NTSB Cooperative Boating Accident Investigation

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In 2006, following the Ethan Allen accident, NTSB held a training seminar on NTSB marine accident investigations of sole-state passenger vessel accidents which provided the initiative to revise the Model Act for charter Vessel Safety. Recreational boating accident investigations jointly worked between a state and NTSB are a much different process and sharing the lessons learned from the April 12, 2009 Jacksonville boating accident jointly investigated by Florida FWC and NTSB will benefit both the NTSB and NASBLA membership in future cooperative investigations and recognition of each others roles and responsibilities in boating safety.

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NTSB Cooperative Boating Accident Investigation

  1. 1. Office of Marine Safety Cooperative Boating Accident Investigation Presented to NASBLA September 30, 2009, Corpus Christi, Texas By Rob Henry
  2. 2. Presentation Overview • Brief description of NTSB • NTSB marine accident investigation • NTSB safety recommendations • April 12th Jacksonville, Florida boating accident • Opportunities and challenges
  3. 3. 42 Years Ago - 1967-2009 Created in 1967 by the Congress with the authority to investigate aviation, marine, rail, highway, pipeline, and hazmat transportation accidents. In 1974, Congress made the NTSB completely independent of the DOT.
  4. 4. Mission of the NTSB The NTSB is charged with • Determining the probable cause(s) of transportation accidents, and • Making recommendations to prevent their recurrence.
  5. 5. The Safety Board Members The Safety Board consists of five Members, appointed by the President, with the advice and consent of the Senate. Members serve 5-year staggered terms.
  6. 6. Authority to Investigate Marine Accidents • May Investigate Any Major Marine Accident Involving a Foreign Vessel Which Occurs in U. S. Waters • May Investigate Any Major Marine Accident Involving a U.S. Ship Anywhere in the World • Shall Investigate Any Collision Between a Public and a Non-Public Vessel • May Investigate Other Marine Accidents of a Recurring Nature
  7. 7. Major Marine Accident Definition • Six or More Lives Lost • Total Loss of a Self-Propelled Vessel of 100 Gross Tons or more • $500,000 or more in Property Damage • Serious Threat to Life, Property, or the Environment From the Release of Hazardous Materials
  8. 8. There Are Many Different Types of Marine Accidents The Office of Marine Safety Investigates. . .
  9. 9. Collisions
  10. 10. Groundings
  11. 11. Fires
  12. 12. Explosions
  13. 13. And Last,
  14. 14. But Not Least . . .
  15. 15. We Also Investigate
  16. 16. Sinkings
  17. 17. There are Many Different Types of Vessels Involved in Marine Accidents, Including . . .
  18. 18. Foreign Passenger Ships
  19. 19. Domestic Passenger Vessels
  20. 20. Commercial Fishing Vessels
  21. 21. Offshore Service Vessels
  22. 22. Offshore Supply
  23. 23. Mobil Offshore Drilling Units
  24. 24. Tankships
  25. 25. Tugboats
  26. 26. Towboats
  27. 27. Barges
  28. 28. Containerships
  29. 29. And Last, But Not Least,
  30. 30. Recreational Boats
  31. 31. Number of Accidents • In An Average Year, About 6000 Commercial Vessel Accidents Reportable To The Coast Guard • About 30-40 Of These Accidents Meet At Least One Criteria For Major Marine Accident • NTSB Investigates Approximately 6-8 Major Marine Accidents Each Year
  32. 32. Independent Investigation Under NTSB Rules • Accident Has Significant Safety Issues • Accident Has High Loss of Life or Major Pollution • Accident Has Wide Public Interest, or • Accident Involves Public Vessel or Major Coast Guard Function
  33. 33. Under NTSB Rules • Launch “GO TEAM” – On 24-Hour Call – 365 Days A Year – Enroute In 2 Hours of Notification
  34. 34. Typical Go Team • Investigator-In-Charge • Marine Engineering Group Chairman • Human Performance Group Chairman • Survival Factors Group Chairman • Other Group Chairmen, As Necessary – Fire Science – Metallurgy – Hazardous Materials
  35. 35. Member Launch • Safety Board Member May Launch With Team, Depending Upon Seriousness • Typically will include a public affairs officer and a family assistance specialist.
  36. 36. Investigation to Report • On scene investigation usually takes one to two weeks • Report development will take a year for a complex major marine investigation
  37. 37. Board Meeting The Board Members conduct a public meeting to discuss and approve a final report on the accident. The final report includes conclusions, a statement of probable cause, and recommendations.
  38. 38. Safety Recommendations Safety recommendations are the Board’s most important product They are developed to remedy system, hardware, operational or policy failures identified during investigations
  39. 39. Safety Recommendations Recommendations are issued to DOT and its modal administrations, DHS (US Coast Guard), manufacturers, transportation operators, trade associations, labor unions and state and local governments
  40. 40. Major Accomplishments • Improved Fire Protection on Cruise Ships – Sprinkler Systems – Smoke Detectors • Improved Lifesaving Equipment on Commercial Fishing Vessels – Life rafts – Survival Suits – EPIRBs • Improved Navigation Safety – Bridge Resource Management Training – Standardization of Integrated Bridge Navigation Systems
  41. 41. “Most Wanted” List Safety recommendation issue area selected by the Board for intensive follow-up because it: – Will impact or enhance safety on the national level – Has high public visibility and interest – Can be implemented in a reasonable period of time; and – Is an area that would benefit from this special form of encouragement
  42. 42. NTSB Safety Initiatives • 1993 Recreational Boating Safety Study • 1998 PWC Safety Study • 2006 public forum on life jackets • 2006 sole state waters seminar
  43. 43. Prior NTSB Boating Accidents • July 3, 1999,Bayport, MN - Advantage & Bayliner - 5 of 5 fatal • December 29, 1997, Charleston, SC – Morning Dew - 4 of 4 fatal • August 21, 1994, Juneau, AK – Questar - 1of 2 fatal
  44. 44. Office of Marine Safety Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, Florida April 12, 2009
  45. 45. Arial photos
  46. 46. Arial photos
  47. 47. M/V Little Man II - damage
  48. 48. Crownline 22 damage
  49. 49. Consequences of Accident • 14 Passengers – none ejected • 5 fatalities • 9 seriously injured • 3 medevaced to local hospitals • No one walked away from the accident unscathed • Unique opportunity to conduct a Federal- State Cooperative boating accident investigation
  50. 50. Launch • Early decision between NTSB and USCG on Federal primacy • Duty Board Member to launch • Go Team • Notification of launch to Florida FWC • Lead investigator contact • Public affairs contact • Team arrival Jax and press conference
  51. 51. Arrival On Scene • Set Up Command Post • IIC Holds Organizational Meeting – Designates Parties to the Investigation – Explains Ground Rules – Forms Investigative Groups • Groups Disperse to Conduct Investigation • Progress Meetings Every Evening
  52. 52. Party Designation • Organizations are Named as Parties Because they Have Special Knowledge or Resources that the Board Needs to Complete the Investigation. • Party Representatives Can Not Be Lawyers or Insurers & Must Have Technical Qualifications
  53. 53. Parties to investigation • Florida FWC – Region supervisor – 5 investigators, 1 PAO • U.S. Coast Guard – Senior investigating officer (LT) – Inspections division chief (LT)
  54. 54. Causal Issues – proximate cause Human factors • Deceased sitting “operator” – Lacked training and experience, inattention, view obstructions, line of sight, distractions • Surviving standing “operator” – Intoxication, inattention, distractions • Owner of record – Responsibility for oversight of vessel operation, intoxication
  55. 55. NTSB Authority • Issues Subpoenas • Take Testimony Under Oath • May Enter Any Property Where Accident Has Occurred • Copy Pertinent Files and Documents • Order Autopsy of Accident Victims • Test any component of the wreckage
  56. 56. NTSB Resources • Materials laboratory • Transportation disaster assistance/ family assistance • Medical evaluation of autopsies and tox tests. MD on staff • Commercial vessel A/I experience • Weather data retrieval and analysis • Data recorder recovery and analysis • Human factors specialist • Tox laboratory
  57. 57. State Capability and Resources • Accident reconstruction and documentation expertise • Local knowledge • Site security • Logistical support
  58. 58. Challenges to Cooperation • Early communications and coordination • Non-criminal process • Lawyers/due process • Overlapping investigation needs – Interviews – Data and evidence collection – Access to accident site • Limited opportunity to investigate recreational boating accidents
  59. 59. Challenges • Public dissemination of information • Conflicting A/I protocols – Safety vs. law enforcement – Rights of interviewees • Warnings • Immunity • Self-incrimination • Representation – Collection of evidence (rules of, chain of custody) – Transparency of NTSB investigation
  60. 60. Conclusion Why is mutual cooperation important to each of us?
  61. 61. Judicial Process and NTSB • Board employees may testify once (through deposition or interrogatories) for all civil litigations (49 CFR § 835.5) • NTSB makes available unique factual information not otherwise available • NTSB Board Reports may not be used or admitted into evidence in any action for damages arising from an accident (49 CFR § 835.3) • Interaction with United States Attorneys is rare and limited • General Counsel determines if staff may testify in criminal matter (49 CFR § 835.10)
  62. 62. NTSB NTSB and the Coast Guard • Joint Regulations (49 CFR Part 850) • NTSB – USCG Memorandum of Understanding, signed December 19, 2008 •Coast Guard a party to NTSB-led investigations
  63. 63. NTSB Has Three Options: • Request the Coast Guard to Investigate On Behalf of the Safety Board With No NTSB Participation, or • Conduct a Joint Investigation With the Coast Guard Under Coast Guard Rules, or • Conduct an Independent Investigation Under NTSB Rule.
  64. 64. Investigating Marine Accidents • Entire Marine Investigative Staff Works Out of Washington, D.C. Headquarters • Current Marine Technical Staff - Persons • Master Mariners • Licensed Marine Engineers • Naval Architects • Human Performance • Survival Factors

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