FY-2002 AFLOAT SAFETY REPORT by pme11655

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									FY-2002 AFLOAT SAFETY REPORT




FOR COAST GUARD CUTTERS, CUTTER BOATS,
        AND SHORE-BASED BOATS


           Commandant (G-WKS-4)
            Afloat Safety Division
                  TABLE OF CONTENTS


Why This Report                           pg 3

Message from the Chief of Afloat Safety   pg 4

Cutter Mishaps Section                    pg 5

Shore-Based Boat Section                  pg 12

Class A&B Mishap Summaries                pg 16

Afloat Safety Initiatives: TCT            pg 18

Common Mishap Discrepancies               pg 20

Contact Us                                pg 23




                                                  2
               WHY THIS REPORT?
The purpose of this report is to help promote safety awareness
within the afloat community. It is just one part of an overall
effort to provide program managers, operational commanders,
and individual operating units with information regarding
accident trends experienced by our cutters and small boats.

Awareness is important in our efforts to reduce mishaps.
Knowledge of problems that have resulted in accidents helps us
anticipate and recognize hazards that may exist elsewhere.
This report contains comprehensive analyses of reported FY02
mishaps with a focus on causal factors, mishap types, and
mishap rates (based upon operating hours); cutter, cutter boat,
and shore-based boat fleets are included. Where applicable,
the FY02 data is compared to historical trends.

We hope units with afloat assets will find this report useful and
will share the information up and down the chain of command.
Combined with the operational mishap messages that are sent
fleetwide, the awareness of potential hazards generated by this
report should allow units to take a critical look at operational
procedures and safety programs.

As always, any ideas and comments are valuable in improving
the Coast Guard’s safety and environmental health program.
Please share them with Unit Safety Coordinators the
applicable MLC detached Safety and Environmental Health
Officer (SEHO’s), or the appropriate Headquarters point of
contact listed at the end of the report.




                                                                    3
         A SHORT NOTE FROM CHIEF, AFLOAT AND
            MARINE SAFETY DIVISION (G-WKS-4)
Thanks for taking the time and interest to review the FY02 Afloat Safety Report.

Reflecting the pace of our entire service, this has been a busy year for G-WKS-4. While
20-40% understaffed, we’ve undergone a re-organization; implemented a new system for
capturing and tracking mishap information, and significantly revised our facilitator
support process for team coordination training.

We started FY02 as the Afloat Safety Division. In anticipation of the Coast Guard’s
move to a more “Activities” based operational organization, we have added marine safety
staffs, units and operations as customers, becoming the Afloat and Marine Safety
Division. Although the name change is relatively minor, the scope of responsibility has
greatly increased. Accordingly, all future reports will include a look at the entire
maritime ops domain.

During the past fiscal year, we dedicated hundreds of man-hours to reviewing each
mishap and ensuring that it was properly entered in the database. During this process, we
found that approximately 40-45 % of reported mishaps had not been making it into the
database, significantly impacting the reliability of the data and statistics that we use and
provide. To counter this and improve accuracy and reliability, we implemented a web-
based mishap entry system: E-Mishap. Fully operational by early FY03, this system
allows units to directly input their data into the database. Its use eliminates the
requirement for messages in the case of all non-operational mishaps and will generate the
text of the message for mishaps that require one. With separate menus for personnel
casualties and property damage, the system prompts you to enter necessary information
and omits unneeded data input. Within months of its introduction, approximately 80-
90% of mishaps are now reported by the E-mishap system. However, connectivity is and
will continue to be an issue, therefore, use of this system is voluntary and those without
intranet access will be able to submit mishaps via message.

Team coordination training (TCT) is primarily delivered through a cadre of facilitators.
Until recently, monies to support their travel to units for delivery of training came
through a complicated series of AFC-56 to AFC-30 conversions and transfers. To
streamline the process, better compete for limited training funds, and provide a more
robust mechanism for tracking TCT completion, the support process was completely re-
engineered, ensuring a more efficient flow of AFC-56 funds directly to facilitators as well
as providing for entry of course completions into the CG Human Resources Management
System (CGHRMS).

Thank-you again for taking the time to look at our report. Please let us know if there is
other information that you would find useful. HAVE A SAFE DAY!!!
                                                                                        4
CDR Tommey H. Meyers
COAST GUARD




 CUTTERS
              5
  Coast Guard Cutter Operational Mishaps
120
                                                    A       106
                                                    B
100
                                                    C

  80                     72
                64
                                               61
  60
                                   48

  40

  20
            1                      1           2            1
        1                1
                     0         1           0            1
   0
        FY98         FY99      FY00       FY01          FY02




This graph depicts the major (Class A-C) operational mishaps
reported by our cutter fleet from FY98 to FY02. Excluded from
this graph are mishaps that took place while off duty (such as
sports-related and motor vehicle injuries) and mishaps that
occurred outside of the shipboard environment. Although there
appears to be a very significant increase in mishaps in FY02, the
majority of this increase was due to our exhaustive review of the
mishap data base and the resulting input of many incidents that
were not being captured before, as well as a reclassification of
mishap types. For these reasons, comparisons from previous FY’s
may not be appropriate and are not included in many of the
subsequent analyses. However, not all of the increase can be
attributed to such benign causes; a portion of the increase was due
higher numbers of accidents, serving as a reminder of the
importance of being vigilant and using operational risk
management while operating in the dangerous marine
environment.                                                        6
             58
                   Number of Cutter Mishaps by Type
     60
                                                      53

     50
                   42
                                                                      41
     40                   37


     30
                                       24

     20                                                                       19                                      17
                                                                                                      17
                                                              15

     10
                                                                                                               3                      3
                                                 1                                          1                                 0
      0




                                                                                                                                      WYTL
                                                                                                                              WIX
                   270


                           210


                                       87


                                                 82


                                                        110




                                                                              WLM




                                                                                                               WTGB
                                                                                          WLI




                                                                                                                       WLR
            WHEC




                                                                      WLB
                                                               WAGB




                                                                                                      WLIC
The above graph compares the number of reported Class A-D Marine mishaps by cutter type. As expected the
platforms with the most operational hours tend to have the most mishaps..
Below, marine mishaps are then computed per 100,000 resource hours for cutter types. With overall resource hours
remaining steady (within a half of a percent (0.5%) of FY01 numbers) and the overall number of mishaps included in
the system jumping 71% (as discussed previously), a a significant jump in the mishap rates is also apparent.


                           Cutter Mishap Rates by Type
    250
                          (per 100,000 Resource Hours)

          171.5
                                                                               164.6



    125            111.5                                              106.6                     108.9                 106.9

                                                                                                                                         81.7
                            75.1
                                                              61.6
                                                      50.9
                                                                                                                              38.6
                                            34.2                                                             28.9


      0
                                                                                                                                             7
                                                                                                             WLI




                                                                                                                                             WLR
                                                                                                                      WLIC
                                                                                                WLM
                                                                                    WLB
                                                                       WAGB
           WHEC




                                                                                                                               WTGB
                                            87


                                                      82
                    270


                                 210




                                                              110




                                                               Cutter Type
                         Types of Cutter Mishaps

90                                                                                  83
80
70                                                     64
60
50
40
                                                              32
30
                   16                                                                        19
20
10         8                       7         8
                                                                      3
 0




                                                                                 Equipment
                                Grounding


                                            Flooding
       Overboard




                                                                     Explosion
                                                       Fall


                                                              Fire




                                                                                             Collision
                    Near Miss




What types of mishaps are occurring? This graph details the types of
mishaps our cutters and crews are experiencing. Equipment mishaps (fouled
screws, etc.), fires, collisions (both with fixed and floating objects), and falls
were again the most common causes for the third consecutive year. In FY02,
the Main Space Fire Doctrine was set 26 times.




                                                                                                         8
             Cutter Mishap Rates By MISSION
              (per 100,000 Resource Hours)
80                                                                            74.6
                       FY01
70                     FY02
                                                59            61.3
60
                                                                       50.8
50                              44.3   44.7            44.2
               42.2

40
                      31.5
30    26.3


20

10

0
         ELT               IO             SAR             SRA             TRG




Enforcement of Laws and Treaties, Ice Ops, SAR, Short-Range ATON, and Training
comprise the majority of mission types in which mishaps occurred. There was a
noticeable increase over FY01 in the mishap rate for all of the above categories. The
most noticeable increase of 25 additional mishaps per 100K of Op hours while training,
although primarily due to the benign causes noted previously, point to a need to apply
risk management to greater degree during drilling so that we use the training to increase
our effectiveness in dealing with future emergency situations and not to become the the
emergency of the present.
In addition to the missions you see above, 71 mishaps took place during Maintenance
and Repair (M+R) periods, both in ports away from homeport and in homeport. These
are not computed as rates since there are no resource hours reported for M+R. This
number is down from 93 mishaps a year ago. Given the expected increase simply due to
better reporting and accounting, this decrease is even more significant. Keep up the
good work!!



                                                                                  9
  Causal Factors to Cutter Mishaps
                                               Planning/ Risk
                       Sports
                                                Assessment
                        9%
                                                    12%
     Misc.
     12%                                                        Judgement
                                                                   37%




Environment/ Wx
      6%
                  Experience       Equipment
                     8%
                                     16%

                       62 % of cutter mishaps are due to
                                 human error.




                                                                10
              Cutter-Based Boat Mishaps
     25                       FY99
     20                       FY00
     15                       FY01
     10                       FY02

     5
     0
              Cutter Boat -                           Cutter Boat -
                  MSB                                   OTHER

 The above graph is a comparison of total number of cutter boat mishap
 for FY99 through FY02. It does not take into account the operational
 hours of the various boat types.
 Below, the mishaps are broken down into various “types”.


          Cutter-Based Boat Mishaps by TYPE
10                        9
                      8                               FY99                                        8
                  8
8                                                     FY00                   7
          6                                           FY01               6
6                                                                                5        5
              4               4
                                                      FY02
                                      4                              4
4                                             3             3

                                  2       2            22
2     1                                                         1                     1
                                                                                              0
                                                  0
0     Collision       Injury          Capsizing       Grounding     Overboard        Equipment
                                                                                                  11
SHORE-BASED




  BOATS
              12
                    Number of Shore-Based Boat Operational
           140
                                   Mishaps
                                                                                                                                             136
           120                          A
                                        B
           100
                                        C
              80                                                                                           62
              60
                                                                              36
              40
              20                   2    8
                                                                         1                            2                                  2          2
                          1                                          0                      1

                0
                          FY99                                   FY00                  FY01                                              FY02

The above graph depicts major (Class A-C) mishaps associated with Shore-based boat operations from
FY99 to FY02. While Class A & B mishaps have remained quite steady, there was a significant increase of
class C mishaps in FY02. As previously noted, much of this increase was due to better entry and
classification; however these factors alone don’t account for the entire rise in mishaps. The increased
operational tempo over the past year is also a major contributing factor.
Below the mishap rates are compared for FY02. As the Small Boat fleet transitions between new
platforms the number of mishaps and the operational hours vary widely making the two year comparison
difficult to extract any trends from.



                     Boat Mishap Rate per 100,000 Resource Hours
              90
                                                                                    FY01
              80
                                                                                    FY02
              70
              60
              50
              40
              30
              20
              10
               0
                                                                                                                                                    PUNT/SKIFF
                                            RHI/NSB (non ATON)




                                                                                                           RESPONSE BOAT NSB
                                                                                     TPSB




                                                                                                                                         MISC NSB
                                                                                                ATON NSB
                     41

                              44

                                   47




                                                                         49

                                                                               55
                                                                 52/30




                                                                                                                               MSO NSB




                                                                                                                                                                 13
                                      Boat Mishap Rates by MISSION
                                       (per 100,000 Resource Hours)
             120
                                                                      104                                        FY99
                                                                                                                 FY00
             100                                                                                                 FY01
                                                                                                                 FY02
                                                                                      75
                80
                                                                                 60                              59
                                                                 55
                60
                                       37                                                                37                32
                40          23
                                                     30                                                                         29
                                             21
                20
                  0
                                    TRG                               SAR                                        ELT
Above is a four year comparison of the mishap rates for the three most significant missions for shore boats.
Below is a look at the types of mishaps. There have been consistent increases in overboard and grounding mishaps
over the past four years. Much of the large increase in FY02 was due to better reporting and classification.




                                        Boat Mishaps by Mishap Types
                   80
                                                                      FY99
                                                                      FY00
                   60                                                 FY01
                                                                      FY02
                   40
                   20
                       0
                                              Equip Dmg




                                                                                                     Grounding
                                                                      Flooding

                                                                                      Fouled Screw




                                                                                                                                Overboard
                                                          Fire




                                                                                                                  Injury
                                 Collision




                                                                                                                                            14
                               Overboard/PIW Rates by Boat Type
             40
             35
             30
             25
             20
             15
             10
              5
              0




                                                                                                                PUNT/SKIFF
                   41


                          44


                                 47




                                            49


                                                   55


                                                         TPSB




                                                                           RESPONSE
                                      MSB




                                                                ATON NSB



                                                                           BOAT NSB


                                                                                      MSO NSB


                                                                                                  MISC NSB
 The above graph depicts the rate of mishaps in which personnel unintentionally entered the water by type
 of platform. Overall, the rates of these types of mishap occurring on a non-standard boat was almost
 equivalent to that for standard boats. This is an improvement over FY01 in which the rate was two times
 higher for NSB’s.



                        Causal Factors in Boat Mishaps
         Environment /Wx                         Misc.                                          Planning/ Risk
               12%                               11%                                             Assessment
                                                                                                    12%
Equipment
  11%




Communication
    7%                                                                                                       Judgement
                        Experience
                                                                                                                36%
                          11%


                                                                                                                             15
            *77% of the boat mishaps are due to human error.
                         CLASS A AND B MISHAP SUMMARY
The table below summarizes Class A and B mishaps for boats and cutters over the last five fiscal
years. The primary cause of 62% of the serious cutter mishaps was human error. Mechanical and
                                   n
environmental causal factors accouted for the remaining 38% of those mishaps. Human error
accounted for the primary cause in 78% of the serious small boat mishaps, while environmental
factors accounted for the remaining 22% of those mishaps. Human error was the primary cause in
100% of the cutter and small boat Class A mishaps, and was the primary cause in 54% of the Class
B mishaps.

While it is well known that mishaps are seldom the result of a single cause, these statistics clearly
show that human error continues to be ourleading causal factor. That conclusion underscores the
                                     f
importance of training programs that ocus on minimizing human error--such as Team Coordination
                                e
Training--and of implementing th concepts embedded in the Operational Risk Management policy.

                                     CLASS A AND B MISHAP SUM  MARY
                                                   FY97 – FY01
     DATE    CL                       NARRATIVE                                          CAUSE
    02/12/97 A    WHILE CONDUCTING RESCUE OF SAILING VESSEL, 44’ UTB   POOR JUDGMENT, LOSS OF SITUATIONAL
                  CAPSIZED CAUSING THE DEATH OF 3 OF 4 CREWMEMBERS     AWARENESS, FLAWED RISK ASSESSMENT.
                  AND DESTRUCTION OF THE BOAT.
    03/08/98 A    WHILE REPLACING A LIGHT ON A 41’ UTB, CG MBR APPEARS DROWNING. THE EXACT CAUSE IS UNNOWN,
                                                                                                     K
                  TO HAVE SLIPPED, HIT HIS HEAD AND FALLEN INTO THE    BUT NO EVIDENCE EXISTS TO SUGGEST THIS
                  WATER. THERE WERE NOT WITNESSES TO THIS ACCIDENT. WAS ANYTHING OTHER THAN AN ACCIDENT.
                  THE DIVE TEAM RECOVERED MBR’S BODY, AND WAS
                  PRONOUNCED DEAD.
    06/11/98 A    CG MBR WAS ALOFT ON THE MAINMAST WITH TOOLS TO       NO EVIDENCE TO DETERMINE THE EXACT CAUSE
                  PERFORM MAINTENANCE AND FELL APPROX. 100 FT FROM     OF FALL OR TO SUGGEST THAT THERE WAS ANY
                  THE RIGGING. NO WITNESSES TO INITIAL FALL. MBR WAS   FAILURE OF EQUIPMENT OR RIGGING. HUMAN
                                  D
                  PRONOUNCED DEA WHILE ON A HELO EN ROUTE TO           ERROR PRIMARY FACTOR IN THAT MBR
                  HOSPITAL.                                            APPARENTLY DID NOT PROPERLY CLIP TO A
                                                                       SECURE POINT.
    10/04/98 A    DURING SAR RESPONSE, RHI LOST PROPULSION AND         ENGINES STALLED DUE TO EXCESSIVE SEA
                  CAPZISED IN THE SURF. BOAT WAS STRANDED FOR MORE     CONDITIONS, RESULTING IN CAPSIZE.
                  THAN 24 HOURS.                                       BREAKDOWN IN OVERALL DECISION -MAKING
                                                                       PROCESS, LOSS OF SITUATIONAL AWARENE SS.
    02/24/00 A                                                                            NG, CREW FATIGUE,
                  WHILE MOORING AT HOMEPORT PIER, WHEC EXPERIENCED 2INADEQUATE PIER FENDERI
                  FT BY 4-INCH GASH IN PORT SIDE, FLOODING ENG ROOM ANDCREW DISTRACTION.
                  DESTROYING THE GAS TURBINE ENGINE (ESTIMATED DAMAGE
                  OVER $1M). GASH CAUSED BY PROTRUDING FENDER ANCHOR
                  BOLT.
    03/23/01 A                                                       INABILITY TO SAFELY MANUEVER IN EXISTING
                  WHILE UNDERWAY FOR A MLE PATROL, A RHI STRUCK A WAVE
                  AND CAPSIZED. 2 OF 4 POB DROWNED AND THE SURVIVERS SEA STATE, SAR DELAY DUE TO VESSEL’S
                  SUFFERED HYPOTHERMIA.                              DEVIATION FROM ORIGINAL PLAN, EXTENDED
                                                                     EXPOSURE TO COLD WATER.
    05/14/97 B    WLB COLLIDED WITH A 757 FT CONTAINER SHIP IN REDUCED HUMAN ERROR BY THE PILOT OF THE CONTAINER
                  VISIBILITY CAUSING APPROX $890K IN DAMAGE.           SHIP IN NAVIGATING HIS VESSEL, INCLUDING
                                                                       EXCESSIVE SPEED AND LOSING AWARENESS OF
                                                                       THE EBBING CURRENT DURING THE TURN. POOR
                                                                       COMMUNICATIONS AND NEAR ZERO VISIBILITY
                                                                       CONTRIBUTED TO THE MISHAP.
    07/26/98 B    CG MBR PLACED BOILER FUEL CONTROLS IN MANUAL,        FAILURE TO FOLLOW ESTABLISHED
                  ALLOWING FUEL TO ENTER THE COMBUSTION CHAMBER        PROCEDURES FOR LIGHTING OFF BOILER AND
                  WHILE FILLING THE BOILER W/ FEEDWATER. BOILER        TAG-OUT, LACK OFQUALIFIED SUPERVISION,
                  EXPLODED CAUSING BURNER ACCESS DOOR TO VIOLENTLY     INADEQUATE DIRECTIONIN NIGHT ORDERS.
                  SWING OPEN, STRIKING AND INJURING MBR.
    10/02/98 B    DURING A SAR RESPONSE, RHI WAS STRUCK ABEAM BY A    SUDDEN, UNANTICIPATED WORSENING OF SEA
                  WAVE CAUSING IT TO CAPSIZE. THE RHI LATER WASHED UP STATE AND LIMITED VISIBILITY.
                  ON SHORE WITH ESTIMATED DAMAGE OF $50K.
    11/17/98 B    WHILE AT ATON DETAIL, MBR CAUGHT GLOVED HAND         LACK OF SITUATIONAL AWARENESS,
                  BETWEEN A BLOCK AND WIRE ROPE, SEVERING PARTS OF     INATTENTION.
                  THREE FINGERS AND CAUSING TENDON DAMAGE IN
                  FOREARM.
                  TWO TPSB’S COLLIDED NEARLY BOW ON WHILE TRANSITTINGFAILURE TO CONDUCT PRE
    08/22/99 B
                  CHANNEL IN VICINITY OF CATALINA ISLAND FERRY.
                                                                                                        16
                                                                                            -MISSION BRIEF,
                                                                     FAILURE TO COMMUNICATE WITH OTHER
                                                                     VESSELS IN THE AREA, FAILURE TO MAINTAIN
                                                                     PROPER DISTANCE FROM THE FERRY AND
                                                                     MANEUVER SAFELY IN THE CHANNEL.
CLASS A AND B MISHAP SUMMARY (cont.)

   10/31/99 B   CRANKCASE EXPLOSION TO NO. 2 MDE ON WPB WHILE        MECHANICAL FAILURE.
                TRANSITTING ON ELT PATROL. ESTIMATED DAMAGE $414K.
   03/09/00 B   WHILE DRYING OUT A CRACK IN THE HULL OF A RHI, CG MBR UNFAMILIARITY WITH CONSTRUCTION OF RHI,
                                 UMES TRAPPED IN THE BILGE, CAUSING INADEQUATE TRAINING IN REPAIR PROCEDURES.
                IGNITED GASOLINE F
                THE BOAT TO EXPLODE.
   10/01/00 B   CG MBR EJECTED FROM RHI AND SUBSEQUENTLY STRUCK INCOXSWAIN ERROR CAUSED INITIAL MISHAP OF
                THE HEAD BY SKEG AND PROP FROM RUNAWAY RHI.       CREW EJECTION AND RUNAWAY OF RHI;
                                                                  INAPPROPRIATE RISK ASSESSMENT TO STOP THE
                                                                  RUNAWAY RHI.
   11/25/00 B   WHILE PREPARING TO LAUNCH A MSB FOR A LE BOARDING, UNFORESEEABLE METALLURGICAL FAILURE DUE
                                                                   TO                         A
                AFT DAVIT ARM SNAPPED, EVENTUALLY CAUSING THE MSB TO METAL FATIGUE OF THE AFT DVIT ARM.
                                      ZE
                ROLL TO PORT AND CAPSI AFTER ENTERING WATER. THE
                CREW WAS EJECTED, BUT SUBSEQUENTLY RECOVERED WITH
                NO SERIOUS INJURIES. MSB COULD NOT BE RECOVERED, SO
                IT WAS ABANDONED AND DECLARED A HAZARD TO
                NAVIGATION.
   01/10/01 B   WHILE CONDUCTING A LE MISSION, DPB SUBJECTED TO WX CONDITIONS, POTENTIAL DESIGN FLAW IN
                SUDDEN WX CHANGE. HEAVY WAVE ACTION FLOODED THE DPB, INATTENTION BY BOAT CREW.
                ENGINE COMPARTMENT DAMAGING BOTH ENGINES.
   02/10/01 B               N
                WHILE CROSSI G THE BAR, VESSELS STERN WAS LIFTED 20 PARTIALLY AIR BOUND FUEL SYSTEM DUE TO
                DEGREES BY A SWELL CAUSING BOTH GENERATORS AND      LOW FUEL LEVEL ANDWEATHER CONDITIONS.
                MDES TO STALL AND STEERING TO FAIL. VESSEL THEN
                STRUCK THE JETTY, CAUSING DAMAGE TO THE BOW AND
                FORWARD AREAS.


                                                       Table 1




                                                                                                       17
          Team Coordination Training
As announced in the FY      -2001 Afloat Safety Report, the American
Council on Education (ACE) reviewed the TCT Correspondence Course
                                                 -
and recommended college credit in the upperdivision baccalaureate
                                     i
category, 3 semester hours in decsion making and problem solving.
The ACE identification number is CG      -1406-0011 and is effective for
TCT Correspondence Courses successfully completed by members since
March 1996. Detailed information about this course is available on the
CG Institute’s web site at http://www.uscg.mil.hq/cgiTo access, click on
the tab labeled “Member”, select “Earn College Credit”, select “ACE
Guide Online”, click on “Search Courses”, then type in the field called
ACE ID: CG-1406-001. The TCT Correspondence Course is ti            tled
“Introduction to Team Coordination Training by Correspondence” and
is available from the CG Institute. The course short title is “TCTSG”
and Course Code-Edition is 0652-2. Members interested in earning
college credit will be one                        i
                             -step closer by visit ng their Educational
Service Officer and completing a CG Institute Enrollment/Test Request
Form for this course. Ideally, members scheduled to receive or have
recently completed TCT through a resident training courses (TCT
Group Operations, TCT Cutter Op           erations, Cutter Prospective
Operations Officer (POPS), TCT Facilitator) or Exportable, TCT     -Unit
Level Training are highly encouraged to enroll and complete the TCT
Correspondence Course.

In December 2000, Chief, Command and Operations School, USCG
                                                   -
Academy, initially sought approval of the threeday TCT Cutter
Operations (Course Code 500686) to meet the requirements set forth in
Title 46, Code of Federal Regulations (46 CFR), Part 10.205(o) and the
Standards of Training, Certification and Watchkeeping for Seafarers
(STCW). In December 2002, Commanding Officer, USCG National
Maritime Center (NMC) approved the TCT Cutter Operations course
as meeting the requirements for STCW certification for Bridge
Resource Management (BRM). This approval is effective as of 01
January 2003 and is valid through the expiration date of 31 January
2005. Subsequent five  -year renewals may be granted upon a written 18
request to the NMC at least 90 days before the exp       iration date.
Three annual convenings of the TCT Cutter Operations course are offered at the
Command and Operations School, USCG Academy. The 23 students successfully
completing the 14-16 January 2003 TCT Cutter Operations Course (Session # 0008)
were the first to receive the STCW certificate of training - titled “24-hour Team
Coordination Training (TCT) Cutter Operations” – satisfying the BRM training
requirements of 46 CFR 10.205(o) and Section B-VIII/2, Part 3-1 of the STCW Code.
The next convening of this course is scheduled for 09-11 September 2003. For all you
ever wanted to know about STCW or other information on U.S. mariner licensing and
documentation requirements as well as how to meet the requirements, please visit:

http://www.uscg.mil/STCW/s-history.htm

Furthermore, the Command and Operations School has embedded the three-day TCT
Cutter Operations Course curriculum into the two-week CG Prospective Operations
Officer (POPS) Afloat Program (Course Code 501080). The 20 students successfully
completing the 15-17 April 2003 TCT Cutter Operations Course embedded in the 07-18
April 2003 CG POPS Afloat Course (Session # 0003) received the STCW certificate as
discussed above.

For the most up-to-date convening date information on resident training courses,
established course prerequisites, and the procedures for obtaining approval and
submitting Short-Term Training Requests (STTRs) or Electronic Training Requests
(ETRs), please visit the CG Training Quota Management Center (TQC) web site:

http://www.uscg.mil/hq/tqc




                                                                             19
                   FY-2002 TCT STATISTICS

 Total number of students receiving TCT Resident Training: 117

   32 TCT-Group Operations (Course Code 500687)
   49 TCT-Cutter Operations (Course Code 500686)
   26 TCT-Facilitator Training (Course Code 500688)

 Total number of students receiving Exportable, TCT Unit-Level
  Training (Course Code 500834) (as reported by District TCT
  Administrators and LANT/PAC Area Training Teams):

   6,991    (4532 Active Duty, 509 Reservists, 1950 Auxiliarists)

 Total number of active district TCT Facilitators is 69 (does not
  include LANT/PAC AREA Training Team instructors).

 The Exportable, TCT unit-level training program averaged about
  $18.68/quota, which keeps it competitive for limited training dollars
  (reducing training expenses while optimizing performance).

 Total number of students receiving TCT embedded in other Resident
  Training Courses: 17

  17 Cutter Prospective Operations Officer (POPS) (Course Code 501080)




                                                                          20
In accordance with Team Coordination Team (TCT), COMDTINST 1541.1,
all requests for exportable, TCT-unit level training (500834) shall be
forwarded to the cognizant District TCT Administrator and/or coordinated
through the appropriate Auxiliary division captains for Auxiliary TCT.
Current (as of 01 May 2003) District TCT Administrators (and work phone
numbers) are listed below for reference:
D1(reserve):           CDR M. Cicalese         (617) 227-3979
D5(oax):               CWO W. Orvis            (757) 398-6509
D7(oax):               CWO R. Flynn            (305) 415-7053
D8(oax):               CWO B. Barr             (504) 589-6620
D9(osr):               LT N. Novotny           (216) 902-6118
D11(osr):              QMC S. Tierney          (510) 437-5366
D13(cc):               LT C. J. Cunningham     (206) 220-7004
D14(osr):              LT M. Wessel            (808) 541-2312
D14(osr):              LT Jeff A. Janszen (relieves LT Wessel in June 2003)
D17(oan)               MCPO D. Coffman         (907) 463-2266
Other helpful information:
 COMDT TCT Program Manager:
   LCDR Kathryn L. Oakley koakley@comdt.uscg.mil (202) 267-2965
 Afloat & Marine Safety Division (G-WKS-4) / TCT/ORM web site:
   http://www.uscg.mil/hq/G-W/g-wk/g-wks/g-wks-4/index.htm
 Office of Boat Forces (G-OCS) Boat Forces Newsletter web site:
   http://cgweb.comdt.uscg.mil/g-ocs/BFN%20home.htm
 Training Quota Management Center (TQC) web site:
   http://www.uscg.mil/hq/tqc
 Coast Guard Institute (CGI) web site:
   http://www.uscg.mil.hq/cgi
                                                                         21
Common Mishap Discrepancies                        What are the Mishap Descriptions?
                                                    Mishap                         Description
Failure to use the proper message format           Severity
                                                   Class A    Cost of reportable property
   The format for submitting mishap message                        damage is $1,000,000 or greater.
   reports was changed in June of 2001 and                    Vessel is missing or abandoned,
   promulgated in change 5 to the Safety &                         recovery is impossible or
   Environmental Health Manual, COMDTINST                          impractical, vessel cannot be
   M5100.47. Several minor ch      anges were                                          .
                                                                   repaired economically
   made in change 8 as well. These changes                    An injury or occupational illness results in a fatality
   can be downloaded from the G     -WKS web-                 or permanent total disability.
   site at the link provided on the last page of
                                                   Class B    Cost of reportable property damage is
   the report. Use of the E-Mishap system will
                                                                   $200,000 or more, but less than
   automatically      generate    a    correctly
                                                                   $1,000,000.
   formatted message
                                                              Injury/Illness results in permanent partial
                      s
Misclassification of Mi haps                                       disability.
                                                              Three or more people are inpatient
   The table to the right outlines the mishap                      hospitalized.
   classification criteria. Probably the most                 For small boats 30 feet in length or
   frequent      misclassifications    involve                     greater, damage is $50,000 or
   groundings and personnel injuries. All                          more.
   groundings, no matter how minor are Class                  For small boats less than 30 feet in
   C mishaps. Likewise, any mishap in which                       length, damage is equal to, or
   an individual is placed on more than 30                        greater than, half of the
   days of limited duty or is determined to be                    replacement cost of the boat.
   Not Fit For Duty (NFFD) or sick in quarters
                                                   Class C    Cost of property damage is $20,000 or
   for one or more days. Use of the E-Mishap
                                                                   more, but less than $200,000.
   system will automatically determine the
                                                              Non-fatal injury/illness results in any loss
   correct classification.
                                                                   of time from work beyond the day
                       ost
Failure to include the c of property                                                           ,
                                                                   or shift on which it occurredor more
damage                                                             than 30 days of limited duty.
                                                              A person falls overboard accidentally.
   Mishaps have an economic impact on the                     Any grounding, capsizing, rollover, or
   servicez: replacement parts, commercial                                                   s
                                                              knockdown greater than 90 degree from an
   repairs, even the value of Coast Guard                     even keel that does not meet higher criteria.
   man-hours that could be spent doing other
                                                   Class D                          ween $1,000 and $20,000.
                                                              Cost of property is bet
   important work. We need to do a better job
   of capturing these costs.                                  Non-fatal injury/illness does not meet
                                                                   criteria of a Class C.
Failure to capture lessons learned from                       Any firearm discharge, or electrical
Near-Misses                                                        shock occurs that does not meet
                                                                   the criteria of a higher classification
   Some of the best lessons learned come
   from those that did not happen. HIPOs                                                   a
                                                              HIPO: Near mishaps, lessons lerned events, or

   range from those events in which nothing                   other events with a HIgh POtential for injury or

   short of divine intervention prevent a
                                      ed                      damage.

   mishap from occurring to ones in which
   ORM or strong team skills broke the error
   chain. Please consider sharing your HIPOs
   with the field.                                                                                     22
                      CONTACT US
Your comments of this report, how to improve it's content, and any
other suggestions concerning the afloat safety program will be greatly
                                               e
appreciated. Please feel free to call, fax, or -mail (preferred) us with
                                e
any comments, questions or conc rns.


           AFLOAT SAFETY DIVISION (G-WKS-4)

CDR Tommey H. Meyers               (202) 267-6863
LCDR Kathryn L. Oakley             (202) 267-2965
LT Scot A. Brown                   (202) 267-1491
CWO Josh O. Henley                 (202) 267-2964
FAX:                               (202) 267-4355
http://www.uscg.mil/hq/G-W/g-wk/g-wks/g-wks-4/index.htm

         MAINTENANCE & LOGISTICS COMMAND
                         SAFETY POCs
MLC ATLANTIC (kse)
Mr. Vincent Andreone                (757) 628-4412
CWO Chris Shultis (vsl specialist)  (757) 628-4409
http://cgweb.lant.uscg.mil/KDiv/kseHomePage.htm

MLC PACIFIC (kse)
Mr. Kenneth Koutz                   (510) 437-5928
http://cgweb.mlcpac.uscg.mil/mlcpk/SafEnvHlthBran.htm




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