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Safety Recommendation Details

Safety Recommendation M-11-020
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 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.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 12/28/2017
Addressee(s) and Addressee Status: Commonwealth of Massachusetts (Closed - Unacceptable Action - No Response Received)
Commonwealth of Pennsylvania (Closed - Unacceptable Action - No Response Received)
Commonwealth of Puerto Rico (Closed - Reconsidered)
Commonwealth of Virginia (Closed - Reconsidered)
Humboldt Bay Harbor, Recreation and Conservation District (Closed - Reconsidered)
Port of Hueneme, Oxnard Harbor District (Closed - Unacceptable Action)
San Diego Bay Pilots Association, Inc. (Closed - Acceptable Action)
State of Alabama (Closed - Unacceptable Action - No Response Received)
State of Alaska (Closed - Acceptable Action)
State of California (Closed - Acceptable Action)
State of California, City of Long Beach, California, Harbor Department (Closed - Acceptable Action)
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 - Acceptable Action)
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 - Acceptable Action)
State of New Jersey (Closed - Reconsidered)
State of New York (Closed - Acceptable Action)
State of North Carolina (Closed - Unacceptable Action - No Response Received)
State of Oregon (Closed - Acceptable Action)
State of Rhode Island (Closed - Acceptable Action)
State of South Carolina (Closed - Acceptable Action)
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: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performance, compared to 8-hour shifts. Other studies of commercial drivers have found an exponential increase in crash risk with increasing driving times, especially for driving periods that extend beyond 8 or 9 hours. The NTSB has made numerous recommendations concerning hours of service across the transportation modes. A common theme of those NTSB recommendations has been an emphasis on establishing hours-of-service limits that are scientifically based, that set limits on hours of service, that provide predictable work and rest schedules, and that consider circadian rhythms and human sleep requirements. The second issue discussed in the CSB Evaluation with which the NTSB has experience concerns the lack of explicit requirements regarding essential elements of a fatigue management program. The CSB Evaluation remarks that The use of the word ‘should’ for most elements of a Fatigue Risk Management System (FRMS) in the RP means that they are optional, not required. In what is already a voluntary standard to begin with–employers can choose to conform to them, but they are not required by force of law to do so–‘should’ statements have very little force. The lack of required FRMS elements raises additional concerns because RP-755 states that its hours-of-service limits were “developed in the context of the existence of a comprehensive FRMS” and that “Consistently working at the limits shown is not sustainable and may lead to chronic sleep debt.” Hence, while RP-755 does not require the use of an FRMS, it does ostensibly allow operators to persistently schedule workers at the noted limits. The NTSB has recommended requiring the implementation of fatigue management programs. For example, as a result of its investigation of a June 2009 multivehicle accident near Miami, Oklahoma, in which a truck driver’s fatigue resulted in his failure to react to and avoid colliding with a slowing traffic queue, the NTSB emphasized the importance of comprehensive fatigue management programs. The report described the North American Fatigue Management Program (NAFMP), which is designed to address scheduling policies and practices, fatigue management training, sleep disorder screening and treatment, and fatigue monitoring technologies. In the report, the NTSB stated that “if the NAFMP guidelines remain voluntary—and are used by some carriers but ignored by others—this important safety tool might have only a limited effect in reducing fatigue-related highway accidents.” As a result of its investigation, the NTSB called on the Federal Motor Carrier Safety Administration to implement the following NTSB safety recommendation: H-10-9 Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. The NTSB has also made recommendations in the highway, railroad, and aviation modes to establish ongoing programs to evaluate, report on, and continuously improve fatigue management programs implemented by operators (NTSB Safety Recommendations H-08-14, R 12-007, A-06-11, and A-08-45). I hope that this information about the NTSB’s history of investigating fatigue-related accidents and the recommendations we have issued will be useful as the CSB moves forward with the evaluation of the API and USW responses to the fatigue-related CSB recommendation resulting from the Texas City investigation.

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: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performance, compared to 8-hour shifts. Other studies of commercial drivers have found an exponential increase in crash risk with increasing driving times, especially for driving periods that extend beyond 8 or 9 hours. The NTSB has made numerous recommendations concerning hours of service across the transportation modes. A common theme of those NTSB recommendations has been an emphasis on establishing hours-of-service limits that are scientifically based, that set limits on hours of service, that provide predictable work and rest schedules, and that consider circadian rhythms and human sleep requirements. The second issue discussed in the CSB Evaluation with which the NTSB has experience concerns the lack of explicit requirements regarding essential elements of a fatigue management program. The CSB Evaluation remarks that The use of the word ‘should’ for most elements of a Fatigue Risk Management System (FRMS) in the RP means that they are optional, not required. In what is already a voluntary standard to begin with–employers can choose to conform to them, but they are not required by force of law to do so–‘should’ statements have very little force. The lack of required FRMS elements raises additional concerns because RP-755 states that its hours-of-service limits were “developed in the context of the existence of a comprehensive FRMS” and that “Consistently working at the limits shown is not sustainable and may lead to chronic sleep debt.” Hence, while RP-755 does not require the use of an FRMS, it does ostensibly allow operators to persistently schedule workers at the noted limits. The NTSB has recommended requiring the implementation of fatigue management programs. For example, as a result of its investigation of a June 2009 multivehicle accident near Miami, Oklahoma, in which a truck driver’s fatigue resulted in his failure to react to and avoid colliding with a slowing traffic queue, the NTSB emphasized the importance of comprehensive fatigue management programs. The report described the North American Fatigue Management Program (NAFMP), which is designed to address scheduling policies and practices, fatigue management training, sleep disorder screening and treatment, and fatigue monitoring technologies. In the report, the NTSB stated that “if the NAFMP guidelines remain voluntary—and are used by some carriers but ignored by others—this important safety tool might have only a limited effect in reducing fatigue-related highway accidents.” As a result of its investigation, the NTSB called on the Federal Motor Carrier Safety Administration to implement the following NTSB safety recommendation: H-10-9 Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. The NTSB has also made recommendations in the highway, railroad, and aviation modes to establish ongoing programs to evaluate, report on, and continuously improve fatigue management programs implemented by operators (NTSB Safety Recommendations H-08-14, R 12-007, A-06-11, and A-08-45). I hope that this information about the NTSB’s history of investigating fatigue-related accidents and the recommendations we have issued will be useful as the CSB moves forward with the evaluation of the API and USW responses to the fatigue-related CSB recommendation resulting from the Texas City investigation.

From: NTSB
To: State of Alaska
Date: 3/26/2013
Response: The oversight authority that the Alaska Board of Marine Pilots exercises over state pilots, including adherence to hours-of-service limitations (codified in state law at 12 Alaska Administrative Code 56.963) and the information provided to pilots about the hazards of fatigue and effective strategies for preventing it, satisfies Safety Recommendation M-11-20. Accordingly, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: State of Alaska
To: NTSB
Date: 1/21/2013
Response: -From Jeff Jones, Special Assistant, Office of Governor Sean Parnell, State of Alaska (dated 1/21/2013): Thank you for writing to Governor Sean Parnell on July 23, 2012 to request clarification, through the Office of the Governor, to the Alaska Board of Marine Pilots' response to National Transportation Safety Boards' Safety Recommendation M-11-20. At the Board of Marine Pilots' meeting in Anchorage on Oct 1, 2012, the Board approved the attached response to your request. If you have any questions, please feel free to contact our office. -From Curtis W. Thayer, Chairman, Alaska Board of Marine Pilots (dated 10/3/2012): Reply Regarding Safety Recommendation M-11-20 The Office of the Governor received a request for clarification from the National Transportation Safety Board (NTSB) on July 11, 2012 regarding Alaska Board of Marine Pilots" (the Board) response to Safety Recommendation M-11-20 stated below. NTSB requested clarifying information to address the following concerns: • By what methods, and how frequently are pilots informed of the hazards of fatigue and effective strategies for preventing it? • What specific hours-of-service rules have been implemented to address the issues raised in element (2) of this recommendation? Board Oversight Inasmuch as the Alaska maritime domain is a vast operational environment, so too are the dispatch practices and procedures that each of the three pilot organizations employs in order to safely address the pilotage requirements of their respective regions. Consequently, the Board codified the hours of duty in regulation 12 AAC 56.963: A pilot may not be on duty for more than 15 hours in a 24-hour period or more than 36 hours in a 72-hour period, except in an emergency. The Board also regulates parameters for the dispatch of more than one pilot to service passenger and non-passenger vessels. 12 AAC 56.960(b) and (e) read: (b) A passenger vessel in transit of compulsory pilotage waters not excluded under 12 AAC 56.110 must carry two pilots on board except during an entry transit between a pilot station and a harbor or anchorage within compulsory pilotage waters or an exit from compulsory pilotage waters where the entry or exit transit is normally less than eight hours. (c) A non-passenger vessel in a continuous transit of compulsory pilotage waters of Southeast Alaska that is expected to exceed eight hours must employ two pilots. 12 AAC 56.083 delegates responsibility to the regional pilot organizations to develop, implement, and maintain a board approved training program. All three organizations require course completion of Bridge Resource Management (BRM) training at an American Pilots Association (APA) approved training facility. BRM training is a recurring requirement for state licensure in Alaska, so that every state-licensed pilot receives this training at least once every three biennial licensing periods. Fatigue awareness and prevention is a standard module in APA approved BRM courses. Organizational Oversight SEAPA. The Southeast Alaska Pilots' Association (SEAPA) operates in Region 1. SBAPA employs the following measures: o SBAPA pilots are reminded of the hazards of fatigue at the beginning and end of each cruise ship season during the membership meeting. o SBAPA attends most of the APA pilot conventions and this is perennial topic for lecture and discussion. • SEAPA has incorporated into its by-laws and operating rules clauses that allow for a pilot to take his/her name of the dispatch for reasons of fatigue. • SBAPA adheres to the Standards of Training, Certification and Watch keeping for seafarers (STCW) proscribed hours of duty. o SEAP A dispatches two (2) pilots for assignments expected to exceed six (6) hours unless mutually agreed upon by the pilot and the association's dispatch. Additionally, SEAPA Operating Rules specifically address fatigue concerns: o Each member is encouraged to monitor his own level of fatigue and consider the cumulative effects of fatigue; Q A member may remove himself from the dispatch roster for reasons of fatigue without loss of earnings; - A member shall notify the association dispatcher in the event that the pilot's personal fatigue threshold may be exceeded. SWAP A. Region II is served by the Southwest Alaska Pilots Association (SWAPA). SWAPA dispatch procedures are tailored to meet the operational requirements of the tenninal at ValdCZt and providing pilotage services to the Kodiak Island Group, Cook Inlet, and Seward. SWAP A employs the following measures: o Assignments to Valdez are two (2) pilots for two (2) weeks in duration. o Pilots stationed in Valdez generally receive notice for dispatch within 24 to 36 hours prior to vessel movements. o SWAP A provides for the dispatch of a third pilot to Valdez should the shipping require extra manpower. • Assignments covering Cook Inlet, Seward. and Kodiak allow for a rotating dispatch system in accordance with state pilotage regulations. Additionally, SWAPA requires that all pilots, deputy pilots, trainees, and observers sign and adhere to a "Return to Work Policy" that requires them to notify the office dispatcher in a timely manner if there are any physical or mental limitations or conditions that would hinder, obstruct, prohibit or negatively affect the full performance of their duty, to include fatigue. AMP. The Alaska Marine Pilots (AMP) operate in Region III. In response to NTSB safety recommendations, AMP has added a Fatigue Mitigation and Prevention Education Program to its business plan. AMP also includes components of fatigue awareness in its newsletter and annual membership meeting. Topics covered in education program include: • Signs and symptoms of fatigue • Fatigue risk factors • Managing fatigue Pilotage assignments in Region III can last for a week or more in duration. In order to maintain a dispatch rotation that provides timely pilotage services to a steady volume of marine traffic across Region III’s vast area, AMP deploys teams of up to four (4) pilots to Dutch Harbor for two (2) to four (4) weeks at a time. This team concept allows AMP to respond to pilotage requirements while also allowing the pilots adequate rest and recovery while on-station. Safety and the prevention of fatigue is a premier consideration across all three of Alaska's pilotage regions, as evidenced by the organizations' strict adherence to state regulations governing hours of duty and recurring training requirements. Given the nature of piloting operations in each region, the pilot organizations have demonstrated commendable initiative in their implementation of protocols and measures to ensure their pilots are afforded optimum opportunity to mitigate and prevent fatigue. -From Captain Larry Pullin, President, Southeast Alaska Pilots Association (dated 9/16/2012): In response to your request addressing NTSB Safety Recommendation M-11-20, SEAPA offers the follow clarification to the questions posed: 1. "By what methods, and how frequency, are pilots informed of the hazards of fatigue and effective strategies for preventing it?" 2. "What specific hours-of-service rules have been implemented to address the issues raised in element (2) of this recommendation?" 1. a. SEAPA pilots are reminded of the hazards of fatigue at the beginning and end of each cruise ship season during the membership meeting. b. SEAPA attends most of the APA pilot conventions and this is perennial topic for lecture and discussion. c. SEAPA has incorporated Into its by-laws and operating rules clauses that allow for a pilot to take his/her name of the dispatch for reasons of fatigue. d. The STCW regulations restrict hours of duty. e. State regulations address this concern with an 8 hour maximum. d. SEAPA required continuing education courses every third renewal period include BRM classes that include fatigue instruction. 2. a. Ship movements that may exceed 8 hours of transit and berthing time require 2 pilots. b. SEAPA dispatches to a maximum 6 hour standard using 2 pilots. -From Captain Michael D. Stone, President, Southwest Alaska Pilots Association (dated 9/12/2012): This letter is in response to the correspondence dated July 17, 2012 from Deborah A.P. Hersman of the NTSB requiring clarifying information for item M-11-20. SWAPA understands that fatigue is an issue that can present itself in many forms especially given the area and type of work an Alaskan marine pilot performs. Weather, volume of traffic, routes and conditions are all relevant facts that require a pilot be able to prevent and mitigate fatigue as it specifically affects him/her. SWAPA requires that all pilots, deputy pilots, trainees and observers sign and adhere to a "Return to Work Policy" which requires them to notify the office dispatcher in a timely manner if there are any physical or mental limitations or conditions, that would hinder, obstruct, prohibit or negatively affect the full performance of their duty (fatigue is therefore one such condition). In addition, factors that affect bow and when a pilot works ate regularly addressed at membership meetings, which SWAP A generally holds on a quarterly basis. Matters regarding travel to/from assignments and the number of pilots required for vessel transits are addressed. (including, but not limited to; length of transit, difficulty of transit, route, weather conditions or time of day). Pilots are willing, able and encouraged to present and share any issues, observations or information relating to the method in which work is performed in order to mitigate fatigue (recent examples are discussions of travel to/from cruise vessels, requirements and lD8Dning for winter ice rules when in effect and pre-dispatching where possible to ensure pilots have time to prepare and rest before a scheduled job). APA approved Bridge Resource Management (BRM-P) courses, (Safety Recommendation M- 11-21), generally cover fatigue and fatigue prevention and STCW courses may include a stress and fatigue module. Furthermore, State Regulation 12 AAC 56.963 requires that a pilot may not be on duty for more than 15 hours in a 24-hour period or more than 36 hours in a 72-bour period, except in an emergency. Additionally, 12 AAC 56.960 (b) states that a passenger vessel in transit of compulsory pilotage waters not excluded under 12 AAC 56.110 must carry two pilots on board except during an entry transit between a pilot station and a harbor or anchorage within compulsory pilotage waters, or an. exit from compulsory pilotage waters where the entry or exit transit is normally less than eight hours. SWAPA operates a rotational dispatch system which allows for pilots to have adequate rest periods between jobs. As an example, pilots covering the Cook Inlet, Seward and Kodiak regions are dispatched based on an allowed drive time or scheduled flight time in order to arrive at a job, however, our dispatch rules state that "A pilot may, for personal reasons, take an earlier or later flight, respectively, or a longer time driving but that will not change the dispatch status." This encourages a pilot to leave earlier for a job when necessary in order to ensure he/she gets the adequate rest they specifically need without being penalized for it. Two pilots cover vessels servicing the Trans-Alaska Pipeline in Valdez, These pilots are predispatched and generally spend two weeks in Valdez. Pilots stationed in Valdez generally receive notice of 24 to 36 hours prior to vessel movements so arc able to ensure they get adequate rest between jobs and can plan accordingly. At the discretion of the SWAPA pilots on station in Valdez a third pilot may be dispatched should shipping require the extra manpower. SWAPA puts no specific limits on how much time a pilot can take in the way of vacation or personal time should they require it. SWAPA reviews its' manpower needs on a regular basis and currently bas seventeen Marine Pilots. one trainee, two observers and two apprentices. Manpower is an important issue to ensure the optimal number of pilots in order to perform the work in a safe and efficient manner. Our letter to yourselves dated January 1,2012, regarding the 201 I NTSB Safety Recommendation, listed many ways we endeavor to mitigate fatigue with regards to the type of work performed and should be referred to in this case. Bach situation has to be treated on an individual basis, there is no "one size fits all" regarding fatigue mitigation given the 1D1ique characteristics of the system of marine pilotage in Alaska. We therefore encourage open communication between members, deputies and trainees to ensure the most effective use of manpower to ensure the safety and protection of shipping, human life, property and the marine environment. If you have any questions, please do not hesitate to contact me. -From Captain William A. Gillespie, Secretary, Alaska Marine Pilots, LLC: This letter is in response to the correspondence dated July 17, 2012 from D. Hersman of the NTSB requiring clarifying information for item M-11-20. State regulation 12ACC 56.963 requires that a pilot may not be on duty for more than 15 hours in a 24-hour period of more than 36 hours in a 72 hour period, except in an emergency. AMP holds each individual pilot responsible to manage their hours of duty. A pilot, when given a job assignment, who is not in compliance with 12ACC 56,963 will inform dispatch that he is not available for duty. AMP will then reassign a pilot to that vessel. In keeping with the recommendations of the NTSB, Alaska Marine Pilots has added a Fatigue Mitigation and Prevention Education Program to the business plan. AMP includes components of fatigue awareness in our newsletter and the annual membership meeting. The newsletter contains educational excerpts from various information sources addressing fatigue. Some examples of the subject are: - Signs and symptoms of fatigue - Fatigue risk factors - Managing fatigue - Understanding fatigue - What is fatigue? The newsletter is distributed continually throughout the year and will insure maximum exposure to all the pilots in Alaska Marine Pilots dispatch service. Alaska Marine Pilots holds an annual membership meeting attended by all pilots not on dispatch. We have included a session at that meeting to address fatigue mitigation and prevention. There can be challenges to the system of marine pilotage given the vastness of the region and the regions unique characteristic. Alaska Marine Pilots encourages continual communications between all members to overcome these challenges and to ensure the protection of shipping, human life, property, and the marine environment.

From: NTSB
To: State of Alaska
Date: 7/17/2012
Response: We appreciate the Board’s overview of Alaskan pilot operations, and understand the workload variances associated with the seasonal cruise ship traffic. However, the information we have recived regarding SEAPA, SWAPA, and the AMP’s work assignments do not address the intent of this recommendation, particularly regarding the issues of rotation and of fatigue education, mitigation, and management. Accordingly, please provide us this clarifying information: • By what methods, and how frequently, are pilots informed of the hazards of fatigue and effective strategies for preventing it? • What specific hours-of-service rules have been implemented to address the issues raised in element (2) of this recommendation? Pending our receipt and review of this information, Safety Recommendation M 11-20 is classified OPEN—ACCEPTABLE RESPONSE.

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's Operating Rules were designed to address the effects of fatigue. See insert below. Operating Rules Section 1. Dispatching of Pilots. A. As assignments vary greatly in location and length of time involved, simple rotation often is not equitable, nor does it ensure distribution of ships and geographical areas to keep experience current for state license renewal. Therefore pilots will be assigned to vessels and ports in accordance with an overall consideration of the following factors: I. Rotation; II. Equality of monthly workdays; III. Type and length of assignment; IV. Recent assignments of pilots by area and type of ship; V. License limitations; VI. Opportunity to broaden local knowledge of pilots; B. Any pilot receiving an assignment to a vessel or port may decline their initial assignment and ride as an observer without loss of pay if he feels that he does not have the necessary experience for the assignment. C. Assignments greater than 6 hours shall be dispatched with two (2) pilots unless mutually agreed upon by the Pilot and the Association's dispatch. D. Pilot Fitness-For-Duty. Members and trainees are individually responsible for knowledge of and compliance with pilot fitness for duty requirements established by the board of marine pilots. I. Members shall not accept a dispatch assignment or act in any other capacity as a required pilot while that person does not meet the fitness for duty requirements established by the board of marine pilots. II. Trainees shall not act in any capacity as a trainee (either observing or conducting supervised maneuvers) while that person does not meet the fitness for duty requirements for pilots established by the board of marine pilots. III. A member on the dispatch roster who becomes not-fit-for-duty and unable to meet their dispatch requirements shall notify the dispatcher as soon as practicable. IV. A member on the dispatch roster who becomes not-fit-for-dutv may be excused from dispatch assignment for not more than three (03) days without loss of earnings. A member that becomes not-fit-for-dutv exceeding three (03) days will be removed from the dispatch roster until fit-for-duty and is subject to the provisions of SEAPA Bylaws Article IX. Disability and Benefits. V. A member on the dispatch roster who becomes not-fit-for-duty for a period in excess of three (03) consecutive days shall provide to the Association dispatcher, certification by a licensed physician of their not-fit-for-duty status. VI. A member on the dispatch roster or a trainee on the training schedule who is not-fit-for-duty for a period greater than three (03) days and less than 90 days shall be considered ineligible for dispatch or training until they provide to the Association dispatcher. a fit-for-duty certification from a licensed physician. VII. A member or trainee who is incapacitated as a pilot or trainee for a period of 90 days or more shall comply with the requirements of 12 AAC 56.970. VIII. Pilot Fatigue. a. Each member or trainee must monitor their own level of fatigue and consider the effects cumulative fatigue may have on their own fitness-for-duty. b. A member may remove him/herself from the dispatch roster for reasons of fatigue without loss of earnings, for up to 24 hours after completion of an assignment. c. A member shall notify the Association dispatcher in the event that the pilot's personal fatigue threshold may be exceeded. Factors for consideration (not necessarily all inclusive) may include: i. Transit times to or from the assignment; ii. Typical length of time to complete the assignment; iii. Difficulty of the assignment, including factors such as waterway congestion; iv. Navigational hazards, environmental conditions, effects of circadian rhythms on different shifts; v. Standby time while on assignment when adequate quarters are not provided. Pilot assignments to ships are drawn up through the SEAPA Office by the President of the Association. The assignments are expected to be rotated as fairly as possible with equal opportunity/exposure to the different jobs, ships and other pilots, commensurate with an individual's license and experience. There are some 48 fully licensed pilots in SEAPA, and 8 deputies. Cruise ship assignments are made by the President weeks in advance. As two pilots are assigned to a cruise ship, the President also takes into consideration the personalities involved as well as any reasonable requests from Industry (Company or Master) or from the pilots themselves. Numerous other factors may come into play when scheduling for the cruise season. For any job that is scheduled for over eight hours of actual piloting, or for any Cruise Ship transiting the inside waters of South East Alaska two pilots are dispatched to share the duties. Usually the pilots split the watches and one works solo while the other rests. Seldom are two Pilots working together on the Bridge. For limited times in critical waterways such as Wrangell Narrows and Peril Straits both pilots may be on the bridge working together in which case the Lead Pilot remains at the conn and the second pilot is essentially incorporated between the Lead Pilot and the Bridge Team. The second pilot is used to clearly communicate critical information to the Lead Pilot, answer VHF radio calls, report on visual ranges, soundings and traffic, in effect, any information deemed critical to the passage of the vessel. I) As an Association we have coped over the years with the Irregularity of Work Hours and Sleep. There is no Association mandated daily routine, no mandated watch schedule or sleeping schedule. Each member or trainee must monitor their own level of fatigue and consider the effects cumulative fatigue may have on their own fitness-for-duty. See SEAPA Operating Rule VII. m) There are no mandated or regular time-off periods during the summer unless a pilot requests to go off roster. n) Cumulative fatigue that inevitably occurs during our summer schedule is to have sleeping conditions that are conducive to obtaining periods of meaningful rest. This specifically means both pilots are provided with quiet, dark and reasonably clean cabins on the ships they work, where they will be able to get a restful sleep. Although most companies have recognized the benefit of this, some have chosen in general not to provide suitable accommodation. SEAPA asks the BMP to revisit and adopt minimum room standards for Cruise Ships, as was adopted by the State of Washington and the Pacific Pilotage Authority of Canada. -From Captain Michael D. Stone, President, Southwest Alaska Pilots Association: This letter is in response to your correspondence dated November 30th and the request for information following the NTSB Safety Recommendation regarding the Sabine-Neches Canal multi-vessel collision on January 23, 2010. Please be advised that SWAPA complies with State regulations and pilots attend risk assessment and advanced simulator training with industry members, which is in addition to current regulations. We would also like to specifically address the NTSB recommendations as follows: Recommendations M-1l-19 and M-1l-20 As the Board is aware, SWAPA has implemented a "Return to Work Policy" which every pilot, deputy pilot, trainee and observer is required to participate in and adhere to at all times. This policy promotes and ensures the highest level of safety and states: A person required to participate in the Policy MUST notify the Dispatch office, in a timely manner, if they become aware of; • "physical or mental limitations that would hinder or prevent performance of duties' • "any medical or physical condition which will prohibit, obstruct, or negatively effect the full performance of their duty and be free from any medical conditions that pose a risk of sudden incapacitation which would affect transferring to and from and operating or working on vessels. " (State of Alaska MAR Form 08-4560 [rev 09/28/10]). Once notification has been given, the person shall, accordingly, be considered ineligible for dispatch or training until they are able to perform their duties as prescribed by law. The policy promotes and ensures the highest level of safety by confirming that a pilot, as an independent contractor, is confirming that it is his/her responsibility to inform the Dispatch office of any physical or mental limitations or medical or physical conditions that thereby make them ineligible for dispatch or training. Physical, mental and medical can obviously cover limitations or conditions such as stress or fatigue if such condition "would hinder or prevent performance of duties" or "will prohibit, obstruct, or negatively affect the full performance of their duty". As the American Pilots' Association clearly states, marine pilots have been aware of fatigue and ways to mitigate it for many years and "during their multi-year progression from trainees to full branch pilots, learn how to sleep efficiently, how to maximize sleep benefits and when to sleep during a pilot rotation to ensure they are fully prepared for their assignments". As an example, a pilot may ask for a room to be made available on a ship prior to sailing if his dispatched flight time will allow for extra rest before the vessel's departure especially if the transit is expected to be long or conditions are challenging. In addition to this ongoing "Return to Work" policy, pilots are required to submit to USCG physicals on an annual basis and the State of Alaska additionally requires its' own physical exams every two years. The Board, for good cause, may also submit a pilot to a physical or mental exam in addition to the biennial requirement. SWAPA works closely with its' customers to ensure best safety practices and SWAPA pilots also adhere to 12 AAC 56.963 (hours of duty). The following are a few examples of how we implement these practices; Vessels transiting from Homer to Anchorage generally require two pilots due to transit time and always require two pilots when ice rules are in effect. We also carefully monitor conditions, time of day and ship particulars when determining if any vessel transit will require two pilots. For jobs in excess of twelve hours, two pilots are required and if there is a question on the length of a job, two pilots may be assigned. On "two pilot" jobs, only one pilot is required on watch at a time and the other pilot is below resting. Traditionally work assignments are six hours on watch and six hours of rest. Another example of a "two pilot" job is when ice rules are implemented in Cook Inlet. Tankers going to KPL or Drift River are required to have two pilots up-bound and two pilots on standby at the dock whilst the ship is alongside. During the summer cruise season, SWAPA has recently implemented pre-dispatching to ensure effective and best use of our manpower allowing for less travel time for pilots and better preparedness where possible. Generally, vessels cruising Prince William Sound will be a two pilot job, depending on vessel itinerary and accordingly, "on duty" times are carefully monitored. The "Eagle Otome" required two pilots working together; in the South Central region we require two pilots on specific jobs, as described above, to ensure that one rested pilot is available throughout the voyage. SWAPA pilots, as independent contractors, will prepare for each dispatch on a case by case basis taking into account all factors involved, including, but not limited to weather conditions, type of vessel, time of day, length of transit etc. If a pilot assigned to a job determines that the job requires a second pilot, he may request that an additional pilot is dispatched. -From Captain Carter Whalen, President, Alaska Marine Pilots, LLC: Our Pilot assignments in Dutch Harbor are very different than pilot assignments in SW or SE Alaska. A Docking or Undocking evolution in Dutch Harbor averages between 60 minutes and 90 minutes in duration. Depending on the time of year, and the number of ships calling on Dutch Harbor, AMP will have 2 to 4 pilots who share the work assignments on rotation so as to afford each pilot an adequate rest period.

From: NTSB
To: State of California
Date: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Feder