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Safety Recommendation Details

Safety Recommendation M-11-021
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: Require local pilot oversight organizations that have not already done so to implement initial and recurring bridge resource management training requirements.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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:
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 (Open - Acceptable Response)
Commonwealth of Virginia (Closed - Reconsidered)
Humboldt Bay Harbor, Recreation and Conservation District (Closed - Reconsidered)
Port of Hueneme, Oxnard Harbor District (Closed - Acceptable Action)
San Diego Bay Pilots Association, Inc. (Closed - Acceptable Action)
State of Alabama (Closed - Unacceptable Action - No Response Received)
State of Alaska (Closed - Reconsidered)
State of California (Closed - Reconsidered)
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 - Acceptable Action)
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 - Reconsidered)
State of Maine (Closed - Reconsidered)
State of Maryland (Closed - Reconsidered)
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 - Reconsidered)
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: Because, since 1997, Alaska pilots have been required to take the initial and recurrent BRM training we recommend, Safety Recommendation M 11 21 is classified CLOSED—RECONSIDERED.

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: SEAPA has been especially proactive in this regard. All trainees are required to attend a formal BRM-P course and all Members are required to attend a BRM-P refresher course every five years. Most Pilots attend these courses much more frequently. SEAPA also periodically conducts several "in house" seminars where veteran and deputy pilots interact together solving potential piloting problems that may arise during the course of an assignment. Discussions on managing the bridge team through close cooperation, coordinating and utilizing all resources available to answer questions such as when to deploy and how to use tugs in the most efficient and optimum manner given the massive windage of most cruise ships. All this and more occur throughout the summer season starting in the spring as pilots ramp up to begin the summer season. Thank you. -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: Recommendation M-ll-21 Bridge Resource Management Training - SWAPA, in accordance with its' Board Approved Training Program and State statutes requires all Pilots and Deputy Marine Pilots complete a State approved Manned Model course. Continuing education requires that Manned Model courses are then completed at least once every six years in addition to other substantial training programs required for continuing education requirements. These courses include ship handling and BRM certifications. BRM courses address the pre-eminent role that pilots play in vessel navigation and accordingly these courses are specifically designed for pilots. As mentioned above, SWAPA pilots also attend simulator training with other industry members and attend multi day courses such as "Advanced and Emergency Ship Handling". SWAPA pilots understand that being fit for duty and properly trained are essential as their livelihoods and personal safety, as well as the safety and protection of shipping, human life, property and the marine environment depend on it. If you have any questions, please do not hesitate to contact me. -From Captain Carter Whalen, President, Alaska Marine Pilots, LLC: Alaska Marine Pilots LLC has a BRM requirement for initial licensing. Furthermore, our pilots practice a pilot / Master conference prior to transit and or docking / un-docking to discuss the passage plan, tides, currents, anticipated weather, traffic concerns, the berthing arrangement, the availability of adequate tugs, tug use, mooring line arrangement, and to identify any vessel deficiencies that may impact the safe and efficient maneuvering of the vessel within state pilotage waters. As part of our continuing education, AMP observed the Bridge Resource Management practices aboard containerships and tankers along the 52-mile Houston Ship channel this December. These are examples of what AMP does to keep current with bridge resource management.

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. The NTSB notes that, since the mid-1990s, the BOPC has mandated that San Francisco pilots complete initial and recurrent BRM training. Accordingly, Safety Recommendation M-11-21 is classified CLOSED—RECONSIDERED.

From: NTSB
To: State of California
Date: 2/29/2012
Response:

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-11-21 This recommendation calls for requiring local pilot oversight organizations that have not already done so to implement initial and recurring "bridge resource management" training requirements. The BOPC, as part of its statutory duty, implemented and administers a pilot continuing education program for licensed pilots. The subject of "Bridge Resource Management" is a major part of the training program. There is a 2I-hour seminar with simulation exercises and special emphasis placed on situational awareness, situational and risk analysis, and decision-making process used by pilots. The training segment is combined with Emergency Ship Handling Procedures. Completion of this training course is mandatory for pilots who must repeat the training every five years. The course is continuously updated with relevant information. Having an effective and mandatory bridge resource management professional continuing education course, the San Francisco Bar Pilots are in compliance with the NTSB safety recommendation M-11-21. While it is our assessment that existing statutory, regulatory, and BOPC oversight of the San Francisco Bar Pilots appears to satisfy the safety 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. 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 are aware that Connecticut has had a BRMp training requirement in place since the American Pilots Association’s training resolution was issued in 2000, and are pleased to learn that, in 2013, Connecticut established a fund specifically to pay for safety equipment and pilot training. These provisions satisfy Safety Recommendation M-11-21, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of Connecticut
To: NTSB
Date: 2/11/2016
Response: -From James Redeker, Commissioner, State of Connecticut, Department of Transportation: The Department working with CSP has implemented recurring Bridge Resource Management Training. The course covers Fatigue Mitigation and Prevention as well as Hazards of Fatigue and effective strategies for prevention, and should be repeated every three years. In 2013, state regulations established a Training Fund dedicated to pilot training and safety equipment. This training fund is supported by a fee charged vessels calling in Long Island Sound for each pilot boat transfer. Starting in the 2017 pilot licensing year there will be a Policy and Procedure Fatigue Mitigation Notice each pilot will have to sign acknowledging that he has read and understands the policy notice. It is the Department's opinion that the existing regulations and safe guards in place meet the current Policy and Procedures relative to Fatigue Mitigation. The Connecticut Pilot Commission will continue to monitor the CSP organizations safety and training policies, and modify policy as needed.

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 HPA sends each of its pilots to recurrent BRM training every 5 years, and did so before Safety Recommendation M 11 21 was issued, 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: HPA already sends all their pilots on a rotational basis every five years to bridge resource management training.

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 administratively, no letter was ever sent using CC# 201200440.

From: NTSB
To: State of Louisiana
Date: 7/17/2012
Response: Because Louisiana’s requirement for pilots to take initial and recurrent BRM training was in place prior to our issuance of Safety Recommendation M-11-21, this recommendation is classified CLOSED—RECONSIDERED.

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: Although the Commission requires only initial BRM training of its state-licensed pilots, we are pleased that the state’s two local pilot associations, the Port of Portland Pilots Association and the Penobscot Bay and River Pilots Association, both APA members, have required initial and recurrent BRMp since 2000, 11 years before we issued this recommendation. Accordingly, Safety Recommendation M-11-21 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: All Maine state pilots are required to attend a Bridge Resource Management [for Pilots] course (BRM) as a condition of state licensure per Maine Department of Transportation Chapter 1, Rule A.1. In addition to BRM, the Maine State Pilot Commission also requires, through Chapter 1, Rule A.4, RADAR observer and Automatic Radar Plotting Aids (ARPA) as conditions of licensure. BRM training is not currently required to be periodically refreshed under the Maine Pilotage Rules, nor is there a Federal requirement for such training. RADAR and ARPA refresher training is already a license renewal requirement (every five years) under Chapter 1, Rule A.4 of the Maine Pilotage Rules.

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: Because Maryland pilots have been required since 1997 to take both initial and recurrent BRM training, Safety Recommendation M 11 21 is classified CLOSED—RECONSIDERED.

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 licensed state pilots are required to complete an American Pilots Association?approved Bridge Resource Management and Emergency Handling course, which also addresses fatigue and fatigue prevention. This continuing education is required not only by the association but also by PDA DPH. Because these training requirements were in place before we issued Safety Recommendation M 11-21, 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: Because New Jersey has required its pilots and docking masters to complete initial and recurrent bridge resource management training every 2 years since 2004, prior to issuance of Safety Recommendation M-11-021, it is classified CLOSED—RECONSIDERED.

From: State of New Jersey
To: NTSB
Date: 8/10/2016
Response: -From Andre M. Stuckey, Executive Director: In 2004 when the Commission was initially granted the authority to license Docking Pilots, it funded a joint course in Bridge Resource Management Training to ensure the two sets of pilots worked together and understood their respective roles. Upon successful completion of that course the pilots were then mandated to attend Bridge Resource Management Training every two years as part of their recurrent training program. As part of their state licensing requirements, our apprentices are required to write a narrative of a proper master /pilot exchange before they can receive their state license.

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 1995, the Board has required all pilots to participate in initial and recurrent BRM training; accordingly, Safety Recommendation M-11-21 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: Because the Board for Branch Pilots requires all its pilots to attend initial and recurrent BRM training and this requirement was in place before we issued Safety Recommendation M 11-21, 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 requires its pilots to complete bridge resource management training on a five year rotation. The Virginia Pilots have participated in this training for the past twenty years. This American Pilots Association approved training course includes a portion on fatigue mitigation and education. The Virginia Pilot Association training for this course will be completed by the Commonwealth's licensees during the months of December, 2015, January and February, 2016. The Board for Branch Pilots endorses this program for education on the issue of fatigue. Although the Board for Branch Pilots has determined that the Virginia Pilot Association is already meeting the recommendations outlined in your letter by its current rules in place for pilots as cited above, the Board decided that going forward, they will review the VPA's rules addressing fatigue each December.

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: 1/10/2017
Response: We understand that you are not yet in a position to fund recurring BRM training; however, we are pleased that you funded initial BRM training for new pilots and a one-time refresher training for all pilots in November and December 2016. Further, we are encouraged that you are evaluating a tariff revision for your pilot operation to fund additional training for pilots, including recurrent BRM training. Pending notification that the Puerto Rico Pilotage Commission has implemented a recurring BRM training program, Safety Recommendation M 11-21 is classified OPEN--ACCEPTABLE RESPONSE.

From: Commonwealth of Puerto Rico
To: NTSB
Date: 11/9/2016
Response: -From Captain Fulgencio Anavitate, President, Comision de Practicaje de Puerto Rico: In response to the National Transportation Safety Board (NTSB) correspondence dated October 17, 2016, the Puerto Rico Pilotage Commission (Commission) is pleased to inform you that during its last monthly meeting, and even though the financial situation has not improved, the Commission approved to temporarily assign funds to guarantee compliance of NTSB Safety Recommendation M-11-21. The Commission ordered the Pilot Associations to schedule two (2) groups that will attend Resolve Maritime Academy to participate in the Bridge Resource Management Training for Pilots. The first group will begin the training on November 28, 2016, and the second group will begin on December 12,2016. The Puerto Rico Pilotage Commission is in the process of evaluating a Tariff Revision for its operation to be able to provide pilots with certain additional training other than licensing requirements.

From: NTSB
To: Commonwealth of Puerto Rico
Date: 10/17/2016
Response: A February 19, 2016, letter from Captain David Aviles, President, Puerto Rico Pilot Commission (commission), informed us that all active Puerto Rico pilots have completed either initial or basic BRM training, and we were encouraged to learn that the commission was in the process of identifying the necessary funds to establish additional or recurrent BRM training for pilots. Pending confirmation that Puerto Rico pilots will receive the recurring BRM training we recommended and our receipt of details regarding recurrent training, Safety Recommendation M 11-021 was classified OPEN—UNACCEPTABLE RESPONSE. Please note that, of the 31 original addressees that received this nearly 5-year-old recommendation, Puerto Rico is the only one that still holds an open classification. As such, we would appreciate receiving a prompt reply on the status of your efforts to secure the necessary funds to establish recurrent BRM training for all pilots. 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-11-021 and our database history of M-11-020 to the commonwealth of Puerto Rico 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: 6/7/2016
Response: We appreciate learning that all active Puerto Rico pilots have completed either initial or basic BRM training and are encouraged to note that the commission is in the process of reviewing ways it might identify necessary funds to establish additional or recurrent BRM training for pilots. However, pending confirmation that Puerto Rico pilots will receive the recurring BRM training we recommended and our receipt of details regarding recurrent training, Safety Recommendation M-11-21 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: Commonwealth of Puerto Rico
Date: 7/23/2015
Response: We note that, because of a lack of resources, the Commission requires only initial BRM training for newly hired pilots and encourages current pilots to obtain additional BRM training on their own rather than requiring recurrent BRM training. The American Pilots Association has mandated that its state pilot associations attend initial and recurrent BRM training, and many ports operating with federal pilots also require initial and recurring BRM training. Accordingly, we request that Puerto Rico reconsider its present position, seek any necessary funding, and require recurrent BRM training, in addition to initial training, for all pilots. Pending your reply to this request, Safety Recommendation M-11-21 is classified OPEN—UNACCEPTABLE RESPONSE.

From: Commonwealth of Puerto Rico
To: NTSB
Date: 5/29/2015
Response: -From Captain Daniel Murphy, Interim President, Puerto Rico Pilot Commission: Unfortunately, The Puerto Rico Pilot Commission does not have the resources necessary to provide BRM training to all current Pilots. However, all newly hired Pilots are required to have this training as a condition of employment. Current Pilots are encouraged to obtain BRM training on their own.

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: On May 1, 2012, based on information contained in Oregon’s January 23, 2012, letter, indicating that the state had established an initial and recurrent BRM training program prior to the issuance of this recommendation and clarifying that pilots are receiving the recommended training, Safety Recommendation M-11-21 was classified CLOSED—RECONSIDERED. For your convenience, copies of both the state of Oregon’s letter and our letter classifying the recommendation are enclosed.

From: NTSB
To: State of Oregon
Date: 5/1/2012
Response: Because Oregon had established an initial and recurrent BRM training program prior to the issuance of this recommendation, and pilots are receiving the recommended training, Safety Recommendation M-11-21 is classified CLOSED—RECONSIDERED.

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: CDLRIP members participate in re-occurring bridge resource management training as required by the OMBP. -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 Otome 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: The Board regulations already require periodic BRM training.

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: Because Rhode Island has required pilots to complete both initial and recurrent BRM training for some time, Safety Recommendation M-11-21 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: Because South Carolina already requires initial and recurrent BRM training for state pilots, Safety Recommendation M-11-21 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: Because Washington has required pilots to complete both initial and recurrent BRM training for some time, Safety Recommendation M-11-21 is classified CLOSED—RECONSIDERED.

From: State of Washington
To: NTSB
Date: 1/31/2012
Response: -From Christine O. Gregoire, Governor: The RCW mandates that all new pilots take vessel simulator training in their first year of active duty and at least every five years thereafter. Many modern vessel simulator training curricula include Bridge Resource Management (BRM) as part of the course. In addition, both PSP and PGH regularly send pilots to various courses to maintain or improve pilotage skills. The range of such courses includes BRM training. For some time, PSP has had a regular training cycle of Bridge Resource Management training provided to its pilots on a recurring basis. This has recently been augmented into a Risk Resource Management class that incorporates Bridge Team Management training with error chain recognition and crisis management. This program was developed by PSP working with a local maritime educator and is a model that has been used around the country. In summary, the Board has consistently managed pilotage in Washington in an aggressive and professional manner. The Board carefully monitors and evaluates pilots throughout their career. The Board's involvement includes: • Using established psychometric standards in developing criteria for selecting potential pilot applicants for entry into the Board's training program. • Evaluating the trainee's performance in a comprehensive training program to determine suitability for a pilot's license. • Monitoring the physical condition of trainees and pilots by requiring thorough annual medical examinations. • Requiring post-licensing training. • Analyzing any circumstance that might indicate that pilot error could have been involved in a near miss or incident. • Providing for remedial actions (including fines and/or revocation of license) where appropriate. • Issuing Safety Advisory Bulletins. • Implementing many other actions as needed to ensure that pilotage in Washington State is as safe and efficient as reasonably possible. I believe that the Board is highly proficient in carrying out the requirements of the Pilotage Act and as a result is already very effectively conforming to the recommendations in your letter. The Board fully understands that it can never "rest on it's laurels." Therefore, it diligently reviews what is happening in our pilotage grounds and others around the world in order to determine ifthere are any aspects of pilotage in Washington that can be improved. One of the ways it does that is to participate in a biennial regional meeting of West Coast pilotage authorities (plus representatives from pilot associations and the shipping industry) from California, Oregon, Washington, British Columbia, and Alaska. Representatives from the American Pilots Association and other national organizations interested in safe navigation attend as well. Such meetings allow an exchange of information that helps all the participating pilotage authorities, pilots, and ship operators to improve maritime safety along the entire West Coast. The Washington Board plans to host the next regional meeting in the last quarter of 2012.

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 note that Humboldt Bay’s Ordinance No. 15, Article 5, Professional Development, Section 5.1.c, requires that pilots undergo simulator and bridge resource management training for pilots at least once every 5 years. Because this requirement was in place before we issued Safety Recommendation M-11-21, the recommendation is classified CLOSED—RECONSIDERED.

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: 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: 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: Port of Hueneme, Oxnard Harbor District
Date: 1/28/2019
Response: Safety Recommendation M-11-21 was classified CLOSED--ACCEPTABLE ACTION on August 13, 2013, based on the information provided in the June 18, 2013, letter from Mr. Pete Wallace (see enclosure). We appreciate receiving your update verifying that you continue to require initial and recurring BRM training for all your pilots. 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: Starting January 1, 2020, the pilots that do not already have a BRM·Certificate, will be required to attend Bridge Resource Management training. The BRM certificate shall be renewed every 5 years.

From: NTSB
To: Port of Hueneme, Oxnard Harbor District
Date: 5/2/2015
Response:

From: NTSB
To: Port of Hueneme, Oxnard Harbor District
Date: 8/13/2013
Response: Because the Port of Hueneme/Oxnard Harbor District will now require that all PHPA pilots take the initial and recurring BRM training we requested, Safety Recommendation M 11 21 is classified CLOSED—ACCEPTABLE ACTION.

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. With consultation with and support from the OHD, the PHPA pilots plan to attend bridge resource management training and establish a recurrent schedule. 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: 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 had established an initial BRM training program prior to the issuance of this recommendation, and has since revised its policies to ensure that pilots are receiving the recommended training on a biannual basis. Accordingly, Safety Recommendation M-11-21 is classified CLOSED—ACCEPTABLE ACTION.

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: The Pilot Training Program requires that all pilots receive annual training, alternating between computer simulated and manned model training. Though not previously a training requirement, the Port's pilots have completed bridge management training in recent years. As the result of this recommendation the Port Pilot Training Program has been changed to include a requirement for Bridge Management Training every other year.

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: Because Port of Long Beach pilots have been required for over 10 years to take the initial and recurrent BRM training that we recommend, Safety Recommendation M 11 21 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. The Council has approved and has fully supported the Jacobsen Pilot Service's Bridge Resource Management Program (BRMP). The BRMP program has been in place for over ten years here at the Port of Long Beach and ALL pilots are required to attend as a condition of employment at Jacobsen Pilot Service. We believe Jacobsen Pilot Service's procedures are fully compliant with and in fact exceed the NTSB recommendations regarding BRMP. The Port of Long Beach extends its gratitude to the NTSB for continuing efforts to safeguard our nation's transportation industries. We also thank the NTSB for providing the opportunity to review your findings and evaluate our own processes in an effort to prevent future accidents and increase safety here at the Port of Long Beach.

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: Because the Port of San Diego revised its pilot regulations, effective September 16, 2014, to require the recommended initial and recurrent BRM training for all pilots, Safety Recommendation M-11-21 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.