The capsized Lady D after its 2004 accident in
    Baltimore.
Safety Marshal

7/1/2007

The tragic accident at the Big Bayou Canot railroad bridge early on the foggy morning of Sept. 22, 1993, turned a harsh spotlight on the inland towboat industry.

Barges being pushed by the towboat Mauvilla hit a bridge near Mobile, Ala., minutes before Amtrak's Sunset Limited was to cross. The resulting train derailment killed 47 and injured another 103.

The National Transportation Safety Board's investigative report on the accident made a raft of recommendations to everyone from the Coast Guard and the U.S. Army Corps of Engineers to the American Waterways Operators.

AWO's experience with NTSB goes back to that accident. "The worst accident our industry has ever had," said Jennifer Carpenter, the trade group's senior vice president, government affairs and policy analysis. It wasn't exactly a good situation for getting acquainted.

But as a result, AWO began developing the Responsible Carrier Program. Since then, "we've made an effort to get to know them," she said, to make sure they understand the industry during more normal times. "And they've been very willing over the years to do that. By and large, we have found that their recommendations make sense. They can move the Coast Guard, but they can also influence us directly."

NTSB recommendations have had a significant impact on the industry. Perhaps best known for probing airline accidents, the independent NTSB is supposed to prevent or reduce the severity of transportation accidents. It has no enforcement power, but it has the power of persuasion.

The nearly 400-employee agency's Office of Marine Safety has 14 investigators. In major marine accidents, the NTSB becomes the lead agency on the scene, which means it evaluates the Coast Guard as well. Several years ago, the two agencies signed a memorandum of understanding that aims to outline how each will handle an investigation.

"We take the primary role," said marine investigator Morgan Turrell. "NTSB determines who the parties will be."

Doug Rabe, chief of the Coast Guard's investigations division, described the current relationship with the NTSB as "excellent. We are cooperating well. We are getting things done together. We talk to each other frequently. They seem to understand how we get our business done. We understand their mandate."

The Coast Guard doesn't always move as fast as the NTSB might want, because the regulatory process takes time. On the other hand, the NTSB has been faulted for taking too long to complete investigations.

INVESTIGATION PROCESS

Once it decides to get involved, the NTSB immediately sends a team of 10 to 15 people including five or six investigators, one of the five members of the politically appointed governing board, a lawyer and a public relations specialist.

The NTSB sets up a command post and examines everything from voyage data recorders to operations to engineering to naval architecture. They get log books, company procedure manuals and phone records, and talk to witnesses.

The on-scene phase lasts about a week. The rest of the investigation could take another six to eight months depending on the circumstances. Pertinent data are sent to the NTSB in Washington for analysis. If the agency does not have the needed expertise, "We do contract out some work," Turrell said.

Once a staff report is complete, it goes to the five-member board for adoption. In any legal dispute involving the accident, only the factual report section, not the board analysis, is admissible, Turrell said.

The Congressional Research Service has raised flags about some aspects of NTSB's procedures. Two issues CRS cited in a report last year are "concerns over industry stakeholders lobbying NTSB officials in attempts to influence the scope or language of NTSB investigative findings, and the NTSB's heavy reliance on experts from transportation entities with a vested interest in the outcome of an investigation for fact gathering and data analysis."

In addition, the Government Accountability Office noted that NTSB has a good track record on getting recommendations implemented, but "investigations are often - sometimes unnecessarily - lengthy." And reports can go through multiple revisions, all of which may hamper the agency's goal of improving transportation safety.

"They move slowly and methodically," said Henry S. Woods, owner of Trident Marine Safety Associates , Houston, who does work for insurance companies, lawyers and risk adjusters. "You get kind of a committee-reviewed report out of NTSB."

If he were grading the agency, Woods said, he'd give it a C-plus. "Sometimes I find that they left out some important aspects. Completeness would be more of a concern than accuracy," he said.

Woods and others said NTSB needs to put more emphasis on human factors and how various elements of an accident are related.

"We do not try to find liability," said Jack Spencer, director of the NTSB's Office of Marine Safety. "Our job is to investigate the accident and identify if there are safety issues that need to be addressed. We never name names. We look for weaknesses."

NTSB tries to identify significant issues and come up with recommendations that can reasonably be implemented, he said, "so we're not going to ask for the moon in general."

As for timing of reports, Spencer said the office is trying to "shoot for a year and make them the absolute best quality we can."

Some have taken a lot longer. For example, the NTSB has not issued a final report on the May 2003 boiler room explosion that killed seven crew members on the cruise ship Norway docked at the Port of Miami.

WEIGHT STANDARDS

The NTSB has been pushing for changes to passenger vessel weight standards, based on the fact that Americans are heavier than when the guidelines were first set in 1942. The added weight can affect stability and load factors. The industry already was considering changes when the NTSB investigated two fatal tour boat accidents. The agency said out-of-date weight standards were partially responsible for the two capsizings. Shortly after the first NTSB report was released last year, the Coast Guard issued voluntary weight guidelines.

In an unusual move, the Coast Guard recently filed detailed comments on the NTSB's findings in one of the two tour-boat accidents - the 2004 capsizing of the Lady D in Baltimore Harbor. NTSB cited stability and load problems and faulted the Coast Guard's certification of the vessel and stability standards.

The Coast Guard disputed the findings and contended that given the weather in the area at the time, the boat should never have gone out. (The Coast Guard has been sued in federal court by the tour company's insurers alleging certification errors.)

A former NTSB investigator created a buzz with his remarks that the probe of the capsizing of the Ethan Allen on Lake George, N.Y., in 2005 was flawed. He questioned, among other things, the testing of a bilge pump and the selection of evidence. Capt. Robert Ford, who is now in private industry, said he left NTSB a little over a year ago because he wasn't able to do the job he wanted to do. Ford was the lead investigator in the NTSB's Ethan Allen probe.

He wants Congress to order the NTSB to reconsider the investigation. "Our staff didn't see anything that indicates there is a need to reopen the investigation," said Mary Kerr, spokesman for the House Transportation and Infrastructure Committee.

"We think we did a real thorough job, and we're satisfied with the report," Spencer said.


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