Marine Accident Report

Allision of Staten Island Ferry Andrew J. Barberi

St. George, Staten Island, New York

October 15, 2003

NTSB/MAR-05/01

PB2005-916401 National Transportation Safety Board

Notation 7628A 490 LíEnfant Plaza, S.W.

Adopted March 8, 2005 Washington, D.C. 20594
National Transportation Safety Board. 2005. Allision of Staten Island Ferry Andrew J. Barberi,

St. George, Staten Island, New York, October 15, 2003. Marine Accident Report NTSB/MAR-05/01.

Washington, DC.

Abstract: This report discusses the allision of the passenger ferry Andrew J. Barberi with maintenance

pier B-1 at the Staten Island ferry terminal on October 15, 2003. The ferry carried an estimated 1,500

passengers and 15 crewmembers. Ten passengers died in the accident and 70 were injured. An eleventh

seriously injured passenger died 2 months later. Damages totaled more than $8 million, with repair costs of

$6.9 million for the Andrew J. Barberi and $1.4 million for the pier.

From its investigation of the accident, the Safety Board identified the following safety issues: actions of

the assistant captain and captain, oversight of ferry operations by the New York City Department of

Transportation, medical oversight of mariners, safety management systems, and the potential contribution

of navigation technology to the safety of ferry operations.

On the basis of its findings, the Safety Board made recommendations to the New York City Department of

Transportation, the U.S. Coast Guard, the States that operate public ferries, and the Passenger Vessel

Association.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2005-916401 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Marine Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Regulatory Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Assistant Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Construction and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Propulsion System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Certification and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Operations of New York City Department of Transportation . . . . . . . . . . . . . . . . . . . . . . . 24

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Passenger Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Crewís Emergency Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Shoreside Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Emergency Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Emergency Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Communication System Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Propulsion System Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Staten Island Ferry Rules and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Coast Guard Oversight of Staten Island Ferries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Medical Oversight of Mariners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Safety Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Other Ferry Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Passenger Vessel Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Actions Since Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Assistant Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Contents iv Marine Accident Report

Medical Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

New York City Department of Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Safety Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Response to Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

On Board Andrew J. Barberi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Shoreside . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Navigation Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

B: Standard Operating Procedures, Staten Island Ferry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

C: Memorandum of Understanding Between New York City Department 

of Transportation and U.S. Coast Guard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

D: Contents Pages from Safety Management System Manuals, 

Washington State Ferries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

E: Example Procedures from Safety Management System, 

British Columbia Ferries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

F: Assessment of Staten Island Ferries by Global Maritime and

Transportation School, U.S. Merchant Marine Academy . . . . . . . . . . . . . . . . . . . . . . 126
v Marine Accident Report

Acronyms and Abbreviations

AIS automatic identification system

APTA American Public Transportation Association

ARPA automatic radar plotting aid

CFR Code of Federal Regulations

COI certificate of inspection

CPR cardiopulmonary resuscitation

EMS emergency medical services

EMT emergency medical technician

FDNY New York City Fire Department 

GMATS Global Maritime and Transportation School

GPS global positioning system

ICAO International Civil Aviation Organization

IMO International Maritime Organization

ISM International Safety Management [code]

MOU memorandum of understanding

NVIC Navigation and Vessel Inspection Circular

NYC DOT New York City Department of Transportation

NYPD New York City Police Department

OCMI Officer in Charge, Marine Inspection

PCP phencyclidine

PDR Physiciansí Desk Reference

PVA Passenger Vessel Association

REC regional examination center

SOLAS International Convention for Safety of Life at Sea

STCW International Convention on Standards of Training, Certification 

and Watchkeeping

TIA transient ischemic attack

U.S.C. United States Code

VTS Vessel Traffic Service
vi Marine Accident Report

Executive Summary

About 1520 on October 15, 2003, the Staten Island Ferry Andrew J. Barberi,

owned and operated by the New York City Department of Transportation, was near the

end of a regularly scheduled trip from Manhattan to Staten Island when it allided with a

maintenance pier at the Staten Island Ferry terminal. Fifteen crewmembers and an

estimated 1,500 passengers were on board. Ten passengers died in the accident and 70

were injured. An eleventh passenger died 2 months later as a result of injuries sustained in

the accident.

Hundreds of emergency personnel and dozens of emergency vehicles, including

several vessels, responded to the accident, dispatched by the New York City Police

Department, the New York City Fire Department (including emergency medical services),

the U.S. Coast Guard, and the U.S. Army Corps of Engineers. Damages totaled more than

$8 million, with repair costs of $6.9 million for the Andrew J. Barberi and $1.4 million for

the pier.

The National Transportation Safety Board determines that the probable cause of

this accident was the assistant captainís unexplained incapacitation and the failure of the

New York City Department of Transportation to implement and oversee safe, effective

operating procedures for its ferries. Contributing to the cause of the accident was the

failure of the captain to exercise his command responsibility over the vessel by ensuring

the safety of its operations.

The Safety Boardís investigation of this accident identified safety issues in the

following areas:

ï Actions of assistant captain and captain.

ï New York City Department of Transportation oversight of ferry operations.

ï Medical oversight of mariners.

ï Safety management systems.

ï Potential contribution of navigation technology to the safety of ferry

operations.

As a result of its investigation, the Safety Board makes recommendations to the

New York City Department of Transportation, the U.S. Coast Guard, the States that

operate public ferries, and the Passenger Vessel Association.
1 Marine Accident Report

Factual Information

Accident Narrative

About 1500 on October 15, 2003, the Staten Island Ferry Andrew J. Barberi

(figure 1) departed Whitehall, at the south tip of Manhattan, on a regularly scheduled,

approximately 22-minute trip to St. George, Staten Island (figure 2). The Andrew J.

Barberi was a large passenger vessel owned and operated by the New York City

Department of Transportation (NYC DOT) and certificated by the U.S. Coast Guard. The

ferry had a maximum capacity of 6,000 passengers but carried a smaller load, estimated at

1,500 people, on the accident trip.1 The vessel was under the command of a captain and

was staffed with an assistant captain, two mates, a chief engineer, an assistant engineer,

two oilers, and seven deckhands. A ladiesí room attendant and two New York City Police

Department (NYPD) uniformed officers were also on duty but were not part of the crew.

1 After the Staten Island Ferry stopped charging passengers in 1997 (see ìAdditional Informationî

section), the number of people riding the ferry was determined by rough estimation. The method, according

to a police officer assigned to the ferry, was to watch the passengers boarding the vessel and observe the

extent to which they filled the accommodation areas. The officer told investigators that ferries later in the

afternoon (4 oíclock and after) might reach the maximum load. 

Figure 1. Andrew J. Barberi in New York Harbor after passing Statue of Liberty en route to 

St. George terminal. The ferryís symmetrical design allows it to approach and leave its 

berth without turning around. The end that docks in Manhattan is known as the New York 

end, and the end that docks in Staten Island is called the Staten Island end. The sides of 

the ferry are referred to as the Brooklyn side and the New Jersey side. The starboard side 

on the trip to Manhattan is the Brooklyn side, while on the trip to Staten Island, the New 

Jersey side is starboard.
Factual Information 2 Marine Accident Report

En route to St. George, the assistant captain was operating the controls in the

pilothouse on the Staten Island end of the ferry. The navigation watch also included a

deckhand who served as lookout. The lookout told Safety Board investigators that he sat

on a stool next to the assistant captain and that they engaged in casual conversation. ìHe

told me some tugboat stories,î said the lookout. ìWe were just having a regular

Figure 2. Route of Andrew J. Barberi in New York Harbor from Manhattan to accident site 

at Staten Island.

ANCHORAGE CHANNEL

Governors

Island

Ellis Island

Statue of

Liberty

STATEN ISLAND

MANHATTAN

BROOKLYN

Hudson River

NEW JERSEY

UPPER BAY

Battery East River

St. George ACCIDENT

SITE

KV Buoy

The Narrows

Whitehall

Newark

Bay

Elizabethport

Kill Van Kull

Ft. Wadsworth Verrazano

Narrows

Bridge

N

Jersey Flats

Bay Ridge Flats
Factual Information 3 Marine Accident Report

conversation.î Crewmembers estimated that the assistant captain was operating the vessel

at the routine speed of 14 to 16 knots.2

About halfway into the trip, the senior mate entered the pilothouse. His station

while passengers disembarked and embarked was on the main deck at the docking end.

His other responsibilities included monitoring the deckhands on the main deck and on one

side of the saloon deck and securing the New York end when the ferry docked in

Manhattan.3 The senior mate first told Safety Board investigators that he went into the

pilothouse to complete work orders for repairing broken doors on the saloon deck. In a

later interview, the senior mate said that he was reading a newspaper while he was in the

pilothouse. He said that he sat on a settee (padded bench) behind the controls, aft of both

the assistant captain and the lookout. The senior mate further stated that he could not see

out the pilothouse window, meaning that he could not observe the course of the vessel and

its approach toward the Staten Island piers.4

According to witnesses, the trip was uneventful until the vessel passed the buoy at

the entrance to the Kill van Kull waterway (the KV buoy), about 1,000 yards from the St.

George terminal (and about 2 minutes away at a speed of 15 knots). The lookout told

investigators that ìsomebodyî had entered the pilothouse and was reading a newspaper on

the bench behind the control platform. He said that when the ferry passed the KV buoy, he

asked permission of the assistant captain to leave the pilothouse. He told investigators that

his intent was to go down to the saloon deck and untie the handles of the broken exit

doors5 in preparation for docking. He said that the assistant captain replied, ìOkay, see you

later.î The senior mate told investigators that he heard the lookout ask permission to go

below and that he also heard the assistant captain agree to the lookoutís request.

According to crewmembers, shortly after the ferry passed the KV buoy, the

standard procedure was for the bridge deckhand on duty to go to the pilothouse on the

docking end of the ferry and make an arrival announcement. Those interviewed stated that

some lookouts always waited to leave the pilothouse until the bridge deckhand arrived;

however, practices varied.6

 On the day of the accident, the lookout left the Staten Island2 The ferryís navigation equipment did not include any means to measure its speed through the water.

See ìVessel Informationî section for details.

3 Duty stations and responsibilities of the ferryís crewmembers are detailed in the ìSurvival Factorsî

section.

4 The settee was lower than the navigation area, which was on a raised platform 4 inches above the

pilothouse floor.

5 The senior mate told investigators that on the day of the accident, the doors on the second, or saloon,

deck on the Staten Island end, New Jersey side, were broken and could not be latched. The senior mate told

investigators that a deckhand had reported the broken doors the day before. Because the wind gusts

exceeded 30 knots, the doors swung freely. The senior mate said that he gave a piece of line to the second

lookout on that shift and instructed him to lash the door handles together to prevent inadvertent passenger

injury from a swinging door. The doors were to be untied before arrival in Staten Island to allow passengers

to disembark and embark.

6 For example, one deckhand told investigators that he made his arrival announcement from the

nonoperating pilothouse.
Factual Information 4 Marine Accident Report

end pilothouse before the bridge deckhand arrived. The lookout told investigators that

when he left, the assistant captain, who had been sitting at the controls, stood up.

Crewmembers indicated that the KV buoy was also the point where the ferry

operators typically began slowing the vessels and applying small course corrections in

preparation for docking. Deckhands and passengers told investigators that normally,

though not on the accident voyage, they could hear when the engines ìbacked downî

(slowed) and that the sound change would inform them that they were ready to dock.

Another Staten Island Ferry captain said that the sound change ordinarily triggered a

ìchain reaction that people start walking forward . . . . They could be half asleep, as soon

as they hear the throttle [slowing], they get up and get moving forward.î

The senior mate told investigators that after the lookout left the pilothouse, he did

not hear the assistant captain say anything. He recalled that the assistant captain was

standing at the controls: ìHe basically never sat down. He would always gear the boat

standing up.î The senior mate told investigators that it ìdid not surpriseî him that the

captain was not present in the pilothouse and did not come to supervise the docking. The

senior mate said that he was still sitting on the settee when he heard a sound and felt a

ìheavy vibrationî as if the vessel had struck an object in the water: ìNothing seemed out

of the ordinary and bang.î He said that he looked up, heard the assistant captain exclaim,

ìJesus,î looked out the window, and saw the ferry alliding with the concrete maintenance

pier (pier B-1) south of the intended docking point. 

The chief engineer, who was in the engineroom, said that he saw from the console

speed and pitch indicators that both the main engine speeds and the pitch of the propulsion

drives were still at full ahead at the time of the allision.7

 In the pilothouse immediately

after the allision, the senior mate saw the assistant captain pull the throttle back to full pitch

astern with his right hand and use his left hand to steer the ferry away from another vessel

moored nearby. The mate said that the ferry stopped at a 45o angle between the moored

vessel and two piers about 600 yards southeast of the intended docking point, slip 5. 

The director of ferry operations told investigators that he was in the St. George

port captainís office when a ferry employee alerted them that the Andrew J. Barberi was

not turning toward slip 5. He said that the port captain ran to the radio and tried to contact

the vessel.8

 He himself ran toward the pier but arrived after the allision. Emergency call

records indicate that the allision occurred about 1520.

A crewmember of the tugboat Dorothy J, which was docked at the maintenance

pier, told investigators that immediately after the allision, he saw ìa person in an officerís

uniformî walk across the top deck and enter the pilothouse on the Staten Island end.

According to the senior mate of the Andrew J. Barberi, the captain entered the pilothouse

ìvery shortly after impact,î immediately moved the assistant captain away from the

controls, and took control of the vessel. The captain maneuvered the vessel away from the

7 See ìVessel Informationî section for a description of the ferryís propulsion system.

8 The ferry was equipped with two ship-to-ship and ship-to-shore VHF radios (see ìVessel

Informationî section).
Factual Information 5 Marine Accident Report

pier and sent the mate below to assess the damage and the extent of injuries. The assistant

captain then left the pilothouse. 

As shown on a videotape from a Coast Guard Vessel Traffic Service (VTS)9

camera on Governors Island (3 miles from the accident site), the ferry drifted several

hundred yards into the harbor southeast of the terminal. The director of ferry operations

said that he instructed the port captain to have the ferry ìget back to St. George [and] turn

around.î The video recording (which started about 10 minutes after the accident) shows

the ferry drifting a few minutes, then moving back toward the terminal and turning around

(so it could dock by the undamaged New York end). 

While the ferry was drifting, the chief engineer told investigators that he tried to

call both pilothouses from the engineroomís sound-powered phone to discover what had

happened, but no one answered.10 After he sent the assistant engineer and the oilers to

survey the damage, he heard the sound-powered phone ring and determined by its

distinctive sound that it came from one of the pilothouses. No one answered when he

picked up the receiver. Leaving the assistant engineer to monitor the propulsion plant, the

chief engineer went to the pilothouse to find the captain.

The chief engineer said that when he entered the pilothouse, the captain

immediately asked him to help transfer propulsion control to the New York-end pilothouse

because the captain ìcouldnít land the boat [at the] Staten Island end, it was destroyedî

and two people were needed to transfer control.11 The chief engineer recalled the captain

saying, ì[The assistant captain] has lost it, he couldnít focusóhe was pacing in a daze.î

The captain then left the pilothouse and entered the New York-end pilothouse to accept the

transfer of propulsion control from the chief engineer at the other end. After the transfer

was complete, the chief engineer saw the assistant captain outside the Staten Island-end

pilothouse and asked him what happened. According to the chief engineer, the assistant

captain said, ìI passed out.î

None of the crewmembers or passengers recalled hearing any warning

announcements, alarms, or other alerts before the accident. Passengers who could see the

impending allision estimated that they had seconds to move away or brace themselves for

the allision. Other passengers took no action to lessen the effects of the accident, such as

those who had no view of the pier or who were facing the opposite direction. Some

passengers with cell phones called 911 to report the accident. 

9 For further information on the VTS, see ìWaterway Informationî section.

10 A sound-powered phone has no external power supply. To make a call, the user selects the number of

the destination station (each has its own line) and cranks a handle to ring a bell at that station.

11 According to ferry officials, captains typically controlled the ferry on the trips from Staten Island to

Manhattan, and the assistant captains were at the controls on the returns to Staten Island. The operator who

had controlled the vessel into the dock (the captain or assistant captain) would maintain propulsion control

in the arriving pilothouse while passengers disembarked and embarked. Just before departure, that operator

would transfer vessel propulsion to the operator in the departing pilothouse. For additional information on

the ferryís propulsion system, see ìVessel Informationî section.
Factual Information 6 Marine Accident Report

A Coast Guard enlisted man, who was a regular ferry passenger, used his cell

phone to contact the Coast Guardís New York command center at Ft. Wadsworth, Staten

Island. Coast Guard records indicate that the command center logged the call at 1525. He

reported that many passengers had been injured and would need medical help. An off-duty

lieutenant with the New York City Fire Department (FDNY) called his dispatcher in

Staten Island, described the accident, and advised sending multiple units and perhaps a

boat in response. He described the scene after the allision as chaos, with people

ìscreaming and yelling.î Passengers reported hearing no emergency instructions from

ferry crewmembers after the allision. Crewmembers told investigators that they helped the

wounded as much as they could, moved debris, and tried to keep uninjured passengers

away from the vesselís damaged areas. (For details of the crewís actions in the emergency,

see the ìSurvival Factorsî section.)

Emergency response records indicate that the ferry reached slip 5 at St. George at

1543, about 20 minutes after the allision. When the ferry docked, personnel from the

FDNY, the NYPD, emergency medical services (EMS), and the Coast Guard immediately

entered the vessel to help the injured. The director of ferry operations, who entered with

the first responders, told investigators that he met the assistant captain on the saloon deck

and that the assistant captain told him, ìIím sorry. I blacked out. Itís all my fault. I killed

these people.î The assistant captain then pulled away and ran to the dock. After sending

two NYC DOT employees after the assistant captain, the director of ferry operations

entered the pilothouse. There, the captain told him that the assistant captain had slumped

over the controls and that he had grabbed the assistant captain off and taken control of the

vessel. However, by that time the allision had occurred.

Injuries

Ten passengers were killed and 70 passengers were injured as a result of the

accident (table 1). One of the injured passengers died 2 months after the accident as a

result of injuries received in the allision. (According to the provisions of Title 49 Code of

Federal Regulations [CFR] part 830, section 2, that passenger was considered seriously

injured.12) Injuries are categorized according to the criteria of the International Civil

Aviation Organization (ICAO). For uniformity, the Safety Board uses the ICAO injury

criteria in all its accident reports, regardless of transportation mode.

12 Title 49 CFR 830.2 defines a fatal injury as any injury that results in death within 30 days of the

accident. It defines serious injury as that which requires hospitalization for more than 48 hours, commencing

within 7 days from the date the injury was received; results in a fracture of any bone (except simple fractures

of fingers, toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon damage; involves any

internal organ; or involves second- or third-degree burns, or any burns affecting more than 5 percent of the

body surface.
Factual Information 7 Marine Accident Report

Table 1. Injuries sustained in Andrew J. Barberi accident.

Damages

The Andrew J. Barberi struck the concrete maintenance pier at an oblique angle

and continued to move forward, allowing the concrete to tear a 210-foot-long gash into the

main deck on the vesselís New Jersey side (figure 3). The vessel was repaired by a Staten

Island company at the Brooklyn Navy Yard at a cost of $6.9 million. The ferry returned to

service in July 2004. 

Injuries Crew Passengers Other Total

Fatal 0 10 0 10

Serious 0 19a 0 19

Minor 0 57 0 57

None 16 1,414 4b 1,434

Total 16c 1,500d 4 1,520

a One seriously injured passenger died on December 16, 2003. 

b

 Includes 2 NYPD officers assigned to the ferry and 2 people working at the concession stand on the bridge deck. 

c Includes 15 crewmembers and 1 restroom attendant.

d Passenger total estimated by the NYC DOT and NYPD.

Figure 3. Postaccident view of Andrew J. Barberi.
Factual Information 8 Marine Accident Report

Approximately 1,500 square feet of the surface of pier B-1 collapsed into the

harbor after the Andrew J. Barberi struck its southeast corner (figure 4). The pier was

repaired at a cost of $1.4 million. 

Personnel Information

Regulatory Requirements

Under 46 CFR parts 70-80, large passenger vessels (those measuring 100 gross

tons or more13) that carry more than 12 passengers for hire14 may not be operated without a

valid Coast Guard certificate of inspection (COI), which is issued by the Coast Guard

Officer in Charge, Marine Inspection (OCMI), for the zone (in this case, New York). The

COI stipulates a number of operating requirements, including minimum staffing needs.

When determining the number and competencies of the crewmembers, the OCMI

considers, among other things, the size of the vessel, its route, the type and horsepower of

Figure 4. View of damage to maintenance pier caused by Andrew J. Barberi.

13 Gross tonnage is a measure of vessel volume, or overall size. 

14 As defined in Title 46 United States Code (U.S.C.) section 2101(21)(21a), passenger for hire means

ìa passenger for whom consideration is contributed as a condition of carriage on the vessel, whether directly

or indirectly flowing to the owner, charterer, operator, agent, or any other person having an interest in the

vessel.î After the Staten Island Ferry stopped charging passenger fares in 1997, questions arose about the

applicability of Federal regulations regarding required Coast Guard inspections. See ìAdditional

Informationî section for further discussion. 
Factual Information 9 Marine Accident Report

the vesselís propulsion machinery, the number of passengers the vessel will carry, the type

and location of lifesaving equipment installed on the vessel, and the hazards peculiar to

the route and service.

According to its COI, the Andrew J. Barberi was required to carry the following

crew complement:

1 master with first-class pilot endorsement

1 first-class pilot

2 licensed mates 

7 deckhands

1 chief engineer

1 licensed assistant engineer

2 oilers

The COI states that ìthe required mate positions may be filled by holders of valid

licenses endorsed for ënon-navigating duties onboard the Staten Island ferries.íî

Both the captain and the assistant captain were licensed as masters and first-class

pilots (the COI required only one licensed master). The senior mate was licensed as a chief

mate on oceans, which meant that he had passed more Coast Guard examinations than

required for mates on inland waters such as New York Harbor. The junior mate held a

first-class pilotís license for Lake Erie (but not for New York Harbor). 

Captain

Background. The captain, age 38, was born in Staten Island, New York, and

graduated from high school in Staten Island in 1984. After graduating, he joined the Navy

and was assigned to the submarine fleet. He was honorably discharged in 1988 at the rank

of quartermaster second class, or E5. He received several decorations and commendations

for performance, including a Meritorious Unit Commendation and letter of commendation

from the Commander in Chief, Atlantic Fleet.

In October 1990, he became a deckhand with the Staten Island Ferry, a position he

held until January 1996, when he was promoted to mate. In February 1996, he was

promoted to the provisional position of assistant captain.15 He was promoted to the

permanent position of assistant captain in February 2002.

At the time of the accident, the captain held an inland Coast Guard license issued

on December 31, 2001, and valid until December 31, 2006. The terms of the license were

as follows:

15 New York City personnel rules allowed employees to serve on the ferry in a position for which they

were qualified and to earn the pay of someone in that position, but they could not be permanently assigned to

those positions until a vacancy was posted, until they met the pertinent NYC civil service requirements for

those positions, and until they then had been selected to fill those vacancies in accordance with NYC civil

service requirements. Thus, employees often served for years in positions that were at higher levels than

those to which they had been ìpermanentlyî assigned.
Factual Information 10 Marine Accident Report

Master of steam or motor vessels upon inland waters of any gross tons. First class

pilot of vessels of any gross tons upon NY Harbor the Upper Bay, from the

Narrows to the Battery; the East River, from the Battery to the Execution Rocks;

the Kill van Kull, from Robbins Reef to Elizabethport; the Hudson River from the

Battery to the George Washington Bridge. Radar observer.

Coast Guard regulations require a captain to hold a valid endorsement as a radar

observer.16 The captainís radar endorsement expired in March 2002, but the Coast Guard,

under 46 CFR 10.480(k), allowed marinersí radar endorsements to extend for up to 2

years beyond their expiration dates so that the renewal dates for licenses and

endorsements could be synchronized.17

NYC DOT personnel records of the captain contained a total of nine performance

appraisals between 1991 and 1998, the most recent appraisal form found in the records.

The captainís performance in the 1991 appraisal was rated as ìvery good,î which was

second to the highest on a 5-point scale that ranged from ìunsatisfactoryî to

ìoutstanding.î His performance in all subsequent appraisals was uniformly rated as

ìoutstanding.î 

No letters of reprimand were found in the captainís personnel records. On August

2, 1991, he received a letter of commendations for the ìprompt action and professional

mannerî in which he helped rescue a passenger who had jumped overboard in New Yorkís

Upper Bay.

The Safety Board repeatedly attempted to interview the captain after the accident.

The Board issued a subpoena to compel him to appear before its investigators, and Federal

judicial authorities enforced the subpoena. He appeared before investigators on November

6, 2003, but he invoked his Fifth Amendment rights against self-incrimination and did not

respond to questions except to give his name and date of birth.

Schedule. In the month before the accident, the captain worked on a shift that

typically began at 1330 and ended at 2130, although the actual start and stop times were an

hour earlier on several days. In keeping with NYC DOT practice, the captain and assistant

captain both worked 4 days and then had 3 days off. The captain was off work on October

11, 12, and 13. He reported for duty on the Andrew J. Barberi on October 14 at 1307 and

worked until 2300, earning an hour and a half of overtime for working past 2130, the end

of the scheduled shift. He reported for work on the day of the accident at 1245, although

the shift did not begin until 1330. The Safety Board was unable to learn more from the

captain about his activities in the days before the accident because of his unwillingness to

cooperate with the investigation.

16 Title 46 CFR 15.815(b): ìEach person who is employed or serves as pilot in accordance with Federal

law on board vessels of 300 gross tons or over which are radar equipped, shall hold a valid endorsement as

radar observer.î

17 Title 46 CFR 10.480(k): ìThe renewal date of a Radar-Observer endorsement may be extended

beyond the normal 5-year duration to coincide with the renewal date of the license to which it pertains. This

extension may not exceed 2 years and will be necessary only once, to synchronize the two renewal dates.î 
Factual Information 11 Marine Accident Report

Assistant Captain

Background. The assistant captain, age 55, was born in Brooklyn, New York.

From 1968 until 1970, he was on active duty in the Army, with a specialty in radar

operations. In 1976, he briefly worked for Murphy Pacific Marine Salvage Company as a

deckhand. From 1976 until late 1985, he worked as a deckhand and tankerman for Poling

Transportation Corporation of Staten Island, New York, a tugboat and barge operator.

There he received training in vessel navigation in New York Harbor. According to the

assistant captainís rÈsumÈ, on file with the NYC DOT, he operated ìon the waters of the

Atlantic Ocean from Maine to Virginia up to 200 miles offshore, including the entrance to

New York Harborî while employed at Poling.

He began his employment with the Staten Island Ferry on September 16, 1985, as a

deckhand. He was promoted to assistant captain on May 11, 1987. NYC DOT personnel

records indicate that on March 24, 1986, he completed instruction in radar use and

interpretation at Marine Simulation, Inc. On February 9, 1996, he completed ìRadar

Observer Recertification-Any Watersî at the Center for Maritime Education, Seamenís

Church Institute of New York and New Jersey.

The assistant captain was promoted to the provisional position of assistant captain

on May 11, 1987, to the provisional position of captain on July 21, 1996, and to the

permanent position of assistant captain on February 2, 2002, the position he held at the

time of the accident. According to the director of administration for the Staten Island

Ferry, the assistant captain acted to gain a higher seniority, which would protect him

against the layoffs the NYC DOT was planning in spring 2003 because of anticipated

budgetary shortfalls. 

The assistant captain held an inland Coast Guard license issued on September 14,

2000, which was valid until September 14, 2005. The terms of the license were as follows:

Master of steam or motor vessels of any registered tons (domestic) upon inland

waters. First class pilot of vessels of any gross tons upon: New York Harbor

Upper Bay, from the Narrows to the Battery; Hudson River from the Battery to the

George Washington Bridge; the East River from the Battery to Hart Island; Kill

van Kull from Robbins Reef to Elizabeth Port. 

The assistant captainís radar endorsement expired in February 2001.18

NYC DOT personnel records for the assistant captain contained 13 performance

appraisals between 1987 and 2001. His performance in the first two appraisals (1987 and

1988) was rated as ìsuperiorî (second to highest) on the NYC DOTís 5-point performance

scale. His performance was uniformly rated in all subsequent appraisals as ìoutstanding.î 

The assistant captainís personnel records contained no letters of reprimand or other

negative assessments. The records contained two letters of commendation, dated March 9,

1990, and April 28, 1995. The first concerned his performance as the assistant captain on

18 See previous note.
Factual Information 12 Marine Accident Report

the Andrew J. Barberi when it experienced a propulsion control failure while docking in

Manhattan, when his actions helped minimize potential injury to passengers and crew and

damage to the vessel. The second letter noted his ìoutstanding leadership and dedication

to dutyî as the captain of the Andrew J. Barberi when it experienced a mechanical failure

while docking in Staten Island. 

Schedule. The assistant captain could not be interviewed in the immediate weeks

after the accident because he had been hospitalized after a suicide attempt (see below).

Nonetheless, his wife and daughter cooperated with Safety Board investigators and

provided information about his activities in the days preceding the accident.19 After the

assistant captain had recuperated, Safety Board investigators tried repeatedly to interview

him. His attorney informed the Board, however, that the assistant captain would invoke

his Fifth Amendment rights against self-incrimination and would not respond to questions

from the Board.

According to his personnel records, the assistant captain worked the same shift

continuously for at least 2 months before the accident, a 1330 to 2130 shift that began on a

Tuesday and ended on a Friday. However, he almost always worked an additional 30

minutes to 2 hours, beyond 2130, in overtime during that period. On October 7 and 8 he

worked until 2230. On October 9 he worked until 2330, and on October 10 he worked

until 2200. He was off work on October 11, 12, and 13. On October 14, he worked on the

Andrew J. Barberi until 2300. He reported for work on the day of the accident at 1315.

According to his wife, 2 days before the accident, on October 13, the assistant

captain awoke at 0730. On the day before the accident, October 14, he was asleep when

his wife left the house at 0815. The night before the accident, October 14, he went to sleep

between 0115 and 0130. On the day of the accident, he was asleep when his wife left the

house about 0815 and arose sometime thereafter. She returned home for lunch about 1220

and found him working around the house. She told investigators that he seemed fine when

she left the house before 1300. 

Actions After Accident. After the allision, the assistant captain telephoned his

wife at her workplace to inform her of the accident. According to other witnesses, the

assistant captain drove home, saw his daughter and grandson, went into a bathroom on the

second level of his house, and refused to leave despite his daughterís entreaties. Shortly

after 1600, the assistant captainís wife arrived home. She also could not persuade him to

unlock the door. The two NYC DOT employees who had been sent by the director of ferry

operations arrived about 1630, forced open the locked door, and found the assistant

captain bleeding from lacerations to his wrist and from a gunshot wound to his chest. They

saw a pellet gun nearby.

The NYC DOT employees immediately called 911 and requested medical

assistance. An ambulance arrived about 1640 and the assistant captain was transported to a

nearby hospital, where he was admitted at 1703. His injuries were considered life

19 On advice from her legal representative, the assistant captainís wife did not provide Safety Board

investigators with information about statements that her husband made to her.
Factual Information 13 Marine Accident Report

threatening and he was sent to the operating room, where he underwent emergency

surgery to repair the effects of the gunshot wound and wrist lacerations. On November 13,

2003, following recuperation from the surgery and after psychiatric treatment in response

to his suicide attempt, the assistant captain was discharged from the hospital.

Medical Status. To determine the assistant captainís medical status at the time of

the accident, the Safety Board obtained records of his medical care before the accident, as

well as dental, employer, and pharmacy records. The Safety Board also obtained records

from the hospital that treated the assistant captain after his suicide attempt. 

The Safety Board obtained a record of prescriptions for the assistant captain at a

Staten Island branch of a national chain of pharmacies.20 According to the pharmacy

records, the assistant captainís primary physician prescribed most of the medications.

Many of the prescriptions, however, were not listed in the primary physicianís medical

records that corresponded to the prescription dates. Further, except for the assistant

captainís dental treatment and a few instances when he got a ìdisability certificateî for

work, the medical records contain no references to limitations on his work because of

medical conditions or treatment. The records of his primary physician included

information on the assistant captainís occupation. No evidence of the assistant captainís

use of prescribed medications was found in the records of either the NYC DOT or the

Coast Guard, nor was documentation of the use of medications required by either agency.

According to medical and pharmacy records, at the time of the accident the

assistant captain had been diagnosed with and continuously prescribed medications for

multiple medical conditions, including high blood pressure, high cholesterol, insomnia,

and chronic back pain. In particular, his physician had prescribed 10 milligrams of

zolpidem (a prescription sedative marketed under the trade name AmbienÆ), to be taken at

bedtime for insomnia,21 and 50 milligrams of tramadol (a prescription narcotic-like

analgesic marketed under the trade name UltramÆ), to be taken every 4 to 6 hours for back

pain. According to the Physiciansí Desk Reference (PDR),22 the drug manufacturers

specify that the total daily dose of zolpidem should not exceed 10 milligrams and that the

total daily dose of tramadol should not exceed 400 milligrams. Common side effects of

20 The Safety Board is confident that it has a complete record of the assistant captainís prescriptions,

because prescriptions at all the chainís branches were examined, the chain had numerous branches in Staten

Island, and few pharmacies not associated with the chain were in the area. All the medical and dental

practitioners were located on Staten Island. Although it is possible that the assistant captain had been treated

by physicians outside Staten Island, several factors suggest that this was unlikely: the comprehensiveness of

the records, both in the diagnoses and treatments described; the length of time he had been treated; the

interrelationships between the physicians noted in the records; and the statements of his spouse.

21 The assistant captainís wife indicated that he would often take half a tablet, or 5 milligrams, at

bedtime.

22 A reference manual for physicians published yearly by Medical Economics Company, Atlanta,

Georgia. The drug manufacturers whose products are listed in the reference prepare the information.
Factual Information 14 Marine Accident Report

tramadol include dizziness and sleepiness,23 and seizures have been reported in patients

both after receiving their first tramadol prescription and after using the drug over time.24

The assistant captain had been taking both zolpidem and tramadol regularly since

2000. He had been prescribed medication for high blood pressure since at least 1989.

Since at least 1998, he also had multiple prescriptions filled for different psychoactive

medications (medications that can alter mood, anxiety, behavior, and cognitive processes)

for dental work. NYC DOT attendance records indicate that the assistant captain was on

sick leave on the days he received dental treatment that involved psychoactive medication

and was off work afterward on regularly scheduled days. 

The assistant captain underwent cardiovascular surgery and cardiological,

neurological, and psychiatric examination and treatment while hospitalized after the

accident. Among the tests administered to him were the following: carotid color duplex

Doppler examination, which can detect abnormalities in the carotid arteries in the neck;

echocardiography, which can detect abnormalities in the walls and valves of the heart; 24-

hour Holter monitoring, which can detect abnormal heart rhythms; computerized

tomography of the head, which can detect abnormalities in the brain; and cardiac

catherization, which can detect abnormalities in the coronary arteries (whose function is to

supply blood to the heart). The assistant captain was found to have significant narrowing

of his coronary arteries (for which he underwent stent placement to open the arteries), but

he had no significant abnormal heart rhythms on 24-hour monitoring. Echocardiography

noted an interatrial septal aneurysm (a bulging of the wall between the two upper

chambers of the heart) and patent foramen ovale (a persistence after birth of an opening in

the wall between the two upper chambers of the fetal heart). 

According to a note in the medical records, a week after the accident the assistant

captain told a cardiologist that ìhe was exhausted at the time [of the accident, but] no more

exhausted than usual.î The cardiologistís note states that ìwhen the boat hit the pier [the

assistant captain] was sitting in a chair.î The records of a neurology consultation state that

the assistant captain had ìno recollection of what happened on the boat . . . he suddenly

passed out, [and] when he regained consciousness there was chaos.î Further, he denied

ìany prior history of loss of consciousness.î The assistant captain was discharged from the

hospital with a diagnosis of and treatment for depression.

Coast Guard medical records of the assistant captain include the results of four

required medical evaluations. The partner of the assistant captainís primary physician in a

two-physician medical practice performed the evaluations on March 31, 1986, October 4,

1989, September 14, 1995, and August 14, 2000; the partner had occasionally treated the

assistant captain. The results, as noted on the completed examination forms (after the first

examination, this was the 1995 version of Coast Guard form 719K), included notations

23 T. Hummel and others, ìAssessment of Analgesia in Man: Tramadol Controlled Release Formula vs.

Tramadol Standard Formulation,î European Journal of Clinical Pharmacology, vol. 51 (1996), pp. 31-38.

24 J. S. Gardner and others, ìTramadol and Seizures: A Surveillance Study in a Managed Care

Population,î Pharmacotherapy, vol. 20, no. 12 (2000), pp. 1423-1431. Seizures were noted in 0.9 percent of

patients after they received their first tramadol prescription.
Factual Information 15 Marine Accident Report

corroborated by the examining physician and (as required for the last two examinations)

by the assistant captain with their signatures, that the assistant captain had not been taking

prescribed medications. For each examination, the physician noted that he considered the

assistant captain ìcompetentî to perform the duties of a merchant mariner.

For example, on Coast Guard form 719K, dated August 14, 2000, under the

question, ìDoes the applicant have or has he/she ever suffered from any of the following?î

ìnoî was written next to ìhigh blood pressure,î ìimpaired range of motion,î and ìother

illness or disability.î Under ìmedications taken,î the word ìnoneî was written, and the

box next to the indication ìno prescription medicationsî was checked. Under ìcomments

on findings,î the box next to ìno significant medical historyî was checked. In response to

the item, ìConsidering the findings in this examination, and noting the duties to be

performed by the applicant aboard a merchant vessel of the United States of America,î the

physician noted that he considered the applicant ìcompetent.î The applicantís signature

appears below the statement: ìI certify that all information provided by me is complete

and true to the best of my knowledge.î Making false or fraudulent statements to a Federal

agency such as the Coast Guard is a crime.25

In August 2004, the assistant captain pleaded guilty in U.S. District Court in

Brooklyn, New York, to Federal charges that he knowingly made a false report to the Coast

Guard on his medical evaluation form that he did not suffer from any illnesses and had not

taken any medications.26 He told the court that he ìjust didnít want the Coast Guard to

knowî because he was afraid that reporting his medications would jeopardize his job.

Vessel Information

Construction and Equipment

The Andrew J. Barberi was built by Equitable Shipyards of New Orleans and

delivered in 1981. Its overall length was 310 feet, its beam was 70 feet, it had a draft of 12

feet, 6 inches, and it displaced 2,721 long tons.27 Data from sea trials conducted by George

G. Sharp, Inc., of New York in 1981 showed that the vessel could come to a complete stop,

from full ahead, in about 420 feet and within about 43 seconds.28 Normal vessel speed at

25 The Coast Guard website <http://www.uscg.mil/STCW> states: ìTitle 18 U.S. Code (U.S.C.),

Section 1001 states that intentionally making false or fraudulent statements or representations in any matter

within the jurisdiction of any department or agency of the United States is a Federal crime punishable by not

more than five years in jail and/or a fine of up to $250,000 for individuals or $500,000 for organizations.

When signing the application and forms to apply for an MMD [merchant marinerís document], License,

Certificate of Registry, or STCW [International Convention on Standards of Training, Certification and

Watchkeeping] you acknowledge awareness of the meaning of the statute in 18 U.S.C. 1001. If there is

evidence that an application was submitted fraudulently, the application may be denied and the case will be

forwarded to the local U.S. Attorney for appropriate action.î

26 The physician who performed the assistant captainís medical evaluations was indicted in the same

jurisdiction on similar charges.

27 One long ton = 2,240 pounds.

28 George G. Sharp, Inc., ìTrial ReportóStaten Island Ferry-Andrew J. Barberi,î New York (1981), p. 94.
Factual Information 16 Marine Accident Report

full ahead was 16 knots. Postaccident testing indicated that the Andrew J. Barberi required

about 5 seconds, from either pilothouse, to generate 100 percent thrust from zero thrust

(see ìTests and Researchî section for further information). 

The Andrew J. Barberiís symmetrical structure, both above and below the

waterline, allowed it to perform equally well in both directions. Thus, the ferry could

approach and leave the dock without turning around. The vessel had four decks, from high

to low called the hurricane, bridge, saloon, and main decks (figure 5). Passengers were not

permitted on the hurricane deck, which held the two pilothouses. A concession stand was

situated on the bridge deck. Passengers embarked and disembarked on the main deck and

on a platform midway between the main and the saloon decks, referred to as the upper

embarkation level. Enclosed stairs led from the saloon deck to the upper embarkation

levels, and ramps led from the upper embarkation levels to the bridge deck. The ferry had

seating for 3,672 passengers;29 passengers in excess of that number had to stand. 

The hull was of steel, all-welded construction, transversely framed on 30-inch

centers and subdivided by watertight bulkheads. The hull was symmetrical about the

midships transverse section. Frame numbers ran in either direction from frame 0, located

midships, to frame 56 at either end of the vessel. Watertight bulkheads were located on

both ends at frames 12, 39/40, and 52. Partial watertight bulkheads, interrupted by the

shaft tunnels, were located at frames 20 and 31. The hull was generally single-bottomed,

with a 4-foot-high inner bottom at the shaft tunnels.

Figure 5. Profile of Andrew J. Barberi.

29 The main deck could seat 1,630 passengers, the saloon deck, 1,258, and the bridge deck, 784.

Pilothouse Pilothouse

Propeller Propeller

Hurricane deck

Bridge deck

Saloon deck

Main deck

Stack
Factual Information 17 Marine Accident Report

Navigation equipment in the pilothouse consisted of short-range (3 centimeter)

and long-range (10 centimeter) radar30 (equipped with an automatic radar plotting aid

[ARPA] that automatically provided information on other vesselsí course, speed, and

closest-point-of-approach), a gyrocompass, and a magnetic compass. The equipment did

not include any means of determining the ferryís speed (speed had to be estimated on the

basis of elapsed time over the 5.2-mile run) or projected path, water depth, or wind speed.

Two radar screens were located behind the operatorís chair, out of his or her field of view.

A repeater screen for the 3-centimeter radar was mounted above the navigation controls,

in full view of the operator (see below). 

Each pilothouse was also equipped with devices for communicating with both the

engineroom and the passengers. The devices included an engine-order telegraph for

quickly communicating commands to the engineers; a sound-powered telephone; and a

lever that rang a cowbell in the engineroom, to signal an emergency in which the

engineers should take over propulsion control. A microphone was on the console behind

the operator for making announcements over the public address system. Other

communication equipment included a general alarm that rang bells throughout the ship in

case of emergency, two VHF radios for ship-to-ship or ship-to-shore transmissions, and a

UHF radio for the crewís walkie-talkies.

Both mates had walkie-talkies, and according to the director of ferry operations,

each of the three passenger decks was supposed to have one. One of the deckhands told

investigators that he had a walkie-talkie and heard it ìcracklingî after the accident but

ignored it. Another deckhand said that he had a working walkie-talkie but that it would not

function in the engineroom.

Propulsion System 

Characteristics. Four General Motors 1,700-horsepower EMD 16-645E6 diesel

engines powered the vessel. The engines were coupled to a Voith-Schneider cycloidal

propeller at either end of the vessel that provided both propulsion and steering. The VoithSchneider cycloidal propeller had five titanium blades, each mounted on a vertical shaft

and attached to the outside of a large circular plate (figure 6). As the blades rotated, they

applied force to the water and pushed the ferry in the desired direction. An automatic

control system maintained the speed of the main engines at about 750 rpm while the vessel

was under way. 

The vessel operator was positioned in the center of the pilothouse, with two

steering directional handwheels on the left and two forward/aft thrust levers (one for each

endís propulsion drive) on the right (figure 7). By using a combination of the levers for

ahead/astern thrust and the handwheels for port and starboard motion, the operator could

quickly and precisely maneuver the vessel in any direction. The operator controlled the

engine speed using levers farther to the left, at the forward end of the console.

30 The designation in centimeters refers to the wavelength of the transmission signal the radar emits.

The signal reflects off a target and thereby detects it. In general, the shorter-wavelength radar is more

suitable for close-in navigation, while the longer-wavelength radar is used for distant targets.
Factual Information 18 Marine Accident Report

Both forward and aft propulsion systems could be controlled from either

pilothouse or from the engineroom. Two operators were needed to transfer control from

one pilothouse to the other. The operator in the controlling pilothouse activated a ìsendî

button on the console. The operator in the other pilothouse then pushed an ìacceptî button

to receive and take control. The engineer could single-handedly take control over either

propulsion system from the engineroom.

Operating Condition At Time of Accident. During the week before the allision,

the Andrew J. Barberiís crew tested the vesselís engines and propulsion units. All were

found to be satisfactory, with no faults in either the machinery or the alarm circuits. The

engineering logbook contained no entries that suggested engineroom problems either

before or during the accident. The ferryís chief engineer told investigators that the

propulsion plant and associated machinery were in satisfactory operating condition the

day of the accident, and that the chief engineer on the previous watch told him that he had

experienced no problems in the engineering spaces. The assistant engineer on watch

during the accident stated that the vesselís two propulsion systems and engineroom

machinery performed as expected and that he had a ìvery normal watchî before the

accident. After the accident, an NYC DOT port engineer boarded the vessel and observed

that the propulsion units were operating normally and that they held the ferry against the

Figure 6. One of Andrew J. Barberiís two Voith-Schneider cycloidal propellers.
Factual Information 19 Marine Accident Report

dock for an hour or more. (The ferries were not tied to the docks during loading and

unloading, but rather were hooked into recessed cleats31 on the dock and held in position

by the propulsion units.)

Certification and Inspection

The Andrew J. Barberi was certificated as a large passenger vessel by the U.S.

Coast Guard and was inspected by the Coast Guard under a memorandum of

understanding (MOU) with the NYC DOT (see ìAdditional Informationî section for

details). The American Bureau of Shipping issued classification documents to the vessel

on November 29, 1996, and May 14, 2002. The Coast Guard issued a certificate of

documentation on September 11, 2003.

The Coast Guard conducted its last annual inspection of the Andrew J. Barberi

before the accident on January 15, 2003, and issued a COI. The Coast Guard also

31 Fasteners, usually with two projecting horns, around which a line (rope) can be secured.

Figure 7. Pilothouse controls on ferryís Staten Island end. Thrust levers are on right of 

operatorís chair, handwheels on left. Behind operatorís chair (outside his field of view) is 

monitor for 10-centimeter radar display with automatic plotting aid showing other vesselsí 

course, speed, and closest-point-of-approach. Data (blips) on 3-centimeter radar display 

(smaller screen behind operator) are repeated on monitor hanging above controls.
Factual Information 20 Marine Accident Report

conducted quarterly inspections on April 17 and July 25 during the year before the

accident. The Safety Board noted only minor deficiencies in the inspection records, such

as missing locks, loose wires, or cracked casings. The ferry was due for another quarterly

inspection on October 16, 2003óthe day after the accident.

Wreckage 

After the accident, the ferryís propulsion system was found undamaged. The

vesselís main deck sustained the bulk of the damage, with some tearing of the deck into

various voids, machinery, and ballast tank spaces below (figure 8). The leading edge of the

starboard passenger cabin on the main deck (Staten Island end), at frame 54, appeared to

have taken the brunt of the allision. The bulkhead at frame 54 was fully torn from the

deck, from the starboard deck edge inboard through to a point about 12 feet to the left of

the centerline. 

All bulkheads and associated frames, structural support columns, and saloon deck

support frames between frames 54 and 44 on the starboard side were missing. The stairs

between the main deck and the saloon deck were fully collapsed (figure 9). The centerline

support column at frame 36, the forwardmost support column (that is, closest to the Staten

Island end) for the pilothouse remained intact and appeared to have provided the main

support for the forward pilothouse after the starboard support columns were destroyed.

The deck around the cleat on the starboard side (forward of the cabin) was found

largely intact but with a 15-inch longitudinal and 8- to 10-inch transverse tear that created

an opening to the ballast tank space below. Four tears that exposed the propulsion room

below the main deck were also found. The first, of approximately the same dimensions as

the forward tear, was found aft of the cleat. The second, about 4 feet aft of the cleat in the

area of the bunker (fuel) station, was associated with numerous flattened and bent pipes

leading to the propulsion room (lubrication oil fill connections, fire main connections, fuel

oil fill pipes, water tank fill pipes, and tank vents). The third tear was 12 feet inboard of

the bulkhead, where a ventilator trunk had been ripped out. The fourth tear was aft of the

vent trunk, where a pipe duct had been torn off.

Vertical steel support columns for the frame member that supported the forward

superstructure were sheared off on the Staten Island end aft of frame 54 to frame 4. The

outboard attachment point of the column at frame 20 was sheared off, but the inboard

attachment point was intact. The saloon deck sagged 2 to 3 inches near the forward

starboard corner of the pilothouse because of the damage to the supports. The side shell

was peeled back from frame 54 at the Staten Island end to frame 25 at the New York end.

Bulkheads, seating areas, bulkhead trim, ceiling panels, lighting cables, fixtures, and

plumbing systems were destroyed from the bow to about frame 20, inboard of a point

about 12 feet left of the centerline. 
Factual Information 21 Marine Accident Report

Figure 8. Plan view of ferryís main deck highlighting damaged areas.

STATEN ISLAND END

NEW YORK END

Frame 4

Frame 20

Frame 36

Frame 54

Frame 25

Torn decking

Cleat

Destroyed stairway

to saloon deck

Torn

decking

Frame 0

Damaged area

Destroyed

support column
Factual Information 22 Marine Accident Report

Waterway Information

The Port of New York and New Jersey is the largest port complex on the East

Coast of North America32 and was the worldís eighteenth busiest port in 2002.33 Its harbor

is divided at the Narrows into the Lower Bay and the Upper Bay (figure 2). The Verrazano

Narrows Bridge crosses the Narrows to link Staten Island with Brooklyn. The anchorage

channel, the main passage through the center of the bay, runs west of Governors Island at

the Upper Bay entrance to the East River. A shallow area with depths of 8 to 20 feet lies

east of the anchorage channel, and a shallower area lies to the west, off the New Jersey

shore.34 Lighted buoys mark the anchorage channel.

Figure 9. View of damage to New Jersey side of main deck showing collapsed stairway to 

saloon deck, destroyed columns, crushed seats, ruined ceiling panels, dislodged cables 

and fixtures, debris, and other destruction.

32 Source: <http://www.panynj.gov/commerce/marmain.htm> (accessed April 26, 2004).

33 In tonnage of annual cargo passing through it (Information Please Almanac

<http://www.infoplease.com/ipa/A0104779.html> [accessed March 22, 2005]).

34 National Oceanic and Atmospheric Administration, National Ocean Service, United States Coastal

Pilot, vol. 2 (Atlantic Coast: Cape Cod to Sandy Hook), 2003, p. 372.
Factual Information 23 Marine Accident Report

The route of the Andrew J. Barberi was between St. George, Staten Island, and

Whitehall Street, Manhattan, in the Upper Bay of the harbor (figure 2). The Whitehall

Street terminal was on the East River side of the Battery, located at the southern tip of

Manhattan, where the East River and the Hudson River meet. Because of the terminalís

location, ferry operators were required to execute a 90o left turn to enter the ferry slips, and

conversely, a turn right on the return to Staten Island. Beyond the Battery, the route to

Staten Island continued past the west side of Governors Island on a south-southwesterly

course in the anchorage channel.

The route continued past Ellis and Liberty islands toward the KV buoy, which

marked the north side of the entrance channel into the Kill van Kull.35 After passing the KV

buoy on the vesselís starboard side, the route continued past the Kill van Kull and turned

toward the designated ferry slip. The distance from the KV buoy to the ferry slips was

about 1,000 yards, and the distance from Whitehall to the KV buoy was about 4 miles.

The Coast Guard operated and maintained a VTS to facilitate the orderly flow of

vessels on the waterways in the Port of New York and New Jersey.36 The vessel traffic

center was located at Ft. Wadsworth on Staten Island and was staffed continuously. The

center used a VHF-FM radiotelephone network to obtain and disseminate vessel traffic

information to vessel operators, as well as radar and low-light closed-circuit television to

confirm and supplement this information. Low-power, remote VHF-FM sites were located

throughout the New York/New Jersey waterway environment. Staten Island Ferry

operators routinely called the VTS center when they left the dock but did not call when

they arrived at their assigned slip, according to the VTS operator.

The VTS system had limited video and radar recording capability. The operator at

Ft. Wadsworth told investigators that, after being notified of the accident, he focused the

VTS camera on Governors Island toward the Andrew J. Barberi. The camera recorded

approximately 11 minutes of the ferryís postaccident actions while it maneuvered in the

harbor before it docked.

As of December 31, 2004, certain domestic vessels that use the New York VTS,

including passenger vessels of 100 gross tons or more, were required by the Maritime

Transportation Security Act of 2002 to have an installed, operational automatic

identification system (AIS).37 AIS is a shipboard broadcast system, operating in the VHF

maritime band, that can send and receive ship information such as identity, position,

course, and speed. 

35 Kill van Kull is a 4-mile channel that connects the Upper Bay of New York Harbor to Newark Bay

and the channels on the west side of Staten Island. Vessels entering or departing the waterway pass through

the same area the ferries use between the KV buoy and the St. George ferry slips.

36 Vessel Traffic Service New York Userís Manual <http://www.navcen.uscg.gov/mwv/mwv_files/

VTS_NY_UM.pdf> (accessed April 28, 2004).

37 The AIS carriage requirements were established by the Maritime Transportation Security Act of 2002

(Public Law 107-295, November 25, 2002). The Coast Guard published the final rule for implementing the

act on October 22, 2003 (Federal Register, vol. 68, no. 204, pp. 60559-60570). The final rule became

effective on November 21, 2003.
Factual Information 24 Marine Accident Report

Operations of New York City Department of Transportation

According to information published on its website,38 the NYC DOT manages

much of the cityís transportation infrastructure, including city streets, highways,

sidewalks, and bridges. DOT is responsible for installing and maintaining street

signs, traffic signals, and street lights, resurfacing streets, repairing potholes and

other street defects, installing and maintaining parking meters, managing

municipal parking facilities, and operating the Staten Island Ferry.

DOT supervises the cityís franchise agreements with seven private bus

companies, oversees private ferry operations on city-owned piers, manages the

cityís contracts with companies that provide transportation to pre-kindergarten

special education children, issues parking permits to people with disabilities, notfor-profit agencies and governmental entities, and commercial vehicle permits for

trucks, issues construction permits for work in city streets, and manages the cityís

Adopt-a-Highway program. DOT also promotes safe travel by bicyclists and

pedestrians, and offers programs to foster traffic safety education.

The Staten Island Ferry, a division of the NYC DOT, had been a municipal service

since 1905, and at the time of the accident carried over 19 million passengers a year. The

ferry division operated seven vessels in three ferry classes of different design and capacity

(Kennedy, Barberi, and Austen), as well as two passenger terminals, a maintenance

facility, and a fuel storage and transfer facility. As many as five ferries operated at any one

time, depending on time and day. The division had an annual budget of $452 million and

430 to 450 employees. Of those, 19 were captains and 16 were assistant captains. 

The NYC DOT had no established minimum requirements for its personnel to

qualify as ferry assistant captain or captain. Ferry operating personnel began as deckhands

and then qualified as either mates (nonnavigating officers) or assistant captains, who could

then be promoted to captains. The NYC DOT required both assistant captains and captains

to have mastersí and first-class pilotsí licenses, with extensions to the Upper Bay of New

York Harbor, the East River from the Battery to Execution Rock, the west river (Hudson

River) from the Battery to the George Washington Bridge, and Fresh Kills from the KV

buoy to Elizabethport, New Jersey.

No Coast Guard documentation was required of deckhands on the Staten Island

ferries. The deckhands reported to the mates, who reported to the captain during vessel

operations. The assistant captain and the captain both reported to two port captains. The

port captains were the immediate supervisors of the ferry officers who oversaw day-to-day

ferry operations and who wrote the officersí performance appraisals. The port captains

reported to the director of ferry operations, who oversaw ferry operations and

maintenance. 

38 ìDOT: Who We Are & What We Doî <http://www.nyc.gov/html/dot/html/about/dotdoes.html>

(accessed March 8, 2004).
Factual Information 25 Marine Accident Report

The director of ferry operations, along with the director of terminal operations and

the director of administration, reported to the assistant commissioner, who oversaw all

aspects of ferry operations (operations, maintenance, terminals, ferry personnel,

budgeting). The assistant commissioner reported to the NYC DOT deputy commissioner,

who reported to the NYC DOT first deputy commissioner, who then reported to the NYC

DOT commissioner.

In September 2000, construction began on a new Whitehall ferry terminal, with the

NYC DOT as one of the project overseers; renovation of the St. George terminal had

gotten under way the year before.39 In April 2003, the mayor of New York announced his

fiscal year 2004 budget. Among other cuts the mayor proposed in the face of the cityís

$3.8 billion budget deficit were reductions in rush-hour services on the Staten Island Ferry

and the elimination of over 200 NYC DOT jobs.40

Meteorological Information

According to National Weather Service data, on the day of the accident, a lowpressure system, with a central pressure of 976 millibars, was located just north of New

York State. Data from the immediate vicinity of the accident site indicate winds from the

west at 25 to 30 knots, with scattered to broken sky conditions and a temperature of 64o F

(18o C). Observations at the three weather stations closest to the accident site (Newark

Liberty International Airport, 6 nautical miles away; New York Central Park, 11 nautical

miles away; and John F. Kennedy International Airport, 14 nautical miles away) were

similar, although they indicated stronger peak winds and stronger wind gusts.41 Visibility

was 10 miles in the area.

National Ocean Service data for the New York and New Jersey harbor, recorded at

Battery Park, New York, and Sandy Hook, New Jersey, indicate that at 1530, winds were

from the west at 35 to 40 knots, atmospheric pressure was approximately 998 millibars,

and the air temperature was about 60o F (15.5o C). The water level was approximately 2 feet

above the mean, with an outgoing tide, and the water temperature was 62o F (16.6o C). 

39 Archives of the Mayorís Press Office, New York City, June 9, 1999, and September 25, 2000

<http://www.ci.nyc.ny.us> (accessed January 24, 2005).

40 ìLeaving No City Service Intact: The Mayorís Executive Budget(s) for Fiscal Year 2004î (New

York: City Project, May 8, 2003), p. 10.

41 Kennedy Airport recorded the highest wind speeds, with peak winds of 47 knots and gusts of

41 knots at 1451. Newark Airport recorded peak winds of 40 knots at the same time. 
Factual Information 26 Marine Accident Report

Medical and Pathological Information

Passenger Injuries

Most furnishings and seating areas and most supporting structures of the vessel

about the midships sections on the main deck New Jersey side were severely damaged or

destroyed by the allision and by the vesselís continued momentum against the pier as the

concrete decking passed through the passenger cabin. The resulting debris entangled many

passengers who were gathering in the primary impact area to disembark.

Ten passengers were found dead by emergency response personnel who met the

vessel after it docked.42 Emergency personnel identified the locations of the fatally injured

passengers several days after the accident. All the fatally injured passengers were found

on the New Jersey side of the vesselís main deck (figure 10). The cause of death of the

fatally injured was blunt force trauma and its consequences, with numerous severe injuries

to head, torso, and extremities. 

About 70 passengers were injured in the accident. The injuries of those admitted to

area hospitals ranged from minor ones requiring observation to more serious ones such as

bone fractures, internal organ damage, limb amputations, and other injuries requiring

major surgery. Thirty-five passengers were taken to Staten Island University Hospital; 10

were admitted and 25 were treated for minor injuries and released. Between October 16,

the day after the accident, and October 31, an additional 13 passengers were treated at

Staten Island University Hospital for injuries they received in the accident. None was

admitted overnight.

Three passengers were taken from the accident site to Staten Island University

Hospital South. One was admitted and two were treated and released. On October 16, an

additional passenger went to that hospital for the treatment of injuries sustained in the

accident. He was treated and released.

Thirty passengers, and later the assistant captain, were taken to St. Vincentís

Hospital on Staten Island. Eight passengers were admitted and 22 were treated and

released. The assistant captain was admitted, underwent emergency surgery, and remained

in postsurgical and, later, psychiatric care through mid-November 2003.

Six passengers were taken to hospitals in Brooklyn. Three were transported to

Kings County Hospital, where they were treated and released. Three were taken to

Lutheran Medical Center, where they too were treated and released.

Toxicological Testing

Shortly after the accident, the Andrew J. Barberi crew, except for the assistant

captain, submitted blood and urine specimens to the Coast Guard and to the NYPD for

toxicological testing in response to a combined NYPD/Coast Guard request. For all

crewmembers, the results were negative for alcohol and the five drugs of abuse that the

42 An eleventh passenger died in December 2003 from injuries she received in the accident. 
Factual Information 27 Marine Accident Report

Figure 10. Locations on main deck where emergency personnel recovered bodies of 

fatally injured passengers. When emergency personnel arrived on board, some bodies 

had been moved from where fatal injuries occurred. 

STATEN ISLAND END

NEW YORK END

Brooklyn Side New Jersey Side
Factual Information 28 Marine Accident Report

U.S. Department of Transportation screens for in postaccident testing (marijuana, cocaine,

opiates, amphetamines, and phencyclidine [PCP]).

The Safety Board requested and obtained blood and urine samples of the assistant

captain that St. Vincentís Hospital had obtained on his admission. The Board sent the

samples to the Federal Aviation Administrationís Civil Aerospace Medical Institute for

toxicological analysis. The results were negative for alcohol and illegal drugs. The

analysis found 0.76 micrograms/milliliter of tramadol in the blood and diphenhydramine

(a sedating antihistamine43) in the urine.

Survival Factors

Crewís Emergency Actions 

Safety Board investigators interviewed the Andrew J. Barberiís senior and junior

mates, the seven deckhands, and the four crewmembers in the engineroom (chief engineer,

assistant engineer, and two oilers). The investigators also interviewed two crewmembers

of the Dorothy J, the tugboat that assisted after the accident.

The senior mate (mate No. 1) was sitting on the settee in the Staten Island-end

pilothouse when the ferry struck the pier. According to the standard operating procedure,

his station during docking was on the main deck at the ferryís inshore end. His duties were

to secure the New York end and supervise deckhands on the main deck and the New

Jersey side of the saloon deck. After the accident, the senior mate, as instructed by the

captain, went below to assess the situation. The mate told investigators that when he

walked out of the pilothouse, he confronted panicky passengers and tried to assure them

that everything was all right. He made his way to the New York end and down the stairs.

On the main deck, he witnessed two deckhands assisting the injured and applied what he

could remember of his emergency medical technician (EMT) training from 20 years

before to help injured passengers. He told investigators that he attempted triage and used

his belt and the straps from a lifejacket as tourniquets. He ìinstructed crew members as

they came by,î sending one for a defibrillator and telling others to move everyone to the

saloon deck who was not involved in helping or was not critically injured. He directed

EMS personnel to the most seriously injured passengers when they came on board. 

The standard operating procedure called for the junior mate (mate No. 2) to be on

the upper embarkation deck at the inshore end of the ferry during docking. His duties were

to secure the Staten Island end and to supervise deckhands on the bridge deck and on the

Brooklyn side of the saloon deck. The junior mate told investigators that he was making

his way toward the Staten Island end of the ferryís main deck, Brooklyn side, and was

about 15 feet from the doors when the ferry struck the pier. He thought they had hit

another vessel and had no idea that the ferry was close to the dock. After they hit the pier,

he ran to the New Jersey side, where all the damage was, and helped injured passengers.

43 Found in such over-the-counter medications as NytolÆ, BenadrylÆ, and Tylenol PMÆ.
Factual Information 29 Marine Accident Report

Because the damaged area looked unsafe to him, he had deckhands direct passengers who

could walk to the saloon deck or toward the New York end. He directed other deckhands

and an off-duty Staten Island Ferry mate to assist the approaching tug he could see

ìthrough the hole in the hull.î Next, he went down to the engineroom to see why the

vessel was not moving. The chief engineer told him that he had no communication with

the pilothouse, so the junior mate gave the chief engineer his radio, then ran up to the

pilothouse to inform the captain. The assistant captain asked for his cell phone and the

junior mate gave it to him. Then he went back to the main deck, where he witnessed the

senior mate and a nurse applying a tourniquet to an injured passenger. When the rescue

workers came on board, the junior mate said that he showed a fireman where the deck

needed to be shored up and took detectives to the pilothouse to see the captain. 

Deckhand No. 1 was on the main deck at the time of the accident, on his way to the

restroom near the engineroom. His duty station was the bridge deck, New Jersey side. He

was also responsible for making departure and prearrival announcements from the

pilothouse. He told investigators that after the accident, he rushed up to the bridge deck,

telling passengers to don lifejackets on his way. He said, ìPeople were going . . . crazy.

There was chaos going on.î Then, he said, he realized that the saloon deck might fall on

the main deck, so he ran down to the saloon deck and told passengers to move to the

Brooklyn side. After a passenger told him there were many wounded on the main deck, he

ran to the pilothouse to inform the captain. Then he went back to the main deck to help

with the injured, but he told investigators that after he saw body parts and corpses, he was

ìno good.î He said the crewmembers were ìrunning all over the place.î He said he heard

no emergency announcements.

Deckhand No. 2 was at his duty station on the saloon deck, Brooklyn side, at the

time of the accident; his assignment was to attach and release the safety chain at the gates,

look after passengers, and clean. He told investigators that after the allision he made sure

that passengers who could walk stayed away from the damaged end and helped the junior

mate attend to the injured.

Deckhand No. 3 was the lookout assigned to the accident trip. The standard

operating procedure listed no specific duties for the lookout, stating only that deckhands

were to ìact as a lookout as assigned.î The lookout left the pilothouse shortly after the

ferry passed the KV buoy. His duty station was the New Jersey side of the saloon deck,

where he had the same responsibilities as deckhand No. 2. The lookout told investigators

that he had just untied the saloon-deck doors and was at the top of the staircase between

the saloon and main decks at the time of the accident. He said that when he realized that

the ferry had not slowed down, he chased passengers to the other end of the boat, then

grabbed a man and held onto the stair rail when the ferry hit the pier. After that, he kept

people away from the collapsed stairway. He said he saw the assistant captain descend

what was left of the stairs, climb over the wreckage, and ìgo around the side.î He said,

ìPeople were panicking, putting on lifejackets and everything.î He said he heard no

alarms or other danger signals before the accident. 

Deckhand No. 4 was sweeping the menís rooms on the saloon deck at the time of

the accident. His duty station was all the menís rooms and the crewís locker room. The
Factual Information 30 Marine Accident Report

impact knocked him down. He went outside, helped a fallen passenger, then ran to the

bow, which he could not see because of the debris. He saw dead and injured passengers

and yelled to the bridge for a police officer. Then he ran to the pilothouse to tell the captain

not to move the ferry because the bow was not intact. He went down again and heard the

captain yell to get a line to the tugboat. He said he tried to move passengers to the stern

and assured them that the ferry was not sinking. He then went back to the pilothouse,

where the captain was trying to contact the engineroom. The deckhand said he grabbed a

radio and ran down to the engineroom, where he determined that the crew was uninjured

but that the radios and phones were not working. He said that he tried to make an

announcement on the public address system but that it also was not working. He told

investigators that he did not try to call either of the mates on his radio and that he could not

think of where his emergency station was.44

Deckhand No. 5 was walking toward the Staten Island end of the main deck at the

time of the accident. His duty station was the New York half of the main deck. He told

investigators that he ran to the New York end, making his way among passengers who were

grabbing and putting on lifejackets. Then he went to the bridge to find out what the captain

wanted the crew to do. The captain told him to find the chief engineer. On his way to the

engineroom, he said he saw other deckhands controlling the crowd and helping passengers.

He told investigators that he heard no alarms and no announcements to put on lifejackets.

Deckhand No. 6 was sitting on the main deck, amidships on the Brooklyn side, at

the time of the accident. His duty station was the Staten Island half of the main deck. He

told investigators that he had been trying to keep the doors closed, which the wind kept

blowing open. After the ferry hit the pier, he said he ran to the bow, than ran back,

encountering dead and injured passengers. The senior mate asked him to find the

defibrillator, which he did. He said, ìI did the best as I could to help people.î When the

ferry docked at slip 5, he helped fasten the hooks.

Deckhand No. 7, the utility bridge deckhand, was cleaning out a lifejacket locker

at the time of the accident. His duty station was the Brooklyn side of the bridge deck, the

ramps to the upper embarkation area, the New York-end pilothouse, and the officerís

locker room. He told investigators that he had his back to the windows when the ferry hit

the dock and was not paying attention to the vesselís location but was waiting for the

engines ìto back down.î He heard no alarms before the accident and thought the ferry had

run aground. He ran toward the bow, went to the saloon deck, and saw the lookout moving

people back. He said the captain yelled at him from the pilothouse to go get the engineer,

but he saw that the engineer was already on his way up. He continued to move people on

the saloon deck to the New York end, then went to the main deck to help shift debris out of

the way and to move people to the New York end. 

The engineering staff were all in the engine control room at the time of the

accident. The chief engineer told investigators that he was sitting in front of the control

board when the ferry started shaking as if it had gone aground. He looked at the engine

speed indicators and said, ìHow come he is not slowing down?î Then he heard crunching

44 See ìEmergency Plans,î below.
Factual Information 31 Marine Accident Report

ìlike something going under the hull and being caught in the wheel.î He told investigators

that he tried to call both pilothouses but got no response, so he sent the assistant engineer

and the two oilers to the deck to find out what had happened. As the assistant engineer and

oilers were leaving, debris fell into the engineroom. The phone was ringing from the

bridge, but when the chief engineer picked it up, he got no answer. Meanwhile, the

engines had slowed and the pitch had been taken off. 

The assistant engineer and the oilers came back and the chief engineer said he put

the assistant engineer in front of the controls and went on deck himself. He said it looked

like a bomb had gone off. He went to the Staten Island pilothouse, where the captain told

him that the assistant captain ìhad lost it.î The captain then went to the New York end and

the engineer transferred power to him there. The chief engineer told investigators that the

ferry did not lose power when it hit the pier, that no alarms went off, and that ìnothing

blinked.î The Staten Island propeller was still turning but the engineers shut it down

because the FDNY needed to enter the shaft housing.

The assistant engineer told investigators that he was looking at the electrical panel

in the engineroom when he heard ìa violent crash.î He told investigators that he heard no

shipís whistles or alarms beforehand: ìIt was a very normal watch preceding the

accident.î He said that after the crash the chief engineer sent him with the oilers to check

for damage at the ends of the ferry. At the top of the stairs they saw what had happened

and as a former advanced EMT, he tried to help one person but had to leave the accident

area because he felt so disturbed. He went back to the engineroom to inform the chief

about the situation on deck. After the chief engineer left the engineroom, the assistant

engineer closed the water lines because water was coming in and also closed a surface air

line and double-checked the boiler because he thought the steam lines might be broken.

He told investigators that the generator lights flickered but the vesselís lights never went

out. He said he stayed in the engineroom the rest of the time. 

Both oilers were in the engine control room at the time of the accident. One was

sitting across from the assistant engineer and the other was standing. One of the oilers said

that he thought the ferry had hit something in the middle of the harbor. He told

investigators that he heard no alarms or bells or changes in the engine sounds before the

accident. Both oilers went on deck, as instructed by the chief engineer, to check for

damage to the propulsion system. One oiler told investigators that he helped pull debris off

an injured passenger. 

The engineer of the Dorothy J told investigators that no deckhands were available

to help with the lines, and that as a result, he jumped back and forth from the tugboat to the

ferry three times to tie and untie lines. He said that one of the ferryís passengers helped

him with the lines. The tugboatís mate said that the deckhands stopped passengers from

getting on the tugboat while it was attaching lines to the ferry.

Shoreside Emergency Response

New York Cityís 911 emergency notification system was first notified of the

accident at 1522 by a caller who informed the operator that the Andrew J. Barberi had
Factual Information 32 Marine Accident Report

struck a dock. In response, the FDNY dispatched three engine companies, two hook-andladder companies, and a battalion chief to the St. George terminal. Subsequent callers to

911 provided information about the scope of the accident and the consequent injuries. One

caller reported a passenger in the water. In response to that information, the FDNY

dispatched a fireboat to the scene. Early callers also gave inaccurate information about the

accident, such as a report that an explosion had occurred on the vessel. At 1526, the first of

two EMS life support ambulances was dispatched.45

At 1527, the first FDNY personnel arrived on scene. Under existing agreements

between New York City first responders, the FDNY was responsible for overseeing the

response to multiple casualty incidents and accidents. FDNY personnel established an

incident command system to oversee rescue efforts. Also at 1527, the FDNY received reports

of numerous injured on board and a minute later, it learned of at least one fatality on board.

At 1529, the first EMS unit arrived on scene. The ferry had not yet arrived at the terminal.

At 1530, a second life support ambulance and an EMS supervisor were dispatched

to the scene. Two minutes later, scuba-trained and tactical support personnel were

dispatched. At that time, the incident commander also transmitted a notification signal

alerting all personnel dispatched to the scene that they would be needed to participate in

the response and automatically dispatching another engine company, another ladder

company, and two more battalion chiefs. As described in a memo to the Safety Board after

the accident, FDNY on-scene operations were organized as follows:

Operations were conducted under the incident command system, utilizing chief

officers as sector or function commanders, each being assigned the number of

units required to accomplish the task assigned. Operating units were rotated to

avoid fatigue. [As a result] . . . additional units were called to the scene either

individually or by transmitting multiple alarms.

At 1536, the FDNY was informed that more than one person was in the water near

the accident scene. In response, a second fireboat, a water rescue unit from another ladder

company, and additional support and supervisory personnel were dispatched. Three

minutes later, the off-duty FDNY lieutenant who was on board the ferry as a passenger

called dispatchers with information about conditions on board, including information

about multiple casualties. The FDNY then dispatched an additional rescue company, a

squad company, a special operations chief, and a safety chief. FDNY records indicate that

the Andrew J. Barberi arrived at the terminal at 1543.

When the ferry docked, emergency personnel entered the vessel from two levels

simultaneously, searching for victims and providing them with initial medical care. Those

in need were stabilized and transported to area hospitals. Other emergency personnel

located and extricated trapped victims and helped brace the upper decks of the vessel on

the New Jersey side. As the severity of the accident became clear, information was relayed

to the incident commander, who transmitted a major emergency signal that automatically

brought more FDNY and EMS assets to the scene.

45 Life support ambulances carry many of the materials found in a hospital emergency room.
Factual Information 33 Marine Accident Report

All told, the FDNY dispatched 213 personnel to the accident, including 2 staff

chiefs, 3 deputy chiefs, 16 battalion chiefs, 16 engine companies, 10 ladder companies, 3

rescue companies, 2 fireboats, a squad company, a tactical support unit, a hose wagon, a

fireground rehabilitation unit, a field communications unit, a technical response unit, and a

collapse rescue unit. In addition, 59 EMS personnel, 24 ambulances, 15 advanced life

support and 9 basic life support units, and 2 logistical support units participated in the

response.

After responding to the first 911 call, units from the NYPD continued to arrive.

Over 311 NYPD personnel assisted during the afternoon and evening of October 15ó

helping the injured and taking witness statements, interviewing crewmembers and

passengers, organizing crowd control and traffic control, and forming a protective area

around the ferry terminal.

The local Coast Guard operational field command facility, Coast Guard Activities

New York, was notified of the accident at 1525, as noted previously, by a Coast Guard

enlisted person who was a passenger on the Andrew J. Barberi. At 1533, Coast Guard

Station New York, the local Coast Guard search-and-rescue facility collocated with Coast

Guard Activities New York, launched a 25-foot small response boat and a 27-foot utility

boat to the St. George terminal, located 3 miles from the Coast Guard facilities at Ft.

Wadsworth. At 1535, Coast Guard Station New York launched a 41-foot utility boat to the

ferry. At 1537, personnel from the Coast Guardís 27-foot boat reported that the Andrew J.

Barberi had sustained major damage to its New Jersey side above the waterline. At 1545,

Coast Guard Activities New York dispatched a safety officer and an investigating officer

to begin the Coast Guardís investigation of the accident.

At 1553, Coast Guard on-scene personnel established a 250-yard security zone

around the ferry and broadcast to vessels in the waterway that an approximately 400-yard

debris field was moving through the waterway, as a result of the ebb tide and westerly

winds. At 1559, Coast Guard Activities New York halted all Staten Island Ferry

operations. A ferry under way from Manhattan was ordered to return. During this period,

three organizations involved in the waterborne responseóthe Coast Guard, the NYPD,

and the U.S. Army Corps of Engineersósent additional rescue and response vessels to the

scene. By 1700, 15 vessels in addition to the FDNY boats were participating in the

waterborne responseó6 from the Coast Guard, 5 from the NYPD, and 4 from the Army

Corps of Engineers. Coast Guard vessels searched for people in the water between St.

George and the Verrazano Bridge until 2040. Because no accurate count was made of the

number of passengers, rescue personnel had no indication of how many people might be

missing and in the water. Only one person, it turned out, had to be rescued from the water.

Coast Guard personnel remained on scene throughout the evening to assist with

the investigation, search the areas next to the ferry terminal, keep water traffic not

involved with the accident away from the terminal, and monitor possible hazards in the

water. Their numbers increased the next morning before ferry operations resumed at 0500.

Altogether, 15 Coast Guard officers, 6 enlisted personnel, and 4 Coast Guard Investigative

Service agents responded to the emergency. 
Factual Information 34 Marine Accident Report

Emergency Plans

The ferryís station bill (list of crewmembersí duties in emergencies such as fire or

abandon ship) stated that during an emergency, the crew was to be notified in the

following manner: The shipís whistle and general alarm would be continuously sounded

for at least 10 seconds. Additional signals on the whistle and general alarm (one to five

blasts and rings) would designate the location of the emergency. According to the station

bill, general alarm controls were in the pilothouse and control room, and the shipís whistle

controls were in the pilothouse, along with controls for the public address system.

When they heard the emergency alarm, crewmembers were to report to their

assigned stations. Each crewmember (captain, assistant captain, senior mate, deckhand

No. 1, and so forth) had designated duties or assignments. In case of fire in the

engineroom, for example, the deck crew was directed to arrive on scene with emergency

equipment such as fire hoses, axes, and fire extinguishers and wait for instructions from

the chief engineer. Mates were instructed to act under the direction of the master,

deckhands under the direction of the mate. The captain or assistant captain was expected

to make announcements over the public address system. Crewmembers were instructed to

ìstay calm, listen for instructions and signals . . . and remember that instruction(s) to the

passengers will minimize panic and confusion.î The station bill was posted outside the

pilothouse and at other locations on the ferry.

The station bill required crews to participate in weekly fire and rescue drills.

According to ferry crewmembers, the same drills were conducted every week: fire and

emergency, abandon ship, and emergency anchoring. The drills were conducted after

hours without passengers, with crewmembers working an hour or two extra before or after

a shift to participate. The drills began with the ferry captain or assistant captain sounding

the shipís whistle to initiate the general alarm bell. The crew would then gather to simulate

actions taken during an emergency, according to the type of drill signaled. New deckhands

were given verbal training, informally conducted on the job. No training was given for a

mass casualty event, such as the type that the Andrew J. Barberi experienced.

The station bill contained general instructions for crewmembers on (1) recognizing

and responding to emergency events, (2) required emergency announcements, (3) duties

during emergencies, and (4) station locations during emergencies. Crewmembers did not

receive, nor were they required to receive, training or procedures in such areas as crowd

control or bridge resource management. 

The six officers of the Andrew J. Barberi (captain, assistant captain, two mates,

chief engineer, assistant engineer) received training in first aid and cardiopulmonary

resuscitation (CPR) as a condition of being licensed by the Coast Guard. Crewmembers

received no training in first aid or basic lifesaving techniques. At the time of the accident,

automated external defibrillators were present on the ferry and the crew was being trained

in their use (they were not used in the accident). The defibrillator training included CPR

instruction. 
Factual Information 35 Marine Accident Report

Emergency Equipment 

Lifesaving. According to the vesselís COI, the Andrew J. Barberi was required to

have the following lifesaving equipment:

Notices were stenciled on the lifejacket lockers (located along the bulkheads and

under seats), indicating whether they contained childrenís or adultsí lifejackets. Other

notices directed passengers to the locations of lifejacket lockers. According to the COI,

the ferry was not required to be equipped with lifeboats, immersion suits, portable lifeboat

radios, or an emergency position indicating beacon. 

Firefighting. The COI lists the following firefighting equipment on the ferry:

ï Two fire pumps.

ï Four fire hoses, each 50 feet long.

ï Two fixed carbon dioxide fire-extinguishing systems: a 3,100-pound-capacity

system in the engineroom, and a 200-pound-capacity system in the emergency

generator room.

ï Thirty-seven portable or semiportable fire extinguishers: 17 class A-II, 9 class

B-II, 3 class B-V, and 8 class C-II.46

Tests and Research

Two days after the accident, the Safety Board participated in tests of the Andrew J.

Barberiís communication and propulsion systems.

Rescue boats/platforms 4

Inflatable rafts 4 (32 people)

Life floats/buoyant apparatus 20 (400 people)

Adult life preservers 6,022

Child life preservers 603

Ring buoys with lights 8

Ring buoys with lines 4

46 Class A extinguishers are for fires involving ordinary combustibles, such as wood, cloth, and paper.

Class B extinguishers are for fires involving flammable liquid, grease, or gas. Class C extinguishers are for

fires involving energized electrical equipment, such as appliances, switches, panel boxes, and power tools

(these extinguishers are also rated for class A and class B fires). According to the Coast Guard classification

system, type A-II portable extinguishers hold 5 pounds of dry chemical; class B-II, 10 pounds; class B-V, 50

pounds; and class C-II, 10 pounds.
Factual Information 36 Marine Accident Report

Communication System Tests

New YorkñEnd Pilothouse. The engine-order telegraphs, both thrust and steering,

were tested in the New York-end pilothouse. An individual in the pilothouse sent orders to

another in the engine control room via the telegraph system. A VHF radio was used to

communicate between stations for verification that the orders were being received at both

stations properly. Both engine-order telegraphs were found to work satisfactorily.

The sound-powered phone systems were tested by phoning from the pilothouse to

an individual in the engineroom. Calls made to the engineroom were completed

satisfactorily, while calls made to the other pilothouse would ring in the pilothouse but the

audio circuit was not completed.

The public address system was tested and found to perform satisfactorily. It was

heard clearly throughout the vessel.

The pilothouse shipís whistle was tested using two methods. One involved

depressing a console pushbutton, which in turn opened a solenoid admitting air to sound

the whistle. The other involved manually pulling an overhead pull cable in the pilothouse,

which was mechanically linked to the valve at the whistle itself, thereby sounding it. The

whistle performed satisfactorily irrespective of the method used. 

The ìcowbell system,î essentially a pull lever in both pilothouses that connected

directly to a cable that was attached to two cowbells in the engine control room, was tested

in the pilothouse. The system performed satisfactorily.

Staten IslandñEnd Pilothouse. Tests found that the public address system, the

cowbell signaling system, and the whistle from the pilothouse worked satisfactorily,

similarly to the systems in the New York end. Several deficiencies, however, were found

in the sound-powered phone system. All calls initiated from the pilothouse, regardless of

the location being called, had no audio circuit. The ringer would ring at the selected call

destination, but no audio connection was made. Calls from the engineroom or the New

York-end pilothouse met with the same resultsóthe phones would ring but the people

could not talk to each other.

Tests of the engine-order telegraph also found deficiencies. When a command was

ordered from the pilothouse, the engine-order telegraph rang in the engineroom but the

telegraph needle did not move to indicate the speed change being ordered. Engine-order

telegraph commands from the engineroom showed the same results in the pilothouseóa

ring indicating an incoming engine-order telegraph command was heard but no

corresponding needle movement was observed. This test was performed in both

directions, for each speed from stop to full astern, and from stop to full ahead, with the

same results.

Propulsion System Tests

The propulsion system was tested without applying rotational drive from the main

engine to the unitís gearboxes. That was because of concern about the effect of vibrations

from the main engine and propulsion system on the structural integrity of the upper deck,
Factual Information 37 Marine Accident Report

which had been weakened by the accident. The tests were intended to demonstrate the

operation and response of the propulsion units themselves, not of the driving medium.

The hydraulic drive pumps were started and the system was brought to operating

pressure. Investigators were positioned at the pilothouse controls and at the propulsion

systemís actual location. Control was transferred from the engine control room to each of

the two pilothouses, and the investigators in the pilothouses varied both the thrust and the

steering from zero to 100 percent in both directions. The results showed that the

propulsion system performed satisfactorily in both end units, through all phases of thrust

and steering testing. Units in both ends were found to have a response time from zero to

100 percent thrust of approximately 5 seconds in any direction, and a response time from

full ahead to full astern of between 7 and 8 seconds.

The investigative team tested the transfer of propulsion control from the

engineroom to the pilothouse stations, as well as between pilothouses. All propulsion

transfers from operating station to operating station in each pilothouse, and from each

operating station to the engineroom, were completed satisfactorily. 

Additional Information 

Staten Island Ferry Rules and Policies

The NYC DOT required deckhands (the starting ferry operations position) to have

2 years of sea time or related experience before being hired. After personnel were hired as

deckhands, the NYC DOT had no minimum or maximum time intervals in which they

were to serve at each step before they could be promoted. According to the director of

operations, deckhands could serve as little as 6 months before being promoted to assistant

captain, provided they met the Coast Guard licensure requirements. The NYC DOT

required assistant captains and captains to demonstrate knowledge of ferry procedures and

ferry routes, including markers, buoys, and other navigational features. Applicants for the

assistant captain or captain position submitted their rÈsumÈs and were subsequently

interviewed by the port captains and the director of operations, who then made the final

selections.

The NYC DOT had no formal curriculum for training deckhands or mates for

assistant captain positions. When new deckhands reported for duty, they were given verbal

instructions and trained on the job. Those selected for the assistant captain position would

begin training by steering the vessel under the supervision of the captain, before taking the

civil service examination for the position.

At the time of the accident, no formal safety management system was in place, nor

was one required to be, and management directives were communicated verbally to

crewmembers. Emergency information listed in the vesselís station bill covered alarm

signals and announcements for fire, man overboard, and abandon ship emergencies, and

listed fire stations and boat stations for crewmembers. 
Factual Information 38 Marine Accident Report

According to the director of ferry operations, ìdirectives [and] memosî delineated

standard operating procedures that were made available to ferry personnel. No system was

in place to document crewmembersí receipt of the directives and memos. Safety Board

investigators, as a routine part of their investigation, asked the NYC DOT for a copy of the

operating procedures. The NYC DOT provided the Board with an 8-page, undated

document, ìStandard Operating Procedures for Captains, Assistant Captains, Mates,

Deckhands, and Female Attendants While the Boats Are Loading, Off Loading and

Underwayî (appendix B). According to that document, the captain was required to be in

the operational pilothouse ìupon dockingî and to be in the ìoff shoreî pilothouse ìupon

undocking to receive the signal from the assistant captain that the boat is let go.î

According to the procedure, the captain was responsible for operating the boat safely and

for emergency and rescue operations. The assistant captain, in addition to assisting the

captain in the operation of the ferry, was responsible for advising the captain of any

dangers to navigation. This officer also observed passenger embarkation and

disembarkation and when the boat had cleared the dock, was directed to go to the

operating pilothouse.

According to the director of operations, no single procedure explicitly directed the

captain or assistant captain to remain at certain locations during the voyages. Rather, he

said, ìYou have to kind of put them [the procedures] together.î By doing so, the director

said, ìYou see that theyíre to be together [captain and assistant captain]. In weather,

absolutely, positively together all the time.î He told investigators that he would talk to

operators who were discovered not to follow this procedure. If they refused to follow the

procedure, he would discipline them according to the NYC DOTís disciplinary procedures

(which he did not specify).

The two port captains disagreed on the existence of an NYC DOT requirement for

both the captain and assistant captain to be present in the pilothouse after propulsion

control had been transferred from one end of the ferry to the other. One said that such a

procedure was in place and that captains and assistant captains were expected to follow it.

The other said that the decision was up to the captain of the vessel: ìIf he doesnít want to

be in the pilothouse, if he has to go do something, he can do it, as long as he knows a

qualified person is in the pilothouse.î In addition, Safety Board investigators could find no

evidence that the NYC DOT had a procedure that required crewmembers to signal or

otherwise sound an alert to indicate that docking preparations were to be made.

According to the director of ferry operations, the two port captains would regularly

ride in the ferry pilothouses during their duty hours and observe the performance of

crewmembers, although there was no standard inspection procedure mandating this

practice or describing how the observation was to be carried out. The observations enabled

the port captains to determine the extent to which the crewmembers followed the required

procedures. According to the director, he or the port captains would document unusual

situations or instances in which crewmembers did not follow procedures.

Coast Guard Oversight of Staten Island Ferries

Under 46 U.S.C. 3301, the Coast Guard has inspection authority over U.S.-flag

vessels that charge passengers a fare to board. Coast Guard Activities New York was the
Factual Information 39 Marine Accident Report

local Coast Guard office in charge of vessel oversight. The OCMI of Activities New York

had final authority for vessel inspection, licensing, and investigation of marine casualties

and accidents, among other responsibilities (33 CFR 1.01-20). 

The Coast Guardís inspection authority was defined in terms of passengers paying

for their passage. On July 1, 1997, the NYC DOT eliminated the fares that it had been

charging its passengers, to integrate the Staten Island Ferry into the New York City mass

transit systemís ìOne City, One Fareî program. As a result, a question arose whether the

ferries would continue to be inspected by the Coast Guard. On May 19, 1998, the Coast

Guard and the NYC DOT signed an MOU to maintain the Coast Guardís inspection of the

ferries, in light of their ìmutual interest and concern for the safe operation of the Staten

Island Ferries.î47

The document stated, ìThe parties have entered into this MOU to formalize

procedures for developing standard operating procedures and agreements between OCMI

NY and the NY City DOT to achieve the following goals: (1) improve passenger safety, (2)

improve the quality of Ferry maintenance and operations, and (3) expedite the Coast Guard

inspection process.î The MOU called for quarterly meetings ìto exchange information and

discuss issues of mutual concern.î Further, any agreements specifying procedures or

operations would be ìformalized in writingî and the MOU would be ìthoroughly reviewed

periodically by each party.î At the time of the accident, no agreements amending the MOU

had been reached and no other written agreements had been added to it. The Coast Guard

continued to examine the Staten Island ferries and issue COIs.

Safety Assessment. In November 1998, new Coast Guard rules went into effect

under 46 CFR 199 (subchapter W) that required vessel operators to install additional

survival equipment, including lifeboats, liferafts, rescue boats, and associated appliances,

which had been originally intended for oceangoing passenger vessels. Subchapter W

consolidates the lifesaving regulations for U.S. inspected vessels and implements chapter

3 of the International Convention for Safety of Life at Sea (SOLAS), 1974, as amended.48

The new regulations gave operators until October 1, 2003, to install the lifesaving

equipment. Under the provisions of 46 CFR 199.630(f), however, operators were allowed

to obtain an approved safety assessment as an alternative to equipping their vessels with

the additional survival craft. The regulations required the alternative safety assessment to

address (1) the navigation and vessel safety conditions in the vesselís planned operating

area, and (2) a comprehensive shipboard safety management and contingency plan that

was ìtailored to the particular vessel,î ìeasy to use,î ìunderstood by vessel management

personnel both on board and ashore,î and ìupdated regularly.î In February 2003, the

Coast Guard issued a Navigation and Vessel Inspection Circular (NVIC 01-03) describing

the alternative safety assessment and giving guidance for having it approved.49 A previous

47 See appendix C.

48 SOLAS is an international treaty concerning the safety of merchant ships. The first version of

SOLAS was adopted in 1914 after the Titanic sinking. A new Convention was adopted in 1974 and is

sometimes referred to as SOLAS, 1974, as amended, because of its numerous updates and amendments.

49 U.S. Coast Guard, ìGuide to the Subchapter W Safety Assessments Under 46 CFR 199.630(f),î

NVIC 01-03 (Washington, DC: U.S. Department of Transportation, 2003).
Factual Information 40 Marine Accident Report

Coast Guard circular described shipboard management and contingency plans, focusing

on emergency procedures.50

In June 2000, George G. Sharp, Inc., in accordance with 46 CFR 199.630(f) and at

the request of the NYC DOT, completed a safety assessment of the Staten Island ferries.51

The results of the Sharp assessment were submitted to the Coast Guard. The assessment

included a description of the ferry fleetís safety equipment and scope of operation. It

described vessels, routes, crew requirements, schedules, vessel traffic characteristics, and

environmental factors, and outlined basic emergency procedures and drills. The report

noted that ìthe navigating risk is highest near the two terminals,î where ìthe ferry crosses

perpendicular to the prevailing vessel traffic flow.î Appendix A to the report

(ìContingency Planningî) detailed procedures to be followed in case of collision,

flooding, grounding, abandon ship, loss of power or steering, fire and explosion, bomb

threat, and oil spill. According to section A.1.1, ìonly collision carries a significant

potential of passenger injury.î Section A.1.2.1 identified the bridge team as the most

important element in preventing collisions and assuring safe vessel operation, with the

Coast Guardís VTS as the next most important element.

On August 7, 2000, the Commanding Officer of Coast Guard Activities New York

informed George G. Sharp by letter that its safety assessment provided the ferries ìa

satisfactory alternative to the installation of primary lifesaving gearî that was required

under the new regulations. The letter added, however, that final approval of the

substitution of ìrisk-reducing featuresî for lifesaving gear would ìbe determined after

reviewing crew training and witnessing safety drills.î 

An amended version of the Sharp safety assessment received final approval on

March 30, 2004. It was much longer than the original version (250 pages, largely

unnumbered, versus the originalís 38 pages) and contained a shipboard safety

management and contingency plan for each of the three vessel classes (not, however, as

stand-alone documents). A crew safety training manual had been added, including

information about emergency signals, basic firefighting, lifesaving equipment, and basic

first aid. Training materials for supervisors dealing with drug and alcohol testing had also

been added. The risk assessment section had been augmented with a risk matrix that

considered the following accident scenarios: fire, collision/allision, grounding, security

threat, and loss of power or propulsion. All scenarios were rated as having a low risk of

requiring vessel evacuation. 

Inspections. Coast Guard safety oversight was limited to inspections of the

ferriesí hulls, establishing and overseeing crew medical standards and licensing of ferry

operating personnel, and enforcing rules of the road and environmental regulations. The

Coast Guard inspected each vessel quarterly and conducted more in-depth inspections of

the vessels annually. 

50 U.S. Coast Guard, ìShipboard Management and Contingency Plans for Passenger Vessels,î

NVIC 1-97 (Washington, DC: U.S. Department of Transportation, 1997).

51 George G. Sharp, Inc., ìNew York City Ferry Safety Assessment,î prepared for NYC DOT, June 2000.
Factual Information 41 Marine Accident Report

As stated at 46 CFR 71.25-10, annual Coast Guard vessel inspections entail the

following:

The annual inspection shall include an inspection of the structure, boilers, and

other pressure vessels, machinery and equipment. The inspection shall be such as

to insure that the vessel, as regards the structure, boilers and other pressure

vessels, and their appurtenances, piping, main and auxiliary machinery, electrical

installations, life-saving appliances, fire-detecting and extinguishing equipment,

pilot boarding equipment, and other equipment is in satisfactory condition and fit

for the service for which it is intended, and that it complies with the applicable

regulations for such vessels, and determine that the vessel is in possession of a

valid certificate issued by the Federal Communications Commission, if required.

The lights, means of making sound signals, and distress signals carried by the

vessel shall also be subject to the above-mentioned inspection for the purpose of

ensuring that they comply with the requirements of the applicable statutes and

regulations.

Coast Guard rules that apply to international passenger vessels call for a

comprehensive safety management system under SOLAS. (For details, see ìSafety

Management Systems,î below.) Because the Staten Island Ferry operated in domestic

service, it was exempt from the SOLAS requirement. As a result, the Coast Guard did not

refer to or assess the quality of the NYC DOTís operating procedures.

After the September 11, 2001, attacks on the United States, the Coast Guard, in its

capacity as the Federal agency overseeing the security of U.S. waterways,52 required

numerous changes to Staten Island Ferry operations to increase the level of both vessel

and port security. The director or ferry operations worked closely with the Coast Guard to

upgrade security on the ferries. Among the changes, car ferries were not allowed to carry

vehicles and police officers were posted to each ferry while under way.

Medical Oversight of Mariners

The NYC DOT had no independent medical standards for ferry operators. Coast

Guard standards governing medical evaluations and Coast Guardñmaintained medical

records were the only medical standards and medical record-keeping system that applied

to ferry operators. The NYC DOT did, however, track the number of absences of

individual employees to ensure that the absences were within the number permitted by

established NYC DOT policy. When employees exceeded the limits, they were required to

present physiciansí notes explaining the reason for their absence.

Mariners holding Coast Guard licenses are required to undergo a physical

examination once every 5 years, or when their licenses are upgraded, to determine that

they are in sound health and have no physical limitations that would hinder or prevent

performance of duties. A licensed physician, physician assistant, or nurse practitioner can

perform the Coast Guard-required examination for license holders, as indicated on form

52 The Coast Guard retained this responsibility after its transfer to the Department of Homeland

Security, although some aspects of its security oversight were assigned to the Transportation Security

Administration.
Factual Information 42 Marine Accident Report

719K. Mariners then submit proof of their fitness to the Coast Guard, according to

regulations at 46 CFR 10.209(d) or (e). Form 719K provides information to the examining

health practitioner on the medical evaluation and on general duties required of licensed

mariners.

The Coast Guard requires mariners with pilot endorsements, which includes

captains and assistant captains on the Staten Island Ferry, to be examined annually

(46 CFR 10.709). Form 719K does not apply to the annual pilot medical evaluation, and

the regulations and other published material do not provide additional information on the

medical evaluation or the documentation necessary after the evaluation is completed.

Mariners with pilot endorsements do not have to submit proof of their medical

examinations outside the 5-year or license-upgrade interval. The regulations require pilots

to possess such proof, however, and make it available to Coast Guard personnel on

demand (46 CFR 10.709[e]).53

Neither Coast Guard Activities New York nor representatives of the Coast Guardís

New York regional examination center (REC), the office responsible for overseeing and

approving mariner licensing in the New York area, requested proof of compliance with the

annual medical evaluation requirement from either the captain or the assistant captain of

the Andrew J. Barberi. Coast Guard personnel also did not ask any Staten Island Ferry

captain or assistant captain for such proof in the 12 months before the accident. The Safety

Board was unable to establish that the Coast Guard enforced compliance by ferry

operating personnel with the annual examination requirement in that interval or at any

other time.

Medical standards differ according to the general assignment of applicants (deck

or engineering). For example, deck officers are required to have vision correctable to

20/40 in each eye, engineering officers to 20/50 in each eye. After completing the

examination, the health practitioner signs Coast Guard form 719K and indicates whether

the applicant is considered medically qualified. (The Coast Guard makes the final

determination of a marinerís qualifications.) Other forms may be used, provided that the

examination is carried out in accordance with the standards listed in form 719K. At the

end of the examination, the examiner provides the applicant with form 719K or, if

warranted, with a certificate that the applicant is in good health and otherwise meets the

physical requirements at 46 CFR 10.209(d) or 12.02-27(d). Applicants can choose

whether to submit the evaluation results to the Coast Guard.

53 ìUpon request, a first class pilot shall provide the Coast Guard with a copy of his or her most recent

physical examination.î
Factual Information 43 Marine Accident Report

In January 2002, the Coast Guard revised form 719K. Four and a half years earlier,

on June 26, 1997, as a result of its investigation of the grounding of the passenger vessel

Star Princess north of Juneau, Alaska,54 the Safety Board had issued the following Safety

Recommendation to the Coast Guard: 

M-97-42

Review, in consultation with experts in occupational health, your medical

standards, guidelines, and examination forms to ensure that they require

the disclosure and appropriate evaluation of the history or presence of any

medical conditions, symptoms, or medication use that would affect an

individualís fitness to pilot a vessel.

According to the commander of the Coast Guardís National Maritime Center,

physicians experienced in the physical evaluation of mariners provided guidance for the

revisions published in 2002. The revised form explains a marinerís duties and contains a

section where applicants and physicians are to list all medications being taken, dosages,

possible side effects, and relevant medical conditions. The form includes a medical history

section and requires a signed statement by the physician as to whether the applicant is

competent, not competent, or in need of further review. The applicant certifies that the

information is complete and true. In light of these revisions, on February 3, 2003, the

Safety Board classified Safety Recommendation M-97-42 as ìClosedóAcceptable

Action.î 

Before it revised the evaluation form, the Coast Guard published NVIC No. 2-98,55

ìPhysical Evaluation Guidelines for Merchant Marinerís Documents and Licenses,î

which is available from any Coast Guard REC, the Coast Guardís Washington, D.C.,

headquarters, or from the Coast Guard website. The 10-page document describes general

physical demands that mariners may be expected to meet, and provides guidance to

physicians and applicants on mariner medical qualifications. The NVICís list of

ìPotentially Disqualifying Conditionsî includes impaired vision (uncorrected vision

worse than 20/800), impaired color vision, or impaired hearing; poorly controlled

diabetes; lung disease such as chronic or active asthma or tuberculosis; chronic/recurrent

pancreatitis; chronic renal failure; multiple or recent myocardial infarctions; psychiatric

disorders such as psychosis, suicidal behavior, drug or alcohol addiction; convulsive

disorders; conditions that seriously limit balance such as Parkinsonís disease; narcolepsy;

somnambulism; infectious diseases; and medications such as anticoagulants or

psychotropics; or ìany other disease, constitutional defect, medication (side effects), sleep

disorders or therapy which would result in gradual deterioration of performance of duties,

sudden incapacitation or otherwise compromise shipboard safety, including required

response in an emergency situation.î In short, any condition that poses a risk of

incapacitation or debilitating complication, and any condition requiring medication that

54 Grounding of the Liberian Passenger Ship Star Princess on Poundstone Rock, Lynn Canal, Alaska,

June 23, 1995, Marine Accident Report NTSB/MAR-97/02 (Washington, DC: National Transportation

Safety Board, 1997).

55 Also listed in Coast Guard references as COMDTPUB.P16700.4.
Factual Information 44 Marine Accident Report

impairs judgment or reaction time, is potentially disqualifying and requires a detailed

evaluation before the mariner will be considered fit to qualify for a license.

Mariners who develop disqualifying physical conditions before their next

scheduled physical examinations are not required to inform the Coast Guard. However, if

the Coast Guard becomes aware that a licensed mariner has developed a disqualifying

physical condition, it would investigate the situation and possibly begin suspension and

revocation proceedings. The Coast Guard has no formal mechanism that allows physicians

or other interested persons to notify them of a mariner who has a disqualifying physical

condition. 

Because of the manner in which data from medical evaluations are maintained, the

Coast Guard cannot examine trends in form 719K results. Limitations in the data storage

system prevent the Coast Guard from categorizing the results to determine trends in the

findings of examining physicians, the number of applications completed by a single health

practitioner, or the percentage of applicants found physically qualified by individual

health practitioners. In addition, the Coast Guard does not compare the results of reviews

by its own RECs to determine the extent of commonalities or differences in the review

process. Coast Guard personnel engaged in the review of mariner medical evaluations

indicated to Safety Board investigators that the RECs may not be consistent in their

approval or denial decisions for identical medication use.

Applicants who choose to provide the results of the examinations to the Coast

Guard send them to the nearest REC. There, evaluators review the results of the completed

evaluations according to policy, regulations, and guidance published in the Coast Guardís

Marine Safety Manual and in NVIC No. 2-98. According to personnel at the National

Maritime Center, after receiving the results of the medical evaluations, REC evaluators

place the results into one of three categories, in which applicants are found to be (1)

physically qualifiedóa medical approval would thus be granted, (2) not qualifiedó

approval would thus be denied, or (3) not qualified but by a ìvery minorî disqualifying

factor. Applicants with ìvery minorî disqualifying conditions may be granted waivers

after demonstrating that they can perform the job safely. Personnel at the National

Maritime Center said that REC examiners would forward applications from mariners with

ìvery minorî disqualifying conditions to the National Maritime Center, with the

recommendation that a waiver be granted. Examiners at the National Maritime Center

would then further review the application and, if still uncertain, would forward the

application to one of two medical officers, who would make the final determinations. 

Of the 50,000 to 60,000 applications that the Coast Guard is estimated to receive

annually, National Maritime Center personnel estimated that 1,200 to 1,400 are sent to the

center for further review. The Coast Guard keeps no central record of the number of

applications that are denied. National Maritime Center personnel informed the Safety

Board that the Coast Guard plans to centralize the medical evaluation process, with a

hoped-for date of 2007 to implement the change.

The Coast Guard retained two physicians, both permanently employed by the

Public Health Service but assigned to the Coast Guardís National Maritime Center, to
Factual Information 45 Marine Accident Report

make the final determination regarding the approval of a marinerís physical condition.

The physician in charge of these determinations was the Coast Guard personnel command

senior medical officer. The senior medical officer told Safety Board investigators that he

had no formal training in occupational medicine.56 He stated that if he had questions

regarding whether to grant a waiver for a mariner, he relied on the marinerís health care

provider for guidance. If the health care provider considered the condition not debilitating

and one with which the mariner was able to perform his or her job, he would grant the

waiver. The senior medical officer said that he would almost always follow the guidance

of the examining or treating physician.

The Coast Guard does not maintain a list of prohibited medications. REC

examiners referred to the PDR for guidance when considering medication use. In general,

however, as long as the treating physician believed that the medication was controlling the

condition without side effects, the senior medical officer indicated that the Coast Guard

would grant a waiver. The senior medical officer considered the use of certain medications

to be disqualifying. For example, medications for sleep such as AmbienÆ or SonataÆ were

disqualifying because a mariner taking these pharmaceuticals might not be able to

function if performing nighttime duty. Similarly, use of any kind of narcotic would

disqualify a mariner because of the likelihood of drowsiness. 

The senior medical officer said that he would send the request of an applicant who

had been using the pain reliever tramadol back to the treating physician to determine

whether the applicant was drowsy as a result of the medication. Unless such information

was provided, or unless he had information from his employer or others that they observed

the person in a drowsy state, he told Safety Board investigators that he would grant the

waiver because, in his opinion, it would be very difficult to assess a potential risk of

sudden incapacitation due to medication such as tramadol.

Two weeks after Safety Board investigators met with the personnel command

senior medical officer and others at the National Maritime Center, its commanding officer

wrote to inform the Safety Board that the senior medical officer ìmisspoke at the meeting

and asked to clarify his statement.î The commanding officer stated that the physician said:

When I was asked at the NTSB Inquiry about a waiver possibility for Tramadol, I

was under the mistaken opinion that Tramadol was not a narcotic. Since the

meeting, I have checked the PDR . . . and realized that it is a narcotic. If possible,

you may want to inform the board attendees that I was mistaken and had

responded too quickly to their question. You might also add that I do refer to the

PDR when a mariner is on a medication with which I am unfamiliar.

Coast Guard personnel informed the Safety Board that the Coast Guard was

planning, in the near future, to revise the medical standards that mariners would be

required to meet. As of the date of this report, the Coast Guard had not yet issued proposed

revisions to its medical standards for licensing mariners.

56 Training in occupational medicine can range from a multiweek course to residency and board

certification.
Factual Information 46 Marine Accident Report

Safety Management Systems

A safety management system is a structured, documented system developed to

enhance the safe operation of vessels, prevent human injury or loss of life, and avoid

damage to the environment. With a safety management system, ship owners and operators

are encouraged to resolve safety problems before casualties or incidents occur (ìselfregulateî), rather than simply comply with regulations imposed from outside, which

usually means waiting for notification of defects before taking corrective action. 

Background. International safety management standards were developed in the

early 1990s in response to a number of serious marine casualties whose cause was

identified as human error or management failure and that occurred despite improvements

in engineering and technology designed to prevent them. One of the most serious was the

March 1987 capsizing of the passenger/car ferry Herald of Free Enterprise off the Belgian

coast, which killed 193 people. The investigating British justice described the ferry

managementís failures as ìthe disease of sloppiness.î57

In the aftermath of that disaster, the International Maritime Organization (IMO), a

specialized agency of the United Nations, began developing guidelines for safe ship

management, focusing at first on roll-on, roll-off ferries such as the Herald of Free

Enterprise. In May 1991, work began on what became the International Safety

Management (ISM) code,58 whose stated purpose is ìto provide an international standard

for the safe management and operation of ships and for pollution prevention.î In 1993, the

IMO decided to make the ISM code mandatory, and in May 1994, IMO members,

including the United States, adopted the ISM code as chapter 9 of SOLAS. Chapter 9 of

SOLAS went into force on July 1, 1998. On that date, the ISM code became mandatory for

the following vessels on international voyages: passenger ships, high-speed craft

(passenger and cargo) of 500 gross tons or more, tankers, and cargo carriers. For other

cargo ships, the code came into force on July 1, 2002. 

U.S. Regulations. The ISM code has the force of law in countries that are

signatories to SOLAS. In October 1996, Congress revised 46 U.S.C. chapter 32

(ìManagement of Vesselsî) to incorporate the ISM code into the laws of the United States.

In May 1997, the Coast Guard published a Notice of Proposed Rulemaking setting out

Federal regulations for safety management systems for U.S. vessels ìengaged on a foreign

voyage.î59 The proposed regulations included standards that would allow companies to

satisfy international certification requirements for safety management systems and also to

seek voluntary certification of safety management systems for U.S. domestic vessels. On

December 24, 1997, the Coast Guard issued final regulations for implementing the ISM

code (33 CFR 96, ìRules for the Safe Operation of Vessels and Safety Management

Systemsî); the final rule became effective on January 23, 1998. 

57 Department of Transport (United Kingdom), MV Herald of Free Enterprise, Report of Court No.

8074óFormal Investigation, Hon. Mr. Justice Sheen, Wreck Commissioner (London: Her Majesty's

Stationery Office, 1987).

58 The full name of the code is International Management Code for the Safe Operation of Ships and for

Pollution Prevention.

59 Federal Register, vol. 62, no. 84 (May 1, 1997), p. 23705.
Factual Information 47 Marine Accident Report

Objectives. The objectives of a safety management system, as given in 33 CFR

96.230, are as follows:

(a) Provide for safe practices in vessel operation and a safe working environment

onboard the type of vessel the system is developed for.

(b) Establish and implement safeguards against all identified risks.

(c) Establish and implement actions to continuously improve safety management

skills of personnel ashore and aboard vessels, including preparation for

emergencies related to both safety and environmental protection. 

(d) Ensure compliance with mandatory rules and regulations.

Main Elements. A safety management system aims to create a ìculture of safetyî

throughout an organization by documenting a vessel ownerís operational policy, chain of

authority, and operational and emergency procedures; specifying the responsibilities of the

owner or operator, managers, and masters; and outlining procedures for management

review, internal audits, and correction of nonconformities (failure to adhere to procedures

or regulations). Procedures are compiled in a safety management manual and a copy is

kept on board the vessel. A person or persons are designated in writing to monitor the

safety management system, and managers conduct regular audits to ensure that employees

follow the procedures. Checklists are supplied for critical areas. When deficiencies are

noted or an accident or a nonconformity occurs, corrective action is taken until the

problem is resolved, and the problem is documented from start to finish. 

Application. The Federal regulations for safety management systems apply to

U.S. vessels ìengaged on a foreign voyageî that carry more than 12 passengers or that are

tankers, bulk freight vessels, or mobile offshore drilling units of 500 gross tons or more

(33 CFR 96.210). The regulations do not apply to barges, recreational vessels not engaged

in commercial service, fishing vessels, vessels operating only on the Great Lakes or its

tributary and connecting waters, or public vessels. The Staten Island Ferry was not

required to comply with the regulations because it operates on a strictly domestic route.

Requirements. Operators whose vessels fall under the Federal regulations must

prepare internal audit reports that demonstrate compliance with the ISM code (33 CFR 96

subpart B). They must also hold a valid Document of Compliance certificate and a Safety

Management Certificate as evidence of compliance with the ISM code (33 CFR 96 subpart

C). Organizations can be authorized by the Coast Guard to act on behalf of the United

States to perform safety management audits and certification (33 CFR 96 subpart D). 

A complete list of documents required for a safety management system under the

Federal regulations is found at 33 CFR 96.250. Briefly, they include the following:

(a) Safety and environmental impact statements, which are to be carried out and

kept current at all levels.

(b) Statements of responsibilities and authority.

(c) Designation in writing of a person or persons to monitor the safety

management system.
Factual Information 48 Marine Accident Report

(d) Written statements defining the masterís responsibilities and authorities.

(e) Written statements that the master has overriding responsibility and authority

to make vessel decisions.

(f) Personnel procedures and resources available on shore and on board ship.

(g) Vessel safety and pollution prevention operation plans and instructions for key

shipboard operations.

(h) Emergency preparedness procedures.

(i) Reporting procedures on required actions.

(j) Vessel maintenance procedures.

(k) Safety management system document and data maintenance.

(l) Safety management system internal audits that verify the vesselís safety and

pollution prevention activities.

Audit Procedures. The ISM code requires companies to demonstrate how safety

is managed on shore and on its vessels, through both internal and external audits. Internal

audits allow companies to measure the effectiveness of their own systems. Companies

prepare their own internal procedures for auditing their safety management systems,

setting out the objectives, scope, and responsibilities involved. They develop an audit

schedule that specifies which ships and office locations to audit and target dates for

carrying out and completing the audits. Reporting lines are clearly defined and reports are

distributed to all relevant personnel.60

External audits are performed at the request of the operating organization by an

approved outside organization, usually a marine classification society, for a fee paid to the

auditor by the requestor organization. The external auditor reviews the results of the

operating organizationís internal audits and all elements of its management system. The

auditor questions management and vessel crews about their knowledge of the system,

examines safety records, and verifies that procedures are followed. It may take an entire

day to audit one vessel. If the audit is successful, a Safety Management Certificate is

issued and the ship can continue operations. If critical areas have deficiencies, a vessel

operator can lose its Document of Compliance.

Voluntary Compliance. Under 33 CFR 96.110(b), vessel operators that are not

required to comply with the ISM code can voluntarily meet the standards and have their

safety management systems certificated. Guidance for voluntary compliance is provided

in Coast Guard NVIC 5-99.61 As stated in the NVIC, ì33 CFR 96 is the basis for the

requirements of a voluntary safety management system.î However, as outlined in the

60 For further information, see Guidelines on the Application of the IMO International Safety

Management (ISM) Code, 3rd ed. (London: International Chamber of Shipping and International Shipping

Federation, 1996), pp. 34-51.

61 U.S. Coast Guard, ìGuidance Regarding Voluntary Compliance with the International Management

Code for the Safe Operation of Ships and for Pollution Prevention (International Safety Management [ISM]

Code),î NVIC 5-99 (Washington, DC: U.S. Department of Transportation, 1999).
Factual Information 49 Marine Accident Report

Coast Guardís Marine Safety Manual, an equivalent to ISM code compliance has been

established for small passenger vessels, certificated under 46 CFR subchapter T, for which

full accordance with 33 CFR 96 would be ìtoo extensive.î62 The Coast Guard has

prepared guidance documents (booklet and computer disc) for use in developing

equivalent safety management systems. Vessel operators must apply in writing to

participate in the equivalent safety management program.

Conclusion. The Coast Guard concluded from its casualty studies that ìin excess

of 80 percent of all high consequence marine casualties may be directly or indirectly

attributable to the ëhuman element.íî The Coast Guard stated that ìthe use of safety

management systems by all U.S. commercial vessels would result in significant benefits

and we will support the development of such programs.î However, it also noted that

ì46 U.S.C. 3202 . . . does not provide the Coast Guard with the authority to require such

safety management systems on these U.S. domestic vessels.î63

Other Ferry Systems

Nationwide. According to the National Ferry Database, ferry systems operate in

40 of the 50 States, plus Puerto Rico, the Virgin Islands, and the Northern Mariana

Islands.64 The American Public Transportation Association (APTA) counts about 30

metropolitan areas and small cities in the United States that offer transit ferry service

across rivers or bays or to offshore islands, where bridges or other modes of transportation

are nonexistent or impractical.65 In Alaska, ferries operated as part of the Alaska Marine

Highway System connect areas along 8,000 miles of coastline that are not linked by roads. 

Some of the ferries are privately owned, some publicly owned, and some represent

public/private partnershipsóusually, a public transit authority contracting with a private

company that owns and operates the vessels. The vessels include vehicle ferries, which

carry both vehicles and passengers; passenger-only ferries, which may carry bicycles in

addition to pedestrians; and water taxis, which are very small passenger-only ferries that

operate on fixed routes or provide on-demand service. 

APTA statistics show that ferries operated by 42 transportation agencies carried

nearly 58 million passengers in 2002, with an average trip length of 5.8 miles and total

passenger miles of 333 million. According to APTA, the largest number of ferry operators

are found in New York/New Jersey, San Francisco Bay, and the Boston area. In the San

Francisco area, voters have approved funding for a major ferry expansion that, it is hoped,

62 U.S. Coast Guard, Marine Safety Manual, vol. II, section E, chapter 3, ìSafety Management Systems

(SMS)î (revised May 2000), pp. E3-13ñE3-15. 

63 The Coast Guard published these statements in its discussion of the final rule for 33 CFR 96 (Federal

Register, vol. 62, no. 247 [December 24, 1997], pp. 67492 and 67503).

64 National Ferry Database, U.S. Department of Transportation, Bureau of Transportation Statistics

<http://www.transtats.bts.gov/Tables>. The database lists 224 ferry operators, including those that operate

small ferries, many cable-operated, that carry 4 to 6 cars or farm equipment across rivers or canals on

backroads not served by bridges.

65 Information obtained from APTA website <http://www.apta.com/research/stats/ferry/fbagency/cfm>

(accessed December 12, 2004). 
Factual Information 50 Marine Accident Report

will relieve traffic congestion on bridges and highways. By 2025, the San Francisco Bay

Water Transit Authority plans to triple annual ferry ridership to 12 million, adding 31 new

ferryboats and 7 new ferry routes.66 As shown in table 2, annual ferry ridership exceeds

1 million in five urban areas of the country, with the largest ferry operation being the

Washington State Ferries.

Table 2. Largest U.S. urban ferry operations (annual ridership over 1 million).

SOURCE: APTA website <http://www.apta.com/research/stats/ferry/fbridership>; also, for Seattle 

<http://www.wsdot.wa.gov/ferries>; San Francisco <http://www.watertransit.org, http://www.baycrossing.com>, personal 

communication, San Francisco Bay Area Water Authority; New Orleans <http://www.dotd.state.la.us>; Boston 

<http://www.bostonharborcruises.com>, <http://www.harborexpress.com>, personal communication, Massachusetts Bay 

Transportation Authority, Boston Harbor Cruises. 

a San Francisco Bay Area Water Transit Authority, charged with expanding transportation service, has no authority over 

existing commuter ferry operations: city of Alameda/Port of Oakland, city of Vallejo Baylink Ferry, Blue and Gold Fleet, and 

Golden Gate Bridge, Highway and Transportation District. 

Washington State Ferries. The largest ferry system in the United States, in terms

both of ridership and vessel size, is the Washington State Ferries, owned and operated by

the Washington State Department of Transportation. The ferries carry over 26 million

passengers a year across Puget Sound and its inland waterways, serving eight counties in

Washington State and in British Columbia, Canada. One of the largest vessels in the

Washington fleet, the Wenatchee in the Jumbo Mark II class, is 450 feet long and carries

2,500 passengers on 35-minute commuter runs in the harbor between Seattle and

Bainbridge Island, Washington. The ferry system has over 1,800 employees, 20 terminals,

and 29 vessels of various sizes. All but one of the routes carries cars. The ferries charge

fares for passengers and cars.

66 <http://www.watertransit.org/about_us.shtml> (accessed December 30, 2004).

Transit 

Authority/Operator

Area Served

Annual 

Ridership 

(million)

Number 

Vessels

Maximum Vessel 

Capacity 

Waterway (passengers)

Primary 

City 

Washington State 

Ferries

Puget Sound Seattle 26 29 2,500

Staten Island Ferry New York 

Harbor

New York 

City 

19 7 6,000

(a) San 

Francisco 

Bay

San 

Francisco

4 14 788

Louisiana 

Department of 

Transportation, 

Crescent City 

Connection Division

Lower 

Mississippi 

River

New 

Orleans

3.1 5 1,000

Massachusetts Bay 

Transportation 

Authority (Harbor 

Express and Boston 

Harbor Cruises)

Boston 

Harbor

Boston 1.3 11 400
Factual Information 51 Marine Accident Report

All mariners employed by the Washington State Ferries are documented by the

Coast Guard. Deck officers all have pilotage endorsements for Puget Sound and crews

receive basic safety training, including advanced firefighting. The ferry management uses

a comprehensive computer system that tracks employee qualifications and ensures that

certificates are up to date. Deck officers, for example, receive letters 90, 60, and 30 days in

advance of the due date for their required annual physicals.

Washington State Ferries operate under a comprehensive safety management

system that specifies procedures for the entire fleet, for each particular vessel, and for each

route (appendix D reproduces the tables of contents for the various safety management

system manuals). The procedures include bridge manning and approach speeds to the

dock. For example, on the Wenatchee run, the ferry is required to slow 0.7 mile from the

terminal and the quartermaster is required to steer until 0.3 mile from the dock, when

either the captain or the chief mate takes manual control. At the terminal, the second mate,

bosun, and able-bodied seaman attend to the discharge of vehicles and loading of vehicles

and passengers. Time at the terminal is about 15 minutes, and after the gates close, a strict

sequence of commands begins. Once under way, the second mate plays a recorded safety

briefing for passengers. 

New radar equipment is installed on the Washington State Ferries every 5 years.

The newest radars have AIS technology integrated into the display. The ferries have a 24-

hour communication system that is always manned. Ships are tracked by means of AIS

every 3 minutes and monitor a single VHF frequency. Management is exploring a new

vessel-tracking system that will capture AIS data from all nearby traffic, and is also

investigating a wireless radio network and a computerized intranet that could be used in

conjunction with the safety management system. 

British Columbia Ferries. The British Columbia Ferries of Canada is one of the

largest ferry services in the world, with 25 routes, 35 ships, 47 terminals, and 4,500

employees. All vessels in the fleet carry both passengers and cars, transporting 21 million

passengers and 8 million vehicles a year. The ferries make over 500 runs a day. The two

largest vessels, the Spirit of Vancouver Island and the Spirit of British Columbia, can carry

2,100 passengers and crew and 470 cars. The fleet includes eight other vessels with a

capacity of between 1,000 and 1,700 passengers and crew. Most of the large vessels have

runs that last nearly 2 hours. British Columbia Ferries have served British Columbiaís

coastal communities for 44 years. In 2003, the company converted from a Crown

corporation (corporation owned by the government) to an independent, regulated

company, which in 2004 announced a long-term plan to introduce 22 new vessels over the

next 15 years.

British Columbia Ferries began implementing a safety management system in

1995 after an accident in Departure Bay that resulted in passenger fatalities. The safety

management system, which is not mandatory because the ferries run inside Canadian

waters, includes a bridge watch table that specifies the number of persons in the pilothouse

for various vessels, routes, and conditions (see appendix E for a sample procedure).

Specific procedures for arrival and departure are detailed, even stipulating the precise

words to be used in radio transmissions. 
Factual Information 52 Marine Accident Report

Two of the largest British Columbia ferries are now equipped with electronic chart

systems, and the ferries are considering a 24-hour communication center like that of the

Washington State Ferries. For emergency medical care on board, the ships have a full

emergency kit with a trauma kit, drugs, and defibrillator. On some longer runs in remote

areas, a doctor or paramedic is carried on board.

Passenger Vessel Association

The Passenger Vessel Association (PVA) is an association of small passenger

vessel owners and operators in the United States. The organization serves the interests of

more than 350 vessel owners and operators in the domestic passenger vessel industry,

which represents about 65 percent of the industry nationwide. Association members

operate more than 1,100 passenger vessels in the United States carrying up to 200 million

passengers annually. Members offer services including dinner cruises, tour and excursion

services, car and passenger ferries, private charters, whale-watching trips, overnight

cruises, and riverboat gaming. According to the National Ferry Database, about 45 ferry

companies across the United States are PVA members. 

The PVA has a committee responsible for reviewing, developing, and

implementing programs to encourage enhanced training and safety among its members.

The programs are designed to improve the loss record for the industry. The PVA publishes

risk management and training manuals to help its member companies improve the safety

of their passenger vessel operations. 

Actions Since Accident

After the Andrew J. Barberi accident, the NYC DOT requested the Global

Maritime and Transportation School (GMATS) at the U.S. Merchant Marine Academy to

conduct an assessment of the Staten Island Ferry with respect to vessel operations, human

factors, safety, and management. The GMATS assessment was completed in February

2004 (appendix F). Among its recommendations, the assessment called for the

establishment of a safety management system; standard manning with three licensed deck

officers, so as to provide certainty that two licensed deck officers would be in the

pilothouse at all times; significant increases in personnel; greater emphasis on technical

training and professional development; the creation of specific operating procedures; the

use of technology to assist in navigation; and an immediate upgrade in the systemís ability

to respond to emergency conditions or mass casualty events.

Staten Island Ferry officials informed the Safety Board by letter on July 9, 2004,

that they had changed or planned to change various aspects of the ferry operations.

According to the letter, ìmost of [the planned improvements] revolve around the

establishment of a Safety Management System.î At the time, officials estimated that it

might take 2 years to develop and implement such a system. The system would address

ìall aspects of vessel operations, safety and emergency response, and maintenance.î

Improvements already implemented were listed as installation of global

positioning system (GPS) units, ARPA collision avoidance equipment, and automated
Factual Information 53 Marine Accident Report

passenger announcement systems. Training programs had been established for the new

equipment, according to the letter. Further, new procedures designated specific stations

and responsibilities for crewmembers, both while under way and while docked. Ferry

management was reportedly reviewing scheduling and medical response capabilities. Rest

periods had been established for deckhands and crewmembers had been issued walkietalkies and uniforms.

In an update received on February 11, 2005, the NYC DOT informed the Safety

Board that it intends to follow the GMATS recommendations.67 According to its letter, the

agency has embarked on ìan aggressive hiring program,î has installed safety equipment

on ferries, and has retained a firm to develop its safety management system. The NYC

DOT further stated that it has already revised manuals and that new policies and checklists

have been drafted, with some already in place. Currently, October 1, 2005, is set as the

date for completion of the safety management system, with a target of December 2005 for

receiving a Document of Compliance from the American Bureau of Shipping. Bridge

team procedures already stipulate the use of three licensed officers, with two in the

pilothouse at all times. All ferries are now equipped with GPS, ARPA, and AIS

capabilities.

67 Discussions between the Safety Board and NYC DOT personnel indicate that certain of the

automated equipment recommended by GMATS actually requires manual activation, including the

prerecorded passenger announcements (already installed) and the ìvessel speed indicators with alarm

functionsî (planned for installation).
54 Marine Accident Report

Analysis

General

The analysis first identifies factors that can be readily eliminated as causal or

contributory to the Andrew J. Barberi accident. It then discusses what the Safety Boardís

investigation revealed about the actions of the assistant captain and the captain, NYC

DOT oversight of ferry operations, medical oversight of mariners, safety management

systems, and the potential contribution of navigation technology to the safety of ferry

operations.

Exclusions

The evidence indicates that the Andrew J. Barberiís propulsion systems,

propulsion system controls, and main engines functioned without defect before, during,

and after the accident. The assistant engineer on watch during the accident stated that the

vesselís two propulsion drives and related controls performed without fault and that he

had a ìvery normal watchî before the accident. No plant alarms sounded to indicate a

propulsion problem before the allision. After the accident, the captain had complete

control of the propulsion system in maneuvering the vessel to slip 5, and the propulsion

system effectively held the vessel tight against the dock there for an hour or more. Further,

the transfer of control from pilothouse to pilothouse was carried out without incident, and

the Safety Boardís postaccident testing found that the ferryís propulsion systems

responded correctly to commands from both pilothouses.

National Ocean Service data for the New York/New Jersey harbor indicate that the

tide was ebbing, and according to the National Weather Service, visibility was at least

10 miles in the area. The wind was strongónearby winds were from the west, measured at

20 knots with gusts of up to 35 knots. Nonetheless, the wind velocity had no adverse effect

on the shipís handling ability or on the ability of the shipís operators, both the captain and

assistant captain, to control it. According to the senior mate in the pilothouse, he heard ìno

complaintsî from either operator about the wind affecting control of the ferry. 

Except for the assistant captain, the ferryís crew submitted blood and urine

specimens to the Coast Guard and to the NYPD for toxicological testing shortly after the

accident. The Safety Board obtained a blood and a urine sample taken from the assistant

captain when he was admitted to the hospital about an hour and a half after the accident.

Results for all Andrew J. Barberi crewmembers were negative for both alcohol and the

five illicit drugs that U.S. Department of Transportation regulations require screening for.

Therefore, the Safety Board concludes that none of the following were factors in the

accident: the vesselís propulsion systems, environmental conditions, alcohol, or illicit

drugs. 
Analysis 55 Marine Accident Report

Accident 

The vessel departed Manhattan at 1500 and struck the pier about 1520. According

to both crewmembers and passengers, the ferry was operating at full speed when it allided

with the maintenance pier. Witnesses stated that the vessel never slowed down or altered

direction, and that the engine sound changes that crewmen and regular passengers

routinely heard when the engines slowed down before docking were not heard. The chief

engineer stated that the pitch was at 100 percent at both ends of the vessel and never

changed before the ferry hit the pier. The Safety Board, therefore, concludes that the

Andrew J. Barberi was operating at full speed when it struck the maintenance pier. 

According to the lookout and the senior mate, the lookout and the assistant captain

were in the Staten Islandñend pilothouse when the senior mate joined them halfway

through the transit. Both the lookout and the senior mate reported that the assistant captain

had been conversing with the lookout during the transit until just before the ferry reached

the KV buoy, when the lookout left the pilothouse and while the mate was reading a

newspaper. The mate told investigators that the captain entered the pilothouse after the

accident. Neither the lookout nor the senior mate recalled seeing the captain in the

pilothouse before that, from the time the ferry left Manhattan until after the accident. From

the circumstances of the accident and the statements of the crew and other witnesses, the

evidence indicates that the captain was not in the pilothouse until after the allision.

Therefore, the Safety Board concludes that at the time of the accident, the assistant captain

was at the controls, the senior mate was seated in the aftmost section of the pilothouse

reading a newspaper, and no one else was in the pilothouse at the ferryís Staten Island end. 

The evidence is clear that the assistant captain made no changes before the impact

to slow or change the ferryís course for the approach to the terminal, as he should have

done near the KV buoy. Immediately after the accident, he told the chief engineer that he

had ìblacked outî and then told the ferry director that he had ìpassed out.î His

postaccident medical records noted that he told hospital physicians that he ìsuddenly

passed out,î although the records also indicated that he had no recollection of the events

surrounding the allision. In addition, he told physicians that he was ìexhausted,î though

ìno more exhausted than usualî at the time of the accident. 

According to the senior mate, immediately after the impact he observed the

assistant captain standing, making an exclamation, and actively manipulating the controls

to maneuver the vessel away from the dock. In the estimated 1- to 2-minute period after

the ferry passed the KV buoy, when speed and course should have been changed, visual

cues to the impending allision would have been unmistakable. The assistant captain would

have needed no information other than the increasing proximity of the maintenance pier to

tell him what he needed to do to avoid the accident. The mateís description of the assistant

captain as standing and alert immediately after the impact indicates that the assistant

captain was conscious at that time. Had he lost consciousness, he most likely would have

fallen. Even though he was aft in the pilothouse reading, the senior mate would most

likely have noticed such a fall because people perceive a change, such as someone falling,

more readily than they do the absence of change. Therefore, the Safety Board concludes
Analysis 56 Marine Accident Report

that the assistant captain was apparently upright but unresponsive to his surroundings and

the visual cues of the impending allision for an estimated 1 to 2 minutes before the

accident. 

The distance between Manhattan and the Staten Island pier is 5.2 miles (9,152

yards). At the vesselís normal crossing speed of between 14 and 16 knots, the ship would

travel roughly a quarter of a mile (440 yards) in 1 minute. The normal length of a transit is

about 21 minutes and the accident voyage lasted approximately 20 minutes, an elapsed

time that was within the routine range for the transit.

According to what they told investigators, mates and deckhands typically prepared

for docking at Staten Island on hearing the sounds associated with the engines slowing

down, which generally occurred near the KV buoy, about 1,000 yards from the dock.

Although one of the deckhands would ordinarily have made an arrival announcement, on

the accident voyage no crew announcement was made. Passengers and crew typically

recognized the impending docking by the changes in the sounds associated with the

engines. In the absence of the engine sound changes and a prearrival announcement, only

one crewmember recognized the projected path of the vessel. Thus, only one deckhand

warned passengers of the impending allision. The other crewmembers were unaware of

the impending allision and took no action to warn either passengers or other crew or to

prepare them for the accident. Therefore, the Safety Board concludes that the crew did not

recognize that the ferry was in danger because of the absence of changes in sounds that

they typically used as cues for arrival, because they were not attending to visual cues

outside the vessel, and because of the absence of any crew announcement or alert. 

Assistant Captain

The Safety Board examined the nature of the assistant captainís unresponsiveness

to clear visual cues that the vessel was about to crash in an attempt to determine why he

failed to prevent the allision, given his consistent, superior employment history with the

NYC DOT. Although he did not agree to cooperate with the Safety Board, the Board

obtained considerable information about his work history because his wife agreed to be

interviewed, his daughter provided the Board with information, and coworkers and

supervisors gave information about his work habits and history. In addition, the Board

examined pertinent NYC DOT personnel records and medical, dental, and pharmaceutical

records. 

The Safety Board sought to determine whether a medical or behavioral

explanation could account for the assistant captainís episode of unresponsiveness on the

day of the accident, in light of the absence of any similar documented episode in his years

with the NYC DOT. The senior mate, the only person present during the period of the

assistant captainís unresponsiveness, told the Safety Board that when he looked up

immediately after the allision, the assistant captain was standing at the controls. The

lookout who had left the pilothouse near the KV buoy described the assistant captain as

fully responsive and effectively performing the duties of vessel operator while he was in
Analysis 57 Marine Accident Report

the pilothouse. The senior mate and the lookout were the only two crewmembers to have

seen the assistant captain just before the accident. None of the other crewmembers who

saw him on the day of the accident remarked to Safety Board investigators on anything

unusual about the assistant captainís behavior. His wife, who saw the assistant captain

about 3 hours before the accident, said that his behavior was normal and unremarkable at

that time. 

The Safety Board studied the assistant captainís sleep, work, and medical history

to determine whether fatigue contributed to his actions. Several factors, such as his

medication use, history of insomnia, and chronic back pain may have been associated with

fatigue. On the other hand, the assistant captainís work and sleep schedule were not

consistent with someone who was fatigued, making it difficult to determine whether his

actions were affected by fatigue. 

The assistant captain had been diagnosed with chronic back pain and had been

taking a prescribed pain reliever, tramadol, for several years. A side effect of this

medication, as documented by the manufacturer, is an increased risk of seizures. The

episode that the assistant captain experienced was potentially consistent with a brief,

nongeneralized seizure, with symptoms such as the temporary inability to maintain normal

awareness of and contact with the environment. Episodes such as these are usually

followed by a full recovery of alertness after a transition that can last anywhere from

seconds up to an hour. However, other factors, such as the lack of information regarding

when the assistant captain had last taken tramadol, the lack of a previous reported seizure,

and the absence of supporting evidence from extensive neurological and cardiovascular

tests, do not support such a determination. 

A postoperative cardiac examination after the assistant captainís suicide attempt

found a congenital heart abnormality (patent foramen ovale). The defect, which would not

have been detected in routine cardiac examinations and would not have affected his dayto-day activities or his job performance, increased the likelihood of a transient ischemic

attack (TIA) or ìmini-stroke,î a condition that might have matched the symptoms that the

assistant captain manifested at the time of the accident. TIAs by definition do not result in

lasting changes to the brain. Both seizures and TIAs cause similar effectsóa temporary

loss of responsiveness, with or without concurrent physical manifestationsóand both

leave no evidence of their presence afterward. Given the absence of evidence from the

extensive cardiological and neurological examinations that the assistant captain underwent

following his suicide attempt, as well as the absence of evidence to allow a determination

of fatigue or other physiological or behavioral condition, the Safety Board is unable to

determine what, if any, medical or behavioral factor, alone or in combination, led to the

assistant captainís failure to respond to the cues of the impending allision. Although these

medical events are somewhat consistent with the assistant captainís actions in the minutes

preceding the accident, none is especially compelling, and there are insufficient data to

determine which, if any, might have occurred. Therefore, the Safety Board concludes that

the cause of the assistant captainís unresponsiveness to cues clearly indicating an

impending allision could not be determined. 
Analysis 58 Marine Accident Report

Yet, several of the assistant captainís known medical conditions and medications

should have called into question his ability to pilot a vessel safely. In particular, the

assistant captain had chronic back pain, continuously treated with tramadol, a potentially

impairing medication that had the additional risk of increasing the likelihood of seizures.

In addition, he was being treated for a variety of other ailments (high blood pressure, high

cholesterol, insomnia) by several physicians and dentists and had regularly taken

medications prescribed by those health practitioners. Although the assistant captain

performed effectively before the accident and consistently received good evaluations of

his performance as a ferry captain and assistant captain, some of his medical conditions

and medication use increased the likelihood of incapacitation or impaired performance. In

a safety-critical system such as the Staten Island Ferry, operator performance without

medical oversight is unacceptable; the associated risk of a potentially catastrophic

accident is too high. At the time of the accident, the NYC DOT took no role to ensure the

continued medical fitness of its ferry captains and assistant captains, but instead, relied

entirely on the Coast Guard regulations covering licensed mariners and Coast Guard

enforcement of those regulations.

Nonetheless, the assistant captain and his physician omitted critical information

regarding details of the assistant captainís medical conditions and treatment on form 719K

used for Coast Guard medical evaluations. Consequently, the Coast Guard was effectively

prevented from performing the requisite evaluation of the assistant captainís medical

fitness to serve as ferry operator. In each of the evaluations submitted to the Coast Guard,

the assistant captain and the examining physician indicated that the assistant captain was

not taking medication and had no medical condition that required the use of medication.

As a result of their false information, the Coast Guard was never afforded the opportunity

under its current medical oversight system to evaluate the compatibility of the assistant

captainís medical conditions and medication use with his duties. In his appearance before

a Federal judge over a year after the accident, the assistant captain pleaded guilty to

knowingly submitting false medical information to the Coast Guard.68 Therefore, the

Safety Board concludes that because accurate medical information about the assistant

captain was not provided to the Coast Guard by the assistant captain and his physician, the

Coast Guard had no opportunity to evaluate his fitness to maintain his marinerís license. 

Medical Oversight

The Coast Guard has the responsibility to oversee compliance with regulations

governing the medical qualifications of licensed mariners. Licensed deck and engineering

officers are required to undergo medical evaluations every 5 years. Able-bodied seamen,

ordinary seaman, food handlers, and those without critical responsibility for vessel

operation need only meet a partial list of medical requirements. For pilots of vessels over

1,600 gross tons, Coast Guard regulations at 46 CFR 10.709 require ìthorough physical

68 The false information was that the assistant captain did not suffer from any illnesses and was not

taking any medication. As noted earlier, the examining physician was indicted for his role in providing false

information about the assistant captain on the Coast Guard form.
Analysis 59 Marine Accident Report

examinations each year while holding the license or endorsement.î The regulation applies

to all NYC DOT ferry captains and assistant captains because they are required to hold

pilot endorsements to their Coast Guard licenses, but there is no requirement for pilots

subject to the regulation to report the results of their annual medical appraisal, either to the

Coast Guard or to their current employer. The Coast Guard regulation merely calls for

mariners to provide the Coast Guard with a copy of their most recent physical examination

on request. 

In the absence of any interval reporting requirements, a marinerís medical status is

reviewed only every 5 years, during which time he or she could experience new medical

symptoms, see a health care provider, take new medications, or be hospitalized. The Coast

Guard maintained no record of annual medical evaluations of mariners in its New York

jurisdiction, and the NYC DOT did not maintain records of its employeesí compliance

with this requirement. 

In addition to the absence of any review of the annual physical examination

required of licensed pilots, the Coast Guard does not provide guidance on acceptable

methods of meeting its requirements for the annual review. The Coast Guard does not

provide information on the thoroughness of the examination, nor does it give guidance to

examiners performing the annual evaluation. The Safety Board is concerned that the lack

of specificity in fulfilling the annual evaluation requirements, compared with the thorough

requirements delineated in form 719K for the 5-year evaluation, may inhibit effective

compliance. Therefore, the Safety Board believes that the Coast Guard should revise

regulation 46 CFR 10.709 to require that the results of all physical examinations be

reported to the Coast Guard, and provide guidance to mariners, employers, and mariner

medical examiners on the specific actions required to comply with these regulations. The

Safety Board further believes that the NYC DOT should require its licensed pilots to

provide proof of compliance with the Coast Guard medical certification requirements. 

In attempting to determine the medical status of the assistant captain, the Safety

Board found additional shortcomings in the Coast Guardís system of medical oversight of

mariners. For example, headquarters Coast Guard personnel overseeing the medical

evaluation process knew little about the quality of regional reviews of medical

evaluationsóthe initial, and for most mariners, the final evaluator of the results of

medical examinations. Consequently, differences between regions in their reviews and

determination of fitness may be present and undetected, potentially having an adverse

effect on the reliability of the medical oversight system. 

The Safety Board also noted potential difficulties with the Coast Guardís storage

of medical data. The data maintained in the medical data storage system could provide the

Coast Guard with valuable information about changes in marinersí medical fitness over

time, across regions of the country, between different health care providers, or in any

number of other critical areas. However, deficiencies in the data storage system make it

impossible for the Coast Guard to discern even these most basic measures of medical

oversight or mariner medical status. Coast Guard representatives informed the Safety

Board that they hoped to modernize and centralize the data storage system within 4 years
Analysis 60 Marine Accident Report

of this accident. The Board hopes that the Coast Guard meets this objective at the earliest

opportunity.

Finally, the Coast Guardís senior medical officer, the final authority in the Coast

Guardís mariner medical oversight process, told Safety Board investigators that he had no

formal training in occupational medicine. Given the importance of his responsibility as the

final determiner of a marinerís medical qualification to obtain a license, this lack of formal

training is discouraging.

Despite the number of shortcomings in the Coast Guard system of medical

oversight identified during the investigation, the Safety Board determined that none of the

problems played a role in the Andrew J. Barberi accident. The Safety Board, therefore,

concludes that while the Coast Guardís system of medical oversight has deficiencies, they

were unrelated to the accident. Nevertheless, the Safety Board found the elements

necessary for an effective system of medical oversight within the Coast Guard medical

oversight system:

ï Evaluation form with specific guidance for examiners.

ï Actual authority over certification of medical fitness, rather than delegation of

such authority to examiners.

ï Retention of the data from the exams that mariners submit. 

Form 719K provides considerable information to examiners and, if read

thoroughly before an examination, should facilitate the examinerís task. The Coast Guard

also makes the determination regarding the medical fitness of mariners, rather than

delegating this decision to the examining health care practitioner. In addition, it retains the

data from the evaluations. Thus, the Coast Guard has the foundation on which to build an

effective medical oversight system. Therefore, the Safety Board recommends that the

Coast Guard, in formal consultation with experts in the field of occupational medicine,

review its medical oversight process and take actions to address, at a minimum, the lack of

tracking of performed examinations; the potential for inconsistent interpretations and

evaluations between medical practitioners; deficiencies in the system of storing medical

data; the absence of requirements for mariners or others to report changes in medical

condition between examinations; and the limited ability of the Coast Guard to review

medical evaluations made by personal health care providers. 

New York City Department of Transportation

The Safety Board sought to determine whether this accident reflected a set of

operating deficiencies unique to this trip, or whether the accident resulted from a systemic

weakness in NYC DOT ferry operations. The evidence indicates that numerous

deficiencies were present in the Staten Island Ferry in the form of ferry operating

procedures that were poorly understood, ineffectively disseminated, inconsistently

applied, and inadequately overseen. These deficiencies adversely affected the safety of the
Analysis 61 Marine Accident Report

ferry system. Largely because of them, the assistant captain permitted the lookout, the

only other crewmember who would have been in a position to be aware of the impending

allision, to leave the pilothouse shortly before docking. Further, because the captain failed

to inform other crewmembers of his location on the ferry, did not establish

communications with other crewmembers, was absent from the pilothouse until after the

accident, failed to specify a watch in his absence, and did not exercise the oversight

responsibilities of the captain of the vessel, neither he nor any other crewmember was in a

position to prevent the accident.

Throughout the accident voyage, two qualified operatorsóthe captain and the

assistant captainówere on duty. Yet, the evidence indicates that the captain was not in the

operating pilothouse until after the accident. Further, for a substantial part of the accident

trip, three NYC DOT employeesóthe assistant captain, the lookout, and the senior

mateówere in the pilothouse, but none of them remarked on the captainís absence. Given

the circumstances, it is probable that (1) the captain considered it acceptable, both

operationally and in terms of the evaluation of his performance, to be absent from the

pilothouse for almost an entire voyage without informing any other crewmember of his

location, and (2) his absence was sufficiently commonplace to have been accepted by

those individuals without comment. 

As master of the vessel, the captain had a duty to oversee its safety. This

responsibility required him to properly oversee its crew and ensure that they performed in

a safe manner. Although he could not have realistically anticipated the assistant captainís

episode of unresponsiveness, he should have been prepared for the possibility, no matter

how unlikely. Had he properly exercised his command responsibilities, he either would

have been present in the pilothouse, informed other crewmembers of his location,

established communications with other crewmembers to enable him to exercise his

command responsibilities immediately if needed, briefed the crew on actions to take

during his absence, or taken any number of other actions that would have enhanced the

safety of the vessel. Because he did not do so, he was absent from the pilothouse and

unavailable during the assistant captainís unresponsiveness and therefore, was not in a

position to prevent the allision or to mitigate its severity. Therefore, the Safety Board

concludes that the captain failed to exercise his command responsibilities over the Andrew

J. Barberi. 

NYC DOT operating procedures for the ferries in its fleet, to the extent that they

were in effect, were contained in an 8-page handout. The procedures called for the captain

ìupon docking . . . to be [present] in the inshore pilothouse.î The Safety Board found that,

in addition to the lack of specificity regarding the captainís actions and the precise time or

point in the voyage at which he or she was to be present in the pilothouse, this requirement

was poorly understood by ferry crewmembers and ineffectively enforced by its managers.

The two supervisors responsible for the enforcement of the procedures offered conflicting

interpretations of the policy itself. One said that the captain was required to be present in

the pilothouse, the other said that the captain could determine where he or she should be

located. By contrast, the Safety Boardís examination found that procedures employed by
Analysis 62 Marine Accident Report

another large-scale ferry operator, British Columbia Ferries, unambiguously describe tasks

and statements that crewmembers critical to vessel operations are to use.

The Safety Board sought to determine why the captain was not present in the

pilothouse until after the accident, and why none of the other three NYC DOT employees

remarked about his absence. The captain refused to cooperate with Safety Board

investigators in the investigation of this accident. The Board asked numerous ferry

personnel about their understanding of NYC DOT procedures, interviewed NYC DOT

managerial personnel, and examined NYC DOT procedural documentation. Safety Board

investigators received conflicting interpretations of the existence of a requirement for the

vessel master to be present in the pilothouse after propulsion control had been transferred.

The conflicting viewpoints extended to the highest levels of ferry management. These

conflicting views were consistent with, and enabled by, the sparse documentation and

dissemination of organizational procedures.

NYC DOT operational procedures were not specific to particular phases of

operations. They were not housed in a single manual or in a readily accessible reference

location at headquarters. There was no systematic method to disseminate procedures to

operating personnel and no mechanism to record who received the procedures and when.

Further, the NYC DOT had no effective method to determine the extent to which operators

understood the procedures and implemented them during vessel operations. NYC DOT

oversight of ferry operations consisted primarily of the two port captains riding in the

pilothouses during daylight voyages, without a formal method of assessing individual

crew performance. 

The NYC DOT ferry operating procedures that were provided to the Safety Board,

which purported to cover the entire conduct of a ferry voyage, were in the form of eight

sheets of paper with no dissemination date. Although some procedures were written, they

were general and did not assign locations and specific duties to key personnel (captains,

assistant captains, and mates) for critical phases of ferry operations. To illustrate, no

procedure:

ï Prohibited lookouts from leaving the pilothouse just before docking.

ï Required the captain to enter and remain in the pilothouse for the duration of

the voyage once the transfer of propulsion control was complete.

ï Specified duties that the senior mate was to accomplish as the vessel

approached the dock. 

By contrast, procedures of other passenger-carrying ferry organizations69 contain

explicit instructions regarding actions that crewmembers are to take through all phases of

ferry operations and specific words crewmembers are to say in response to precise

commands during selected operating phases. In the Safety Boardís opinion, unambiguous,

detailed operating procedures are a prerequisite to managing a safe transportation system.

Explicit procedures provide the guidance operators need to operate the systems as

69 See appendixes D and E.
Analysis 63 Marine Accident Report

intended and ensure that regardless of the individual, the system will be controlled as

appropriate for each phase of operation. In any ferry system, each crewmember should

have duties delineated in the procedures for all operational phases, for both routine and

emergency conditions. Because people vary in their experience, training, and perceptions,

explicit operating procedures reduce the likelihood of variation in operator control of the

system. Without specific, formal procedures, effective dissemination, and operational

validation through systematic oversight, the NYC DOT could not be certain that the

ferries would be operated as intended throughout all phases of the voyages, and that

crewmembers would respond appropriately to emergency situations.

Transportation systems such as the Staten Island Ferry, in which the consequences

of operator error or equipment failure can be catastrophic, must develop and implement

ìsystem defensesî70 to (1) minimize the opportunity for operators to commit errors, and

(2) mitigate, to the extent possible, the consequences of those errors that are committed.

Redundancy is the hallmark of all safe system operation, because it can help prevent a

single-point failure, such as the error of a lone operator, from easy translation into system

failure. The stationing of two qualified operators in the pilothouse is just such a system

redundancy. Although the NYC DOT appears to have recognized its value by mentioning

in its standard operating procedures that the captain was to be present in the inshore

pilothouse ìwhile docking,î this was not pursued with the systematic rigor that is required

in repeated operations where, over time and with deceptive monotony, the need for

redundancy may not appear necessary. 

Because a redundancy requirement had not been implemented or enforced, the

captain was absent from the pilothouse and unavailable to all crewmembers until after the

allision, and the assistant captain permitted the lookout to leave the pilothouse without

clearing his absence with the captain and without securing effective backup in the

lookoutís place. As a result, no one was in the pilothouse attending to vessel operations

when the assistant captain became unresponsive and the allision occurred. Therefore, the

Safety Board concludes that the NYC DOT failed to implement and oversee safe and

effective operating procedures for its ferries. 

Safety Management Systems

In organizations that lack proactive risk reduction measures, deterioration in safety

margins in operations may go unnoticed. Organizational complacency, attention to the

economic necessities of operation rather than to the safety aspects, and the absence of

external audit and accountability can lead organizations, from the operators themselves to

the very highest organizational levels, to fail to recognize and act on risks to safe

operations until an accident occurs. In operations such as the Staten Island Ferry, where

risks can lead to catastrophic loss of life, there is little room for such complacency. Chief

among the countermeasures against organizational complacency, or system defenses as

described previously, measures that are recommended by maritime authorities (and

70 J. T. Reason, Human Error (New York: Cambridge University Press, 1990). 
Analysis 64 Marine Accident Report

required of oceangoing vessels), is an aggressive safety management system. Such a

system entails a top-to-bottom risk assessment, the development of safety-centered

practices and procedures for which documents and training are provided, and internal and

external audits to ensure consistent performance. 

The NYC DOT had performed a safety assessment before the accident,

commissioning George G. Sharp to conduct an assessment in lieu of a Coast Guard

requirement for additional lifesaving equipment on its new vessels and eventually, on all

existing vessels. That report was never intended, nor did it provide, the type of systematic,

thorough examination of operational risks necessary to lay the foundation for effective

safeguards against safety-related risks.

A safety management system necessitates a cultural change in an organization,

where the safety of operations is the objective behind every action and decision by both

those who oversee procedures and those who carry them out. The system leads to

standardized and unambiguous procedures for each crewmember, during both routine and

emergency operations. Duties and responsibilities are specified and supervisory and

subordinate chains of command delineated, again for standard and emergency operations.

Each crewmember, as a result, understands precisely what he or she is to do, and say, in

critical phases of operations. In addition, safety management systems call for the creation

of plans for responding to a range of possible emergency situations, with crewmember

duties and responsibilities specified.

As discussed previously, despite a Coast Guard requirement that vessels engaged

in oceangoing service implement safety management systems, inland ferry operators are

not required, but are encouraged, to do so. Ferries operated by the State of Washington and

the Province of British Columbia, two of the largest ferry operators in North America,

have implemented safety management systems to enhance the safety of their operations.

Comparing the documented procedures of such systems with the broad generalities and

vague responsibilities included in the NYC DOT procedures before the accident is

instructive. As illustrated in appendix E, the operating practices under such a system

include exact location of crew, specific crewmember duties and responsibilities, and even

precise language to use during critical phases of operation. By contrast, the NYC DOT

procedures were so ambiguous as to be of little use in addressing potential risks to safety.

After the accident, the NYC DOT commissioned GMATS to assess its ferry

operations. Among other recommendations, GMATS recommended that the NYC DOT

adopt a safety management system for its continued operations, and, in a July 9, 2004,

letter to the Safety Board, the NYC DOT indicated that it agreed with this

recommendation and planned to implement such a system. The NYC DOT updated the

Safety Board on its progress in a February 11, 2005, letter. It indicated that it had retained

an organization to develop its safety management system, and that it expected to have its

system completed by October 2005, with the receipt of a Document of Compliance in

December 2005. The Safety Board supports the decision and subsequent actions of the

NYC DOT to implement a safety management system and believes that they are in the

best interests of the safety of its operations. Therefore, the Safety Board believes that the

NYC DOT should adhere to its October 2005 target for implementation of a
Analysis 65 Marine Accident Report

comprehensive safety management system, incorporating all matters recommended by the

GMATS assessment, and ensuring medical fitness oversight (requiring, minimally,

assurance of compliance with Coast Guard requirements). 

Within the United States, recent data indicate that 42 ferry organizations

transported 58 million passengers annually. Despite the total size of this industry and the

very large carrying capacity of individual vessels, only organizations that operate

internationally or that have voluntarily adopted the approach operate under safety

management systems. Given the thousands of passengers who daily ride ferries on U.S.

waterways, both those that are subject to Coast Guard oversight and those that are not, the

Safety Board is concerned that the absence of a requirement to implement safety

management systems could result in the type of safety-deficient operations found in the

Staten Island ferries. With the proper legislative authority, the Coast Guard could mandate

that all ferries that carry members of the public implement a safety management system,

thereby ensuring that they maintain the high standards of safety that the Coast Guard

requires of U.S. oceangoing vessels. Therefore, the Safety Board believes that the Coast

Guard should seek legislative authority to require all U.S.-flag ferry operators to

implement safety management systems, and once obtained, require all U.S.-flag ferry

operators to do so. 

The Safety Board believes that the Passenger Vessel Association should encourage

its member ferry operators to voluntarily request application of the Federal requirements

at 33 CFR 96 for implementing a safety management system, if they have not already

done so. The Safety Board also believes that the States operating public ferries should

encourage their public ferry operators to voluntarily request application of the Federal

requirements at 33 CFR 96 for implementing a safety management system, if they have

not already done so. 

Response to Emergency

On Board Andrew J. Barberi

After the vessel struck the maintenance pier, an undetermined interval passed

before the captain entered the pilothouse and assumed control of the vessel. With the chief

engineerís assistance, the captain shifted propulsion control from the Staten Island to the

New York pilothouse, maneuvered the vessel to the dock, and docked it with the ferryís

undamaged New York end heading into its intended slip. He also directed the senior mate

to assess the damage and report back to him. The mate, however, failed to return until after

the vessel docked, and the captain did not follow up on his direction to the mate. The

Safety Board evaluated the appropriateness of the captainís actions in moving the ferry to

its intended berth after the accident rather than using the maintenance pier as the docking

pier, and the effectiveness of the crewís response to the aftermath of the accident. 

The maintenance pier is long and narrow, with dimensions that would have

interfered with the ability of numerous responding vehicles to approach the vessel and
Analysis 66 Marine Accident Report

quickly exit. In contrast, the vehicle ramp at the ferry terminal is horseshoe-shaped,

designed to allow traffic to flow smoothly and with ample space for the vehicles of the

emergency responders. Further, the ferry had no gangways other than the open-ended

ramps, so passengers would have had no means of egress to the maintenance pier and

would have had to remain on board the ferry until an alternate means of disembarking

could be found. Maneuvering the vessel to its intended dock thus allowed responders safer

and quicker access to the victims than if the vessel had docked at the maintenance pier,

and also allowed safer and quicker disembarkation of the passengers. Finally, the

maintenance pier itself was damaged, with no quickly accessible locations where the

vessel could be moored. Given the many advantages to docking at the regular slip, even at

the expense of the additional time it took, the Safety Board concludes that the captainís

maneuvering the ferry back to its intended berth was appropriate. 

The Safety Board also examined the effectiveness of the crewmembersí response

to the accident. Passengers and crewmembers told Board investigators that before and

immediately after the accident, they heard no warning sounds or public address

announcements offering information about the accident or actions to take in its aftermath,

or other information potentially useful to both passengers and crew. 

The ferryís station bill states that, in the event of an emergency, crewmembers are

to be alerted by the sounding, for at least 10 seconds, of the shipís whistle and general

alarm, with additional signals and alarms designating the location of the emergency.

However, the captain did not sound the requisite 10-second alarm, made no emergency

announcements over the public address system, gave no commands or directions to

crewmembers over the walkie-talkies or the public address system, and did not inform

passengers of the vesselís situation. 

The evidence indicates that crewmembers reacted individually to what each

immediately saw, rather than performing a coordinated response to the emergency.

However, had crewmembers attempted to coordinate a response, they would have been

hampered by the lack of communication devices. Some crewmembers had walkie-talkies,

but others did not. Without access to immediate information, even the best command and

control system would not have been maximally effective. Since the accident, NYC DOT

has issued walkie-talkies to all ferry crewmembers.

Without hearing the 10-second alarm or comparable spoken alert from the captain,

the crew did not have the signal they had been repeatedly trained to rely on to initiate a

response to an emergency. Because of the lack of an alarm or alert, some crewmembers

were unaware of the accident and did not respond until they either directly saw the need

for a response or heard from passengers or crew of the accident and the location of the

injured. The Safety Board, therefore, concludes that the failure of the captain to sound an

alarm or provide a spoken alert calling for the initiation of crew actions in response to the

emergency adversely affected the quality of the crewís response. 

During the approximately 20-minute period between the allision and the docking,

rather than awaiting instructions, three different crewmembers independently went to the

pilothouse to obtain information about the accident or the response. The captain sent two
Analysis 67 Marine Accident Report

to the engineroom because he was unable to contact the chief engineer by phone and

needed to coordinate the shift in propulsion control with the engineer. 

At the time of the accident, the engineers and oilers remained in the machinery

spaces while the remainder of the crew was dispersed throughout the vessel. According to

both passengers and crewmembers, deckhands reacted to the accident according to what

they could see and immediately assess. Some directed passengers back to the New York end

on the saloon deck of the vessel. Others tended to the injured they encountered as best they

could, then moved on to other injured passengers. Crewmembers who were located away

from the damage were unable to assess its severity unless they walked to the affected area

and saw the damage for themselves. Some had no immediate knowledge of the allision with

the pier and therefore did not immediately respond. Only one crewmember foresaw the

impending allision and warned passengers of the accident just seconds before it occurred. 

The Safety Board recognizes that the crew faced an emergency that was

considerably beyond anything they had been prepared or trained for, and one for which no

guidance was available. Many of the individual responses were ineffective, albeit well

intentioned. For example, two crewmembers ran to retrieve defibrillators, despite the fact

that they were of little use in response to the traumatic injuries the victims sustained. The

nature of many of the injuries was also beyond anything for which the crew had been

prepared, either in training or with equipment. Several injured passengers required

tourniquets to stanch severe bleeding; one deck officer applied a tourniquet to an injured

passenger using a belt and a lifejacket strap. In addition, while attempting to attend to the

injured, crewmembers also had to manage the vesselís operation, thus limiting their ability

to perform either activity effectively.

Crewmembers had minimal, if any, emergency medical training. Officers were

required to take a CPR and an advanced first aid course to be licensed. One of the mates

had received advanced emergency medical training 20 years earlier. However, because of

the extensive severe injuries the fatally injured passengers received, even the timeliest

medical treatment would not have substantially improved the likelihood of survival. As a

result, given the severe nature of several of the injuries, any shortcomings of the crew

response had little effect on the overall survivability of those most severely injured.

Although the shortcomings did not adversely affect the survivability of the injured in this

accident, had the accident occurred during rush hour, considerably more passengers would

have been on board and many more injured passengers may have needed prompt

emergency response services. The Safety Board is concerned that without improvement,

crew response to potential future accidents could compromise passenger survivability. 

Moreover, no single command and control source guided crewmembers in

responding to the emergency. Crewmembers responded as best as they could, but no single

individual directed the crew response to the accident, unlike the system that managed the

response of the shoreside emergency personnel. Consequently, crewmember response was

uncoordinated, made up of individual crewmember actions to individual passengers who

were within view. Other than the single 10-second alarm, the NYC DOT had no

procedures calling for a single source to guide the crew in assessing the emergency, and

then using that information to respond in a coordinated and effective manner.
Analysis 68 Marine Accident Report

Further, the training that the crew received was inadequate to provide for a

coordinated response to a mass casualty event. Ferry crews held weekly drills to practice

responding to an onboard fire or emergency. The drills were invariant and, over time,

elicited rote responses to predictable scenarios. Given the sameness in the scenarios they

repeatedly encountered, the crewís preparedness to respond to a scenario that was outside

the inflexible parameters used in the practice drills, let alone one of the magnitude of this

accident, was limited at best.

The Safety Board found that individual crewmembers responded appropriately to

the emergency, given limitations in resources, inadequate training, and poorly delineated

procedures, which limited the quality of their response. However, the evidence indicates

that overall, the crewís response to the accident was uncoordinated. Therefore, the Safety

Board concludes that although a superior crew response would most likely have made no

difference in the survivability of the injured, deficiencies in the NYC DOT procedures,

training, and equipment could compromise the survivability of passengers and crew in

other potential accident scenarios. 

Shoreside 

Many passengers used cell phones to notify emergency personnel of the allision. The

first 911 call was recorded at 1522. Dispatchers notified the FDNY within 2 or 3 minutes of

that, and within 5 minutes of the accident the first FDNY personnel arrived at the terminal.

Two minutes after that, the first EMS unit arrived. Even before the ferry docked, requests for

additional FDNY and EMS personnel and equipment were made as the magnitude of the

accident became apparent to some on the ferry, including an off-duty FDNY officer. The

FDNY dispatched over 200 personnel to the accident, plus nearly 60 EMS personnel, 24

ambulances, and 26 fire engine or ladder companies, plus rescue companies and support

units. Contributing to the timeliness and effectiveness of the response was the presence of

the off-duty FDNY officer who repeatedly contacted FDNY dispatchers with updates on the

nature of the emergency, and with requests for specific types of assistance.

A Coast Guard enlisted person on board the vessel notified the Coast Guard

incident command center of the accident at 1525, and Coast Guard personnel arrived on

scene before the ferry arrived at the dock. The Coast Guard response included six vessels

of various sizes that were used to search for people in the water, patrol the harbor, and

monitor the debris field created by the allision. In addition, over 300 NYPD personnel

responded, including a dive team. A total of 17 vessels from a variety of agencies,

including the NYPD, the FDNY, the Coast Guard, and the Army Corps of Engineers,

participated in the waterborne response. 

By 1543, the time the Andrew J. Barberi docked at the pier, numerous emergency

response vehicles and vessels and trained paramedics were in place to deal with the

emergency. Injured passengers and crew were promptly attended to, and those in need

were quickly transported to nearby hospitals. Given the scope of the emergency and the

timeliness and effectiveness of the response, the Safety Board concludes that shoreside

emergency response was effective. 
Analysis 69 Marine Accident Report

Navigation Technology

The Safety Board noted that, at the time of the accident, the pilothouses of the

Staten Island ferries lacked many of the common technological innovations that can assist

operators during restricted visibility conditions in determining vessel location, heading,

speed, approaching vessels, and other key navigational parameters. Modern equipment is

also available to monitor vessel condition and alert operators to recognize out-of-profile or

unsafe conditions. Vessels lacked even such basic instrumentation as speed indicators. 

Further, bridge layout was found to be suboptimal in presenting critical

information to operators. For example, radar target information was presented behind the

operator, requiring him or her to leave the controls, turn around, and lose external visual

references to see the information. These potential deficiencies, which can lead to deficient

operator performance, were noted by the GMATS assessment that was performed after the

accident at the request of the NYC DOT. The assessment suggested that the NYC DOT

acquire equipment such as ARPA, AIS, and electronic chart display and information

systems, as well as digital, multidirectional vessel speed indicators with alarm functions

that provide vessel speed information to vessel operators, including approach speed to

berths. The GMATS assessment concluded that the installation of integrated navigation

bridge systems ìwill be crucial to provide enhanced safe navigation of the vessels.î71

GMATS also recommended the accelerated installation of prerecorded, automated safety

and emergency announcements, to be delivered over the public address system before the

ferries depart and when they approach the pier. 

As noted earlier, on February 11, 2005, the NYC DOT informed the Safety Board

that it agreed to follow the GMATS recommendations, and that it already had installed

GPS receivers, ARPA, and AIS units on its vessels. The Safety Board is encouraged by the

NYC DOTís acceptance of the GMATS recommendations with regard to navigation

technology. However, the full integration of the advantages of technology into navigation

practices and system monitoring requires careful evaluation and thorough review. The

GMATS assessment indicated that navigation technology should be fully operable at all

times and that navigation personnel should receive initial and then periodic training in the

effective use of navigation technology. The Safety Board agrees with these judgments.

However, Board discussions with NYC DOT personnel indicate that the prerecorded

announcements that have already been installed are not automatic but require manual

activation, and that the alarm functions related to speed indicators that are planned for

installation will also require manual activation. In the Safety Boardís opinion, manual

activation is not consistent with the GMATS recommendations. 

The GMATS assessment did not call for the type of systematic evaluation that

regularly assesses the effectiveness of existing bridge navigation technology in light of

new technologies that become available. Such a system of regular technological

assessment would help ensure that NYC DOT vessels take maximum advantage of

available technology to enhance the safety of ferry operations. Therefore, the Safety

71 See appendix F.
Analysis 70 Marine Accident Report

Board recommends that, as part of its response to the GMATS assessment, the NYC DOT

should fully comply with the technology-related recommendations of GMATS, and

establish a recurrent evaluation process to assess the use of navigation technology.
71 Marine Accident Report

Conclusions

Findings

1. None of the following were factors in the accident: the vesselís propulsion systems,

environmental conditions, alcohol, or illicit drugs. 

2. The Andrew J. Barberi was operating at full speed when it struck the maintenance

pier.

3. At the time of the accident, the assistant captain was at the controls, the senior mate

was seated in the aftmost section of the pilothouse reading a newspaper, and no one

else was in the pilothouse at the ferryís Staten Island end.

4. The assistant captain was apparently upright but unresponsive to his surroundings and

the visual cues of the impending allision for an estimated 1 to 2 minutes before the

accident.

5. The crew did not recognize that the ferry was in danger because of the absence of

changes in sounds that they typically used as cues for arrival, because they were not

attending to visual cues outside the vessel, and because of the absence of any crew

announcement or alert.

6. The cause of the assistant captainís unresponsiveness to cues clearly indicating an

impending allision could not be determined. 

7. Because accurate medical information about the assistant captain was not provided to

the Coast Guard by the assistant captain and his physician, the Coast Guard had no

opportunity to evaluate his fitness to maintain his marinerís license.

8. While the Coast Guardís system of medical oversight has deficiencies, they were

unrelated to the accident.

9. The captain failed to exercise his command responsibilities over the Andrew J.

Barberi.

10. The New York City Department of Transportation failed to implement and oversee

safe and effective operating procedures for its ferries.

11. The captainís maneuvering the ferry back to its intended berth was appropriate.

12. The failure of the captain to sound an alarm or provide a spoken alert calling for the

initiation of crew actions in response to the emergency adversely affected the quality

of the crewís response. 
Conclusions 72 Marine Accident Report

13. Although a superior crew response would most likely have made no difference in the

survivability of the injured, deficiencies in the New York City Department of

Transportation procedures, training, and equipment could compromise the

survivability of passengers and crew in other potential accident scenarios. 

14. Shoreside emergency response was effective. 

Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the assistant captainís unexplained incapacitation and the failure of the

New York City Department of Transportation to implement and oversee safe, effective

operating procedures for its ferries. Contributing to the cause of the accident was the

failure of the captain to exercise his command responsibility over the vessel by ensuring

the safety of its operations.
73 Marine Accident Report

Recommendations

As a result of its investigation of the Andrew J. Barberi allision, the National

Transportation Safety Board makes the following safety recommendations.

To the New York City Department of Transportation:

Require your licensed pilots to provide proof of compliance with the Coast Guard

medical certification requirements. (M-05-01)

Adhere to your October 2005 target for implementation of a comprehensive safety

management system, incorporating all matters recommended by the Global

Maritime and Transportation School assessment, and ensuring medical fitness

oversight (requiring, minimally, assurance of compliance with Coast Guard

requirements). (M-05-02)

As part of your response to the Global Maritime and Transportation School

assessment, fully comply with the technology-related recommendations of the

Global Maritime and Transportation School, and establish a recurrent evaluation

process to assess the use of navigation technology. (M-05-03)

To the U.S. Coast Guard: 

Revise regulation 46 CFR 10.709 to require that the results of all physical

examinations be reported to the Coast Guard, and provide guidance to mariners,

employers, and mariner medical examiners on the specific actions required to

comply with these regulations. (M-05-04)

In formal consultation with experts in the field of occupational medicine, review

your medical oversight process and take actions to address, at a minimum, the

lack of tracking of performed examinations; the potential for inconsistent

interpretations and evaluations between medical practitioners; deficiencies in the

system of storing medical data; the absence of requirements for mariners or others

to report changes in medical condition between examinations; and the limited

ability of the Coast Guard to review medical evaluations made by personal health

care providers. (M-05-05)

Seek legislative authority to require all U.S.-flag ferry operators to implement

safety management systems, and once obtained, require all U.S.-flag ferry

operators to do so. (M-05-06)

To the States Operating Public Ferries:

Encourage your public ferry operators to voluntarily request application of the

Federal requirements at 33 CFR 96 for implementing a safety management

system, if they have not already done so. (M-05-07)
Recommendations 74 Marine Accident Report

To the Passenger Vessel Association:

Encourage your member ferry operators to voluntarily request application of the

Federal requirements at 33 CFR 96 for implementing a safety management

system, if they have not already done so. (M-05-08)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN ENGLEMAN CONNERS

Chairman

CAROL J. CARMODY

Member

MARK V. ROSENKER

Vice Chairman

RICHARD F. HEALING

Member

DEBORAH A. P. HERSMAN

Member

Adopted: March 8, 2005
75 Marine Accident Report

Appendix A 

Investigation

The Safety Board was notified of this accident by its communication center about

1600 on October 15, 2003. The Board immediately notified the Coast Guard of its

selection to lead the investigation under the Safety BoardñCoast Guard memorandum of

understanding. The Board then dispatched a team of investigators from Washington, D.C.,

to the accident site, and an investigator from its Parsippany, New Jersey, Aviation

Regional Office to control the scene until the team arrived. The team, consisting of an

investigator-in-charge and specialists in deck operations, marine engineering, human

factors, survival factors, and vehicle recorders, arrived at the Staten Island ferry terminal

about 2300 on October 15. The Chairman of the Safety Board joined the team at the

accident site, as well as representatives from the Safety Boardís Office of Transportation

Disaster Assistance. The on-scene investigation concluded on October 25, 2003.

The Safety Board investigated the accident under the authority of the Independent

Safety Board Act of 1974, according to Safety Board rules. The designated parties to the

investigation were the U.S. Coast Guard, the New York City Department of

Transportation, and the New York City Fire Department.
76 Marine Accident Report

Appendix B

 Standard Operating Procedures, Staten Island Ferry
Appendix B 77 Marine Accident Report
Appendix B 78 Marine Accident Report
Appendix B 79 Marine Accident Report
Appendix B 80 Marine Accident Report
Appendix B 81 Marine Accident Report
Appendix B 82 Marine Accident Report
Appendix B 83 Marine Accident Report
Appendix B 84 Marine Accident Report
85 Marine Accident Report

Appendix C 

Memorandum of Understanding Between New York City 

Department of Transportation and U.S. Coast Guard
Appendix C 86 Marine Accident Report
Appendix C 87 Marine Accident Report
88 Marine Accident Report

Appendix D 

Contents Pages from Safety Management System Manuals, 

Washington State Ferries 
Appendix D 89 Marine Accident Report
Appendix D 90 Marine Accident Report
Appendix D 91 Marine Accident Report
Appendix D 92 Marine Accident Report
Appendix D 93 Marine Accident Report
Appendix D 94 Marine Accident Report
Appendix D 95 Marine Accident Report
Appendix D 96 Marine Accident Report
Appendix D 97 Marine Accident Report
Appendix D 98 Marine Accident Report
Appendix D 99 Marine Accident Report
Appendix D 100 Marine Accident Report
Appendix D 101 Marine Accident Report
Appendix D 102 Marine Accident Report
Appendix D 103 Marine Accident Report
Appendix D 104 Marine Accident Report
Appendix D 105 Marine Accident Report
Appendix D 106 Marine Accident Report
Appendix D 107 Marine Accident Report
Appendix D 108 Marine Accident Report
Appendix D 109 Marine Accident Report
Appendix D 110 Marine Accident Report
Appendix D 111 Marine Accident Report
Appendix D 112 Marine Accident Report
Appendix D 113 Marine Accident Report
Appendix D 114 Marine Accident Report
Appendix D 115 Marine Accident Report
116 Marine Accident Report

Appendix E 

Example Procedures from Safety Management System, British 

Columbia Ferries 
Appendix E 117 Marine Accident Report

	



 
		

 	

 

	
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Appendix E 124 Marine Accident Report
Appendix E 125 Marine Accident Report
126 Marine Accident Report

Appendix F 

Assessment of Staten Island Ferries by Global Maritime and 

Transportation School, U.S. Merchant Marine Academy 
Appendix F 127 Marine Accident Report

Global Maritime and Transportation School 

At the United States Merchant Marine Academy 

Assessment of 

Staten Island Ferry 

Operations 

Prepared for: New York City 

 Department of Transportation 

Prepared by: Global Maritime and Transportation School 

 At the United States Merchant Marine Academy 

 Kings Point, New York, USA 

 Telephone: +1 (516) 773-5120 

 Facsimile: +1 (516) 773-5353 

 E-mail: gmats@usmma.edu 

Date: February 12, 2004
Appendix F 128 Marine Accident Report

Assessment of Page 1 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Table of Contents 1 

Executive Summary 2-5 

Long-term Areas of Focus 6-11 

Specific Comments and Observations for Immediate Consideration 12-17 

APPENDICES 

A – Job Description for Chief Operations Officer (COO) 

B – Sample Short-term Management Organization Matrix 

C – Sample Long-term Management Organization Matrix 

D – Job Description for Senior Port Captain 

E – Job Description for Senior Port Engineer 

F – Job Description for Safety Manager/Designated Person 

Note that comments and remarks provided in this report are based on observations made during 

on-site assessments and reflect conditions as they existed at that time. Specific conditions 

discussed in this report may not exist in a similar condition today. 

This report is a review and assessment of Staten Island Ferry operations only as they existed at 

the time of observation. It is not a comprehensive safety inspection or accident investigation. 

This report shall not imply any form of certification or approval of any operation or indicate 

compliance with any applicable international, federal, state, or local laws or regulations. 

It is also critical to understand that the comments and remarks provided herein may be subject to 

modification and/or change based on further and more thorough examination of ferry operations 

as this assessment continues to evolve and proceed.
Appendix F 129 Marine Accident Report

Assessment of Page 2 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Executive Summary 

Following the tragic Staten Island Ferry accident on October 15, 2003, the New York City 

Department of Transportation (NYC DOT) requested the Global Maritime and Transportation 

School (GMATS) at the United States Merchant Marine Academy (USMMA) develop a 

proposal to conduct an assessment of Staten Island Ferry Operations. By the end of October 

2003, the GMATS and the NYC DOT had agreed in principal for the GMATS to conduct the 

assessment in four main topical areas: vessel operations, human factors, safety, and management. 

On November 3, 2003, the NYC DOT signed a Letter of Intent/Notice to Proceed for assessment 

of the Staten Island Ferry Operations. GMATS began work on the project immediately and 

commissioned two assessment teams to conduct an initial review of operations, management, 

policies, procedures, manuals, and other documents related to the operation of the Staten Island 

Ferry. Both assessment teams performed on-site surveys (including discussions with ferry crews 

and shore-based management as well as observations aboard underway ferries) during November 

2003 through mid-January 2004. The first team focused on overall operations and management; 

engineering; safety; and conformity with regulatory schemes and maritime industry best 

practices and standards. The second assessment team focused primarily on human factors and 

bridge team management. 

Based on these assessments, the goal of this report is to provide a framework and suggested 

guidance for operation and management of a world-class Staten Island Ferry system that is safe, 

secure, fiscally sound, and environmentally sensible. 

To its credit, the Staten Island Ferry system appears to be a good operation overall considering 1) 

the limited levels of funding and human resources the organization has at its disposal and 2) the 

existence of a corporate culture within the ferry organization which may not be conducive to 

operating a first-rate marine transportation system. 

GMATS feels the NYC DOT is committed to operating a ferry service that inspires public 

confidence in that system and is dedicated to making improvements and changes in the following 

areas: 

x Safety Management System (SMS) - The foundation of the revitalization of the 

Staten Island Ferry system will be the establishment of a Safety Management System 

(SMS) – in accordance with the International Management Code for the Safe 

Operation of Ships and for Pollution Prevention (more widely known as the 

International Safety Management (ISM) Code). Implementation of a SMS has 

become a maritime industry standard around the world and critical in making the 

Staten Island Ferry system mainstream with its best passenger-carrying 

contemporaries in the global arena. SMS application within the Staten Island Ferry 

system will forge a new era of safety and environmental protection benefiting 
Appendix F 130 Marine Accident Report

Assessment of Page 3 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

passengers, crew, and the City of New York. The functional requirements of a SMS 

(as outlined in the ISM Code) for the Staten Island Ferry system will incorporate: 

a) a safety and environmental protection policy; 

b) instructions and procedures to ensure safe operation of ferries and protection of 

the environment in compliance with relevant international, national, and local 

laws and regulations; 

c) defined levels of authority and lines of communication between, and amongst, 

shore-based and ferry personnel; 

d) procedures for reporting accidents and non-conformities with the provisions of the 

SMS; 

e) procedures to prepare for and respond to emergency situations; and 

f) procedures for internal audits and management reviews. 

The goal of a Staten Island Ferry SMS is to assure that ferry system best practices are 

clearly defined, that documented practices conform to regulatory requirements, and 

the opportunity for continuous improvement is available to all who are covered by the 

Staten Island Ferry SMS. Refer to Long-term Areas of Focus section (pages 6-7) for 

further information. 

x Bridge Team Management – GMATS recommends establishment of a new 3-

member bridge team comprised of licensed deck officers to 1) provide enhanced safe 

navigation of Staten Island Ferry vessels, suitable rest breaks, and support for more 

comprehensive watch relief procedures; 2) meet new vessel security officer and other 

maritime security statutory requirements to be implemented by July 1, 2004; and 3) 

incorporate additional tasks and responsibilities mandated under the SMS (all while 

maintaining a minimum of 2 licensed deck officers in the pilothouse at all times when 

underway). Additional personnel (from the existing on-watch crew) may be required 

to support the 3-member bridge team during operations in foul weather and adverse 

environmental conditions. 

As part of this bridge team program, all personnel required to be present on the 

navigation bridge while underway will be assigned specific duties and responsibilities 

so that all human resource capacity is effectively engaged in a coordinated, managed, 

and more efficient manner. Each bridge team member will also be adequately trained 

and qualified in the operation and capabilities of all navigation, communication, and 

other pilothouse equipment and technologies. 

Further assessment and development of the bridge team management structure 

specific to the Staten Island Ferry system will be required in order to formulate the 

best practices in this area. The first step in this process will be to conduct an 

inventory of all bridge team tasks required for operation of the ferries in various 

conditions and situations. The second step will be to develop a formal, bridge team 
Appendix F 131 Marine Accident Report

Assessment of Page 4 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

operations manual which will be part of the SMS. The final phase in this process will 

be to develop and deliver a bridge resource management course. This curriculum will 

be customized to meet the unique operational characteristics of the Staten Island 

Ferry system. Refer to Specific Comments and Observations for Immediate 

Consideration Section (page 15) for further information. 

x Organizational Structure and Human Resources – GMATS feels the immediate 

hiring of a Chief Operations Officer (COO) to provide leadership and direction for 

the operation of the Staten Island Ferry system is absolutely critical in guiding the 

organization through this period of renewal, transition, and implementation of a 

Safety Management System. GMATS recognizes a person of this caliber (refer to 

Appendix A for a detailed job description) serving as COO in a comparable maritime 

organization would typically be compensated with an annual salary of $160,000 to 

$180,000 per annum. In order to attract the best person for this position, NYCDOT 

may have to authorize relocation benefits as well. Further, GMATS feels a long-term 

commitment (e.g. 5 years) for the COO position would serve the NYCDOT well. 

Further, it is clearly evident, based on this initial review of documents and 

observations, the operations function of the ferry system is 95 persons short of 

staffing levels required to implement a safety management system and to provide for 

other enhancements. These staffing shortfalls result in large overtime expenditures as 

well as a potential for increase in fatigue, reduction in safety, decline in service, or 

any combination of all four of these issues. This recommendation for additional 

staffing was based on three central issues: 1) the ferry system is currently not staffed 

to support a safety management system, 2) more senior personnel need to be on board 

the vessels in command positions, and 3) as people are sent for training and 

compliance issues there will be a need for additional personnel in the system to offset 

any fatigue, hours of labor issues, etc. that will come up during the training process. 

Refer to Long-term Areas of Focus section (pages 7-10) for further information. 

x Technical Training and Professional Development – The need for a comprehensive 

technical training and professional development program for vessel crews and shorebased personnel will be an integral component of the SMS. The Staten Island Ferry 

should establish and maintain procedures for identifying training which may be 

required in support of the SMS and ensure that such training is provided for all 

personnel concerned. Professionally trained personnel are an asset to the SMS and 

the Staten Island Ferry system. Maintaining one of the Kennedy-class vessels (in a 

fully-operational status) after delivery of the new ferries will be crucial in meeting the 

needs of this comprehensive training program. Refer to Long-term Areas of Focus 

section (page 10) and Specific Comments and Observations for Immediate 

Consideration Section (page 16) for further information. 
Appendix F 132 Marine Accident Report

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Staten Island Ferry Operations February 12, 2004 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

x Operations Procedures – 

 Staten Island Ferry needs to conduct a full review of at-sea casualty and 

emergency response plan (including search and rescue operations) and 

plan coordinated, table-top and other exercise scenarios with external 

response assets (NYPD Harbor Units, FDNY Marine Units, U.S. Coast 

Guard, NJ State Marine Police, private harbor tugs, etc.). 

 Develop operational checklists (vessel departures, arrivals, foul weather, 

emergencies, etc.) required to be used by afloat personnel. 

 Establish formal, internal policies and procedures for and publicize an 

alternate ferry service operational schedule for foul weather and adverse 

environmental conditions (i.e. reduced visibility, high winds, excessive 

wave and/or current action, etc.). 

Refer to Specific Comments and Observations for Immediate Consideration Section 

(pages 16-17) for further information. 

x Security - Begin planning for implementation of Vessel and Facility Security Plans 

as soon as practicable and provide related training to appropriate vessel crew and 

shore-based staff. Vessel and Facility Security Plans have been submitted to the 

Coast Guard for approval. Changes and/or modifications may have to be made to the 

plans based on feedback from the Coast Guard. *** Implementation and subsequent 

changes/modifications (post U.S. Coast Guard approval) may result in a requirement 

for hiring of additional crew and shoreside personnel to put the facility and the vessel 

security plans in effect by July 1, 2004 as required. *** 

x Utilization of Advanced Marine Technologies – Equipment to be updated or newly 

installed aboard Staten Island Ferries include RADAR, Automated RADAR Plotting 

Aids (ARPA), Electronic Chart Display and Information System (ECDIS), Automatic 

Identification System (AIS), and digital, multi-directional vessel speed indicators 

with alarm functions (which allows vessel personnel to monitor vessel speed fore/aft 

and athwartships including approach speeds to berths). Installation of integrated 

navigation bridge systems aboard all ferries will be crucial to provide enhanced safe 

navigation of the vessels. 
Appendix F 133 Marine Accident Report

Assessment of Page 6 

Staten Island Ferry Operations February 12, 2004 

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Kings Point, New York, USA Email: gmats@usmma.edu 

Long-term Areas of Focus (12 –36 months) 

GMATS recommends the following organizational strategies receive the highest priority in way 

of design, development, formalization, and implementation. 

x Safety Management System (SMS) 

The foundation of the revitalization of the Staten Island Ferry system will be the 

establishment of a Safety Management System (SMS) – in accordance with the International 

Management Code for the Safe Operation of Ships and for Pollution Prevention (more 

widely known as the International Safety Management (ISM) Code). The main objectives of 

a SMS (as outlined in the ISM Code) for the Staten Island Ferry system are to: 

a) provide for safe practices in ferry operations and a safe working environment; 

b) establish safeguards against all identified risks; and 

c) continuously improve safety management skills of personnel ashore and aboard ferries, 

including preparing for emergencies related both to safety and environmental protection. 

Implementation of a SMS has become a maritime industry standard around the world and 

critical in making the Staten Island Ferry system mainstream with its best passenger-carrying 

contemporaries in the global arena. SMS application within the Staten Island Ferry system 

will forge a new era of safety and environmental protection benefiting passengers, crew, and 

the City of New York. The functional requirements of a SMS (as outlined in the ISM Code) 

for the Staten Island Ferry system will incorporate: 

a) a safety and environmental protection policy; 

b) instructions and procedures to ensure safe operation of ferries and protection of the 

environment in compliance with relevant international, national, and local laws and 

regulations; 

c) defined levels of authority and lines of communication between, and amongst, shorebased and ferry personnel; 

d) procedures for reporting accidents and non-conformities with the provisions of the SMS; 

e) procedures to prepare for and respond to emergency situations; and 

f) procedures for internal audits and management reviews. 

On November 4, 1993, The International Maritime Organization adopted Resolution 

A.741(18), the International Safety Management (ISM) Code for the Safe Operation of Ships 

and for Pollution Prevention. An integral part of the Code is the requirement that vessel 

operators establish a Safety Management System (SMS). The goal of a SMS is to assure the 

best practices are clearly defined, that documented practices conform to regulatory 

requirements, and the opportunity for continuous improvement is available to all who are 

covered by the Safety Management System. The SMS is to provide “best practice” 
Appendix F 134 Marine Accident Report

Assessment of Page 7 

Staten Island Ferry Operations February 12, 2004 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

guidelines for all members of the Staten Island Ferry system (employees) in a standardized 

approach to routine, critical and emergent activities. SMS policies and procedures provide a 

structure within which managers and employees are expected to use sound judgment in the 

performance of their duties. An effective SMS will ensure safety, prevention of human 

injury or loss of life and avoidance of damage to the environment, in particular to the marine 

environment and to property. The SMS will incorporate crisis management, incident 

response, training and standard operating procedures covering every aspect of operation and 

maintenance of the vessels and terminals. The Staten Island Ferry system and the traveling 

public will both benefit from its creation by: 

a) ensuring that all industry standards and best practices are complied with; 

b) helping to prevent accidents from occurring; 

c) ensuring procedures are in place for dealing with any emergency situation aboard the 

ferries; 

d) ensuring there are adequate communications between ferry and shore-based personnel; 

e) ensuring that all individuals know their role and responsibility and are adequately trained 

and have the appropriate resources to do their job; and 

f) ensuring that all activities and operations are planned, controlled, and verified. 

x Organizational Structure 

GMATS feels the immediate hiring of a Chief Operations Officer (COO) to provide 

leadership and direction for the operation of the Staten Island Ferry system is absolutely 

critical in guiding the organization through this period of renewal, transition, and 

implementation of a Safety Management System. The COO candidate (refer to Appendix A 

for a detailed job description) needs to be the strongest advocate of a SMS. 

The Safety Management System will establish a corporate culture that is committed 

enthusiastically to the policy’s success from the highest level of Staten Island Ferry 

management. The management should define and document the responsibility, authority and 

interrelation of all personnel who manage, perform and verify work relating to and affecting 

safety and pollution prevention. Management will be responsible to ensure that adequate 

resources and shore-based support are provided to enable all levels of the organization to 

carry out their functions under the SMS. A short-term management organization matrix 

conducive to this goal might look like the chart in Appendix B. A long-term organizational 

matrix might look like the chart in Appendix C. 

Prior to implementation of the short-term management organization matrix, several key 

shore-based management personnel need to be hired or realigned in order to introduce a new 

SMS. These position descriptions are outlined in Appendices D-F. 
Appendix F 135 Marine Accident Report

Assessment of Page 8 

Staten Island Ferry Operations February 12, 2004 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

x Human Resources 

In broad terms, ferry personnel who were interviewed by the assessment teams put their best 

foot forward and had the desire to do well in the workplace. However, without the proper 

funding, staffing, and professional training programs, these inherent individual aspirations 

will not be sufficient and little will change to improve safety. 

A similar situation exists for shore-based management staff. During on-site interviews and 

observations, it was a rare moment when a manager being interviewed was not being paged 

or responding to telephone calls. The pace is such that decisions are being made reactively 

instead of proactively; long term planning appears to be a luxury, not a staple. Again, the 

prevalence of inadequate staffing and funding levels seems to have contributed to the 

apparent erosion of the overall ferry system organization. 

Originally GMATS was tasked with observing and making recommendations. We made our 

recommendations based on the existing labor contracts (which incorporate a 30-hour work 

week). A change of work hours, from 30 to 40, should make an impact on these 

recommendations. However, the impact may be smaller than expected. The first category of 

new hires (24 of the recommended 95 new personnel additions) will enable the Staten Island 

Ferry system to run all vessels under the current operating schedule without requiring crew 

members to work inordinate amounts of overtime in order to meet minimum vessel manning 

requirements. The remaining 71 new personnel are needed to create a labor pool to provide 

critical support to: 

x the design, development, and implementation of the SMS (this may take as long as 24 

months utilizing existing vessel personnel); 

x surge training and professional development requirements as a result of the 

implementation of the SMS (this may take as long as 36 months and require vessel crew 

members to be withdrawn from their regular watchstanding duties to attend training 

sessions – on-call crew personnel will be required to fill-in these positions); 

x a new 3-member bridge team structure incorporating enhanced bridge team management 

functions; 

x increased crew responsibilities to meet maritime security regulations; 

x work/rest break rotations and watch reliefs; and 

x increased interaction between vessel crew members and ferry passengers (i.e. customers). 

 

GMATS feels that following implementation of the new safety management system and after 

surge training requirements are fulfilled, there may or may not be a need for maintaining the 

recommended overall crew staffing levels discussed above (i.e. 71 of the 95 new positions). 

There most likely will be a gradual “weaning” process take place within the ranks of the 

afloat personnel over the next several years. In GMATS’ estimation, 1) some current 

employees will not feel comfortable with the new system and will retire or move on, 2) some 

current employees will find that in the new way of doing things they will want to become 
Appendix F 136 Marine Accident Report

Assessment of Page 9 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

part of the management structure instead of the crew, and 3) normal attrition. In the same 

vein, some of the “new hires” will not work out and will not be retained. A thorough 

analysis of afloat personnel staffing needs should be conducted following SMS 

implementation and completion of surge training requirements (in 24-36 months) to 

determine appropriate crewing requirements at that point. 

Additional Personnel Requirements (as soon as practicable) 

First Category (24 of 95 total personnel) - to enable the Staten Island Ferry system to operate 

all vessels under the current operating schedule without requiring crew members to work 

inordinate amounts of overtime in order to meet minimum vessel manning requirements.

1 x Captain 

1 x Assistant Captain 

1 x Mate 

1 x Ferry Terminal Supervisor 

15 x Deckhands 

1 x Chief Marine Engineer 

4 x Marine Oilers 

Second Category (71 of 95 personnel) – develop labor pool vital to accomplishing SMS, 

training, and other areas of critical support noted previously.

8 x Assistant Captains 

10 x Mates 

13 x Deckhands 

1 x Marine Engineer 

1 x Senior Port Captain (shore-based, non-union) 

1 x Senior Port Engineer (shore-based, non-union) 

4 x Relief Captains 

4 x Relief Assistant Captains 

4 x Relief Mates 

9 x Relief Deckhands 

4 x Relief Chief Marine Engineers 

4 x Relief Marine Engineers 

8 x Relief Marine Oilers 

The Senior Port Engineer and Senior Port Captain are to be utilized for day-to-day 

management of the ferries. This will allow for long-term planning and proactive decisionmaking by upper management staff. 
Appendix F 137 Marine Accident Report

Assessment of Page 10 

Staten Island Ferry Operations February 12, 2004 

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Kings Point, New York, USA Email: gmats@usmma.edu 

GMATS feels that appropriate opportunities be given to well-qualified personnel from within 

the Staten Island Ferry system to fill these positions. The Deckhands will be brought in from 

outside the Staten Island Ferry system as this is an entry-level position. 

Specifically, the Relief positions will be utilized to allow the permanent crew to be focused 

on their 1) training while maintaining a level of safety on the boats, and 2) to allow regular 

personnel to be utilized for any “Special Projects” where their expertise may be better 

utilized for the benefit of the Staten Island Ferry system. 

Whatever decision is made concerning the employment of these additional personnel, 

GMATS strongly believes that due consideration be given to upgrading licensed employees 

from within the fleet. This may mean the waiver of existing civil service testing and hiring 

procedures for current employees. New hires filling upgrades could be tested as per usual. 

The reason for this is to improve morale within the fleet. The cooperation and enthusiastic 

acceptance by Staten Island Ferry employees of a new SMS system is key in the success of 

that system. 

*****Note, additional staffing beyond what is noted above may be required to implement 

facility and vessel security plans as required by the International Ship and Port Facility Code 

(ISPS Code), the Maritime Transportation Security Act of 2002 (MTSA), and United States 

Coast Guard’s maritime security regulations by July 1, 2004.***** 

x Technical Training and Professional Education 

The need for a comprehensive technical training and professional development program for 

vessel crews and shore-based personnel is obvious. The desire among ferry system personnel 

to participate in educational programs is apparent. Additionally, the need for an infusion and 

acceptance of “new blood” is equally evident as it appears the corporate culture has 

prevented professional growth in the ferry system’s workforce. 

The Staten Island Ferry system needs to ensure that each vessel is manned with qualified, 

certificated, and medically fit personnel with the implementation of the Safety Management 

System. The SMS will establish procedures so that new personnel and personnel transferred 

to new assignments related to safety and protection of the environment are given proper 

familiarization with their duties. The Staten Island Ferry system should establish and 

maintain procedures for identifying any training which may be required in support of the 

SMS and ensure that such training is provided for all personnel concerned. Professionally 

trained personnel are an asset to the SMS and the Staten Island Ferry system. As such, all 

costs pertaining to the professional education of its workforce should be the burden of the 

Staten Island Ferry System. Ferry personnel should not be required to use vacation time to 

attend needed training. 
Appendix F 138 Marine Accident Report

Assessment of Page 11 

Staten Island Ferry Operations February 12, 2004 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

x Work Schedules and Employee Compensation 

During negotiations with labor unions, every effort should be made to eliminate built-in 

overtime. It is imperative to move to a standard forty (40) hour week for employees to 

reduce labor costs. Failing a compromise, vessel schedules can be arranged to accomplish 

this goal. In hiring new employees, NYC DOT needs to provide professionally documented, 

certified, medically fit, and qualified personnel to the Staten Island Ferry system. 

A marine industry salary survey should also be undertaken to ensure the Staten Island Ferry 

system compensation structure is closely aligned with similar domestic ferry operations (e.g. 

Washington State Ferries). This will help to positively impact recruiting, retention, and 

morale. 

x Budget and Finance 

New revenue sources need to be found to carry out the mission of Staten Island Ferry system. 

This could include new vessel and terminal concession contracts or other alternative revenue 

sources. Long-term recommendations in this report are going to require long term funding 

sources dedicated to Staten Island Ferry operations and maintenance. Capital programs need 

to be clearly defined for both the short- and long-term and managed directly by the Staten 

Island Ferry system. 

Software systems need to be acquired that link management to the budget and provides for 

real-time reporting on expenditures of labor and materials. Each division head within the 

Staten Island Ferry system should formulate a fiscal year budget he or she is directly 

accountable for managing. 
Appendix F 139 Marine Accident Report

Assessment of Page 12 

Staten Island Ferry Operations February 12, 2004 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Specific Comments and Observations for Immediate Consideration 

Safety 

x Strengthen relations with United States Coast Guard (USCG) Sector New York 

(previously known as Activities New York) wherein USCG marine inspection elements 

recognize Staten Island Ferry vessels as 46 CFR Subchapter H – Passenger Vessels. 

x Conduct a full review of at-sea casualty and emergency response plan (including search 

and rescue operations) and plan coordinated, table-top and other exercise scenarios with 

external response assets (NYPD Harbor Units, FDNY Marine Units, U.S. Coast Guard, 

NJ State Marine Police, private harbor tugs, etc.). 

Current emergency contingency plans rely too heavily on external resources, the 

ability to conduct a vessel-to-vessel transfer at-sea, and the capacity to bring a ferry 

in the harbor back to one of the ferry landing piers. While the existence and close 

proximity of extensive and very capable external response resources are critical and 

should remain an integral component of any ferry contingency plan, it is prudent to 

have the internal capacity to deal with all possible emergency scenarios as a “first 

responder.” Circumstances may dictate that a ferry-to-ferry transfer of passengers, 

moving a vessel to a pier, or use of external response resources does not provide for 

a practical, safe, or timely response scenario. 

x Increase lifesaving resources (lifeboats, liferafts, rescue craft, and inherently buoyant 

apparatus) on all vessels sufficient for 80% of passenger carrying capacity (this amount 

would be above and beyond what is required for similar types of passenger vessels 

subject to Coast Guard inspection). 

These resources are currently not required for the Staten Island ferries by the U.S. 

Code of Federal Regulations, but may be critical to prevent loss of life and/or serious 

injury to passengers and crew in certain emergency contingencies. Also, consider 

replacing existing davit-launched, antiquated, low-freeboard, manually-powered 

rowboat with a quick–launching, Zodiac-type rigid hull inflatable with a 50-

horsepower outboard propulsion motor. 

x Install marine evacuation slides on all vessels. 

In conjunction with the increase of lifesaving resources listed above, installation of 

marine evacuation slides may greatly decrease the risk of loss of life and/or serious 

injury to passengers and crew in certain crisis scenarios by keeping people out of the 

water during these events. 
Appendix F 140 Marine Accident Report

Assessment of Page 13 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

x Install additional Personal Flotation Device (PFD) storage compartments on car deck 

tunnels of Kennedy class vessels. 

During some emergency scenarios, passengers and crew may need to assemble on the 

car deck and PFDs should be accessible in that location as well -- provided a 

comprehensive risk assessment is completed considering safety versus security issues 

in allowing passengers easy, open access to the car decks – see related comment 

below regarding removal of metal gates/fencing/screen on car decks. 

x Confirm each vessel has enough PFDs to meet or exceed 100% passenger and crew 

carrying capacity. 

During testing for alternate compliance (wherein a simulated transfer of passengers 

between ferries took place), GMATS observed PFDs from different vessels on the 

crew members. It is possible that PFDs assigned to a particular vessel may be utilized 

aboard other vessels in the fleet. 

x Replace scissor-type gates currently used for crowd control aboard the vessels with 

rolling, expanded metal gates to afford additional protection for children. 

These gates currently are approximately 14” above the deck. This gap opens the 

possibility for a child to “scoot” out over the side without any protective barrier. 

x Move passengers away from the bow “picklefork” areas while vessel is docking. 

This has already been partially implemented. A small rope has been installed. 

Passengers outside are exposed to risk of injury should a collision or hard landing 

occur. Passengers should be prohibited from “picklefork” area while vessel is 

landing to prevent injury or loss of life. 

x Remove expanded metal gates/fencing/screen on car decks of Kennedy class ferries. 

This allows for assembly of passengers prior to evacuation. *** A comprehensive 

risk assessment must be conducted to consider an appropriate balance between safety 

and security in allowing passengers easy, open access to the car decks in the event of 

an emergency situation. Removal of these security measures may not be viable.*** 

x Provide complete set of blueprints, vessel plans, and engineering equipment manuals for 

each engine room. 

Currently there are no plans in the engine room. In case of an emergency, the 

engineers would not have the availability to utilize prints for damage control or 

manuals to conduct underway diagnosis, maintenance, and repairs. 
Appendix F 141 Marine Accident Report

Assessment of Page 14 

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x Post fire and emergency control plan/schematic in the engine room and on the navigation 

bridge of each vessel. 

Regulations require and accepted industry practice dictates a Fire and Emergency 

Plan be posted in these areas. 

x Confirm fire main shore connections on all vessels are appropriately marked and easily 

accessed and identifiable by New York City Fire Department (FDNY) as well as other 

regional fire emergency response personnel that may respond to an emergency situation 

aboard the ferries. 

Currently, markings for the FDNY shore connection are located on a large, bolted 

panel well above the actual shore connection device. This could lead to confusion or 

delay in an emergency situation. Also, both shore connections aboard the Kennedyclass vessels are located behind the locked gates referred to previously. Further, it 

appears that the shore connection is co-located with an individual fire station and may 

not directly tie into the central fire main piping as required. 

x Provide Self-Contained Breathing Apparatus (SCBA) aboard each vessel enough for each 

crew member below the rank of Captain. 

Accepted industry practice dictates proper firefighting resources be provided to crew 

members to include SCBAs. 

x Accelerate installation of pre-recorded, automated safety and emergency announcements 

for delivery over public address systems prior to departure and while approaching pier 

landing area before docking. 

These formalized safety announcements may be critical in saving lives prior to an 

emergency. 

x Improve medical response and first aid capabilities aboard ferries. 

Increase crew medical knowledge and training and supply sufficient equipment to 

provide adequate first response to a wide-range of possible medical-related 

emergencies and non-emergency situations. 

x The NYC DOT and the US Coast Guard should work together to examine all the safety 

recommendations listed above to determine appropriateness for each particular ferry. 

The table top exercises described on page 12 may be helpful in this activity. 
Appendix F 142 Marine Accident Report

Assessment of Page 15 

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Bridge Team Management 

x Create multiple, standardized watchstanding conditions requiring extra manning during 

adverse environmental and weather situations. 

x Require and enforce that all navigation bridge electronics and communications gear be 

energized and fully operational at all times while underway regardless of weather 

conditions and sea state unless special circumstances exist. 

x Update navigation bridge equipment and improve layout. 

Existing layout of navigation bridge equipment does not provide for the most efficient 

monitoring of critical sensor, communications, and navigation gear by persons 

responsible for the safe navigation and piloting of the ferries. Equipment to be 

updated or newly installed include RADAR, Automated RADAR Plotting Aids 

(ARPA), Electronic Chart Display and Information System (ECDIS), Automatic 

Identification System (AIS), and digital, multi-directional vessel speed indicators 

with alarm functions (which allows vessel personnel to monitor vessel speed fore/aft 

and athwartships including approach speeds to berths). Consider installation of 

integrated navigation bridge systems aboard all ferries. 

x Develop operational checklists (vessel departures, arrivals, foul weather, emergencies, 

etc.) required to be used by afloat personnel. 

Use of formal operations checklists will be part of the safety management system and 

reduces potential for complacency, tedium, and creates error traps. 

x Provide specific navigation bridge equipment operations training. 

All vessel personnel with responsibility for the safe navigation and piloting of the 

ferries should have initial as well as periodic refresher training in the capabilities, 

limitations, and operation of all navigation bridge equipment. 
Appendix F 143 Marine Accident Report

Assessment of Page 16 

Staten Island Ferry Operations February 12, 2004 

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At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

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Training 

x Establish a formal process and methodology for documenting mariner and shoreside 

personnel training and qualifications. 

This is to promote qualified training and to eliminate the possibility of nepotism and 

discrimination. 

x Provide formal Situational Awareness and Human Factors training to all personnel 

responsible for ferry operations including shoreside personnel. 

These programs will be part of a comprehensive, long-term training and education 

plan which will be an integral component of the safety management system. 

x Provide crisis management training (including crowd management and control training) 

to all vessel personnel including galley employees in accordance with U.S. and 

international regulatory requirements and accepted industry practices. 

Currently, vessel personnel have no formal training in crowd control procedures and 

techniques. This training may be critical to saving lives in an emergency. 

Operations 

x Establish formal, internal policies and procedures for and publicize an alternate ferry 

service operational schedule for foul weather and adverse environmental conditions (i.e. 

reduced visibility, high winds, excessive wave and/or current action, etc.) 

U.S. navigation law requires that foul weather and other adverse environmental 

operating conditions be considered when determining a safe vessel speed. Normal 

ferry service speed while operating in these conditions is not appropriate. Making 

sure the riding public is made aware of the impacts of these factors on ferry 

operations including necessitated changes to the schedule is crucial in order for 

customers to make the most informed decisions about their travel. 

x Institute constant and continuous safety and security rounds by the deckhands while 

ferries are underway. 

GMATS observations indicate that deck crews do not make routine rounds for safety, 

security, and to enforce posted policies (e.g. smoking and alcohol consumption). 

x Expand the content and delivery method of the existing passenger survey program. 
Appendix F 144 Marine Accident Report

Assessment of Page 17 

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Kings Point, New York, USA Email: gmats@usmma.edu 

x Accelerate schedule to uniform deckhands and all engine room employees; make 

distinction between oilers and CME/ME with traditional maritime uniforms. 

At present time, crew members are difficult to distinguish from passengers. In a 

crisis, the passengers will look for clear direction from uniformed crew members. 

x Modify existing work schedules and crew exchanges for afloat personnel to provide for 

proper amounts of rest and to reduce fatigue. 

Current watch rotations and work schedules may be negatively impacting ability for 

crew to gain appropriate rest time to maintain the highest levels of alertness. 

x Establish formal procedures and standing orders and develop methods for monitoring to 

ensure compliance with these procedures and orders. 

This will be part of the safety management system and subject to change based on a 

more thorough assessment and implementation of a bridge team organization. 

However, development of standing orders and procedures and a system to monitor 

compliance can be done now. 

x Limit radio communications aboard the ferries (especially during approach, docking, and 

undocking evolutions) to operational necessities. 

GMATS observed communication exchanges between shoreside staff and afloat crew 

during critical operational periods described above. The substance of these 

conversations related to overtime and other administrative topical matters. 

Other Areas 

x Provide public safety and security resources for all vessels and terminals in the Staten 

Island Ferry system through formal arrangements with agencies to facilitate utilization of 

federal, state, and local law enforcement elements. 
Appendix F 145 Marine Accident Report

Assessment of APPENDIX A 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Management Position Description 

Title: Chief Operations Officer – Staten Island Ferries

The Chief Operations Officer (COO) – Staten Island Ferry reports directly to the Deputy 

Commissioner, Passenger Transport Division, New York City Department of Transportation 

(NYCDOT). The COO provides the leadership and direction for the operation of Staten Island 

Ferry vessels and terminals. A key role of the COO is to ensure the Staten Island Ferry operates 

as a first-class marine transportation system that is safe, secure, fiscally sound, and 

environmentally sensible while providing superb customer service for the citizens of the City of 

New York and others who utilize the Staten Island Ferry marine transportation system. 

Principal Duties and Responsibilities 

1) Overall management and control of Staten Island Ferry system and NYCDOT terminal 

operations. 

2) Direct activities of and provide policy direction and guidance to senior Staten Island Ferry 

management personnel, specifically, subordinate Directors of Finance, Human Resources, 

Maintenance, Marine Operations, and Terminal Engineering. 

3) Manage appropriated funding to successfully accomplish Staten Island Ferry mission 

statement. 

a) Ensure adequate resources are made available to provide for an effective safety 

management system (SMS) and proper maintenance of vessel fleet and shore-side 

facilities, infrastructure, and equipment, and other NYCDOT-controlled assets. 

b) Protect existing funding sources and recommend alternative sources to ensure proper 

funds required to maintain and upgrade the Staten Island Ferry system. 

c) Identify areas of operational cost reductions, when feasible. 

4) Provide overall direction for and ensure compliance with established safety management 

system (SMS). 

5) Ensure safety, security, health, and environmental standards are met throughout the 

operation. 

6) Promote and maintain a workforce culture of good order, discipline, high morale, and ethical 

soundness within the Staten Island Ferry system. 

a) Ensure NYCDOT policies and procedures are applied consistently and fairly within the 

Staten Island Ferry organization. 

b) Ensure all Staten Island Ferry system employees have working knowledge and 

understanding of all applicable NYCDOT policies and procedures. 

c) Meet with employees as necessary to clarify and discuss policy, procedures, and rules 

issues. 
Appendix F 146 Marine Accident Report

Assessment of APPENDIX A 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

7) Facilitate continuous professional growth of Staten Island Ferry system employees through 

professional education, technical training, and mentorship programs. 

8) Manage the Staten Island Ferry system in accordance with all applicable laws, regulations, 

and industry best practices. 

a) Maintain close liaison with the NYCDOT legal staff and obtain legal opinions on 

decisions as necessary. 

9) Translate broad goals articulated by the NYCDOT Commissioner into Staten Island Ferry 

action plans. 

10) Provide customer service levels commensurate with demand and goals. 

11) Act as senior advisor on maritime matters to the NYCDOT Commissioner and/or Deputy 

Commissioner as well as other individuals or organizations as directed by the Commissioner. 

12) Apprise the Commissioner of significant events and potential problem areas within the Staten 

Island Ferry system in a timely manner. Coordinate Staten Island Ferry system activities 

with key NYCDOT staff. 

13) Promote and maintain close working relationships with federal, state, and local government 

agencies, including the U.S. Coast Guard and the Metropolitan Transportation Authority 

(MTA) – Staten Island Ferry system’s intermodal connections. 

14) Prepare and deliver testimony and reports as directed by the Commissioner. 

15) In close coordination with the NYCDOT Offices of the Commissioner and Public 

Information, serve as primary representative of the Staten Island Ferry system to the public. 

a) Provide fast, factual, and frank information for response to media inquires. 

b) Speak at public functions representing the Staten Island Ferry system. 

c) Maintain liaison and facilitate positive working relations with key citizen and other 

stakeholder groups. 

Knowledge, Skills, and Abilities 

Education: Requires a college degree in operations management, business management, marine 

transportation, nautical science, marine engineering, or related discipline. Industry relevant work 

experience may be substituted for college degree. 

License: United States Coast Guard license as Master or Chief Engineer. 

Experience: Requires at least seven to ten years experience with a large passenger ferry system 

in a management capacity with significant experience in labor relations and contract 

negotiations. Requires at least five to ten years experience serving as either Captain and/or Chief 

Engineer aboard large passenger ferries. 
Appendix F 147 Marine Accident Report

Assessment of APPENDIX A 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Specialized Knowledge: 

1. Must have extensive knowledge of ferry terminal and ferry operations. This includes 

marine engineering and vessel maintenance and repair. 

2. Must have a working knowledge of proven managerial and leadership principles, with the 

ability to influence other management team members and lead a department of 

technically proficient individuals. 

3. Must have extensive knowledge of safety, health, and environmental issues as they affect 

the workplace, including all applicable regulatory schemes. Must be familiar with 

maritime and admiralty law. 

4. Must have knowledge of safety management system principles, policies, and procedures 

and the ability to effectively implement them. 

5. Must have working knowledge of budget preparation, financial management, and their 

applications. This includes an understanding of basic accounting, statistics, problem 

solving, goal setting, and business applications. 

Skills: 

1. Must be able to demonstrate strong leadership, influencing, and motivation skills. 

2. Must have demonstrated negotiation skills. 

3. Must be able to exercise sound business judgment in order to set direction and establish 

priorities. 

4. Requires excellent managerial skills, including planning, organizing, and directing work. 

5. Requires advanced level verbal and written communications skills in English, in addition 

to effective interpersonal skills. 

6. Requires excellent analytical skills, including the ability to extract and analyze data. 

7. Requires exceptional time management, due to fast-moving, demanding work 

environment. 

8. Must be able to create and deliver effective presentations. 

9. Must be able to exercise discretion and good judgment, with an ability to understand the 

effect of decisions in the overall organization. 

10. Must be able to use a desktop and laptop computer and standard business software 

applications with ease. 

11. Requires the ability to successfully represent the Staten Island Ferry system to the public, 

the City of New York, government agencies, and other stakeholders. 

12. Requires the ability to positively interface with customers and employees with tact and 

courtesy. 

13. Must be adept in corporate communications and public relations. 
Appendix F 148 Marine Accident Report

Assessment of APPENDIX B 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Sample Short-term Management Organization Matrix 

Director of Municipal 

Ferry Operations 

Vessel Maintenance & Repair Terminal Maintenance Senior Port Captain 

(Shore-based, non-union, management) 

Senior Port Engineer 

(Shore-based, non-union, management) 

Safety – 

Designated Person 
Appendix F 149 Marine Accident Report

Assessment of APPENDIX C 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Sample Long-term Management Organization Matrix 

Chief Operations Officer 

Director of 

Finance 

Director of 

Marine Operations 

Director of 

Terminal Engineering 

Affirmative Action Officer Confidential 

Secretary 

Director of 

 Maintenance 

Director of 

Human Resources 

Accounting 

Administrative 

Services 

Contracts/Legal 

Private Ferries 

Budget 

Auditing 

Information Technology 

Planning 

Employee 

Development 

Human Resources 

Services 

Labor Relations 

Payroll 

Senior 

Port Engineer 

Vessel 

Maintenance 

Vessel 

Preservation 

Senior 

Port Captain 

Operations 

Center 

Customer 

Service 

Terminal 

Construction 

Terminal 

 Maintenance 

Terminal 

Design 

Safety – 

 Designated Person 

Operations 

Planning 

Material 

Management 
Appendix F 150 Marine Accident Report

Assessment of APPENDIX D 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Management Position Description 

Title: Senior Port Captain

Position Objective 

Manage day to day marine operations including vessel traffic, licensed and unlicensed deck 

personnel, and facilities, to assure ferry system reliability and efficiency. Set standards for safety 

of crew and passengers in accordance with all applicable safety rules, regulations, industry 

standards, and best practices. Directly supervise and provide leadership to all deck department 

ferry personnel. Coordinate regulatory interaction with ferry system. Develop budget for input 

to Director of Municipal Ferry Operations. 

This position reports to the Director of Municipal Ferry Operations 

Qualifications 

The Senior Port Captain must possess a wide range of operating knowledge of all the ferry 

systems. The position calls for inspired leadership to motivate shipboard and shore side 

personnel with an emphasis on regulatory agency compliance. Possess a strong background in a 

Safety Management System environment. Experienced in labor relations, negotiations and 

grievance resolution. Must be able to work within the community to develop good community 

relations. 

Must possess a United States Coast Guard License as Master. 

Nature and Scope 

This is a mission critical position responsible for the day to day management of the Staten Island 

Ferry deck departments and deck personnel. This position supervises all phases of deck 

operations and personnel. As Senior Port Captain, responsible to coordinate all activities of 

vessels and operating personnel from an operational perspective. Candidate will interact with 

regulatory agencies and civil authorities to keep vessels and personnel in compliance with all 

known regulations. Will be the lead technical advisor to Director of Municipal Ferry Operations 

for labor negotiations. Will prepare budgets and supervise expenditures related to the deck 

department. Will directly oversee all operational functions including, but not limited to, 

certification of personnel. Is the first point of contact for issues relating to the deck department. 
Appendix F 151 Marine Accident Report

Assessment of APPENDIX D 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Principal Responsibilities 

Manage day to day ferry system deck operations. 

Maintain deck department crewing schedules within the framework of a Safety Management 

System. 

Supervise deck department personnel and staffing on a 24 hour a day basis. 

Approve labor, materials, supplies, equipment and parts within vessel deck department operating 

budgets. 

Evaluate routine deck department work orders, stores requests and labor expenditures to assure 

they comply with budgetary constraints. 

Manage vessel regulatory compliance for nautical and radio areas. 

Be the technical advisor to the CEO for corporate communications involving the deck 

department.
Appendix F 152 Marine Accident Report

Assessment of APPENDIX E 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Management Position Description 

Title: Senior Port Engineer

Position Objective 

Manage day to day engine department operations and maintenance, including facilities and 

personnel, to assure vessel propulsion system reliability and efficiency. Maintain vessels for 

safety of crew and passengers in accordance with all applicable safety rules, regulations, industry 

standards, and best practices. Directly supervise and provide leadership to licensed and 

unlicensed engine department professional marine engineers and oilers. Schedule vessel 

maintenance with Staten Island Ferry repair yard or commercial yards and direct routine vessel 

maintenance programs. Coordinate regulatory interaction with vessel engine departments. 

This position reports to the Director of Municipal Ferry Operations 

Qualifications 

The Senior Port Engineer must possess a wide range of operating knowledge of engine room 

operation and maintenance practices of a large marine passenger ferry operation. The position 

calls for shipyard contract management experience with an emphasis on regulatory agency 

compliance. Possess a strong background in a Safety Management System environment. 

Experienced in labor relations, negotiations and grievance resolution. 

Must possess a United States Coast Guard License as Chief Engineer. 

Nature and Scope 

This is a mission critical position responsible for the day to day management of the Staten Island 

Ferry engine rooms and personnel. This position supervises all licensed and unlicensed engine 

room personnel. As Senior Port Engineer, responsible to coordinate all maintenance items 

related to the vessels, to include commercial yard and repair facilities. First point of contact in 

dealing with regulatory agencies to keep vessels and personnel in compliance with all known 

regulations. Ensure vessels are crewed, stored and maintained to meet and complete Staten 

Island Ferries scheduled runs. 
Appendix F 153 Marine Accident Report

Assessment of APPENDIX E 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Principal Responsibilities 

Manage day to day engine operations and maintenance. 

Maintain vessels within the framework of a Safety Management System. 

Supervise engine room personnel and staffing on a 24 hour a day basis. 

Approve labor, materials, supplies, equipment and parts within vessel engine department 

operating budgets. 

Evaluate routine work orders, stores requests and labor expenditures to assure they comply with 

budgetary constraints. 

Manage vessel regulatory compliance. 
Appendix F 154 Marine Accident Report

Assessment of APPENDIX F 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Management Position Description 

Title: Safety Manager/Designated Person

Position Objective 

Directs the Safety Management System (SMS) for Staten Island Ferries and oversees the 

Corrective Action Reporting (CAR) Program and the SMS internal audit system. Manage the 

day to day coordination of the Safety Management System to ensure the Staten Island Ferries are 

in full compliance with the International Safety Management (ISM) Code for the Safe Operation 

of Ships and for Pollution Prevention. Supervise compliance with 46 CFR Subchapter W, Part 

199.630, Alternatives for Passenger Vessels. Develops and supervises formal training of vessel 

personnel to comply with alternative provisions of the ISM Code. 

This position reports to the Director of Municipal Ferry Operations and to the Deputy 

Commissioner as required by the ISM Code. 

Qualifications 

Thorough knowledge of all international and domestic regulatory requirements, application of 

marine safety management system programs and must possess a Master’s or Chief Engineer’s 

license. Knowledge of policies and procedures in the operation and maintenance of a large 

marine passenger ferry organization. Ability to plan strategic and effective positions for a 

successful and safe operating program. 

Nature and Scope 

This mission critical position is responsible for identifying and recommending solutions for SMS 

policy issues across the organization and has access to the CEO for SMS policy issues that 

demand the highest level of organizational action. 
Appendix F 155 Marine Accident Report

Assessment of APPENDIX F 

Staten Island Ferry Operations February 12, 2004 

Global Maritime and Transportation School Telephone: +1 (516) 773-5120 

At the United States Merchant Marine Academy Facsimile: +1 (516) 773-5353 

Kings Point, New York, USA Email: gmats@usmma.edu 

Principal Responsibilities 

Functions as the Designated Person for Staten Island Ferries and directs the Safety Management 

System. 

Is the key link between vessel and shore in Staten Island Ferries SMS program, holding authority 

to inspect all SMS records and work sites, hold drills and bring SMS problems to the attention of 

appropriate personnel. 

Directs labor and non-labor budget planning and management for the Safety Office. 

Participates in vessel casualty investigations. 

Participates in investigations involving injury to passengers or crew. 

Participates in investigations involving pollution of the environment. 

Supervises the content of SMS documentation and advises the CEO of SMS matters that require 

the highest level of attention. 

Oversees the Corrective Action Reporting System and conducts timely audits of vessels and 

terminals. 

Keep current all formal training of Staten Island Ferry personnel to comply with SMS 

requirements.