Department of Homeland Security
 

Marine Accident Reporting, Investigations, and 


Enforcement in the United States Coast Guard
 

OIG-13-92 May 2013
 
 

 

              

            

       

     

       

   

       

ards

pector General for Audits

         

           

  

                     

                    

                     

                         

                       

                        

                     

                     

                          

                       

                        

                   

                       

                     

                    

                 

                             

              

   

 OFFICE OF INSPECTOR GENERAL 

 Department of Homeland Security 

 Washington, DC 20528 / www.oig.dhs.gov 

MAY 23 2013

MEMORANDUM FOR:	 Rear Admiral Stephen P. Metruck

Assistant Commandant for Resources and

Chief Financial Officer

United States Coast Guard

FROM:	 Anne L. Rich

Assistant Ins

SUBJECT:	 Marine Accident Reporting, Investigations, and

Enforcement in the United States Coast Guard

Attached for your action is our final report, Marine Accident Reporting, Investigations,

and Enforcement in the United States Coast Guard. We incorporated the formal

comments from the United States Coast Guard in the final report.

Based on information provided in your response to the draft report, we consider

recommendations 1 through 3 and 5 through 7 open and resolved, and

recommendation 4 resolved and closed. As prescribed by the Department of Homeland

Security Directive 077‐01, Follow‐Up and Resolutions for Office of Inspector General

Report Recommendations, within 90 days of the date of this memorandum please

provide a written update for each open recommendation. Once your office has fully

implemented the open recommendations, please submit a formal closeout letter to us

within 30 days so that we may close the recommendations. The memorandum should

be accompanied by evidence of completion of agreed‐upon corrective actions.

Consistent with our responsibility under the Inspector General Act, we are providing

copies of our report to appropriate congressional committees with oversight and

appropriation responsibility over the Department of Homeland Security. We will post

the report on our website for public dissemination.

Please call me with any questions, or your staff may contact Mark Bell, Deputy Assistant

Inspector General for Audits, at (202) 254‐4100.

Attachment
 

 

 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Table of Contents 

Executive Summary ............................................................................................................. 1 

Background ........................................................................................................................ 2 

Results of Audit ................................................................................................................... 3 

Coast Guard Marine Accident Response Personnel ............................................... 3 

Corrective Actions ................................................................................................... 5 

Enforcement ........................................................................................................... 7 

Recommendations ................................................................................................ 10 

Management Comments and OIG Analysis .......................................................... 11 

Appendixes 

Appendix A: Objectives, Scope, and Methodology ............................................ 14 

Appendix B: Management Comments to the Draft Report ............................... 16 

Appendix C: Major Contributors to This Report ................................................ 20 

Appendix D: Report Distribution ........................................................................ 21 

Abbreviations 

CFR Code of Federal Regulations 

CGBI Coast Guard Business Intelligence 

CY calendar year 

DHS Department of Homeland Security 

GAO Government Accountability Office 

INCOE Investigations National Center of Expertise 

MISLE Marine Information for Safety and Law Enforcement 

MSM Marine Safety Manual

MSU Marine Safety Unit 

NOV Notice of Violation 

OIG Office of Inspector General 

USCG United States Coast Guard

www.oig.dhs.gov OIG-13-92
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Executive Summary

The purpose of the investigations program in the United States Coast Guard (USCG) is to 

ensure the safety of mariners and vessel passengers by preventing marine accidents, 

protecting the environment from oil spills, and minimizing property loss and disruptions 

to commerce. The USCG is responsible for identifying, investigating, and enforcing 

reporting requirements related to marine accidents involving commercial vessels. Our 

audit objective was to determine whether the USCG has adequate processes to 

investigate, take corrective actions, and enforce Federal regulations following reported 

marine casualties. 

The USCG does not have adequate processes to investigate, take corrective actions, and 

enforce Federal regulations related to the reporting of marine accidents. These 

conditions exist because the USCG has not developed and retained sufficient personnel, 

established a complete process with dedicated resources to address corrective actions, 

and provided adequate training to personnel on enforcement of marine accident 

reporting. As a result, the USCG may be delayed in identifying the causes of accidents; 

initiating corrective actions; and providing the findings and lessons learned to mariners, 

the public, and other government entities. These conditions may also delay the 

development of new standards, which could prevent future accidents. 

We made seven recommendations to improve the efficiency and effectiveness of 

USCG’s marine accident investigations and enforcement of reporting requirements. 

USCG has concurred with all seven recommendations and is implementing corrective 

actions. 

www.oig.dhs.gov 1 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Background 

USCG is charged with preventing and responding to major marine accidents. Its Marine 

Safety Program is responsible for ensuring the safety of tens of thousands of U.S. 

mariners and millions of passengers on ferries and other vessels. Through the 

prevention of marine accidents, which minimizes property loss and disruptions to 

maritime commerce, the USCG also protects the marine environment from oil spills and 

the introduction of other harmful substances, and strengthens the economy. 

The USCG Marine Safety Program accomplishes these goals through a multifaceted 

approach that includes standards development, compliance enforcement, investigation 

and casualty analysis, and public outreach. The program is responsible for ensuring the 

safe and environmentally sound operation of U.S. flagged vessels and foreign vessels 

operating in U.S. waters. The USCG is the lead Federal agency for operations within the 

nation’s marine transportation system, which consists of 25,000 miles of inland, 

intracoastal, and coastal waterways. According to the Marine Safety Performance Plan, 

the majority of the Nation’s food, clothing, oil, and other raw materials reach 

warehouses, stores, and gas tanks through use of the marine transportation system. 

The USCG reported that it conducted approximately 6,200 incident investigations for 

reportable vessel and pollution marine accidents in 2011, using teams of inspections 

and investigations staff. Inspectors and investigators are required to train extensively, 

ensuring they have the proper knowledge to conduct investigations after accidents 

occur. The USCG has extensive training requirements and qualifications related to 

specific vessel types to ensure its staff has the requisite knowledge to identify accident 

causes and develop corrective actions to prevent accidents in the future. 

This audit was initiated to review both the USCG’s process for accident reporting and its 

personnel who respond to accidents once they are reported. Federal regulations 

mandate that mariners report marine accidents, including those that involve property 

damage of more than $25,000 or injuries requiring treatment beyond first aid. Once an 

accident occurs that meets these requirements, mariners must immediately notify the 

USCG and then follow up with a written report of the accident within 5 days. Mariners 

failing to either immediately notify the USCG or file a written report can be cited with an 

enforcement action including a written warning, a Notice of Violation (NOV), or a Civil 

Penalty ranging up to $35,000. The USCG is responsible for conducting accident 

investigations, identifying corrective actions that can prevent future accidents, and 

enforcing accident reporting requirements when mariners fail to immediately notify the 

USCG of an accident and file a written report. 

www.oig.dhs.gov 2 OIG-13-92
 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Results of Audit 

The USCG does not have adequate processes or sufficient personnel to investigate, take 

corrective actions, and enforce regulations related to the reporting of marine accidents 

as required by Federal regulations and USCG policy. These conditions exist because the 

USCG has not developed and retained sufficient personnel, established a process with 

dedicated resources to address corrective actions, and provided adequate training. As a 

result, the USCG may be delayed in identifying the causes of accidents; initiating 

corrective actions; and providing the findings and lessons learned to mariners, the 

public, and other government entities. These conditions may also delay the 

development of new standards that could prevent future accidents. 

Coast Guard Marine Accident Response Personnel 

The USCG has not developed and retained sufficient staff to perform inspections 

and investigations work in response to marine accidents, and does not have a 

sufficient number of qualified staff to train new inspectors and investigators.1 In 

addition, the Director of Prevention Policy provides personnel with career 

management guidance that suggests they should leave this specialty to improve 

their promotion potential, because of the USCG’s emphasis on personnel 

attaining a wide variety of experience. Personnel indicated that both 

investigations and inspections suffer from investing time and money into training 

people only to have them leave the specialty. The USCG has initiated 

development of a Human Capital Plan to revamp its career guidance and

improve retention, but it has not yet finalized and implemented this plan. The 

Coast Guard Authorization Act of 2010, as amended, allows promotions by 

specialty in order to encourage retention and continuity to maintain sufficient, 

qualified personnel. However, the USCG has not implemented these provisions

of the Act. 

In 2011, the USCG established requirements for inspectors and investigators, 

which included formal training, on-the-job training, and work experience to 

ensure that personnel can perform their assigned duties. The USCG’s 

Investigations Division is primarily responsible for conducting investigations into 

marine accidents. However, according to USCG personnel, inspectors are part of 

the two-person team that responds to marine accidents. To determine if staff 

met these requirements, we conducted testing at five sites for inspections 

personnel and six sites for investigations personnel. Although the USCG has 

made some progress in training personnel, the majority of inspectors and 

1 Qualifications were established for inspectors and investigators, with new guidance issued in October 2011. 

www.oig.dhs.gov 3 OIG-13-92
 
 

 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

investigators did not meet USCG’s requirements for their assigned positions, as 

shown in Figures 1 and 2.2

Personnel Meeting United States Coast Guard Qualifications3

Figure 1. Inspections Personnel Figure 2. Investigations Personnel

18 

(36%)

32

(64%)

Inspections

Qualified Inspectors

Unqualified Inspectors

10 

(33%)

20 

(67%)

Investigations

Qualified Investigators

Unqualified Investigators

The USCG established an Investigations National Center of Expertise (INCOE) to 

provide crucial, time-sensitive guidance for a variety of complex investigative 

issues. Specifically, INCOE personnel provide on-scene support for major marine 

accidents and assist in certifying the qualifications of local office investigators. 

However, testing of staff qualifications (see Figure 2) revealed that the majority 

of INCOE personnel did not meet the USCG requirements to be assigned as 

investigators. In fact, only two of eight (25 percent) of the investigations staff 

met those requirements. 

According to the USCG, there is a shortage in the number of personnel assigned 

to inspections positions. This shortage will be further compounded when the 

regulations implementing the Coast Guard and Maritime Transportation Act of 

2

 The USCG has different levels of inspectors, including apprentice, journeymen, and advanced 

journeymen marine inspectors. Testing results include journeymen and advanced journeymen, positions 

which require previous inspections experience and qualifications to inspect specific vessels. 3

 Qualifications were established for inspectors and investigators, with new guidance issued in October

2011. 

www.oig.dhs.gov 4 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

2004, as amended, are phased in, which will expand the inspections workload. 

The Act requires the USCG to inspect approximately an additional 5,200 

traditional towing vessels, 1,800 assistance vessels, and other vessels engaged in 

towing. 

Some local USCG office staff maintain that it is difficult to complete inspections 

and investigations with current resources. Without sufficient qualified staff, the 

USCG will not be able to complete future inspections and investigations in a 

timely manner, which may reduce marine safety. 

Corrective Actions 

The USCG investigations and inspections processes do not ensure that all 

investigations and Traveling Inspections corrective actions are addressed and 

implemented. Corrective actions, in the form of safety recommendations, result 

from both investigations of marine casualties and reports by the USCG’s 

traveling inspectors—very experienced inspectors stationed at headquarters 

who visit field units to assist with unique inspections issues. The USCG is unable 

to ensure that all corrective actions are addressed because it does not have 

complete processes and dedicated resources to track, review, and implement 

recommendations for all investigations and Traveling Inspections reports. 

According to USCG personnel in charge of the corrective action process, no 

formal, written instructions or policies exist to ensure recommendations are 

addressed and implemented. Without a complete process, the USCG risks delays 

in implementing safety improvements and preventing future accidents. 

The USCG’s Traveling Inspectors also do not have a process for addressing safety 

recommendations contained in their reports. They visit local offices to provide 

assistance on complex inspections issues, such as inspections of complex vessels. 

Following these visits, they issue reports on their determinations, which include 

safety recommendations for preventing future inspections issues. After 

Traveling Inspectors issue their reports, however, they do not follow up with the 

associated local office or track the implementation of their safety 

recommendations. According to USCG personnel, each office that requests the 

Traveling Inspectors’ assistance is solely responsible for addressing the report’s 

safety recommendations. We notified the USCG about these deficiencies, and it 

already has taken action by implementing a process to ensure recommendations 

are tracked and implemented. 

www.oig.dhs.gov 5 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Open Investigations 

The absence of dedicated resources has caused a backlog of more than 6,000 

open investigations, which include safety recommendations that need to be 

addressed. However, safety recommendations cannot be addressed until 

headquarters closes the associated investigations. Therefore, USCG will be 

unable to address these safety recommendations in a timely manner without 

dedicated resources. 

Open Recommendations 

USCG policy describes that the purpose of safety recommendations is to propose 

corrective actions the USCG can implement to prevent unsafe conditions from 

contributing to future casualties. If corrective actions are not addressed and 

implemented in a timely manner, preventable marine accidents may occur, 

resulting in the loss of life or property, injuries, pollution, or unnecessary use of 

USCG resources. 

To assess the USCG’s safety recommendations process, testing was conducted to 

determine whether it had taken any action on safety recommendations from 

investigations initiated in calendar years (CY) 2009–11. Review of a judgmental 

sample of 67 local office safety recommendations indicated that the USCG had 

not initiated implementation on the vast majority of corrective actions (see 

Figure 3). Of the 63 recommendations upon which no action has been taken, 

49 have been awaiting headquarters review for more than a year. 

Figure 3. Safety Recommendations by Local Offices From CYs 2009–11 

4 (6%)

63 (94%)

Safety Recommendations by 

Local Offices From CYs 2009–11*

Action Ongoing

No Action Taken

*Recommendations with action ongoing include those with statuses indicating the USCG is currently 

addressing them. Recommendations with no action taken include those with statuses indicating they are 

open pending decisions or investigations, were closed by the USCG without action, and have a status of “N/A.”

www.oig.dhs.gov 6 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

In contrast, a review of a judgmental sample of 81 safety recommendations that 

USCG headquarters prepared indicated that it had closed or initiated action on 

the majority of those recommendations, as summarized in Figure 4. The USCG 

has done a better job addressing headquarters safety recommendations because 

the investigations are larger and higher profile. 

Figure 4. Safety Recommendations by Headquarters Offices From CYs 2009–11

*Recommendations with action ongoing include those with statuses indicating the USCG is currently 

addressing them. Recommendations with no action taken include those with statuses indicating the USCG 

did not concur and those that have no status. Closed recommendations have been completely addressed. 

46 (57%)

14 (17%)

21 (26%)

Safety Recommendations by 

Headquarters Offices From CYs 2009–11*

Action Ongoing

No Action Taken

Closed

Enforcement 

At the local office level, the USCG does not consistently enforce requirements 

related to reporting marine accidents. According to the Marine Safety Manual 

(MSM), the investigator must provide at least a formal written warning for any 

violation of marine accident reporting requirements. For more serious offenses, 

the penalty increases to a NOV, or a Civil Penalty up to $35,000. Site visits to 

local offices revealed inconsistencies in how investigators handled enforcement 

actions. For example, some offices do not always issue written warnings as 

required, but rather provide verbal warnings that are not documented or 

tracked. Personnel do this because they believe it is more effective to engage 

the mariners in a discussion and educate them on reporting requirements. 

However, the insufficient documentation makes it difficult for USCG to track 

marine accident history for future enforcement. USCG’s MSM indicates that 

enforcement actions do not include verbal warnings. 

Civil Penalties are one tool available to the USCG investigators to ensure 

compliance with statutes and regulations. For all violations, “it is imperative that 

www.oig.dhs.gov 7 OIG-13-92
 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

penalties exceed the benefits of noncompliance.”4 For example, the penalty 

assessed on an individual or company that has spilled oil must be high enough to 

encourage the entity to take steps to prevent spills. If the penalty assessed does 

not exceed the economic benefits of noncompliance, there is little incentive for 

future compliance. For violations of marine casualty reporting requirements, the 

USCG Commandant’s Instructions on Civil Penalty Procedures specifically 

indicate that a violation “warrants the initiation of a Civil Penalty and/or other 

remedial action.”

When the USCG initiates a Civil Penalty, investigators should comply with case 

development guidance issued by the USCG Hearing Office. The Hearing Office is 

responsible for reviewing and making the final determinations on Civil Penalty 

cases. Guidance issued by the Hearing Office stipulates that a Civil Penalty is not 

a punishment and that the amount recommended by the local office should be 

only that which is necessary to achieve compliance and deterrence. When 

investigators assemble a Civil Penalty case, they must provide evidentiary 

support for each element of the charged violation(s), and may include evidence 

of factors that influenced the penalty amount they recommended. A Hearing 

Officer reviews the case to verify allegations; he or she considers local office 

recommendations, but makes a determination on the appropriate penalty 

amount. Hearing Officers consider a number of factors in making a 

determination on the appropriate penalty, including prior violation history, 

extenuating or mitigating circumstances, and the gravity of the offense. 

USCG guidance requires Hearing Officers to provide the local office with 

feedback to facilitate the submission of better cases in the future. However, 

USCG field personnel stated that the Hearing Office does not always provide 

sufficient feedback. Even though the Hearing Office may also provide general 

training on the Civil Penalty process and the role of the Hearing Officer, USCG 

personnel indicated it has done so only once. Providing additional feedback and 

training to investigations personnel may improve the civil penalty process and 

case development. 

When Civil Penalties are used, those penalties are often reduced. Between 

CYs 2009–11, the Hearing Office reviewed 66 Civil Penalty cases, which included 

81 citations alleging violations of marine casualty reporting requirements. Of the 

81 citations reviewed, the Hearing Office found 62 (77 percent) to be proven. 

USCG should provide more training to investigation personnel on the Civil 

Penalties process. The Investigating Officer Course at the USCG Training Center 

4

 Civil Penalty Procedures and Administration, Commandant Instruction 16200. 3A, issued October 16, 1992. 

www.oig.dhs.gov 8 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

in Yorktown, Virginia, dedicates only 4 hours of a 4-week course to instruction on 

the Civil Penalty process. The training center has identified enforcement training 

as a particular area of weakness. It stated that the administrative enforcement 

case preparation and investigative process is a vital skill set that USCG personnel 

need to have to ensure that evidence required to support an alleged violation of 

law or regulations is properly supported. Currently, the USCG has no formal or 

informal training process for personnel preparing enforcement cases. As result, 

this training gap has fostered broad inconsistencies in how these cases are 

prepared and has had a negative effect on the ability of USCG personnel to 

exercise investigative and enforcement responsibilities. Therefore, personnel 

have requested that USCG headquarters consider adding a course geared 

specifically toward enforcement. 

Enforcement actions are the USCG’s method of ensuring compliance with marine 

reporting requirements. Without consistent application of the enforcement 

requirements, there is no effective deterrent to mariners’ failure to report 

accidents. As a result, mariners may not be reporting marine accidents to the 

USCG, potentially reducing marine safety. At the same time, many USCG offices 

proactively seek to make mariners aware of reporting requirements through 

Industry Days, which are educational outreach events covering a variety of 

topics. According to one USCG official, one local office has even reached out to 

area hospitals to make them aware of reporting requirements. 

Although the USCG has conducted significant outreach, more needs to be done 

to ensure compliance with accident reporting requirements. It must properly 

enforce regulations outlined in statute to enhance marine safety. 

Conclusion

The USCG has not developed and retained sufficient staff, ensured all corrective 

actions are addressed and implemented, and needs to enforce requirements 

related to reporting marine accidents consistently. As a result, it may be delayed 

in identifying causes of accidents; initiating corrective actions; and providing the 

findings and lessons learned to mariners, the public, and other government 

entities. These conditions may also delay the development of new standards, 

which could prevent future accidents. 

www.oig.dhs.gov 9 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Recommendations 

We recommend that the USCG Assistant Commandant for Resources and Chief 

Financial Officer implement the following recommendations to improve the 

efficiency and effectiveness of the USCG’s marine accident investigations and 

enforcement of reporting requirements: 

Recommendation #1: 

Implement an investigations and inspections retention plan to ensure qualified 

personnel are retained within the inspections and investigations specialties. 

Recommendation #2: 

Revise and strengthen its personnel management policies by implementing 

provisions of the 2010 Coast Guard Authorization Act, which allows promotions 

by specialty for marine inspectors and investigators to foster retention and 

continuity. 

Recommendation #3: 

Develop a complete process with sufficient resources to review, track, and 

address all recommendations resulting from investigations reports. 

Recommendation #4: 

Develop a formalized process with sufficient resources to review, track, and 

address all recommendations resulting from Traveling Inspections reports. 

Recommendation #5: 

Provide training and guidance to all investigations personnel on all enforcement 

options. 

Recommendation #6: 

Develop Civil Penalty enforcement training guidelines for preparing and 

supporting Civil Penalty cases for all investigations staff. USCG should consider 

using officers with previous experience in the Hearing Office to complete this 

task. 

www.oig.dhs.gov 10 OIG-13-92
 
 

 

 

 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Recommendation #7: 

Instruct the Hearing Office to provide feedback in accordance with existing policy. 

Management Comments and OIG Analysis 

The USCG provided formal comments to our report. A copy of the USCG’s 

response in its entirety is included as Appendix B. The USCG also provided 

technical comments and suggested revisions to our report in a separate 

document. We reviewed the technical comments and made changes in the 

report when appropriate. 

The USCG concurred with all seven recommendations, and has formulated plans 

to implement the recommendations contained in the report. A summary of the 

responses and our analysis follows. 

Response to Recommendation #1: Concur. The USCG has already taken action 

and is pursuing additional measures. It is currently developing a Maritime

Prevention Enhancement Plan that will continue and refine improvement efforts, 

including a consistent focus on retaining prevention professionals. It expects to 

complete this plan in fiscal year 2014. 

OIG Analysis: The USCG’s response addresses the intent of our recommendation. 

The recommendation will remain open and resolved until we can verify, through 

review of supporting documentation, that the USCG has completed the 

development of a Maritime Prevention Enhancement Plan that provides a 

consistent focus on retaining prevention professionals. 

Response to Recommendation #2: Concur. The USCG anticipates establishing 

policies which allow for the utilization of Enhanced Status Quo, as authorized in 

the Coast Guard Authorization Act of 2010. The USCG expects to initiate its 

corrective actions during 2014. 

OIG Analysis: The USCG’s response addresses the intent of our recommendation. 

The recommendation will remain open and resolved until we can verify, through 

review of supporting documentation, that the USCG has established policies 

which allow for the utilization of Enhanced Status Quo, as authorized in the 

Coast Guard Authorization Act of 2010.

Response to Recommendation #3: Concur. The USCG will establish national 

policy to track all actions on safety recommendations. In the interim, the USCG 

will develop an aide/tool to assist USCG Headquarters program offices and other 

www.oig.dhs.gov 11 OIG-13-92
 
 

 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

units in the tracking of safety recommendations for which they are responsible. 

In the long term, Marine Information for Safety and Law Enforcement (MISLE) 

and Coast Guard Business Intelligence (CGBI) system functionality will be 

developed to provide the means to carry out requirements of the national policy. 

The anticipated implementation date is end of CY 2013 for interim aide tool 

development and CY 2014 for long-term MISLE/CGBI functionality. 

OIG Analysis: The USCG’s response addresses the intent of our recommendation. 

The recommendation will remain open and resolved until we can verify, through 

review of supporting documentation, that the safety recommendation process 

has been strengthened based on the interim actions, national policy, and longterm plans. 

Response to Recommendation #4: Concur. The USCG has implemented a 

database and process to track, follow up, and address Traveling Marine Inspector 

Report recommendations. The USCG considers Recommendation #4 closed as of 

October 2012. 

OIG Analysis: The USCG’s actions satisfy the intent of the recommendation and 

it has provided documentation to support full implementation of the necessary 

corrective actions. The recommendation is closed. 

Response to Recommendation #5: Concur. The USCG is working to develop an 

Enforcement Course, which will provide education and training on how to 

properly investigate and document NOV and Civil Penalty enforcement actions. 

This course will include violation selection and analysis, casework write-up, and 

documentation in the MISLE database. The anticipated implementation date is 

fiscal year 2014, pending the availability of training funding. 

OIG Analysis: The USCG’s response addresses the intent of our recommendation. 

The recommendation will remain open and resolved until we can verify, through 

review of supporting documentation, that the enforcement course has been 

developed and all investigations staff have received the training. 

Response to Recommendation #6: Concur. The USCG will ensure the training 

guidelines for preparing and documenting a Civil Penalty are included in the 

curriculum developed for the Enforcement Course. Course development 

includes soliciting recommendations from accomplished performers in the field 

to include within the curriculum. The anticipated implementation date is fiscal 

year 2014. 

www.oig.dhs.gov 12 OIG-13-92
 
 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

OIG Analysis: The USCG’s response addresses the intent of our recommendation. 

The recommendation will remain open and resolved until we can verify, through 

review of supporting documentation, that the enforcement training guide and 

course has been developed and all investigations staff have received the training. 

Response to Recommendation #7: Concur. The USCG’s Judge Advocate General 

will instruct Hearing Officers to provide feedback in accordance with Chapter 2.C 

of Commandant Instruction MI6200.5A, consistent with their assigned duties. 

The anticipated implementation date is fiscal year 2014. 

OIG Analysis: The USCG’s response addresses the intent of our recommendation. 

The recommendation will remain open and resolved until we can verify, through 

review of supporting documentation, that the Judge Advocate General has 

instituted a new instruction requiring feedback to the field on cases reviewed by 

the Hearing Office. 

www.oig.dhs.gov 13 OIG-13-92
 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix A 

Objectives, Scope, and Methodology 

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. 

We conducted this audit to determine whether the USCG has adequate processes for 

investigating and taking corrective actions following reported marine casualties, and for 

enforcement of reporting requirements outlined in 46 CFR 4.05-1 and 46 CFR 4.05-10. 

We conducted site visits to— 

Coast Guard Headquarters Sector Puget Sound – Seattle, WA 

Coast Guard Hearing Office – Arlington, VA MSU Morgan City – Morgan City, LA 

Sector Boston – Boston, MA MSU Chicago – Chicago, IL

Sector Delaware Bay – Philadelphia, PA Marine Safety Detachment Peoria – 

Peoria, IL 

Sector Houston/Galveston – Houston, TX INCOE in New Orleans – New Orleans, LA 

Sector New Orleans – New Orleans, LA National Mariners Association – 

New Orleans, LA 

Sector Upper Mississippi River – 

St. Louis, MO 

Three law enforcement agencies – 

Boston, MA

Sector San Francisco – San Francisco, CA Two marine industry companies – Boston, 

MA 

We based our site visit selections on marine accident investigation numbers reported in 

the USCG system, and identified the locations with the largest number of accidents and 

sites with varying areas of responsibility and waterways. At these site visits, we 

interviewed employees and officials, made direct observations, and reviewed applicable 

documents. We also interviewed officials at USCG’s headquarters in Washington, DC. 

We performed testing to verify whether marine inspectors and marine investigators had 

the qualifications, training, and experience required by the USCG to conduct 

investigations. We identified the USCG’s current Marine Inspector Performance 

Qualification Standards and Marine Investigations Standards, and conducted testing of 

all personnel assigned to either a domestic inspector or investigation position at the 

time of our visit to determine if staff met the standards for their assigned position.

www.oig.dhs.gov 14 OIG-13-92
 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

We conducted this testing at the six sites we visited: Sector Delaware Bay, Sector 

Houston/Galveston, Sector Puget Sound, Sector San Francisco, Marine Safety Unit 

Chicago, and the National Center of Expertise. 

We performed testing to determine if USCG was reviewing, addressing, and tracking

corrective actions identified in investigation reports. We reviewed a judgmental sample 

of corrective actions identified by the field and corrective actions identified by USCG 

headquarters from CYs 2009–11. We also performed testing to determine if the field 

was enforcing accident reporting requirements and if the Hearing Office was upholding 

field enforcement actions. We reviewed all enforcement actions from CYs 2009–11. 

We conducted this performance audit between January and December 2012 pursuant 

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

government auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our

findings and conclusions based upon our audit objectives. We believe that the evidence 

obtained provides a reasonable basis for our findings and conclusions based upon our 

audit objectives. 

www.oig.dhs.gov 15 OIG-13-92
 
OFFICE OF INSPECTOR GENERAL 

 Department of Homeland Security 

Appendix B 

Management Comments to the Draft Report 

U,S, Department of Commandant 2100 Scocond Slrect, S. W .• Stop 7245 

Hom.'and Security United SUtes Cout GIWd Wuhington. DC 20593 SurrSymbol:CG-823 

Unttad States Phone: (202) 312·3533 Fax: (202) 372·23 II Coast Guard 

7501 

APR 23 2013 

From: 

ME~S. P. ~ Metruek, RDML Reply to Audit Manager 

COMDT (CG-S) Attn of: Mark Kulwicki 

(202) 372-3533 

To: A, L. Richards 

Assistant Inspector General for Audits 

Department of Homeland Security (DHS) 

Subj: DHS OIG DRAFT REPORT: "MARINE ACCIDENT REPORTING, 

lNVESTlGA TlONS, AND ENFORCEMENT IN THE UNITED STATES COAST 

GUARD" 

Ref: (a) OIG P'ojeet No. 12-027-AUD-USCG, dated Ma.ch 21 , 2013 

I. This memorandum transmits the Coast Guard's response to the findings and recommendations 

identified in reference (a). 

2. The Coast Guard concurs with the report's recommendations. 

3. If you have any questions, my point of contact is Mr. Mark Kulwicki who can be reached at 

202-372-3533. 

# 

Enelos"",: (1) USCG Response 

www.oig.dhs.gov 16 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

 Department of Homeland Security 

UNITED STATES COAST GUARD RESPONSE ON DHS OlG DRAFT REPORT OIG 

PROJECT NO. 12-027-AUD-USCG - MARINE ACCIDENT REPORTING, 

INVESTIGATIONS, AND ENFORCEMENT IN THE UNITED STATES COAST 

GUARD 

RECOMMENDATION AND USCG RESPONSE UPDATES 

Recommendation #1: Implement an investigations and inspections retention plan 10 ensure 

qualified personnel are retained within the inspections and investigations specialties. 

USCG Response: Concur with the intent of this recommendation - keeping in mind the Coast 

Guard has already taken action and has the intention of pursuing additional measures. The Coast 

Guard implemented a plan to improve competency and capacity in marine inspections and 

investigations - including specific measures to retain personnel in these fields. The Coast Guard 

Marine Safety Enhancement Plan (MSEP) issued in 2009 and other action taken since then 

improve retention in inspection and investigations billets by: establishing apprentice, journeyman 

and master journeyman tours; providing for back-to--back field tours for officers assigned as 

inspectors and investigators; requiring investigators to first be qualified inspectors; increasing the 

number of civilian inspector and investigators in the workforce; and enhancing the inspections 

and investigations training facilities and curriculum. The Coast Guard also initiated a prevention 

curriculum at the U.S. Coast Guard Academy to bring new officers into the program. and issued 

career guides that assist personnel in planning their careers, as well as showing junior officers 

that repeated tours in inspections and investigation may lead to positions of progressively greater 

responsibility within the program. 

The Coast Guard is currently developing a Maritime Prevention Enhancement Plan (MPEP) that 

will continue and refine our improvement efforts, including a consistent focus on retaining 

prevention professionals. 

Note that the Coast Guard has closed out the recommendations associated with OIG Report: 

Revisions to the Marine Safety Performance Plan and Annual Update Supplement will Facilitate 

Improved Management (OIG-I 1-22). 

RecommendatioD #2: Revise and strengthen its personnel management policies by 

implemen/in8prollisions of the 2010 Coast Guard Authorizalion Act, which allows promotions 

by specialty for marine inspectors and irwestigalors to foster retention and continuity. 

USCG Response: Concur. The Coast Guard anticipates establishing policies which allow for 

the utilization of Enhanced Status Quo (ESQ), as authorized in the Coast Guard AUlhorizalion 

Act 012010. 

In order to utilize ESQ. several actions are being taken: 

(a) Identify each position with a talent need. The initial designation has been completed. and the 

positions are under continual review. This approach establishes the requirements which each 

talent area, or specialty, will be evaluated to determine the annual need for ESQ. 

(b) Identify the existing talent available. Approximately 3,900 active duty and 550 reserve 

officers were assigned officer specialty codes in the summer of2012. This list requires 

validation from the officer corps, which will begin when the Officer Specialty Management 

System policy is published. 

Enclosure (1) 

www.oig.dhs.gov 17 OIG-13-92
 
 

OFFICE OF INSPECTOR GENERAL 

 Department of Homeland Security 

(c) Establish a means for new officers to earn a specialty designation. Policy and procedures for 

assigning officer specialty codes are pending approval. Specialty Program Managers have 

established and documented criteria for earning officer specialty codes. 

(d) Promulgate Polices. Currently. the Officer Specialty Management System Manual is pending 

approval. The specific selection modification policy is under development. 

Once these initiatives are fully implemented. then the Commandant will determine which 

specialties, if any, to apply the retention capability permitted by ESQ on an annual basis. 

As provided in the Coast Guard Authorization Act of2010, ESQ is not specific to the Marine 

Accident lnvestigation/Marine Inspector workforce. Needs within this workforce must be 

evaluated against all workforce requirements of the Coast Guard. 

The anticipated implementation date is dependent upon successfully validating assigrunent of 

specialty codes for individual officers. OPM will begin sampling data during Promotion Year 

2014 to build confidence in data accuracy. Once a reasonable confidence level is achieved, 

implementation will proceed. 

Recommendation #3: Develop a complete process with sufficient resources to review, track, 

and address all recommendations resilitingfrom investigations reports. 

USCG Response: Concur. The Coast Guard will establish national policy to track aU actions on 

safety recommendations. In the interim, the Coast Guard will develop an aide/tool to assist 

USCG Headquarters program offices andlor other units in the tracking of safety 

recommendations for which they are responsible. In the long-tenn, Marine Infonnation for 

Safety and Law Enforcement (MISLE) and Coast Guard Business Intelligence (CGBI) system 

functionality will be developed to provide the means to carry out requirements of the national 

policy. The anticipated implementation date is end of calendar year 2013 for interim aide/tool 

development and calendar year 2014 for long tenn functionality in MISLElCGBI. 

Recommendation #4: Develop aformalized process with sufficient resources to review, track, 

and address all recommendations resuJtingjrom Traveling Inspections reports. 

USCG Response: Concur. The Coast Guard has implemented a database and process to track, 

follow-up, and address Traveling Marine Inspector Report recommendations. The Coast Guard 

considers Recommendation #4 closed as of October 2012. 

Recommendation #5: Provide training and gUidance to all investigations personnel on all 

enforcement options. 

USCG Response: Concur. The Coast Guard is working to develop an Enforcement Course 

which would provide education and training on how to properly investigate and document all 

Notice of Violation and Civil Penalty enforcement actions. This course would include violation 

selection and analysis, case work write-up, and documentation in MISLE database. The 

anticipated implementation date is fiscal year 2014. pending availability of training funding. 

Recommendation #6: Develop Civil Penalty enforcement training guidelinesfor preparing and 

supporting Civil Penalty casesfor all investigations staff USCG should consider using officers 

with previous experience in the Hearing Office to complete this task. 

Page 2 of3 

www.oig.dhs.gov 18 OIG-13-92
 
 Department of Homeland Security 

USCG Response: Concur. The Coast Guard will ensure the training guidelines for preparing 

and documenting a Civil Penalty are included in the curriculum developed for the Enforcement 

Course. Development of the course includes soliciting recommendations from accomplished 

performers in the field to include within the curriculum. The anticipated implementation date is 

fiscal year 2014. 

Recommendation 117: Inslt'ucllhe Hearing Office 10 provide feedback in accordance with 

existing policy. 

USCG Response: Concur. The Coast Guard 's Judge Advocate General will instruct Hearing 

Officers to provide feedback in accordance with Chapter 2.C ofCOMDTINST M16200.5A. 

consistent with their assigned duties. The anticipated implementation date is fiscal year 2014. 

Page 3 of3 

 

www.oig.dhs.gov 19 OIG-13-92
 

OFFICE OF INSPECTOR GENERAL 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix C 

Major Contributors to This Report 

Brooke Bebow, Audit Director 

Stephanie Christian, Audit Manager 

Patricia Benson, Program Analyst 

Dianne Leyva, Program Analyst

Philip Emswiler, Program Analyst 

Carolyn Floyd, Auditor 

Emily Pedersen, Program Analyst 

Kevin Dolloson, Communications Analyst 

Sean Pettersen, Independent Referencer

www.oig.dhs.gov 20 OIG-13-92
 
 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix D

Report Distribution 

Department of Homeland Security

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chief of Staff

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs

Assistant Secretary for Office of Legislative Affairs 

USCG Component Liaison 

Acting Chief Privacy Officer 

Office of Management and Budget

Chief, Homeland Security Branch 

DHS OIG Budget Examiner

Congress

Congressional Oversight and Appropriations Committees, as appropriate 

www.oig.dhs.gov 21 OIG-13-92
 
 

ADDITIONAL INFORMATION AND COPIES 

To obtain additional copies of this document, please call us at (202) 254-4100, fax your 

request to (202) 254-4305, or e-mail your request to our Office of Inspector General 

(OIG) Office of Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov. 

For additional information, visit our website at: www.oig.dhs.gov, or follow us on Twitter 

at: @dhsoig. 

OIG HOTLINE 

To expedite the reporting of alleged fraud, waste, abuse or mismanagement, or any 

other kinds of criminal or noncriminal misconduct relative to Department of Homeland 

Security (DHS) programs and operations, please visit our website at www.oig.dhs.gov 

and click on the red tab titled "Hotline" to report. You will be directed to complete and 

submit an automated DHS OIG Investigative Referral Submission Form. Submission 

through our website ensures that your complaint will be promptly received and 

reviewed by DHS OIG. 

Should you be unable to access our website, you may submit your complaint in writing 

to: DHS Office of Inspector General, Attention: Office of Investigations Hotline, 245 

Murray Drive, SW, Building 410/Mail Stop 2600, Washington, DC, 20528; or you may 

call 1 (800) 323-8603; or fax it directly to us at (202) 254-4297. 

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