ntsb cooperative boating accident investigation

Office of Marine Safety

Cooperative Boating Accident InvestigationCooperative Boating Accident Investigation

Presented to NASBLASeptember 30, 2009, Corpus Christi, Texas

By Rob Henry

Presentation OverviewPresentation Overview

• Brief description of NTSB

• NTSB marine accident investigation

• NTSB safety recommendations

• April 12th Jacksonville, Florida

boating accident

• Opportunities and challenges

42 Years Ago - 1967-200942 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.

Mission of the NTSBMission of the NTSB

The NTSB is charged with

• Determining the probable cause(s) of transportation accidents, and

• Making recommendations to prevent their recurrence.

The Safety Board MembersThe 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.

Authority to Investigate Marine AccidentsAuthority 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

Major Marine Accident DefinitionMajor 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

There Are Many Different Types of Marine Accidents

The Office of Marine Safety Investigates. . .

Collisions

Groundings

Fires

Explosions

And Last,

But Not Least . . .

We Also Investigate

Sinkings

There are Many Different Types of Vessels Involved in Marine Accidents, Including . . .

Foreign Passenger Ships

Domestic Passenger Vessels

Commercial Fishing Vessels

Offshore Service Vessels

Offshore Supply

Mobil Offshore Drilling Units

Tankships

Tugboats

Towboats

Barges

Containerships

And Last, But Not Least, And Last, But Not Least,

Recreational BoatsRecreational Boats

Number of AccidentsNumber 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

Independent Investigation Under NTSB Rules

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

Under NTSB RulesUnder NTSB Rules

• Launch “GO TEAM”– On 24-Hour Call– 365 Days A Year– Enroute In 2 Hours of Notification

Typical Go TeamTypical 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

Member LaunchMember Launch

• Safety Board Member May Launch With Team, Depending Upon Seriousness

• Typically will include a public affairs officer and a family assistance specialist.

Investigation to ReportInvestigation to Report

• On scene investigation usually takes one to two weeks

• Report development will take a year for a complex major marine investigation

Board MeetingBoard 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.

Safety RecommendationsSafety Recommendations

Safety recommendations are the Board’s most important product

They are developed to remedy system, hardware, operational or policy failures identified during investigations

Safety RecommendationsSafety 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

Major AccomplishmentsMajor 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

“Most Wanted” List“Most Wanted” List

Safety recommendation issuearea 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

NTSB Safety InitiativesNTSB Safety Initiatives

• 1993 Recreational Boating Safety

Study

• 1998 PWC Safety Study

• 2006 public forum on life jackets

• 2006 sole state waters seminar

Prior NTSB Boating AccidentsPrior 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

Office of Marine Safety

Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, Florida

Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, Florida

April 12, 2009

Arial photos Arial photos

Arial photos Arial photos

M/V Little Man II - damageM/V Little Man II - damage

Crownline 22 damageCrownline 22 damage

Consequences of AccidentConsequences 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

LaunchLaunch

• 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

Arrival On SceneArrival 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

Party DesignationParty 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

Parties to investigationParties to investigation

• Florida FWC– Region supervisor– 5 investigators, 1 PAO

• U.S. Coast Guard – Senior investigating officer (LT)– Inspections division chief (LT)

Causal Issues – proximate causeCausal 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

NTSB AuthorityNTSB 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

NTSB ResourcesNTSB 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

State Capability and ResourcesState Capability and Resources

• Accident reconstruction and documentation expertise

• Local knowledge• Site security• Logistical support

Challenges to CooperationChallenges 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

ChallengesChallenges• 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

ConclusionConclusion

Why is mutual cooperation important to each of us?

Judicial Process and NTSBJudicial 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)

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

NTSB Has Three Options: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.

Investigating Marine AccidentsInvestigating 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