Lessons from investigation of Collision between DUKW 34 and

Lessons from investigation of
Collision between DUKW 34 and
Caribbean Sea/The Resource
Thomas K. Roth-Roffy
Presented at SOCP Fall 2012 Meeting, October 2012, Providence, RI
1
The Accident
• Date:
July 7, 2010
• Location: Delaware River, near Philadelphia, PA
• Vessels: - Barge The Resource
- Tugboat Caribbean Sea
- APV DUKW 34
• Injuries: 2 fatal, 27 minor
• Damage: $130,000
2
Caribbean Sea
•
•
•
•
•
Photo by Joe Becker
3
Type:
Length:
Breadth:
Draft:
Crew:
Tug
78.9 ft
24 ft
8 ft
5
The Resource
Photo by Brian E. Stover
•
•
•
•
•
Type:
Length:
Breadth:
Draft:
Crew:
4
Tank Barge
250 ft
50 ft
3 ft – 6 in
0
DUKW 34
•
•
•
•
•
•
Photo by Joe
Becker
5
Type:
Length:
Breadth:
Draft:
Crew:
Pax:
APV
33 ft
8 ft
5 ft
2
35
Accident Timeline
• 1315 – Caribbean Sea under way
• 1415 – DUKW 34 enters river
• 1425 – DUKW 34 mechanical
problem
• 1429 – DUKW 34 anchor deployed
• 1436 – DUKW 34 VHF callouts
• 1437 – Collision
6
Animation - Description
7
Animation
Animation can be view at NTSB website:
http://www.ntsb.gov/news/events/2011/philadelphia_pa/animation.html
8
Damage to DUKW 34
9
Investigation - Exclusions
• Crew qualifications & certificates
• Crew medical and toxicological
• Waterway conditions
• Weather conditions
10
Investigation Exclusions (cont’d)
• Caribbean Sea propulsion, steering,
communications, navigation
equipment
• DUKW 34 mechanical systems
11
Safety Issues
• Vehicle maintenance
• Maintaining an effective lookout
• Use of cell phones by crewmembers
on duty
• Response to the emergency by Ride
The Ducks International personnel
12
Parties to the Investigation
• U.S. Coast Guard
• K-Sea Transportation Partners, LP
• Ride The Ducks International, LLC
13
Probable Cause
“… the failure of the mate of the Caribbean Sea to maintain a proper
lookout due to (1) his decision to operate the vessel from the lower
wheelhouse, which was contrary to expectations and to prudent
seamanship, and (2) distraction and inattentiveness as a result of his
repeated personal use of his cell phone and the company laptop
computer while he was solely responsible for navigating the vessel.
Contributing to the accident was the failure of Ride The Ducks
International maintenance personnel to ensure that DUKW 34‘s surge
tank pressure cap was securely in place before allowing the vehicle to
return to passenger service, and the failure of the DUKW 34 master to
take actions appropriate to the risk of anchoring his vessel in an active
navigation channel. “
14
Safety Recommendations
•
To the U.S. Coast Guard:
•
Develop and implement an investigative protocol that directs your investigation officers
to routinely check for nonoperational use of cell phones and other wireless electronic
devices by on-duty crewmembers in safety-critical positions involved in marine
accidents. (M-11-1)
•
Revise your commercial vessel accident database (MISLE) to maintain a record of
nonoperational use of cell phones and other wireless electronic devices by on-duty
crewmembers in safety-critical positions when such use is causal or contributory to
marine accidents. (M-11-2)
•
Regulate and enforce the restriction on nonoperational use of cell phones and other
wireless electronic devices by on-duty crewmembers in safety-critical positions so that
such use does not adversely affect vessel operational safety.
•
(M-11-3)
•
Until you can develop regulations governing nonoperational use of cell phones and
other wireless electronic devices by on-duty crewmembers in safety-critical positions,
continue your outreach program of information and education to the maritime industry
on this issue. (M-11-4)
15
Safety Recommendations
To Ride The Ducks International, LLC:
•
Review Ride The Ducks International‘s existing safety management program and
develop improved means to ensure that your company‘s safety and emergency
procedures are understood and adhered to by employees in safety-critical positions.
(M-11-5)
To K-Sea Transportation Partners L.P.:
•
Review K-Sea Transportation‘s existing safety management program and develop
improved means to ensure that your company‘s safety and emergency procedures
are understood and adhered to by employees in safety-critical positions. (M-11-6)
To The American Waterways Operators:
•
Notify your members of the circumstances of this accident, and encourage them to
ensure that their safety and emergency procedures are understood and adhered to
by employees in safety-critical positions. (M-11-7)
16
The Lessons
• Reducing Distracted Operation
• Improving Effectiveness of Safety
Management System
17