DEPARTMENT OF HOMELAND SECURITY 

Office of Inspector General 

United States Coast Guard’s Management 

of the Marine Casualty Investigations Program 

OIG-08-51 MAY 2008 
MAY

Office ()f Inspector General 

U.S. Department of Homeland Security 

Washington, DC 20528 

Homeland 

Security 9 2008 

Preface 

The Department of Homeland Security (DHS) Office of Inspector General (OIG) was established by 

the Homeland Security Act of 2002 (Public Law 107-296) by amendment to the Inspector General 

Act of 1978. This is one of a series of audit, inspection, and special reports prepared as part of our 

oversight responsibilities to promote economy, efficiency, and effectiveness within the department. 

This report addresses a congressional request from the Committee on Transportation and 

Infrastructure, U.S. House of Representatives, and the Committee on Commerce, Science and 

Transportation, U.S. Senate, regarding the United States Coast Guard's management of the marine 

casualty investigations program. It is based on interviews with employees and officials of relevant 

agencies and institutions, direct observations, and a review of applicable documents. 

The recommendations herein have been developed to the best knowledge available to our office, and 

have been discussed in draft with those responsible for implementation. It is our hope that this 

report will result in more effective, efficient, and economical operations. We express our 

appreciation to all of those who contributed to the preparation of this report. 

Richard L. Skinner
 

Inspector General
 
Table of Contents/Abbreviations
 

Executive Summary 1
 

Background 2
 

Results of Audit 6
 

Qualifications of Marine Casualty Investigators 7
 

Marine Casualty Investigations 12
 

Backlog of Marine Casualty Investigations 15
 

Recommendations 16
 

Management Comments and OIG Analysis 17
 

Appendices 

Appendix A: Purpose, Scope, and Methodology 21
 

Appendix B: Management Comments to the Draft Report 23
 

Appendix C: Congressional Request for Audit.. 36
 

Appendix D: Coast Guard's G-MOA Policy Letter 2-02 38
 

Appendix E: Responses to Committees' Concerns .43
 

Appendix F: Major Contributors to this Report .46
 

Appendix G: Report Distribution 47
 

Abbreviations 

1988 Standard June 1988 Marine Casualty Investigation Standard
 

Basic Course Basic Marine Investigator Course
 

Coast Guard United States Coast Guard
 

CFR Code of Federal Regulations
 

DHS Department of Homeland Security
 

FY Fiscal Year
 

OIG Office of Inspector General
 

Marine Board Marine Board of Investigation
 

MISLE Marine Information for Safety and Law Enforcement
 

NTSB National Transportation Safety Board
 
Guard's

OIG
 

Department ofHomeland Security 

Office ofInspector General 

Executive Summary 

This report provides our response to a joint request from the Committee on 

Transportation and Infrastructure of the House of Representatives and the 

Committee on Commerce, Science, and Transportation of the Senate on the 

United States Coast Guard's management of the marine casualty 

investigations program. The Cominittees requested that we audit the extent to 

which marine casualty investigations and reports result in information and 

recommendations that prevent or minimize the effect of similar casualties. 

Although the Coast Guard's marine casualty investigations program has 

resulted in numerous safety alerts and recommendations designed to prevent 

similar casualties, the program is hindered by unqualified personnel 

conducting marine casualty investigations; investigations conducted at 

inappropriate levels, and ineffective management of a substantial backlog of 

investigations needing review and closure. Because of these management 

shortfalls, the Coast Guard may not be able to determine the causal factors of 

accidents and may miss opportunities to issue safety alerts or 

recommendations that could prevent or minimize similar casualties. To 

address these shortfalls, in September 2007, the Coast Guard issued a plan to 

enhance its marine safety program. Many of the actions of this plan are 

similar to the recommendations in our report. 

To improve the management and accountability of the marine casualty 

investigations program, we are making eight recommendations to the 

Commandant, United States Coast Guard, including: 

•	 Developing and implementing a plan to increase the number of 

qualified marine casualty investigators, including hiring civilians; and 

•	 Implementing quality control procedures to ensure marine casualty 

investigations are conducted at the recommended levels. 

The Coast Guard agreed to seven of the recommendations, but did not concur 

with our recommendation to revise the August 2007 marine casualty 

investigation qualification standard to include the prequalification of Hull or 

Machinery, and Small Vessel Inspectors. The Coast Guard's comments to our 

report are incorporated into the body of this report, as appropriate, and are 

included in their entirety as Appendix B. 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 1 
Background 

The United States Coast Guard has been responsible for conducting marine 

casualty investigations for over 60 years. The marine casualty investigation 

program presently resides in the Coast Guard's Prevention Directorate, 

employing approximately 150 uniformed and civilian staff nation-wide. 

According to the Coast Guard's Marine Safety Manual, the objective of the 

marine casualty program is to obtain information for the prevention of similar 

casualties,' as far as practicable. According to 46 Code of Federal Regulations 

(CFR) § 4.07-1, the investigations of marine casualties and accidents and 

determinations made are for the purpose of taking appropriate measures to 

promote safety of life and property at sea, and are not intended to fix civil or 

criminal responsibility. Based upon information gathered during an 

investigation, the Coast Guard may take corrective actions, such as instituting 

standards for safety and recommending marine safety legislation. 

Further, according to 46 CFR § 4.05-1, upon the occurrence of a marine 

casualty and immediately after addressing resultant safety concerns, the 

owner, agent, master, operator, or person in charge of a vessel, shall notify the 

Coast Guard whenever the vessel is involved in­

(1)	 An unintended grounding, or an unintended strike of (allision with) 

a bridge; 

(2) An intended grounding, or intended strike of a bridge, that creates 

a hazard to navigation, the environment, or the safety of a vessel, 

or that meets any criterion in paragraphs (3) through (8); 

(3) A loss of main propulsion, primary steering, or any associated 

component or control system that reduces the maneuverability of 

the vessel; 

(4)	 An occurrence materially and adversely affecting the vessel's 

seaworthiness or fitness for service or route, including but not 

limited to fire, flooding, or failure of or damageto fixed fireextinguishing systems, lifesaving equipment, auxiliary powergenerating equipment, or bilge-pumping systems; 

(5) A loss of life; 

(6) An injury that requires professional medical treatment (treatment 

beyond first aid) and, if the person is engaged or employed on 

board a vessel in commercial service, that renders the individual 

unfit to perform his or her routine duties; 

(7) An occurrence causing property damage in excess of $25,000, 

including the cost of labor and material to restore the property to 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 2
 
of

its condition before the occurrence, but not including the cost of 

salvage, cleaning, gas-freeing, drydocking, or demurrage; or 

(8) An occurrence involving significant harm to the environment 

[§ 4.03-65]. 

Types of Marine Casualty Investigations 

The Coast Guard defines the following levels of marine casualty 

investigations: 

•	 Preliminary investigations are initial investigative efforts of casualties to 

determine whether to assign a case as a data collection activity, an 

informal investigation, or a formal investigation, depending on the 

severity and value to marine safety. If a case is not assigned, it remains a 

preliminary investigation. 

•	 Data collection activity investigations do not require any significant 

investigative effort, and usually consist only of collecting basic factual 

information and entering it into the Coast Guard's Marine Information for 

Safety and Law Enforcement (MISLE) database for future reference and 

analysis. Only minimum follow-up to verify accuracy and completeness 

of the data collected should be conducted, as necessary. 

•	 Informal investigations are less exhaustive than formal investigations, but 

include the determination and reporting on the causes of a casualty. This 

is the minimum level of investigative effort required to initiate 

enforcement actions. Some of the criteria for an informal investigation 

include casualties in which property damage exceeds $100,000 but is less 

than $1 million, any collision or allision resulting in property damage 

exceeding $25,000, and a medium discharge of oil, i.e., between 1,000 and 

10,000 gallons to inland waterways and between 10,000 and 100,000 

gallons to coastal waters. 

•	 Formal investigations are reserved for the more serious or significant 

incidents in which the most investigative value can be gained. Some of 

the criteria for conducting a formal investigation include two or more 

deaths, property damage exceeding $1 million, and a major discharge of 

oil, i.e., more than 10,000 gallons to inland waterways and over 100,000 

gallons to coastal waters. 

In addition, the Commandant of the Coast Guard may convene a Marine 

Board of Investigation (Marine Board) as a result of preliminary evidence, 

recommendation by a District Commander, or information from any other 

source, when it appears that a marine casualty is of such magnitude or 

United States Coast Guard's Management the Marine Casualty Investigations Program 

Page 3 



.2!:

Qualifications of Marine Casualty Investigators 

Based on the Coast Guard's June 1988 marine casualty investigation standard 

(1988 standard), 68% of investigators in our sample were not qualified to 

conduct marine casualty investigations. 1 

Qualifications for Marine Casualty Investigators Not Fully Met 

The Coast Guard's 1988 standard required a combination of experience, 

investigative tasks, and training for an investigator to be qualified. 

Specifically, to be considered prequalified for the marine casualty 

investigations program, personnel had to be: 

•	 Qualified as a Hull Inspector or Machinery Inspector, and a Small 

Vessel Inspector, all of which are responsible for checking the 

maintenance and capability of vessels, 

•	 Trained in Port Operations as: 

o	 A Boarding Officer, responsible for verifying the legitimacy of 

those on board and vessel systems; 

o	 A Facility Inspector, responsible for verifying the safety of 

waterfront assets, such as oil and natural gas buildings; and 

o	 A Harbor Safety Officer, responsible for conducting patrols 

and enforcing safety zones. 

The 1988 standard also required that personnel satisfactorily (1) initiate a 

marine casualty investigation, (2) conduct a marine casualty investigation, (3) 

prepare a written investigative report, (4) prepare marine investigation 

products, (5) conduct a boating accident investigation, and (6) assure Privacy 

Act and Freedom of Information Act requirements are maintained during and 

after the investigation. In addition, personnel were to satisfactorily complete 

the Basic Marine Investigator Course (Basic Course). Once these tasks and 

training were completed, the commanding officer certified that the 

qualification standards had been met. 

Based on our site visits, 15 of the 22 (68%) marine casualty investigators 

reviewed were not qualified under the 1988 standard. Five of the 15 did not 

attend the required Basic Course. Table 4, on the next page, illustrates the 

I According to the Coast Guard's Office of Investigations and Casualty Analysis, the standard for determining who is 

qualified to conduct marine casualty investigations was the 1988 standard. The Coast Guard issued a revised standard in 

August 2007. 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 7 
results of our testing of marine casualty investigator prequalifications and 

basic training attendance. As the worst case scenario, investigators 15, 16, 19, 

and 21 did not meet any of the requisite qualifications, nor did they attend the 

Basic Course. 

Conversely, 7 personnel met the prequalification standards by either fulfilling 

all Port Operations requirements or through a combination of inspector 

qualifications. For example, investigator 1 met the prequalification standard 

because the investigator was qualified as a Boarding Officer, Facility 

Inspector, and Harbor Safety Officer. Investigator 3 also met the 

prequalification standard because the investigator was qualified as a 

Machinery Inspector and a Small Vessel Inspector. 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

PageS
 

checklist that required knowledge of local industry, waterways, and 

jurisdictions, as well as interviewing techniques, MISLE, and chemical 

testing. Additionally, Sector New York did not use the 1988 standard. 

Instead, it developed a training and qualifications program checklist based on 

the one used in Sector Hampton Roads. Neither Sector Hampton Roads nor 

Sector New York received approval from Coast Guard headquarters to use 

local standards. Such diverse application of the 1988 standard contributed to 

inconsistency in investigator qualifications across the Coast Guard. 

In August 2007, the Coast Guard issued a revised standard, which both added 

to and detracted from the qualifications for marine casualty investigators. The 

Coast Guard added to the standards by updating the tasks that an investigator 

must perform to qualify for the position. Those tasks include preparing for an 

investigation, initiating an investigation, generating an incident timeline, 

conducting causal analysis, conducting human error analysis, drawing and 

recording conclusions, developing safety recommendations/alerts, 

recommending enforcement actions, and completing the Basic Course. 

The August 2007 standard also removed the prequalification requirement of a 

Hull or Machinery and Small Vessel Inspector, which, in essence, lowered the 

standard. Coast Guard personnel stated knowledge in these specialty areas is 

essential to the ability of investigators to correctly identify the causes of 

marine casualties and issue appropriate safety alerts and recommendations. 

Removing this standard may affect the qualifications and capabilities of Coast 

Guard marine casualty investigators. When investigators do not have the 

experience or ability to determine that a hull failure or loss of propulsion are 

possible causes of a marine casualty, they may not be able to issue the 

appropriate safety alerts or recommendations to possibly prevent or minimize 

the effect of similar casualties in the future. 

By way of contrast, the United Kingdom's Marine Accident Investigation 

Branch, Australian Transport Safety Bureau, and Transportation Safety Board 

of Canada all require their investigators to be Master Mariners or Chief 

Engineers with several years of experience. Although these foreign entities 

have had difficulty recruiting individuals who meet the experience 

requirements, officials from the entities indicated that such standards help 

ensure that marine casualty investigations are conducted by qualified 

investigators. 

Management Controls to Ensure Qualified Investigators 

The Coast Guard has not effectively managed and controlled aspects of the 

marine casualty investigation program to ensure that it obtains and develops 

qualified investigators. The difficulty in assigning qualified investigators can 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 10 
be attributed to competing Coast Guard priorities and a limited number of 

experienced personnel. This makes it difficult to ensure that all investigator 

positions are filled with qualified staff. Specifically, headquarters assignment 

officials select personnel to fill sector investigator positions from a pool of 

available candidates. There are a limited number of candidates from which to 

draw. 

The Coast Guard has not established a clear and desirable career path for 

investigators, which can further impede recruitment efforts. At the Sectors, 

commanders have the discretion to assign experienced and qualified 

investigators to meet higher priority mission needs, leaving less trained and 

qualified personnel to perform investigative duties. Given competing mission 

demands, there is no assurance that an investigator will perform investigative 

work. Instead, investigators may be called upon to work in areas such as 

inspections or facilities, outside of their specialty area. For example, a tour in 

the Prevention Directorate could mean yearly rotations across specialty areas, 

such as waterways management and drug and alcohol testing. Given the lack 

of a career path and the unpredictable nature of investigation assignments, 

potential Coast Guard candidates also may not want to become investigators. 

Hull and Machinery Inspectors told us that promotion to the position of 

marine casualty investigator would not advance their careers. 

Additionally, according to Coast Guard personnel, tour of duty rotations 

hinder investigators in acquiring the experience needed for career 

development. The agency's uniformed investigators generally are not in their 

positions for more than a single, three-year tour of duty in the same location. 

The forced rotations preclude the investigators from acquiring the extensive 

knowledge of local waterways and industries that experienced casualty 

investigators have told us is needed to be an effective investigator. 

In contrast, civilian marine casualty investigators are not subject to the threeyear tour of duty rotation standard. Over time, they can gain a greater 

knowledge of specialties such as local waterways and industries or experience 

in enforcing maritime regulations to enhance their qualifications. Of the 22 

marine casualty investigators that we reviewed, one was a civilian. In FY 

2007, the Coast Guard reported there were six civilians serving as full time 

marine casualty investigators. 

Prior Reports on Marine Casualty Investigations 

Unqualified marine casualty investigators are not a new issue. Coast Guard 

studies in the mid 1990s of various aspects of the marine casualty program 

also identified problems with marine casualty investigator qualifications: 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 11
 
iS5ued

•	 The Coast Guard Research and Development Center report, U.S. Coast 

Guard Marine Casualty Investigation and Reporting: Analysis and 

Recommendations for Improvement, August 1994, included 

recommendations for organizational change, such as encouraging 

specialization in investigations and using civilian investigators to help 

increase the numbers and qualifications of marine casualty 

investigators. 

•	 The Coast Guard's Report on the Quality Action Team on Marine 

Safety Investigation, January 1995, included recommendations for 

maximizing staff utilization and updating the marine casualty 

investigation process. 

The Coast Guard has implemented a number of these study recommendations, 

resulting in improvements to the program. For example, as defined in the GMOA Policy Letter 1-00, the Coast Guard instituted the levels of 

investigation. In addition, the Coast Guard now requires investigators to 

complete causal analysis training. However, more needs to be done. The 

Coast Guard has not focused on addressing recommendations related to 

investigator qualifications. Until it does, unqualified personnel may continue 

to conduct marine casualty investigations, inhibiting the ability of the Coast 

Guard to identify causes and make appropriate recommendations for 

preventing or minimizing similar casualties. 

Marine Casualty Investigations 

The Coast Guard did not always conduct marine casualty investigations 

according to its own policies. Due to the September 11,2001, terrorist attacks 

and to promote consistency and free staff resources for other duties, the Coast 

Guard permitted formal marine casualty investigations to be conducted at the 

informal level, not to be downgraded further, and informal investigations to be 

conducted at the data collection activity level, not to be downgraded further. 

This initiative became known within the Coast Guard as the "9/11 

downgrade." 

In September 2002, the Coast Guard a policy letter that superseded the 

"9/11 downgrade" and returned the investigative levels to the 

pre-September 11, 2001 levels. (See Appendix D for the Coast Guard's GMOA Policy Letter 2-02.) However, the Coast Guard headquarters did not 

effectively communicate to the Sectors that the "9/11 downgrade" was 

rescinded. Some Sectors did not stop the "9/11 downgrades" until mid-2006, 

four years later. 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 12 
Our review of marine casualty investigations from five Coast Guard locations 

throughout the United States showed that 53% of the investigations in our 

sample were conducted at a lower level than recommended by Coast Guard 

guidance. For example, the Coast Guard conducted eight investigations at the 

data collection activity level, two levels below the formal level recommended 

by the guidance. Specifically, 

•	 A barge carrying construction equipment capsized and sank; the 

owners reported $12 million in damages. 

•	 A barge under tow ran aground causing $1.5 million in damages to the 

vessel, and also resulted in the discharge of approximately 10,000 

gallons of gasoline into a river. The marine casualty investigators 

referred the incident for enforcement action because of the discharge. 

According to the Coast Guard's G-MOA Policy Letter 2-02 and based on the 

dollar values in both incidents and the discharge of gasoline in the second 

incident, the Coast Guard should have conducted an investigation to identify 

the causal factors of the casualty. Further, a formal investigation of the 

second incident would have been useful in providing the evidence needed to 

support a judge's decision in an enforcement action. Coast Guard officials 

stated that Sector commands made the decision to conduct the investigations 

at two levels below the prescribed level. The Sector commands have the 

leeway to conduct investigations at other than the recommended level. 

However, to maintain control over the program, the Sector commands should 

document departures from Coast Guard guidance. 

As summarized in Table 5, on the next page, 48 marine casualty investigations 

were conducted at the incorrect level pursuant to the "9/11 downgrade." 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 13
 

struck a platform, causing $275,000 in property damage. This 

preliminary investigation should have been conducted two levels 

higher at the informal level. The preliminary investigation does not 

include steps to identify causal factors. 

These investigations were not conducted at recommended levels for varying 

reasons. For example, some Coast Guard Sectors did stop the "9111 

downgrade" until mid-2006 because of communication problems from Coast 

Guard headquarters regarding issuance of the G-MOA Policy Letter 2-02. 

According to Coast Guard officials, there were also conflicting interpretations 

of how to apply the Coast Guard's G-MOA Policy Letter 2-02. For example, 

according to the policy letter, loss of propulsion should be investigated at the 

informal level. However, some marine casualty investigators defined loss of 

propulsion as lost propulsion from one engine even though there might be 

multiple engines, whereas others defined loss of propulsion as when a vessel 

cannot remain underway. 

Further, some marine casualty investigators relied on the Coast Guard's 

outdated Marine Safety Manual for investigation guidance, which also created 

confusion. The Coast Guard has not substantially updated its Marine Safety 

Manual since February 1989. As such, the manual does not include the 

investigation levels defined in G-MOA Policy Letter 2-02, nor does it refer to 

MISLE. In November 2004, the Coast Guard issued a Draft Marine Safety 

Manual for comment and review to ultimately update the February 1989 

version. Since this update has not been finalized and approved to supersede 

the February 1989 version, marine casualty investigators are not certain which 

manual is the authoritative guidance for conducting marine casualty 

investigations. 

As a result of formal and informal investigations conducted at the lower data 

collection activity level, causal factors were not always determined. Without 

such determinations, the Coast Guard may have lost the opportunity to issue 

safety recommendations or alerts to prevent or minimize the effect of similar 

casualties occurring again. 

Backlog of Marine Casualty Investigations 

Coast Guard headquarters is not timely in reviewing or closing marine 

casualty investigation reports. On November 9,2006, Coast Guard 

headquarters had a backlog of 4,240 investigations, of which 2,466 (58%) 

were open and had been awaiting review and closure for more than six 

months. However, one Coast Guard headquarters staff was responsible for 

reviewing and closing all of the investigations. This staff member estimated 

that, at best, she could devote 50% of her time to this function. Assigning this 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 15 
significant workload to one person is not sufficient and contributes even 

further to creating a backlog in marine casualty investigations. 

To reduce the backlog, the Coast Guard resorted to a mass closure of 

investigations without the proper headquarters review. Specifically, on 

September 29,2006, Coast Guard headquarters closed 3,848 investigations 

that it deemed "low risk" based on the criteria that the casualty: 

•	 Occurred in calendar years 2002-2004; 

•	 Involved no fatalities or missing persons; 

•	 Involved injuries to fewer than six persons; 

•	 Involved total dollar damages of less than $250,000; 

•	 Involved less than 100 gallons of oil spilled; and 

•	 Involved no total losses of vessels. 

Included in the September 29,2006, closure project were 194 informal 

investigations and 1 formal investigation. Although the Coast Guard deemed 

them low risk, some investigations merited reviews because they involved 

serious incidents requiring causal analysis. Enforcement actions also may 

have resulted from these investigations. 

Further, closing investigations without thorough review resulted in lost 

opportunities to identify errors input to the MISLE database. The MISLE data 

can support trend analysis and studies that may result in recommendations and 

safety alerts. Likely, no one will go back to check for errors or make 

corrections to those included in the mass closure project. In our testing of 145 

marine casualty investigations, we identified 43 (30%) that contained at least 

one MISLE data error. The Coast Guard corrected the errors, such as incident 

dates, numbers of persons at risk, and levels of investigation, that we brought 

to their attention. With a thorough review at headquarters, the number of 

errors could be further reduced. Assigning more staff to manage the 

investigation review and closure process would also help. 

Recommendations 

To improve the management and accountability of the marine casualty 

investigations program, we recommend that the Commandant, United States 

Coast Guard: 

1.	 Develop and implement a plan to increase the number of qualified marine 

casualty investigators, including hiring civilian marine casualty 

investigators, and improving the career path for marine casualty 

investigators. 

United States Coast Gnard's Management of the Marine Casualty Investigations Program 

Page 16 
2.	 Evaluate re-instituting the four-year tour of duty for active duty marine 

casualty investigators and ensure that they complete the entire tour of duty 

as a marine casualty investigator. 

3.	 Develop and implement a plan to ensure attendance at the basic and 

advanced courses for those qualified to attend. 

4.	 Revise the August 2007 marine casualty investigation qualification 

standard to include the prequalification of Hull or Machinery, and Small 

Vessel Inspectors. 

5.	 Implement quality controls to ensure that marine casualty investigations 

are conducted at the recommended levels; consistent information is 

gathered; and causal factors are determined when appropriate. 

6.	 Review and revise the criteria for the levels of marine casualty 

investigations, make any appropriate changes to reduce or eliminate 

conflicting interpretations, and ensure criteria are consistently applied 

throughout the Coast Guard. 

7.	 Finalize and issue the Marine Safety Manual. 

8.	 Reorganize the headquarters review and closure process to include 

sufficient staff responsible for reviewing and closing marine casualty 

investigations, and ensure that the review and closure process is completed 

in a timely and effective manner. 

Management Comments and OIG Analysis 

The Coast Guard agreed to seven of the recommendations, but it did not 

concur with our recommendation to revise the August 2007 marine casualty 

investigation qualification standard to include the prequalification of Hull or 

Machinery, and Small Vessel Inspectors. We consider this recommendation 

unresolved until the standard has been revised. Four of the recommendations 

will remain open until details and documentation are provided on actions 

taken so that we can determine whether these actions adequately address the 

substance of our findings and recommendations. 

Management Comments to Recommendation #1: 

The Coast Guard concurred with our recommendation and stated that it is 

seeking to increase both field investigating officers and marine investigations 

staff support personnel. Consistent with the Coast Guard's efforts to enhance 

its marine safety program, the FY 2009 President's Budget includes a request 

for 276 additional Coast Guard marine safety personnel. Of the 276 positions 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 17 
in this request, 221 will be marine inspectors and investigators, 28 positions
 

are for program management and training, and 27 positions are for support.
 

OIG Analysis
 

We agree with the actions the Coast Guard has taken to address the intent of
 

our recommendation. However, the recommendation will remain open until
 

the Coast Guard provides us with documentation that specifically details
 

actions taken to ensure that the number of qualified marine casualty
 

investigators is increased and the career path for marine casualty investigators
 

is improved. The documentation should include annual reporting
 

requirements and the identity of organizational entities responsible for the
 

implementation.
 

Management Comments to Recommendation #2:
 

The Coast Guard concurred with our recommendation and stated that it has
 

issued Coast Guard-wide guidance directing field units to ensure personnel
 

remain in their original assigned position for their entire tour, and will
 

continue to enforce a four-year tour of duty as broadly as possible.
 

OIG Analysis
 

The Coast Guard has been responsive to our recommendation by enforcing a
 

four-year tour of duty as broadly as possible and ensuring personnel complete
 

their entire tour in their assigned position. We consider the recommendation
 

closed.
 

Management Comments to Recommendation #3:
 

The Coast Guard concurred with our recommendation and stated that priority
 

to attend the basic and advanced courses is given to individuals who are
 

assigned to investigating officer positions and conducting investigations.
 

OIG Analysis
 

The Coast Guard has been responsive to our recommendation in developing
 

and implementing a plan to ensure attendance at the basic and advanced
 

courses for those qualified to attend. We consider the recommendation
 

closed.
 

Management Comments to Recommendation #4:
 

The Coast Guard did not concur with our recommendation and stated the
 

prequalification as a hull, machinery, or small vessel inspector is required to
 

attend the basic marine investigator course. In addition, the Coast Guard
 

stated that anyone of these inspection qualifications provides the basic
 

knowledge needed to begin investigator officer training.
 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 18
 
OIG Analysis 

We maintain that the Coast Guard should revise its marine casualty 

investigation qualifications standard to include the prequalification of Hull or 

Machinery, and Small Vessel Inspectors because the August 2007 guidance 

removed the prequalification requirement which, in essence, lowered the 

standard. We consider this recommendation unresolved until the standard has 

been revised. Coast Guard personnel stated that knowledge in these specialty 

areas is essential to the ability of investigators to correctly identify the causes 

of marine casualties and issue appropriate safety alerts and recommendations. 

In addition, based on our site visits, 15 of the 22 (68%) marine casualty 

investigators reviewed were not qualified under the June 1988 marine casualty 

investigation qualification standard. Ten of the 15 attended the required basic 

marine investigator course. 

Management Comments to Recommendation #5: 

The Coast Guard concurred with our recommendation and stated that it 

delineated quality control measures, outlining suggested levels of effort and 

types of investigations in the updated edition of the Marine Safety Manual, 

promulgated on April 24, 2008. In addition, the Coast Guard stated that its 

headquarters staff review investigation activities prior to closure to ensure 

compliance with policy. 

OIG Analysis 

We agree with the actions the Coast Guard has taken to address the intent of 

our recommendation. However, the recommendation will remain open until 

the Coast Guard provides us with documentation that specifically details 

actions taken to ensure that marine casualty investigations are conducted at 

the proper levels, that consistent information is gathered, and that casual 

factors are determined when appropriate. The documentation should also 

include annual reporting requirements and identify the organizational entities 

responsible for implementing these corrective actions. 

Management Comments to Recommendation #6: 

The Coast Guard concurred with our recommendation and stated that it 

established clear and sufficient criteria for the levels of marine casualty 

investigations in the updated edition of the Marine Safety Manual, 

promulgated on April 24, 2008. In addition, the Coast Guard stated that it 

ensures consistent application of the criteria through courses at Training 

Center Yorktown, periodic training at various units, and informal postings on 

its web portal. 

OIG Analysis 

We agree with the actions the Coast Guard has taken to address the intent of 

our recommendation. However, the recommendation will remain open until 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 19 
the Coast Guard provides us with documentation that specifically details
 

actions taken to ensure that the criteria for the levels of marine casualty
 

investigations are reviewed and revised, any appropriate changes to reduce or
 

eliminate conflicting interpretations are made, and the criteria are consistently
 

applied throughout the Coast Guard. The documentation should include
 

annual reporting requirements and identify the organizational entities
 

responsible for implementing these corrective actions.
 

Management Comments to Recommendation #7:
 

The Coast Guard concurred with our recommendation and stated that it issued
 

an updated edition of the Marine Safety Manual on April 24, 2008.
 

OIG Analysis
 

The Coast Guard has been responsive to our recommendation in finalizing and
 

issuing the Marine Safety Manual. We consider the recommendation closed.
 

Management Comments to Recommendation #8:
 

The Coast Guard concurred with our recommendation and stated that
 

sufficient resources need to be in place to review and close marine casualty
 

investigations in a timely and effective manner.
 

OIG Analysis
 

We agree with the actions the Coast Guard has taken to address the intent of
 

our recommendation. However, the recommendation will remain open until
 

the Coast Guard provides us with documentation that specifically details
 

actions taken to ensure that Coast Guard headquarters assigns sufficient staff
 

to manage the investigation review and closure process and timely review and
 

close marine casualty investigation reports. The documentation should also
 

include annual reporting requirements and identify the organizational entities
 

responsible for implementing the corrective actions.
 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 20
 
op~imal

.

Appendix A 

Purpose, Scope, and Methodology 

Our audit was performed in response to a congressional request from the 

Committee on Transportation and Infrastructure of the House of 

Representatives and the Committee on Commerce, Science and 

Transportation of the Senate regarding the Coast Guard's management of its 

marine casualty investigations program. Our objective was to determine the 

extent to which marine casualty investigations and reports resulted in 

information and recommendations that prevent or minimize the effect of 

similar casualties. 

We reviewed Coast Guard documentation and manuals related to marine 

casualty investigations, including the Coast Guard's G-MOA Policy Letters 1­

00, 2-02, 2-04 and 6-02. 

In addition to conducting fieldwork in Washington, D.C., we also made site 

visits to five Coast Guard locations: Sector St. Petersburg, Florida; Sector 

Portland, Oregon; Sector Hampton Roads, Virginia; Sector New Orleans, 

Louisiana; and Sector New York, New York. 

We also interviewed officials from the Coast Guard, the NTSB, Gulf Coast 

Mariners Association, and the Towing Vessel Safety Advisory Committee. 

We communicated with officials from the United Kingdom's Marine Accident 

Investigation Branch, the Australian Transport Safety Bureau, and the 

Transportation Safety Board of Canada. 

We analyzed an extract of the MISLE database of 15,327 marine casualties 

and related enforcement actions to determine the sampling 

methodology. We determined our sampling based on those Coast Guard 

Districts with the highest percentage of informal and formal investigations. 

From these Districts, we identified the following Sectors with the highest 

percentage of informal and formal investigations: Sector St. Petersburg, 

Florida; Sector Portland, Oregon; Sector Hampton Roads, Virginia; and 

Sector New Orleans, Louisiana. We randomly selected 100 investigations 

from those four Sectors. In addition, we judgmentally selected five 

investigations from each of the four Sectors. Further, we judgmentally 

selected 25 data collection activity investigations from the District with the 

highest incidence of these investigations and selected the Sector within the 

District with the highest incidence of these investigations, which was Sector 

New York, New York. 

We relied on an extract from the Coast Guard's MISLE database on 15,327 

marine casualties that occurred during the period January 1, 2003, through 

October 31, 2006. Although we identified some data input errors as discussed 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 21
 
Appendix A 

Purpose, Scope, and Methodology 

in the body of the report, we concluded that the data was sufficiently reliable 

to be used to support our audit findings. 

We conducted our audit between November 2006 and April 2008 under the 

authority of the Inspector General Act of 1978, as amended, and according to 

generally accepted government auditing standards. 

We would like to extend our appreciation to the Coast Guard for the 

cooperation and courtesies extended to our staff during this review. 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 22
 
.

TIris

Appendix B 

Management Comments to the Draft Report 

U.S. Department Commandant 2100 Second SoW.

Homeland Security States Coast Washington, DC 20593-0001 

Slaff Symbol: Phone: (202) 372-3533 United States 1202) Coast Guard Ema; : 

7500 

- 2

Reply to CG·823 

Attn of: Mark Allen Kulwicki 

372-3533 

To: Inspector General 

Subj: DHS OIG REPORT: "UNITED STATES COAST GUARD'S MANAGEMENT OF 

THE MARINE CASUALTY INVESTIGATIONS PROGRAM" 

Ref: (a) 010 Draft Report 

1. letter transmits our proposed response to the Office ofInspector General (OlG) draft 

report findings and recommendations contained in reference (a). 

2. Please contact Mark Kulwicki at (202)-372-3533, ifyou have any questions. 

# 

Enclosures: (1) U.S. Coast Guard Response to OIG Audit 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 23 
organized

AppendixB 

Management Comments to the Draft Report 

UNITED STATES COAST GUARD
 

STATEMENT ON INSPECTOR GENERAL REPORT
 

TITLE: "UNITED STATES COAST GUARD'S MANAGEMENT OF THE MARINE 

CASUALTY INVESTIGATIONS PROGRAM" (Draft Report dated April 28, 2008) 

The United States Coast Guard generally concurs with the orG's recommendations included in 

this report and appreciates the efforts ofDHS OIG in documenting areas for improvement. We 

are currently taking actions to address these recommendations. The Coast Guard provides the 

following comments in response to the findings ofthe report. They are under five 

sections: introduction, recommendation and responses, supplemental comments, technical 

comments, and editorial comments. 

RECOMMENDATIONS AND RESPONSES 

Recommendation #1: Develop and implement a plan to increase the number ofgualified 

marine casualty investigators, including hiring civilian marine casualty investigators, and 

improving the career path for marine casualty investigators. 

Concur. The Coast Guard is seeking to increase both field Investigating Officers (lOs) and 

marine investigations staff support personnel. We are taking into account current staffing levels 

and increasing demand for services in our planning efforts. These efforts are part ofa broad plan 

to improve marine safety which is attached as Enclosure I. 

On September 25,2007, the Coast Guard delivered this plan (Enclosure I) to Congress to outline 

efforts to enhance the Marine Safety Program. Our plan provides a vision and multi-year 

roadmap for improving the effectiveness, consistency, and responsiveness ofthe Coast Guard 

Marine Safety program to promote safe, secure, and enVironmentally sound maritime commerce. 

The Coast Guard will reinvigorate industry partnerships, improve mariner credentialing services, 

bolster inspector and investigator capacity, improve technical competencies, and expand 

rulemaking capability to ensure that we meet current and future industry needs. 

Consistent with this plan, the Fiscal Year 2009 President's Budget includes a request for 276 

additional Coast Guard Marine Safety personnel. Ofthe 276 positions in this request, 221 will 

be marine inspectors and investigators, 28 positions are for program management and training, 

and 27 positions are for support. There are currently 552 marine inspectors and investigators in 

the field at Coast Guard units. Therefore, the additional 221 personnel added to the field . 

represent a 40% growth in the existing number ofmarine inspectors and investigators. These 

personnel will begin to increase our capacity to perform both vessel inspections and casualty 

investigations. 

United States Coast Guard's Management of the Marine Casualty Iuvestigations Program 

Page 24 
Machinery,

Appendix B 

Management Comments to the Draft Report 

Recommendation #2: Evaluate re-instituting the four-year tour ofduty for active duty marine 

casualty investigators and ensure that they complete the entire tour ofduty as a marine casualty 

investigator. 

Concur. A return to a four-year tour would provide additional time and training opportunities to 

develop a strong knowledge base for investigating officers. We also agree that assigned 

personnel should complete their entire tour in their assigned billet. The Coast Guard Personnel 

Command recently issued Coast Guard-wide guidance directing field units to ensure personnel 

remain in their original billet assignment, and will continue to enforce a four-year tour ofduty as 

broadly as possible. 

Recommendation #3: Develop and implement a plan to ensure attendance at the basic and 

advanced courses for those qualified to attend. 

Concur. Priority is given to individuals who are assigned to Investigating Officer billets and 

conducting investigations. This was recently re-emphasized in a directive from Coast Guard 

Headquarters to field units (Enclosure 2). 

Recommendation #4: Revise the August 2007 marine casualty investigation qualification 

standard to include the prequalification of Hull or and Small Vessel Inspectors. 

Do not concur. Prequalification as a hull, machinery, or small vessel inspector is required to 

attend the basic marine investigator course. Anyone ofthese inspection qualifications provides 

the basic knowledge needed to begin investigating officer training. On April 24, 2008, the Coast 

Guard's Assistant Commandant for Marine Safety, Security, and Stewardship, sent Coast Guardwide guidance to reiterate and emphasize the importance ofpolicies currently in place that strive 

to ensure the integrity ofthe Marine Casualty Investigations program (Enclosure 2). This 

.message states the importance ofproper training and upholds core competencies and 

prerequisites for becoming a qualified Marine Casualty Inspector. We are working to ensure 

billets are staffed in the field with a corps ofwell-trained, certified, and experienced Marine 

Casualty Investigators. 

Recommendation #5: Implement quality controls to ensure marine casualty investigations are 

conducted at the proper levels to make certain that consistent information is gathered and that 

casual factors are determined when appropriate. 

Concur. However, quality control measures are already delineated in Chapter A5 ofthe Marine 

Safety Manual Vol. V, Commandant Instruction M16200.10A. The Marine Safety Manual 

outlines suggested levels ofeffort and types ofinvestigations. Quality control also exists within 

the MISLE database that requires specific data entries based on the level of investigation. For 

example, if an informal level ofinvestigation is selected, MISLE requires that Causal Analysis 

be entered. Policy in the MISLE Process Guide also requires at least one level ofreview of an 

investigation prior to forwarding to Coast Guard Headquarters. Coast Guard Headquarters staff 

2 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 25 
quality

(1):

AppendixB 

Management Comments to the Draft Report 

reviews investigation activities prior to closure to ensure compliance with policy. These 

control measures will be enhanced by additional personnel. 

Recommendation #6: Review and revise the criteria for the levels ofmarine casualty 

investigations. make-any appropriate changes to reduce or eliminate conflicting interpretations. 

and ensure criteria are consistently applied throughout the Coast Guard. 

Concur. We believe the criteria for the levels ofmarine casualty investigations established in 

the Marine Safety Manual Vol. V are clear and sufficient. We ensure consistent application 

through courses at Training Center Yorktown, periodic training at various units, and informal 

postings on our web portal. However, we agree there is room for improvement in applying the 

criteria consistently and are committed to reviewing and revising all criteria. 

Recommendation #7: Finalize and issue the Marine Safety Manual. 

Concur. An updated edition ofthe Marine Safety Manual (MSM) was promUlgated on 24 April 

2008 as Commandant Instruction M16200.IOA. 

Recommendation #8: Reorganize the Headquarter review and closure process to include 

sufficient staffresponsible for reviewing and closing marine casualty investigations. and ensure 

that the review and closure process is completed in a timely and effective manner. 

Concur. We agree there needs to be sufficient resources in place to review and close marine 

casualty investigations in a timely and effective manner. 

Encl Marine Safety Improvement Plan
 

(2): ALCOAST 241806 Z APR 2008
 

3 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 26 
Executive

"Enhancing Coast

~afety

leader

al~o increa~d from

The~e dynamic~

~ervices focu~ thi~ mi§ion.

~teps sy~tem,

responsivenes~

indu~try

expand

CapaCity

Expand

Eltpand

dllvelopment.

through

AppendixB 

Management Comments to the Draft Report 

Summary 

Guard Marine Safety Program" 

25 September 2007 

Background. The Coast Guard ensures the ofmaritime transportation and 

commerce through a layered, interwoven system of authorities, compliance, collaboration, 

enforcement and public dialogue. We have been a in promoting global maritime 

safety, security, and environmental protection. Notwithstanding, the maritime industry is 

experiencing unprecedented complexity and growth, while facing risk
 

transnational threats.
 lead to a greater demand for Coast Guard Marine 

Safety and call for a renewed on core Coast Guard 

Way Ahead. While we.have taken to improve this we acknowledge much 

more must be done. I am directing the development of a strategy that provides a vision 

and roadmap for improving the effectiveness, consistency, and ofthe Coast 

Guard Marine Safety program to promote safe, secure, and environmentally sound 

maritime commerce. The Coast Guard will reinvigorate partnerships, improve 

mariner credentialing services, bolster inspector and investigator capacity, improve 

technical competencies, and rulemaking capability to ensure that we meet current 

and future industry needs. The Coast Guard will develop metries to continually assess our 

progress towards achieving Marine Safety goals and objectives. 

This strategy, to be developed in'consultation with industry partners, will include the 

following decisive actions (some ofwhich are underway) to improve Marine Safety 

mission effectiveness: 

Improve the Coast Guard's Marine Safety and Performance 

o Increase marine inspector and investigator capacity. 

o	 Strengthen marine inspection and investigation consistency through addition of 

civilian positions. 

o .Increase accessions from U.S. Merchant Marine Academy and maritime 

institutions.. . 

professional Marine Safety training and education. 

opportunities for maritime industry training. 

o Enhance engineering capacity for plan review, policy and standards 

Enhance Service Delivery to Mariners and Industry Customers 

o Establish Centers ofExcellence. 

o Improve information technology systems. 

o Increase rulemaking capacity to meet regulatory implementation. 

o Improve credentialing greater efficiency, transparency and capacity. 

the 

o. Strengthen Marine Safety career paths. 

o 

o 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 27 
Mechanisms

are

AppendixB 

Management Comments to the Draft Report 

Expand Outreach and Advisory for Industry and Communities 

o Establish Assistant Commandant for Marine Safety, Security, and Stewardship. 

o Establish a national council ofmaritime advisors for the Commandant. 

o	 Exercise leadership at international, national, regional, state, and local safety, 

security, and environmental committees. 

We confident these courses of action will result in needed improvements, although 

many require additional planning to ensure proper implementation and efficacy. A more 

thorough review ofresource requirements is needed before developing specific timelines 

and milestones. 

2 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 28 
"Enhancing Coast

Current st!lJe. Safety the

conduct

future

control

out with industry to

Discussion. Safety

trends industry

Industry the

Safety

trillion

Department

percept industry

indUStry's that

Safety

activity

industry

safety,

security

with

AppendixB 

Management Comments to the Draft Report 

GuardMarine Safety Program" 

The Coast Guard's Marine program is responsible for ensuring 

safe operation and navigation of some 20,000 U.S. and foreign-flagged vessels. We 

conduct over 70,000 domestic vessel inspections and 10,000 port state control 

examinations each year to safeguard maritime commerce, international trade and supply 

chain security. We also 14,000 casualty, suspension and revocation, and civil 

penalty cases annually to leverage lessons-learned and prevent maritime tragedies. 

These missions are accomplished by a cadre ofapproximately 1,000 uniformed and 

civilian inspectors, investigators and port state officers stationed domestically and 

around the world. They are carried through a shared commitment 

facilitate safe, secure, and environmentally sound marine transportation. 

The Coast Guard's responsibility to improve Marine service delivery is 

time-eritical given growth in the maritime and increase in demand for 

Marine Safety services. growth and increased complexity over last 10 years 

outpaced commensurate growth in the Coast Guard Marine program, resulting in a 

performance gap. For example, last year United States deep-draft seaports and seaportrelated firms employed over 8 million American citizens while adding nearly $2 

our domestic economy. From 2002 to 2005, U.S. port calls oflarge, ocean-going merchant 

vessels (i.e., over] 0,000 gross tons) increased nearly] 0 percentto 61,047 according to 

U.S. ofTransportation statistics. Moreover, over the last five years, the 

number ofU.S.-flag passenger vessels increased by seven and offshore oil 

vessel growth exceeded 35 percent. We recognize concem our Marine 

Safety program lacks sufficient capacity to be responsive, inclusive, accessible, and 

customer-focused. We share in their desire to aggressively address this concern. 

Projected growth areas for Marine services include: 

o New inspection requirements for as many as 7,000 uninspected towing vessels; 

o Market-driven shifts in port due to increased demand for such products as 

liquefied natural gas, petroleum, dangerous cargoes, and containerized freight; 

o Proportional growth in marine investigations resulting from growth; 

o Increased demand for commercial fishing vessel examinations; and 

o Continued growth in requirements to publish implementing regulations. 

An integrated Coast Guard approach to environmental protection, waterways 

management, and best ensures the long-terin success ofthe global maritime 

transportation system. The goal in preventing or responding to major marine incidents, 

regardless ofcause, is the same: to save lives, preserve property, protect the environment, 

and minimize disruption to the maritime transportation system. The Coast Guard's 

operational model is flexible, adaptive, efficient and capable of succeeding myriad 

3 

the 

to 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 29 
industry

the Program Performance

consistency

dismbute

program

will

maritime

Safety

to

AppendixB 

Management Comments to the Draft Report 

maritime scenarios. Today, as in the past, our safety, security, and stewardship program 

goals and authorities to act are inextricably linked. 

Following the terrorist attacks of9/1 I, our longstanding partnerships were critical 

to protecting the global marine transportation system. These partnerships remain vital 

today. We must ensure resources match the growing demand for our Marine Safety 

services. Our marine safety capacity and effective engagement with stakeholders demand 

senior leadership's attention. We will improve Marine Safety program focus and 

perfonnance. 

Course ofAction. The Commandant is directing the development of a strategy that 

includes the following courses of action, (some ofwhich are underway): 

Improve COQSt Guard's Marine Safety Capacity and 

Increase marine inspector and investigator capacitv. 

Within budget, the Coast Guard will add more marine inspectors, port state control 

officers, and investigators. We will use these full-time positions to meet current and 

anticipated growth in maritime commerce and expansion ofthe regulated fleet. Demand 

for inspection and investigation work is increasing and capacity to match these demands 

must be built and sustained as a result ofgrowth factors such as projected Liquefied 

Natural Gas (LNG) ships and facilities, thousands oftowing vessel examinations, non-tank 

vessel response plan reviews, ballast water management oversight, and regulatory 

development. 

Strengthen marine inspection and investigation by adding civilian positions. 

Within budget, we intend to increase the number of civilian inspectors and investigators. 

Additional civilian inspector/port state control officer positions and investigating officers 

will help the Coast Guard retain expertise and geographic-specific competencies while 

ensuring long-tenn continuity in critical mission areas. We will civilian 

positions according to demand and to complement the military workforce. Military 

personnel must continue to serve as marine inspectors and investigators to ensure 

innovation,' and gamer requisite experience for future management and command 

responsibilities. A blend ofmilitary and civilian personnel is critical to building and 

sustaining consistency and competence. 

Increase accessions from U.S. Merchant Marine Academy and maritime institutions. 

The Coast Guard strengthen recruiting efforts at the maritime colleges through 

additional liaison officers and by seeking opportunities for Coast Guard officers to serve as 

faculty at those institutions. Maintaining and sustaining competency within the Marine 

Safety program begins with recruitment and accession of additional maritime 

professionals, and active partnerships with educational institutions. 

Strengthen Marine career paths. 

We will demonstrate the value the organization places on the Marine Safety profession by 

revising personnel management policies. These policies must continue ensure a viable 

career path to the most senior ranks in the Coast Guard, and value and promote the 

competencies ofmarine safety specialists. These policies could include, but arll not limited 

4 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 30 
Safety

are

industry

Therefore,

ethical

expertise.

Delivery Industry Customers

AppendixB 

Management Comments to the Draft Report 

to: direct commission programs; direction and guidance to officer selection panels relating 

to the need for specific Marine Safety specialties; increased tour lengths; incentives to 

retain qualified inspectors and investigato.rs; institutional recognition ofMarine Safety 

leadership positions in the field: and continuation contracts for officers possessing critical 

skills. Recognize those who advance from apprentice, to journeyman, to expert marine 

safety professional status. 

Expand professional Marine training and education. 

We recently completed extensive review, update, and field testing ofMarine Safety course 

and qualification material. The Coast Guard will expand formal and infonnal training and 

education opportunities to improve Marine Safety competencies, skills and qualifications. 

These programs will include additional resident educational'opportunities for the military 

and civilian marine safety workforce, and enhanced pipeline training for field personnel to 

ensure better continuity and consistency in service. Through continuous evaluation, we 

will ensure training, education and qualification standards responsive to the dynamics 

ofthe marine transportation system. A robust marine inspector and investigator workforce 

also requires additional expert field personnel to conduct unit training in order to build and 

sustain these critical competencies. . 

Expand 0Dportunities for maritime training. 

The Merchant Marine Industry Training (MMll) program is a model ofindustry 

partnership and professional development. the MMIT program will be 

expanded to include both formal and informal assignments to maximize interaction and 

experience. We will adjust the MMIT to industry's technological innovations, complexity, 

and growth as a means for the CoastGuard to better understand and address emerging 

safety, security, stewardship, and economic issues. The Coast Guard will engage industry 

within applicable legal and guidelines to maximize training opportunities and fully 

immerse participants in industry operations. The Ship Rider and other industry 

familiarization programs will be offered to a larger group ofMarine Safety professionals. 

Enhance engineering capacity for plan review, policy, and standards development. 

We will seek additional capacity and expertise for plan review ofvessels and facilities. 

Increased technical capacity is needed to address plan review of commercial non-tank: 

vessels, marine fire fighting and salvage, standards development and vessel construction 

specialties at Coast Guard Headquarters and the Marine Safety Center. Increased growth 

and complexity in ship design and construction, inclUding high capacity fast ferries, LNG 

ships, mega container and cruise ships, and novel structural designs, call for an innovative 

and knowledgeable technical staff to develop guidance, standards, and policy. As industry 

evolves, so too does the demand for technical 

Enhance Service to Mariners and 

Establish Centers of Excellence. 

We plan to establish additional Centers ofExcellence (CaE) to provide venues for 

professional development and exchange between industry and Coast Guard personnel. 

COEs will focus on specialized areas ofindustry to improve inspector competencies and 

promote consistency across ports. For example, the Coast Guard Cruise Ship CaE in 

Miami, Florida was created to recognize and address cruise ship complexity, industry 

s 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 31 
cruise

marine

rulemakjnS'

greater

Virginia,

tUlly

lUld

AppendixB 

Management Comments to the Draft Report 

growth, and attendant risk. Specialized vessel inspection approaches were developed to 

improve inspector competence, effectiveness, and efficiency in nationwide cruise ship 

inspections. The support staff manages a resident 6·day course which provides instruction 

on USCG policy, and covers technical and management issues for foreign flagged 

ships. COEs are appropriate for existing industry sectors and projected growth areas 

including investigations, LNG ships, towing vessels, fishing industry vessels, and outer 

continentai shelf activity. COEs also will provide deployable casualty response and surge 

capacity. 

Improve infonnation technology systems. 

The Coast Guard will incorporate tools to improve access and the exchange ofinformation 

between industry and government using existing exchanges as a model. Such 

systems provide real-time, technology-based infonnation to capture and manage the 

maritime transportation system. The Coast Guard will enhance web-based portals for 

sharing information and lessons learned between Coast Guard field personnel and industry, 

and include Coast Guard office directories and cOntact methods. The Coast Guard also will 

provide help-desks and FAQs to facilitate transparency. 

InCrease capacity to expedite regulatory jmplementation. 

The Coast Guard will increase capacity to address current and anticipated rulemaking 

projects. Increased rulemaking capacity requires additional support for project 

management, rulemaklng development, economic analysis, environmental analysis, 

technical writing, and administrative law capacity to ensure legal sufficiency and efficacy 

of implementing regulations. We will publish timely guidance to assist regulated industry 

with implementation. To the extent practicable, the Coast Guard also will prepare 

legislative change proposals that minimize required rulemaking. process time. 

Improve mariner credentialing through efficiency. transparency and capacity. 

The National Maritime Center (NMC) consolidation began in 2005. Located in West 

recent accomplishments include implementation ofthe Mission Management 

System and reduction in cycle time by 25 percent since September 2006. The following 

milestones will further improve service delivery to the mariner: 

o Credentialing help desk staffed by February 2008; 

o Online self-heip application tracking and payment options via www.pay.gov; 

o Bulk application processing for academies, schools and industry groups; 

o Issue ofmerchant mariner licensing documents in less than one week; 

o Rebuild primary computer system and implement web-based processing. 

6 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 32 
Expand andAdvisory Industry

leader

partners.

policy

partnerships.

military

safety,

.

rmiritime

Appendix B 

Management Comments to the Draft Report 

Outreach Mechanisms/or and Communities 

Establish an Assistant Commandant for Marine Safety, Security. and Stewardship 

The Assistant Commandant for Marine Safety, Security, and Stewardship will direct and 

integrate Marine Safety, security, and environmental protection doctrine, policy, plans, and 

regulations. This flag officer will be the Coast Guard's national Marine Safety and 

will ensure alignment throughout the Coast Guard and among federal and international 

This flag officer will be responsible for developing and promulgating national 

in prevention, response and waterways management, as well as leading and 

overseeing the important work ofnumerous federal advisory committees and industry 

Establish a national council of maritime advisors for the Commandant.
 

A council ofmaritime advisors will inform the Commandant of national maritime trends
 

and issues of concern. This council will draw its membership from industry leaders,
 

governors, academics, fonner
 and government officials, and media. 

Exercise leadership at international. national. regional. state. and local security, and 

environmental committees 

We will commit resources to lead, support, and engage these committees to collectively 

advance the shared goals ofsafety, security, and environmental stewardship. These fora 

also offer important opportunities to shape regulatory initiatives, and develop nonregulatory solutions where appropriate. We will incorporate customer engagement using 

quality processes to elicit input as previously done with the "Prevention through 

People" philosophy. 

Conclusion. The Coast Guard has established a clear way ahead to enhance the Marine 

Safety program. The proposed courses of action are responsive to external stakeholders 

and overseers, and supportive ofwork in progress and ongoing initiatives. 

7 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 33 
FM CO~DT WASHINGTON

CO~DT

MANUAL

eO~DTINST

MAR

MARINE PROGRAM.

AND

INFOR~,

A

MARINE

PROGRAM, PLAN

A

MARINE

PLAN THERE

COMMANDERS AND COMMANDING

MARINE

4.

PREPARED

BECO~ING

MARINE

AND PROGRAM

MAY GRANT MINI~UM

STANDARD

COMMANDS

AN MARINE

MARINE

MARINE

MARINE

ALL

ARE

COMMAND

PROGRAM

ADVANCED MARINE

AppendixB 

Management Comments to the Draft Report 

R 241806Z APR 08 ZUI ASN-AOOl15000012 ZYB COGARD 

DC//CG-51/ TO ALCOAST BT UNCLAS IIN1673211 ALCOAST 194/08 COMDTNOTE 

16732 

SUBJ: MARINE CASUALTY INVESTIGATING OFFICER DOCTRINE A. eOGARD 

WASHINGTON DC 191735Z NOV 07/ALCOAST 541/07 B. MARINE SAFETY 

VOLUME V, M16000.10A C. MARINE SAFETY MANUAL VOLUME I, 

COMDTINST M16000.6 D. COMCOGARD PERseOM ARLINGTON VA 250057Z 

08/ALCGOFF 037/08 E. COMDT COGARD WASHINGTON DC 081630Z AUG 07/ALCOAST 

387/07 1. REFERENCE A PROVIDED INITIAL GUIDANCE ON RESPONSE DOCTRINE 

FOLLOWING SIGNIFICANT INCIDENTS. THIS MESSAGE REITERATES AND EMPHASIZES 

THE IMPORTANCE OF POLICIES CURRENTLY IN pLACE THAT STRIVE TO ENSURE THE 

INTEGRITY OF THE CASUALTY INVESTIGATIONS IN SUPPORT OF 

THIS EFFORT, THIS MESSAGE ANNOUNCES THAT REFERENCE B HAS BEEN 

PROMULGATED THIS DATE AND WILL BE PUBLISHED SHORTLY. 

2. THERE HAS BEEN AN OVERALL DECREASE IN THE EXPERIENCE OF COAST GUARD 

MARINE CASUALTY INVESTIGATING OFFICERS (10). THIS IS DUE IN PART TO THE 

ASSIGNMENT OF NEWLY COMMISSIONED OFFICERS OTHER OFFICERS THAT DO 

NOT MEET THE ESTABLISHED PREREQUISITES AND HAVE NO PRIOR EXPERIENCE AS 

INVESTIGATING OFFICERS AND TO THE BUT ROUTINE, PRACTICE OF 

ROTATING THESE OFFICERS THROUGH SEVERAL "PROFESSIONAL GROWTH 

ASSIGNMENTS" DURING THEIR TOUR AT SECTOR OR SUBORDINATE UNIT. 

3.	 IN AN EFFORT TO STRENGTHEN THE CASUALTY INVESTIGATION 

COMDT (CG-545) IS DEVELOPING AN ACTION THAT WILL ENSURE 

10 BILLETS ARE STAFFED WITH CORPS OF WELL TRAINED, CERTIFIED AND 

EXPERIENCED CASUALTY INVESTIGATING OFFICERS. 

UNTIL THE IS FULLY COMPLETED AND IMPLEMENTED ARE SEVERAL 

STEPS THAT SECTOR MSU OFFICERS MUST TAKE TO 

ENSURE THAT THE OVERSIGHT AND COMPLETION OF CASUALTY 

INVESTIGATIONS IS DONE BY CERTIFIED MARINE CASUALTY INVESTIGATORS. 

I CANNOT OVERSTRESS THAT PROPER TRAINING IS ONE OF THE MOST 

IMPORTANT ASPECTS OF ENSURING OUR PERSONNEL ARE AND MOTIVATED 

TO DO THE JOB. CORE COMPETENCIES, PREREQUISITES FOR A MARINE 

CASUALTY INVESTIGATOR AND COMPLETING EACH STEP IN THE TRAINING AND 

CERTIFICATION PROCESS, MUST BE UPHELD. 

5. COMDT (CG-545) IS RESPONSIBLE FOR DETERMINING MISSION ESSENTIAL 

TRAINING REQUIREMENTS FOR ALL CASUALTY INVESTIGATORS IN ORDER TO 

MEET COAST GUARD OPERATIONAL COMMITMENTS. 

ONLY COMDT (CG-545) A WAIVER TO ANY CERTIFICATION OR 

FOR TRAINING. UPDATED PERFORMANCE QUALIFICATION STANDARDS WERE 

ANNOUNCED IN REFERENCE E. COAST "GUARD SHALL ENSURE THAT ALL 

PERSONNEL REQUESTING AND ASSIGNED TO TRAINING MEET ALL COURSE 

PREREQUISITES. 

6. IN ACCORDANCE WITH POLICY IN REFERENCES BAND C, PERSONNEL ASSIGNED 

TO OPERATIONAL BILLET AS A CASUALTY INVESTIGATOR SHOULD 

ALREADY BE FAMILIAR WITH SAFETY LAWS AND REGULATIONS THROUGH 

PRIOR TRAINING AND QUALIFICATIONS, GENERALLY, AS A INSPECTOR 

PRIOR TO BEING ASSIGNED TO CASUALTY INVESTIGATION DUTIES. TO 

FACILITATE THIS REQUIREMENT DURING AY 2009 ASSIGNMENT SEASON AND 

BEYOND, I HAVE DIRECTED COMDT (CG-545) TO WORK WITH THE APPROPRIATE 

HEADQUARTERS OFFICES AND PERSONNEL COMMAND TO ENSURE THAT 

INVESTIGATING OFFICER BILLETS PROPERLY CODED TO INDICATE THE 

PREREQUISITE QUALIFICATIONS REQUIRED FOR PERSONNEL TO BE ASSIGNED AND 

TO FACILITATE THE EFFORTS BY PERSONNEL TO FILL THE BILLETS WITH 

APPROPRIATE CERTIFIED PERSONNEL. 

7.	 THE MARINE CASUALTY INVESTIGATIONS IS CONSIDERED AN 

LEVEL OF THE COAST GUARD SAFETY COMMUNITY. 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 34 
MAY

THE COMMAND

AND

AND

AND

AND

MARINE

MARINE

AN

MARINE AND

YOUR

PERSO~EL

INFORMATION

BILLET,

COMMANDANT

SENDS;

'

AppendixB 

Management Comments to the Draft Report 

ACCORDINGLY, QUICK INTERNAL ROTATION THROUGH AN INVESTIGATING OFFICER 

BILLET IS INAPPROPRIATE. PERSONNEL ASSIGNED ARE EXPECTED TO HAVE HAD 

PRELIMINARY TOURS RENDERING SUCH TICKET-PUNCHING UNNECESSARY. AS WITH 

SHORT TOURS, ACTIVE DUTy MARINE CASUALTY INVESTIGATORS OCCASIONALLY 

BE SELECTED FOR REASSIGNMENT WITHIN A UNIT. SUCH REASSIGNMENTS ARE 

BASED ON THE NEEDS OF AND ARE OFTEN REQUIRED TO FILL 

CRITICAL POSITIONS WITHIN THE COAST GUARD. BECAUSE OF THE ENORMOUS 

INVESTMENT OF TRAINING EXPERIENCE REQUIRED TO CERTIFY AS A MARINE 

CASUALTY INVESTIGATOR TO GAIN TECHNICAL COMPETENCE, INTERNAL 

ROTATIONS SHORT TOURS ARE HIGHLY DISCOURAGED AND SHOULD BE MADE 

ONLY IN ACCORDANCE WITH REFERENCE D. 

8. IN ORDER TO BECOME CERTIFIED AS A MARINE CASUALTY INVESTIGATOR, THE 

10 MUST COMPLETE PQS SIT BEFORE A QUALIFICATION BOARD CONSISTING OF 

PERSONNEL THAT ARE CERTIFIED IN THAT SPECIALTY. TO BE CONSIDERED 

CERTIFIED AS A CASUALTY INVESTIGATOR THE 10 MUST BE ASSIGNED TO 

AN OPERATIONAL BILLET AS A CASUALTY INVESTIGATOR, BE DESIGNATED 

IN WRITING AS 10 BY THE COGNIZANT OCMI, HAVE ATTENDED THE BASIC 

INVESTIGATING OFFICER COURSE (IOC) AT TRACEN YORKTOWN AND HAVE 

COMPLETED THE MARINE CASUALTY INVESTIGATOR 

(FO) QUALIFICATION. UNTIL THE 10 HAS COMPLETED THEIR CERTIFICATION, 

THEY SHALL, AT ALL TIMES, BE UNDER THE SUPERVISION OF A CERTIFIED 

CASUALTY INVESTIGATOR SHALL NOT BE AUTHORIZED TO CONDUCT AN 

INDEPENDENT MARINE CASUALTY INVESTIGATION. PERSONNEL MUST COMPLETE THE 

PQS ANNOUNCED IN REFERENCE E. LOCAL QUALIFICATIONS ARE NOT AUTHORIZED. 

IN ORDER TO ALLOW PROPER IDENTIFICATION OF CERTIFIED PERSONNEL, UNITS 

SHOULD ENSURE THEY KEEP THE TMT DATA BASE UP TO DATE WITH 10 AND OTHER 

CERTIFICATIONS. 

9. IF UNIT LACKS THE APPROPRIATE CERTIFIED PERSONNEL TO CONDUCT A 

MARINE CASUALTY INVESTIGATION, THEN YOU SHALL SEEK ASSISTANCE OUTSIDE 

OF YOUR UNIT. COMDT (CG-545) IS CONDUCTING A STUDY OF THE STATUS OF 10 

QUALIFICATIONS, INCLUDING CURRENTLY ASSIGNED TO 10 BILLETS 

AND THOSE WITH 10 CERTIFICATIONS NOT ASSIGNED TO 10 BILLETS. ON APRIL 

18, COMDT (CG-545) REQUESTED DATA FROM ALL UNITS DOCUMENTING 

CERTIFICATION AND BILLET ON ALL INVESTIGATING OFFICERS. IF, 

IN THE PROCESS OF COMPLETING THE DATA CALL, A UNIT WITH A SHORTFALL OF 

CERTIFIED MARINE CASUALTY INVESTIGATORS IDENTIFIES A CERTIFIED MARINE 

CASUALTY INVESTIGATOR NOT CURRENTLY ASSIGNED TO AN 10 BILLET, THE UNIT 

SHOULD CONSIDER FOLLOWING THE GUIDANCE OF REFERENCE D TO INTERNALLY 

ROTATE THAT CERTIFIED pERSON INTO AN 10 OR AS AN ALTERNATIVE, 

IDENTIFY THEM AS A RESOURCE TO SUPERVISE ALL MARINE CASUALTY 

INVESTIGATIONS UNTIL SUCH TIME AS THE UNIT IS ASSIGNED CERTIFIED 

PERSONNEL. IF A UNIT HAS NO CERTIFIED MARINE CASUALTY INVESTIGATORS, 

COMDT (CG-5451 WILL WORK TO IDENTIFY AVAILABLE RESOURCES TO ASSIST. 

10. RDML BRIAN SALERNO, ASSISTANT FOR MARINE SAFETY, 

SECURITY AND STEWARDSHIP, 

11. INTERNET RELEASE AUTHORIZED. 

BT 

NNNN 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 35 
Richard

Inspector General

Department of Security

Washfugton,

Inspector

Skinner:

and House

lind

We are a

caliualty findings

Committees examine

marine investigations in

simil.ar minimize of·si01i1ar

c:aliualties, given bas

that

or protect

duty practices;

invelltigators;

aIid

ofbest investigation practices

other

Branch programs;

marine for

Appendix C 

Congressional Request for Audit 

December 16, 2005 

Mr. L. Skinner 

Homeland 

DC20528 

Artn:Office of General 

Dear Mr. 

Onbehalfofthe Committee on Transportation 1nfrastmctnre ofthe of 

Representatives the Committee on Commerce, Science llI1d Ttanliportation of the 

Senate, writing to request your office to conduct study of the Coast Guard's 

marine investigation program and to report tothese Committees the and 

rec;ortll'i1endations ofthatstudy not later thanJune 30, 2007. 

The expect that the study and report shall the extent to 

which casualty and reports result information and 

recommendations that prevent casualties; the effect 

that it occurred; and maximize lives saved in si:tnilar casualties, 

given the vessel has become uninhabitl1ble. 

The Conunitteesalso suggest that the study ineludethe follOWing to promote the 

safety ofalI who work on travel by water and to the marine·environment: 

•	 the adequacy ofreS{)llfces devoted to marine caslJlllty investigations considering 

caseload, and assignment 

•	 training and experience ofmarine casualty 

•	 investigation standards methods, including a comparison ofthe fonnal and 

infonnal investigation processes; 

•	 lise considering transportation investigation 

practices used by Federal agencies and foreign governments; inclUding 

British Marine Accident Investigation 

•	 usefulness of the casuaItydata base marine casualty prevention 

programs; 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 36 
' ~J .--/\.../

L.O

Appendix C 

Congressional Request for Audit 

2 

•	 the extent to which marine casualty data and information have been used to 

improve the survivability and habitability of vessels invol ved in marine casualties; 

•	 any changes to current statutes that would clarify Coast Guard responsibilities for 

marine casualty investigations and report; and 

•	 the extent to which the Coast Guard has reduced the frequency of fonnal 

investigations, or changed the types of incidents for which it has carried out a 

fOffilal investigation process. in the past five years, 

We thank you for your important contribution to our Committees' oversight over 

the Coasl Guard's marine safety missions, and we look forward to receiving your report. 

Sincerely, 

/ 

DON YOUN TED STEVENS
 7 Chairman


Committee on Transportation Committee on Commerce, 

and fnfrastmcture Science and Transportation 

United States House of Representatives United States Senate 

DANIEL K, IN 

nking Democratic Member Ranking Democ 

Committee on Transportation Committee on C r mcree, 

and Infrastructure Science and Tra , )ortation 

United States House of Representatives United States 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 37 

Guard

apply

and

Quality

necessary once

Preliminary Investigations

severe

Ooce

cognizant

Data CoUection A.ctivities

fUture

veritY

Investigations formal

investigative effort

can

District

AppendixD 

Coast Guard's G-MOA Policy Letter 2-02 

Enclosure (1) 

Levels a/Investigative Effort 

I. Purpose 

This enclosure provides guidance to implement new policy and process for the investigation,
 

reporting, and record-keeping associated with Coast
 marine casualty investigations. This 

policy does not to: 

•	 46 CFR 4.05 requirements for notice and written reports ofcasualties; 

•	 46 CPR 4.06 33 CFR 95 requirements for post-casualty chemical testing and the 

reporting ofchemical test results; 

•	 Regulations and policy regarding pollution investigations; 

•	 Personal action investigations oflicensed or documented maril1ers; and 

•	 Investigation ofcivil or criminal offenses. 

II. Levels ofInvestigative Effort 

The Action Team on Marine Safety Investigations suggested that three levels of
 

investigation are
 a preliminary investigation verifies an incident has occurred and 

assesses its apparent severity. This policy implements those levels ofinvestigation: 

•	 are initial investigative efforts undertaken to ascertain 

whether a report is genuine, how the inCident is or will become, whether the Coast 

Guard has jurisdiction, whether other agencies or offices must be notified, and what level 

ofCoast Guard investigative effort is necessary. a preliminary investigation 

verifies that a reportable marine casualty as defmed in 46 CFR 4.05-1 bas occurred, the 

investigative authority assigns the incident for investigation as a data collection 

activity, informal investigation, or fonnal investigation, depending on severity and value 

to marine safety. 

• do not require any significant investigative effort, and usually 

consist only ofcollecting and entering basic factual information into MISLE for 

reference and analysis. Only minimum follow-up to accuracy and completeness 

should be conducted as necessary. 

•	 I"formal are less exhaustive investigative efforts than 

investigations, but include the determination and reporting ofthe causal factors of a 

casualty and violation analysis, when applicable. This is the minimum level of 

reqUired to initiate enforcement actions. 

•	 Formal Investigations are reserved for the more serious or significant incidents
 

investigated under 46 USC Chapter 63 from which the most value
 be gained. Marine 

Boards ofInvestigation convened by the Commandant and other fonnal investigations 

convened by the Commander or OCMI/COTP fit into this category. 

2 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 39 
Conduct

Prelimina,yl1JVestigations

defme4

flag vessel.

that a

occurred,

investigation,

the

CFR

required

Process

the require

Data Colhclio"

Formal

be the

Entry.

inm

accuracy Investigations

is

investigation

Exceptions.

criteria,

verify

the

uninspected

pollution,

toes.

nerve, organ

AppendixD 

Coast G-MOA Policy Letter 2-02 

III. of Investigations and Data Collection Activities 

A preliminary investigation shall be conducted for any report or 

evidence of a reportable marine casualty as in 46 CFR 4.05-1 involving aU.S. or foreign 

commercial The following criteria applies: 

•	 When a preliminary investigation reveals reportable marine casualty as defined in 

46 CFR 4.05-1 has in fact the level ofinvestigative effort shall be raised to a 

data collection activity, informal or formal investigation. 

•	 When a preliminary investigation reveals that a marine casualty meets MlSLE Data 

Entry Exemption below, is not reportable under 46 4.05-1, or it cannot be verified 

that a marine casualty has occurred, no additional Investigative effort is and the 

results ofthe preliminary investigation shall be documented in MISLE in accordance 

with the Investigations and Enforcement Guide. 

•	 Investigations closed at preliminary level never finding offact (timeline) 

enmes. 

Activities A data collection activity shall be conducted for all reportable marine 

casualties as derIDed in 46 CFR 4.05-1 not assigned to InflmnalInvestigation or 

Investigation. MlSLE data entry requirements shall in accordance with Investigations and 

Enforcement Process Guide. 

•	 MISLE incident Investigation Data Normally, the reported casualty 

information should be entered MISLE with only minimum effort expended to verify 

its and completeness in accordance with the and Enforcement 

Process Guide. The intent ofthis policy to reduce the unit workload resulting from 

ofminor marine casualties to an absolute minimum while retaining basic 

event infonnation for trend and statistical analysis. 

•	 MlSLE Ineident Investigation Data Entry No MlSLE data entry beyond 

the MISLE notification Information is necessary or desired for marine casualties 

meeting the below criteria. For incidents meeting this the CG-2692 and any 

other material received should be documented in the notification after minimal review to 

that the incident meets one of the criteria. When feasible, the unit shalL 

electronically attach the 00-2692 and other material to the MISLE notification. Until 

that time, the CO-2692 and other material shall be sent to Commandant in accordance 

with current policy. 

I. Groundings involving "bump and go" touching of bottom on Western Rivers (as 

defined in 33 USC 2003) by uninspected towing vessels and barges in the 

navigation channel with no damage. no no personnel injuries, no breaking 

apart ofthe tow, and no a$sistance required to resume voyage. 

2.	 Casualties invoLving only minor injury. A minor injury is any injury that does not 

result in broken bones (other than fingers, or nose), loss oflimbs, severe 

hemorrhaging, severe muscle, tendon, or internal damage, or in 

hospitalization for more than 48 hours within 5 days ofthe injury. 

3 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 40 
diabetes

determine

unless

for

'VeSsel and meeting

accordance and

!ni!!!Y: fractured bones

hemorrhaging, nerve. tendon,

than homs

an

than inland

damage: e'Vent vessel and

than damage

occurrence,

damage natln'al resources, of

fire; adversely

a

AppendixD 

Coast Guard's G-MOA Policy Letter 2-02 

3.	 Casualties involving injuries when the injuries result from a pre-existing medical 

condition and not from a marine operation. (Le. a mariner with suffers a 

spell ofblurry vision, and during the spell trips because he did not see a deck fitting 

and breaks a leg.) Ifthe mariner holds license or merchant mariner's document the· 

incident should be investigated to ifsuspension and revocation proceedings 

should be pursued by reason ofmedical incompetence. 

4.	 Casualties (other than collisions and allisions) reported only because ofproperty 

damage in excess of $25,000 where the property damage does not exceed $100,000. 

5.	 Casualties involving U.S. state-numbered commercial vessels exempt from reporting 

to the Coast Guard under 46 CFR 4.01-3(a), a fonnal or informal investigation 

is conducted. 

Informal Investigations An informal investigation should be conducted any casualty 

involving a U.S. or foreign flag commercial any ofthe below criteria. 

MISLE data entry requirements shall be in with the Investigations Enforcement 

Process Guide. 

•	 Death; One death. Death cases may be downgraded to the Data Collection Activity level 

ofinvestigation after credible evidence (such as a death certificate) indicates death from 

natural causes (including a pre-existing medical condition) or suicide. 

• One injury which results in (other than fmgers, toes, or nose), loss 

oflimbs, severe severe muscle, or internal organ damage, 

or in hospitalization for more 48 within 5 days ofllie injury. 

•	 Vessel loss: Loss of uninspected vessel ofless than 500 OT, or loss of a barge ofmore 

100 OT on waters (as defmed in 33 USC 2003). 

•	 Property An involving a resulting in property damage 

exceeding $100,000 but less $1,000,000. The value comprises the cost of 

labor and material to restore the property (vessels, shoreline facilities, pipelines, OCS 

facilities, etc.) to its original condition before the but does not include 

to or the cost salvage, cleaning, gas-freeing, dry-docking, or 

demurrage. Damage value.s should be the best estimates available immediately following 

the accident. 

•	 Collision: Any collision or allision resulting in property damage exceeding 525,000. 

•	 Loss ofpropulsion or steering; Any loss ofpropulsion or steering, even ifmomentary, 

affecting an inspected U.S. vessel anywhere, or affecting a foreign flag vessel or an 

uninspected U.S. vessel over 100 GT onU.S. navigable Waters. 

•	 Flooding or Flooding or fire that affect a vessel's fitness for service on an 

inspected U.S. vessel anywhete, or on foreign flag vessel or an uninspected U.S. vessel 

over 100 OT on U.S. navigable waters. 

4 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 41 
Coast primary

Casualty:

recl;eational PUIPOses.

FortnalInvestigation

cdteria.

accordance

~: 2 more

than fingers,

se\lere

days

inspected

dlQJl3ge:

to

before

cleaning; gas-freeing,

in 300.5). regulated

or

property.

AppendixD 

Coast Guard's G-MOA Policy Letter 2-02 

• or seriously disabling injuries or 6 or more injuries which result in 

fractured bones (other 

•	 Equipment failure: Failure of Guard-approved lifesaving equipment or 

Coast Guard-approved firefighting equipment. 

•	 Discharge: Medium discharge ofoil or medium release of a hazardous substance (as 

defined in 40 CPR 300.5), or ofhazardous cargoesregulated under 46 CPR Subchapter 

0, in which a vessel isthe source or the cause ofthe discharge orrelease. 

•	 Commercial Diving Casualty, Death or injury ofpersons diving from a vessel for
 

commercial purposes.
 

•	 Recreational Diving Death or injury ofpersons diving from a vessel in federal 

waters for 

A fonnal investigation should be conducted for any casualty involving a 

U.S. or foreign flag commercial vessel and meeting any ofthe below MISLE data entry 

requirements shall be in with the Investigations and Enforcement Process Guide. 

•	 Death: 2'or more deaths. 

. 

toes, or nose), loss oflimbs, severe hemorrhaging, 

muscle, nerve, tendon, or intemal organ damage, or in hospitalization for more 

than 48 hours within 5 ofthe injury. 

•	 Vessel loss: Loss ofan vessel, or loss ofan uninspected vessel of 500 GT or 

more. 

•	 Property An event involving a vessel and resulting in property damage 

exceeding $1,000,000. The damage value comprises the cost oflabor and material 

restore the property (vessels, shoreline facilities, pipelines. OCS facilities, etc.) to its 

original condition the occurrence. but does not include damage to natural 

resources, orthe cost ofsalvage. dry-docking. or demurrage. 

Damage values should be the best estimates available immediately following the 

accident. 

• Discharge: Major discharge ofoil or major release ofa bazardoussubstance (as defmed 

40 CFR or ofbazardous cargoes under 46 CFR Subchapter 0. in 

which a vessel is the source the cause ofthe discharge or release. 

Foreign Flag Ex.ception: A formal investigation is not required for a casualty involving only a 

foreign flag vessel (i.e., no U.S. vessel involved. no damage to U.S. and no injury 

ofU.S. citizens). 

Barge Exception: A fonnal investigation is not required for the loss of a barge on inland 

waters (as defined in 33 USC 2003). 

5 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 42 
AppendixE 

Responses to Committees' Concerns 

The Committee on Transportation and Infrastructure of the House of 

Representatives and the Committee on Commerce, Science and 

Transportation of the Senate requested us to examine the extent to which 

marine casualty investigations and reports result in information and 

recommendations that prevent, minimize the effect of, and maximize lives 

saved in similar casualties. See Appendix C for the Committees' request. 

The Committees also suggested that our review include the following: 

a.	 The adequacy of resources to marine casualty investigations 

considering caseload and duty assignment practices. The majority of 

personnel conducting marine casualty investigations are not qualified to 

conduct investigations, and the resources for the review and closure 

process of investigations are inadequate, resulting in a substantial backlog 

of investigations at Coast Guard headquarters. 

b.	 The training and experience of marine casualty investigators. 15 of 

the 22 marine casualty investigators who we tested were not qualified 

under Coast Guard policy to conduct these investigations. Also, 3 of 15 

marine casualty investigators have not taken either the basic or advanced 

marine casualty training course. Further, marine casualty investigators are 

not generally in their positions for more than one tour of duty at the same 

location. According to Coast Guard personnel, a reasonable career path to 

become an experienced marine casualty investigator would entail more 

than one tour of duty in the same location. Increasing the number of 

civilians in the marine casualty investigations program or extending the 

tour of duty for Coast Guard personnel could result in increased 

knowledge of local waterways and industries. 

c.	 Investigation standards and methods, including a comparison 

between the Formal and Informal investigation processes. Informal 

investigations are less exhaustive than formal investigations, but still 

include the determination and reporting of the causal factors. Formal 

investigations are reserved for the more serious or significant casualties 

where the most value can be gained. 

d.	 The use of best investigation practices considering transportation 

investigation practices used by other federal agencies and foreign 

government, including British Marine Accident Investigation 

programs. The United Kingdom's Marine Accident Investigation 

Branch, Australian Transportation Safety Board, and Transportation 

Safety Board of Canada focus on maritime safety and do not assign fault 

or determine civil or criminal liabilities. Similarly, the United States 

National Transportation Safety Board does not assign fault or determine 

United States Coast Guard's Management of the Marine Casualty Investigations Program
 

Page 43
 
AppendixE 

Responses to Committees' Concerns 

liabilities, but is focused on safety and preventing similar casualties. 

Further, these organizations on average conduct 18 marine casualty 

investigations per year, while the Coast Guard on average conducts 3,800 

investigations, including approximately 266 informal and formal 

investigations per year. Also, these organizations do not have 

enforcement powers. According to Coast Guard officials, the Coast 

Guard's enforcement powers and assignment of fault do not prevent the 

Coast Guard from determining the casual factors of the marine casualties. 

e.	 Usefulness of the marine casualty database (MISLE) for marine 

casualty prevention programs. While there are various types of data 

input errors in MISLE, it is useful. With a thorough review at Coast 

Guard headquarters, these errors could be further minimized. Coast Guard 

provides routine training to the field personnel for MISLE. Coast Guard 

officials stated MISLE is a better system than the previous system; it is 

user-friendly and can be used to identify patterns with casualties. Yet, 

these officials and an official from an external entity stated that in some 

areas the causal analysis function could be improved. Safety advisory 

committees and other customers have used MISLE data. The Towing 

Safety Advisory Committee used MISLE data to develop a report 

regarding the proposed towing vessel inspection regulations. This report 

utilized Coast Guard-gathered marine casualty data on towing vessels 

from 1994-2005. This information was used to determine the severity and 

causes of these marine casualties. 

f	 The extent to which the marine casualty data and information have 

been used to improve survivability and habitability of vessels involved 

in marine casualties. The Coast Guard has issued numerous safety alerts 

and recommendations based on its marine casualty investigations. For 

example, as a result of a charter fishing vessel capsizing while crossing the 

Tillamook Bay Inlet in Oregon, the Coast Guard issued a risk based matrix 

to mariners to determine whether crossing of the inlet was permitted. 

Another example resulted from multiple allisions by a casino vessel with 

the St. John's Pass Bridge, in St. Petersburg, Florida. The Coast Guard 

came to an agreement with the casino operators not to pass by the bridge 

unless currents and winds are at a safe level. Sector Hampton Roads 

issued a safety alert for full body harnesses for towing vessel operators, 

which, according to a towing vessel operator, vastly improved the safety 

in the industry. The Coast Guard also issues safety alerts for general 

operations, cargo operations, engineering, navigation equipment, and 

safety equipment. These safety alerts and recommendations by the Marine 

Casualty Investigations Program contribute to the general safety of the 

waterways. 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 44 
h.

AppendixE 

Responses to Committees' Concerns 

g.	 Any changes to current statutes that would clarify Coast Guard's 

responsibilities for marine casualty investigations and reports. 

Although we did not identify any required changes in statutes or 

regulations regarding marine casualty investigations, we did identify 

conflicting interpretations and applications of the Coast Guard's 

September 2002 policy letter. For example, per the policy letter, loss of 

propulsion should be investigated at the informal level. However, some 

marine casualty investigators define loss of propulsion as lost propulsion 

from one engine even though there might be multiple engines, whereas 

others defined loss of propulsion as when a vessel cannot remain 

underway. In addition, the dollar estimates for damages should be 

updated to reflect more current costs of repair. The Coast Guard should 

review the criteria for various levels of investigations and make 

appropriate changes, and ensure that the criteria are consistently applied 

throughout the Coast Guard. Further, the Coast Guard must finalize an 

updated version of the Marine Safety Manual. 

The extent to which the Coast Guard has reduced the frequency of 

Formal investigations, or changed the types of incidents for which it 

has carried out Formal investigations, in the past five years. Based on 

our review of an extract from the MISLE database on the 15,327 marine 

casualties that occurred during the period January 1, 2003 through October 

31,2006, the Coast Guard conducted 13 formal investigations. However, 

based on our testing, we identified an additional 134 marine casualties that 

should have been conducted at the formal level. The Coast Guard 

conducted these investigations at the lesser informal or data collection 

activity levels. 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 45 
Appendix F 

Major Contributors to this Report 

Washington, D.C. Office 

Richard T. Johnson,
 

Director, Coast Guard and Maritime Security Operations Division
 

Boston, MA Field Office 

Maureen Duddy, Auditor Manager 

Edward Jeye, Auditor-in-Charge 

Michael Brunelle, Program Analyst 

Lindsey Cabral, Auditor 

David DeHaven, Auditor 

Paul Exarchos, Program Analyst 

Jeanne Genao, Program Analyst 

Colin Sullivan, Auditor 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 46 
Appendix G 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chief of Staff 

General Counsel 

Executive Secretary 

Director, GAO/DIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

Commandant, USCG 

USCG Audit Liaison 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS DIG Budget Examiner 

Congress 

Committee on Transportation and Infrastructure of the House of 

Representatives 

Committee on Commerce, Science and Transportation of the Senate 

Congressional Oversight and Appropriations Committees, as appropriate 

United States Coast Guard's Management of the Marine Casualty Investigations Program 

Page 47 
Additional Information and Copies 

To obtain additional copies of this report, call the Office of Inspector General (OIG) at 

(202) 254-4199, fax your request to (202) 254-4305, or visit the OIG web site at 

www.dhs.gov/oig. 

OIG Hotline 

To report alleged fraud, waste, abuse or mismanagement, or any other kind of criminal 

or noncriminal misconduct relative to department programs or operations: 

• Call our Hotline at 1-800-323-8603; 

• Fax the complaint directly to us at (202) 254-4292; 

• Email us at DHSOIGHOTLINE@dhs.gov; or 

• Write to us at: 

DHS Office of Inspector General/MAIL STOP 2600, Attention: 

Office of Investigations - Hotline, 245 Murray Drive, SW, Building 410, 

Washington, DC 20528. 

The OIG seeks to protect the identity of each writer and caller.