# Presentation: 457646

## Safety Management PracticesofDomestic Maritime Carriers

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## 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.”**

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## Industry Initiatives

** **_**Industry Initiatives**_
** ****Electronic navigational tools **
** ****Electronic Charting w/ DGPS+**
** ****Company incident investigation**** ****efforts**
** ****Root cause analysis**

- Ingram/NTSB Presentation

## Electronic Navigation Tools

***Electronic Navigation Tools***

**Electronic Charts**
**Pinpoint/Riverpro**
**Satellite tracking/positioning**
**DGPS+ accuracy**
**Radar Overlay**
**Advanced Vessel Management Systems**

- Ingram/NTSB Presentation

**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**

***Electronic Charting System***

- Ingram/NTSB Presentation

## Electronic Charting System

***Electronic Charting System***

- Ingram/NTSB Presentation

## An Electronic Chart

***An Electronic Chart***

- Ingram/NTSB Presentation

## Electronic Navigation Systems

***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.**
** **

- Ingram/NTSB Presentation

## 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.

_**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.**

***Electronic Navigation Systems***

- Ingram/NTSB Presentation

## Electronic Chart with Radar Overlay

***Electronic Chart with Radar Overlay***

- Ingram/NTSB Presentation

## 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.

_**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.**

***Electronic Navigation Systems***

- Ingram/NTSB Presentation

## 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.)

***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.)**

- Ingram/NTSB Presentation

## Incident Investigation

**Coast Guard is primary agency for investigating incidents **
**Very large events usually also involve the NTSB and other authorities **

- Ingram/NTSB Presentation

## 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 **

- Ingram/NTSB Presentation

## 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**

- Ingram/NTSB Presentation

## 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!**

- Ingram/NTSB Presentation

## 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.**

- Ingram/NTSB Presentation

## 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.

**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.**

*Ingram ISAFE Process*

- Ingram/NTSB Presentation

## 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.

**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.**

*Ingram ISAFE Process*

- Ingram/NTSB Presentation

## 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.

**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.**

*Ingram ISAFE Process*

- Ingram/NTSB Presentation