor District
Date: 4/19/2013
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents we investigate and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendations M-11-19 through -21, which we issued on November 4, 2011, as a result of our investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. Although it has been more than a year since these recommendations were issued, we have received no information to date regarding Port Hueneme’s actions to address them; accordingly, we would appreciate receiving a reply regarding any actions that you have either taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our November 4, 2011, letter issuing Safety Recommendations M-11-19 through -21 is enclosed. The full report of our investigation of the January 23, 2010, marine accident at the Port of Port Arthur, Texas (Report Number MAR-11-04), is available on our website at www.ntsb.gov.

From: NTSB
To: Port of Hueneme, Oxnard Harbor District
Date: 6/14/2012
Response: This letter concerns Safety Recommendations M-11-19 through -21, stated below, which the National Transportation Safety Board (NTSB) issued to 26 addressees, including the state of California, on November 4, 2011. These recommendations resulted from the NTSB’s investigation of the January 23, 2010, collision of the tankship Eagle Otome with the general cargo vessel Gull Arrow and the tank barge Kirby 30406, which was being pushed by the towboat Dixie Vengeance, at the Port of Port Arthur, Texas. On January 12, 2012, Ms. Traci Stevens; Acting Secretary; California Business, Transportation and Housing Agency, advised the NTSB that the only pilot group regulated by the state is the San Francisco Bar Pilots, which operates in the bays of San Francisco, San Pablo, Suisun, Monterey, and the tributaries to Sacramento and Stockton. Because the state of California does not exercise regulatory authority over Humboldt Bay, Port Hueneme, the Port of Los Angeles, the Port of Long Beach, or the Port of San Diego, and the regulatory authority lies exclusively with each of these local jurisdictions, the following recommendations are also being issued to the individual jurisdictions for action. We understand that the state of California previously forwarded these recommendations to you; for your convenience, a copy of our November 4, 2011, letter issuing the recommendations is enclosed. When responding, please refer to Safety Recommendations M-11-19 through -21.

From: Port of Hueneme, Oxnard Harbor District
To: NTSB
Date: 2/8/2012
Response: -From Pete Wallace, Deputy Executive Director, Maritime Services, Port of Hueneme, Oxnard Harbor District: The Oxnard Harbor District, Harbor Safety Committee is in receipt of a correspondence from the office of the Governor of California the honorable Edmund G. Brown Jr., to which is included the recommendations from the NTSB as referenced above. The letter and recommendations have been shared with the Port Pilots Advisory Committee and they are taking them under advisement. Thank you for your time and consideration in this important matter.