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Safety Recommendation Details

Safety Recommendation M-09-004
Details
Synopsis: On Wednesday, November 7, 2007, about 0830 Pacific standard time, the Hong Kongregistered, 901-foot-long container ship M/V Cosco Busan allided with the fendering system at the base of the Delta tower of the San Francisco Oakland Bay Bridge.1 The ship was outbound from berth 56 in the Port of Oakland, California, and was destined for Busan, South Korea. Contact with the bridge tower created a 212-foot-long by 10-foot-high by 8-foot-deep gash in the forward port side of the ship and breached the Nos. 3 and 4 port fuel tanks and the No. 2 port ballast tank. As a result of the breached fuel tanks, about 53,500 gallons of fuel oil were released into San Francisco Bay. No injuries or fatalities resulted from the accident, but the fuel spill contaminated about 26 miles of shoreline, killed more than 2,500 birds of about 50 species, temporarily closed a fishery on the bay, and delayed the start of crab-fishing season. Total monetary damages were estimated to be $2.1 million for the ship, $1.5 million for the bridge, and more than $70 million for environmental cleanup.
Recommendation: TO THE UNITED STATES COAST GUARD: Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. (Supersedes M-05-005)
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Marine
Location: San Francisco Bay, CA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA08MM004
Accident Reports:
Allision of Hong Kong-Registered Containership M/V Cosco Busan With the Delta Tower of the San Francisco-Oakland Bay Bridge
Report #: MAR-09-01
Accident Date: 11/7/2007
Issue Date: 5/8/2009
Date Closed:
Addressee(s) and Addressee Status: USCG (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 1/31/2019
Response: The National Transportation Safety Board (NTSB) has reviewed the US Coast Guard’s notification of availability and request for comments regarding its draft Merchant Mariner Medical Manual, which was published in 83 Federal Register 56272, on November 13, 2018. The request seeks comments about the manual’s “readability, clarity, and ease of use” as well as whether the draft Manual adequately addresses safety concerns in situations where the Coast Guard receives information indicating that a medical certificate holder has developed a medical condition that poses a significant risk of sudden incapacitation, or is taking a medication that poses a significant risk of impairment. The NTSB is pleased that the Coast Guard has developed the draft manual and appreciates the opportunity to respond to this request. As a result of its investigation into the 2003 allision of the Staten Island Ferry Andrew J. Barberi, the NTSB found shortcomings in the Coast Guard’s system of medical oversight of merchant mariners and issued the following two safety recommendations to the Coast Guard in 2005.1 M-05-4 Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations. M-05-5 In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers. Over the ensuing years, the Coast Guard took action and created a system that now provides 100 percent review of applications for medical certificates and ensures review occurs before certificates are issued. In addition, the Coast Guard issued Navigation and Vessel Inspection Circular (NVIC) 04-08, “Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials,” and has updated it several times to ensure mariners and health care providers have access to medical guidance regarding adequate treatment of identified medical conditions. As a result, in the NTSB’s 2009 report on the allision of the Cosco Busan with the San Francisco-Oakland Bay Bridge, Safety Recommendation M-05-4 was “Closed?Acceptable Alternate Action” and Safety Recommendation M-05-5 was “Closed?Acceptable Action?Superseded.” The combination of the Coast Guard’s increased oversight of medical certification and development of medical guidance appears to be highly effective at addressing safety concerns regarding medical conditions that pose a significant risk of sudden incapacitation. Since 2009, the NTSB has not found any medical conditions to have contributed to the probable cause of a marine accident. However, the NTSB continues to find effects from impairing substances (alcohol and over-the-counter, prescription, or illicit drugs) to have contributed to the probable cause across all modes of transportation. The NTSB finds that the Coast Guard’s draft Merchant Mariner Medical Manual aptly streamlines the guidance available for mariner medical certification. The information is straightforward. The table of contents and bookmarking make specific information on a given topic easy to find. Further, the manual provides a level of detail that should assist medical personnel during mariner medical certification exams. In addition, the NTSB believes the current effort to separate a medical certificate from a mariner’s credentials is appropriate. A new medical diagnosis may disqualify an individual from serving in certain positions due to safety concerns but does not remove or negate an individual’s skill and experience at sea. The NTSB supports the Coast Guard’s development of the draft Merchant Mariner Medical Manual to continue to ensure merchant mariners are medically fit for duty, and the NTSB also appreciates the opportunity to comment on this important notice.

From: NTSB
To: USCG
Date: 2/17/2017
Response: Although this issue is included in a current rulemaking project addressing regulations for merchant mariner medical conditions, given that more than 7 years that have passed with no substantive details of the intended action nor a timeline for completion, Safety Recommendation M-09-4 is classified OPEN--UNACCEPTABLE RESPONSE. We would appreciate specific details regarding how you plan to address this recommendation and a timeline for completion in your next update.

From: USCG
To: NTSB
Date: 10/18/2016
Response: -From Charles W. Ray, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: This issue is included in a current rulemaking project addressing regulations for merchant mariner medical conditions.

From: NTSB
To: USCG
Date: 3/11/2016
Response: This letter concerns 40 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Coast Guard between 2002 and 2015. For several years, the NTSB received an annual update on all open safety recommendations issued to the Coast Guard; however, for 25 of the 40 recommendations listed, we have received no update in over 2 years regarding the status of action 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 that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Please respond to this letter electronically at correspondence@ntsb.gov regarding your progress in addressing these safety recommendations, and do not submit both an electronic and a hard copy of the same response. To assist with your response, enclosure (1) is a list of the 40 recommendations highlighting the recommendation number, current status, source of the recommendation, and date of the last Coast Guard update; enclosure (2) is a print-out from our database with the complete correspondence history of each open recommendation.

From: NTSB
To: USCG
Date: 5/13/2014
Response: Given the more than 5 years that have passed with no substantive update from the Coast Guard regarding this recommendation, and apparently no significant progress having been made to address it during that time, Safety Recommendation M-09-4 is classified OPEN—UNACCEPTABLE RESPONSE. Please provide details regarding how you plan to address this recommendation in your next update.

From: USCG
To: NTSB
Date: 1/28/2014
Response: -From Peter V. Neffenger, Vice Admiral, Deputy Commandant for Operations: Enclosed is our semiannual report of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board. There are currently 39 safety recommendations with an "open" status issued to the Coast Guard. Of those, I am providing our initial response to six new recommendations, proposing that seven recommendations be closed as acceptable, and updating five previously issued recommendations. At this time, there are no significant changes in action to be reported for the remaining 21 recommendations. These recommendations include: M-02-5, M-07-6, M-09-4, M-09-10, M-09-14, M-09-15, M-09-16, M-10-5, M-10-6, M-11-4, M-11-13, M-11-15, M-11-16, M-11-23, M-11-24, M-11-25, M-11-26, M-11-27, M-12-1, M-12-2, and M-12-3.

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

From: NTSB
To: USCG
Date: 5/1/2013
Response: Notation 8484: The National Transportation Safety Board (NTSB) has reviewed the US Coast Guard’s notice and request for comments titled, “Merchant Mariner Medical Evaluation Program,” published in 78 Federal Register No. 63 (19725–19726) on April 2, 2013. The notice and request for comments concern assessing the relative merits of applying a system similar to that of the Federal Aviation Administration (FAA) or the Federal Motor Carrier Safety Administration (FMCSA) to the Coast Guard’s merchant mariner medical evaluation program. Under the current Coast Guard medical oversight system, which the Coast Guard terms an “open” system, applicants for original or renewed merchant mariner credentials are medically evaluated at regular intervals by licensed physicians, nurse practitioners, or physician assistants. The mariner then submits the evaluation results, documented on Coast Guard form 719K, to the Coast Guard. Coast Guard examiners then review the applications and, based on the information provided on form 719K, either approve or deny them or defer approval or disapproval pending the solicitation and review of additional medical information. The Coast Guard is considering two alternative methods of medical evaluation, one referred to as a “closed” system and the other a “hybrid” system. In a closed system, designated medical professionals would be authorized by the Coast Guard to conduct mariner medical evaluations and, in accordance with Coast Guard guidance, issue or deny mariner medical certificates. In a hybrid system, designated medical professionals would, in accordance with Coast Guard guidance, issue medical certificates when mariners meet certain pre-established criteria, and the Coast Guard would review only those applications for mariners who have certain conditions. The FAA and FMCSA employ systems similar to the hybrid system the Coast Guard describes. The FAA authorizes specially trained and certified physicians to act as aviation medical examiners. These designated physicians perform standardized medical evaluations and then issue or deny a provisional medical certificate to airmen based on agency guidelines. Agency physicians review and ultimately decide on all applications for medical certificates. Pilots whose initial application is denied for failure to meet requirements may apply for a special issuance medical certificate. These certificates typically require pilots to submit additional medical information and may specify follow-up testing and be time limited. Beginning this year, FMCSA authorizes medical examiners who are licensed, certified, and/or registered, in accordance with applicable state laws and regulations, to issue or deny medical certificates to commercial motor vehicle drivers based on agency guidelines and the results of physical examinations. Drivers whose applications are denied can request waivers, which FMCSA personnel review and then recommend final disposition to the Administrator. Both agencies designate only specific health professionals?physicians in the case of the FAA or health practitioners for FMCSA?who receive initial training on the respective medical oversight systems and on medical fitness requirements related to the occupations. To remain certified, the designated health professionals must complete recurrent training at regular intervals. NTSB’s Previous Actions Regarding Coast Guard Mariner Medical Oversight The NTSB previously addressed the Coast Guard’s medical oversight system in its investigation of two accidents in which mariner medical conditions and/or medication use played a role. As a result of its investigation of the 2003 allision of the Andrew J. Barberi, the NTSB issued two safety recommendations to the Coast Guard concerning its merchant mariner medical oversight system: M-05-04 Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations. M-05-05 In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers. In response to these safety recommendations, the Coast Guard modified its mariner medical oversight system and, with the exception of addressing the absence of a requirement for mariners to report changes in medical condition between examinations, the changes the Coast Guard implemented largely met the intent of the recommendations. The current medical oversight system is considerably more capable than was the previous system of identifying mariners with potentially impairing medical conditions or who use impairing medications, thereby enhancing the safety of marine operations. As a result, with the exception of the portion of Safety Recommendation M-05-05 that called for the Coast Guard to require mariners to report changes in their medical condition or medication use, the NTSB, in its investigation of the 2007 allision of the M/V Cosco Busan, classified Safety Recommendations M 05 04 “Closed?Acceptable Alternate Action” and classified Safety Recommendation M 05 05 “Closed?Acceptable Action—Superseded.” Recommendation M 05 05 was superseded by Safety Recommendation M 09 04, which calls on the Coast Guard to: M-09-04 Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. The NTSB awaits the Coast Guard’s final action in response to Safety Recommendation M 09 04, which is classified “Open—Acceptable Response.” The Coast Guard’s adoption of an alternative medical evaluation system and use of designated medical examiners would likely result in considerable efficiencies, such as those described below. A system that enables the Coast Guard to more effectively monitor changes in mariners' health and medication use between certifications and, thereby, update medical status when a significant change occurs in the mariner's health or use of potentially impairing medications would enhance marine safety. The NTSB urges the Coast Guard to include provisions for addressing changes in mariner medical fitness as part of its program enhancements. The NTSB believes both alternatives the Coast Guard is considering—a closed system or a hybrid system—would enhance the efficiency of its medical oversight system by restricting the health practitioners who can perform medical evaluations to those who have received specific training in the occupational demands of the marine system and the Coast Guard’s medical fitness requirements for mariners. Under the current system, few medical evaluators are likely to possess such expertise, and those seeking additional information must consult Coast Guard form 719K or the 80+ page Navigation and Vessel Inspection Circular (NVIC) 04-08. For health professionals unfamiliar with merchant mariner medical evaluations, taking the time necessary to gain familiarity with the Coast Guard documents during or preceding a medical evaluation is unrealistic—and often omitted. With fewer health practitioners qualified to administer mariner medical evaluations, the Coast Guard could more quickly and efficiently communicate necessary medical information or guidance regarding the evaluations. Under the current system, the Coast Guard makes such information available through its website in changes to NVIC 04-08 and form 719K. Restricting the number of health practitioners to those with a demonstrated interest in maintaining an awareness of such changes would enable the Coast Guard to more readily communicate with those health practitioners and help to ensure a more effective medical evaluation program. Allowing health practitioners to provide mariners with provisional medical certificates, as the FAA does, will ease the Coast Guard’s administrative burden by limiting medical review to those mariners whose applications warrant additional consideration. Provided that the number and geographic distribution of medical evaluators the Coast Guard designates meets the needs of mariners, a hybrid or closed medical oversight system would ease administrative demands on the Coast Guard and reduce the time needed to provide mariners disposition on their medical evaluations. Further, as both the hybrid and closed system alternatives would authorize only health practitioners with the requisite occupational and medical expertise, errors in completing form 719K should decrease, thereby further reducing the administrative burden on both mariners and the Coast Guard. Designated medical evaluators also could immediately inform mariners of additional information the Coast Guard would need to issue waivers regarding specific medical conditions and/or medication use. Either alternative system the Coast Guard is considering could enhance the quality of the waiver process by reducing the likelihood of erroneous waivers being issued because designated medical practitioners would have considerable input in guiding mariners to the relevant documentation needed to support requests for waivers. Evaluators also could advise mariners of medical conditions and/or medications for which the Coast Guard would not issue waivers. Such guidance could result in fewer waiver applications submitted that warrant denial and less extraneous and unnecessary medical information provided in support of valid waiver applications. To realize these efficiencies, however, the Coast Guard must incorporate measures to ensure that a sufficient number of medical evaluators are designated so that mariners can undergo examinations and their applications for initial and renewed certification can be reviewed, as necessary, and acted upon without undue delay. While both systems would reduce administrative burdens and enhance the efficiency of the medical evaluation process, the NTSB believes a hybrid system would afford the Coast Guard greater program oversight and quality management of health practitioners conducting medical evaluations. A disadvantage of a closed system is that critical decisions related to marine safety?specifically, determining mariner medical qualification and issuing medical certificates?would be outside Coast Guard review. Relying solely upon individual providers’ interpretations of Coast Guard policy may lead to variable medical certification decisions, and the net safety benefits of the system would suffer. By contrast, under a hybrid system, medical evaluators would issue certificates only for mariners who met specific, pre established criteria. This added requirement in the certification process would provide a significant safety advantage by providing final review and approval authority of mariners with complex medical issues to Coast Guard medical authorities. The NTSB further suggests that designated medical evaluators, whether operating under a closed or hybrid system, be limited to health practitioners licensed, certified, and registered to perform physical evaluations and to prescribe medications. In addition to establishing substantial medical qualifications for examiners, this requirement would increase the likelihood that these individuals would possess greater expertise in the nature of possible impairing medications as well as an applicant’s medical condition. Summary Observations The NTSB believes these possible changes to the Coast Guard’s merchant mariner medical evaluation system would improve marine safety by enhancing the relevant medical and occupational expertise of practitioners conducting the evaluations, facilitating communications between the Coast Guard and designated medical evaluators, reducing the administrative burden on the Coast Guard and mariners, and shortening the time needed to provide mariners with approved medical certificates. To provide greater oversight of medical practitioners conducting evaluations and recommending and/or issuing mariner certifications, the NTSB supports changing the current Coast Guard medical oversight system to a hybrid system. Thank you for the opportunity to comment on potential changes to the Coast Guard’s system of mariner medical oversight.

From: USCG
To: NTSB
Date: 4/9/2013
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: Please find enclosed our agreed upon semiannual update of actions on safety recommendations issued to the Coast Guard by the National Transportation Safety Board that are currently assigned an "open" status by the Board and are awaiting Coast Guard response. There are currently 42 safety recommendations with an "open" status issued to the Coast Guard. Of those, we attest that our actions are complete for six, six are pending resolution, and five require long-term agency action. Updates for the remaining 25 have been or will be provided in separate correspondence. Enclosure (1) provides specific information for each recommendation. Initial responses and updates of action since the previous update for the following 25 recommendations have been or are being provided (recommendations M-12-8, M-12-9, and M- 12-10) in separate correspondence: M-09-4 Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. M-10-5 Require installation of voyage data recorders that meet the international performance standard on new ferry vessels. M-10-6 Require installation of voyage data recorders on ferry vessels built before the enactment of voyage data recorder carriage requirements that will record, at a minimum, the same video, audio, and parametric data specified in the International Maritime Organization's performance standard for simplified voyage data recorders. M-11-8 Develop and implement procedures for your special purpose craft - law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. M-11-9 Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. M-11-10 Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. M-11-11 Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. M-11-12 Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. M-11-13 Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, determine from that whether the risk is unacceptable, and if so, develop risk mitigation strategies. M-11-14 Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. M-11-15 Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. M-11-16 Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. M-11-23 Establish standards for new and existing commercial fishing industry vessels of 79 feet or less in length that (1) address intact stability, subdivision, and watertight integrity and (2) include periodic reassessment of the vessels' stability and watertight integrity. M-11-24 Require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use of vessel stability information regardless of plans for implementing the other training provisions of the 2010 Coast Guard Authorization Act. M-11-25 Require each person on deck of a commercial fishing industry vessel to wear a flotation aid at all times. M-11-26 Require owners of commercial fishing industry vessels to (1) install fall overboard recovery devices appropriate for the vessel, (2) periodically ensure the functionality of such equipment, and (3) regularly conduct drills in which crewmembers demonstrate their competence in the use of such devices. M-11-27 Require all crewmembers to provide certification of completion of safety training before getting under way on commercial fishing industry vessels, such training to include both prevention of and proper response to emergency situations as well as actual use of emergency equipment. M-12-1 Require new-construction U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be equipped with alarms that audibly and visually alert the operator to deviations between the operator's propulsion and steering commands and the actual propeller response. M-12-2 Where technically feasible, require existing U.S.-flag passenger vessels with controllable pitch propulsion, including cycloidal propulsion, to be retrofitted with alarms that audibly and visually alert the operator to deviations between the operator's propulsion and steering commands and the actual propeller response. M-12-3 Require all operators of U.S.-flag passenger vessels to implement safety management systems, taking into account the characteristics, methods of operation, and the nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. M-12-6 Develop and implement a policy to ensure adequate separation between vessels operating in the Bayport Channel and Bolivar Roads Precautionary Areas and any other similarly configured precautionary areas in the Houston Ship Channel. M-12-7 Graphically delineate precautionary areas on appropriate Houston Ship Channel nautical charts so they are readily identifiable to mariners. M-12-8 Align your standards for postaccident toxicological testing of Coast Guard military personnel with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-9 Align your standards for postaccident toxicological testing of Coast Guard civilian personnel, seeking appropriate legislative authority if necessary, with the requirements specified in 46 Code of Federal Regulations 4.06-3. M-12-10 Disseminate guidance within the Coast Guard so that commanding officers have unambiguous instruction detailing the requirements for timely drug and alcohol testing of Coast Guard military and civilian personnel whose work performance may be linked to a serious marine incident.

From: NTSB
To: USCG
Date: 2/4/2013
Response: The NTSB understands that, although Safety Recommendation M-09-4 asks that the Coast Guard require notification by all mariners whenever they experience a substantive change in their medical condition, the Coast Guard’s Navigation and Vessel Inspection Circular (NVIC) 04-08 addresses only such self-reporting for medical conditions that change after a mariner has been granted a medical waiver. We also understand that the Coast Guard’s Merchant Marine Personnel Committee and its Towing Vessel Safety Advisory Committee have reviewed this issue and, to date, no action has been initiated. Despite these facts, the NTSB is somewhat encouraged that the Coast Guard intends to develop regulations specifically to address medical requirements for merchant mariners and to ensure that an adequate review of the requirements is made by those impacted by the regulations. Pending an update indicating timely progress being made on this initiative, Safety Recommendation M-09-4 remains classified OPEN—ACCEPTABLE RESPONSE. Please note, however, that, as more than 3 years have passed since this recommendation was issued without progress having been made beyond discussion of the issue, should action not be initiated soon to implement the recommendation, the NTSB will have no alternative but to reclassify it in an unacceptable status.

From: NTSB
To: USCG
Date: 11/13/2012
Response: The NTSB understands that, although Safety Recommendation M-09-4 asks that the Coast Guard require notification by all mariners whenever they experience a substantive change in their medical condition, the Coast Guard’s Navigation and Vessel Inspection Circular (NVIC) 04-08 addresses only such self-reporting for medical conditions that change after a mariner has been granted a medical waiver. We also understand that the Coast Guard’s Merchant Marine Personnel Advisory Committee and its Towing Vessel Safety Advisory Committee have reviewed this issue and, to date, no action has been initiated. Despite these facts, the NTSB is somewhat encouraged that the Coast Guard intends to develop regulations specifically to address medical requirements for merchant mariners and to ensure that an adequate review of the requirements is made by those impacted by the regulations. Accordingly, pending our receipt of an update indicating progress made on this initiative, Safety Recommendation M-09-4 remains classified OPEN—ACCEPTABLE RESPONSE. Please note, however, that, as more than three years have passed since this recommendation was issued without progress having been made beyond discussion of the problem, should action not be initiated soon to implement the recommendation, the NTSB will have no alternative but to reclassify it in an unacceptable status.

From: USCG
To: NTSB
Date: 8/24/2012
Response: J.A. Servidio, Rear Admiral, U.S. Coast Guard, Assistant Commandant for Prevention Policy: We concur with the intent of this recommendation. The Coast Guard Navigation and Vessel Inspection Circular (NVIC) 04-08 contains policy associated with the medical waiver process whereby the conditions for granting the waiver include the requirement to immediately report any deterioration of the waived medical condition to the Coast Guard. In certain cases, such as a progressive medical condition, a condition of the waiver may also include the requirement for the mariner to submit medical examination and/or test results at specified intervals to allow the Coast Guard to track the status of the medical condition. This policy was vetted through and received concurrence from both the Merchant Marine Personnel Advisory Committee (MERP AC) and Towing Safety Advisory Committee (TSAC). While we believe this to be a significant improvement over current policy, we do acknowledge its limitations as it would only apply to mariners who have been granted a medical waiver. In addition to NVIC 04-08, the Coast Guard has considered including the requirement for all mariners to report substantive changes in their medical condition in a recent rulemaking project. However, it has since been determined this was not appropriate for that particular rulemaking because it was considered after the supplemental notice of proposed rulemaking had been published and the necessary supporting documentation was not developed. The Coast Guard intends to develop regulations specifically on the medical requirements for merchant mariners, and will ensure an adequate review of the requirements is made by those impacted by the regulations. We will keep the Board informed of the Coast Guard's progress on this recommendation.

From: USCG
To: NTSB
Date: 8/15/2012
Response: -From Peter V. Neffenger, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: The Merchant Mariner Medical Advisory Committee (MMMAC) met on May 8-9, 2012 to discuss matters relating to medical certification determinations for issuance of merchant mariner credentials, medical standards and guidelines for physical qualifications of operators of commercial vessels, medical examiner education, and medical research. A specific agenda item was to discuss possible revisions to NVIC 04-08. At this time we are still reviewing the results of the committee meeting and suggestions to address this issue. We will keep the Board informed of our progress on this recommendation.

From: NTSB
To: USCG
Date: 11/16/2011
Response: This letter concerns 29 open safety recommendations, enclosed, that the National Transportation Safety Board (NTSB) issued to the U.S. Coast Guard between 1995 and 2010. For some of these recommendations, the NTSB has not received an update in almost 3 years regarding the status of action either taken or planned to address the important safety issue that the recommendation addresses. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. NOTE TO FILE (not in original letter): The 29 safety recommendations are: M-95-013, M-98-033, M-98-037, M-99-001, M-00-004, M-01-001, M-02-005, M-04-003, M-05-006, M-06-001, M-06-002, M-07-001, M-07-006, M-07-007, M-08-001, M-08-002, M-09-001, M-09-002, M-09-003, M-09-004, M-09-009, M-09-010, M-09-014, M-09-015, M-09-016, M-09-017, M-10-005, M-10-002 and M-10-006.

From: NTSB
To: USCG
Date: 11/4/2011
Response: M-09-4 was reiterated in the report regarding the 810-foot-long oil tankship Eagle Otome which collidied with a 597-foot-long general cargo vessel Gull Arrow at the Port of Port Arthur, Texas on January 23, 2010. From the Eagle Otome greensheet dated 11/4/2011 and issuing recs M-11-13 through -16 to the United States Coast Guard. The Coast Guard concurred with the intent of the recommendation but stated that to require all mariners to report changes in their medical condition would require a regulatory change, which the Coast Guard believed would be met with resistance. The Coast Guard stated that it was reviewing options to address the issue. In November 2009, the NTSB classified Safety Recommendation M-09-4 “Open—Acceptable Response.” The first pilot on board the Eagle Otome was diagnosed with obstructive sleep apnea (OSA) in the Spring of 2008. He did not report this diagnosis on his subsequent 719K form, dated February 2009, nor was he required to do so because the version of the form in effect at that time did not specifically ask about the diagnosis of sleep disorders. The Coast Guard’s subsequent version of the 719K form, released in November 2009, does inquire about sleep disorders, and the first pilot disclosed his OSA diagnosis during his subsequent medical certification in February 2010. However, had M-09-4 been implemented, the first pilot on the Eagle Otome would have been required to promptly notify the Coast Guard of his OSA diagnosis in 2008; as it was, he ultimately did not report it until nearly 2 years later, after the accident. Because of the loophole that currently and because other mariners who may be diagnosed with a serious health condition do not currently need to promptly report it to the Coast Guard, the NTSB reiterates M-09-4 in the Eagle Otome report.

From: NTSB
To: USCG
Date: 9/27/2011
Response: Notation 8344: The National Transportation Safety Board (NTSB) has reviewed the U.S. Coast Guard’s supplementary notice of proposed rulemaking (SNPRM) titled, “Implementation of the Amendments to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, and Changes to Domestic Endorsements,” published in 76 Federal Register (FR) 45908 on August 1, 2011. The SNPRM proposes changes to regulations governing the licensing of mariners on international voyages. The SNPRM also provides Coast Guard responses to comments it received in response to its issuance of an Interim Rule on this subject, published on June 26, 1997 (62 FR 34505). Reporting Changes in Medical Condition and Medication Use The NTSB notes that the Coast Guard is incorporating STCW revisions into its regulations pertaining to medical standards. The revisions will increase the frequency of required medical evaluations of mariners from once every 5 years to once every 2 years (pilots continue to be medically evaluated each year). Although the NTSB supports the Coast Guard decision to shorten the interval between medical evaluations from 5 to 2 years—as doing so increases the Coast Guard’s opportunity to monitor changes in mariners’ health—the 2-year interval will not alert the Coast Guard to significant changes in mariners’ health that might develop within even shorter periods. A 2-year interval can still allow considerable time to elapse before the Coast Guard learns of changes in mariners’ medical conditions or medication use that could adversely affect their performance and, hence, marine safety. In February 2009, the NTSB issued Safety Recommendation M-09-4, which urged the Coast Guard to: Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. In its July 27, 2009, response, the Coast Guard indicated that it concurred with Safety Recommendation M-09-4 but that implementing such a change to its medical evaluation system would require a regulatory change, which the Coast Guard believed would be opposed by maritime labor interests. As a result of the Coast Guard’s response, the NTSB classified Safety Recommendation M-09-4 “Open—Acceptable Response” in November 2009. The NTSB believes that this SNPRM now provides the Coast Guard the rulemaking opportunity to implement the regulatory change to its medical evaluation system. The NTSB urges the Coast Guard to expedite its efforts to implement Safety Recommendation M-09-4.

From: NTSB
To: USCG
Date: 9/27/2011
Response: Notation 8344: The National Transportation Safety Board (NTSB) has reviewed the U.S. Coast Guard’s supplementary notice of proposed rulemaking (SNPRM) titled, “Implementation of the Amendments to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, and Changes to Domestic Endorsements,” published in 76 Federal Register (FR) 45908 on August 1, 2011. The SNPRM proposes changes to regulations governing the licensing of mariners on international voyages. The SNPRM also provides Coast Guard responses to comments it received in response to its issuance of an Interim Rule on this subject, published on June 26, 1997 (62 FR 34505). The NTSB notes that the Coast Guard is incorporating STCW revisions into its regulations pertaining to medical standards. The revisions will increase the frequency of required medical evaluations of mariners from once every 5 years to once every 2 years (pilots continue to be medically evaluated each year). Although the NTSB supports the Coast Guard decision to shorten the interval between medical evaluations from 5 to 2 years—as doing so increases the Coast Guard’s opportunity to monitor changes in mariners’ health—the 2-year interval will not alert the Coast Guard to significant changes in mariners’ health that might develop within even shorter periods. A 2-year interval can still allow considerable time to elapse before the Coast Guard learns of changes in mariners’ medical conditions or medication use that could adversely affect their performance and, hence, marine safety. In February 2009, the NTSB issued Safety Recommendation M-09-4, which urged the Coast Guard to: Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. In its July 27, 2009, response, the Coast Guard indicated that it concurred with Safety Recommendation M-09-4 but that implementing such a change to its medical evaluation system would require a regulatory change, which the Coast Guard believed would be opposed by maritime labor interests. As a result of the Coast Guard’s response, the NTSB classified Safety Recommendation M-09-4 “Open—Acceptable Response” in November 2009. The NTSB believes that this SNPRM now provides the Coast Guard the rulemaking opportunity to implement the regulatory change to its medical evaluation system. The NTSB urges the Coast Guard to expedite its efforts to implement Safety Recommendation M-09-4.

From: NTSB
To: USCG
Date: 11/10/2009
Response: The NTSB is aware that Navigation and Vessel Inspection Circular (NVIC) 04-08 contains new policy regarding the Coast Guard’s medical waiver process, requiring mariners who have been granted a medical waiver to immediately report any deterioration of the waived medical condition. The NTSB agrees that this new policy improves the quality of the Coast Guard’s medical oversight of licensed mariners. However, NVIC 04-08 does not require mariners to report substantive changes in their medications or medical conditions unrelated to the waived medical condition. This issue represents a significant deficiency in the mariner credentialing system because considerable changes in a mariner’s medical status or medication use can take place over the 5-year period between medical evaluations for non-pilot mariners and during the 1-year period between pilot physicals, without the Coast Guard being aware of such changes. The absence of such a reporting requirement can allow a mariner with a known potential for cognitive or physical performance degradation to serve in a safety-critical position on a vessel in any U.S. waterway, a problem clearly identified in both the Andrew J. Barberi and Cosco Busan accident investigations. The NTSB notes that the Coast Guard anticipates that maritime labor interests will resist regulations that would satisfy this recommendation. Nevertheless, the Coast Guard has indicated that it concurs with the intent of the recommendation, is reviewing how it might address the issue, and is evaluating the effects of NVIC 04-08 and possible revisions needed. Accordingly, pending completion of action by the Coast Guard that requires all mariners to report substantive changes in medication use and medical conditions between medical evaluations, Safety Recommendation M-09-4 is classified OPEN -- ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 7/27/2009
Response: Letter Mail Controlled 8/4/2009 2:27:17 PM MC# 2090499 - From W.D. Rabe, Chief, Investigations Division: We concur with the intent of this recommendation. Navigation and Vessel Inspection Circular (NVIC) 04-08 contains new policy associated with our medical waiver process whereby the conditions for granting the waiver would include the requirement to immediately report any deterioration of the waived medical condition to the Coast Guard. In certain cases, such as a progressive medical condition, a condition of the waiver may also include the requirement for the mariner to submit medical examination and/or test results at specified intervals to allow the Coast Guard to track the status of the medical condition. This policy has been vetted through and received concurrence from both the Merchant Marine Personnel Advisory Committee (MERPAC) and Towing Safety Advisory Committee (TSAC). While we believe this to be a significant improvement over our current policy, we acknowledge its limitations as it would only apply to mariners who have been granted a medical waiver. Expanding this policy to require all mariners to report changes in their medical condition would require a regulatory change, which we believe would be met with significant resistance from maritime labor interests. At this time we are still reviewing our options to address this issue and anticipate determining a course of action after we have evaluated the effects of NVIC 04-08 and any needed revisions. We will keep the Board informed of our progress on this recommendation.

From: NTSB
To: USCG
Date:
Response: 10/13/2010: We are in the process of completing our investigation into the Eagle Otome accident of this past January. As you may be aware, one of the two pilots onboard was diagnosed with obstructive sleep apnea (OSA), and had recently changed his medication regimen for another diagnosed condition before the accident. We dealt with the issues of OSA and Coast Guard requirements vis a vis reported changes in medical condition/medication use in four recommendations that the NTSB issued to the Coast Guard. At present the status of this recommendation is OPEN -- ACCEPTABLE RESPONSE. A public meeting on this accident is tentatively planned for early next year. We anticipate that the Board members will discuss those recommendations, evaluate the Coast Guard response to them, and possibly change the classification based on the Coast Guard's response to the recommendations in light of the Eagle Otome accident. At the Board meeting NTSB staff will be expected to accurately convey the Coast Guard position, discuss the issues from staff's perspective, and answer the Board's questions. We are now finishing up our draft report of the accident, which will include discussions of those recommendations. In order to provide the best information for the Board's consideration, we would like to meet with you and/or your representative(s), including people working on those recommendations, so that the Coast Guard and NTSB staff have a good mutual understanding of each other's positions and concerns, and the status of your work on the recommendations. It is short notice, but we would like to meet next week to start the dialog, recognizing that subsequent meetings may be in order.