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