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Safety Recommendation Details

Safety Recommendation M-16-004
Synopsis: On September 23, 2014, about 0635, the 110-foot-long US Coast Guard cutter Key Largo collided with the 42-foot-long fishing vessel Sea Shepherd in the Virgin Passage, about 9miles east-northeast of Vieques Island, Puerto Rico. Just before the collision, the two Sea Shepherd crew members, who were hauling lobster traps on board, jumped in the water. No one was injured. The Key Largo sustained minor damage; the Sea Shepherd sank about 2 hours after the collision.
Recommendation: TO THE UNITED STATES COAST GUARD: Address the risks associated with watch stander fatigue by implementing Commandant Instruction3500.2, Crew Endurance Management, issued on March30, 2006, in all operational units.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Marine
Location: Virgin Passage - Caribbean Sea, PR, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA14PM019
Accident Reports: Collision between US Coast Guard Cutter Key Largo and Fishing Vessel Sea Shepherd, with Subsequent Sinking of Sea Shepherd
Report #: MAB-16-09
Accident Date: 9/23/2014
Issue Date: 7/14/2016
Date Closed:
Addressee(s) and Addressee Status: USCG (Open - Acceptable Response)

Safety Recommendation History
From: NTSB
Date: 11/30/2016
Response: We are pleased that you will continue to improve and refine CEM implementation in all of your operations, and will keep us updated of your progress on this issue. Pending further updates, Safety Recommendation M-16-04 is classified OPEN—ACCEPTABLE RESPONSE. Please respond to this letter electronically at regarding your progress in addressing Safety Recommendation M-16-4, and do not submit both an electronic and a hard copy of the same response. Thank you for your commitment to marine safety.

From: USCG
Date: 10/7/2016
Response: -From Charles W. Ray, Vice Admiral, U.S. Coast Guard, Deputy Commandant for Operations: I concur with this recommendation. Coast Guard operations will challenge human endurance limits. Unpredictable and long work hours, harsh working conditions, extreme temperatures, frequent separation from loved ones, and sleep deprivation are all too familiar demands that our people encounter on a regular basis. The Crew Endurance Management (CEM) program exemplifies the Coast Guard's acknowledgement of the hazards and commitment of resources to identify, assess, and manage this operational risk. To that end, the Coast Guard has been recognized for their efforts to develop state-of-the-art tools to proactively manage endurance risk. The Crew Endurance Management System (CEMS) uses computer based tools to deliver endurance management guidance, evaluate sleep/work patterns for circadian disruptions and sleep debt, and assess exposure to 18 endurance risk factors. The Safety Mobile Assessment Response and Training (SMART) unit assessments performed by the Coast Guard Health, Safety and Worklife Service Center evaluate compliance with CEM requirements and provide unit-level assistance with CEM concerns and challenges. Additionally, Coast Guard aviation forces, boat forces, and cutter forces programs each have taken steps to implement the crew endurance management principles in Commandant Instruction (COMDTINST) 3500.2 in their respective operations policies and procedures. Coast Guard aviation forces have aligned with many of the requirements and guidance set forth in COMDTINST 3500.2 with the exception of the challenge associated with forming a unit CEM Working Group. COMDTINST 3710.1G, Coast Guard Air Operations ·Manual, covers aviation fatigue and endurance addressing specific items, including Reverse Cycle Operations, consecutive duty days, and crew rest. Coast Guard boat forces have incorporated the requirements of COMDTINST 3500.2 into COMDTINST Ml6114.32D, U.S. Coast Guard Boat Operations and Training (BOAT) Manual, Volume/, establishing underway limits to ensure that boat crewmembers are not operating the craft in a fatigued status that might impair their judgment or subdue their motor skills during normal or emergency mission requirements. Additionally, there is extensive information and policy defining maximum underway hours and required rest periods to avoid crew fatigue and operational mishaps. Coast Guard cutter forces are also operating under the guidance of Commandant Instruction 3500.2, and perform crew endurance/fatigue analysis as part of the operational risk management (ORM) process delineated in COMDTINST 3500.3, Operational Risk Management. The next update to COMDTINST M5400.16, Cutter Organizational Manual, will reinforce the importance of crew endurance management and incorporate the tenants of COMDTINST 3500.2 into our cutters' operational planning and risk mitigation planning processes. In addition, validating the implementation of crew endurance management principles will continue during standard safety inspections. While much has been already been done to implement crew endurance management policies as provided in COMDTINST 3500.2, the Coast Guard will continue to take action to improve and refine its implementation. I will keep the Board informed of our progress on this recommendation.