Testimony Before The House Transportation And Infrastructure Subcommittee On Coast Guard And Maritime Transportation “A Review Of Coast Guard Efforts To Improve Small Passenger Vessel Safety”

Good morning, Chairman Carbajal, Ranking Member Gibbs, and members of the subcommittee. Thank you for inviting the National Transportation Safety Board (NTSB) to testify, discuss our marine accident investigations and the lessons we have learned from those investigations, and reiterate how critical it is for our federal agency partners, our partners in industry, and for the Congress to heed those lessons learned and take action to help avoid future accidents.

As you know, the NTSB is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in other modes of transportation—highway, rail, marine, pipeline, and commercial space. We determine the probable cause of the events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we conduct special transportation safety studies and special investigations, and coordinate the resources of the federal government and other organizations to assist victims and their family members who have been impacted by major transportation disasters. We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and the United States Coast Guard, and we also adjudicate appeals of civil penalty actions taken by the FAA.

The NTSB does not have authority to promulgate operating standards, nor do we certificate organizations, individuals, or equipment. Instead, we advance safety through our safety recommendations. Those recommendations are issued to any entity that can improve safety, including the United States Coast Guard (USCG).[1] Our goal is to identify issues and advocate for safety improvements that, if implemented, would prevent tragedies and injuries, and save lives.

Marine Safety and Reauthorization

Before we get too far, I do want to thank the Coast Guard for collaborating with us to investigate marine casualties and improve marine safety. We conduct our marine safety investigations concurrent with the USCG’s, and we often reach the same conclusions; on the occasions when we reach different conclusions, we regularly make recommendations to address identified issues in the USCG’s regulations and processes. Either way, we approach these investigations with mutual respect and with the goal of improving safety on our nation’s waterways.

We have a broad mandate when it comes to marine safety. The NTSB investigates “major marine casualties,” [2] which can be anywhere in the world if a US-flagged vessel is involved. Our work touches vessels owned by the US government as well as private vessels. We also investigate select catastrophic marine casualties involving foreign-flagged vessels in international waters, especially if US citizens are on board.

Our current authorization expires at the end of this fiscal year. We have transmitted to Congress a reauthorization proposal to provide more resources and flexibilities which will allow us to hire, invest in our workforce in terms of training and development, and purchase equipment. Even as we have seen tremendous growth and change in transportation over the last two decades, the agency is the same size as it was in 1998. In just the last ten years, the NTSB’s Office of Marine Safety has dramatically increased its number of investigations. Before 2012, the office investigated and developed six reports annually on average. Subsequently, the office has been investigating all major marine casualties. Now, the caseload is over 40 per year, and at times over 50, while the cases have also grown more complex. However, our marine investigative staff has not grown with that increase, and we currently have 11 marine investigators. It is critical to have additional resources to respond to casualties without impacting timeliness, quality, and our independence. Our reauthorization proposal to Congress included a request for resources and hiring flexibilities to increase the number of investigators in our Office of Marine Safety, as well as in our other modes. These resources will allow us to hire professionals with the needed skills, purchase the equipment necessary for those skilled professionals to do their jobs, and invest in staff training and development. Our workforce is our greatest asset and is essential to our mission.

The Conception: Lessons Learned

I want to thank you, Chairman Carbajal, your colleagues in the California delegation, and the members of this committee for your commitment to marine safety and for enacting small passenger vessel safety provisions as part of the Elijah E. Cummings Coast Guard Authorization Act of 2020.[3] This legislation addressed 11 NTSB recommendations to improve small passenger vessel safety. Of those, 7 were made to the USCG as a result of our investigation of the September 2, 2019, fire and resulting sinking of the Conception here, near Santa Cruz Island, California. The Conception was a 75-foot commercial diving vessel on its last night of a 3-day diving trip with 39 people on board. The vessel caught fire while anchored in Platts Harbor, and 33 passengers and one crewmember died, making this the largest loss of life in a US marine casualty in decades and the greatest maritime loss of life in California in more than 150 years.

We determined the probable cause of the accident was the failure of the operator, Truth Aquatics, Incorporated, to provide effective oversight of its vessel and crewmember operations. The lack of both oversight and adherence to certain safety requirements allowed a fire of unknown cause to grow, undetected. In addition, the lack of a USCG regulatory requirement for smoke detection in all accommodation spaces and inadequate emergency escape arrangements from the vessel’s bunkroom contributed to the undetected growth of the fire and the high loss of life.

The Conception investigation was my first maritime investigation as an NTSB Board member, and the experience deepened my commitment to improving marine safety. During my time on scene, I met with the families of those on board the vessel and gave them the only promise we at the NTSB have to give: that we would find out what caused the fire aboard the Conception, to prevent similar suffering for other families.

Today, I will share some of the lessons learned from our investigation of the Conception accident and the roughly 50 marine accidents that we typically investigate annually. In particular, I will focus on the importance of safety management systems (SMSs); fire safety aboard small passenger vessels; safety issues unique to amphibious vessels, known as DUKW boats; and adequate options for emergency escapes in all cases. Additionally, although beyond the scope of this hearing, we have made equally important recommendations to the USCG to improve fishing vessel safety. These recommendations, which are included in the appendix, remain open because the USCG has taken unsatisfactory or no action to address them.

The NTSB has made multiple recommendations to the USCG and the maritime industry that must be implemented to close known safety gaps and to avoid another tragedy like the Conception. These recommendations specifically address:

inadequate company oversight;
voyage data recorders;
insufficient regulations for means of emergency egress;
lack of regulations requiring fire and smoke detection in machinery and all accommodation spaces of small passenger vessels;
neglected nighttime roving patrols;
insufficient reserve buoyancy; and
insufficient watertight integrity of vessels.

Safety Management Systems

For two decades, the NTSB has advocated for all passenger vessel operators to implement an SMS: a comprehensive, documented system to enhance safety. This call to action was first on our Most Wanted List of Transportation Safety Improvements over 10 years ago, and is again on our current list under “Improve Passenger and Fishing Vessel Safety.” [4] In fact, the NTSB has recommended SMSs in all modes of transportation—aviation, rail and transit, pipelines, marine, even manufacturers. In 2015, the Federal Aviation Administration (FAA) required commercial airliners to develop a comprehensive SMS to improve safety for the flying public, and this mandate has contributed to the remarkable record of safety in commercial passenger aviation. In fact, in 7 of the last 10 years, there have been no major commercial airline passenger fatalities. The number of accidents, the number of fatalities, and the fatality rate across the aviation industry have also decreased.

As an example, the FAA requires commercial airlines to develop and implement an SMS with four components:

A safety policy that outlines the methods, processes, and organizational structure needed to support safe operations.
A safety risk management process to constantly identify new hazards and control risk.
Safety assurance methods, such as audits, to evaluate if the desired safety outcomes are being achieved.
Safety promotion, also known as safety culture, which is a less tangible—but no less vital—aspect of a successful SMS.

For marine passenger vessels, regardless of a company’s size, an SMS ensures that each crewmember is given standard and clear procedures for routine and emergency operations. An SMS specifies crewmember duties and responsibilities, as well as delineates supervisory and subordinate chains of command, so that each crewmember understands what to do during critical vessel operations and emergency scenarios. Developing an SMS includes creating plans for crewmember responses to a range of possible emergency situations. SMSs also include procedures for performing and tracking preventive maintenance, as well as for crew training, emergency preparedness, documentation and oversight, and other actions that prioritize safe operations.

Since 2012, following the allision of the passenger ferry Andrew J. Barberi with a terminal at Staten Island, New York, the NTSB has recommended the USCG require all operators of US-flagged passenger vessels to implement an SMS, taking into account the characteristics, methods of operation, and nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate.[5] This is consistent with requirements imposed by the International Maritime Organization (IMO). In 2010, Congress mandated that the USCG develop appropriate SMS regulations for all US-flagged passenger vessels. As a result of the Conception investigation, we reiterated this recommendation, and the USCG published an advance notice of proposed rulemaking (ANPRM), “Safety Management Systems for Domestic Passenger Vessels,” in January 2021.[6] The Board submitted comments to the ANPRM and subsequently updated the status of this safety recommendation to “Open—Acceptable Response.”[7]

The NTSB’s investigation of the Andrew J. Barberi was hampered by a lack of voyage data recorder (VDR) information. A VDR is a fire- and crash-protected recorder that captures critical vessel information as well as audio from the bridge environment. This information can be accessed by investigators following accidents and reviewed by vessel operators as part of their SMS programs to help prevent accidents. In 2014, we recommended that the USCG require installation of VDRs on new and existing ferry vessels, where technically feasible, and develop a standard for smaller ferry vessels.[8] These recommendations are currently classified “Open—Unacceptable Response.”

Further, we have recommended that the USCG require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical

systems.[9] We generally expect recommended actions to be completed in 5 years, but this has

languished for 20 years and, therefore, is in an unacceptable status. This is our oldest open marine safety recommendation. We have kept it open because the USCG has informed us since 2012 that it would include this action as a component of a broader requirement for SMS.

We continue to believe that an SMS is an essential tool for enhancing safety on board all

US passenger vessels, and that the USCG is the appropriate authority to require such systems. We

fully support the requirement mandated by Congress. We also believe that an SMS is not a

substitute for important safety regulations that are issued by the USCG. Safety regulations need to

be implemented and an SMS enhances the impact of those regulations.

Fire Safety for Small Passenger Vessels

As a result of the Conception disaster, we issued seven new safety recommendations

specifically related to fire safety and egress. All seven were addressed by the Elijah E. Cummings

Coast Guard Authorization Act of 2020 and are currently classified “Open—Acceptable

Response.”

To ensure fire safety aboard small passenger vessels, redundancy is critical. First, we

made several recommendations to the USCG to update its regulations regarding accommodation

spaces in all passenger vessels, including those constructed prior to 1996. We recommended that

they require all accommodation spaces, for new vessels and those currently in service, have

smoke detectors".[10] Second, we recommended that the USCG develop and implement an

inspection procedure to ensure that operators are conducting “roving patrols” as required by

regulations and which has been codified in US law since 1871. [11] The current statute states that

“the owner, operator, or charterer of a vessel carrying passengers during the nighttime shall keep

a suitable number of watchmen in the vicinity of cabins or staterooms and on each deck to guard

against and give alarm in case of fire or other danger.”[12] This was not the practice on

Conception, other vessels owned by Truth Aquatics, nor, according to interviews, other dive

boats in Southern California.

Even if a fire breaks out, loss of life is still preventable with adequate options for and

awareness of emergency egress. The Conception had two means of escape from the bunkroom:

spiral stairs forward and an escape hatch aft, accessible from either port or starboard aisles by

climbing into one of the top aftermost inboard bunks. However, both paths led to the salon, which

was filled with heavy smoke and fire, and the salon compartment was the only escape path to

exterior (weather) decks. Therefore, because there was fire in the salon, the passengers and one

crewmember housed below were trapped and were not able to escape. If regulations had required

the escape hatch to exit to a space other than the salon, optimally directly to the weather deck, the

passengers and crewmember in the bunkroom would have likely been able to escape. For those

reasons, we recommended that the USCG update its regulations for small passenger vessels with

overnight accommodations, including those constructed prior to 1996, to require a secondarymeans of escape into a different space so a single fire will not affect both escape paths and to ensure there are no obstructions to egress.[13] These recommendations are currently classified “Open—Acceptable Response,” because we understand that the Coast Guard has initiated a rulemaking project to implement the recommendations for all small passenger vessels with overnight accommodations, including vessels constructed prior to 1996.

In addition to fire safety in vessels with accommodation spaces, prior to the Conception

tragedy, we issued two recommendations to the USCG regarding unmanned spaces. We

recommended that they require fire-detection systems in unoccupied spaces with machinery or

other potential heat sources on board small passenger vessels, and for them to issue a marine safety information bulletin regarding the need to use only approved material and components in fuel tank level-indicator systems.[14] The USCG has issued the bulletin and the recommendation has been closed successfully, but further action is needed to require additional fire detectors.

Again, we appreciate Congress addressing these safety issues in legislation, and for the

cooperation and partnership of the USCG. We look forward to the USCG issuing a final rule to

implement our recommendations and improve safety.[15] Until that time, the recommendations will

remain open. In the meantime, operators of vessels with overnight accommodations can act now

to improve the safety of their passengers and crew. They can start with the following even before

the USCG completes rulemaking:

Install smoke detectors in sleeping quarters and ensure they are interconnected so when one detector goes off, they all do. The Conception crewmember who discovered the fire could not hear the fire alarm from the crew berthing on the upper deck.

Ensure that the primary and secondary emergency escape paths do not lead to the same space, which can be blocked by a single hazard. The Conception had two means of escape from the lower deck bunkroom, but both led into the salon, which was filled with heavy smoke and fire. Tragically, the salon compartment was the only escape path to the weather deck. Because there was fire in the salon, the passengers were trapped.
Keep the escape routes unobstructed at all times.

Remind crewmembers to perform roving patrols and why they are so important. Our investigation found that the Conception fire was uncontrollable by the time it was discovered because the crewmember, who ultimately died, was asleep in the bunkroom.

Amphibious Passenger Vessel Safety: The Importance of Action

Unfortunately, we know that the consequences of failing to address the lessons learned

from our safety investigations can be further tragedies. Almost 20 years after the sinking of an

amphibious passenger vessel that killed 13 people in Arkansas, we investigated the sinking of a

DUKW amphibious passenger vessel, Stretch Duck 7, on Table Rock Lake near Branson,

Missouri.[16] We discovered that long-known safety issues caused the sinking and resulted in the loss of 17 lives. I want to thank you for addressing these safety issues in H.R. 6865, the Coast Guard Authorization Act of 2022.

DUKW amphibious vehicles were designed and built in the 1940s for military use during World War II; some were later converted for commercial service.[17] They are unique vessels with special challenges that must be addressed to ensure passenger safety.

Five minutes into its voyage on July 19, 2018, the Stretch Duck 7, with 31 passengers aboard, encountered a severe storm known as a derecho. While trying to reach land, 7 minutes into the voyage, the vessel took on water and sank approximately 250 feet away from the exit ramp. Passengers were caught by the vessel’s canopy as it sank. Only a few of the surviving passengers stated that they were able to float free without encountering any obstructions. Several hours prior to the accident, the National Weather Service had issued a severe thunderstorm watch for the area, followed by a severe thunderstorm warning a minute before the vessel departed.

NTSB investigators found that the accident vessel was originally constructed with a low freeboard, an open hull, and no subdivision or flotation, resulting in a design without adequate reserve buoyancy. We determined the probable cause of the sinking was the operator’s continued operation of waterborne tours after a severe thunderstorm warning was issued for Table Rock Lake, exposing the vessel to a derecho, which resulted in waves flooding through a non-weathertight air intake hatch on the bow. Contributing to the sinking was the USCG’s failure to require sufficient reserve buoyancy in amphibious passenger vessels. Contributing to the loss of life was the Coast Guard’s ineffective action to address emergency egress on amphibious passenger vessels with fixed canopies, such as the Stretch Duck 7, which impeded passenger escape.

As noted, these safety issues were not new when the Stretch Duck 7 sank. They were identified after the 1999 sinking of the Miss Majestic, another DUKW amphibious passenger vessel, on Lake Hamilton, near Hot Springs, Arkansas.[18] As a result of that sinking, 13 passengers died. Survivors of the Miss Majestic accident confirmed that the vehicle sank less than a minute after the deck edge at the stern was submerged, leaving insufficient opportunity for passengers to escape. Vessel maintenance, reserve buoyancy, and survivability—specifically, impediments to passenger egress caused by the vessel’s canopy—were among the major safety issues identified by our investigation of the Miss Majestic accident.

As a result of the Miss Majestic sinking, we recommended that the USCG require greater stability and reserve buoyancy in amphibious passenger vessels.[19] Further, until the goals of that recommendation were achieved, we urged the USCG to require—among other measures—that canopies be removed from waterborne vessels, or that such vessels have installed a USCG-approved canopy that does not restrict horizontal or vertical escape by passengers in the event ofsinking.[20] These recommendations were closed unacceptably in 2003 and 2007, respectively.

Regrettably, had these recommendations been implemented, a future tragedy could have been

avoided.

More than 15 years later, because of the Stretch Duck 7, we recommended again that

amphibious passenger vessels have sufficient reserve buoyancy so they remain upright and afloat

in the event of damage or flooding, and that for DUKW vessels without sufficient reserve

buoyancy, that they require the removal of canopies, side curtains, and their associated framing

during waterborne operations to improve emergency egress in the event of sinking.[21] The USCG

has not been able to identify a feasible solution to achieve the necessary level of reserve buoyancy, and contracted with the National Academy of Sciences (NAS) to conduct an independent review of potential modifications. The USCG has also issued a marine safety information bulletin recommending removal of canopies as an initial step.[22] For these reasons, both recommendations remain classified “Open—Acceptable Response.”

In 2015, we investigated a highway crash of a DUKW in Seattle, Washington. [23] As a

result, we recommended the USCG amend its Navigation and Vessel Inspection Circular (NVIC)

1-01, a guidance document that relies on voluntary compliance, to ensure passengers unbuckle

before waterborne operations and the crew confirms that passengers have complied.[24] Following

the Stretch Duck 7 sinking, we recommended reviewing and revising the NVIC.[25] Although the

USCG has communicated to us it will make the recommended revisions, the NVIC has not been

updated; therefore, these recommendations remain classified “Open—Acceptable Response.”

Lastly, the benefits of these safety improvements are not realized if crews have insufficient

awareness. Accordingly, we have recommended that the USCG review and revise training,

especially as it relates to severe weather.[26] Each of these recommendations is on our 2021–2022

Most Wanted List. Again, thank you for addressing these issues in the pending Coast Guard

authorization.

Conclusion

The loss of 34 lives on the Conception, less than 100 feet from shore, shook this community

and the country. It reminds us that the potential for catastrophe is always present, including on

small passenger vessels, and we must do what we can to prevent needless deaths and mitigate

injuries. Passenger vessels should have SMSs and provide adequate fire detection and

extinguishing systems and enhanced emergency egress options. Inaction can lead to further

tragedy, as we saw with the Stretch Duck 7 almost 20 years after the Miss Majestic sinking. We recognize the progress that has been made, yet, there remains room for improvement. The NTSB stands ready to work with you and this Committee to continue improving passenger vessel safety.

Thank you again for the opportunity to testify today. I am happy to answer your questions.

[1] There are currently 93 open safety recommendations to the USCG, 32 of them with the status “Open—Unacceptable Response.” Of the 93 recommendations, 24 are associated with our Most Wanted List of Transportation Safety Improvements item, “Improve Passenger and Fishing Vessel Safety,” and 8 of those are currently classified “Open—Unacceptable Response.” These recommendations are included in the appendix to this testimony.

[2] Defined in 49 Code of Federal Regulations 850.5 as a “casualty involving a vessel, other than a public vessel, that results in (1) The loss of six or more lives; (2) The loss of a mechanically propelled vessel of 100 or more gross tons; (3) Property damage initially estimated as $500,000 or more; or (4) Serious threat, as determined by the Commandant and concurred in by the Chairman, to life, property, or the environment by hazardous materials.”

[3] Enacted as part of the National Defense Authorization Act for Fiscal Year 2021 (PL116-283, Division G, sec. 8441).

[4] 2021–2022 Most Wanted List of Transportation Safety Improvements. Improve Passenger and Fishing Vessel Safety. Washington, DC: NTSB.

[5] Safety Recommendation M-12-3.

[6] Safety Management Systems for Domestic Passenger Vessels. 89 Federal Register (FR) 3899.

[7] NTSB Comments on USCG-2020-0123.

[8] Safety Recommendations M-14-3, -4, and -5.

[9] Safety Recommendation M-02-5.

[10] Safety Recommendations M-20-14, -15, and -16.

[11] Safety Recommendation M-20-17.

[12] 46 United States Code (USC) 8102

[13] Safety Recommendations M-20-18, -19, and -20.

[14] Safety Recommendations M-18-13 and -14.

[15] Fire Safety of Small Passenger Vessels. 86 FR 73160.

[16] Sinking of Amphibious Passenger Vessel Stretch Duck 7, Table Rock Lake, near Branson, Missouri, July 19, 2018. (NTSB, MAR 20/01).

[17] DUKW (pronounced “duck”) is an acronym that signifies the characteristics of the WWII amphibious vessel: D = 1942 (the year of design); U = utility; K = front-wheel drive; and W = two rear-driving axles. DUKW vessels are also referred to as vehicles due to their dual function of being operated on land and in water.

[18] Sinking of the Amphibious Passenger Vehicle Miss Majestic, Lake Hamilton, Near Hot Springs, Arkansas, May 1, 1999. (NTSB, MAR 02/01).

[19] Safety Recommendation M-02-1.

[20] Safety Recommendation M-02-2.

[21] Safety Recommendations M-19-15 and-16.

[22] US Coast Guard Marine Safety Information Bulletin. Recommendation for DUKW Passenger Vessel Canopy Removal. Washington, DC: 2020. MSIB-15-20.

[23] Amphibious Passenger Vehicle DUCK 6 Lane Crossover Collision with Motorcoach on State Route 99, Aurora Bridge, Seattle, Washington, September 24, 2015. (NTSB, HAR-16/02)

[24] Safety Recommendation M-16-26.

[25] Safety Recommendation M-20-2.

[26] Safety Recommendation M-20-3.