U.S. GOVERNMENT PUBLISHING OFFICE

30–345 PDF WASHINGTON : 2018

EXAMINATION OF REPORTS ON THE ‘‘EL FARO’’ 

MARINE CASUALTY AND COAST GUARD’S ELECTRONIC HEALTH RECORDS 

(115–34) 

HEARING 

BEFORE THE

SUBCOMMITTEE ON 

COAST GUARD AND MARITIME TRANSPORTATION 

OF THE

COMMITTEE ON 

TRANSPORTATION AND 

INFRASTRUCTURE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JANUARY 30, 2018 

Printed for the use of the 

Committee on Transportation and Infrastructure 

( 

Available online at: https://www.govinfo.gov/committee/house-transportation?path=/ 

browsecommittee/chamber/house/committee/transportation 

(II) 

COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE 

BILL SHUSTER, Pennsylvania, Chairman 

DON YOUNG, Alaska 

JOHN J. DUNCAN, JR., Tennessee, 

Vice Chair 

FRANK A. LOBIONDO, New Jersey 

SAM GRAVES, Missouri 

DUNCAN HUNTER, California 

ERIC A. ‘‘RICK’’ CRAWFORD, Arkansas 

LOU BARLETTA, Pennsylvania 

BLAKE FARENTHOLD, Texas 

BOB GIBBS, Ohio 

DANIEL WEBSTER, Florida 

JEFF DENHAM, California 

THOMAS MASSIE, Kentucky 

MARK MEADOWS, North Carolina 

SCOTT PERRY, Pennsylvania 

RODNEY DAVIS, Illinois 

MARK SANFORD, South Carolina 

ROB WOODALL, Georgia 

TODD ROKITA, Indiana 

JOHN KATKO, New York 

BRIAN BABIN, Texas 

GARRET GRAVES, Louisiana 

BARBARA COMSTOCK, Virginia 

DAVID ROUZER, North Carolina 

MIKE BOST, Illinois 

RANDY K. WEBER, SR., Texas 

DOUG LAMALFA, California 

BRUCE WESTERMAN, Arkansas 

LLOYD SMUCKER, Pennsylvania 

PAUL MITCHELL, Michigan 

JOHN J. FASO, New York 

A. DREW FERGUSON IV, Georgia 

BRIAN J. MAST, Florida 

JASON LEWIS, Minnesota 

PETER A. DEFAZIO, Oregon 

ELEANOR HOLMES NORTON, District of 

Columbia 

JERROLD NADLER, New York 

EDDIE BERNICE JOHNSON, Texas 

ELIJAH E. CUMMINGS, Maryland 

RICK LARSEN, Washington 

MICHAEL E. CAPUANO, Massachusetts 

GRACE F. NAPOLITANO, California 

DANIEL LIPINSKI, Illinois 

STEVE COHEN, Tennessee 

ALBIO SIRES, New Jersey 

JOHN GARAMENDI, California 

HENRY C. ‘‘HANK’’ JOHNSON, JR., Georgia 

ANDRE ́ CARSON, Indiana 

RICHARD M. NOLAN, Minnesota 

DINA TITUS, Nevada 

SEAN PATRICK MALONEY, New York 

ELIZABETH H. ESTY, Connecticut, Vice 

Ranking Member 

LOIS FRANKEL, Florida 

CHERI BUSTOS, Illinois 

JARED HUFFMAN, California 

JULIA BROWNLEY, California 

FREDERICA S. WILSON, Florida 

DONALD M. PAYNE, JR., New Jersey 

ALAN S. LOWENTHAL, California 

BRENDA L. LAWRENCE, Michigan 

MARK DESAULNIER, California 

SUBCOMMITTEE ON COAST GUARD AND MARITIME TRANSPORTATION

DUNCAN HUNTER, California, Chairman 

DON YOUNG, Alaska 

FRANK A. LOBIONDO, New Jersey 

GARRET GRAVES, Louisiana 

DAVID ROUZER, North Carolina 

RANDY K. WEBER, SR., Texas 

BRIAN J. MAST, Florida 

JASON LEWIS, Minnesota, Vice Chair 

BILL SHUSTER, Pennsylvania (Ex Officio) 

JOHN GARAMENDI, California 

ELIJAH E. CUMMINGS, Maryland 

RICK LARSEN, Washington 

JARED HUFFMAN, California 

ALAN S. LOWENTHAL, California 

ELEANOR HOLMES NORTON, District of 

Columbia 

PETER A. DEFAZIO, Oregon (Ex Officio) 

(III) 

CONTENTS Page 

Summary of Subject Matter .................................................................................... v 

TESTIMONY 

PANEL 1 

Rear Admiral John P. Nadeau, Assistant Commandant for Prevention Policy, 

U.S. Coast Guard ................................................................................................. 4 

Hon. Earl F. Weener, Ph.D., Board Member, National Transportation Safety 

Board, accompanied by Brian Curtis, Director, Office of Marine Safety, 

National Transportation Safety Board ............................................................... 4 

PANEL 2 

Rear Admiral Erica Schwartz, Director of Health, Safety, and Work-Life, 

U.S. Coast Guard ................................................................................................. 19 

Rear Admiral Michael J. Haycock, Assistant Commandant for Acquisition 

and Chief Acquisition Officer, U.S. Coast Guard .............................................. 19 

David A. Powner, Director of Information Technology Management Issues, 

U.S. Government Accountability Office .............................................................. 19 

PREPARED STATEMENTS SUBMITTED BY MEMBERS OF CONGRESS 

Hon. John Garamendi of California ....................................................................... 30 

PREPARED STATEMENTS SUBMITTED BY WITNESSES 

Rear Admiral John P. Nadeau, Assistant Commandant for Prevention Policy, 

U.S. Coast Guard ................................................................................................. 33 

Hon. Earl F. Weener, Ph.D., Board Member, National Transportation Safety 

Board, accompanied by Brian Curtis, Director, Office of Marine Safety, 

National Transportation Safety Board ............................................................... 52 

Rear Admiral Erica Schwartz, Director of Health, Safety, and Work-Life, 

U.S. Coast Guard 1

Rear Admiral Michael J. Haycock, Assistant Commandant for Acquisition 

and Chief Acquisition Officer, U.S. Coast Guard 1

David A. Powner, Director of Information Technology Management Issues, 

U.S. Government Accountability Office .............................................................. 66 

SUBMISSIONS FOR THE RECORD 

U.S. Coast Guard, responses to questions for the record from Hon. John 

Garamendi, a Representative in Congress from the State of California ......... 36 

Hon. Earl F. Weener, Ph.D., Board Member, National Transportation Safety 

Board, responses to questions for the record from Hon. John Garamendi, 

a Representative in Congress from the State of California .............................. 62 

David A. Powner, Director of Information Technology Management Issues, 

U.S. Government Accountability Office, responses to questions for the 

record from Hon. John Garamendi, a Representative in Congress from 

the State of California ......................................................................................... 81 

1 RADM Schwartz and RADM Haycock did not submit written statements for the record. 

Page

IV 

Reports referenced in the Summary of Subject Matter on pages v–x: 

Coast Guard Marine Board of Investigation Recommendations 2 ................ 86 

Action by the Commandant, U.S. Coast Guard, December 19, 2017, 

‘‘Steam Ship El Faro (O.N. 561732) Sinking and Loss of the Vessel 

with 33 Persons Missing and Presumed Deceased Northeast of Acklins 

and Crooked Island, Bahamas, on October 1, 2015’’ .................................. 92 

National Transportation Safety Board Recommendations 3 ......................... 123 

2This is an excerpt from the 199-page U.S. Coast Guard Marine Board report entitled, 

‘‘Steam Ship El Faro (O.N. 561732) Sinking and Loss of the Vessel with 33 Persons Missing 

and Presumed Deceased Northeast of Acklins and Crooked Island, Bahamas, on October 1, 

2015’’ and available online at https://media.defense.gov/2017/Oct/01/2001820187/-1/-1/0/ 

FINAL%20PDF%20ROI%2024%20SEP%2017.PDF. 3This is an excerpt from the 282-page National Transportation Safety Board report entitled, 

‘‘Sinking of U.S. Cargo Vessel SS El Faro, Atlantic Ocean, Northeast of Acklins and Crooked 

Island, Bahamas, October 1, 2015’’ adopted December 12, 2017, NTSB/MAR-17/01, PB2018- 

100342 and available online at https://www.ntsb.gov/investigations/AccidentReports/Reports/ 

MAR1701.pdf. 

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(1) 

EXAMINATION OF REPORTS ON THE ‘‘EL 

FARO’’ MARINE CASUALTY AND COAST 

GUARD’S ELECTRONIC HEALTH RECORDS 

TUESDAY, JANUARY 30, 2018 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON COAST GUARD AND MARITIME

TRANSPORTATION, 

COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10 a.m., in room 

2167, Rayburn House Office Building, Hon. Duncan Hunter (Chairman of the subcommittee) presiding. 

Mr. HUNTER. Good morning. The subcommittee will come to 

order. 

The subcommittee is convening today to examine the fatal sinking of the U.S.-flagged cargo ship, SS El Faro and, on a second 

panel, the Coast Guard’s failed efforts to implement an electronic 

health record system. 

On October 1, 2015, the 790-foot U.S.-flagged cargo ship SS El 

Faro sank in the Atlantic Ocean about 40 nautical miles northeast 

of Acklins and Crooked Island, Bahamas. An unusual storm path, 

reliance on outdated weather reports, and failure to implement 

proper bridge resource management techniques resulted in El Faro 

sailing almost directly into Hurricane Joaquin, a category 4 storm 

with an estimated sustained wind speed of 115 knots. 

The loss of the U.S.-flagged cargo vessel El Faro, along with its 

33-member crew, ranks as one of the worst maritime disasters in 

U.S. history and resulted in the highest death toll from a U.S. commercial vessel sinking in almost 40 years. 

The last comparable U.S. maritime disaster was the sinking of 

the U.S. bulk carrier Marine Electric off the coast of Virginia in 

February 1983, in which all but 3 of the 34 persons aboard lost 

their lives. The Coast Guard instituted major changes following 

that tragedy to improve safety and prevent similar events from occurring in the future. 

Despite those efforts to improve safety, tragedy befell the El 

Faro. 

On October 31, 2015, a U.S. Navy vessel located the main wreckage of El Faro and the vessel’s voyage data recorder was successfully recovered. It contained 26 hours of bridge audio recordings 

and other critical navigation data that were used by the Coast 

Guard and the NTSB investigators to understand the causes of this 

2 

horrible incident and develop recommendations to prevent future 

tragedies. 

The Coast Guard Marine Board of Investigation made 31 safety 

and 4 administrative recommendations to address the causes of the 

El Faro’s sinking. In December 2017, the Commandant of the 

Coast Guard released his Final Action Memo on the Marine 

Board’s recommendation. The Commandant concurred with 29 of 

31 safety recommendations and 3 of 4 administrative recommendations. 

The National Transportation Safety Board launched an investigation as soon as the sinking of El Faro was confirmed, ultimately providing numerous recommendations for responsible entities, including the Coast Guard, the International Association of 

Classification Societies, and the owner of El Faro. 

The Nation relies on our merchant mariners and the U.S.-flagged 

ships they sail. It is critical that policies are in place and adopted 

as standard practice to ensure mariners’ safety. In order to do so, 

we must learn from the loss of the El Faro. I look forward to discussing how this tragedy occurred and what steps are being taken 

to prevent another such incident from occurring. 

Notwithstanding the importance and gravity of the El Faro tragedy, on panel 2 we will examine the Coast Guard’s apparent inability to implement an electronic health record system to manage data 

for its over 56,000 Coast Guard members and retirees. 

After wasting more than $66 million over a 5-year period, the 

Coast Guard canceled its electronic health records effort, referred 

to as the Integrated Health Information System project. 

The Service has nothing to show for the time and money expended and finds itself in a worse position than before it awarded 

the first contract almost 8 years ago. 

Today the Coast Guard is still handling all medical information 

using paper records, records that cannot be shared with the Department of Defense or the Department of Veterans Affairs system. 

Following a subcommittee request to review Coast Guard actions, 

the Government Accountability Office found that for nearly the entire span of the project, the Coast Guard allowed program managers to act without sufficient oversight by acquisition professionals. Even when the Coast Guard established its nonmajor acquisition process policies to provide oversight for information technology acquisitions, things like the Integrated Health Information 

System project, they did not implement any oversight. 

Despite chartering several oversight bodies for the project, GAO 

found that the Coast Guard, ‘‘could not provide evidence that the 

boards had ever been active in overseeing the project prior to its 

cancellation.’’ 

Other than realizing they had been throwing away good money 

for years, the Coast Guard still cannot provide a solid explanation 

as to why it canceled the Integrated Health Information System 

project. 

The Coast Guard needs to show what it has learned and how 

things have changed as it works to finally implement an electronic 

health record system. We understand the Service is following its 

acquisition policies for the current effort and has conducted signifiVerDate Aug 31 2005 13:58 Jun 11, 2018 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 P:\HEARINGS\115\CG\1-30-2~1\30345.TXT JEAN
3 

cant research which pointed to a recommended solution of using an 

existing Federal agency system. That is amazing. 

After a 5-year epic failure, these are positive steps. However, we 

need to hear more about the policies and procedures that are now 

in place to prevent the waste of taxpayer money in the future. 

I look forward to discussing how this debacle occurred, what 

steps the Coast Guard is taking to ensure nothing like this can 

happen again, and where the Coast Guard is in the process of finally acquiring an electronic health record system. 

I thank the witnesses for being here today, and I look forward 

to hearing all the various testimony on the various issues. 

And I yield to Ranking Member Garamendi. You are recognized. 

Mr. GARAMENDI. I yield to—— 

Mr. HUNTER. Yield to the ranking member of the full committee, 

Mr. DeFazio. 

Mr. DEFAZIO. Thank you, Mr. Chairman. And I thank the ranking member for that. I have to run to a press event and then I will 

be back. 

First off, I am concerned that we are merging two totally unrelated subjects here. Certainly, the acquisition failure is important. 

Whether it merits a hearing or not, I am not sure, but it certainly 

shouldn’t be taking away from a focus on the El Faro tragedy. 

This was totally preventable. And I think there are a number of 

factors and things that require the attention of the subcommittee. 

First off, there are real questions about the Coast Guard, whether their budget is adequate to carry out this very, very important 

function. I think it is not. I think we have spread them too thin. 

And they are relying far too much on classification societies without any substantial oversight of those classification societies. 

And from some in the industry, I understand there are companies who do a good job and there are other companies, if you pay 

them, they will certify your rust bucket as seaworthy. 

Now, that is just not right, and that really requires some scrutiny. It also requires us to question how we got to that point, and 

what we can do to rectify that. 

I think that the Coast Guard should have resources adequate to, 

minimally, to oversee these classification societies. Perhaps we 

need to have some sort of a system where we either certify them 

or decertify them for U.S. certification. 

Now, they can go to these nonexisting countries with these registries and certify rust buckets. We can’t control that, but we can 

control whose certifications we accept here in the United States of 

America, and that, I think, played a substantial role in this. 

Plus, real questions about, obviously, the management of TOTE 

and the training that TOTE provided, the adequacy of the lifesaving supplies on the ship, all the questions about when the ship 

had a major conversion, why it wasn’t considered a major conversion, and, therefore, they didn’t have to upgrade things, what 

brought that about, which might have saved lives in this case. 

There is just a host of questions. And I hope we can really drill 

down on that, and I hope we don’t get distracted with the second 

panel. 

Thank you, Mr. Chairman. 

Mr. HUNTER. I thank the ranking member. 

4 

From I understand, too, it is hard to get committee time, because 

we won’t do in this full committee multiple subcommittees at the 

same time. So we don’t do freeways and Coast Guard, which enables the ranking member and others to attend, but we are out of 

days for stuff. So we are going to focus for the first hour on the 

El Faro, or however long it takes us, before we move on. 

Mr. Garamendi, you are recognized for your opening statement. 

Mr. GARAMENDI. Let’s get on with the hearing. Without objection, 

my testimony will be in the record. 

Mr. HUNTER. Without objection, so ordered. 

Mr. GARAMENDI. And I think I will just let it go at that, with a 

couple of very brief statements. 

It was 35 years ago that the Marine Board of Investigation made 

a report about the faults of two systems in the maritime safety programs. Here we are again, essentially the same report being 

issued, this time on the El Faro situation. 

The question is, why are we back with the same recommendations to address the tragedy of the El Faro? Bottom line is, why 

didn’t we get it right in the last 35 years? 

With that, my testimony, my written, will be in the record. 

Mr. HUNTER. I thank the gentleman. 

And I ask unanimous consent that members not on the subcommittee be permitted to sit with the subcommittee at today’s 

hearing and ask questions. Without objection, so ordered. 

On the first panel we will hear from Rear Admiral John Nadeau, 

Assistant Commandant for Prevention Policy for the United States 

Coast Guard, and the Honorable Earl Weener, Member of the National Transportation Safety Board, accompanied by Mr. Brian 

Curtis, Director of the Office of Marine Safety for the NTSB. 

Admiral Nadeau, you are recognized to give your statement, and 

welcome back. 

TESTIMONY OF REAR ADMIRAL JOHN P. NADEAU, ASSISTANT 

COMMANDANT FOR PREVENTION POLICY, U.S. COAST 

GUARD; AND HON. EARL F. WEENER, PH.D., BOARD MEMBER, 

NATIONAL TRANSPORTATION SAFETY BOARD, ACCOMPANIED BY BRIAN CURTIS, DIRECTOR, OFFICE OF MARINE 

SAFETY, NATIONAL TRANSPORTATION SAFETY BOARD 

Admiral NADEAU. Good morning, Chairman Hunter, Ranking 

Member Garamendi, distinguished members of the subcommittee. 

I am honored to be here today. 

Mr. Chairman, I want to especially thank you for your leadership 

and enduring support to the Coast Guard. 

On behalf of all the men and women in the Coast Guard, I offer 

our deepest condolences to the families of the 33 mariners lost onboard El Faro. As our Commandant noted in the Final Action Memo, the loss of 

the El Faro and everyone aboard was a tragic and preventable accident. This is a call to action for the entire maritime community. 

The Commandant is committed to making improvements within 

the Coast Guard and the maritime industry and has directed me 

to do so. 

The Marine Board of Investigation conducted an exhaustive 2- 

year investigation in full view of the public. While the primary 

5 

cause of the casualty was the decision to navigate El Faro too close 

to the path of Hurricane Joaquin, there were other contributing 

factors. 

These include, one, the failure of TOTE Services, Incorporated, to 

maintain an effective safety management system; two, the failure 

of the ship’s classification society, ABS [American Bureau of Shipping], on multiple occasions to uncover or otherwise resolve longstanding deficiencies that adversely affected the safety and seaworthiness of vessels; and, three, failure of the Coast Guard to 

properly oversee the work conducted by ABS on our behalf. 

To determine if these issues revealed in the El Faro investigation 

are pervasive throughout the fleet, I directed a team of senior marine inspectors to closely examine more ships currently enrolled in 

the Alternate Compliance Program, or ACP. We have found additional evidence of breakdowns in the safety framework, and our 

findings confirm concerns raised in the investigation about the material condition of several other U.S.-flagged vessels. 

All elements of the safety framework—the vessel owners and operators, the class societies, and the Coast Guard—must all improve. 

The vessel owner is accountable for properly maintaining and ensuring the safe operations of the vessel. 

The class society plays a key role in ensuring safety by providing 

thorough and accurate surveys and compelling corrective actions 

when needed. 

The Coast Guard is the final element in the safety framework by 

verifying compliance with mandatory safety standards. 

As was noted in the Federal Register announcing the program 

more than two decades ago, ACP was created in response to the 

needs expressed by the U.S. maritime industry to reduce the regulatory burden and alleviate duplication of effort between the Coast 

Guard and class societies. 

Since day one, the Coast Guard has committed to providing oversight to ensure that vessels participating in ACP are maintained 

and operated to the same level of safety as vessels inspected by the 

Coast Guard under the traditional process. 

Today we remain committed to this goal and acknowledge we 

must do better. 

The U.S., like other flag states around the globe today, now relies far more heavily on third parties than ever before. In fact, the 

vast majority of the U.S. sealift fleet that DoD relies on to transport America’s soldiers, Marines, and their equipment overseas, 

uses class societies for many of their compliance activities. 

Now, more than ever, we need to get this right. The Coast Guard 

must and will restore the safety framework with robust and thorough oversight and accountability. 

I am taking a number of steps to do so. I will lead the actions 

directed by the Commandant in response to this tragedy. I am reforming our oversight program and directing changes to the organization, the procedures, the policy, the training, and the capture and 

management of key information. 

These actions are needed to ensure accountability for the maritime industry, the authorized class societies, and the Coast Guard. 

The Coast Guard has the authority and the competency needed to 

6 

successfully accomplish this. As I pursue these actions, I will be 

transparent and keep you all informed. 

At the end of the day, this is about the lives of the men and 

women who go to sea in support of the Nation’s economic prosperity, in support of our military readiness, and in support of our 

national security. 

I recently had the opportunity to visit the El Faro Memorial in 

Jacksonville. I also met some of the mariners who had once sailed 

on the El Faro and now mourn the loss of their shipmates. It was 

a moving and humbling experience. 

This tragedy has shined a spotlight on failures of the safety 

framework. We must honor the 33 lost mariners with a strong bias 

towards action. 

The Coast Guard, after the vessel owner and the class society, 

is the final element in the safety framework responsible for ensuring compliance with mandated safety standards. The Coast Guard 

must and will restore the safety framework. 

Again, thank you for your strong support of the Coast Guard. 

Thank you for the opportunity to testify today. I ask my written 

statement be entered into the record. I look forward to your questions. 

Mr. HUNTER. Without objection. Thank you, Admiral. 

Mr. Weener, you are recognized. 

Mr. WEENER. Good morning, Chairman Hunter, Ranking Member Garamendi, and members of the subcommittee. Thank you for 

inviting the NTSB to provide testimony today. 

Mr. HUNTER. Would you mind pulling the microphone a bit closer 

to you? Thank you. 

Mr. WEENER. I am accompanied by Brian Curtis, the Director of 

our Office of Marine Safety. 

My testimony will discuss the NTSB’s investigation into the sinking of the cargo ship El Faro and the loss of all 33 crewmembers 

aboard. 

The NTSB-led investigation and was a joint effort with the 

United States Coast Guard. Four days after the sinking, the NTSB, 

Coast Guard, and many other organizations began a collaborative 

search of the ocean floor seeking the El Faro wreckage and in an 

effort to locate and retrieve the ship’s voyage data recorder, or 

VDR. 

Data recorders are important investigative tools critical to many 

of our investigations. It took three missions to recover the VDR. 

Analysis revealed significant data, including 26 hours of audio, 

which was crucial in determining the probable cause of El Faro’s 

sinking. 

On September 29, 2015, at 9:48 p.m., the El Faro and its crew 

departed Jacksonville, Florida, for San Juan, Puerto Rico. Operated 

by TOTE Services, the U.S.-flagged ship was slated to arrive in the 

early morning hours of October 2. However, rather than routing 

around the approaching storm, the ship sailed directly—— 

Mr. HUNTER. Mr. Weener, I am sorry, there is wind going 

through here and I have bad ears. Do you mind pulling that thing 

really close, please, and speak louder if you could. There is like 

wind blowing through here behind us. And I have got artillery ears. 

7 

Mr. WEENER. On September 29, 2015, at 9:48 p.m., the El Faro 

and its crew departed Jacksonville, Florida, for San Juan, Puerto 

Rico. Operated by TOTE Services, the U.S.-flagged ship was slated 

to arrive in the early morning hours of October 2. However, rather 

than routing around the approaching storm, the ship sailed directly 

into the path of the hurricane and sank at approximately 8 a.m. 

on October 1. 

My written testimony provides more detail regarding what happened during the voyage that led to the ship’s being in harm’s way. 

For now, I will focus on major safety issues identified in our report. 

The NTSB’s probable cause determination for this accident included the captain’s decisionmaking and actions, which put the El 

Faro and its crew in peril. The captain did not divert to safer 

routes to avoid Hurricane Joaquin, failing to heed junior officers 

who suggested an alternate course was necessary to avoid the hurricane. 

We found that although the El Faro received sufficient weather 

information to facilitate appropriate decisionmaking by the captain 

regarding the vessel’s route, the captain did not use the most current weather information available to him. 

In addition, the investigation revealed the captain’s light regard 

for the crew’s suggestions and the crew’s lack of assertiveness in 

stating their concerns to the captain. The NTSB found that the 

bridge crew did not use all available resources, nor act effectively 

as a team to safely operate the ship. 

The El Faro, sailing on a collision course with Hurricane Joaquin, was further imperiled by the failure to maintain the ship’s 

watertight integrity. Seawater entered a cargo hole through an 

open scuttle. The resulting flooding caused improperly secured 

automobiles to impact an inadequately protected fire pump supplied by piping carrying seawater. 

The damaged piping allowed seawater to flow unchecked into the 

ship. This exacerbated other flooding causes, caused by water entering through open, unsecured ventilation closures. 

In addition, the TOTE safety management system was inadequate. Its lack of oversight in critical aspects of safety management denoted a weak safety culture in the company and contributed to the sinking of the El Faro. 

Finally, the captain’s decisions to muster the crew and abandon 

the ship were late and likely reduced the crew’s chance of survival. 

The severe weather, combined with El Faro’s list, made it unlikely 

that liferafts or lifeboats available on the ship could be launched 

or boarded by crewmembers once in the water. The lifeboats onboard would not have provided adequate protection, even if they 

had been launched. 

Coast Guard standards do not require older ships, such as the El 

Faro, to adhere to the latest safety standards. 

These are just a few of the issues identified out of a total of 81 

findings and 53 safety recommendations. As with all investigations, 

our aim is to learn from this tragedy to prevent similar events from 

occurring again. We believe that the adoption of our recommendations will help improve safety for current and future generations of 

mariners. 

8 

Thank you again for the opportunity to testify, and I am happy 

to take your questions. 

Mr. HUNTER. Thank you, sir. 

Mr. Curtis, you are recognized. 

OK. You are just accompanying. So I will start out by recognizing 

myself. Thank you very much for being here. 

My question is pretty simple. If they would have closed the 

hatches or the ventilation systems, right, so the water could not get 

in, in the heightened sea states that they had, would they have 

been OK, if their engines would not have failed and they hadn’t 

taken on water? Could they have sailed through? 

Mr. WEENER. I think our investigation showed that this was a 

series of events, a chain of events that had it been interrupted at 

any point, the chain would not have been completed. So it started 

with a decision to not avoid the hurricane. Once they got into 

heavy weather, they had a scuttle that got flooding in one of the 

holes—— 

Mr. HUNTER. When you say an open scuttle, what is that? Can 

you tell the committee what that is? 

Mr. WEENER. That is a hatch going between decks that for heavy 

weather should have been closed and locked, but it was left open. 

So they got down-flooding with that. Basically, there was a whole 

series of events. 

Mr. HUNTER. Mr. Curtis? Admiral? 

Admiral NADEAU. Sir, I would add to that. 

In the Coast Guard’s perspective, I think it is difficult to say. It 

is hard to simplify it to that level. It is a series of events that go 

on, that chain of events that occurred, and I think it would be very 

difficult for us to say with any degree of certainty whether or not 

simply closing vents would have prevented this casualty. 

Mr. HUNTER. What I am trying to get at is you have all of these 

recommendations, right? And you can go through a ship or an airplane or anything, military or civilian, and say, this isn’t up to 

code, or this is unsatisfactory, or we are going to allow this to slide 

because of the age of the vessel or the aircraft or whatever. 

But what I am trying to get at is, if all of those things were followed then the right decisions would have been made in the first 

place and the chain of events would not have happened. 

But it is not like the ship broke in half because the weld wasn’t 

right or something or it passed an inspection where it failed on the 

structure of the ship. It was decisionmaking and not paying attention to detail that caused the initial stuff, right? 

I mean, the captain sailed into the hurricane, not around it, and 

they had basically open hatches on the ship that allowed water to 

get in, and then, boom, right? That is sort of the really fast chain 

of events, I am guessing. 

Is that correct, roughly? 

Admiral NADEAU. Sir, our investigation concluded that it is likely 

the material condition of the ship did contribute as well and that 

the watertight fittings that would be relied upon to prevent progressive flooding were not in the condition they should have been 

maintained. 

Mr. HUNTER. Mr. Curtis. 

9 

Mr. CURTIS. Certainly, as you point out, that was a significant 

event in the series of events, having the hatch open. And our report 

made recommendations to that very point to hopefully prohibit it 

from happening in the future, with having alarms and notifications 

if a hatch is left open, that it should be closed. 

But it was, as you said, a significant—— 

Mr. HUNTER. To me, you had, when I was in Fallujah, you had 

M1 Abrams tanks every now and then that would roll over into ravines and the Marines would die. They would go over into irrigation canals, right? 

It wasn’t anything wrong with the tank. They might have had 

some things that weren’t up to code, but it is wartime, but there 

wasn’t anything wrong with the tank, but they changed how they 

drove around irrigation canals. And I would guess that that is a 

lot of your recommendations that say, do this next time, don’t do 

that, right? 

Mr. CURTIS. Certainly in our report. Yes, sir. 

Admiral NADEAU. Sir, I would only add, during this investigation 

we went aboard the sister vessel, the El Yunque, which was in 

similar service, similar build date, maintained by the same company, and that ship ended up being scrapped after we went onboard based on the material condition. 

Mr. HUNTER. And TOTE was in the process of rebuilding these— 

or building the new class of these anyway, right, as this happened. 

[Admiral Nadeau nods.] 

Mr. HUNTER. This ship, the El Faro, was going to be pulled out 

of the line, I would assume, in the next couple—or now, right, if 

it had stayed afloat. 

Admiral NADEAU. Sir, I believe the intent was to shift the El 

Faro to the northwest so that it would go into trade back and forth 

to Alaska while they were still working to deliver the final two new 

containerships that were being built. 

Mr. HUNTER. Thank you. 

Mr. Garamendi, you are recognized. 

Mr. GARAMENDI. I am not going to spend a lot of time focusing 

on the mistakes made by the captain and the crew along the way. 

Those are well documented in the report. 

Going forward, the utility of the National Transportation Safety 

Board report and the Coast Guard is really where I want to focus 

here. How can we prevent this kind of accident from occurring 

again? 

So to the Coast Guard who has oversight of the safety of ships 

and the associations that are specifically responsible for reviewing 

a ship, what are you doing to assure us that the various associations and organizations that review the safety of ships is actually 

taking place and is robust enough to assure that the ship is safe? 

Then there is a series of questions about the competency of the 

men and women on the ship. 

So, first, what are you doing to assure us that the organizations 

that review the safety of the ships actually do their job? 

Admiral NADEAU. Ranking Member Garamendi, for starters, we 

want to see how pervasive these conditions were throughout the 

fleet. So I have a team out visiting what we would view as the 

high-risk vessels that are enrolled in ACP, based on their age, 

10 

based on their history, based on their casualties, et cetera. And the 

findings indicate that it is not unique to the El Faro, we have other 

ships out there that are in substandard condition. 

We have moved out to reform our oversight program. It starts 

with governance and having the proper people in place with the 

proper focus to call attention and hold others accountable. That 

also involves having the right policy and procedures in place, the 

right information management systems to capture the data, collect 

it, and then engage with our third parties and communicate to hold 

them accountable. 

So it is an ongoing effort. It will take us a little time. But we 

have launched and we are underway and committed to rectifying 

the problems that we are finding. 

Mr. GARAMENDI. Do you have a tracking system, a review system 

in place, so that you know what is actually taking place as you attempt to improve your oversight? 

Admiral NADEAU. We have a—it is called MISLE, it is an information management system we use for all of our marine safety activities and others. It has not been able to capture some of the information we want it to capture, so we are making changes now 

to improve that system. 

At this time it is difficult for our people in the field, when they 

do find things, to properly incorporate it into MISLE so we can roll 

up all that data, all that information, and then engage with our 

third parties to talk to them about the problems we are finding. 

Changes are underway, so we will have that capability and be 

able to make sure we have the information to engage with them. 

Mr. GARAMENDI. So there is a reporting system that has not 

worked well in the past when your people in the field find something is amiss. No reporting up the chain of command, and then 

no action by the chain of command. Is that what has happened in 

the past? 

Admiral NADEAU. The procedures, the processes, the training, 

and the information capture all need to be improved. 

Mr. GARAMENDI. Well, we are towards the end of January here, 

and I suppose you have a tracking system in place so that you 

know that there are improvements underway? 

Admiral NADEAU. We do, sir. We are working, have a team assembled that is working on this, and we have moved out to actually 

look at the ship. 

So I guess there are a couple efforts. One, again, is in the field, 

getting aboard the ships, and trying to call out those requirements 

and raise the condition of those ships that need it. And the second 

thing is to actually make structural changes within our processes 

and our procedures and those tools we use to better enable us to 

conduct the proper oversight. 

Mr. GARAMENDI. All right. I was just talking to our chairman 

and his staff. I am going to turn this back to the chairman about 

a request for a matrix on exactly what you are doing and timeframes. 

Mr. HUNTER. Which you have, which you are going to give us, 

right? 

Admiral NADEAU. I can do that for you, sir. 

Mr. HUNTER. We have already asked you for it. 

11 

Admiral NADEAU. OK. 

Mr. HUNTER. So somebody is working on it. Anybody here working on it who would know when it would be given to us? 

OK. 

Mr. GARAMENDI. Well, let me just take it up here. 

If you have a system in place to improve the review and oversight not only of the work you—that the Coast Guard is doing, but 

also of the various organizations to whom you have assigned responsibility, this committee would like to have that tracking system, that matrix, that reporting program, as to exactly how you are 

tracking the safety programs, and then an update, a report 6 

months from now as to how it is going. 

Can you do that? 

Admiral NADEAU. Yes, sir. 

Mr. GARAMENDI. Good. Thank you. 

For the NTSB, with regard to the action in itself, you report you 

have, I don’t know, I am trying to add up the number of at least 

20 or 30 different recommendations. Do you ever go back and follow up on your recommendations as to whether they are actually 

done, Mr. Weener? 

Mr. WEENER. Yes, we do. We make these recommendations, safety recommendations, to a variety of parties, but the majority in this 

case have gone to the Coast Guard. We send these recommendations off, we expect acknowledgment of receipt, and then we track 

them from that point on. 

We have some expectations of how long it is going to take to get 

a response. But we constantly keep track of the recommendations 

until such time as they are ‘‘Closed Acceptable,’’ in some cases 

‘‘Closed Unacceptable,’’ but we track them all the way through. 

Mr. GARAMENDI. So your recommendations came out more than 

a month, almost 2 months ago now, the final version, I think that 

is the date. And have you had any success or have you seen any 

improvement, any action on your recommendations yet, some to the 

Coast Guard, some to the shipowners? 

Mr. WEENER. At this point in time we would just expect to be 

getting an acknowledgment that they have the recommendation. At 

this point we would hope that they would give us some idea of 

what their plan was and how long it was going to take. 

Mr. GARAMENDI. Our role here with regard to the Coast Guard 

is to make sure they are doing their task of maritime safety. And 

for the NTSB, your work to report to us, Mr. Curtis, I think this 

is your specific responsibility. 

What is your timeframe on following up on the recommendations, 

both to the shipping industry as well as to the Coast Guard? We 

just asked the Coast Guard for their matrix for review, and I am 

asking you for your matrix for review, your timeframe, your schedule. 

Mr. CURTIS. Yes, sir. So as you said, the recommendations would 

go out as the adoption date shortly after once they are forwarded 

to the parties, and they have 90 days to make their initial response 

to how they respond to the recommendation, what they would do. 

And TOTE has implemented some changes to those recommendations. There are about 10 recommendations to TOTE. 

12 

But for all parties, whether they go to the Coast Guard, TOTE, 

other agencies, NOAA, some to NOAA, they have 90 days for the 

initial response. And then we have an office, Office of Safety Recommendations, which corresponds directly with them on an ongoing basis. And when they get a response back from those recipients 

of the recommendations, specific ones are forwarded back to our office to respond that we feel whether they are appropriate or not. 

And so we work through back to the Safety Recommendations 

Office and ultimately back to the recipient of the recommendation. 

So in this case there were 53 recommendations, so we will be very 

active and proactive in working with the Office of Safety Recommendations and the recipients. 

Mr. GARAMENDI. It seems to me that the committee should be 

aware of this response loop that you just described. I would appreciate it if you could provide to the committee a continuous update 

on the progress by both the Coast Guard and the shipping industry 

in addressing the multiple recommendations that you have made. 

When might you be able to provide that update to us? 

Mr. CURTIS. Sir, we can provide that any time. I can work with 

through Office of Government Affairs to work with your folks to 

give you an update at any period you specify. Certainly we are 

available at any time to give those updates. 

Mr. GARAMENDI. I am going to yield back at this point, but before 

I do, for me and my particular role here, the NTSB’s recommendations and the response of both the Coast Guard and the shipping 

industry generally, written large, is really important. 

So I would appreciate it if the NTSB, towards the middle of this 

coming year, like maybe June, report back to us on what progress 

has been made, what outreach you have done to NTSB with regard 

to the recommendations that you have made. They are of no value 

unless somebody follows up on them. So I would appreciate it, Mr. 

Curtis and Mr. Weener, if you would do that. 

And similarly the Coast Guard with regard to all of the recommendations and updating both with regard to the recommendations as well as with regard to the improvements on the oversight 

of the various organizations that do the safety reviews. 

And with that, I yield back. Thank you, Mr. Chairman. 

Mr. HUNTER. I thank the ranking member. 

Quick question. Does every ship being built now have an indicator for the hatch being closed, the hatches around the ship, if 

they are below a certain—— 

Admiral NADEAU. There are standards in place for newer ships 

that are being built, yes, sir. 

Mr. HUNTER. So that is in effect now? So all big ships being built, 

cargo ships, have a little light with all the hatches that says that 

they are closed or open? 

Admiral NADEAU. They have indicators, as well as there is flooding detection in the hold spaces to alert them if there is water coming into that space. Yes, sir. 

Mr. HUNTER. Thank you. 

I would like to yield to the ranking member, which we are honored to have here with us. 

Mr. DEFAZIO. Thanks, Mr. Chairman. 

13 

Well, I read a lot about this, and I really don’t like systems that 

foster preventable tragedies that take 33 lives. 

Admiral, the Coast Guard subsequently looked at the sister ship, 

El Yunque. What was the condition of that ship? 

Admiral NADEAU. It was in substandard condition. 

Mr. DEFAZIO. And so we can assume that El Faro was, as the 

sister ship, in similar substandard condition? 

Admiral NADEAU. The Coast Guard’s Marine Board certainly 

made that same conclusion, sir. 

Mr. DEFAZIO. And was this boat certified by ABS? 

Admiral NADEAU. Yes. 

Mr. DEFAZIO. And what did they say about the boat? Did they 

note deficiencies? How recent was their inspection? Isn’t it annual? 

Admiral NADEAU. Yes, they would be on there every year, as 

would the Coast Guard. I don’t know when the last survey had 

been. I don’t recall on the El Yunque when the last survey was. 

Certainly, we found things that should have been captured in the 

course of the normal routine of surveys and Coast Guard inspections. 

Mr. DEFAZIO. So things were omitted. 

Now, when is the last time that you are aware that one of these 

alternative compliance folks told a company they had to take a ship 

out of service and make very significant repairs or just retire it, as 

they did El Yunque once you looked at it? 

Admiral NADEAU. I am aware of others that have been in similar 

condition that have had to come out of service. But I would say 

probably—it is not frequent. It is not frequent. 

Mr. DEFAZIO. Right. I mean, it is a competitive industry, right? 

And so I hire you, I am hiring you to certify my rust bucket, I 

would rather not hear about it, or you tell me about it and then 

I am probably not going to hire you again, right? I mean, if they 

aren’t being adequately overseen. 

What is the liability of the classification people in this case? Is 

there potential liability for them? Are they being sued because they 

overlooked things? 

Admiral NADEAU. That is a little bit outside my area of expertise 

regarding the liability. I can reassure you that certainly we recognize the importance of proper oversight over all classification societies, all third parties that we entrust to do our work, to help us. 

And we are committed, again, to trying to rectify that. 

Mr. DEFAZIO. Do you feel there is any conflict in your mission 

here where you are both to facilitate and promote seaborne commerce and at the same time you are supposed to protect the life 

and safety of the mariners? 

Many years ago, I offered an amendment in this committee 

where the FAA had that dual mandate, and I asked, is that a problem, and they said no. 

Then we had a tragic, totally preventable airplane crash. And 

after that came out, somehow my amendment got into the bill 

without having been passed on either side of the Hill, because people realized that this was a horrible problem for the FAA, to be 

both promoting an industry which is very mature and didn’t need 

promotion and regulating safety, and I substantially took away the 

promotional aspects. 

14 

Should we be moving the promotional aspects or mandate over 

to Commerce? It seems a more logical place than the Coast Guard. 

Admiral NADEAU. I don’t know that I find my role as promotion. 

I think that we balance, we try and be practical and apply common 

sense when we apply the standards that are either developed by 

Congress or that industry has asked for. I think we rely more on 

the safety side of things and we try and ensure that there is a level 

playing field out there, that we equally apply the regulations. 

And I would offer also, sir, that we are not the only flag in the 

world, the only country in the world that relies on third parties. 

Virtually every flag state out there today relies on these classification societies in some way, shape, or form. It is just the way the 

system has evolved. But we need proper oversight in order to ensure that all parties are doing what they are responsible for doing. 

Mr. DEFAZIO. Yeah. And what would constitute proper oversight? 

I mean, in this case, let’s just say had the Coast Guard had adequate staff, El Faro was surveyed, deficiencies were not noted. And 

if you had followed on with a comprehensive inspection and found 

deficiencies that weren’t noted, what would be in consequences for 

that classification society? 

Admiral NADEAU. Well, first off, we would have made sure that 

the ship—should have made sure the ship is in proper condition 

and does not have the problems that were found. Secondly would 

be to have a scheme in place to make sure that we do hold those 

class societies accountable. 

So it starts at the basic level of getting onboard the ship to observe the standards onboard the ship to see if they are meeting the 

minimum standards. 

Secondly, it is digging into the safety management system 

aboard the ship and aboard that company that they have to make 

sure that they have the proper systems in place to maintain the 

ship. 

And, thirdly, it is looking at the quality system in place by those 

third parties to make sure that they have the proper training, the 

proper procedures in place to make sure they capture and resolve 

these things when they find them. 

Mr. DEFAZIO. Is there any way to assess a penalty against the 

classification society that does an inadequate survey that endangers life and safety or to suspend their capability to do alternate 

compliance? 

Admiral NADEAU. I don’t know that we would pursue the penalty. I think probably the larger ramifications would be either preventing them from doing that work on our behalf. They all have a 

reputation they try and uphold. It is a competitive business. They 

are generally pretty responsive when we ask them to be. We need 

to make sure that we are on them, holding them accountable, and 

ensuring they take the proper response. 

Mr. DEFAZIO. I mean, it just all reminds me a little bit of the 

junk bonds on Wall Street that caused the worst economic collapse 

since the Great Depression where all of these bonds were given 

very high ratings because it was well known if you didn’t give this 

junk high ratings, they wouldn’t hire you to give the junk high ratings, and you lose business. I don’t see how it is any different here. 

15 

Admiral NADEAU. Sir, I would say, here the difference is we 

know how to do this work. I have asked myself over and over 

again, how did this happen? We learned this lesson, yes, with Marine Electric. Since then we have doubled down time and time 

again, investing more and more in third parties, whether it is 

through Congress or the industry asking us to push more and more 

through the third parties. 

And we have gone through changes in the Coast Guard where we 

stood up sectors. We used to have marine safety offices working for 

district M captains. Now we have sectors, which are very powerful, 

allow us to do things we could never do before, like we saw this 

summer in response to the hurricanes. But along the way I think 

we have lost a little bit of our focus and we are doubling down now 

to get that back. 

Mr. DEFAZIO. And you have got adequate resources to do that? 

Admiral NADEAU. As always, you could do more if you had more. 

But this is not strictly a capacity problem. There are elements to 

training. If you just gave me another 1,000 marine inspectors, it 

wouldn’t solve this problem. This problem involves training. This 

problem involves getting the right information. This problem involves getting the right policy and procedures in place. 

Entry-level marine inspections is not what I am talking about. 

I need to have a small corps—it is not a lot—a small corps of people that can get out and are highly trained and proficient and stay 

focused on this area until we get it right. 

Mr. DEFAZIO. OK. All right. Thank you. 

Thank you, Mr. Chairman. 

Mr. HUNTER. I thank the ranking member. 

Does anybody else have any questions for this panel? Any of my 

Republican colleagues? I will take that as a no. 

I thank you very much for being here and talking with us on 

this. And with that, we will move on to the next panel. 

Mr. GARAMENDI. Mr. Chairman. 

Mr. HUNTER. Please. 

Ms. GARAMENDI. Before we move on, we have a series of questions that we would like to submit for the record. Many of these 

have already been discussed here. Let me just review very quickly 

and make sure that we cover what we want to cover. 

I want to specifically ask Admiral Nadeau, the recommendations 

from the NTSB, numerous as they are, I am just going through 

them, I think there are 20 or 30 of them, have you responded to 

those recommendations? Almost all of them are specific to the 

Coast Guard. 

Admiral NADEAU. Thank you for that question. 

We look forward to getting the entire report so we can go 

through them. We have seen the recommendations that were published, I guess a summary notice when the hearing was held. 

In looking at those, I can already tell, they are very close to the 

recommendations we made in our own Marine Board investigation, 

our own report. We had 36 recommendations. Many of those are 

very, very similar to what is coming from the NTSB. 

So, yes, I think that we will respond. We have a process in place 

to provide them feedback on each one of those, and we will careVerDate Aug 31 2005 13:58 Jun 11, 2018 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6633 P:\HEARINGS\115\CG\1-30-2~1\30345.TXT JEAN
16 

fully assess their information, the report, and each recommendation. 

Mr. GARAMENDI. When will you have your initial review and response to the recommendations? 

Admiral NADEAU. As soon as we get the report—as soon as the 

report is published, we will begin our review. And as I indicated, 

I think there is a timeline, I don’t think it is laid out in our MOU, 

but there is a timeframe we meet. I don’t know if it is 30, 60 or 

90 days. But we will certainly meet that and do our best to meet 

the timeline that is established in the procedures. 

Ms. GARAMENDI. Mr. Curtis, when will it be finalized? 

Mr. CURTIS. The report will be out mid-February, the 15th, and 

the recommendation letters right around that time. 

Mr. GARAMENDI. So the 90-day response cycle, is that—— 

Mr. CURTIS. The 90-day response cycle will start right around 

mid-February, maybe a little earlier, but soon. But they have been 

released in the abstract of the report. 

Mr. GARAMENDI. OK. And presumably, I can’t count, there are 53 

specific recommendations. I lost count somewhere around 30. We 

will be interested in hearing the response from the Coast Guard. 

Also, does the shipping company or companies also respond? 

Mr. CURTIS. Yes, it is the same process for all recipients of NTSB 

recommendations, sir. 

Mr. GARAMENDI. OK. We will await that. Thank you very much. 

I yield back and thank you. And I do have specific questions for 

the record. 

Mr. HUNTER. Without objection, we will give the gentleman authority to submit questions for the record. 

So we are looking for from the Coast Guard and from NTSB the 

matrix that he is talking about earlier. I got those confused. He 

would like the types of ships—and correct me, Mr. Garamendi, if 

I am wrong—the types of ships that are like the El Faro that you 

have been looking at now, the same year range, I guess, that are 

out there. 

I think that is what he is asking for, not the matrix of recommendations and accomplishments, which is separate. So both of 

those things. But we would like to see all of those ships that you 

are out there looking at now, saying these could be at risk. 

In closing, I drive a 1997 Expedition. If you were to go through 

the check list on my truck, there is probably a lot of stuff on it that 

is not correct, like the middle seatbelt in the back doesn’t work, the 

airbag is out on the passenger side. 

But if I take my seatbelt off, as a driver, when it is pouring down 

rain and go driving on the freeway at 90 miles an hour and crash 

it, you can look to all those things that weren’t up to code in my 

truck, but the reason that it crashed and I died is because I drove 

it without my seatbelt in pouring rain at 90 miles an hour. 

In the end, you can make all the recommendations you want to, 

but if you leave hatches open in high sea states and drive into a 

hurricane, bad things could happen. 

I think at the end of this that is what I am kind of taking out 

of this, is all the structural issues, from the age of the ship and 

classifications and giving the ship approval to set sail, those are all 

17 

good things, but if you drive at 90 miles an hour in an old truck 

with no seatbelt on in pouring rain, you might crash. 

So with that, yes, sir, closing statement, it is all yours. 

Admiral NADEAU. Sir, I could see why you draw that conclusion. 

But I guess we looked a little further beyond this particular incident, caused us to look at other vessels in the fleet, and did cause 

us concern about their condition. 

It is almost like your same old car. Some of our fleet—our fleet 

is almost three times older than the average fleet sailing around 

the world today. Just like your old car, those are the ones likely 

to break down. Those are the ones that are more difficult to maintain and may not start when I go out and turn the key. 

Our fleet is older than the average fleet. That presents some 

challenges. And some of our fleet, particularly the Military Sealift 

Command, where it is a Ready Reserve component that kind of sits 

idle for long periods of time, that presents challenges for us, sir. 

We are working very closely with partners at Military Sealift 

Command, Admiral Mewbourne, as well as MARAD Admiral 

Buzby, to make sure that we pay proper attention to that. 

Mr. HUNTER. Thank you. 

Mr. Garamendi is recognized. 

Mr. GARAMENDI. Mr. Chairman, thank you for opening another 

avenue here that I had neglected. I know we are running up 

against the clock also. 

There is the ship and all of the adequacies or inadequacies of the 

ship itself. In this particular situation, as the chairman was saying, 

the driver on the freeway made a serious mistake. 

Are the men and women who are responsible for the safe operation of the ship, both from shore as well as on the ship itself, are 

they adequately trained? Are they over a period of time recertified? 

Are there questions that we should be raising about the adequacy 

of the men and women responsible for the ship itself? And is the 

Coast Guard also investigating that piece? 

Admiral NADEAU. Yes. There were recommendations related to 

training, both with respect to weather forecasting, meteorology, 

and also with bridge resource management, and other aspects that 

were highlighted here. 

Mr. GARAMENDI. OK. Obviously, we are not going to be able to 

question any of the personnel that were on the ship. But it appears 

that there were mistakes made in the operation of the ship, perhaps both from shore as well as from the ship itself while at sea. 

Does the NTSB or the Coast Guard have any concerns about the 

adequacy of training of the personnel that are on American ships 

that are currently on the oceans? Do we have any recommendations for upgrade, for continuing classification, and for review of 

their ability to properly conduct the ship? 

Mr. WEENER. The NTSB has recommendations related to training and bridge resource management, both recurrent training as 

well as initial training, for things like heavy weather, for advanced 

meteorology, for deck crews. So that aspect of training has also 

been included in their assessment in our investigation. 

Mr. GARAMENDI. My final point is that the ability and capability 

of the men and women in charge of running the ship has to be continually observed and with a high level of assurance that they are 

18 

competent and capable. In the NTSB report, among your 53 recommendations, there are several that speak to that issue. I would 

expect that in the responses, both from the shipowner as well as 

from the Coast Guard, that this will be an issue that will be taken 

up in the responses. 

My concern goes beyond this particular company and the men 

and women that are hired to operate the ships for this company, 

but rather to the entire U.S. Fleet and the adequacy of the training 

and the capability of the men and women that are responsible. So 

I would like the Coast Guard to also pick up that issue beyond just 

this one company. 

With that I will yield back. Thank you. 

Mr. HUNTER. I thank the ranking member. 

Just in closing, you had two Navy ships crash last year, and it 

wasn’t any mechanical anything. It was they took away, the last 

couple years, they took away surface warfare officer training, it became on-the-job training with a DVD. It used to be a 6-month 

school up until, I don’t know, 4 or 5 years ago. They got rid of it. 

Training saves a lot of lives. 

And looking through everything, it looks like this was poor decisionmaking that exacerbated physical problems with the ship. And 

I think that is what we take out of this and we will keep drilling 

down. 

If we could get those matrixes of the ships, right, that you are 

looking at, so we can kind of see what is out there right now, and 

then the recommendations and what has actually been accomplished with those 53—52. The Commandant said, let’s go with it 

two out of the three, the admin recommendations, he said, let’s go 

with it. We would like to see what actions were taken that match 

those recommendations. 

And I think June 1. Is that too long? Could you get them before 

that? We can get the ship matrix before that probably. But as soon 

as you have it, we would like to see it. 

Mr. GARAMENDI. June 1 is good. 

Mr. HUNTER. June 1 is good with the ranking member, so it is 

good with me. 

And with that, thank you all very much. And we will move on 

to the next panel. 

Lady and gentlemen, thanks for being here. 

We will move on to the second panel. We will hear from Rear Admiral Erica Schwartz, Director of Health, Safety, and Work-life 

with the United States Coast Guard; Rear Admiral Michael 

Haycock, Assistant Commandant for Acquisition and Chief Acquisition Officer with the United States Coast Guard; and Mr. David 

Powner, Director of Information Technology Management Issues 

with the Government Accountability Office. 

Admiral Schwartz, you are recognized. 

19 

TESTIMONY OF REAR ADMIRAL ERICA SCHWARTZ, DIRECTOR 

OF HEALTH, SAFETY, AND WORK-LIFE, U.S. COAST GUARD; 

REAR ADMIRAL MICHAEL J. HAYCOCK, ASSISTANT COMMANDANT FOR ACQUISITION AND CHIEF ACQUISITION OFFICER, U.S. COAST GUARD; AND DAVID A. POWNER, DIRECTOR 

OF INFORMATION TECHNOLOGY MANAGEMENT ISSUES, U.S. 

GOVERNMENT ACCOUNTABILITY OFFICE 

Admiral SCHWARTZ. Chairman Hunter, Ranking Member 

Garamendi, honorable members of the subcommittee, good morning 

and thank you very much for your oversight and for your continued 

strong support of the United States Coast Guard. I am honored to 

testify before you today with my colleague, Rear Admiral Haycock. 

Let me state now, bottom line, upfront, we sincerely regret what 

happened with the Integrated Health Information System, or IHiS. 

The Coast Guard attempted to develop an electronic health record 

that was ultimately unsuccessful. 

What began as a project to develop a simple electronic health 

record increased in scope and expanded into a much larger concept, 

which added work-life and safety services. While well intentioned, 

this project lacked appropriate oversight and governance and resulted in a project that had significant mission creep, untimely 

delays and increased cost. 

Upon realizing that IHiS was not going to be completed in a reasonable time, at a reasonable cost, the Coast Guard made the decision to cancel IHiS. 

We are incorporating lessons learned as we move forward with 

our new electronic health record. Recognizing the criticality of the 

new electronic health record, it has been formally designed and 

designated with an acquisition with the necessary and appropriate 

level of governance and oversight that IHiS lacked. 

As the program sponsor representative, it is my highest priority 

to work alongside the chief acquisition officer, the chief information 

officer, and other members on the governance board to leverage lessons learned and to ensure that the best choice that meets service 

requirements is acquired and implemented as soon as possible. 

Since our outdated electronic health record had significant IT security concerns, we continued with just paper health records. 

As a physician, I know firsthand the risk of managing a medical 

program based on paper health records. Whether it is the challenges of scheduling an appointment, difficulty in reading handwritten clinical notes, storing volumes of information, or decreased 

productivity, the Coast Guard cannot continue without an electronic health record system long term. 

Our clinics and sick bays are managing with a paper health 

record system, but this is not a permanent solution. We must have 

an electronic health record system that is interoperable with the 

DoD and one that allows our members to officially transition to the 

Department of Veterans Affairs. 

As the Coast Guard’s chief medical officer, I oversee the 

healthcare delivery and medical services for more than 48,000 

members of the Nation’s fifth armed service. I have a passion for 

ensuring the Coast Guard has superior access to healthcare. It is 

my duty and responsibility to ensure that our healthcare system is 

able to serve our greatest asset, our people. 

20 

As we continue to pursue the very best electronic health record 

solution for our members, the Coast Guard is thankful for your interest and assistance on this important issue. Supported by sustained internal governance and your continued support, I am confident that the Coast Guard will implement the finest electronic 

health record solution. 

Thank you. 

Mr. HUNTER. Thank you, Admiral. 

Admiral, you are recognized. 

Admiral HAYCOCK. Chairman Hunter, Ranking Member 

Garamendi, good morning. 

First, I would like to thank you for your continued support of the 

Coast Guard and the guidance that you provide to our military 

service. As my colleague has mentioned, the Coast Guard recognizes the critical need to move to an electronic health record system. And as the chief acquisition officer, I appreciate the opportunity to discuss the improvements that we have made over the 

last several years to apply disciplined governance to these types of 

investments throughout our Service. 

As you are well aware, over the last 15 years or so, with the tremendous assistance of this subcommittee, the Coast Guard has undertaken significant efforts to improve the oversight and the management of our major acquisitions, such as our vessels and our aircraft. 

Our acquisition framework is designed to constrain and validate 

requirements to provide checks and balances and provide continuous and effective oversight at all stages of the acquisition life 

cycle. Until recently, we did not use the same level of rigor to govern key decisions for our smaller investments. 

We have learned several lessons from our experience with the Integrated Health Information System. The most important of these 

lessons are related to oversight and program management. 

Without the oversight and guidance normally provided to our formal acquisition programs, well-meaning people were overcome by 

the task at hand and that program simply outgrew their capabilities. And as a result, we have made significant process improvements to manage all sizes of acquisitions, including nonmajor acquisitions. 

To that end, the Coast Guard overhauled its processes of our 

nonmajor programs. We established formal roles and responsibilities and requirements in the same manner that we use for major 

acquisition programs. 

These new processes established a governance framework and 

provided a roadmap for improving program execution and managing risk. This framework leverages the expertise of our technical 

authorities, including the chief information officer, to ensure that 

nonmajor programs remain on track and key decisions represent 

the priorities of all communities across the Coast Guard. 

Additionally, we recently instituted new processes to identify 

candidates for formal acquisition management and oversight which 

allows us to look out for those investments, like IHiS, to prevent 

them from falling through the cracks. 

We created an oversight council specifically to provide oversight 

and governance for nonmajor programs. This provides senior staff 

21 

from across the Service a forum to regularly assess performance, 

raise issues, and address concerns, and it also ensures we have 

people with the right talents and skills managing our programs. 

Recognizing the continued urgent need to address our healthcare 

record system, in 2016 the Coast Guard established a formal 

nonmajor acquisition program to modernize the management of 

healthcare acquisition for approximately 50,000 Active Duty and 

Reserve members and improve the exchange of healthcare information with the Department of Defense, the Department of Veterans 

Affairs, and commercial care providers. 

We initiated activities to explore several possible alternatives 

and are in close contact with DoD and Department of Veterans Affairs to ensure the new solution is interoperable with their 

healthcare records systems. 

Last year, we initiated market research to gather data on cost, 

schedule, and performance capabilities, and potential solutions currently available in the commercial marketplace. We are evaluating 

the benefits and the risks associated with several approaches and 

are developing the best procurement strategy to expedite the acquisition. 

The Coast Guard recognizes the urgency to support the health of 

our most valuable asset—our people—and our current governance 

framework ensures that we have the processes and policies in place 

to oversee our current electronic healthcare acquisition program. 

We continue to incorporate the recommendations made as a result of the invaluable oversight of this subcommittee and the GAO. 

And I am committed, along with Admiral Schwartz, to the expeditious and responsible delivery of a high-quality electronic health 

record solution for our men and women in the field. 

Thank you again for the subcommittee’s staunch support and 

your oversight of Coast Guard programs and for the opportunity to 

testify today. I look forward to answering your questions. 

Mr. HUNTER. Thank you, Admiral Haycock. 

Now to Mr. Powner. You are recognized. 

Mr. POWNER. Chairman Hunter, Ranking Member Garamendi, 

thank you for inviting GAO to testify on the Coast Guard’s failed 

effort to acquire an electronic health record. This morning I will 

provide details of what went wrong with the acquisition and what 

needs to be done to manage this more appropriately in the future. 

This lookback is important to make sure that the Coast Guard corrects the management and governance flaws that led to about $60 

million being wasted. 

This effort started in September 2010 and was to be a 5-year 

project and cost about $14 million. Due to growing scope and mismanagement, the cost grew to about $60 million before the project 

was terminated in October 2015 with nothing to show for it. 

There is a long list of things that went wrong that are laid out 

in great detail in the report we are releasing today. The highlights 

are: 

The project was behind schedule. 

There were questions about whether the Coast Guard was using 

appropriate funding sources to pay for it. 

Expected system capabilities were not being delivered. 

22 

The system had limited security features, which is alarming 

given the sensitivity of the data residing in these electronic health 

records. 

The Coast Guard wasn’t completely following its own processes 

to acquire a system. Examples include not involving users of the 

system and not testing it adequately. 

Executives who should have been involved were not, as several 

governance boards were established to oversee this and they were 

simply not active. 

I would like to highlight the words ‘‘not active.’’ We at GAO have 

reported on failed IT acquisitions over the years and the message 

is usually that executive boards were not effective or not involved 

enough, not ‘‘not active.’’ 

Finally, post-cancellation, no equipment or software was delivered for reuse and the Coast Guard continued to pay millions to 

vendors after the cancellation to satisfy contractual commitments. 

In fact, our report highlights two payments scheduled for next 

month that collectively total more than $5 million. Yes, nearly 21⁄2

years after cancellation, we are still paying contractors. 

Compounding the situation is the fact that 3 months after the 

October 2015 cancellation, the Coast Guard decommissioned its 

older existing legacy system because it was not complying with 

international medical coding requirements. This left the Coast 

Guard to predominantly use a paper process to maintain health 

records. 

To its credit, the Coast Guard is attempting to use some DoD applications and workarounds to supplements its paper process. But 

let’s be clear, using paper is inefficient and dangerous. 

Coast Guard clinical staff reported major issues to us that include problems with incomplete records, issues with tracking medications, and challenges scheduling appointments. 

The Coast Guard is planning a new electronic health record. A 

request for information went out in April 2017, but the Coast 

Guard has yet to determine its specific electronic health record solution. 

Moving forward, we have five recommendations for the Coast 

Guard: 

Number one, make sure managers and executives with the right 

IT background are involved with this acquisition. Most importantly, this includes the chief information officer. 

Number two, executive governance needs to be active and frequent. This governance needs to be driven by the CIO and the witnesses here today. 

Number three, project management disciplines need to be carried 

out. This would include implementing the appropriate 

cybersecurity measures and involving the user community extensively, since business process change will be significant to effectively deploy commercial products in this area. 

Number four, the Coast Guard needs to consider adjustments or 

tailoring of its processes it uses to manage what it calls smaller or 

nonmajor acquisitions. Dollar thresholds alone shouldn’t drive the 

rigor and attention projects get. Mission criticality should. 

23 

And finally, the Coast Guard needs to strongly consider the EHR 

solution that DoD and the Department of Veterans Affairs are pursuing. 

Mr. Chairman, this concludes my statement. Thank you for your 

oversight of this important acquisition. 

Mr. HUNTER. Thank you, Mr. Powner. And to the other witnesses, thank you very much. 

I guess let us go with what you were saying. What was your last 

recommendation? 

Mr. POWNER. The last recommendation is you really need to look 

at what DoD and Department of Veterans Affairs are doing. I 

mean, we made a bold decision for VA to go with the solution that 

DoD was using. And I understand competition in this industry. 

Mr. HUNTER. But is the Coast Guard DoD? The Coast Guard is 

a military service, right? Why wouldn’t you go with DoD in the 

first place? Why not be interchangable with DoD? Why not save all 

that money and time and be efficient and use DoD’s product? 

Admirals. 

Admiral SCHWARTZ. The Coast Guard is looking with great interest at what DoD is doing and what the Department of Veterans Affairs is doing with regards to their new electronic health record 

system. 

Mr. HUNTER. But why would you not use that? 

Admiral SCHWARTZ. So, sir, as a military service we certainly are 

looking at what they are doing with respect to the new MHS GENESIS product. And what we are doing is looking at what their lessons learned are. 

Mr. HUNTER. But why would you not use that? Why would you 

not use what DoD is already doing? 

Admiral SCHWARTZ. As part of the acquisition process, which I 

will yield to my colleague here, we are looking at various GOTS 

[Government off-the-shelf] and COTS [commercial off-the-shelf] solutions. 

Mr. HUNTER. I understand that you are doing that. Why would 

you not use DoD’s solution? 

Admiral HAYCOCK. Mr. Chairman, I can’t speak to something 

that happened that long ago. 

Mr. HUNTER. No, now. Why would you not use DoD’s solution 

now? 

Admiral HAYCOCK. That is our—— 

Mr. HUNTER. It is a waste of money and time going to look at 

stuff when it exists right now. I don’t think you would say that the 

Navy is less complicated than the Coast Guard, right, or the Army. 

It is a lot more complicated, and larger and more spread out, and 

they are able to do it. So why wouldn’t you just use that? 

Admiral HAYCOCK. As you know, Mr. Chairman, when you start 

getting into major acquisitions of great scope and complexity there 

is discipline that we have to put in the process, and that is what 

prevents us from getting into trouble. 

We are going through that process. We have done an analysis of 

alternatives, which is looking at what exists out there for us to potential solutions. 

One of those solutions is using a Federal service provider. That 

is the solution that we would like to go for and that is what we 

24 

are working with the Department of Veterans Affairs and DoD to 

make happen. We are in close conversation with them informally 

on probably a weekly basis and meeting with them formally on a 

monthly basis. We have been invited to be part of their executive 

steering group and we are participating in that. 

So we are tracking down that direction, but we need to follow the 

discipline of the acquisition process or we will end up in messes 

like other programs have seen in the past for not doing it. 

That is when gives me great confidence on eHRA [electronic 

health record acquisition] going forward, is that we have stood it 

up as a formal acquisition program and it is getting that discipline 

and the oversight. The very same people that oversee all of our 

major acquisitions, like ships and aircraft and such, they are providing the oversight for eHRa now, and that includes the chief information officer and every stakeholder and tech authority in the 

Coast Guard. 

Mr. HUNTER. OK. I would highly encourage you guys to do what 

is easy and efficient and effective, especially when you have got 

really big services with lots of money doing it for you and you can 

just piggyback onto that. 

Let me switch over. There is no code, there is no software, there 

is no code and no machinery, right? 

Admiral SCHWARTZ. Sir, IHiS is considered a software as a service product. And so what we did was we contracted with various 

software companies and they produced, developed modules for our 

safety program, for our health program, for our work-life program. 

But because it is a software as a service, once we stopped paying 

for those services we don’t have a final product to show. 

Mr. HUNTER. So you didn’t have any intellectual property? 

Admiral SCHWARTZ. That is correct, sir. 

Mr. HUNTER. Whose decision was it to cancel it? 

Admiral HAYCOCK. I guess it was probably three-quarters of the 

way through 2015 the Executive Oversight Committee, their counsel was sought out by the project. The executives on that team 

heard the brief, saw the risks involved, and recommended that the 

Coast Guard, the Vice Commandant, cancel the program. 

Mr. HUNTER. I think it is very strange that there is nothing, that you got $60 million and you literally got nothing out of it. 

Is that usual, Mr. Powner, I mean, to retain no intellectual property? 

Mr. POWNER. You know, I think you can write contracts in a way 

where you do maintain some of—I understand the software as a 

service concept, but you can write that in a way that you have 

some reusability. 

If you have nothing, that might even be more of a reason to go 

with what the Department of Veterans Affairs and DoD are already doing, because if we don’t have anything to reuse—I agree 

with you on your comment about piggybacking on what is already 

there. And they are ahead of the game, so you can look at lessons 

learned and learn from that. That is what the Department of Veterans Affairs is doing with DoD right now. 

And there are lessons learned on the business processes and the 

like. To me, that makes sense, to go that route, especially given the 

fact that we have nothing. 

25 

Mr. HUNTER. My last question is to stress this point. Is there 

anything that makes coastguardsmen different from any other 

servicemember besides what they do in their specialty? Is there 

anything special about being in the Coast Guard that would not 

allow you to be in the Department of Defense’s health record system? 

Admiral HAYCOCK. No, Mr. Chairman. We are a military service, 

so our Active Duty coastguardsmen are just like all the other Active Duty military. 

I think some things that may play into it that make us a little 

unique is the size of our Service. So infrastructure is a little bit different, the types of patients that we see and that the Department 

of Veterans Affairs sees might be a little bit different. But for the 

most part there is nothing special there. 

Mr. HUNTER. The Coast Guard has got a lot of missions that do 

a lot of totally different things. And I think what you are doing is 

complicating your own lives here. I mean, you can’t have a core 

competency of everything. 

With that, I would like to yield to the ranking member. You are 

recognized, Mr. Garamendi. 

Mr. GARAMENDI. I think I have been through too many of these. 

Electronic health records are now standard in virtually every 

health system in the Nation. And every one of them have made 

mistakes and in most every system the first effort failed. But we 

have more than enough models in place so that this should not 

have happened. But it did. 

My real issue is, who was the contractor? I was looking through 

the report and never a name of the contractor. 

Admiral SCHWARTZ. Sir, there were numerous contractors that 

supported the IHiS effort. 

Mr. GARAMENDI. Who are they? 

Admiral SCHWARTZ. Sir, I don’t have a list of the contractors with 

me today, but we certainly can make that list available to you. 

Mr. GARAMENDI. Somebody ought to be accountable here. We are 

holding the Coast Guard accountable, but the contractor also 

screwed up. I want to know who screwed up. Who is the contractor 

that screwed up here? 

Mr. Powner, do you know? 

Mr. POWNER. We can get you a list of the contractors who were 

involved in that. 

Mr. GARAMENDI. I am sorry, this whistling behind just wiped you 

out. Could you say that again? 

Mr. POWNER. Yes, we can get you a list of the contractors involved. 

I think you bring up a good point. I have testified in front of Congress on many failed acquisitions over the years. And is there mismanagement on the Government side? Yes. But there is also an obligation on the contractual side to work in partnership on this, and 

we need more of that going forward, clearly. 

Mr. GARAMENDI. I am just willing to bet, without knowing who 

they are, I will bet they have screwed up before and I will bet we 

have hired the same folks that screwed up before to do another 

screwup. 

26 

Yes, I would like to know the name of the companies that failed 

to perform. That is the first issue. 

The second issue was the question raised by the chairman, Mr. 

Hunter, and that is, the Department of Defense is in the process 

of developing an electronic medical record. And if I recall correctly, 

they finally decided, out of a fit of wisdom, that it would also be 

the same records that the Department of Veterans Affairs used. In 

other words, they were transferrable one to another. 

That took about 10 years’ fight between the two agencies, but I 

guess somewhere along the line both decided that an active member and reservist in the military, the Department of Defense, might 

at some time in the future become a veteran and that their medical 

records really ought to be available to the Department of Veterans 

Affairs. 

Does the Coast Guard also see the wisdom of this transferability 

of the medical records from the Coast Guard to the Department of 

Veterans Affairs? Are you taking that into account? 

Admiral SCHWARTZ. Absolutely, sir. And just to be clear, right 

now, even though we are on paper health records, we do transfer 

our paper health records to the Department of Veterans Affairs. It 

is through a system called the Health Artifact and Image Management Solution, which is the same system DoD uses right now. We 

digitize our paper health records when a member leaves the Service, and that record is uploaded into HAIMS and the Department 

of Veterans Affairs can extract the record from HAIMS. 

Mr. GARAMENDI. So at least you are thinking about it with regard to paper. And you are going to do that with regard to the electronics if and when you ever get there? 

Admiral SCHWARTZ. Absolutely, sir. 

Mr. GARAMENDI. The chairman was pushing the point, I think 

correctly, that you ought to be using the same system as the Department of Defense. Are you contemplating doing that? It wasn’t 

quite clear to me in the responses, Admirals, that you are or are 

not. 

Admiral HAYCOCK. The alternatives analysis is—— 

Mr. GARAMENDI. Please really speak loud, this whistling behind 

us is most distracting. 

Admiral HAYCOCK. So the alternatives analysis that we conducted, that is one of the preferred alternatives, and we are working through the details to make that happen. 

Mr. GARAMENDI. And when do you expect to make a decision? 

Admiral HAYCOCK. We are approaching Acquisition Decision 

Event 2A/2B, which probably doesn’t mean much. But we have a 

major acquisition decision coming up here probably end of February. 

Mr. GARAMENDI. I know of several clinics in California that have 

more than 50,000 lives in their clinics. They have established electronic medical records. I mean, some of this stuff is now off the 

shelf. 

Mr. Powner, you have been at this a long time. You have found 

more than enough problems. Your recommendations in your report 

are rather general. Do you have specific recommendations? And is 

one of those recommendations—— 

27 

Mr. POWNER. Yes. I would say the key recommendation, and I 

have seen this, you can have the best project management on these 

technology projects, but if you don’t have executives that are accountable and breathing down the neck of project managers, that 

is what makes this stuff work, when you get executives involved. 

Example, the U.S. Census Bureau, OK? Now we are going to spend $3 billion more on the Census Bureau. What happened? Secretary Ross is now involved with the Census Bureau and they set 

up adequate governance. 

The Coast Guard has a governance process in their policies, they 

just need to execute it. It starts with the admirals at this table, 

with the CIO, with the CFO, and they need to drive the delivery 

of this system. 

Good governance, that is what actually works in Government, 

when you have the executives accountable and pushing hard to 

make sure we get deliveries, not only from the Government but 

from contractors too. You sit down with contractors, you demand 

the A team. 

That is the stuff that has worked over the years, and I can give 

you positive examples, too, where it has worked. 

Mr. GARAMENDI. I agree entirely. 

So, Admirals, are you engaged? 

Admiral HAYCOCK. Yes, Congressman. IHiS was kind of a watershed event, shook our foundations. It really caused us to kind of 

sit back on our heels and try to figure out what happened. 

IHiS did not have the appropriate executive oversight. That is 

probably the biggest problem. There are other things that complicate IHiS, but they all lead to this failed oversight on our part. 

So we have stood up a formal acquisition program for eHRa, and 

it has the right executives providing the oversight. Admiral 

Schwartz is a member of the EOC, the Executive Oversight Committee, our CIO is, and a host of others that have a stake in this. 

So I assure you, we have the right executives breathing down the 

neck. 

Mr. GARAMENDI. You just described everybody is responsible and 

therefore nobody is responsible. So which of the two of you are responsible? 

Admiral HAYCOCK. I am responsible because I am the acquisition 

officer. 

Mr. GARAMENDI. Admiral Schwartz. 

Admiral SCHWARTZ. Sir, I am responsible for ensuring the requirements document is delivered to our acquisition officer to delineate what we need and what we want for an electronic health 

record system. 

Mr. GARAMENDI. Isn’t that readily available from a dozen different organizations that already have electronic medical records? 

Admiral SCHWARTZ. We have completed the operational requirements document. We delivered it to the hands of our chief acquisition officer. And we are moving as quickly as we can to get this 

EHR out in the field. 

Mr. GARAMENDI. Have you consulted with Mr. Powner on his recommendations? 

Admiral SCHWARTZ. Sir, we have read the GAO’s draft report and 

we have taken them absolutely to heart. 

28 

As Admiral Haycock mentioned, governance was a significant 

issue with IHiS. IHiS was stovepiped in the medical program. We 

did not involve the chief information officer. We did not involve the 

chief acquisition officer. 

No more. As we move forward, we have this cross-directorate 

governance that includes the CIO, that includes the chief acquisition officer and others on the governance board. 

Mr. GARAMENDI. You have developed an AOA? 

Admiral HAYCOCK. An alternatives analysis, yes. 

Mr. GARAMENDI. Have you developed one? 

Admiral HAYCOCK. We have. 

Mr. GARAMENDI. Have you presented that to the committee, us? 

Admiral HAYCOCK. I don’t—— 

Mr. GARAMENDI. Well, why don’t you do so? We have seen AOAs 

on God knows how many things under Defense on the House 

Armed Services Committee. I would love to see your AOA. 

Mr. Powner, have you reviewed the AOAs? 

Mr. POWNER. No, I have not reviewed that in great detail. 

Mr. GARAMENDI. Should you? 

Mr. POWNER. Yes. But I would say you could eliminate the AOAs 

down to—as was mentioned here, this is a robust area when you 

look at commercial products. So I don’t know why we would look 

at anything beyond commercial products. 

And then I will narrow it further. Let’s piggyback on DoD and 

the Department of Veterans Affairs. Let’s make it simple. We are 

making it too complicated. 

I understand we have to follow the process—— 

Mr. GARAMENDI. Admiral Schwartz, you heard what he said? 

Admiral SCHWARTZ. Sir, as the chief medical officer, I absolutely 

would love to go with DoD and the Department of Veterans Affairs. 

I have provided my requirements. We worked very closely to look 

at what DoD was doing to ensure that the operational requirements documents that we provided to the acquisition officer was 

very similar to what the DoD system is. 

Mr. GARAMENDI. I find it astounding that—I mean, this is so— 

this is not complicated. There are commercial applications out 

there. I know four clinics that in the last 3 years have purchased 

off-the-shelf electronic medical records that also allow them the opportunity to convert their previous paper records to electronic 

records, all done. It is off the shelf. And they have more lives than 

the Coast Guard has. 

I guess one question is that the GAO comes in after there is a 

screwup. It seems to me that there ought to be an iterative process 

here. 

Mr. Powner, you have got a lot more knowledge than either of 

the two admirals here about these kinds of things. This has been 

your life or at least you more recent life’s work. Maybe you ought 

to quit GAO and become a consultant. But stay where you are, we 

need you there. 

But it would seem to me that it would be worthwhile for the 

Coast Guard to consult with the GAO and to learn from their experiences. I know you have two different tasks. 

Mr. POWNER. If I can add. So we do some postmortems at GAO 

on things that go wrong, but we also do a lot of work for the ConVerDate Aug 31 2005 13:58 Jun 11, 2018 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6633 P:\HEARINGS\115\CG\1-30-2~1\30345.TXT JEAN
29 

gress when acquisitions are in flight. And that is when it is most 

effective, working alongside. We can still maintain our independence and work alongside while acquisitions are in flight to ensure 

that governance and project management, contractor oversight, and 

all those things are occurring. 

Mr. GARAMENDI. Well, given that, I have just requested an 

AOA—or the AOA. I would appreciate your review of the AOA, 

while it is in process. Postmortems are usually over dead and troubled projects. We can avoid that, I think, by working together here. 

I yield back. 

Mr. HUNTER. I thank the gentleman. 

One thing we looked at, and I don’t know if you have heard of 

this, Mr. Powner, but it is called the Distributed Common Ground 

System, DCGS, for the Army. It is like $4 billion they put into it. 

It never worked. They had about 30 nice contractors that all did 

modules and they could all plug and play theoretically, but nothing. It didn’t work, period. 

And it was billions of dollars and it required the Chief of Staff 

of the Army now, General Milley, to kind of do what you are doing, 

Admiral Haycock, and taking a hard look at this, as a four-star. 

Because when you are spending billions of dollars or tens of millions of dollars for the Coast Guard, I mean, you have to make sure 

you have it right, especially with software. 

It would be nice to be a software contractor in town here. I can 

do stuff for you and never give it to you and you will pay me. 

Mr. GARAMENDI. I want to know who the contractor was. 

Mr. HUNTER. I think it is absurd you are paying next month for 

this, even though the whole thing is over. But what is in the past 

is in the past. We don’t want to beat on the Coast Guard too much 

right now. You have got things straightened up. And hopefully 

moving forward, Mr. Powner will have good things to say. 

And again, I am of the mind to make you get on DoD’s thing no 

matter what you think. We ought to just tell you to do it. You don’t 

need to be going off and doing your own thing when it comes to 

healthcare. 

I think that is not Mr. Garamendi and I or this committee micromanaging. It is saying you guys don’t get to go off on your own and 

just use taxpayers’ dollars because it is fun when you have the Department of Defense doing it. 

So I think that is something we ought to look at, is just telling 

you what to do, especially in this case. I think that would be a 

smart thing for us to look at and see if that is even possible. 

With that, thank you very much for being here. And hopefully we 

get this straight. 

With that, the hearing is adjourned. 

[Whereupon, at 11:36 a.m., the subcommittee was adjourned.] 

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Æ 


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