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.

1. Office of Marine Safety
Cooperative Boating
Accident Investigation
Presented to NASBLA
September 30, 2009, Corpus Christi, Texas
By Rob Henry

2. Presentation Overview
• Brief description of NTSB
• NTSB marine accident investigation
• NTSB safety recommendations
• April 12th Jacksonville, Florida
boating accident
• Opportunities and challenges

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. 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. 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. 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. 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. There Are Many Different Types of
Marine Accidents
The Office of Marine Safety
Investigates. . .

9. Collisions

10. Groundings

11. Fires

12. Explosions

13. And Last,

14. But Not Least . . .

15. We Also Investigate

16. Sinkings

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

18. Foreign Passenger Ships

19. Domestic Passenger Vessels

20. Commercial Fishing Vessels

21. Offshore Service Vessels

22. Offshore Supply

23. Mobil Offshore Drilling Units

24. Tankships

25. Tugboats

26. Towboats

27. Barges

28. Containerships

29. And Last, But Not Least,

30. Recreational Boats

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

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. 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. 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. 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. 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. 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. 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. “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. NTSB Safety Initiatives
• 1993 Recreational Boating Safety
Study
• 1998 PWC Safety Study
• 2006 public forum on life jackets
• 2006 sole state waters seminar

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. 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. Arial photos

46. Arial photos

47. M/V Little Man II - damage

48. Crownline 22 damage

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. 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. 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. 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. Parties to investigation
• Florida FWC
– Region supervisor
– 5 investigators, 1 PAO
• U.S. Coast Guard
– Senior investigating officer (LT)
– Inspections division chief (LT)

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

56. 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

57. 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

58. State Capability and Resources
• Accident reconstruction and
documentation expertise
• Local knowledge
• Site security
• Logistical support

59. 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

60. 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

61. Conclusion
Why is mutual cooperation important to
each of us?

63. 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)

64. 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

65. 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.

66. 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