Human error usual cause of boating fatalities

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PHILADELPHIA – Like most accidents, it wasn’t just one thing that went wrong when a barge rammed into a tour boat on the Delaware River in July, killing two.

First, the engine malfunctioned on the duck boat, an amphibious craft popular with tourists visiting Philadelphia. The boat’s master turned off the engine, dropped anchor and waited for help.

Then a towboat guiding a 250-foot barge down the river failed to change course, even as it bore down on the duck boat anchored in the channel.

A tug boat similar to this one operating on the Potomac River at Piney Point was involved in the fatal crash on the Delaware River. THE CHESAPEAKE staff photo

The master of the duck boat radioed the towboat to change course, but there was no response. He told accident investigators he picked up an air horn in a last-minute attempt to get attention but the horn didn’t work.

When the collision occurred, some of the 37 passengers who landed in the water had their life jackets in their hands or had none at all.

The tug Chief in Norfolk harbor Copyright 2010 THE CHESAPEAKE

The series of mistakes led to the deaths of two Hungarian students who were visiting the U.S. on a faith-based exchange program. Their bodies were found in the river two days later.

Eight years ago, the National Transportation Safety Board recommended that passenger boats implement safety management systems to decrease the chance of accidents like the one that happened on the Delaware. A safety system is essentially a checklist that covers everything from crew training and equipment maintenance to what to do in case of an emergency. It provides a regimen for inspecting and operating boats that is meant to reduce human errors.

The recommendation grew to include passenger ferries after a high-profile accident in 2003 in which the Staten Island ferry Andrew J. Barberi crashed into a pier, killing 11 and injuring 70. That same ferry crashed into another pier in May, injuring 37. The latter accident is still being investigated.

A barge ran over a Duck boat which had experienced engine trouble and had anchored awaiting assistance.

It expanded to towboats in 2007 after workers on a towboat in Louisiana failed to secure a 5-ton steel shaft that slipped from its place and struck an underwater gas line. The resulting fireball consumed the towboat and the barges it was pulling, killing the towing vessel’s master and four barge workers.

All of the accidents involved people making mistakes, which account for as many as 80 percent of all marine accidents, according to the U.S. Coast Guard.

Since the NTSB recommended safety management systems in 2002, there have been about 1,700 accidents involving domestic passenger vessels, according to a News21 analysis of Coast Guard records. Safety board investigators believe many of them would have been prevented if safety systems had been in place.

In February, the safety board bumped up its recommendation on safety systems to its “Most Wanted” list, marking it as a top priority of the marine safety division. It is the only marine-specific recommendation on the federal list.

What the NTSB wants is a document that outlines safety and operating standards that must be met every time a boat goes in the water, said Jack Spencer, director of the board’s Office of Marine Safety. A Coast Guard official or authorized third party would do spot checks to monitor compliance. If safety problems are discovered, a company would be penalized.

Last year, the Coast Guard proposed rules that would require passenger ferries that carry more than 399 passengers to have safety management systems. But it balked at going further, in part because the boating industry doesn’t support the measures.

Among the fiercest opponents is the Passenger Vessel Association, the country’s largest passenger boat trade association.

Beth Gedney, director of safety, security and risk management for the association, said the Coast Guard already inspects larger passenger boats and smaller boats don’t need formalized safety systems because owners and operators intimately know their boats.

“It’s hard to explain to them the value of a written document when they’re on their vessels every day,” she said.

When accidents do happen, companies react, Gedney said. For example, after the 2003 Staten Island ferry accident the company adopted a safety management system much like the one the NTSB recommends, she said. Many other large operators have done the same.

Gedney also argued that forcing safety management systems on smaller companies would be financially crippling for many.

Spencer said the Coast Guard has been too quick to buy industry arguments.

“They agree with what the PVA is saying and that’s the end of the story,” he said. “There really hasn’t been an effective dialogue on this.”

If the NTSB could prove that safety management systems significantly decrease accidents, it might be easier to persuade the industry to get on board.

But there are few hard numbers. The safety board has relied mostly on anecdotes and educated guesses about how many accidents could be avoided.

“It’s hard to measure the success of a program if you’re basing it solely on the accidents that you did not have,” NTSB board member Robert Sumwalt said.

Vessels that operate on international waters have been subject to a safety management code since 1998. While almost everyone agrees that the code has helped reduce the number of accidents, there is no central reporting system.

Besides, accidents may be down because of recent technological improvements and other safety measures, said James Scheffer, chief of the NTSB’s marine investigative division.

It took a catastrophic 1987 ferry accident off the Belgian coast to shock the international industry into adopting the code. Crew members forgot to close the bow doors and water rushed on board the boat, which was already weighted down with water for ballast. Almost 200 people died when the ferry capsized.

That accident was so distressing — and got so much publicity — that the International Maritime Organization, the international marine regulatory agency, adopted the safety code without waiting for member support.

“There was no universal buy-in by any stretch of the imagination,” said Daniel Sheehan, a former Coast Guard official. But, he said, as it “becomes more and more a part of the way of life on ship and more and more folks have grown up with it, I think it’s proven its worth.”

Rather than wait for a catastrophe, the NTSB is trying to bolster its case that safety management systems are needed for domestic ferries and passenger vessels.

Spencer said that soon investigators will ask a few more questions after every marine accident: Did the company have a safety management system in place? If not, could the accident have been prevented with one?

“We just really haven’t gotten very far with the moral argument that it’s a good thing and they ought to do it,” Spencer said. “What I have to do is make a better case and make it harder for the Coast Guard and the industry to say that they don’t have a need for it.”

Towboat operators are much closer than ferries to embracing the kinds of safety systems the NTSB advocates, and cruise lines already have taken that step. In both cases, major accidents provided the spark.

In 1994, barges being pushed by a towboat near Mobile, Ala., hit a railroad bridge, knocking it askew just minutes before a train crossed. The train derailed and several of its cars fell in the water and caught fire. Forty-seven people died and more than 100 were injured.

The accident prompted a re-examination of the industry’s safety standards, said Jennifer Carpenter, senior vice president for national advocacy at American Waterways Operators, which represents about 80 percent of towboat operators.

The association worked with the Coast Guard to develop a safety management system that was introduced in 1996. Four years later, the association stopped accepting members that did not comply.

At first, some members threatened to pull out, but only 13 did, Carpenter said. And companies have seen a payoff in lower insurance rates and fewer accidents. The number of accidents in the towing industry dropped from a peak of 2,000 in 1996 to 1,500 in 2009, according to Coast Guard statistics.

Still, the industry needs the Coast Guard to enforce safety systems if they’re really going to work, Carpenter said.

Congress passed legislation in 2004 that would require safety management systems for towboats, but the Coast Guard is still waiting on approval from the Department of Homeland Security to enforce the new rules.

For cruise lines, the turning point came after a series of accidents and environmental problems, said Peter Randall, who worked for Norwegian Cruise Lines from 2001 to 2009. The company was caught pumping oily water into the ocean and failed a Coast Guard inspection because of a faulty sprinkler system.

Cruise lines already had safety management systems in place — required because they operate in international waters — but that doesn’t mean they were following them, Randall said.

“You said you had a safety management system. It was a sham,” he said.

After the incidents, companies got much more conscientious about enforcing the rules, partly because of concerns that bookings would drop if people believed cruise ships were unsafe, Randall said.

Ferry systems don’t have the same concerns about losing business that cruise lines do.

“With the ferry industry, I can’t go anywhere else with my dollar. I don’t have a lot of choice,” said Randall, who worked with the Cape May-Lewes ferry system that runs between New Jersey and Delaware before moving to Norwegian Cruise Lines.

More than 65,000 people use the Staten Island ferry each weekday, many to get to and from jobs in Manhattan.

Today, a description of the ferry system’s safety management system is displayed prominently on every boat, and its compliance is evident in the way it operates. But before the 2003 accident, things were much different, longtime commuters say.

Loudspeaker announcements were hard to hear or nonexistent. Barriers to prevent people from falling overboard were missing on some parts of boats. Coast Guard and fire officials were rarely seen on board.

“Before the 2003 accident, it was obvious that safety wasn’t a top priority,” said Norman Serafin, a Staten Island resident who has been taking the ferry to work since 1983. “It would have kept on going that way without the accident. (But now) everything’s controlled.”

Even if the ferry system hadn’t made changes Staten Island residents would have continued to ride, said Tami Kelly, a Staten Island resident who has been taking the ferry to work in Manhattan for 15 years.

“If you live on Staten Island, this is what you do,” she said “It’s part of our community. It’s part of our DNA.”

If safety management systems are ever going to work, the very culture of the boating industry has to change, safety experts say.

Too many companies still don’t think about safety until an accident happens, Spencer said.

“It starts from the top, and it really is a cultural thing,” he said. “As with any cultural changes, it takes a lot of time for this sort of thing to happen.”

Doug Rabe, who spent more than a decade in the NTSB marine safety office and more than two decades with the Coast Guard, said regulations alone will never be enough. Safety systems need to be cost-effective, and they need to be flexible.

For a major cruise line, a manual might take thousands of pages, but for a mom and pop towboat company, it may need to be only a few pages, he said. More than that and resistance mounts.

Randall said he hopes the CEO of a large passenger vessel company will go public with support for safety systems and lean on other company owners to follow suit.

“That needs to happen, as opposed to government shoving requirements that everyone is going to try to throw back out,” he said.

News21 is a cooperative project among 12 research universities, including the University of Maryland, College Park designed to experiment with new forms of investigative and in-depth reporting. It is funded by the Carnegie Corp. and Knight Foundation.

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