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Safety Management Practices of Domestic Maritime Carriers 6/15/2009 Ingram/NTSB Presentation 1 Domestic Maritime Carriers Coast Guard - AWO (American Waterways Operators) Safety Partnership Quality Action Teams Partnership initiatives Industry Initiatives Electronic navigational tools Electronic Charting w/ DGPS+ Company incident investigation efforts Root cause analysis 6/15/2009 Ingram/NTSB Presentation 2 CG - AWO Safety Partnership CG - AWO Safety Partnership was formed in Fall of 1995 It was a product of the Coast Guard’s “Prevention Through People” initiative Premise: 80% of all accidents have their root cause in the human element “a long term strategy to rebalance the safety equation by refocusing prevention efforts on casualties caused by human error.” 6/15/2009 Ingram/NTSB Presentation 3 CG - AWO Safety Partnership The partnership is aimed at a common goal of improved marine transportation safety and environmental protection Business competitors and the CG join forces to work on solutions to common problems Share information and data Share resources Open dialog to develop “do-able” non-regulatory solutions 6/15/2009 Ingram/NTSB Presentation 4 CG - AWO Safety Partnership Partnership was praised by the Vice President’s National Partnership for Reinventing Government Awarded the “Hammer Award” for excellence in public private partnerships 6/15/2009 Ingram/NTSB Presentation 5 CG - AWO Safety Partnership Quality Action Teams Two dozen different teams. Examples: Towing Vessel Crew Fatalities Tank Barge Transfer Spills Aids to Navigation Downstreaming Barge Inspection Consistency Major and Medium Tank Barge Spills 6/15/2009 Ingram/NTSB Presentation 6 Quality Action Teams Towing Vessel Crew Fatalities Completed in 1996 Reviewed historical data Attempted to fill in data voids Identified high risk activities Analyzed causes Developed a broad based response 6/15/2009 Ingram/NTSB Presentation 7 Quality Action Teams Towing Vessel Crew Fatalities (cont.) Action Plan Developed CG-AWO S.A.F.E. Decks campaign and a fall overboard prevention guide for industry-wide use • Over 30,000 distributed • Regional Committee produced a training video and informational handout to address the practice of “downstreaming” Fall overboard prevention requirement of the AWO Responsible Carrier Program is added as a result of QAT recommendation 6/15/2009 Ingram/NTSB Presentation 8 Industry Initiatives  Industry Initiatives  Electronic navigational tools  Electronic Charting w/ DGPS+  Company incident investigation efforts  Root cause analysis 6/15/2009 Ingram/NTSB Presentation 9 Electronic Navigation Tools Electronic Charts Pinpoint/Riverpro Satellite tracking/positioning DGPS+ accuracy Radar Overlay Advanced Vessel Management Systems 6/15/2009 Ingram/NTSB Presentation 10 Electronic Charting System Installed on all Ingram boats: Electronic Charts displayed on a 20” monitor using DGPS+ to continuously update the boat’s position Overlay of Radar Targets onto the Electronic Chart Display Archiving of boat’s “track” and each radar target 6/15/2009 Ingram/NTSB Presentation 11 Electronic Charting System 6/15/2009 Ingram/NTSB Presentation 12 An Electronic Chart 6/15/2009 Ingram/NTSB Presentation 13 Electronic Navigation Systems Why DGPS+? GPS accurate to within 100 meters 95 % of the time. Differential GPS (D GPS) accurate to 3 meters 99 % of the time. 6/15/2009 Ingram/NTSB Presentation 14 Electronic Navigation Systems Benefits are improved safety Pinpoint accuracy day or night in any weather. Ability to track past position & selected data. Superimpose radar image onto chart. Zoom in & zoom out capability. Integration with depth sounder & auto pilot. Visual & Audible alarms. Aid in post incident investigating. 6/15/2009 Ingram/NTSB Presentation 15 Electronic Chart with Radar Overlay 6/15/2009 Ingram/NTSB Presentation 16 Electronic Navigation Systems Benefits also include improved productivity Help meet demand for more experienced personnel. Transfer route knowledge between Captains & share “Bar Book” information. Accelerate training in steersman program. Ability to transmit “best possible route” during changing or adverse river conditions. Monitor speed and regulate fuel burn. 6/15/2009 Ingram/NTSB Presentation 17 Electronic Navigation Systems The Future Improve satellite and other communication capabilities. Develop “Advanced Vessel Management System”. Will allow Vessel to Office and Vessel to Vessel communication of actual trip profiles Can be tied into other vessel systems (Engine Room, fathometer, etc.) 6/15/2009 Ingram/NTSB Presentation 18 Incident Investigation Coast Guard is primary agency for investigating incidents Very large events usually also involve the NTSB and other authorities 6/15/2009 Ingram/NTSB Presentation 19 Incident Investigation CG has been evaluating their casualty data collection systems for a number of years due to their own concerns with the data being collected Issues include: The accuracy of information Whether it gets to the root cause of incidents Differences in level of experience and expertise Only significant events are handled by senior staff Data limited to readily available facts Analysis tends to be limited Focus is on data collection and not seeking root causes 6/15/2009 Ingram/NTSB Presentation 20 Incident Investigation Companies have been keenly concerned with casualty prevention. Incidents have multiple affects on operations and productivity Losses from damages injuries and claims • Jones Act employee litigation $$$$ Lost productivity Diminished image in the community Risk of regulatory response 6/15/2009 Ingram/NTSB Presentation 21 Incident Investigation Incident investigation has historically been heavily focused on litigation issues Property damage accidents tend to involve large dollar value losses Liability is frequently disputed Crew personal injury claims are outside of workers compensation arena and subject to tort litigation at the hands of a very aggressive plaintiff’s bar Your efforts to improve are thrown back in your face as part of the plaintiff’s proof of liability! 6/15/2009 Ingram/NTSB Presentation 22 Ingram ISAFE Process ISAFE is Ingram’s program to investigate incidents and near misses. The goal of ISAFE is to identify root causes and trends, then design countermeasures or corrective actions to prevent or reduce the likelihood or recurrence. 6/15/2009 Ingram/NTSB Presentation 23 Ingram ISAFE Process Initiated in 1995, updated in 1999 Ingram looked at the comprehensive investigative methodology used by the NTSB and tried to capture the quality of the process within the finite resources available to the organization. 6/15/2009 Ingram/NTSB Presentation 24 Ingram ISAFE Process The ISAFE process is a Collaborative process involving Vessel Operations, Engineering, Safety, and Claims Departments The “Lessons Learned” will be shared throughout the organization and integrated into revised practice and procedures. 6/15/2009 Ingram/NTSB Presentation 25 Ingram ISAFE Process Associates are trained in fact gathering techniques and perform preliminary findings and analysis Data is collected and monitored to identify trends and problem areas The ISAFE team reviews the findings and identifies root causes and develops action plans to address those causes. 6/15/2009 Ingram/NTSB Presentation 26