PROCEEDINGS

Winter 2015–2016 Vol. 72, Number 4

Overview

6 National Centers of Expertise 

Critical force multipliers.

by LCDR Randy Waddington

9 INV-NCOE Agency Partnerships

Established relationships leverage efforts.

by LCDR Yancee McLemore

Investigations National Center of Expertise

11 Who You Gonna Call?

One man’s view of the INV-NCOE.

by LCDR Willie Pittman III

14 Whodunnit? 

Petroleum oil fingerprinting.

by Ms. Kristy Juaire

18 Marine Incident Investigation

NTSB and Coast Guard collaboration.

by Mr. Keith Fawcett and Mr. Nicholas Parham

21 Commendable Acts

Honor, respect, and keeping faith with the mariner.

by Mr. Keith Fawcett

23 Electronic Evidence

Focus on the basics.

by Mr. Marc DeJesus

26 When Things Go Bump

Western rivers groundings.

by Mr. Les Ledet

28 Marine Formal Board of Investigation

A lead investigating officer’s perspective.

by LCDR Teresa Hatfield

31 Marine Casualty Subpoena Authority and Enforcement

What every investigating officer should know.

by LCDR Damian Yemma
 Suspension and Revocation National Center of Expertise.

34	 Promoting Professionalism and Proficiency

The Coast Guard’s Suspension and Revocation National Center of Expertise.

by LCDR Yancee McLemore

36 Service to the Mariner and the Public

Bringing Coast Guard attorneys into the S&R process.

by Mr. Brian C. Crockett and LCDR Damian Yemma

38 Raising the Bar

How the S&R NCOE improves the S&R process.

by Hon. Walter Brudzinski

41 Prescription Drug Abuse on the Water

A growing problem.

by LT Sarah E. Brennan and CDR Christopher F. Coutu

44 Bearing the Burden of Proof

The Suspension and Revocation NCOE brings drug users to justice.

by Mr. Eric A. Bauer and LT Sara M. Ellis-Sanborn

50	 Medical Certificates

The purpose, the process, and the pitfalls.

by LT Sarah E. Brennan and CDR Christopher F. Coutu

53 Mariners Can Lose Credentials for What?

Navigating through suspension and revocation. 

by Mr. James P. Fink

Communicate

57 Marine Casualty Trends

Looking for commonalities to prevent future occurrences.

by CDR Blake Welborn

60 Coast Guard Reports of Investigation

The Investigations National Center of Expertise’s role.

by LCDR Barbara Wilk

On Deck

4 Assistant Commandant’s Perspective

by Rear Admiral Paul F. Thomas

5 Champion’s Point of View

by CAPT Jason Neubauer

67 Upcoming in Proceedings

62 Chemical of the Quarter

Understanding Nickel Ore

by Ms. Amy Parker

Nautical Queries

63 Engineering

65 Deck

Cover image by Digitalgenetics / iStock / Thinkstock.

Graphics USCG and its licensors, unless otherwise indicated.
Marine investigations provide vital feedback to help improve standards and compliance processes, hold parties accountable when necessary, and prevent reoccurrence of accidents that 

harm people, property, and the environment.

Coast Guard marine investigators are trained to determine incident contributing factors, which 

include assessing vessel and equipment design, construction, operation, and maintenance. The 

subsequent investigation report includes a comprehensive analysis derived from witness statements, forensic scrutiny, technical calculations, and investigator observations. When deemed 

necessary, recommendations are made to the Commandant on specific actions the Coast Guard 

can take to hold people accountable and prevent similar incidents. In this manner, the Coast 

Guard continuously evaluates and improves prevention efforts. 

For example, the joint Coast Guard and Bureau of Safety and Environmental Enforcement investigation report into the explosion and sinking of the foreign-flagged mobile offshore drilling 

unit Deepwater Horizon resulted in more than 50 recommendations, many of which have been 

enacted, including developing new standards for explosion-proof electrical fittings. 

Establishing the Investigations National Center of Expertise (INV-NCOE) has significantly 

enhanced the Coast Guard’s ability to investigate all marine casualties. INV-NCOE investigators 

actively support investigations around the globe, help identify trends, and develop key relationships with investigative counterparts from the National Transportation Safety Board and 

foreign maritime safety agencies. Such relationships are especially essential in the international 

realm, as the Coast Guard has to be invited to participate in investigations that involve U.S. citizens aboard foreign-flagged vessels operating beyond U.S. waters. As an example, INV-NCOE 

investigators have supported five foreign-flagged cruise ship fire investigations within the last 

12 months, which prompted the release of a worldwide safety alert on fuel line maintenance. 

Coast Guard marine investigators also pursue suspension and revocation (S&R) actions against 

merchant mariners for negligent operations, acts of misconduct, violations of law and regulation, falsification of official records or false statements to officials, fraudulent use or obtainment 

of Coast Guard credentials, and use of illicit drugs. The Suspension and Revocation National 

Center of Expertise has been instrumental in assuring that these actions are appropriate and 

consistent. 

Because these investigations may culminate in the suspension or revocation of a mariner’s Coast 

Guard-issued credential, potentially placing his or her livelihood at stake, the S&R NCOE’s 

involvement and oversight is specifically implemented to safeguard mariner rights throughout 

a complex process, while holding parties accountable and preventing incident reoccurrence.

I want to close by thanking the authors who contributed to this edition. Their stories effectively 

highlight the invaluable contributions and capabilities of these specialized units that support 

the Coast Guard’s prevention program.

4 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Admiral Paul F. Zukunft

Commandant

U.S. Coast Guard

The Marine Safety 

& Security Council 

of the 

United States Coast Guard

Rear Admiral Steven D. Poulin

Judge Advocate General

Chairman

Mr. Jeffrey G. Lantz

Director of Commercial 

Regulations and Standards 

Member

Rear Admiral Peter J. Brown

Assistant Commandant 

for Response Policy

Member

Rear Admiral Paul F. Thomas

Assistant Commandant 

for Prevention Policy

Member

Rear Admiral Todd A. Sokalzuk

Assistant Commandant for

Resources, Chief Financial Officer

Member

Ms. Ellen Engleman Conners 

(Acting)

Director for Governmental 

and Public Affairs

Member

Captain Verne B. Gifford

Director of Inspections 

and Compliance

Member

Mr. William R. Grawe

Director of National Pollution 

Funds Center

Member

Mr. Gary C. Rasicot

Director of Marine Transportation 

Systems Management

Member

Captain Anthony Popiel

(Acting)

Director of Incident Management 

and Preparedness Policy

Member

Mr. Michael W. Mumbach

Executive Secretary

Assistant 

Commandant’s 

Perspective

by REAR ADMIRAL PAUL F. THOMAS

Assistant Commandant for Prevention Policy 

U.S. Coast Guard
As I reflect upon my Coast Guard career and experience in marine casualty investigations, 

I recall my assignment as the senior investigating officer at Marine Safety Office Morgan City, 

Louisiana — arguably one of the busiest and most diverse areas of responsibility in the marine 

safety realm. I vividly recollect feeling overwhelmed, attempting to manage a seemingly 

continuous deluge of major marine casualties related to myriad vessel types and operations. 

I was drinking from a fire hose, so to speak. 

Although the unit maintained several investigating officer (IO) billets, the complexities 

involved with incidents occurring on the outer continental shelf and within the congested 

inland waterways highlighted a pressing need to have experts available with an in-depth 

understanding of commercial operations in the region (such as drilling, diving, towing, and 

lightering operations). 

Completing these types of complex investigations in what often equated to on-the-job-training 

mode was often inefficient and led to issues when time-sensitive evidence collection was 

involved. My entire staff frequently felt isolated, but at the same time hesitant to tap into the 

limited technical and engineering support resources available to field commands at the time. 

As time progressed, marine safety program shortfalls and personnel proficiency gaps became 

too glaring to ignore. As a result, in 2007 the Coast Guard developed the Marine Safety 

Enhancement Plan. The prevention program realized immediate benefits, as numerous senior 

civilian and junior officer billets were added to field units nationwide to provide better continuity and bolster training programs. An important part of the new additions included 

national centers of expertise specifically created to focus on enhancing marine inspections 

and investigations. 

The articles in this edition show how essential and integral national centers of expertise have 

become to prevention operations. Centralizing specialized expertise for the infrequent but 

highly complex investigations the marine investigators encounter has made the Coast Guard 

more agile while also improving casualty investigations and suspension and revocation 

actions. 

The national centers of expertise have also established robust working relationships with key 

investigative partners like the National Safety Transportation Board. They also field questions 

from both internal and external stakeholders, including individual companies and industry 

organizations. 

I firmly believe the national centers of expertise have improved consistency and service delivery nationwide by providing the timely resources needed to ensure that prevention personnel no longer have to drink from the fire hose. However, there’s significant potential for even 

greater gains as we strive to attain maximum utilization of national center of expertise services. I hope that the success stories highlighted in this edition will help us achieve that goal.

Champion’s

Point of 

View

www.uscg.mil/proceedings Winter 2015–2016 Proceedings 5

Editorial Team

Barbara Chiarizia

Executive Editor

Diana Forbes

Managing Editor

Leslie C. Goodwin

Art Director

Proceedings is published quarterly 

in the interest of safety at sea under 

the auspices of the Marine Safety & 

Security Council. Special permission 

for republication, either in whole or 

in part, except for copyrighted material, is not required, provided credit is 

given to Proceedings.

The articles contained in Proceedings are submitted by diverse public 

and private interests in the maritime 

community as a means to promote 

maritime safety and security. The 

views expressed by the authors do 

not necessarily represent those of the 

U.S. Coast Guard or the Department 

of Homeland Security or represent 

official policy.

Editorial Contact

Email: HQS-DG-NMCProceedings@

uscg.mil

Mail: Commandant (CG-DCO-84)

ATTN: Editor, Proceedings Magazine

 U.S. Coast Guard Stop 7318

2703 Martin Luther King Jr. Ave. S.E.

 Washington, DC 20593-7318

Web: www.uscg.mil/proceedings

Phone: (202) 372-2316

Subscription Requests

Proceedings is free.

Subscriptions

www.uscg.mil/proceedings

by CAPT JASON NEUBAUER

Office of Investigations and Casualty Analysis

U.S. Coast Guard
6 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

leaders subsequently formed the Investigations National 

Center of Expertise (INV-NCOE) in New Orleans, Louisiana. 

These two units were stood up along with four other NCOEs 

in an effort to foster superb service delivery within the 

broader U.S. Coast Guard marine safety regime. In their 

initial years of operation, these two units functioned under 

the direction of the U.S. Coast Guard Force Readiness Command and the U.S. Coast Guard Traveling Inspection staff. 

However, given their technical skills and high demand in 

field operations, both units were subsequently placed under 

the direction of the Office of Coast Guard Investigations and 

Casualty Analysis in 2013. This change allowed for optimal 

alignment from the top of the organization down to fieldlevel investigators.

The S&R NCOE focuses primarily upon improving the suspension and revocation process, ensuring that investigators 

have access to legal support and that U.S. Coast Guard remedial actions are firmly established in legal precedent while also supporting the organization’s overall goal of promoting safety. The 

INV-NCOE maintains technical systems 

support and lends vessel-specific operational expertise to marine casualty investigators, providing critical support during 

major investigations. Both units play a support/

advisory role with local unit investigators, but 

they also execute mission functions independently. 

The personnel assigned to these units possess a 

wealth of expertise ranging from extensive Coast 

Guard inspections/investigations and marine 

industry experience to broad legal training. The 

units’ initial years of operation have demonstrated 

benefits such as: 

• operational excellence, 

• improved investigator skills, 

• enhanced working relationships with external 

partners. 

In early 1994, the U.S. Coast Guard formed a marine safety 

investigation quality action team to analyze marine casualty investigation and enforcement program efficiency and 

explore improvement methods. In 1995, the team finished its 

report, which contained 57 improvement recommendations. 

While many of these changes were immediately instituted, 

others were longer-term goals. One such recommendation 

was to create a “center of excellence” to provide investigation 

expertise and create a valuable force-multiplying resource 

for investigators. 

National Centers of Expertise (NCOEs) had long been a 

goal of the USCG prevention program, and that goal was 

finally realized in 2009 as part of the comprehensive Marine 

Safety Enhancement Plan. The Suspension and Revocation 

National Center of Expertise (S&R NCOE) in Martinsburg, 

West Virginia, was one of the first six NCOEs established 

(and the first investigation-related NCOE), and Coast Guard 

National Centers of Expertise 

Critical force multipliers.

by LCDR RANDY WADDINGTON

Chief, Investigations Division

U.S. Coast Guard Office of Investigations and Casualty Analysis 

Overview

The national centers of expertise: the Cruise Ship NCOE, Ft. Lauderdale, Florida; the 

Towing Vessel NCOE, Paducah, Kentucky; the Outer Continental Shelf NCOE, Houma, 

Louisiana; the Investigations NCOE, New Orleans, Louisiana; the Liquefied Gas Carrier 

NCOE, Port Arthur, Texas; and the Suspension and Revocation NCOE, Martinsburg, 

West Virginia.

Rufus Young / iStock / Thinkstock
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 7

Operational Excellence_

Investigation Support

The Investigations National Center of Expertise has 

improved overall operational excellence, as demonstrated 

in several recent investigations. For example, on January 26, 

2012, the motor vessel Delta Mariner, a U.S. Coast Guardcertificated oceangoing vessel, allided with a bridge while 

heading downstream on the Tennessee River near Aurora, 

Kentucky. A 300-foot span of the bridge collapsed into the 

waterway and onto the vessel’s bow, damaging its masts 

and navigating bridge. Fortunately, there were no deaths or 

major injuries as a result of this incident. 

After the initial U.S. Coast Guard response, the Coast Guard 

District Eight commander determined a formal investigation was necessary. Formal investigations are extremely 

thorough, comprehensive, and include public hearings to 

establish the facts surrounding an incident. Because these 

types of investigations are often beyond the capability of 

local U.S. Coast Guard unit investigators, INV-NCOE investigators stepped in to assist, getting to the scene of the accident soon after it occurred. 

Once on scene, they leveraged their technical acumen to 

pull data from the navigation equipment and build a digital 

re-creation of the events leading up to the incident, including bridge audio. This highlighted causal factors critical to 

understanding the crew’s decisions prior to the allision. 

Additionally, INV-NCOE investigators played a key role 

in the week-long public hearings, lending their expertise 

to manage the proceedings and support the lead investigating officer in questioning witnesses. Investigations 

National Center of Expertise investigators also proved 

integral in developing the final report of investigation 

analysis, conclusions, and the subsequent proposed safety 

recommendations. 

Informing Broader Marine Safety Eorts

On December 27, 2012, the motor vessel Aiviq was towing 

the manned Modu Kulluk on a voyage from Dutch Harbor, Alaska, to Everett, Washington, when the towing gear 

failed approximately 50 nautical miles southeast of Kodiak 

Island, Alaska. Though the vessel owners dispatched an 

offshore research vessel and tug to assist the towing evolution — and despite the best efforts of the vessels and crews 

involved — on December 31, 2012, the Modu Kulluk grounded 

on the southeast coast of Sitkinack Island. 

This highly visible casualty brought to light a number of 

regional and national issues, including questions regarding 

Arctic oil exploration emergency preparedness sufficiency. 

The 17th District Coast Guard commander determined the 

incident would be best served through a formal investigation, calling once again upon the Investigations National 

Center of Expertise. 

In this instance, INV-NCOE investigators branched out from 

a supportive role to that of managing the entire investigation. Over the next year, INV-NCOE investigators conducted 

public hearings and completed an exhaustive investigation 

report that highlighted the unique challenges of operating in the Alaskan environment as well as the risks associated with a single-vessel tow through the Gulf of Alaska. In 

response, Coast Guard leaders assembled a U.S. Coast Guard 

and Towing Vessel Advisory Committee workgroup specifically to examine lessons learned from the investigation. 

Legal Issues

In early 2014, the U.S. Coast Guard remained the lone federal 

agency utilizing non-lawyers to adjudicate administrative 

law cases on behalf of the agency. This was firmly grounded 

in maritime tradition and was appropriate, as regulations 

clearly supported this practice. 

However, suspension and revocation cases, which typically involve alleged merchant mariner acts of negligence, 

misconduct, incompetence, or alcohol or drug use, were 

becoming increasingly complicated. Given this complexity, 

the S&R NCOE became the ideal solution to address such 

challenges. 

Beginning in late 2014, the Suspension and Revocation Center of Expertise shifted from primarily a support resource 

for investigators to a quality-control clearinghouse for all 

formal complaints issued against merchant mariners. With 

several staff attorneys among its ranks, the S&R NCOE is 

able to ensure that every case complaint that goes before 

an administrative law judge (ALJ) is thoroughly vetted and 

researched in light of the most current case law. 

Additionally, the S&R NCOE supplies legal representation 

for each case that goes to a hearing before an ALJ, improving the integrity of the entire U.S. Coast Guard adjudication 

process and ensuring local units have the support necessary 

to manage complex legal issues. 

Improved Investigator Skills_

The professional life of a U.S. Coast Guard investigator is 

complex, involving myriad talents and proficiencies. An 

investigator must be skilled across a broad spectrum of 

operational and engineering-related vessel issues, be fully 

versed in regulatory standards, understand human performance, and possess a deep understanding of marine safety. 

As such, the NCOEs are integral to assisting and mentoring 

investigators in their roles as well as improving their professional acumen. 
8 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

international casualty investigations. For example, when 

the Costa Concordia sank off the coast of Italy, INV-NCOE 

investigators stepped forward to coordinate more than 100 

interviews of the U.S. citizens aboard.1 This helped document the witness perspectives, glean lessons learned from 

the incident, and provide feedback that supported the Italian government’s investigation. 

More recently, INV-NCOE investigators assisted the Costa 

Rican government in its investigation of the passenger vessel Pura Vida Princess, which sank off the coast of Costa Rica 

in January 2015.2

Intra-agency Eorts

For their part, S&R NCOE personnel have greatly improved 

the working relationship with administrative law judges 

and their staffs. This requires a delicate balance, as the 

working relationships must maintain each entity’s impartiality. The S&R NCOE has also established communication 

channels with docketing center personnel who liaise with 

investigators, ALJs, and respondents (merchant mariners). 

Such overall efforts help to ensure that the suspension and 

revocation process remains efficient and effective. 

The Big Picture

Since their inception, the NCOEs have provided stellar service to U.S. Coast Guard personnel and realized the envisioned program improvements. Both the S&R NCOE and 

INV-NCOE positively impact mission execution, which in 

turn provides an important public service through sound 

investigative and enforcement actions that promote safety 

throughout the maritime domain.

About the author: 

LCDR Randy Waddington has served in multiple capacities during his 

25-year Coast Guard career, most recently as the investigations program 

manager at Coast Guard headquarters. He has also served as chief of the 

investigations division at Sector Los Angeles/Long Beach, chief of the inspections division at Sector Juneau, and senior investigating officer at Sector 

Juneau.

Endnotes: 1. The Italian-flagged cruise ship Costa Concordia was on a Mediterranean Sea cruise 

when the vessel grounded off the Italian island of Isola del Giglio on January 13, 

2012, resulting in the loss of 32 lives. The vessel was carrying 4,229 people at the 

time of the incident. Source: Italy’s Ministry Of Infrastructures and Transports 

report on the safety technical investigation of the Costa Concordia marine casualty; 

see www.safety4sea.com/images/media/pdf/Costa_Concordia_-_Full_Investigation_Report.pdf.

2. On January 8, 2015, the Costa Rican-flagged sightseeing vessel Pura Vida Princess 

sank on the Pacific Coast of Costa Rica near Punta Leona. There were 109 passengers aboard the vessel at the time of the incident; three died as a result of the 

sinking. Source: CG investigator draft findings (report not yet publicly available). 

Communication

Communication is critical to supporting the investigator 

community, so each NCOE takes turns sponsoring weekly 

teleconferences. Besides providing solutions to “hot-button” 

topics and fostering dialogue, these teleconferences also 

provide a forum for specific legal guidance, as there are 

numerous nuances regarding how to best implement U.S. 

Coast Guard policies, U.S. code statutes, Code of Federal 

Regulations, and vessel technical issues. 

In the same vein, recognizing how important it is to foster 

reliable communications, NCOE personnel also now maintain the Marine Investigating Officer Exchange, an internal 

U.S. Coast Guard Intranet website. Through this portal, anyone within the investigator community can access the latest 

information, pose questions, and receive responses from 

colleagues or NCOE personnel, which engenders greater 

awareness for current issues. There are also dedicated areas 

within this information exchange containing internal Coast 

Guard policy guidance documents, technical tools, and 

investigator best practices and lessons learned. 

Additionally, NCOE personnel are just a phone call away 

when local investigators or their commands need help 

working through difficult issues. This subject matter expertise allows units to more efficiently manage their caseloads. 

Enhanced Working Relationships_

Placing dedicated active duty and civilian personnel at the 

NCOEs provides continuity and the ideal opportunity to 

foster long-term working relationships with other investigative bodies. For example, National Transportation Safety 

Board (NTSB) personnel regularly interact with INV-NCOE 

investigators. This pre-established working relationship 

greatly improves field response effectiveness and helps prevent any potential cross-jurisdictional issues. 

Interagency and International Eorts

Whereas a local investigator may be assigned as a liaison 

to an NTSB investigation for the first time, Investigations 

National Center of Expertise investigators are intimately 

familiar with the NTSB investigation process. This level of 

familiarity provides a tremendous resource not only for 

field investigators, but it also allows INV-NCOE investigators to respond to high-visibility investigations and help 

streamline investigative efforts involving multiple investigative bodies. 

Investigations National Center of Expertise staff members also reach beyond domestic borders to assist with 
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 9

After the initial search and rescue efforts, the Coast Guard 

requested travel clearance for USCG and NTSB casualty 

investigators to attend the accident scene, but they had to 

wait more than five weeks to get approval. Furthermore, 

the investigators’ efforts were hindered by the extremely 

limited information the Mexican government shared with 

them regarding the initial search efforts — information that 

could’ve been valuable to the accident investigation. As a 

result of this limited information and the travel delay, their 

efforts were severely hampered.

Though Coast Guard investigators may be familiar with 

the investigation process and the local area, other countries and/or states have their own investigative processes 

and procedures. For that reason, INV-NCOE personnel have 

worked to ease such challenges by ensuring that all involved 

parties understand their respective roles in the process and 

everyone reports on their process in the investigation. 

International Partnerships

In addition to fostering improved working partnerships 

with border governments, INV-NCOE staff members have 

demonstrated their unique ability to interact with and establish working relationships with international partners. 

In one of the largest passenger shipwrecks in modern times, 

the Italian cruise ship Costa Concordia hit an underwater 

reef on the evening of January 2012 and partially sank in 

the Italian coastal waters of the Mediterranean Sea. As part 

of the high-profile, multinational investigation that quickly 

ensued, the USCG Investigations National Center of Expertise quickly joined forces with NTSB investigators to become 

an integral part of the incident’s U.S. representation. 

After the accident, INV-NCOE investigators offered technical expertise and support to the government of Italy’s 

When a major marine casualty1 occurs, there are numerous 

international, federal, state, and local agencies poised and 

ready to engage at a moment’s notice. Since its inception in 

late 2009, the USCG Investigations National Center of Expertise (INV-NCOE) has progressively forged strong partnerships with such agencies to make the most of the specialized 

expertise and resources each brings to the table. 

Closing the Divide 

One such example involves the Coast Guard’s investigation of the loaded tank vessel Eagle Otome. On the morning 

of January 23, 2010, the vessel allided with the tank vessel 

Gull Arrow and a tank barge. As a result, the Eagle Otome 

ran aground, resulting in a major crude oil spill of more 

than 460,000 gallons in the port of Port Arthur, Texas, about 

90 miles east of Houston.2

In addition to National Transportation Safety Board (NTSB) 

marine casualty investigators, the INV-NCOE was notified, 

and personnel immediately sprang into action. The incident 

laid the foundation for what proved to be the beginning of 

a long-lasting partnership between the two agencies, and 

the ensuing investigation showcased the INV-NCOE’s contribution to harmonious investigations that stretch across 

multijurisdictional boundaries. 

Though having pre-established relationships significantly 

improves marine casualty investigation effectiveness, the 

practice doesn’t come without its challenges, as a September 2011 investigation proved. A U.S.-flagged liftboat was 

15 nautical miles offshore in the Bay of Campeche in the 

Gulf of Mexico when it sustained hurricane damage. The 

crew of 10 abandoned the vessel and clung to a life float. 

Three days passed before nine of the 10 crewmembers were 

rescued. Only six survived. Four days later, the body of the 

tenth crewmember was recovered.3

INV-NCOE Agency 

Partnerships

Established relationships leverage efforts.

by LCDR YANCEE MCLEMORE 

Program Manager, Suspension and Revocation 

U.S. Coast Guard Office of Marine Casualty Investigations and Analysis

Overview
10 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Enforcement, INV-NCOE investigators played an integral 

part in the investigation. They were also crucial to the monumental response that included more than 47,000 workers 

and 6,000-plus vessels that cleaned up the estimated 4.9 million barrels of oil discharged into the Gulf of Mexico.4

INV-NCOE and other investigators from various Coast 

Guard field units worked around the clock to identify causal 

factors that may have contributed to the well blowout and 

subsequent explosion and fire. Further, the joint investigation team, composed of Coast Guard and Bureau of Ocean 

Energy Management Regulation & Enforcement (BOEMRE) 

members, held seven public hearings that included testimony from more than 80 eyewitnesses. They analyzed 

hundreds of thousands of pages of evidence. The USCG/

BOEMRE partnership leveraged each agency’s respective 

authorities and expertise and established a standardized 

response framework to manage future incidents.

Looking Forward

The Coast Guard’s fundamental responsibility is to safeguard the lives and safety of its citizens. By building longlasting partnerships with other federal agencies; state, local, 

and tribal governments; marine industries; and individual 

mariners, USCG Investigations National Center of Expertise 

personnel have worked diligently over the past six years to 

improve marine safety through accident investigation lessons learned. 

Marine casualty investigations can be very complex, often 

requiring extensive interagency coordination, information 

management, and outreach. Strong interagency partnerships, unity of efforts, and flexibility are all essential elements that together lay the foundation for success. The 

INV-NCOE staff has played a crucial role in building and 

maintaining these foreign and domestic interagency relationships, establishing a legacy that will live on for years, 

honoring the Coast Guard’s motto: Semper Paratus.

About the author:

LCDR Yancee McLemore is the Suspension and Revocation program manager in the Office of Marine Casualty Investigations and Analysis. He began 

his marine safety career as a domestic vessel inspector and marine casualty 

investigator at Sector Los Angeles/Long Beach. Subsequent tours include 

chief of the investigations division at Sector Corpus Christi and an investigating officer at the Suspension and Revocation National Center of Expertise in Martinsburg, West Virginia.

Endnotes: 1. As defined by 46 Code of Federal Regulations Parts 4.03-1 and 4.02-2.

2. U.S. Coast Guard Formal Report of Investigation, May 19, 2010.

3. NTSB Marine Accident Report; NTSB/MAR-13/01, adopted April 9, 2013.

4. See Final Action Memorandum: Incident Specific Preparedness Review (ISPR) 

Deepwater Horizon Oil Spill, www.uscg.mil/foia/docs/DWH/BPDWH.pdf. 

marine casualty investigators. This proved crucial, as investigators were able to carry out varied and complex activities simultaneously. For example, INV-NCOE personnel 

conducted passenger and crewmember interviews using a 

questionnaire focused on safety, lifesaving apparatus, and 

other survivability-related issues. 

As a result of the comprehensive investigation, INV-NCOE 

staffers were able to document facts based on eyewitness 

accounts, providing key information for the Italian government’s casualty investigation. 

During the Worst of Times

In the wake of the April 2010 Deepwater Horizon explosion, 

the Investigations National Center of Expertise once again 

stepped up to the plate. Within hours of the initial explosion, 

INV-NCOE staff members were assigned to assist with the 

investigation. 

They worked alongside a large number of responsible parties as well as many other federal, state, and local agencies to face the unprecedented challenge. Working closely 

with interagency partners, including the FBI, the Chemical 

Safety and Hazard Investigation Board, and what would 

eventually become the Bureau of Safety and Environmental 

Recurrent INV-NCOE 

Agency Partners

International

United Kingdom’s Accident Investigation Branch

International Maritime Organization

Domestic

National Transportation Safety Board 

Bureau of Safety and Environmental Enforcement 

Oshore Marine Service Association 

Department of Labor 

Occupational Safety and Health Administration 

Army Corps of Engineers

Federal Bureau of Investigations 

Department of Justice 

Chemical Safety Board 

State/Federal/Private

Towing Safety Advisory Committee 

Passenger Vessel Association 

State Pilot Associations
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 11

Back in 2009, as the first national technical advisor for the 

Investigations National Center of Expertise, I was at Marine 

Safety Unit Texas City presenting an introduction on the 

National Centers of Expertise. I was the last presenter before 

lunch, and people were starting to fade fast, so I opened up 

my presentation with: 

“If you have a marine casualty that looks strange — who you gonna 

call?” 

“When things go bump in the night — who you gonna call?” 

“When you have a marine casualty that no one on your staff can 

deal with — who you gonna call?”

Be Careful What You Ask For

That’s the kind of thing that 

can come back and haunt 

you. Soon after my presentation, one of the first calls came 

from Coast Guard headquarters’ Investigations Division. 

The National Transportation 

Safety Board (NTSB) was 

about to release its report on 

the allision of a Liberia-registered fruit juice carrier with a 

U.S.-registered dredge, and the 

Coast Guard case was nowhere 

close to completion. 

They tasked us to review the 

case in the Marine Information 

for Safety and Law Enforcement (MISLE) database and 

analyze NTSB’s case for comparison. Since the investigation was a joint effort, it was 

assumed to be a simple matter 

of comparing and contrasting the two reports. Unfortunately, that was not the case. 

With a history of working primarily in the Gulf of Mexico 

region for years, I thought I had a pretty solid knowledge 

base of all kinds of tank ships, but I’d never heard of a fruit 

juice carrier. I was also surprised the vessel had a flap-type 

rudder, which was somewhat controversial when combined 

with a controllable-pitch propeller. 

As you might imagine, these issues posed a serious learning curve for a three-person unit. Luckily for us, the 

INV-NCOE’s first civilian hire was a former Coast Guard 

Who You Gonna Call?

One man’s view of the INV-NCOE.

by LCDR WILLIE PITTMAN III 

National Technical Advisor 

U.S. Coast Guard Investigations National Center of Expertise 

Investigations National Center of Expertise

The Eagle Otome collided with a barge in Port Arthur, Texas. Photo by U.S. Coast Guard Sector Houston investigating officer.
12 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

her answer on the same day her question was asked, her 

question impacted Coast Guard policy years later. 

Like a Good Neighbor

We also wanted to make sure we could be an asset to local 

units, so we reached out to the Eighth District commander 

and prevention staff to remind them we were just down the 

street if they needed the INV-NCOE.

It was just a few weeks later that they called for assistance 

with the second-largest oil spill in the state of Texas. It happened in Marine Safety Unit Port Arthur’s area of responsibility, and the INV-NCOE supervisor at the time was tasked 

as the lead investigating officer for the casualty that caused 

the spill. The casualty involved a tanker, a tug pushing two 

oil cargo barges, and a moored break-bulk freight ship.

This case would prove to be a precursor of things to come, 

inaugurating INV-NCOE’s long working relationship 

with NTSB personnel on major marine casualties. It also 

showcased just how invaluable vessel bridge digital video 

recorder data could be for identifying causal factors in a 

marine casualty investigation. 

Deepwater Horizon

At about 4:00 a.m. on April 21, 2010, my wife woke me up to 

tell me there was an oil rig on fire in the Gulf of Mexico. Still 

under a sleepy fog, I glanced at the TV and told her it was in 

Morgan City’s zone, so it wasn’t my investigation. 

An hour and a half later, my phone rings — it’s the chief of 

staff for the Eighth Coast Guard District. I’d been tapped as 

a member of the investigation team for the now-infamous 

Deepwater Horizon oil spill — a lot of pressure to take in 

before my first cup of coffee. 

I immediately put together a “go” bag, and one hour later, 

I found myself at the BP facility in Houma, Louisiana. 

I managed media interest, researched Coast Guard jurisdiction regarding the investigation, and used the International 

Maritime Organization Casualty Code for my first time 

ever. I enjoyed the work and the challenge it presented me, 

but was only on the case for three days before the Commandant took over the investigation and appointed handpicked 

personnel to take over the case. Because my supervisor was 

transferring, I was removed from consideration, but two 

members of the INV-NCOE staff worked on the case for the 

next year. 

The next two new INV-NCOE civilian investigating officer 

hires worked in tandem at the Deepwater Horizon evidence 

yard for six months with the FBI as well as the Chemical 

Safety and Hazard Investigation Board, an experience that 

helped shape process guides developed for the field today. 

investigator who was also a Coast Guard-licensed master. 

We were able to track down the circular from Det Norske 

Veritas that clearly articulated the issue with that particular 

rudder/propeller combination, learning that at dead slow 

speed, the vessel loses steerage. With that full understanding of the casualty, we were able to reach out to the local unit 

and expedite the final report. 

Same-Day Service, Long-Term Impact

Soon after that, many more calls started coming in, and our 

standard was to provide same-day service, meaning that if 

you called the INV-NCOE, you would either get an answer 

to your question or a follow-up call that day with an estimate of when you could expect an answer.

For example, we once received a call from a field investigator 

who was trying to figure out if she needed to cite a vessel 

for sailing foreign waters without international documentation, as the vessel had left the continental U.S. on a voyage 

to Guantanamo Bay, Cuba. Considering the vessel’s destination was U.S. Naval Base Guantanamo Bay, it was our 

understanding that a U.S. naval base should be considered 

U.S. soil. We reached out to Coast Guard headquarters, and 

by that afternoon, we had a determination that agreed with 

our assumption that any voyage from a U.S. port to U.S. 

Naval Base Guantanamo Bay would not be considered an 

international voyage. 

That determination was pivotal, because once the U.S. 

gave up control of the Panama Canal, any voyage through 

it became an international voyage, which meant that the 

maritime industry had to be compliant with all applicable 

international laws, rules, and treaties. Prior to the handover, 

the exact same trip had not been considered an international 

voyage. So although the field investigating officer received 

The M/V Patrice McAllister after a fatal fire in which the chief engineer was 

killed and five others were severely injured. Photo by U.S. Coast Guard 

investigator, Marine Safety Detachment Massena, New York.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 13

Time Away

At about this time, I received orders 

to Marine Safety Unit Morgan City as 

the new chief of its inspections division. Though I was away from the 

INV-NCOE for a three-year tour, the 

team I’d painstakingly put together 

began to shine. They found themselves 

deeply involved with or leading a host 

of extremely high-profile marine casualties throughout the Western Hemisphere. 

Some cases that stood out: 

• the Kulluk grounding, 

• the Carnival Triumph fire, 

• the Carnival Splendor fire, 

• the Patrice McAllister fire, 

• the tank ship Elka Apollon/MSC 

Nederland collision.

Following their handling of these cases, 

the staff developed a well-earned reputation for professionalism, experience, 

and commitment.

Back at INV-NCOE

After a successful tour in Morgan City, I returned to the 

INV-NCOE as the fourth national technical advisor and 

assistant supervisor. I found myself living every middle 

manager’s dream, having just walked into a unit with a fully 

qualified and seasoned staff who would never transfer. 

I quickly noted that the unit and our missions had changed 

slightly: Under my new supervisor, the INV-NCOE’s current focus was to assist field units with complicated cases 

without taking over the case, to provide more experience for 

field investigation officers. Another big change to operations 

is that we launch to any investigation involving the National 

Transportation Safety Board. Though we don’t assume the 

lead on the investigation, we do help facilitate the working 

relationship between the local unit and the NTSB. 

For example, on November 4, 2014, the INV-NCOE was 

called to assist in the investigation of the Bahamas Celebration allision that resulted in flooding, power loss, and the 

vessel’s list to port. Because the Coast Guard was investigating the incident as a substantially interested state under 

International Maritime Organization protocols, the INVNCOE provided jurisdiction for NTSB personnel to also 

attend the vessel. This process facilitated a quick investigation that identified a major passenger accountability issue 

aboard the vessel, and this interagency partnership model 

has continued to be very effective. 

The Takeaway

All told, the INV-NCOE has been open for business for six 

very adventurous years. This unit stands ready to assist 

any unit or investigating officer anywhere in the world. Just 

remember: When an investigation might be more than you 

can handle alone ... who you gonna call? The U.S. Coast Guard 

Investigations National Center of Expertise — that’s who. 

About the author:

LCDR Willie Pittman completed Officer Candidate School in December 

1997 and has served in the Coast Guard for more than 20 years. He began 

his field training in New Orleans, Louisiana, and has served as a marine 

casualty investigator and vessel inspector for the majority of his career. He 

was the first member as well as the national technical advisor for the USCG 

Investigations National Center of Expertise in New Orleans, Louisiana. 

As a fully qualified marine inspector, he serves as a subject matter expert 

for outer continental shelf, domestic, and foreign vessel material failure 

investigations.

Coast Guard investigators from the Coast Guard Marine Safety Center and the Investigations National 

Center of Expertise examine the cruise ship Carnival Triumph’s engine room to determine the cause of 

a fire that stranded the ship with its passengers for days in the Gulf of Mexico. U.S. Coast Guard photo 

by LT Jerry Federer.
14 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

with no obvious, single source identified during the physical investigation. Pollution responders may narrow the list 

of possible sources by evaluating vessel traffic logs, transfer 

operations, witness statements, aerial surveillance, or other 

components, but still lack direct evidence implicating a single responsible party. By sampling the spilled oil as well as 

each suspected source, investigators can eliminate suspects 

and may ultimately yield the evidence necessary to identify 

the responsible party.

Additionally, critical investigative details may be obtained 

from fingerprinting a mystery spill even in the absence of 

suspected sources, as the type of petroleum oil discharged 

and how degraded it is can help guide pollution responders. This guidance may spare investigators from wasting 

resources pursuing dead ends, such as examining fuel 

suppliers when the spilled product is lubricating oil. Perhaps equally important, submitting a mystery spill sample ensures the sample is preserved at the chemical level 

(weathering ceases after MSL sample preparation) and at the 

evidentiary level, pending final case disposition. 

The investigation into the SS Jacob Luckenbach epitomizes 

how integral petroleum oil fingerprinting can be to solving 

mystery spill cases.2 During this investigation, an oil spill 

source identification task force comprised of 20 federal and 

state agents worked to determine the source of petroleum 

oil affecting more than 2,000 birds and 220 miles of central California coastline. The 2001–2002 mystery spill event 

shared many commonalities with prior mystery spill events 

occurring in the same area since 1992, prompting the task 

force to re-evaluate the historical events. 

Throughout 1992–2002, the MSL received samples from 

oiled wildlife and suspected sources. While each suspected 

source was a “non-match” to the oiled birds, a vital and 

surprising result did come from the analysis, as the mystery 

spills from 1992–2002 all had the same petroleum oil fingerprint. This finding was imperative for the task force, since it 

The Marine Safety Laboratory (MSL) was established in 

November 1977 to help U.S. Coast Guard pollution responders investigate oil spills and enforce the nation’s environmental laws. Nearly 40 years later, the MSL still stands as 

the Coast Guard’s sole forensic laboratory for oil spill source 

identification and organizes the efforts of various federal, 

state, and local law enforcement agencies to provide analysis 

to field investigators. While the majority of MSL samples are 

from routine oil spills, there are many applications in which 

petroleum oil fingerprinting can be of significant investigative value.

Fingerprinting

Petroleum oil “fingerprinting” is a term adopted in the 

mid-1970s, when the Coast Guard Research and Development Center (RDC) developed the Oil Identification System (OIS). 1 It reflects the idea that every petroleum oil has 

a unique chemical composition, or fingerprint. There have 

been marked technological advancements since then, but 

the premise remains the same: Use a multimethod analytical approach to evaluate the intrinsic composition of oil samples, then make comparisons to determine if the samples 

derive from a common source.

Current MSL analytical techniques include infrared spectroscopy, gas chromatography with flame ionization detector, and gas chromatography with mass selective detector. 

These techniques are sensitive enough to permit staffers to 

evaluate samples at the molecular level and compare fingerprints for similarities and differences. 

Two oil samples “match” if they have the same fingerprint 

after weathering (when chemical, physical, and biological 

factors change the oil) and other contaminants are accounted 

for. A match is significant in that it provides forensic evidence of a chemical relationship between two samples. 

Taking the Mystery Out of Mystery Spills

A routine Marine Safety Laboratory case is one in which 

petroleum oil has been discharged into the environment 

Whodunnit?

Petroleum oil fingerprinting.

by MS. KRISTY JUAIRE

Manager and Supervisory Chemist 

U.S. Coast Guard Marine Safety Laboratory

Investigations National Center of Expertise
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 15

eliminated vessel traffic from the list 

of possibilities. 

Petroleum oil fingerprinting was 

also critical in eliminating natural 

seeps and submerged oil wells as 

the stationary source, leaving investigators with a sunken shipwreck as 

their target. Extensive and laborious 

research led to the SS Jacob Luckenbach, a freighter that sank in 1953 

in shallow water southwest of the 

Golden Gate Bridge. A sample collected from the vessel was a match 

to the oiled birds and the prior mystery events, solving the decade-long 

mystery.

Monitoring Known Spills

In April 2010, the world watched 

as millions of barrels of crude oil 

escaped from the wellhead after the 

Deepwater Horizon (DWH) explosion. 3 Despite the tremendous 

amount of resources and effort 

devoted to containing spilled oil 

and minimizing the impact to shorelines, marshes, and wildlife, major 

damage was done. Oiled birds and 

wildlife were recovered as crude oil 

began washing ashore. 

In the days and weeks following 

the explosion, the source of oil contaminating the Gulf of Mexico was 

fairly conspicuous. Regardless, prudent investigators knew they had 

to collect evidence in an unbiased 

manner, so samples started arriving 

at the MSL one week into response 

activity.

Petroleum oil fingerprinting proved to be an important part 

of Deepwater Horizon response, providing scientific confirmation of the presence of DWH oil in various locations. As 

of February 2015, Marine Safety Laboratory personnel had 

processed 518 cases, assisting investigators at the federal 

and state levels to allocate responsibility for damages. 

Oil fingerprinting has also helped rule out DWH as a source 

of oil in the environment. Significant public and media concern arose in May 2010 when tar balls were discovered in 

Key West, Florida, generating worry Deepwater Horizon oil 

had migrated into the Gulf Current loop. In response, USCG 

Air Station Miami personnel flew tar ball samples to the 

Marine Safety Laboratory for analysis. Within hours of taking custody of the samples, MSL staffers confirmed the tar 

balls did not derive from DWH and were able to notify the 

District Seven response chief, District Seven chief of staff, 

and Sector Key West commanding officer. 

Personnel continued to test the samples Sector Key West 

and Sector Miami submitted through May 2011 (totaling 107 

cases and 241 individual samples), confirming each one a 

non-match to DWH. Through petroleum oil fingerprinting, 

Marine Safety Laboratory personnel extract a sample from an oily water separator bypass 

hose, also known as a “magic pipe.” Photos courtesy of the U.S. Coast Guard Marine Safety 

Laboratory.
16 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Though many times in these “magic pipe” cases, no one 

observes the resultant oil slick or sheen because the discharge occurs out in open water, inspectors may uncover 

evidence of illegal activity during port state exams. For 

example, inspectors are trained to note things like discrepancies in the vessel’s oil record book, freshly painted 

bolts and flanges in the engine room, or an extraneous flexible hose stashed in a corner. USCG inspectors have also 

received reports from whistleblowers who witnessed intentional discharge.

When a spill sample is absent, submitting other samples 

from various locations on the vessel can provide critical 

information to investigators and prosecutors, since detecting petroleum oil where it does not belong is an important 

finding. For example, Marine Safety Laboratory personnel 

have processed samples from marine sanitation devices, 

boiler blow-down valves, and piping on the discharge side 

of oil filtration equipment. When oil is detected in these 

locations, it provides forensic evidence to investigators that 

something is amiss, helping to piece together the events.

Petroleum oil fingerprinting can also corroborate or disprove statements. For example, a lone whistleblower may tell 

a USCG inspector that a flexible hose located in the engine 

room was used to transfer oily bilge waste over the side of 

the vessel. Other crewmembers may insist that such activity 

never occurred, and the flexible hose was used exclusively 

to transfer clean water from one tank to another. Submitting 

the hose to the MSL for solvent extraction can prove whether 

or not petroleum oil passed through it — and who’s telling 

the truth.

Beyond Oil Spills

While MSL analyses most frequently support oil spill investigations, the Marine Safety Laboratory has provided indispensable forensic services for a wide variety of law enforcement activities, as well. 

Conspiracy to Commit Racketeering: The State of New Jersey Division of Criminal Justice Environmental Crimes Unit 

was investigating an underground storage tank testing company that provided readings regarding heating oil storage 

tank integrity. It was alleged that the company knowingly 

used faulty equipment and recorded false readings. 

The company also collected soil samples from each property 

to submit for hydrocarbon testing. Investigators suspected 

that instead of directly sending the samples for testing, the 

company would first spike the samples with diesel fuel to 

ensure a positive hydrocarbon reading. They would then 

provide the false readings to clients to solicit work for a 

related business to remove the “leaking” storage tank and 

remediate the site.

the MSL was able to provide absolute confirmation that 

Deepwater Horizon oil hadn’t reached the Gulf Current loop.

What if No One Sees a Spill?

The USCG and Department of Justice have been working 

together to hold pollution offenders accountable for deliberate discharges of oily waste into the marine environment. 

The International Convention for the Prevention of Pollution 

from Ships requires that bilge waste containing more than 

15 parts per million of oil be transferred to a shoreside facility. Unfortunately, not all operators adhere to this requirement. Offenders may use a variety of novel techniques to 

bypass the vessel’s oil filtration equipment, dumping the 

oily waste directly overboard.

Marine Safety Laboratory 

Customers

Federal

U.S. Coast Guard

Department of the Navy 

Environmental Protection Agency 

National Oceanic and Atmospheric Administration 

Mine Safety and Health Administration 

National Park Service

U.S. Fish and Wildlife Service

Forest Service

Federal Bureau of Investigations

State 

Texas General Land Oce

New Jersey Division of Criminal Justice

New York State Department of Environmental Conservation

Maine Department of Environmental Protection

Mississippi Department of Environmental Quality

Minnesota Pollution Control Agency

Local 

Miami Valley Regional Crime Lab

Orange County Environmental Protection Division

Town of East Lyme Department of Public Safety

Detroit Water and Sewage

Downers Grove Fire Department

Hillsborough County Sheri’s Oce

Montville Wastewater Treatment Plant

Ramsey County Public Health Department
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 17

New Jersey investigators obtained the soil samples submitted for hydrocarbon testing and turned them over to the 

MSL for processing. Marine Safety Laboratory personnel 

compared the petroleum oil fingerprint from each client’s 

property and determined that several sites matched each 

other. This finding would be impossible if each site truly 

did contain a leaking underground storage tank, since completely unrelated physical locations would not have precisely the same petroleum oil history throughout the tank’s 

lifetime. The MSL’s results proved there was indeed a single 

source of diesel fuel contaminating the soil samples rather 

than hydrocarbons from legitimately leaking tanks.

Kidnapping, Armed Robbery, and Motor Vehicle Theft: 

In January 2010, the Miami Valley Regional Crime Lab contacted the MSL for assistance in a kidnapping, armed robbery, and motor vehicle theft case. The suspects allegedly 

parked their vehicle in the victim’s garage during the crime, 

where it leaked oil onto the concrete garage floor. 

Investigators collected samples from the garage floor, the 

victim’s vehicle, and the suspects’ vehicle. Petroleum oil fingerprinting determined the sample from the victim’s vehicle did not match the sample from the garage floor, but the 

sample from the suspects’ vehicle did, so the MSL provided 

forensic evidence placing the vehicle at the crime scene.

Criminal Possession of Stolen Property, Endangering 

Public Health, and Unauthorized Use of a Vehicle: From 

January to March 2012, tankers filled with viscous waste 

oil were being abandoned on the streets of New York and 

New Jersey. As the tankers were discovered, investigators 

submitted samples to the MSL for fingerprint analysis. Each 

sample that came in matched the ones before, indicating that 

the 12 seemingly random abandoned tankers were indeed 

connected.

State investigators suspected that the owner of a commercial 

facility in New York had enlisted help to make his business’s thick oily waste disappear. The person he hired to 

help allegedly stole several empty tanker trailer trucks from 

lots in New Jersey and drove them to the business in New 

York, where employees allegedly filled the tankers with the 

oily waste. The loaded trucks were then abandoned on public streets. Both parties were ultimately charged with several 

felonies.

About the author:

Ms. Kristy Juaire has worked at the USCG Marine Safety Laboratory for 

14 years. She is the USCG voting member to the American Society for Testing Materials regarding oil fingerprinting standards and has provided expert 

testimony in 12 federal criminal trials. She holds a B.S. and an M.S. in 

organic geology-chemistry from Brown University.

Endnotes: 1. Oil Spill Identification System. USCG R&D Center Report No. CG-D-52-77 (NTIS 

#ADA044750), 1977. 

2. CDR Gabrielle McGrath et al., “The Investigation to Identify the SS Jacob 

Luckenbach — Using Technology to locate a Hidden Source of Oil that Caused 

Years of Impacts and the Future Implications of Sunken Shipwrecks,” 2003, IOSC 

Proceedings.

3. Deepwater Horizon Oil Spill. See www.uscg.mil/foia/docs/DWH/BPDWH.pdf.
18 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

The Allision

Arriving on scene, the local Coast Guard investigation team 

members saw flashing lights from emergency response 

vehicles and floodlights illuminating an eerie scene on 

the waterway. An oceangoing ship, the M/V Delta Mariner, 

struck the U.S. Highway 68 bridge over the Tennessee River, 

which connected the communities of Cadiz and Aurora, 

Kentucky. One of the bridge’s 300-foot spans fell onto the 

bow of the ship, leaving portions of the twisted girders 

trailing off the ship’s bow, effectively trapping the ship and 

anchoring it to the river bottom. Fortunately there were no 

deaths, injuries, or pollution associated with this incident.

While local Coast Guard investigators and 

response personnel worked at the scene, 

NTSB leaders followed established protocol 

and selected personnel to participate in the 

joint investigation. Using an already-established memorandum of understanding, 

it was determined that the Coast Guard 

would be the lead in this joint USCG/NTSB 

investigation. In this case, the National 

Transportation Safety Board investigator 

in charge had been working on another 

case in New Orleans, so he was dispatched 

to the accident site to prepare for this new 

investigation. NTSB team members were 

also dispatched, including one who worked 

in roadway accidents as well as one who 

was a technical expert to assist with electronic evidence collection and analysis. 

Fortunately for the investigators, the 

ship was an oceangoing vessel that was 

required to have a simplified voyage data 

recorder (S-VDR) and an electronic chart 

It was early morning. Phones and other high-tech portable 

communication devices began emitting rings and vibrations, notifying marine casualty investigators of an incident on one of America’s waterways. U.S. Coast Guard and 

National Transportation Safety Board (NTSB) investigators 

were independently briefed on the marine casualty, an 

incident where a ship struck a bridge span, affecting two 

segments of the nation’s transportation infrastructure by 

closing down a river and a highway. Local USCG investigators immediately grabbed their “go” bags and headed to the 

scene, arriving shortly after the allision.

Marine Incident Investigation

NTSB and Coast Guard collaboration.

by MR. KEITH FAWCETT

U.S. Coast Guard Investigations National Center of Expertise 

MR. NICHOLAS PARHAM

National Transportation Safety Board

Investigations National Center of Expertise

The bow of the M/V Delta Mariner with the twisted span of the Eggner’s Ferry Bridge anchoring 

the ship to the bottom. The ship was specifically designed to be able to pass under bridges on the 

inland waterways. Photo courtesy of the NTSB.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 19

system (ECS). The S-VDR displays selected information 

about the vessel’s maneuvering control settings as well 

as the recorded audio from five microphones located on 

the inside of the vessel’s wheelhouse and bridge wings. 

The ECS data files contained a chart showing the vessel’s 

movements along with the vessel’s course, speed over 

the ground and through the water, its rate of turn, and 

the water depth. 

In addition, the electronic chart system contained a 

graphic display of any other vessel along its track with 

an automatic identification system (AIS), but it is important to remember that although larger commercial vessels are equipped with an AIS transponder, most recreational vessels don’t appear on this type of ECS chart 

display. 

INV-NCOE Support

Following a request for assistance, the U.S. Coast Guard’s 

Investigations National Center of Expertise (INV-NCOE) 

supervisor dispatched two personnel with the appropriate investigations equipment to support this major marine 

casualty. The INV-NCOE investigators departed immediately for the USCG Marine Safety Unit (MSU) in Paducah, 

Kentucky — the unit responsible for the investigation. After 

reviewing the elements of the case, the U.S. Coast Guard 

District Eight commander designated it a formal district 

investigation. 

On the day following the nighttime allision, the marine 

casualty investigation team, comprised of Coast Guard and 

NTSB personnel, traveled to the scene of the incident. These 

team members, who had never worked together before, 

would be working alongside each other for months to come 

over the course of the investigation.

The Combined Team

Arriving at MSU Paducah, the combined team assembled 

in a conference room to receive information on the incident 

from the local Coast Guard investigators. The Coast Guard 

lead investigating officer in turn briefed the MSU’s commanding officer on the course of action and the investigation’s objectives. The team had already begun the collaborative process based on a shared respect and understanding 

of the priorities of each agency.

The next step was for the team to visit the incident scene to 

view the vessel’s layout, design, construction, and unique 

characteristics and gain a general overview of the vessel’s 

key personnel duties. Once there, the Coast Guard and NTSB 

investigators observed vessel stabilization and preliminary 

salvage operations. They also introduced themselves to the 

vessel personnel, the operating company’s management 

personnel, and attorneys. 

Meanwhile, the NTSB highway accident investigator examined the implications of the incident with respect to vehicular traffic, the highway bridge, and the roadway. The NTSB 

technical expert worked closely with an INV-NCOE Coast 

Guard investigator to gather electronic evidence from 

the vessel’s S-VDR and the ECS. This data was sent to the 

National Transportation Safety Board laboratory for analysis and examination via rigid chain-of-custody protocols, 

in which two members of the joint team accompanied the 

electronic evidence to the lab. 

The Interviews

At the incident site, investigators completed the on-scene 

overview and identified the various potential shipboard witnesses and other witnesses. To accommodate crewmembers 

and the involved parties at this remote location, the lead CG 

investigator chose a small rental cabin at a local state park 

for interviews. This guaranteed privacy in a location close 

to the damaged vessel, the bridge site, and the operating 

company’s shoreside response site, thus providing an ideal 

location.

Recorded interviews followed a structured format, as the 

USCG and NTSB investigators focused on different lines 

of questioning based on agency priorities. Attorneys were 

present throughout most of the interviews, and written 

interview transcripts the NTSB prepared were of great help 

in the formal investigation hearings that were to follow.

The Re-Enactment

During the course of the interviews, it became apparent that 

the investigators could benefit from seeing the vicinity of 

the casualty in conditions similar to those at the time of the 

incident, so the investigators used the USCGC Cimarron, a 

local Coast Guard inland river tender, to recreate the events 

leading up to the allision. 

A technician from the NTSB uses a sophisticated laser imaging device to map the 

twisted steel on the bow of the M/V Delta Mariner while wearing a Coast Guard 

flotation device and an NTSB hard hat, suggesting the epitome of collaboration. 

Photo courtesy of the NTSB.
20 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

and the National Transportation Safety Board 

to ensure a complete and thorough investigation. The investigators looked at the actions 

of shipboard personnel that night, the safety 

management system for the ship, the State of 

Kentucky’s lighting maintenance procedures, 

the Coast Guard’s notice to marines broadcast 

system, and the Coast Guard’s bridge program. 

Investigators also conducted follow-up interviews and gathered additional information and 

documents. This effort was coordinated among 

the various parties of interest and all members involved in 

the investigation. The information was shared between the 

NTSB and the Coast Guard investigation teams to facilitate 

a collaborative investigative effort.

The Reports

At the same time, the NTSB team gathered information that 

was unique to the National Transportation Safety Board 

safety investigation to develop a marine accident brief 

and a formal public report to the NTSB board, which was 

streamed on the Internet.

The Coast Guard lead investigating officer forwarded the 

USCG report of investigation according to Coast Guard 

policy. The report contained findings of fact, analysis, 

conclusions, safety recommendations, and recommended 

enforcement actions. For example, the Coast Guard lead 

investigating officer made recommendations regarding civil 

penalties or mariner enforcement actions as well as safety 

recommendations.

In addition, the USCG team loaded all the evidence and 

other relevant information into the Marine Information for 

Safety and Law Enforcement database to allow the Coast 

Guard to track this incident and other similar incidents to 

enhance the Coast Guard’s marine safety prevention strategy. 

About the authors:

Mr. Keith Fawcett is a staff member at the USCG Investigations National 

Center of Expertise, and is a licensed merchant mariner. He has worked in 

the marine industry for more than 20 years and is the INV-NCOE’s subject 

matter specialist in human factors, VTS operations, and interviewing techniques. 

Mr. Nick Parham is a former USCG lieutenant commander who completed 

Officer Candidate School in February of 2002 and served in the Coast Guard 

for 13 years. He began his field training in Morgan City, Louisiana, and 

served as a marine casualty investigator and vessel inspector for the majority 

of his Coast Guard career.

Bibliography:

Report of Investigation into the Circumstances Surrounding the Allision of the 

Motor Vessel Delta Mariner with the Eggners Ferry Bridge at Mile 41.7 on the Tennessee River Near Aurora, Kentucky, on January 26th, 2012 (draft report not yet publicly 

available nor finalized).

Utilizing the S-VDR audio and the ECS chart playback, 

investigators combined the two sources of information into 

one synchronized display and played it back on a laptop 

computer. Synchronizing this display with an evening transit, investigators had the Cimarron maneuver along the same 

track the Delta Mariner followed the evening of the allision. 

Along the way, the wheelhouse team on the Coast Guard tug 

commented on how a typical vessel would transit through 

that particular part of the waterway, which gave valuable 

insight into the crew’s actions on the night of the incident. 

Later, NTSB highway and technical measurement personnel took extensive measurements of the height, width, and 

clearances of the bridge with sophisticated laser measuring 

tools, then did the same to record the Delta Mariner‘s dimensional properties.

After the on-scene joint investigation concluded, NTSB personnel conducted an “audition” of the S-VDR audio at its lab, 

where team members who were parties of the investigation 

listened to the soundtrack of the events recorded on the 

Delta Mariner’s bridge. The team then compiled a transcript 

of the pilothouse discussions leading up to the incident. 

This information was a critical piece of evidence for the 

investigation.

The Formal Hearing

A formal hearing took place in mid-April 2012, where the 

Coast Guard and NTSB teams interviewed the witnesses. 

The hearing was streamed online, as the Eggners Ferry 

Bridge was out of service, preventing many people who 

had wanted to be present at the formal public hearing from 

attending. 

The hearing lasted for a week, and afterward the investigators reconciled all the exhibits to ensure that each member of 

the hearing understood the various deliverables and expectations as the investigation moved forward. 

During the months following the incident, there was a constant flurry of communication between the Coast Guard 

The panel at the 2012 Delta Mariner formal hearing in Paducah, Kentucky, listen to testimony. 

U.S. Coast Guard photo.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 21

On Easter Sunday in 1969, in the Port of New Orleans, the 

mighty Mississippi River was swollen with winter snow 

melt-off. Aboard two different tugs, Captain Chris Rieder 

studied for his merchant marine license, while Captain 

Douglas Grubbs was coming aboard for duty and dropping 

off an Easter meal for his crew. 

The Incident

Suddenly they heard the rapid blast of a ship’s whistle as 

the Union Faith, a cargo freight ship, and a couple of tugs 

pushing loaded oil barges were an instant from colliding. As 

both tug captains and their crews looked out onto the river, 

they witnessed the moment of impact, flames leaping into 

the early evening sky. The ensuing fire would reach 175 feet 

into the air and scar the paint on the bottom of the Greater 

New Orleans Bridge. 

The burning ship, aflame from bow to 

stern, as well as the burning oil barges 

and oil threatened to spread the fire across 

the New Orleans city wharves, docks, 

and ships moored along the waterfront. 

Scores of river pilots, firefighters, marine 

personnel on tugs, and other marine 

shoreside support personnel gathered to 

assist as the disaster unfolded. 

The Response

Captain Douglas Grubbs and his crew 

aboard the tug Cappy Bisso and Captain 

Chris Rieder aboard the tug McGrath II 

repeatedly braved the pools of flaming 

oil, frantically running through swirling fire and dangerous current to rescue mariners who had jumped from the 

ship, plucking them from the treacherous water. Of the Union Faith’s crew of 51 

(including the pilot), Grubbs and Rieder 

ultimately rescued 26 men.

The two captains also prevented the burning ship from 

drifting downriver, saving the wharves and their contents 

from the potential conflagration. At one point, Captain 

Grubbs went so far as to shackle his towing hawser into 

the anchor chains of the Union Faith to prevent the listing, 

flaming ship from drifting further downriver. His attempt 

couldn’t have succeeded without the heroic actions of the 

Union Faith’s river pilot, Captain Kenneth Scarbrough, who 

was last reported on its bow with the ship’s master, dropping both anchors as flames from the burning tank barges 

consumed the bow of the freighter. 

As the night progressed, Port of New Orleans fireboats 

fought the oil barge fires, finally getting them under control 

by 2 a.m. On the morning of April 7, the Union Faith — still 

Commendable Acts

Honor, respect, and keeping faith with the mariner.

by MR. KEITH FAWCETT

U.S. Coast Guard Investigations National Center of Expertise 

Investigations National Center of Expertise

The SS Union Faith on fire in New Orleans Harbor, April 6, 1969. Photo courtesy of the USCG Historian’s Office.
22 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

for bravery — to Captain Douglas Grubbs and Captain Chris 

Rieder. 

The Legacy

The marine casualties that the Coast Guard investigates 

occur in challenging maritime environments, with people 

working on vessels navigating swollen rivers, creeping 

through dense fog, besting mountainous seas, and transporting dangerous cargoes. The casualties may occur far 

out at sea, or in the heart of our most densely packed cities.

Mariners have an unwritten code as well as a legal responsibility to come to the assistance of mariners in distress, often 

resulting in daring rescues the Coast Guard is unaware of. 

Commendable acts occur any time crewmembers use their 

skill, dedication, or expertise to minimize the effects of a 

casualty by rescuing other mariners, fighting fires, or taking 

quick action to prevent a more dangerous catastrophe — and 

when they do so, recognition is in order.

After a casualty, the Coast Guard lead investigating officer 

gathers facts in an unbiased manner to produce a report of 

investigation (ROI) with both enforcement and safety recommendations. Additionally, a section in the final part of the 

report calls attention to any commendable acts performed 

during and after the incident. Coast Guard leadership at the 

local, district, and headquarters levels review and comment 

on the ROI, and can act on the report’s recommendations.

But mariner recognition is not solely limited to the Coast 

Guard’s accident investigations. The partnership between 

the Coast Guard and the marine industry is in many ways a 

collaborative prevention effort to avoid accidents and keep 

the waterways safe. This recognition can come in a variety 

of forms, from “Bravo Zulu”1 letters or certificates of appreciation to higher-level awards such as the Distinguished and 

Meritorious Public Service Awards. The traditional handshake exchanged when awards are presented is a fitting 

way to underscore the historic, unique partnership between 

the people served by the Coast Guard and the Coast Guard 

itself.

About the author:

Mr. Keith Fawcett is a staff member at the USCG Investigations National 

Center of Expertise and is a licensed merchant mariner. He has worked in 

the marine industry for more than 20 years, has participated in several highprofile marine incident investigations, and is one of the winners of the Sener 

Award for excellence in marine casualty investigations.

Bibliography:

Available at www.uscg.mil/hq/cg5/cg545/docs/boards/unionfaith.pdf.

Endnote: 1. “Bravo Zulu” is a traditional naval signal, indicating “well done.”

burning — capsized and sank. Captain Scarbrough and the 

rest of the crew were presumed to have perished in the fire 

and explosions. 

Following the incident, the Coast Guard and members of the 

National Transportation Safety Board began the investigation, which noted:

“The actions of the crews of the tugs McGrath II and Cappy 

Bisso, which resulted in the saving of twenty-six lives and possibly 

preventing the burning of Union Faith from drifting into the New 

Orleans wharves are highly commendable...”

Eventual Recognition

Fast-forward to 30 years later. In 1999, oil was seen bubbling 

to the surface of the Mississippi River in the heart of New 

Orleans in one of the deepest parts of the river at Algiers 

Point. This oil sheen had bubbled to the surface periodically 

over the years. The Coast Guard Marine Safety Office commander at the time, CAPT Steve Rochon, and retired Rear 

Admiral Paul Pluta, who was the district commander at the 

time, met with a river pilot to talk about the source of the oil 

and create a plan of action for the spill. 

At the meeting, district commander Pluta asked the river 

pilot some questions about the original accident leading to 

the leaking oil. During the discussion he made a connection between the person he was speaking with — Captain 

Douglas Grubbs — and one of the names mentioned in the 

incident. He asked if the river pilot was the father of Captain 

Grubbs, and the man answered that it was he himself who 

had been involved in the rescue that night. 

That meeting sparked the Coast Guard’s awards investigation to recognize the mariners who gave so selflessly that 

night. Finally, over three decades later, on April 20, 2001, 

then-Coast Guard district commander Pluta presented the 

Gold Lifesaving Medal — the Coast Guard’s highest award 

Captain Douglas Grubbs, left, and Captain Chris Rieder hold a framed 

USCG gold lifesaving medal near the site of the catastrophic incident. U.S. 

Coast Guard photo.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 23

during the first hours of an investigation, as some systems 

are time-dependent and should be shut down to avoid crucial information being overwritten.

Navigation Incident Basics

With regard to investigating navigational incidents, bridge 

technology holds a wealth of information. For example, 

information from vessels fitted with an integrated bridge 

system, simplified voyage data recorder (S-VDR), or voyage 

data recorder (VDR) can greatly assist in casualty investigations. These are typically the first items of critical timedependent electronic evidence investigators gather. 

Voyage data recorders, widely regarded as a vessel’s “black 

box,” continuously record chronological records of preselected data items, such as:

• ship’s position, speed, and heading;

• bridge audio;

• VHF radio communications;

• radar data;

At times, marine investigators may become overwhelmed 

with the amount of on-scene information to collect, especially as ships and maritime platforms increasingly develop 

in innovation. However, the basics remain the same: Investigators should remember to methodically navigate through 

the incident details and causal factors prior to and when 

responding to a marine casualty. 

Investigators must also be cognizant of their jurisdictional 

authority described in Title 46, United States Code (U.S.C.), 

Chapters 61 and 63; as well as Title 46, Code of Federal Regulations (CFR), Part 4 when gathering evidence. In any case in 

which an investigator desires to collect electronic evidence, 

the investigator should be able to articulate the relevance of 

that evidence to the investigation.

Timeline Basics

First and foremost, investigators should establish a baseline 

time to reconcile the various ship systems and permit direct 

comparison between the times recorded on such items as 

navigational systems and recorders, alarms, closed-circuit 

television, automation and control systems, and 

other electronic systems and computers. 

Investigators normally use the Global Positioning System (GPS), Differential Global Positioning 

System (DGPS), or the ship’s master clock as the 

baseline time, with the other systems corrected to 

adjust to the established baseline time. For example, 

if the time on a ship system is five minutes behind 

the established baseline time, five minutes would 

need to be added to the ship system’s time to correct to the baseline time. This would be reflected as 

+ 0:05:00.

Incident and Equipment Basics

Another important step in gathering evidence items 

is examining the big picture. When it comes to electronic evidence, the devil is always in the details, 

so investigators should use a systematic approach 

to identify the controlling and monitoring systems 

Electronic Evidence

Focus on the basics.

by MR. MARC DEJESUS

Marine Investigator

U.S. Coast Guard Investigations National Center of Expertise

Investigations National Center of Expertise

Bridge control systems. U.S. Coast Guard photo.
24 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

• depth under keel;

• main alarms;

• rudder order and response;

• engine order and response;

• watertight and fire doors status;

• other sensor data.

The recorded data is stored on the server’s hard drive and 

in a protective capsule (for an S-VDR system) or a fixed 

weather deck-mounted capsule (for a VDR system). Investigators must recognize that the digital recorded information 

is proprietary and therefore requires the necessary playback 

software. Additionally, some playback software requires a 

password. 

On vessels not fitted with an integrated bridge system or 

VDR, other equipment can provide essential recorded information. This equipment includes:

• an electronic chart display and information system 

(ECDIS), which displays information from electronic 

navigational charts and integrates position information 

from the GPS or DGPS and other navigational sensors, 

such as radar, echo-sounder, or the Automatic Identification System (AIS). 

• GPS or DGPS can be a resource in the absence of a VDR 

or ECDIS. These systems provide a list of waypoints and 

the track history used in the voyage, which is extremely 

helpful data to determine a ship’s position and movements prior to an incident. 

• As with GPS or DGPS, AIS is a useful tool in terms of 

electronic evidence collection. Some AIS systems have 

data recording capabilities that provide information 

about the ship’s and other vessels’ movements in the 

area, which is also useful in identifying witnesses. 

However, AIS is prone to inaccuracies and errors in 

various data fields, so investigators should take that into 

consideration. 

• Other basic individual systems such as course recorders, 

automatic radar plotting aids, radar consoles, and depth 

sounders may also hold relevant information.

Dynamic Positioning Incident Basics

When diagnosing an incident involving dynamic positioning (DP), understanding the incident and vessel platform is 

an essential step in identifying the probable failure.

DP technology enables a vessel to maintain its position and 

heading using sophisticated positioning systems and other 

sensors as well as its own power plant, thrusters, and propellers. Extrapolating and interpreting the information from 

the monitoring systems, such as an external data logger 

and/or data stored on the operator station (main machine 

interface) is key. 

Investigators should familiarize themselves with the equipment description and software details in the original, subsequent, and last failure mode effect analysis (FMEA) trial 

report. 

Fundamental questions include:

• Was the vessel in proper DP setup/configuration, 

matching the approved FMEA configuration? Check 

for changes.

• Do the hardware details match? 

• Was the software upgraded? 

• Was a new FMEA trial completed with the vessel’s classification society? If so, examine the automation alarm 

panel logs and review for previous suspended, blocked, 

and inhibited alarms.

• Did weather cause the vessel to exceed its working envelope? 

• Was there external component failure or operator error? 

• Was the vessel redundancy correct for the assigned job? 

• Was there a failure of a key external system, like a sensor or position reference system? 

• In fair and foul weather conditions, was the failure to 

stay on station caused by a backup not engaging or a 

failure of redundant power supplies to controllers or 

sensors? 

Engineering and Propulsion Incident Basics 

Investigators should also recognize that failures in dynamic 

positioning may not just be a result of a localized system 

failure, so analyzing propulsion and machinery failures and 

understanding the technical basics of engineering systems 

is essential. 

Dynamic positioning system flowchart. U.S. Coast Guard graphic.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 25

automation and control systems, integrated bridge systems, 

closed-circuit TVs, and other fire suppression and engineering monitoring systems. 

Human Factor Incident Basics

No matter the evolution, detail, or function, marine investigators must identify or discount marine operator activity 

and determine if electronic devices possibly contributed to 

the incident. Items to consider:

• the type of device and use; 

• who owns the equipment (the operator or the company);

• proximity and accessibility to the crewmember; 

• wireless capabilities. 

Also consider the vessel’s capability to provide wireless connectivity to crewmembers and personal wireless providers. 

Assistance Basics 

Vessels are becoming increasingly complex, so even the best 

marine investigators may encounter unfamiliar systems or 

situations. Proactively obtaining technical assistance in 

areas you’re unfamiliar with is smart insurance. Colleagues 

and special teams such as the Investigations National Center 

of Expertise and/or other national centers of expertise are 

ready to help, supplying you with the best resources the 

Coast Guard has to offer. 

About the author:

Mr. Marc DeJesus is a marine investigator and retired warrant officer at 

the U.S. Coast Guard Investigations National Center of Expertise. He has 

served in multiple operational afloat and marine safety capacities during his 

35 years of service. In his present assignment, Mr. DeJesus specializes in 

electronic evidence collection, offshore supply vessel, and passenger vessel 

casualties. 

Consider starting at the source — the machinery in question may have onboard monitoring systems. From there, 

alarm and monitoring systems within the engine control 

room and on the bridge may hold vital information. The 

integrated bridge system and automation systems will have 

the individual engineering component’s electronic performance history. 

Additionally, when it comes to these types of failures, investigators should review maintenance records. Key questions 

include: 

• Was the equipment maintained in accordance with the 

manufacturer’s specifications?

• Was the equipment serviced by the manufacturer’s 

approved technicians or the ship’s crew?

• Was it being operated within specification?

• Was the equipment maintained in accordance with the 

vessel’s classification society technical standards?

Most engine manufacturers utilize electronic control systems that require a proprietary event data retrieval tool to 

gather engine performance data from event data recorders. 

Some data, such as event and alarm logs, can be viewed on 

engine monitoring screens in standard text files. Be sure 

to obtain data from the electronic engine control units or 

modules, which can provide data trouble codes or onboard 

diagnostics information in addition to critical operating and 

performance data. 

This will often identify the exact cause of machinery or 

component failure, so service technicians must immediately 

recover this data to preserve its integrity. 

Fire Incident Basics

A fire incident is one of the most problematic types to investigate because such incidents often destroy systems. Seek 

out the assistance of professional fire investigators from federal, state, or local authorities. Investigators should pay particular attention to the events/operations leading up to the 

initiating event. First and foremost, thoroughly document 

and photograph the affected areas before crewmembers or 

others disturb the scene or remove critical evidence. Be sure 

to document: 

• power distribution items and panel switch positions;

• fire extinguishing systems, detection, and discharge 

components;

• valve handle positions; 

• suppression agent levels and weights.

After collecting and documenting the affected areas, draw 

stored event information from individual alarm panels, 

Coast Guard LT Ronald Fogan and Petty Officer Josh Hobson review a 

voyage data recorder. U.S. Coast Guard photo by Petty Officer Kyle Niemi.
26 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Considered a marine casualty, such incidents must always 

be reported to Coast Guard personnel, who will follow up 

on the report and determine the appropriate level of investigative effort necessary based on various factors, such as: 

• property damage value, 

• extent of personal injuries, 

• resulting damage to the environment.

Intended Groundings

The second type, an intended grounding, is considered as 

such when it’s a controlled, deliberate maneuver to place the 

vessel or barge in contact with the riverbed. Among other 

reasons, one might choose to attempt an intended grounding to offload passengers, hold position to adjust cargo, or 

hold position to allow safe navigation and passage of other 

traffic in the area. 

Because these groundings are designated “intentional,” 

they’re not required to be reported unless the vessel can’t 

free herself as intended or the intentional grounding causes 

damage to any people, property, or the environment. In any 

of those circumstances, the casualty must be reported to 

the Coast Guard using USCG form 2692. The Coast Guard 

would then evaluate the report to determine the appropriate 

level of investigative effort, as they would with an unintended grounding.

Bump and Go

The final type of grounding is commonly known as the 

“bump and go,” where the involved vessel master or 

licensed mate on watch attests that:

• the grounding (including grounded barges under the 

control of a towing vessel) was only momentary (e.g., 

reversing engines freed the grounded vessel on the first 

attempt);

• no assist vessel was needed to free the vessel and all 

towing connections remained intact;

Grounding incidents occurring on the U.S. western rivers 

can differ greatly from typical groundings due to the unique 

factors of these waterways.1 There are three basic types of 

groundings, explained in depth below.

Unintended Groundings

The first such type of incident is called an unintended 

grounding. This involves any situation in which the vessel 

is inadvertently or accidentally brought into contact with or 

placed on the ground, or riverbed. 

When Things Go Bump

Western rivers groundings.

by MR. LES LEDET

Marine Casualty Investigator 

U.S. Coast Guard Investigations National Center of Expertise

Investigations National Center of Expertise

Cargo from a grounded bulk carrier (right) is offloaded onto a barge. U.S. 

Coast Guard photo by Air Station Traverse City.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 27

• the grounding did not result in any 

other marine casualty criteria being met 

as defined in 46 CFR Part 4.05-1(a)(3) 

through (8).

Under current policy, the Coast Guard does 

not consider an unintended bump and go 

grounding alone to be a reportable marine 

casualty,2 but initial notifications of bump 

and go groundings must still be made to the 

appropriate Coast Guard command center 

as a hazardous condition, per 33 CFR Part 

160.216. 

A Coast Guard prevention officer shall review 

each reported bump and go grounding to 

confirm that it meets the criteria to be excluded from the 

grounding casualty reporting requirements under 46 CFR 

4.05.3

Coast Guard personnel don’t necessarily need to enter such 

information into the Marine Information for Safety and Law 

Enforcement (MISLE) database, but any time a field unit 

does complete an optional investigation on a confirmed 

bump and go grounding, personnel should document the 

activity as a nonreportable casualty in MISLE, with no associated CG-2692.

Reporting and Investigation

As all types of vessel groundings may result in injuries, 

damage to property and the environment, and navigational 

obstructions that block the flow of commerce, it is important 

these casualties be reported so the Coast Guard can take 

appropriate measures to protect the safety of the public, 

the safety of waterway users, and prevent future casualties. 

The marine casualty reporting requirements of 46 CFR 

4.05-1 require that the owner, agent, master, operator, or person in charge of a vessel must report certain marine casualties, including unintended groundings, to the Coast Guard. 

Once aware of the grounding, the Coast Guard will undertake an investigation to determine as closely as possible:

• the cause of the grounding;

• whether there is evidence of any material failure (physical or design) that may have contributed to the casualty;

• whether there is evidence that any act of misconduct, 

inattention to duty, negligence, or willful violation of 

law on the part of any licensed or certified person may 

have contributed to the casualty;

• whether there is evidence that any Coast Guard personnel or employee of any government agency or any other 

person caused or contributed to the casualty;

• whether a marine board of investigations should investigate the casualty, in accordance with regulations in 46 

CFR 4.09.

Coast Guard personnel then compile information from these 

incidents for statistics and provide indications why they 

occurred. This information can help them better determine 

when or under what conditions groundings may be likely 

to occur. For example, groundings may be found to be more 

common during certain times of day or year. Other factors 

affecting grounding incidents include day/night conditions, 

water depths, vessel operations, mechanical issues, weather 

conditions, changes in the waterway bottom, and whether 

the voyage was a vessel’s or ship personnel member’s firsttime transit. 

About the author:

Mr. Les Ledet is a civilian marine casualty investigator at the Investigations 

National Center of Expertise. He began his maritime career in 1974 as a 

deckhand and is currently a licensed towing master/unlimited pilot on the 

inland waters of the United States. He has also served as a civilian vessel 

traffic service watchstander. Mr. Ledet is a subject matter expert in the field 

of inland navigation, ship handling, bridge resource management, rules of 

the road, inland towing operations, and deck licensing.

Endnotes: 1. Inland navigation rules define the term “western rivers” as “the Mississippi River, 

its tributaries, South Pass, and Southwest Pass, to the navigational demarcation 

lines dividing the high seas from harbors, rivers, and other inland waters of the 

United States, and the Port Allen-Morgan City Alternate Route, and that part of 

the Atchafalaya River above its junction with the Port Allen-Morgan City alternate 

route including the Old River and the Red River.”

2. U.S. Coast Guard Casualty Reporting NVIC 01-2015.

3. As defined in 46 CFR 4.05-1 (a)(3) through (8).

A grounded tank vessel blocks deep-draft shipping traffic. U.S. Coast Guard photo.
28 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Second, the investigations division at Marine Safety Unit 

(MSU) Texas City had been the lead on the investigation 

from the beginning, doing an excellent job, and here I come 

out of nowhere to step in and take over the lead. Most 

people would have some heartburn with that — I know 

I would — so I knew we would need to deal with that angst 

right away, because I was going to need them, and we would 

be working very closely together for the foreseeable future. 

I made first contact with the MSU Texas City investigations 

chief during the five-hour drive over to the unit. He came 

right out and said, “I’m not going to lie — I am a little hurt 

about it.” I gave him high marks for bringing it up so we 

could talk about it, and I knew right then that we would be 

fine... and we were. When I showed up at the unit, beyond 

providing me with an office, they also supplied all the support and assistance I could hope for. 

Tech Support

We had audio playback of several key communications that 

we wanted to have available during the hearing. Though all 

parties of interest had their own transcripts, unfortunately 

that didn’t mean they were all in agreement regarding what 

was said. We felt it would be best to have the original audio 

available to try to avoid such discussions. 

Luckily, our designated recorder also happened to be an IT 

wizard. On the Friday before the hearing, we visited the 

courtroom to make sure everything was set up the way we 

wanted and to do one last audio/visual equipment check. 

Despite our best efforts, we still had some difficulty with 

the audio feed during the hearing, but at that point, all we 

could do was press on.

Time Management

I was fortunate to have a well-seasoned and very capable assistant senior investigating officer (ASIO) who held 

On April 4, 2014, I conducted a formal major marine casualty investigation as the lead investigating officer alongside 

National Transportation Safety Board (NTSB) personnel. 

Since the investigation is still open, I’ll focus on what went 

well and investigation lessons learned rather than the incident itself. 

Challenges

I already had two immediate challenges to address upon 

assignment as the lead investigating officer. First, the investigation wasn’t designated “formal” until two weeks after 

the incident, putting me two weeks behind. A formal investigation is convened for the more serious or significant incidents investigated under 46 USC Chapter 63 from which 

the most value can be gained. A lot of things happen in the 

first few hours after an incident, and that much more in two 

weeks, so I had my work cut out for me to get up to speed 

as quickly as I could. 

Marine Formal Board 

of Investigation

A lead investigating officer’s perspective.

by LCDR TERESA HATFIELD

Chief, Investigations Division

U.S. Coast Guard Sector New Orleans

Investigations National Center of Expertise

Here we listen to testimony. That’s me — top row, center. U.S. Coast Guard 

photo by Petty Officer Andrew Kendrick.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 29

down the reins for Sector New Orleans investigations while 

I focused on preparing for the hearing. We chose the first 

week of June for the hearing date, which was a fairly aggressive timeline, but I wanted to move forward quickly because 

I knew my ASIO would be transferring out, and I would be 

needed back at Sector New Orleans.

Weeks flew by as the team, working from our separate units, 

finalized the witness list, developed a list of questions for 

each witness, and assembled the evidence/exhibits we 

would need for each. One thing that saved us quite a bit 

of time was developing our script from an Investigations 

National Center of Expertise (INV-NCOE) script that had 

worked well for them. 

As the hearing approached, we sent out the finalized list 

of witnesses to the parties of interest as well as the witness subpoenas. We decided on the order of testimony that 

would best tell the story, then finalized the script, witness 

questions, and exhibit binders. 

In addition to 32 exhibit binders for the investigations team, 

the NTSB, the parties of interest, and the witnesses, we also 

prepared staff binders holding the script and the questions 

for each witness. Each binder was numbered, assigned to a 

specific person, and handed out each morning and retrieved 

every afternoon during the hearing to ensure accountability 

for each piece of paper.

The Hearing Site

The city of Galveston had a new judicial complex, and they 

offered one of their courtrooms free of charge. Though some 

feel a courtroom isn’t the most effective setting for administrative hearings, this facility had everything we needed:

• plenty of free parking,

• a side room for the investigations team to meet with the 

parties of interest privately,

• security, 

• state-of-the-art visual and audio equipment.

Further, the judicial complex provided two IT techs for the 

duration of the hearing, streamed the entire hearing, and 

it was all free. Though District Eight was set to fund the 

hearing, such cost considerations helped make this a very 

favorable venue. 

Expect the Unexpected

Shortly after I took over the investigation, district legal made 

a determination that I couldn’t re-interview any witnesses 

already interviewed prior to my arrival. We could only contact these people regarding whether we would be calling 

them as witnesses at the hearing — all other questioning 

would have to wait for the formal proceeding. 

This was a new one for me. I’d participated in the preparation for several hearings, as well as countless suspension 

and revocation cases, and we had always been able to go 

back to the well as many times as needed to be ready for 

the hearing. 

Then there was a further complication: One of the key witnesses refused to comply with the Coast Guard subpoena. 

This meant I had to make a quick, unexpected trip to Houston to stand next to the U.S. attorney in front of a federal 

judge to plead our case for subpoena enforcement. Fortunately, we were successful, and I’m hopeful my experience 

will keep others from having to deal with the same issue in 

the future.

Keep the Focus

There were a few other changes necessary mid-stream, 

which we made as the situation required. For example, 

I wanted as many members of the team to get experience 

questioning witnesses during the hearing as possible, since 

the more of us who could get such experience under our 

Tips and Tricks

■ Good Team and Time Management Are 

Critical

 Start out right by choosing a good team, then delegate. You’ll be shocked at how fast the time goes, 

especially if you’re working on other cases. 

■ IT Support

 Make sure one of your team members is an IT wizard.

■ Pre-Hearing Prep

 Do not underestimate the time and eort it takes to 

put exhibit binders together.

■ Choose the Right Venue

 There are many things to consider, and they will be 

dierent for every hearing. Be sure to consider local 

community and media interest, security, room size, 

seating, parking, audio/visual equipment, and cost.

■ Be Flexible, Be Ready For Anything, and 

Be Ready to Make Hard Choices

■ Working with Partners? Build a Bridge

 When the USCG has the lead in an investigation with 

other agencies, conicting policies can cause some 

angst at the eld level. Develop a positive working 

relationship with other agency lead investigators.
30 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

that point, I made the decision to change investigators doing 

the questioning. It was a tough call, but the lead investigating officer has to keep the end goal in focus — sometimes at 

the cost of someone else’s feelings.

Joint Eorts

This was not my first time working with the NTSB. I know 

firsthand that their personnel have their own marching 

orders, their own investigative process, and often the scope 

of their investigation is much wider than ours. 

As the lead agency, we shared all evidence and information 

with NTSB personnel, and they participated in our interviews and all aspects of the investigation at their discretion. Often though, because their scope is wider, they ask for 

additional information, documentation, and other material 

the Coast Guard doesn’t typically require during an investigation. 

That said, when we’re the lead agency, NTSB personnel have 

to go through us to get these things, which can lead to frustration, lending an extra burden to an already intense and 

time-consuming investigation. I recommend keeping the 

door of communication open with your joint lead investigating officer.

My best advice for a joint investigation: 

• Know who your district point of contact is and keep the 

chain of command informed of any and all issues. 

• Lead agency or not, make sure you understand your 

role in the investigation, then hold your investigation 

as close to your role and scope as possible. 

• Ensure that you are familiar with the differences in policies and adhere to the ones that apply according to who 

has the lead. 

• Be fully cognizant that you will need to compromise 

along the way to facilitate the process. This will reduce 

frustrations and keep both agencies on an even keel. 

About the author:

LCDR Teresa Hatfield enlisted in 1986 and received a reserve commission 

in 2001. Returning to active duty after 9/11, she responded to Hurricane 

Katrina and the Deepwater Horizon spill, among other events. She has 

served as supervisor at Marine Safety Detachment Vicksburg, as the INVNCOE’s national technical advisor, and is currently chief of the investigations division at Sector New Orleans.

belts, the more we could pass on to others. With that in 

mind, we divvied up the witnesses for questioning. 

However, not all of us had the same interview style. As the 

lead, it was my job to make sure that we conducted the hearing in such a way so that we got as much information as possible. During the hearing, it was clear to me that one team 

member had a style of questioning that came off as aggressive and off-putting to the witnesses and their attorneys. At 

The Marine Board of Investigation into the Alaska Ranger sinking in 2008 

tours the trawl deck of the Alaska Warrior, another Fishing Company of 

Alaska vessel. The crew of the Alaska Warrior responded to the casualty 

and recovered several of the crew. U.S. Coast Guard photo by Petty Officer 

Sara Francis.

The Marine Board of Investigation listens to testimony in the 2008 sinking of 

the fishing vessel Katmai. U.S. Coast Guard photo by Petty Officer Allyson 

E.T. Conroy.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 31

A subpoena is one of the most important tools available to 

a Coast Guard investigating officer (IO), as that simple piece 

of paper is actually a forceful mechanism to issue a legal 

command. Because they usually move forward unchallenged, IOs may issue subpoenas with little thought as to 

what would happen if a party refused to comply. However, 

it’s important for investigating officers to fully understand 

their subpoena authority — especially the process to enforce 

a subpoena — for those rare situations when enforcement 

action is necessary.

Enforcement of a marine casualty subpoena requires federal 

judicial action, which can be a lengthy process requiring justification from the IO as well as assistance from the servicing 

legal office and the Department of Justice. Therefore, so as 

not to waste any time, it’s essential to ensure:

• every subpoena will be enforceable before issuance, 

• the investigating officer has a general understanding of 

the enforcement process, 

• the IO is prepared to follow through with the enforcement process. 

Marine Casualty Subpoena Authority

A subpoena is a written order commanding a person to 

appear before a court or other tribunal to give testimony 

and/or to produce certain documents or other items. Subpoenas are usually issued by or under the authority of a 

court. Under 46 United States Code §6304, designated investigating officers are invested with the authority to issue subpoenas directly — in other words, without having to petition 

a court to issue a subpoena on their behalf. IOs can use a 

subpoena to compel evidence production, a party in interest, 

or a witness for testimony. Every investigating officer should 

be familiar with and have access to a modifiable version of 

the subpoena template.1

An IO’s subpoena carries the same force, the same effect, 

and has the same limitations as a civil subpoena issued 

by a United States district or federal court.2 One relatively 

recent change to the subpoena rules, however, involves 

geographic limits on service and compliance. In the past, 

investigating officers could legally serve a subpoena only 

within certain geographical limits, generally equivalent to 

Marine Casualty Subpoena 

Authority and Enforcement

What every investigating officer should know.

by LCDR DAMIAN YEMMA

Attorney Advisor

U.S. Coast Guard Investigations National Center of Expertise 

Investigations National Center of Expertise

A blank sample subpeona.
32 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

not necessarily a given in every case, nor is it a party’s only 

option when responding. Under Fed. R. Civ. P. 45(d), a subpoenaed party has the ability to either object to or attempt 

to quash a Coast Guard subpoena.

In the case of a subpoena to produce documents or other 

evidence, under Rule 45(d)(2)(B), a subpoenaed party can 

respond to the IO by objecting to the subpoena. The objection must be in writing and must be served to the investigating officer within 14 days of the subpoena’s date of service. 

In this situation, the IO’s next step would be to pursue judicial enforcement. 

A subpoenaed party can also go to court to attempt to 

quash, or void, a subpoena. Rule 45(d)(3) states that a court 

will quash or modify a subpoena if it does not permit a 

reasonable time for the party to comply, requires the party 

to comply outside of specified geographic limits (see the 

Marine Casualty Subpoena Authority discussion), requires 

disclosure of privileged or protected material, or imposes 

undue burden on the party. IOs should carefully consider 

these factors before serving a subpoena. Additionally, the 

attorney advisor at the INV-NCOE or the staff attorneys at 

the servicing district legal office are available to review draft 

subpoenas and advise IOs on this issue.

Judicial Enforcement Process

In those rare situations where a party objects to or ignores 

a subpoena, the investigating officer should be prepared to 

seek judicial enforcement. The first step involves contacting 

the investigating unit’s servicing legal office, normally at the 

district level, for assistance. Although IOs may have developed a working relationship with assistant U.S. attorneys in 

their area, investigating officers must always work through 

their servicing legal office before requesting Department of 

Justice support. The Coast Guard legal office will coordinate 

referral of the matter to the appropriate U.S. attorney’s office, 

which may not necessarily be in the same federal district as 

where the investigator or investigation is located.3

Similar to the geographical limitation issue discussed, the 

concept of venue determines the appropriate judicial district in which a case may be brought. Under 28 USC §1391, 

venue will normally be determined by where a subpoenaed 

party resides or where subpoenaed property is located. For 

the jurisdictional boundary of the federal district court in 

which the investigation was being conducted. 

For example, before 2013, if an IO conducting a marine casualty investigation in Norfolk, Virginia, needed to examine a 

computer located in Los Angeles, California, he previously 

needed to ask an investigating officer in that Los Angeles 

area to issue the subpoena on his behalf. But the revision 

to the Federal Rules of Civil Procedure (Fed. R. Civ. P.) 45 in 

2013 eliminated that geographical limit on service, allowing 

the IO in Norfolk or any other unit to legally serve a subpoena anywhere in the United States. In situations where 

personal service is not possible, investigating officers should 

accomplish effective service using certified mail with a 

return receipt or some other traceable form of delivery.

Though the limitation on service was eliminated, which was 

good news, unfortunately the bad news is that IOs must 

understand that a limitation on the place for compliance 

remains. Rule 45(c) generally limits compliance to a location 

within 100 miles of where the person resides, is employed, 

or regularly transacts business. Returning to the example 

above, while the investigating officer in Norfolk can now 

serve the subpoena requesting the computer in Los Angeles, 

he or she likely will not be able to require it to be delivered 

to Norfolk. Instead, the investigating officer will likely still 

need assistance from an IO in Los Angeles to get the computer to Norfolk. 

The geographical limitation on compliance is a complex rule 

that will require evaluating factors specific to each case. 

Investigating officers should contact their serving legal 

office or the Investigations National Center of Expertise 

(INV-NCOE) attorney for assistance whenever there is a 

question about setting forth the appropriate place for compliance with a subpoena. 

Additionally, the IO must ensure that the evidence or 

appearance sought is relevant to the investigation. When 

dealing with records, it’s a best practice to describe the 

sought-after records in the greatest detail possible in the 

subpoena. Overly broad descriptions, such as “all records or 

information related to F/V X,” may result in either an unenforceable subpoena or a collection of irrelevant records that 

the IO will then have to review and process in accordance 

with Coast Guard evidence- and documentation-handling 

requirements. 

Quashing or Objecting to a Subpoena

A Coast Guard investigating officer’s subpoena authority 

is well established, and compliance with a subpoena will 

not likely be an issue in the majority of cases. However, 

investigating officers should understand that compliance is 

When dealing with records, it’s a 

best practice to describe the soughtafter records in the greatest detail 

possible in the subpoena.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 33

example, if an IO located at Sector Northern New England 

subpoenas records of a company located in New Orleans, 

Louisiana, he or she (through the servicing legal office) 

would likely need to engage with the U.S. Attorney’s Office 

for the Eastern District of Louisiana. 

Under 46 USC §6304(b), a federal court has jurisdiction to 

judicially enforce a marine casualty subpoena. The IO must 

request that the court issue an order compelling the party to 

comply with the subpoena. A party’s refusal to comply with 

the court order may subject him or her to various sanctions, 

including contempt. 

If the appropriate U.S. attorney’s office agrees to support 

subpoena enforcement, the next step involves drafting and 

filing a petition for enforcement. The petition should be 

accompanied by a written declaration from the Coast Guard 

describing in detail: 

• the casualty,

• the Coast Guard’s role in the investigation, 

• the Coast Guard’s authority to conduct marine casualty 

investigations and issue subpoenas, and 

• details of the contested subpoena, including the manner 

of service and a description of the evidence or appearance being sought as well as the relevance to the investigation.

The investigating officer is the appropriate party to submit this declaration, and therefore should be prepared to 

provide all the above information. The IO’s servicing legal 

office and the INV-NCOE attorney can assist the officer with 

drafting this declaration. Additionally, the Investigations 

National Center of Expertise maintains previously filed 

petitions and declarations, which the IO and servicing legal 

office may review to prepare similar documents for their 

case.

The assistant U.S. attorney working on the case will then file 

the petition with the court and arrange for the petition to be 

served on the party. The party then must respond within 

21 days of service; however, a party may waive formal service to extend the response deadline to 60 days.4 The party 

will then file his or her answer within the specified time 

period, admitting or denying any allegations asserted in the 

petition and also stating any applicable defenses or objections to the subpoena.5

Following the answer, the government and party may 

engage in discovery, motions, preliminary hearings, or various other procedural matters to bring all necessary information before the court for consideration. Local federal court 

rules, which supplement the Federal Rules of Civil Procedure, may also affect this process.

During enforcement proceedings, the IO should be prepared 

to testify in support of the petition, providing information 

to supplement that provided in the declaration. This testimony may also include cross-examination by the opposing 

party. The servicing legal office and assistant U.S. attorney 

will help prepare the investigating officer before testifying. 

It is difficult to estimate how long the judicial enforcement 

process will last. The schedule will depend in part on the 

district court’s previously docketed cases, the judge’s availability, and the party’s and assistant U.S. attorney’s availability. While there may be an expedited process available, 

the applicability of that process will depend largely on 

the specific facts of each case. One recent successful judicial enforcement proceeding, using an expedited process, 

lasted approximately five months from the date the case was 

referred to the U.S. attorney until the date the judge issued 

an order requiring compliance with the subpoena.6

In Sum

Judicial enforcement of a subpoena can be a lengthy process 

requiring significant attention from the investigating officer and supporting Coast Guard and Department of Justice 

attorneys. However, if an item of evidence or an individual’s appearance is important enough to subpoena, then it is 

important enough to follow through with on the enforcement process. Therefore, IOs must ensure their subpoenas 

are enforceable before they are served, and they must be 

prepared to take the necessary steps to enforce every subpoena they issue. 

Coast Guard investigating officers may contact the attorney 

advisor at the INV-NCOE if they have any questions about 

subpoenas, enforcement, or other legal matters related to 

marine casualty investigations.

About the author: 

LCDR Damian Yemma is the attorney at the Investigations National Center 

of Expertise. He has served in the Coast Guard for 14 years, and his prior 

assignments include USCGC Sanibel, Sector Guam, the District Seven 

prevention staff, and the District Eight legal staff. He is a graduate of the 

University of Florida (B.S. in environmental science, 2000) as well as the 

College of William & Mary’s Marshall-Wythe School of Law (J.D., 2010).

Endnotes: 1. Note that the authority listed on the figure is specific to a marine casualty investigation. The authority for a suspension and revocation subpoena will read: 

“46 United States Code §7705 and 46 Code of Federal Regulations 5.301(b).”

2. The general rules governing those federal subpoenas are stated in Rule 45 of the 

Federal Rules of Civil Procedure (Fed. R. Civ. P.).

3. See www.justice.gov/usao/find-your-united-states-attorney for a breakdown of 

the federal judicial districts and corresponding U.S. Attorney’s Offices.

4. Fed. R. Civ. P. 12.

5. Fed. R. Civ. P. 8(b).

6. United States v. Pizzitola, 4:14-cv-02335 (S.D. Tx. Dec. 4, 2014) (order on motion for 

order to show cause).
34 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

environment. Suspension and revocation (S&R) proceedings 

are fundamental to achieving those goals. 

The rules, regulations, and processes involved in S&R proceedings help the Coast Guard administer oversight of mariner conduct where credentialed merchant mariners:

► have been negligent in their responsibilities;

► have acted beyond the scope of their credentials; 

► have been shown to have taken actions that are contrary 

to public safety, such as inappropriately or illegally 

using drugs and alcohol. 

The process helps to ensure that merchant mariners continue to possess and display the essential skills, experience, 

and character to safely operate in America’s maritime transportation system. 

The Genesis

In 2008, under the framework of the Coast Guard’s 2007 

Marine Safety Enhancement Plan, leadership established 

the Coast Guard’s Suspension and Revocation National Center of Expertise (S&R NCOE) to improve the professionalism 

and proficiency of the Coast Guard investigating officer (IO) 

workforce through direct support, oversight, and training. 

Shortly after its establishment, the S&R NCOE became recognized as the central repository of Coast Guard expertise 

and best practices associated with merchant mariner credential suspension and revocation. As such, it is well prepared and proactive in its mission to provide support to the 

people and units who carry out the suspension and revocation mission. The S&R NCOE does so throughout all stages 

of the process to ensure mission operations and activities 

are achieved within the spirit as well as the letter of the law 

and the marine safety program. 

The Coast Guard bears the enormous responsibility of 

ensuring that the 250,000-plus credentialed mariners operating on our nation’s navigable waterways are not only 

competent, but that their conduct promotes marine safety, 

ensures marine security, and protects the public and marine 

Promoting Professionalism 

and Proficiency

The Coast Guard’s Suspension and Revocation 

National Center of Expertise.

by LCDR YANCEE MCLEMORE

Program Manager, Suspension and Revocation 

U.S. Coast Guard Office of Marine Casualty Investigations and Analysis

Suspension and Revocation National Center of Expertise

Suspension & Revocation 

NCOE Functions

► Maintain programmatic expertise in the suspension and revocation process and administrative 

procedures.

► Serve as the eld’s primary liaison with the National 

Maritime Center on S&R-related issues that deal 

with medical and professional incompetence. 

► Provide Coast Guard investigating ocers with 

continual training opportunities on S&R procedures and hearing processes.

► Provide technical assistance with suspension and revocation hearing preparation and 

representation.

► Provide sector commanders with expert advice on 

contentious suspension and revocation cases.

► Provide Coast Guard investigating ocers with 

resources for review and assistance with document filing as well as general advice on case 

management. 
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 35

Located in Martinsburg, West Virginia, the S&R NCOE is 

conveniently housed within the Coast Guard’s National 

Maritime Center (NMC) building. The NMC site was chosen because of its direct association with merchant mariner 

credentialing, imparting a natural synergy to effectively 

and efficiently oversee mariner issues pertaining to S&R 

investigations and provide S&R NCOE staff with direct and 

immediate access to mariner record review and retrieval. 

Suspension and Revocation National Center of Expertise 

staff members are also able to easily coordinate with NMC 

personnel on issues ranging from medical fitness to criminal 

convictions — issues that could possibly preclude a mariner 

from obtaining or maintaining a credential. 

Personnel

The Suspension and Revocation NCOE is staffed by seven 

highly specialized personnel, including two active duty 

Coast Guard officers, three civilian personnel, and two 

dedicated attorneys. The attorneys work together to address 

numerous technical, complex, and often unique S&R issues, 

providing focused legal support to a corps of more than 

170 field investigating officers across the entire country and 

abroad. The staff helps to ensure that IOs interpret Coast 

Guard law and policies correctly and implement the S&R 

program consistently. In addition, the S&R NCOE has established a 24-hour call line to ensure that investigating officers nationwide have continual access to uniform, consistent 

guidance and legal advice. 

Furthermore, Suspension and Revocation National Center of Expertise staff members work closely with staffers 

in the Coast Guard headquarters Office of Investigations 

and Analysis as well as personnel from the Training Center 

Yorktown investigations school to develop, disseminate, and 

implement tools and techniques that help to enhance the 

knowledge and skill of IOs throughout the Coast Guard.

Training

One of the goals of the Suspension and Revocation NCOE is 

to build a corps of proficient, experienced, motivated, and 

competent IOs. To achieve that goal, investigating officers 

must receive continual training and education. S&R NCOE 

staffers have taken a step toward that goal by implementing a weekly investigating officer “roundtable” discussion forum to foster improved teamwork and partnership 

within the IO community and directly link the workforce 

with training coordinators and policymakers from all levels 

within the organization. 

The concept quickly flourished into a much-anticipated 

weekly event, often reaching 50-plus investigating officer 

participants. The forum serves to capture best practices 

and new policy documents while also offering immediate 

peer-to-peer communications. When emerging issues are 

identified, an agenda is developed and reference material 

is distributed to inform the IO community and improve 

overall competency. 

Moving Forward

The marine transportation system can only be as effective 

and dependable as its personnel, and maintaining a corps 

of capable, proficient merchant mariners can be a daunting 

task. Looking ahead, the Suspension and Revocation NCOE 

is positioned to provide even greater professional counsel 

and administrative assistance to Coast Guard investigating 

officers nationwide, providing real-time feedback and leveraging modern technology to deliver specialized, contemporary training on technical suspension and revocation issues. 

About the author: 

LCDR Yancee McLemore is the Suspension and Revocation program manager in the Office of Marine Casualty Investigations and Analysis. He began 

his marine safety career as a domestic vessel inspector and marine casualty 

investigator at Sector Los Angeles/Long Beach. Subsequent tours include 

chief of the investigations division at Sector Corpus Christi and investigating officer at the Suspension and Revocation National Center of Expertise in 

Martinsburg, West Virginia.

Vaeenma / iStock / Thinkstock
36 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

help improve the S&R process and administrative hearing 

procedures. The center is located in Martinsburg, West Virginia, and its attorneys and experienced investigating officers support S&R actions throughout the country. 

While IOs are primarily responsible for investigating cases, 

collecting facts, uncovering regulatory and legal violations, 

and preparing complaints, current Coast Guard policy 

mandates attorney participation in all S&R proceedings. In 

most cases, Coast Guard active duty or civilian attorneys 

from the S&R NCOE or servicing district legal office will 

typically start providing this support near the time of the 

investigation’s completion. These attorneys are involved in 

all prehearing matters, including prehearing conferences, 

motions and discovery practice, and witness preparation. 

Attorneys also participate with an IO in every suspension 

and revocation hearing. 

The Process

Similar in form to federal civil or criminal trial practice, a 

suspension and revocation hearing involves:

• an opening argument from the Coast Guard presenting 

witness testimony and other evidence to support allegations in the complaint, 

• direct and cross examination, 

• the respondent’s defenses or mitigating facts, and 

• a closing argument.2

Further, administrative law judges typically expect posttrial briefs, which Coast Guard attorneys also support. 

Additionally, S&R NCOE attorneys now write all appeal 

A suspension and revocation (S&R) proceeding is a legal 

mechanism by which the Coast Guard exercises authority over a mariner’s credentials. Subject to the Administrative Procedures Act, the S&R proceeding was originally 

designed to be a more efficient alternative to the federal 

court system. 

Coast Guard investigating officers, or IOs, are specifically 

trained and qualified to investigate alleged regulatory violations (such as negligence, incompetence, or drug use) that 

could affect a mariner’s ability to hold a Coast Guard-issued 

credential.1 For decades, Coast Guard IOs presented the 

government’s case, based on their investigations, at administrative hearings, effectively arguing for suspension or 

revocation of a mariner’s credential. Due to the administrative nature of the hearings, IOs often prepared and argued 

their cases without the assistance of a Coast Guard attorney. 

Legal Support

In recent years, however, S&R hearings have become 

increasingly complex and formalized. Administrative law 

judges (ALJs) have demanded stricter adherence to procedural and evidentiary rules, and respondents (mariners) 

have hired legal counsel or received free legal assistance 

from a growing list of attorney volunteers to defend S&R 

actions. Though most investigating officers receive case presentation training, these developments led the Coast Guard 

to realize a greater need to provide dedicated legal support 

for suspension and revocation cases.

In 2008, the Coast Guard established the Suspension and 

Revocation National Center of Expertise (S&R NCOE) to 

Service to the Mariner 

and the Public

Bringing Coast Guard attorneys into the S&R process.

by MR. BRIAN C. CROCKETT

Attorney

U.S. Coast Guard Suspension and Revocation National Center of Expertise 

LCDR DAMIAN YEMMA

Attorney

U.S. Coast Guard Investigations National Center of Expertise

Suspension and Revocation National Center of Expertise
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 37

briefs. Integrating attorneys into the process demonstrates 

the Coast Guard’s commitment to ensuring a mariner’s due 

process in suspension and revocation proceedings.

Complaints

For example, a Coast Guard attorney reviews each complaint before it is served upon the mariner. S&R NCOE 

personnel review the overwhelming majority of new complaints for legal sufficiency, factual support, and nationwide 

consistency. 

This provides two advantages: 

• First, the S&R NCOE personnel ensure that complaint 

allegations have sufficient factual and legal basis. This 

protects mariners from the financial and emotional 

toll of an unjustified suspension and revocation prosecution. It also reduces the Coast Guard’s exposure to 

potential Equal Access to Justice Act claims.3

• Second, this centralized review process ensures nationwide consistency in charging decisions as well as in 

the length of suspension or revocation requested. Prior 

to the policy, mariners in different locations who committed similar offenses could face dissimilar potential 

consequences. The S&R NCOE works to maintain consistency on a nationwide level, leading to greater fairness in S&R actions.

Attorneys also play a vital role in negotiating and crafting 

settlement agreements, as the involved attorney reviews, 

edits, and approves each agreement. This ensures that settlement agreements are legally sound and fair to mariners. 

The Results

Coast Guard attorney involvement in S&R cases also benefits the public, as credentialed mariners hold positions of 

great responsibility, including transporting essential, often 

hazardous cargo on the nation’s waterways. In cases where 

mariners use drugs, conduct negligent operations, or commit other violations, the Coast Guard must zealously pursue suspension or revocation of the mariner’s credential 

to remove them from that position of responsibility and 

protect the public health and well-being. 

By combining the Coast Guard attorney’s legal acumen and 

advocacy experience with the IO’s maritime investigations 

and regulatory enforcement experience, the Coast Guard 

creates teams that provide greater consistency and fairness 

to the mariner and maritime community, ultimately protecting the public.

About the authors:

Mr. Brian C. Crockett is an attorney at the Suspension and Revocation 

National Center of Expertise.

LCDR Damian Yemma is the attorney at the Investigations National Center 

of Expertise. He has served in the Coast Guard for 14 years, and his prior 

assignments include USCGC Sanibel, Sector Guam, District Seven prevention staff, and the District Eight legal staff. He is a graduate of the University 

of Florida (B.S. in environmental science, 2000) as well as the College of 

William & Mary’s Marshall-Wythe School of Law (J.D., 2010).

Endnotes: 1. See 46 USC §7703 and 46 CFR Part 5.

2. See 33 CFR Part 20 for the rules of practice, procedure, and evidence for formal 

administrative proceedings of the Coast Guard.

3. These claims may entitle a mariner to the recovery of attorney’s fees or related 

costs in a case where a Coast Guard complaint is dismissed, not substantially 

justified, and where the mariner meets other qualifying factors. See 49 CFR Part 6 

for Equal Access to Justice Act procedures and information.

Zerbor / iStock / Thinkstock
38 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

ALJs have decisional independence which enables them 

to review the evidence, find facts, and issue decisions free 

from any pressures the parties or officials within the agency 

might apply.3 To help ensure decisional independence, regulations prohibit agencies, including the Coast Guard, from 

controlling judges’ salaries, conducting performance evaluations on them, or providing monetary/honorary awards 

to judges.4

ALJs have decisional independence 

which enables them to review 

evidence, find facts, and issue decisions free from pressure from the 

parties or agency officials.

Because suspension and revocation proceedings are formal, 

judges expect an appropriate level of preparedness and professionalism throughout the process, similar to what a judge 

expects of professional counsel in state or federal court. 

The Players and the Process 

Administrative Law Judges

The Coast Guard is one of approximately 30 federal agencies 

administering laws that require civil administrative adjudication, and there are approximately 1,600 administrative 

law judges in the federal government. The Coast Guard has 

six judges, plus one chief judge. Experienced attorneys who 

wish to become a federal administrative law judge must 

undergo the Office of Personnel Management (OPM)’s competitive screening and qualification process, which involves 

documenting several years of experience in trials and hearings, securing letters of recommendation, passing a written 

examination, and going through structured interviews. 

Upon successfully completing the screening and qualification process, judicial candidates are placed on a register for 

ultimate appointment as administrative law judges. ALJs 

To promote safety at sea, Congress granted the Coast Guard 

authority to suspend or revoke merchant mariner credentials for acts of incompetence, misconduct, negligence, violations of law or regulation, or using dangerous drugs. The 

Coast Guard initiates nearly 600 suspension and revocation 

(S&R) cases each year, most of which are settled. 

Chapter 77 of Title 46 U.S. Code contains the legal authority 

for these proceedings, which requires that administrative 

law judges (ALJs) adjudicate them. These S&R proceedings 

are formal administrative actions that are similar to civil 

trials in state or federal court, but without a jury and with 

streamlined discovery and procedural rules to ensure a just, 

speedy, and inexpensive determination.1

The suspension and revocation process consists of formal 

proceedings prescribed within a framework of legally 

binding regulations and agency rulings. The Suspension 

and Revocation National Center of Expertise (S&R NCOE) 

ensures Coast Guard representatives understand S&R subject matter and possess appropriate advocacy skills.

The Proceedings

Coast Guard investigating officers (IOs) initiate S&R proceedings by serving a complaint on the mariner. ALJs rule 

on motions, hold pre-hearing conferences, issue subpoenas, 

and preside at hearings that involve written and oral testimony with the right of cross-examination. They also review 

briefs and issue written decisions. The parties may appeal 

the judge’s decision to the Commandant and the Commandant’s decision to the National Transportation Safety Board 

(NTSB). NTSB’s decision may be appealed to the appropriate 

Circuit Court of Appeals and ultimately to the U.S. Supreme 

Court. 

The Coast Guard always bears the burden of proving the 

complaint allegations by the preponderance of the evidence, 

and the administrative law judge must determine if the 

Coast Guard has met its burden.2

Raising the Bar 

How the S&R NCOE improves the S&R process.

by HON. WALTER BRUDZINSKI

Chief Administrative Law Judge 

U.S. Coast Guard 

Suspension and Revocation National Center of Expertise
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 39

receive special civil service protections and can 

expect a full career; that is, they are not termlimited. 

Coast Guard administrative law judges also 

function as the Department of Homeland 

Security’s administrative judiciary. They conduct formal proceedings in cases initiated by 

the department’s agency components, such as 

the Transportation Security Administration. 

As time and availability permit, Coast Guard 

judges also adjudicate cases for other agencies on a reimbursable basis to support OPM’s 

ALJ loan program.5 For example, Coast Guard 

judges helped the special master of the September 11th Victim Compensation Fund adjudicate 

claims. This type of assistance brings timely, 

cost-effective resolution to the requesting agency’s pending 

cases and broadens and enhances the Coast Guard judges’ 

analytical and adjudicatory skills.

Investigating Officers

Investigating officers traditionally represented the Coast 

Guard in suspension and revocation proceedings. While 

they were not required to be attorneys, formal S&R proceedings are adversarial, requiring the Coast Guard representative to exercise attorney-like trial advocacy skills as well as 

substantial suspension and revocation case law knowledge. 

Though the investigating officers were very well trained, 

some situations required knowledge, skills, and abilities 

they hadn’t yet had the opportunity to acquire, given the 

limited amount of time in the position, the press of other 

casualty investigations, and the infrequency of contested 

hearings. Despite the investigating officer’s advanced training and expertise, some legal situations develop during the 

proceedings that necessitate the appearance and participation of an attorney. The Coast Guard addressed this issue 

by having some attorneys serve on rotational tours as investigating officers and assigning attorneys from other commands on an “as needed” basis to litigate cases involving 

unique legal issues. 

Having attorneys serve on rotational tours as investigating 

officers and assigning attorneys from other commands on an 

“as-needed” basis addressed this issue, but there remained a 

growing, servicewide need for consistent and reliable S&R 

expertise. The S&R NCOE now meets that need. Since it 

has been in existence, investigating officers have had a consistent source of knowledge, skills, and abilities to draw 

from. An attorney from the Suspension and Revocation 

National Center of Expertise can provide comprehensive 

representation throughout the proceedings. Representation 

may include responding to pre-hearing motions, presenting 

evidence during the hearing before the administrative law 

judge, and/or preparing post-hearing and appellate briefs. 

When attorneys present S&R cases, they ensure the appropriate level of professionalism and preparedness for these 

formal, civil administrative proceedings. Their representation also promotes fairness, minimizes errors in law, and 

ensures cases are adjudicated in accordance with Congress’ 

intent.

Drafting Complaints 

Inadequately drafted complaints may require the time-consuming process of redrafting the allegations and issuing an 

amended complaint. Further, proposed sanctions may vary 

greatly, often resulting in widely different results imposed 

for the same offense. 

In response, the S&R NCOE now reviews complaints to 

ensure legal sufficiency and consistency in proposed sanctions. Clear and legally sufficient complaints drafted correctly and consistently the first time puts the respondent on 

notice of the proscribed conduct and provides a firm basis to 

prepare a defense. It also eliminates delays incurred amending the complaint and promotes consistency in sanctions. 

Consistent sanctions promote fairness. 

Case Presentation 

Presentations of evidence in hearings before administrative 

law judges reflect the degree of the investigating officer’s 

pre-hearing preparation and his/her level of S&R experience. Typically, investigating officers aren’t in their assignments for a period of time sufficient to obtain legal knowledge or gain adequate experience in prosecuting cases. With 

most cases being disposed of by settlement, a majority of 

investigating officers never get the opportunity to put on 

Chief Judge Brudzinski conducts a suspension and revocation hearing. Photo by 

Ms. Megan H. Allison, director of judicial administration, Office of the Chief Administrative 

Law Judge, U.S. Coast Guard.
40 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

services. Respondents are now advised that volunteer attorneys might be able to assist them and are referred to the ALJ 

program to contact a volunteer attorney in their state. With 

few exceptions, most respondents are now represented by 

counsel at S&R hearings. 

The S&R NCOE also benefits the 

Coast Guard by supporting a legal 

representation program for mariners of limited financial means.

In sum, the Suspension and Revocation National Center of 

Expertise has raised the quality of preparation and presentation to a level appropriate for formal proceedings, considering the mariner’s due process rights are paramount in 

these cases. The S&R NCOE has also promoted fairness in 

the process by supporting efforts for both parties to be represented by professional counsel. Finally, the S&R NCOE’s 

efforts provide greater transparency, which enhances the 

public’s understanding of maritime safety and security. 

Most importantly, it leads to greater public confidence in 

the fairness of the process. 

About the author: 

Chief Judge Brudzinski has published several articles concerning suspension 

and revocation. A former career prosecutor who was originally appointed 

administrative law judge in 1996, he holds a B.A. from the University of 

Maryland, a J.D. from George Mason University (with distinction), and a 

master’s and Ph.D. in judicial studies from the University of Nevada. 

Endnotes: 1. 33 CFR §20.103(a) (2014).

2. 33 CFR §§20.701 and 20.702 (2014).

3. See 5 USC §§554 and 556 (2012).

4. See 5 CFR §930.206 (2014).

5. 5 USC §3344 (2012) and 5 CFR §930.208 (2014).

evidence at a suspension and revocation hearing before an 

administrative law judge. 

Fortunately, S&R NCOE attorneys have experience in suspension and revocation litigation. Having experienced attorneys serve as the Coast Guard’s representative at S&R hearings has greatly improved the process. 

How the S&R NCOE Advances the Process 

The S&R NCOE has been instrumental in assisting the Coast 

Guard throughout the entire suspension and revocation 

process. For example, after completing the investigating officer’s course, IOs engage in periodic conference calls with the 

Suspension and Revocation National Center of Expertise, 

during which they’re briefed on the latest developments in 

ALJ decisions, Commandant decisions on appeal, and NTSB 

decisions, as well as other developments. As a result, Coast 

Guard representatives are better prepared for S&R litigation 

by being up to date with the latest case law.

The Suspension and Revocation National Center of Expertise also benefits the Coast Guard by supporting a legal 

representation program for mariners of limited financial 

means. The Office of the Chief Administrative Law Judge 

implemented this program to provide mariners with contact information of attorneys willing to provide no-cost or 

reduced-cost legal representation. At a recent Maritime Law 

Association (MLA) conference, member attorneys presented 

a mock S&R scenario in which S&R NCOE personnel represented the Coast Guard, the MLA attorneys represented 

the mariner, and Coast Guard judges presented the view 

from the bench. 

The MLA member attorneys helped initiate this program 

to encourage other member attorneys to learn more about 

suspension and revocation and perhaps volunteer their 
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 41

Prescription Drug Abuse 

on the Water

A growing problem.

by LT SARAH E. BRENNAN

Marine Investigator

U.S. Coast Guard Suspension & Revocation National Center of Expertise

CDR CHRISTOPHER F. COUTU

Chief

U.S. Coast Guard Suspension & Revocation National Center of Expertise

Suspension and Revocation National Center of Expertise

When a mariner uses dangerous drugs, Congress requires 

the Coast Guard to initiate suspension and revocation (S&R) 

proceedings against his or her merchant mariner credential 

(MMC). This authorizing statute states that the MMC shall 

be revoked unless the mariner provides satisfactory proof 

that he or she is “cured” of any addiction or current use.1

The authority is broad for a reason. Whether a mariner has 

a history of using drugs on or off the water, while on-duty 

or not, Congress means business when it comes to its vision 

of removing all drug users from the water.

The Coast Guard must only prove 

the mariner held a merchant mariner credential at the time of the drug 

use — not that the drug use occurred 

while the mariner was working.

Hence, at an S&R hearing, the Coast Guard must only prove 

the mariner held an MMC at the time of the drug use — not 

that the drug use occurred while the mariner was working 

or “acting under the authority of the credential,” in S&R parlance. More simply put, drug use off the water is as actionable as drug use on the water. 

It’s true: An individual who holds a merchant mariner credential is held to a higher professional standard than other 

nonlicensed professions, and is expected not to engage 

in any illicit activity involving illegal drugs at any time, 

whether on a vessel or on shore leave. 

The Coast Guard’s Authority to Test

The reason for the strict rule is simple: Drug use is not consistent with marine safety. Using drugs off the water is an 

indicator of drug use on the water, and Congress will not 

accept that risk. However, the statute does not apply to prescription drugs.2 But while the use of a prescription drug 

is not inherently illegal, using any controlled prescription 

Robtek / iStock / Thinkstock
42 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

(PCP), and amphetamines — during pre-employment 

screenings, via random testing throughout the year, after 

serious marine incidents, and whenever reasonable suspicion exists.4 The National Maritime Center also requires 

each mariner making an application or application for 

renewal to submit a recent urinalysis or “periodic” test.

Prescription Drugs

The Drug Enforcement Administration’s 2014 National Drug 

Threat Assessment reported that the annual economic cost 

of controlled prescription drug non-medical use (use beyond 

that of prescription) was more than $53 billion in 2011, with 

painkillers being the most commonly abused. It is clear that 

prescription drug abuse is gaining steam throughout our 

society, and this type of drug abuse has the potential to 

impair a mariner’s faculties to a greater extent than the recreational drugs identified and tested for in our regulations.

While the Coast Guard does not mandate testing for prescription drugs, marine employers certainly are wary of 

their abuse. In an effort to ensure vessel, cargo, and employee 

safety, as well as that of the marine environment, marine 

employers may implement their own testing requirements 

that go beyond what Coast Guard and Department of Transportation (DOT) regulations require.

Current regulations don’t require marine employers to 

report the results of non-DOT testing to the Coast Guard, 

which is disappointing to Coast Guard investigating officers 

and the S&R National Center of Expertise (S&R NCOE).5

They are just as interested in the results as marine employers and medical review officers (MROs) across the nation, 

and similarly concerned about the rising nature of these 

cases and the danger they present to marine safety. In 2014, 

marine employers voluntarily reported 54 cases of drug use 

to the Coast Guard that involved positive tests for drugs 

outside of traditional DOT screening.

You’re Busted

Those who abuse prescription drugs (take a controlled substance either without a prescription or beyond the bounds 

of prescribed use) are discovered several ways, and marine 

employers are the key. As part of a company policy, marine 

employers test after an injury, following a reportable marine 

casualty, or because a fellow crewmember or supervisor 

suspects a mariner may be operating under the influence. 

Frankly, a marine employer may choose to test for any reason, but whether the Coast Guard can use those test results 

for suspension and revocation actions depends on a number of factors, particularly if the mariner was provided fair 

notice of the testing requirements. Suspension and revocation action on non-DOT drug tests is generally permissible, 

drug without a prescription would still be considered “drug 

use.” Unfortunately, the Coast Guard has no mechanism in 

place to test for such illicit use at this time. 

Under current regulations,3 marine employers must test 

for five drugs — marijuana, cocaine, opiates, phencyclidine 

Prescription 

Drug-Related Incidents

Any discussion about prescription drug use on the waterways necessarily recalls major accidents stemming from 

their eects. In October 2003, the Staten Island Ferry allided 

with its pier, causing 11 fatalities and 71 injuries. Fatigue 

resulting from painkiller use is noted as contributing to the 

incident.

A Coast Guard small boat patrols in the Port of Oakland near the 

M/V Cosco Busan. Unified Command photo by Petty Officer Prentice 

Danner, U.S. Coast Guard.

In November 2007, the container ship Cosco Busan allided 

with the Oakland Bay Bridge, spilling more than 53,000 

gallons of fuel oil. The pilot’s use of impairing prescription 

medications is cited as one of the main incident causes.

Bibliography:

Report of investigation into the circumstances surrounding the incident 

involving allision/personnel casualties — Andrew J. Barberi on 10/15/2003.

Report of investigation into the allision of the Cosco Busan with the Delta 

Tower of the San Francisco-Oakland Bay Bridge on November 7, 2007.

The outside lower level of the Staten Island Ferry Andrew J. Barberi 

after it struck a pier, killing ten people. U.S. Coast Guard photo by 

Petty Officer Mike Hvozda.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 43

though the Coast Guard must look at the reasons for the 

test with great scrutiny and ensure the test was accurate 

and defendable. 

Currently, the S&R NCOE receives reports of non-DOT positive drug tests at a rate of two cases a week. As these are not 

mandatory reports, we must presume that the rate is higher 

to account for those positive reports handled by marine 

employers on their own. 

It’s unfortunate more marine employers haven’t shared 

non-DOT positive drug tests with the S&R NCOE. In some 

cases, the employer releases the mariner, who then seeks 

employment elsewhere. When the employer doesn’t report 

the case to the Coast Guard, we can’t establish a record, and 

the mariner receives a fresh start with a new employer who 

is left unaware of any prior or recent drug history.

Dealing with Dual Systems

Many cases of prescription drug use come to light via testing 

in tandem with Coast Guard-required testing. Since maritime companies recognize that the scope of the required test 

is limited, employers may also conduct their own “expanded 

panel” test at the same time. 

When done in this manner, companies must ensure that the 

DOT-required test is done first, before any other company 

test. There should be two different samples collected, with 

the first being the DOT sample, completed start to finish, 

before any other company-required test is initiated. Using 

a sample in a manner outside the scope of the regulations 

invalidates the results of the DOT test, and so the Coast 

Guard cannot use the test for S&R purposes.

The Coast Guard requires that marine employers test any 

crewmember directly involved in a serious marine incident, 

“serious” meaning involving any injury incurred requiring 

treatment beyond first aid. Some marine employers choose 

to conduct their expanded testing in those situations, as 

well. This makes good sense. Questioning the involvement 

of drug use is fundamental when determining whether an 

injury was caused by an employee’s own actions, and the 

required five-panel screen may not provide all the necessary 

information. 

Hospitals are a common source of non-DOT tests. When 

mariners are injured and crewmembers are sent to the hospital for care, the treating physician will often conduct further urine or blood testing. Positive results are sometimes 

reported back to the marine employers, then passed to the 

Coast Guard for potential action.

Contractors for large marine employers also may require an 

expanded panel drug test before the mariner is allowed to 

work. These closely resemble a pre-employment screen and 

are common in the Gulf of Mexico outer continental shelf, 

where companies contract offshore supply vessels and crew. 

While the Coast Guard doesn’t require testing in these situations, some marine employers mandate the tests on their 

own to minimize risk. 

How the S&R NCOE Can Help 

These examples provide evidence of industry-wide knowledge and concern for the abuse of drugs beyond those identified in the Coast Guard regulations — namely prescription 

drugs. When unprescribed controlled substances are found 

through expanded non-DOT testing, the Coast Guard can 

and will take action on the positive result if the test was 

conducted in a scientifically valid and reliable manner. 

The Coast Guard has jurisdictional authority under the drug 

use statute to take action against a merchant mariner credential when it receives a positive drug test and can show 

that the mariner has been a user of — or is addicted to — a 

dangerous drug. The Commandant has also provided guidance that specifically recognized that the Coast Guard may 

place in evidence facts (results of non-DOT drug tests) that 

tend to show drug use to prove the charge.6

However, we must carefully review the tests to be sure regulations have not been circumvented. At times, the S&R 

NCOE has rejected an investigating officer’s request to take 

action on a non-DOT positive test, as the test was either not 

collected in accordance with the marine employer’s own 

policy, or the test was taken in an effort to circumvent the 

regulations. 

About the authors:

LT Sarah E. Brennan is a 2003 graduate of Texas A&M University at 

Galveston with a degree in ocean and coastal resources. She also holds a 

master’s degree in environmental policy and management. She has served 

more than 11 years in the Coast Guard, most recently as an investigator at 

the Suspension & Revocation NCOE.

CDR Christopher F. Coutu is the chief of the Suspension and Revocation 

NCOE. He is a 1993 graduate of the University of Rhode Island and a 2001 

graduate of Suffolk University Law School. He has served for 13 years in the 

Coast Guard in legal and prevention positions. 

Endnotes: 1. See 46 USC §7704(c).

2. See 46 USC §7704 notes.

3. 46 CFR Part 16 Chemical Test regulations, 49 CFR Part 40.

4. See 46 CFR §16.113(b).

5. Marine employers are only required to report results from testing pursuant to 

Part 16.

6. See Franks (CDOA 2704).
44 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

When the threat of testing fails to deter mariners from dangerous drug use, it is anticipated such use will be exposed 

by this required testing. Consequently, Part 16 requires the 

marine employer or sponsoring organization to report to 

the Coast Guard in writing when a credentialed mariner 

fails a drug test. 

Failing a Test

When the Coast Guard receives such a report, an investigating officer (IO) commences an investigation. If the investigation yields evidence supporting drug use, the IO will initiate administrative actions against the mariner’s merchant 

mariner credential (MMC) by filing a complaint with the 

administrative law judge (ALJ) docketing center and serving 

it upon the mariner. 

The complaint will charge the mariner with use of or addiction to a dangerous drug, and will seek to either revoke the 

MMC, or the IO may offer a settlement agreement, allowing the mariner an opportunity to remediate the offense 

by proving cure. The matter will be assigned to an ALJ for 

a hearing if:

• the investigating officer chooses not to enter into a 

settlement agreement with the mariner (whom we will 

now refer to as the “respondent”), 

• the respondent declines a settlement agreement, 

• the respondent declines to voluntarily surrender the 

MMC. 

The Hearing

The administrative hearing is a trial-like proceeding where 

the Coast Guard always bears the burden of proof, which 

must be met by a preponderance of the evidence. In other 

words, the Coast Guard must establish that the allegations 

The U.S. Coast Guard has a duty to enforce laws that promote the safety of life and property at sea. Among other 

laws that aid in this effort, Congress enacted Title 46, United 

States Code (USC) §7704, to allow the Coast Guard to remove 

individuals who possess or use drugs from service in the 

U.S. Merchant Marine. Further, the Coast Guard established 

the regulations found in Title 46, Code of Federal Regulations (CFR) Part 16, which provide the means to minimize 

merchant mariners’ use of dangerous drugs and promote a 

drug-free and safe work environment. 

Drug Testing

The regulations set minimum standards for marine employer 

drug testing programs and require marine employers to 

conduct drug testing on four occasions: 

• pre-employment, 

• random, 

• after a serious marine incident (SMI), and 

• for reasonable cause.1

Bearing the Burden of Proof

The Suspension and Revocation NCOE 

brings drug users to justice.

by MR. ERIC A. BAUER

Senior Investigating Officer

U.S. Coast Guard Suspension and Revocation National Center of Expertise

LT SARA M. ELLIS-SANBORN

U.S. Coast Guard Atlantic Area

Suspension and Revocation National Center of Expertise

Jupiterimages / Stockbyte / Thinkstock
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 45

are more likely than not to have occurred. To do this, the 

Coast Guard must prove all of the required elements of the 

offense charged. 

If the Coast Guard successfully proves the jurisdictional and 

factual elements for use of or addiction to a dangerous drug, 

46 USC §7704 and 46 CFR §5.59 leave no discretion on sanction, making revocation of the MMC mandatory unless the 

respondent provides satisfactory proof of cure.

The Burden of Proof for a USCG-Mandated Drug Test

As with other court cases, meeting the burden of proof is 

easier said than done, and involves several elements.

Jurisdictional Element: First off, the Coast Guard must 

prove it has jurisdiction over the MMC. Administrative 

proceedings (also referred to as suspension and revocation 

[S&R] proceedings) are directed solely at merchant mariner credentials or endorsements — not against persons or 

property. 

In the case of drug use, jurisdiction exists if the respondent 

holds a valid MMC. To prove jurisdiction, the Coast Guard 

need only prove that the mariner was issued a merchant 

mariner credential, and that it is valid at the time of the 

hearing. If the mariner does not have a valid MMC, then 

nothing exists for the ALJ to issue an order of suspension 

or revocation against. Once jurisdiction is established, the 

Coast Guard then bears the burden of proving the factual 

elements of the offense by a preponderance of the evidence 

(more likely than not).

Factual Elements: Unless the Commandant, the National 

Transportation Safety Board, or the federal courts modify or 

reject them, Commandant decisions and the principles and 

policies enunciated in appeal decisions are binding upon all 

administrative law judges. 

Regarding appeal decisions,2 until recently, the Vice Commandant (by direction of the Commandant) has stated, “The 

Coast Guard may establish a prima facie case of illegal drug 

use by showing that:

(1) the respondent was tested for a dangerous drug, 

(2) the respondent tested positive for a dangerous drug, and 

(3) the test was conducted in accordance with 49 CFR 

Part 40.”3

To prove these three elements, the Coast Guard needs only 

evidence from the urine collector, the laboratory, and the 

medical review officer (MRO). 

However, in two recent appeal decisions, the Vice Commandant negated the results of the mariners’ failed chemical tests despite the Coast Guard proving the necessary 

elements. In Appeal Decision 2697, the Vice Commandant 

advanced previous appeal decisions by stating, “To establish a prima facie case of drug use based solely on a urinalysis 

test result, the Coast Guard must prove three elements: 

(1) that respondent was tested for a dangerous drug, 

(2) that respondent tested positive for a dangerous drug, 

and 

(3) that the test was conducted in accordance with 46 CFR 

Part 16.” 

With regard to Appeal Decision 2697, the Vice Commandant 

found, as previously noted, that the urinalysis test must have 

been conducted in accordance with 46 CFR Part 16, which 

requires that crewmembers selected for random drug testing be selected by a scientifically valid method. When randomness is at issue, if it is not shown that a respondent was 

Buena / iStock / Thinkstock

Administrative proceedings are 

directed at merchant mariner credentials or endorsements — not 

persons or property.

The administrative hearing is a triallike proceeding where the Coast 

Guard always bears the burden 

of proof, which must be met by a 

preponderance of the evidence.
46 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

the collector provides as evidence must prove he/she is 

properly trained and authorized to collect urine specimens 

for Department of Transportation drug testing. To do this, 

the Coast Guard need only produce documentation that the 

collector, at the time the specimen was collected, met all of 

the regulation’s requirements.6 The collector must also show 

that the mariner was properly identified. 

For example, the collector must see an original employer 

photo ID (other than in the case of an owner-operator or 

other self-employed individual) or a federal, state, or local 

government ID. Employer representative (not a co-worker 

or another employee being tested) positive identification 

is also acceptable. The preferred means of identification is 

viewing the MMC and/or Transportation Worker Identification Credential.

It is worth noting that the majority of drug use cases the 

Coast Guard loses are due to error(s) in the collection process.

The Respondent Failed the Test. The second element to 

prove is that the mariner tested positive or failed the drug 

test, which requires sub-elements also to be proved. To fail a 

chemical test for dangerous drugs per 46 CFR Part 16 means: 

• the result arose from a chemical test conducted in accordance with 49 CFR Part 40, and 

• a medical review officer reported it as “positive” because 

the chemical test indicated the presence of a dangerous 

drug at a level equal to or exceeding those established 

in 49 CFR Part 40. 

To prove this element, the Coast Guard leans slightly on the 

collector and heavily on the laboratory and medical review 

officer. The Coast Guard will offer the laboratory’s copy 

of the federal drug testing custody and control form (also 

referred to as the CCF) into evidence to show the chain of 

custody matches the collector’s copy, indicating the chain 

remained intact. 

Once this is established, the Coast Guard will ask the ALJ to 

take “official notice” of the current list of Health and Human 

Services-certified laboratories and instrumented initial testing facilities that meet minimum standards to engage in 

urine drug testing for federal agencies.7 This combined with 

the CCF should serve as proof the chemical test was conducted in accordance with 49 CFR Part 40.

The Coast Guard must then prove a medical review officer 

reported the results as “positive” because the chemical test 

indicated the presence of a dangerous drug at a level equal 

to or exceeding those established in 49 CFR Part 40. To this 

end, the Coast Guard will first prove the MRO’s qualification by entering into evidence his or her training certificates. 

selected for testing by a scientifically valid random method, 

the drug test has not been shown to have been conducted in 

accordance with 46 CFR Part 16 and one of the elements of 

a prima facie case has not been established.

Later, in Appeal Decision 2704, the Vice Commandant further clarified the statements in Appeal Decision 2697 concerning the three elements required for a prima facie case of 

drug use. In Appeal Decision 2704, the Vice Commandant 

held that a prima facie case of drug use is established when: 

(1) the respondent was the person who was tested for dangerous drugs, 

(2) the respondent failed the test, and 

(3) the test was conducted in accordance with 46 CFR Part 

16 (with the proviso that 46 CFR Part 16 incorporates by 

reference the regulations in 49 CFR Part 40). 

Under this rule, when the test was ordered pursuant to the 

regulations, but the justification for it is not consonant with 

the regulations, or the test is not conducted in accordance 

with 49 CFR Part 40 and is therefore unreliable, there is no 

prima facie case proved.4

The Vice Commandant explained the procedures in 46 CFR 

Part 16 were established not only to protect public safety 

interests, but also to ensure that mariners’ constitutional 

rights are safeguarded throughout the drug testing process. 

By expressly mandating limited, specific types of drug tests, 

the regulation drafters ensured that the constitutionally 

protected privacy interests of the mariner were balanced 

with the overriding need to ensure a drug-free and safe 

workplace. 

The drafters of 46 CFR Part 16 recognized that the Fourth 

Amendment (which protects against unreasonable searches 

and seizures) applies, and that private employers’ testing to 

comply with federal regulatory requirements constitutes 

government action.5 Hence, when the employer conducts 

tests in accordance with 46 CFR Part 16, the employer acts 

as an instrument or agent of the government. Therefore, it is 

vital that if a marine employer orders a mariner to submit to 

a drug test under the authority of 46 CFR Part 16, the reason 

for the test must be fully supported by 46 CFR Part 16. 

The Respondent Was the Person Who Was Tested for Dangerous Drugs. To prove the respondent was tested for a dangerous drug, the Coast Guard leans heavily on the urine 

collector’s training, actions during the collection process, 

documentation, and testimony concerning the proof of identity for the person providing the specimen. 

Since the chemical test must have been conducted in accordance with 49 CFR Part 40, the testimony and documentation 
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 47

Next, the Coast Guard must put into evidence further 

proof the chemical test was conducted in accordance with 

49 CFR Part 40. This is accomplished through the MRO’s 

testimony that the procedures of 49 CFR Part 40, Subpart 

G — Medical Review Officers and the Verification Process — were followed. The medical review officer is the 

independent and impartial “gatekeeper” and advocate 

for the accuracy and integrity of the drug testing process.8 The medical review officer’s testimony that the process outlined by 49 CFR Part 40, Subpart G, was followed 

should also serve as proof that the entire process was conducted in accordance with 49 CFR Part 40.

The Test Was Conducted in Accordance With 46 CFR 

Part 16 (With the Proviso That 46 CFR Part 16 Incorporates by Reference the Regulations in 49 CFR Part 40). 

For this element, the Coast Guard requires evidence and 

testimony from the marine employer to prove the test was 

conducted in accordance with 46 CFR Part 16. To accomplish this, the Coast Guard must present evidence that 

the test was required by the regulation as either a preemployment, random, serious marine incident, or reasonable cause drug test. 

Each of these tests requires different evidence from the 

marine employer.

• For a pre-employment test, the Coast Guard requires 

a copy of the mariner’s application for employment 

and the marine employer’s testimony to introduce the 

application into evidence and testify that the test was 

conducted pursuant to 46 CFR §16.210.

• For a random test, the Coast Guard needs evidence 

that the mariner was selected by a scientifically valid 

method (such as a random number table or a computerbased random number generator). The Coast Guard will 

also need testimony from the marine employer to enter 

the random selection into evidence as well as testimony 

that the test was, indeed, taken because of the random 

test regulation. 

• For a serious marine incident test,9 the Coast Guard 

needs testimony from the marine employer and to have 

the report of marine casualty and the report of required 

chemical drug and alcohol testing following a serious 

marine incident admitted as evidence, as well as testimony that the test was conducted because of the SMI.10

In addition, the Coast Guard may also require other 

evidence and/or additional testimony from the marine 

employer that the casualty was a serious marine incident (or the employer believed it was likely to become a 

serious marine incident) and to prove the mariner was 

directly involved in the casualty.

• For a reasonable cause test, the Coast Guard will need 

testimony and, if available, documentation as to why 

the marine employer (or their representative) believed 

the mariner had used a dangerous drug, as well as testimony that the test was conducted pursuant to the SMI 

Pros and Cons of Non-USCG 

Mandated Drug Testing

The Suspension and Revocation National Center of Expertise seeks to move forward with all reported positive marine 

employer drug tests. However, the first inquiry is how 

the marine employer conducted the test, whether it was 

conducted in an eort to circumvent 46 CFR Part 16, or if it 

was conducted in strict compliance with the marine employer’s drug testing policies. 

Pros

Marine employer tests typically 

capture information that the government-required test cannot. For 

example, they could detect prescription drugs and other drugs not speci-

cally tested for in a Part  16/Part  40 

Coast Guard test. 

If the marine employer takes the 

care, concern, and expense to ensure 

its workforce is drug-free, the Coast 

Guard can better direct its investigating ocer and attorney resources 

to ensure the mariner is rehabilitated 

or removed from the licensed community. 

Cons

There is no reporting requirement for marine employermandated tests, so if the marine employer does not report 

the positive test, the mariner is free to seek employment 

elsewhere without any form of cure or administrative action. 

Hence, while the mariner may be released from one employer’s roster, he enters another — and therefore there is no 

benet to the maritime community as a whole.

Please report your positive drug test results to your nearest 

Coast Guard sector or MSU. Coast Guard personnel will evaluate for potential remedial action. 

Carolina K. Smith, MD / iStock / Thinkstock

The majority of drug use cases the 

Coast Guard loses are due to errors 

in the collection process.
48 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

The Respondent Was Tested for a Dangerous Drug. The 

Coast Guard should first prove the urine collector is properly trained and authorized to collect urine specimens. If the 

collector is trained to the DOT drug-testing standard per 49 

CFR Part 40, Subpart C — Urine Collection Personnel, this is 

done in the same manner as a 46 CFR Part 16 case. The Coast 

Guard need only produce the collector’s training certificates 

or training records. 

If the collector is not trained to the DOT drug-testing standard, the Coast Guard will need to prove the collection was 

conducted in substantial compliance with 49 CFR Part 40, 

Subpart C, by whatever documentation and testimony is 

available, including the drug testing custody and control 

form. 

It is important to note that 49 CFR §40.47 prohibits using 

CCFs for non-federal urine collections. The Coast Guard 

must also prove that the collector affirmatively identified 

the mariner by whatever means possible, preferably in substantial compliance with Part 40 rules. 

The Respondent Tested Positive for a Dangerous Drug. Just 

as when proving this element for a USCG-mandated chemical test, the Coast Guard leans heavily on the laboratory and 

MRO to prove this element for a marine employer-mandated 

chemical test. 

Since the testing is not necessarily in compliance with 46 

CFR Part 16, the meaning of “to fail a chemical test for 

dangerous drugs” has an altered meaning. In a marine 

employer-mandated test the Coast Guard will need to prove: 

• the chemical test analysis was conducted in substantial 

compliance with 49 CFR Part 40, and 

• an MRO reported the result as “positive” because the 

chemical test indicated the presence of a dangerous 

drug at a level equal to or exceeding those established 

in 49 CFR Part 40.

The Coast Guard will introduce and offer into evidence 

the laboratory’s copy of the CCF to show that the chain of 

custody matches the collector’s copy, indicating the chain 

remained intact. 

Again, once it is established that the chain of custody 

remained intact, the Coast Guard will ask the ALJ to take 

“official notice” of the current list of Health and Human 

Services-certified laboratories and instrumented initial testing facilities that meet minimum standards to engage in 

urine drug testing for federal agencies.

However, if the laboratory is not approved, then the Coast 

Guard must establish that the science used to analyze the 

specimen is reliable and probative of drug use. Unlike 

testing requirement (46 CFR §16.250). This evidence must 

be reasonable, articulable, and based on direct observation of specific, contemporaneous physical, behavioral, 

or performance indicators of probable use. Where practicable, this belief should be based on the observation of 

the individual by two persons in supervisory positions.

The Burden of Proof for a Non-USCG Drug Test

The aforementioned appeal decisions 2697 and 2704 not only 

lay out the course for proving a charge of use of a dangerous 

drug based on a USCG-mandated chemical test, they also 

open the door to proving a charge of drug use based on a 

marine employer-mandated chemical test. Appeal Decision 

2704 stated that, for these tests: 

• the employer is not acting as an instrument or agent of 

the government, 

• the constitutional harms that Part 16 seeks to avoid are 

absent, and 

• the Coast Guard may place in evidence facts that tend to 

show drug use in order to prove a charge in accordance 

with 46 CFR §5.35. 11

Jurisdictional Element: For a marine employer-mandated 

chemical test, the jurisdictional elements are identical to 

those for a USCG-mandated chemical test. To prove jurisdiction, the Coast Guard need only prove that the mariner was 

issued an MMC and it is valid at the time of the hearing. 

Factual Elements: Proving the first two factual elements for 

a marine employer-mandated chemical test is very similar 

to proving those elements for a USCG-mandated chemical 

test.

The Coast Guard supports this law 

[46 USC §7704] through its suspension and revocation program, where 

investigating officers work diligently to determine the best means 

for moving forward when notified of 

a failed drug test. 

With the cooperation of marine 

employers who also desire to promote marine safety, the Coast Guard 

is able to ensure a safer day at sea 

for all.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 49

proving a USCG-mandated chemical test, the Coast Guard 

will require the testimony of the laboratory’s certifying scientist and/or a laboratory litigation package to prove the 

laboratory processes samples in substantial accordance with 

the requirements of 49 CFR Part 40.12 This testimony and 

evidence, combined with the CCFs, should serve as proof 

that the chemical test was conducted in substantial accordance with 49 CFR Part 40 or the science is reliable and probative.

The Coast Guard must then prove that a medical review 

officer reported the results as “positive” because the chemical test indicated the presence of a dangerous drug at a level 

equal to or exceeding those established in 49 CFR Part 40. 

To this end, the Coast Guard will first prove the MRO’s 

qualification by entering into evidence his or her training 

certificates. 

Next, the Coast Guard must put into evidence further proof 

that the chemical test was conducted in substantial accordance with 49 CFR Part 40. This is accomplished through 

MRO testimony that the procedures of 49 CFR Part 40, 

Subpart G, were followed and that the medical review officer — as the independent and impartial gatekeeper and 

advocate for the accuracy and integrity of the drug testing process — affirms that the process outlined by 49 CFR 

Part 40, Subpart G, was followed. 

The Test Was Conducted in Accordance With the Marine 

Employer’s Policy. For a marine employer-mandated test, 

the Coast Guard requires:

• testimony from the employer regarding the policy,

• a copy of the marine employer’s drug testing policy, 

• proof that the mariner knew of this policy prior to the 

marine employer drug test, and 

• that the mariner understood the test was pursuant to 

the marine employer’s policy and not 46 CFR Part 16. 

In Sum

When Congress enacted 46 USC §7704 with the intent of promoting the safety of life and property at sea, it recognized 

the threat posed by merchant mariners who use or possess drugs and the necessity to remove them from service. 

The Coast Guard supports this law through its suspension 

and revocation program, where investigating officers work 

diligently to determine the best means for moving forward 

when notified of a failed drug test. 

With the cooperation of marine employers who also desire 

to promote marine safety, the Coast Guard is able to ensure 

a safer day at sea for all.

About the authors: 

Mr. Eric A. Bauer retired from Coast Guard active duty in 2006. During his 

career, he served two tours as a senior investigating officer, as well as tours 

as assistant chief and chief of regional examination centers. He was also a 

senior marine inspector. He has served as the senior investigating officer at 

the Suspension and Revocation National Center of Expertise since 2009. 

LT Sara M. Ellis-Sanborn earned her commission in 2003. After a Coast 

Guard headquarters tour, she was assigned to Sector New Orleans, where 

she earned qualifications as a marine inspector. She then served as chief of the 

Inspections and Investigations Division at Marine Safety Unit Cleveland 

before completing a year of industry training. LT Ellis-Sanborn reported to 

Atlantic Area in 2012.

Endnotes:

1. Although periodic testing requirements are included in 46 CFR Part 16, the marine 

employer plays no role in periodic testing. The requirements for periodic testing 

rest solely upon an applicant, who must pass a chemical test for dangerous drugs 

when executing a merchant mariner credential transaction, as required by 46 CFR 

§§10.225(b)(5), 10.227(d)(5), and 10.231(c)(6).

2. All appeal decisions cited in this article can be found at www.uscg.mil/

Legal/CDOA/Commandant_Decisions/S_and_R_2580_2879/COMDT_S_

and_R_2580_2879.asp.

3. See 49 CFR Part 40.

4. The Vice Commandant footnotes this passage with, “In the absence of the presumption and the associated prima facie elements, as noted in section II of this 

opinion, it is still possible to prove the use of dangerous drugs, but any drug test 

used in such a case must be a non-Part 16 test.”

5. See the Fourth Amendment at https://www.law.cornell.edu/constitution/fourth_

amendment.

6. This can usually be accomplished by entering into evidence a copy of the collector’s training certificates or training records, as described, and a copy of the 

federal drug testing custody and control form.

7. See the Substance Abuse and Mental Health Services Administration, HHS (SAMHSA) website at www.samhsa.gov/workplace/lab-list.

8. As such, “...the laboratory report itself, once it [is] signed by the MRO, [constitutes] 

proof adequate to shift to [the mariner] the burden of going forward with evidence 

that the positive finding of [dangerous drugs] metabolites in [the mariner’s] urine 

was not the product of a wrongful use of the drug.” National Transportation 

Safety Board in KIME v. SWEENEY (Docket ME-155). 

9. 46 CFR 4.03-2 defines a serious marine incident.

10. See CG-2692 (Report of Marine Casualty) at https://www.uscg.mil/forms/cg/

CG_2692.pdf. See CG-2692B (Report of Required Chemical Drug and Alcohol 

Testing Following a Serious Marine Incident) at https://www.uscg.mil/forms/

cg/CG_2692B.pdf.

11. See, e.g., Appeal Decision 2675 (MILLS)(2008) (Part 16 testing requirements are 

the “minimum standards, procedures, and means to be used to test for the use of 

dangerous drugs,” 46 CFR §16.101(b), and a marine employer may require further 

drug testing under its own rules). The Vice Commandant adds to this opinion a 

footnote stating that, “A complaint based on an alleged employer-required test 

independent of [46 CFR] Part 16 should be subjected to close scrutiny to ensure 

that [46 CFR] Part 16 has not been circumvented.”

12. See Decision & Order in USCG v. DAIRE; Docket Number CG S&R 08-0231.
50 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

employment would violate the rule. This is a change, as 

prior to January 24, 2014, U.S. mariner medical certification 

was embedded in the MMC and separate certificates were 

not issued — that is, holding an MMC was evidence that the 

mariner was medically qualified to hold the credential. 

While it is always the responsibility of the mariner to operate in accordance with his/her credential as endorsed and 

within any applied restrictions, the marine employer must 

verify that their mariners hold valid and current medical 

certificates. As the medical certificate now separately verifies fitness, it allows the employers to easily inspect and 

ensure it is valid. With regard to suspension and revocation, 

a marine employer’s failure to inspect the certificate does 

not relieve the mariner of any S&R action. The burden of 

ensuring a valid MMC and medical certificate lies with the 

mariner, who must not work under the authority of the credential unless he or she also holds a valid medical certificate. 

Resolution of Confusion

To qualify for a medical certificate, a mariner must provide 

evidence of meeting the medical and physical standards 

on form CG-719-K or CG-719-K/E, as appropriate. Once the 

National Maritime Center receives the form, NMC medical staff evaluate it to determine whether the mariner is 

medically and physically qualified as described in 46 CFR 

10.302(a). When the Coast Guard determines a merchant 

mariner meets the medical and physical evaluation standards (with or without a waiver and/or limitations), the 

NMC will issue a medical certificate. 

Other than for STCW-endorsed mariners, this will normally 

be done through the course of an MMC transaction, such 

as an original application, renewal, or raise in grade. The 

NMC medical staff may request additional information 

The National Maritime Center (NMC) has been evaluating and issuing medical certificates since January 24, 2014. 

As recent regulations require mariners serving on vessels 

transiting on international voyages to have a valid medical 

certificate by January 1, 2017, and all credentialed mariners 

to hold a valid medical certificate by 2019,1 these certificates 

show that the holders meet the medical and physical standards required. 

The NMC has identified those mariners that these regulations apply to, and the Coast Guard has already begun 

issuing medical certificates to those individuals. As with 

all changes to the credentialing process, there is a potential 

impact upon any suspension and revocation (S&R) action 

that might be taken against the underlying merchant mariner credential (MMC). 

The Process

For example, in 2014, without further application, the NMC 

began proactively issuing medical certificates to mariners 

who held a valid International Convention on Standards 

of Training, Certification and Watchkeeping for Seafarers 

(STCW) endorsement to minimize foreign port state control actions against U.S. vessels, reduce the administrative 

burden, and facilitate international commerce. For all other 

mariners, the Coast Guard issues a medical certificate to 

each qualified mariner after processing an application that 

requires a medical evaluation, such as issuing an original, 

raise-in-grade, or renewal MMC.2

Maintaining a current medical certificate along with the 

MMC is required of all mariners in positions that require 

a merchant mariner credential.3 This brings medical fitness 

front and center, as marine employers are required to ensure 

the mariner holds a current medical certificate. Without it, 

Medical Certificates 

The purpose, the process, and the pitfalls.

by LT SARAH E. BRENNAN

Marine Investigator

U.S. Coast Guard Suspension and Revocation National Center of Expertise

CDR CHRISTOPHER F. COUTU

Chief

U.S. Coast Guard Suspension & Revocation National Center of Expertise

Suspension and Revocation National Center of Expertise
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 51

from the mariner to determine if he or she is qualified for the medical certificate, and if not, the NMC 

will deny the medical certificate. Once the mariner 

has received the medical certificate, he or she must 

carry it with the merchant mariner credential at 

all times.4 The mariner should be ready to present 

the certificate along with the credential during any 

Coast Guard inspection or investigation. 

Further, the medical certificate is valid for varying amounts of time, based on the type of vessel 

on which the mariner serves. If the mariner serves 

aboard vessels to which STCW applies, the medical 

certificate is valid for up to two years, unless the 

mariner is under the age of 18, in which case the maximum 

period of validity would be one year. For those mariners 

serving as a first-class pilot, the maximum period of validity is two years, and for all other mariners, the maximum 

period is five years. 

Finally, mariners who receive a waiver of certain medical 

conditions may receive time-limited certificates, which 

expire in one or two years, depending on the condition. 

Additionally, mariners must comply with the terms of the 

waiver to renew their certificates. This time-limited medical certificate eliminates S&R action on mariners who are 

noncompliant with the previous rules’ waivers. As medical 

fitness was embedded in the former MMCs, those mariners with a medical waiver were obliged to comply with 

its terms, including providing the annual information to 

the NMC. 

However, once issued, the National Maritime Center had 

no administrative mechanism to void or revoke the waivers when necessary. In such cases, the Coast Guard’s only 

recourse was through suspension and revocation action, as 

a mariner operating outside the scope of the medical waiver 

could be sanctioned for misconduct. The Suspension and 

Revocation National Center of Expertise (S&R NCOE), colocated with the NMC, maintained a list of thousands of 

mariners who had difficulty complying with a waiver’s 

terms. Now, with time-limited medical certificates and the 

self-enforcing mechanism that requires a valid certificate to 

accompany the merchant mariner credential, this removes 

the need for suspension and revocation action to compel 

waiver compliance. 

Medical Disqualication 

Regardless of whether a mariner holds a valid medical certificate for one, two, or five years, medical conditions may 

arise during that time frame that could render the mariner 

unfit. If a mariner is on a time-limited medical certificate 

issued due to an existing condition, he/she may have an 

obligation to report a change in the medical condition. If, 

however, a mariner experiences a new condition, there is no 

such reporting obligation. 

However, the Coast Guard learns of new conditions through 

a variety of sources. The NMC may receive medical information from marine employers, Coast Guard investigating officers, and from mariners themselves who are self-reporting. 

For example, during the course of a Coast Guard investigation, investigating officers (IOs) may learn of a medical condition concerning one of the operators. When this happens, 

they forward any relevant medical information to the NMC 

medical staff for review. The National Maritime Center staff 

reviews the information as a new or changed condition and 

then works with the S&R NCOE to advise the Coast Guard 

IO.

In some instances, the NMC requires further medical information to make a more informed decision. In the aforementioned case, the S&R NCOE would work with the local investigating officer to fashion a request for more information via 

a phone call, email, or administrative subpoena. Once the 

National Maritime Center personnel have the information 

necessary to determine the mariner’s fitness, they refer the 

matter to the S&R NCOE for possible suspension and revocation action. 

S&R Investigation and Action

The S&R NCOE has investigating officers on staff who may 

represent the National Maritime Center officer in charge of 

marine inspection in cases throughout the country. While 

the NCOE exercises this authority at times, the preferred 

course of action is to work in partnership with a local investigating officer. 

The S&R NCOE investigating officer team as well as the 

local unit may investigate the mariner to determine whether 

he/she had knowledge of his or her condition before operating under the authority of the credential. If not, then the IO 

Image courtesy of the U.S. Coast Guard National Maritime Center.
52 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

information to the S&R NCOE for review with the National 

Maritime Center medical staff. The S&R NCOE then works 

with the mariner or a local Coast Guard investigating officer 

to issue notice to the mariner (if the mariner was not aware 

of his or her disqualifying condition). 

If they determine that the mariner is no longer qualified to 

hold a medical certificate, the mariner would be informed of 

such and subsequently informed that he or she should not 

operate under the authority of the credential until the medical condition is resolved. Note the credential is not revoked 

or suspended here — only after the mariner operates under 

the authority of the credential, after receiving notice of his or 

her fitness status, would the Coast Guard have jurisdiction 

to pursue suspension and revocation.

Medical certificates clarify the rules of enforcement for 

medical fitness for the Coast Guard as well as the mariner. 

Further, the new rules place much of the burden on marine 

employers, as mariners cannot be employed without the 

certificate. Therefore, mariners are either fit to operate (and 

have a medical certificate), or they are not (and do not have 

the certificate to accompany their MMC). This should reduce 

the Coast Guard’s S&R enforcement efforts in this area. 

About the authors:

LT Sarah E. Brennan is a 2003 graduate of Texas A&M University at 

Galveston with a degree in ocean and coastal resources. She also holds a 

master’s degree in environmental policy and management. She has served 

more than 11 years in the Coast Guard, most recently as an investigator at 

the Suspension & Revocation NCOE.

CDR Christopher F. Coutu is the chief of the Suspension and Revocation 

NCOE. He is a 1993 graduate of the University of Rhode Island and a 2001 

graduate of Suffolk University Law School. He has served for 13 years in the 

Coast Guard in legal and prevention positions.

Endnotes: 1. The Final Rule on the Implementation of the Amendments to the International 

Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, and Changes to National Endorsements.

2. See NVIC 1-14.

3. See 46 CFR 15.401(c).

4. See 46 CFR 15.401(d).

5. See 46 U.S.C. 7703(4) and 46 C.F.R. §5.31.

6. See Appeal Decision 2705 (PLENDER) (2014).

would notify the mariner that the medical condition is disqualifying, and that operating a vessel under the authority 

of the credential could be deemed medical incompetence. 

The IOs must determine whether the mariner continued to 

operate after receiving notice. If so, it is the Coast Guard’s 

responsibility to take action. Simply waiting for credential 

renewal to allow the NMC medical staff to review any new 

medical information is to accept a level of risk that is unnecessary. The Coast Guard is compelled to take action in such 

cases to prevent a casualty from occurring. 

Medical Fitness S&R Enforcement 

Currently, the only way to remove a medically unfit mariner 

from the waterway is via the S&R process. The Coast Guard 

takes action against the credential — not the medical certificate — and can suspend or revoke the merchant mariner 

credential if the holder is found incompetent to operate a 

vessel. For our purposes, incompetence is defined as “the 

inability on the part of a person to perform required duties, 

whether due to professional deficiencies, physical disability, 

mental incapacity, or any combination thereof.”5

Further, on October 1, 2014, the Vice Commandant released 

a decision on appeal that affirmed a previous administrative 

law judge (ALJ) decision to revoke a mariner’s credential 

based on medical fitness.6 The decision defined when an 

act of medical incompetence becomes actionable for S&R 

purposes: The act must relate to the operation of a vessel, 

and for medical incompetence, the mariner must operate 

under the authority of the credential while medically unfit. 

In other words, a mariner will not lose his credential if he is 

deemed unfit but chooses not to operate. Being unfit, in and 

of itself, will not give rise to an S&R proceeding. 

Additionally, for the Coast Guard to seek MMC suspension 

or revocation for medical incompetence, the mariner would 

first have to have a disqualifying medical condition, be notified that that condition is in fact disqualifying, and then 

continue to operate under the authority of that credential 

despite the notice.

There are several ways that a potentially disqualifying medical condition will present itself to the Coast Guard — most 

typically, by way of the application process. Prior to the 

National Maritime Center’s existence, investigating officers 

would make this determination. Now, with the NMC’s team 

of medical review officers, IOs have a resource available to 

help make informed decisions regarding mariner fitness. 

If a potentially disqualifying medical condition is discovered 

during a personnel investigation, investigators forward the 

For more information:

For detailed information regarding medical 

waivers, see NVIC 01-14 and the NMC 

website at www.uscg.mil/nmc/medical/

medical_cert.asp.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 53

For the newly minted merchant mariner, the notion of having your merchant mariner credential (MMC) suspended 

or revoked can be very upsetting. Discussions with fellow 

mariners, even those never subject to a suspension and 

revocation (S&R) proceeding, may conjure up frightening 

scenarios. Even well-seasoned mariners with decades of service may readily blanch when confronted by a Coast Guard 

investigating officer (IO) who may simply be gathering preliminary information relevant to a recent marine casualty. 

We’ll be setting these horror stories aside for now, so we can 

part the curtain of dread, uncertainty, and astonishment 

that has colored the S&R process and cut to the facts: Plain 

and simple, the Suspension and Revocation National Center 

of Expertise (S&R NCOE) helps maintain the standards for 

professional conduct and mariner competency. We attempt 

to seamlessly increase the quality and professionalism of 

the S&R process, all the while remembering the statutory 

intent — promoting safety at sea. 

The Beginning

The Coast Guard’s suspension and revocation enforcement 

system began after the nation and Congress witnessed 

horrible maritime incidents on U.S. waters over hundreds 

of years. Legislation enacted in the late 1800s created the 

Steamboat Inspection Service, which could grant and revoke 

pilot, engineer, master, and chief mate licenses.1 After a 

succession of shifts and changes for the law and the Coast 

Guard, safety at sea still drives the current statutory and 

regulatory provisions that drive the suspension and revocation process. 

Remedial vs. Penal

While the sanctions resulting from S&R enforcement actions 

do not involve monetary fines or jail time, for someone who 

earns a living as a mariner, losing a credential — even if 

only for a short time — can be devastating. Suspension and 

revocation enforcement sanctions span a continuum that 

runs from dismissal (if the case is not proved) to revocation, 

at the highest end. Once a credential is revoked, it may only 

be re-issued under very limited conditions.2

Title 46 United States Code §§7703 and 7704 provide the 

backdrop of offenses Congress has approved where the 

Coast Guard may suspend or revoke a merchant mariner 

credential. By law, certain offenses are actionable only when 

the Coast Guard can prove that the mariner was “acting 

under the authority” of the credential at the time of the 

offense; for others, the mariner must only be a “holder of” a 

credential to be subject to S&R. 

Lesser-known offenses are also applicable to mariners, such 

as incompetence, convictions, or driving under the influence 

(DUI) charges. The consequences arising from such offenses 

can blindside a mariner and cause the loss of an MMC. 

“Holder of” Oenses

The law allows for S&R action when the mariner is simply a “holder” when that mariner is convicted of an offense 

that would prevent issuing or renewing a license. Examples 

include homicide, assault, robbery, destruction of property, 

burglary, and larceny.3

Since the Coast Guard National Maritime Center (NMC) 

serves as an applicant’s adjudicator regarding convictions 

that prevent issuing or renewing credentials, NMC personnel decide if criminal convictions falling outside those specifically identified in regulations will affect the credential. 

It is not uncommon to issue a complaint against a mariner 

who was convicted of a land-based offense such as assault 

or damage to property. 

Since the ultimate purpose of suspension and revocation is 

safety at sea, it makes sound marine safety sense to suspend 

or revoke a merchant mariner credential for offenses that 

Mariners Can Lose Credentials 

for What?

Navigating through suspension and revocation. 

by MR. JAMES P. FINK

National Technical Advisor 

U.S. Coast Guard Suspension and Revocation National Center of Expertise

Suspension and Revocation National Center of Expertise
54 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

focuses upon a mariner’s Transportation Worker Identification Credential (TWIC). The regulations at 46 CFR Part 10 

state, in part, that if the Transportation Security Administration advises the Coast Guard that a mariner has either 

been denied a TWIC or the TWIC has been revoked, the 

Coast Guard may initiate suspension and revocation action 

against the mariner’s MMC.7

Drug Convictions: If a mariner is convicted of violating a 

dangerous drug law, his or her credential will be suspended 

or revoked.8 Further, Congress has authorized the Coast 

Guard to reach back 10 years for these convictions. 

Interestingly, the term “convicted” is not limited to felonies, 

misdemeanors, or NDRA offenses — it is more complex. By 

regulation, the Coast Guard expands convictions to include 

such things as expungements, deferred adjudications, courtmandated classes, judicially enforced contributions, judicially mandated treatment, probation, or supervision. By 

expanding the definition, we can address the underlying 

behavior. 

“Acting Under the Authority” Oenses

“Acting under the authority” means:

• the credential is required by law or regulation for vessel 

operation, and 

• the employer requires the merchant mariner credential 

as a condition of the mariner’s employment. 

Other means of acting under the authority of the MMC 

include when the mariner is engaged in official matters 

regarding the credential, including but not limited to: 

• applying for renewal, 

• taking exams for raise of grade, 

• requesting duplicate or replacement credentials, 

• appearing at a suspension and revocation hearing, 

• responding to Coast Guard subpoenas during marine 

casualty or personnel action investigations, or

• taking a Coast Guard-required drug test. 

Additionally, a person is still acting under the authority of a 

credential while on shore leave from the vessel. 

Violation of a Marine Safety Rule: Violation of a marine 

safety statute or regulation requires that a mariner must 

have been acting under the authority of the MMC to initiate 

suspension and revocation enforcement. The regulations 

also require that the complaint state the specific statute or 

regulation by title, section number, and the particular manner in which it was allegedly violated. 

This offense designation covers a wide swath of laws and 

rules, but complaints alleging these accounted for less than 

otherwise would have prevented its issuance in the first 

place during the application phase. 

Driving Offenses: The S&R statute provides for action 

when a mariner is convicted of an offense described by the 

National Driver Register Act (NDRA), such as driving under 

the influence, reckless driving, racing on the highways, traffic violations connected with a fatal traffic accident, or other 

comparable offenses.4 The conviction must have occurred 

within three years before the S&R complaint is filed. 

Recently, various U.S. state jurisdictions have reclassified 

some convictions that would normally be cited within the 

NDRA. To accomplish this, local courts may label a DUI 

conviction as “obstructing highway or other passageway,” 

which is not an NDRA conviction for the purposes of S&R 

enforcement.5 This results in disparate treatment of mariners, as a mariner who received a DUI may very likely face 

suspension and revocation action, while another mariner 

who also drove while intoxicated might not face S&R for 

receiving an “obstructing the highway” conviction. Therefore, the S&R NCOE works with prosecutors and state jurisdictions to inform them of these types of consequences.

Incompetence: The S&R statute allows action if the holder 

is incompetent with regard to vessel operation. The complementary regulation, 46 CFR §5.31, defines incompetence as 

“the inability on the part of a person to perform required 

duties, whether due to professional deficiencies, physical 

disability, mental incapacity, or any combination thereof.” 

Unfit mariner citations constitute just a sliver of the hundreds of Coast Guard-filed complaints each year, but due 

to their complexity (they are more complex for suspension 

and revocation than most all other offenses), they tend to be 

very controversial.6

For the most part, the S&R NCOE has taken the lead in pursuing these types of cases, shouldering the burden of complexity with the advantage of its co-location at the NMC, 

which has its own medical division. Most notable “unfit” 

cases deal with mariners treated for sudden seizures. In and 

of itself, a seizure or any other debilitating medical condition is not enough to have a merchant mariner credential 

suspended or revoked, but if the mariner operates under 

the authority of the merchant mariner credential after being 

notified by the Coast Guard or a doctor, the Coast Guard will 

take suspension and revocation action. Therefore, receiving 

notice that you cannot operate due to a medical condition is 

(or should be) as effective as any S&R. 

Security Risks: The S&R statute permits action if the mariner is a security risk who threatens the safety or security of a 

vessel or a public or commercial structure. This section was 

added after September 11, 2001, for obvious reasons, and 
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 55

5 percent of filings in 2014.9 Sanctions for this category normally range from one to three months of suspension.

Misconduct and Negligence: S&R action is applicable if the 

mariner, when acting under the authority of the credential, 

commits an act of misconduct or negligence. 

Misconduct is defined as “human behavior which violates 

some formal, duly established rule. Such rules are found 

in, among other places, statutes, regulations, the common 

law, the general maritime law, a ship’s regulation or order, 

or shipping articles and similar sources. It is an act which 

is forbidden or an omission to do that which is required.”10

With its broad definition, misconduct can incorporate 

offenses that fit into other categories, including negligence, 

but all the offenses mentioned are similar in that “acting 

under the authority” of the credential is required for S&R 

jurisdiction. About 25 percent of complaint filings in 2014 

were classified as misconduct.11

The regulations at 46 CFR §5.29 define negligence as “the 

commission of an act which a reasonable and prudent person 

of the same station, under the same circumstances, would 

not commit, or the failure to perform an act which a reasonable and prudent person of the same station, under the same 

circumstances, would not fail to perform.” The first part 

describes someone committing an act that another would 

not (for example, a pilot improperly navigating a commercial vessel). A reasonable and prudent pilot would properly 

navigate the vessel. From the second part of the definition, 

the Coast Guard would seek to charge a mariner’s failure to 

perform an act (such as a pilot failing to sound fog signals 

while in or near fog) where a reasonable and prudent pilot 

would sound signals appropriately. 

Unlike the civil law requirement for negligence, which 

necessitates damage resulting from a breach of a duty, in 

the suspension and revocation context, a casualty resulting 

from the negligent act or omission is not required for the 

Coast Guard to take action. Remember, the purpose of these 

proceedings is to prevent casualties. Any damage resulting 

from the negligence would be identified as an aggravating 

circumstance on the complaint. 

Drug Use: The greatest number of offenses cited in S&R 

complaint filings have been for illegal drug use. Out of 

480 complaint filings in 2014, 264 involved mariners testing positive for use of dangerous drugs.12 Based on federal 

workplace rules, the Coast Guard limits collection of specimens for drug testing to urine. However, marine employers 

are increasingly expanding into other scientifically recognized methods such as hair tests, and also incorporate a 

wider range of drugs in their selection. The Coast Guard 

lauds this proactive approach, and has embraced any extra 

workload from the voluntary reporting of these drug tests 

as a means to ensure a safer maritime transportation system.

Contemplating Sanctions

There are a number of sanctions (orders) the administrative 

law judge (ALJ) may issue at the conclusion of an adversarial 

suspension and revocation proceeding. From the lowest to 

highest impact level to the credential, an ALJ may order: 

• Dismissal (case not proved): nothing happens that 

affects the merchant mariner credential.

• Admonition (case proved): the administrative law judge 

issues a formal warning against the MMC. The mariner 

retains merchant mariner credential possession and is 

able to continue sailing.

• Suspension on probation (case proved): the ALJ issues a 

suspension, but the suspension is placed on probation. 

The mariner retains MMC possession and may continue 

sailing.

• Outright suspension (case proved): the administrative 

law judge issues a period of suspension, and the merchant mariner credential is turned over to the Coast 

Cured From Drugs?

The suspension and revocation statute mandates that 

if a mariner uses or is addicted to a dangerous drug, the 

mariner’s credential will be revoked unless the mariner 

provides satisfactory proof of “cure.” 1

The History

The required drug testing regulations in 46 CFR Part 16 

have been around since the late 1980s, and no other 

oense category has generated as many interpretations 

in the process for all involved. Dened individual roles, 

questions of exactitude in following regulatory intent, 

and equitable treatment of mariners have served to create 

continuing confusion. 

The Cure

To address these issues, the Coast Guard established a standard “proof of cure” process for mariners through a series 

of Commandant decisions.2 The terms in the decisions are 

now embedded within the standard drug use settlement 

agreement. The typical cure process takes 16 months or 

more to complete, but — considering that revocation is the 

only other allowable sanction when drug use is proven at a 

hearing — the cure process is a good option for mariners. 

Endnotes:

1. 46 U.S.C. 7704(c).

2. See CDOA 2535 (SWEENEY), CDOA 2634 (BARRETTA), and CDOA 2638 

(PASQUARELLA).
56 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

It is important to note that the Coast Guard is never obligated to offer a settlement to a mariner, nor to accept any 

proposed settlement. In fact, Coast Guard policy limits 

them. For instance, if a mariner has completed a previous 

settlement for cure within the last three years or has positive drug test results from a serious marine incident testing, settlement is not acceptable and the Coast Guard must 

proceed to a hearing. 

Lastly, an administrative law judge is not bound by a submitted motion for settlement. The ALJ may either approve 

the motion and issue a consent order (beginning the settlement), or reject it based on legal insufficiency or flaws in 

the settlement, including excessive (or lack of) conditions or 

failure of the settlement to adequately reflect the complaint 

offenses.

Looking Ahead 

The suspension and revocation program holds more promise for some, more trepidation for others, as changes in Coast 

Guard policies seek to seamlessly increase the quality and 

professionalism of the process while promoting safety 

at sea. 

Coast Guard regulations provide for a range of remedial 

actions, tempered through a well-structured sieve at multiple levels, from the individual investigating officer all the 

way to the Commandant and beyond. This ensures that 

whether or not S&R action can be done, we give due consideration to whether it should be done. 

About the author:

Mr. Fink is the national technical advisor at the S&R National Center of 

Expertise. He has been an investigating officer for more than 25 years, 

including 13 years as an instructor in the marine inspection and investigation school at CG Training Center Yorktown, Virginia. 

Endnotes: 1. 10 Stat. 61 (1852). Cf. 5 Stat. 305 (1838).

2. See 46 USC §7701(c).

3. 46 U.S.C.

4. 46 USC §7703(3), 49 USC §30304(a)(3)(A) or (B).

5. Texas Penal Code Section 42.03.

6. See CDOA 2698 (HOCKING) and CDOA 2705 (PLENDER).

7. 46 CFR §10.235(h), 49 CFR Part 1572.

8. 46 USC 7704(b). We recognize, however, that not all drug offenses are equal, and in 

2004, amendments to the statute expanded the mandated “revocation only” sanction to allow suspension as an S&R option. This provides a window for settlement 

agreements and is now a recognized remedial response to a conviction instead 

of strict revocation. 

9. Internal review/assessment, Feb. 2015.

10. 46 CFR §5.27.

11. Internal review/assessment, Feb. 2015.

12. Ibid.

13. Ibid.

Guard. The credential is returned when the suspension 

period is completed.

• Outright suspension followed by suspension on probation (case proved): this is a combination of the third 

and fourth bullets. The merchant mariner credential is 

returned after the outright suspension period, then the 

mariner may sail on the MMC during the probationary 

period.

• Revocation (case proved): the administrative law judge 

revokes the merchant mariner credential. Other than 

motioning to the ALJ to re-open the hearing (limited 

conditions), another merchant mariner credential can be 

issued only after certain criteria is met, usually through 

the process of administrative clemency. This may take 

years. 

Settlement Agreements

Settlement agreements, in which mariners and the Coast 

Guard agree on a course of action in lieu of battling out 

the case in court, are on the rise. They are a win/win/win 

for all involved, as the mariner avoids revocation (if for a 

drug case) and is given a second chance, the Coast Guard is 

assured of a mariner who will be safer on the water, and the 

maritime community retains a good worker whose former 

drug use is no longer a concern to marine safety. Settlement 

agreements may be accepted for other offenses, as well, 

and for the 2014 calendar year, out of 480 filed complaints, 

255 resulted in settlement agreements.13

Most of these were for mariners with positive drug test 

results. An approved settlement for drug “cure” can shorten 

the total time for the mariner to be “on the beach;” however, 

cure is not easily met, by any means. The incentive for settlement is obvious — the ultimate return of the MMC upon 

successful completion. Settlements can be tough, however. 

Some mariners may sign them and carry on without considering the terms, but they should be a serious consideration, 

as failure to complete the settlement terms results in merchant mariner credential revocation.

Additionally, settlement agreements are favorable, as they 

may require conditions above and beyond that which an 

ALJ can order after a hearing. Therefore, the S&R NCOE 

makes the most of them, using them to increase mariner 

competency or knowledge by imposing remedial (corrective) actions such as completing professional training or 

instructional courses. Settlements are favorable to the mariner, as well, as he or she may ultimately see the merchant 

mariner credential returned without necessarily having to 

admit wrongdoing because admission is required only to 

the jurisdictional elements of the case (does not apply to 

drug offenses). 
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 57

In “Breakfast Club” terms: “Screws fall out all the time — the 

world’s an imperfect place.”1 When those screws do fall out, 

people make mistakes, the weather adversely impacts mariners, or sea conditions unexpectedly change, marine casualties can —and do — occur. 

Commonalities or Trends 

After studying incident particulars, the next step is to 

evaluate the events or decisions that led to the accident. An 

investigator can create an event timeline and identify links 

between incidents. If there are commonalities between separate incidents, then steps to correct or avert the commonalities may prevent future incidents.

Consider this fictional scenario: On a clear Tuesday evening, an outbound small coastal freight ship collides with 

an inbound offshore supply vessel while navigating a bend 

in a waterway, causing moderate damage to both vessels. On 

a Tuesday two weeks later, an uninspected towing vessel 

pushing 12 loaded barges collides with a small passenger 

vessel in the same general location. Both vessels sustain 

damage. While each incident may seem different at first, 

upon closer examination we can identify several commonalities.

By studying the particulars of incidents within a given area, 

we can detect similarities such as the time of day, time of 

year, tidal cycles, vessel types, weather conditions, type of 

operations, or other factors. Such analysis may show a pattern of factors that could help predict future events, and 

investigators can proactively implement efforts to curb, control, eliminate, or publicize such contributing factors.

What Are Marine Casualties, and Why Do They Happen?

The term “marine casualty” is defined in Title 46 Code of 

Federal Regulations (CFR) Part 4 as an incident that involves 

a vessel and includes, among other things:

• loss of life, injury, or any fall overboard; 

• vessel occurrences that result in a grounding, stranding, 

foundering, flooding, collision, or allision; 

• explosions or fires on vessels, reduction or loss of power, 

or impairments to a vessel’s operation;

• circumstances that affect a vessel’s seaworthiness or 

incidents that cause significant harm to the environment.

In the simplest terms, marine casualties are accidents, and 

accidents occur when an undesirable or unfortunate event 

occurs unintentionally, often resulting in injury, loss, or 

damage.

The captains of the vessels in the scenarios mentioned didn’t 

plan on colliding, but unexpected events happen every day. 

Marine Casualty Trends

Looking for commonalities 

to prevent future occurrences.

by CDR BLAKE WELBORN

Detachment Supervisor

U.S. Coast Guard Investigations National Center of Expertise 

Communicate

2002–2013 marine casualties on U.S. western rivers. Graphic 

courtesy of Dr. James Dobbins.
58 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

The two fictional marine casualties mentioned were collisions occurring in the same area of a waterway on the 

same day of the week. While looking into such incidents, 

an investigator might identify other interconnecting factors. For example, strong currents could have adversely 

affected one or more of the involved vessels, the crew might 

not have made radio calls between the vessels to arrange passing agreements, or fog 

might have been present. Any number of 

similarities might become evident during 

investigations. 

Just the Facts

The key in looking for commonalities is to 

seek events that led to the marine casualty 

that also occurred on vessels in similar situations. For example, the investigations of 

our fictional collisions might find that crews 

of both outbound vessels misinterpreted a 

radar contact or were unfamiliar with river 

current patterns in that stretch of the waterway. Such issues would be of note as commonalities between the incidents.

The investigator could produce an exhaustive list of similarities linking incidents to 

each other, but often the most simple interconnecting criteria proves noteworthy. In 

the first few moments of an incident briefing, 

start with the basic information passed, then 

advance to those facets of the investigation 

that require more probing. 

Vessels under comparable conditions may 

exhibit common characteristics that lead to 

marine casualties. These are the types of 

occurrences that should lead to trend analysis endeavors, when they’re found to take 

place with some frequency. 

Better Data

Dr. James Dobbins was an engineering professor at Vanderbilt University when he conducted research analyzing marine casualties. 

Specifically, his team sought to identify clusters of marine casualties in an effort to pinpoint and chart the most hazardous locations 

on U.S. waterways.2

Using information from U.S. Coast Guard 

databases stretching back as far as 1980, his 

study identified areas where the historical 

records were deficient. Dr. Dobbins advised 

that 60 percent of marine casualty cases used 

for the study had no property damage amount figures, 

or they contained a zero in the corresponding data bank. 

Though this information must be reported to investigators, 

it was not always available in the public data extracts his 

studies utilized. 

Case Study, Sector Hampton Roads

In 2013, Sector Hampton Roads had a series of marine casualties involving 

deep draft ships grounding while moored at the dock. Although these incidents were not at the same dock or even on the same waterway, they were, 

indeed, linked. 

Charted Depth Accuracy

Sector personnel found that crews, agents, and waterfront facilities were 

relying on charted water depths rather than conducting more frequent 

surveys to determine actual waterway conditions.

As a result, the Coast Guard issued a marine safety information bulletin 

cautioning facilities and marine employers in Sector Hampton Roads’ area of 

responsibility to: 

•	 conduct berth hydrographic surveys and soundings at least once annually and maintain survey records; 

•	 consider	tidal variances at their berths and incorporate this into cargo

loading plans; 

•	 become familiar with facilities’ intended loading plans and consider how

those plans may or may not address projected tidal changes and a vessel’s 

draft; 

•	 question facility representatives regarding the currency and validity of

hydrographic surveys and soundings prior to mooring at that facility; and 

•	 request	the assistance of docking masters and assist	tugs	to scan water

depths at berths prior to vessels mooring, especially if there is any doubt 

about draft clearance. 

Sector Hampton Roads’ graphic depicting ship groundings from October to December 

2013. Graphic provided courtesy of CDR Kevin Carroll, prevention department head, 

Sector Hampton Roads.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 59

The team also noted problems with incident location information. Dr. Dobbins stated, “It was hoped that the coordinate data would be precise enough to identify a bridge 

pier or lock wall as commonly involved in allisions, as an 

example. Ostensibly from manual typos, several coordinates 

were transposed or incorrect.” 3 Due to some instances of 

poor data, casualties more than three miles from any waterway were discarded. 

Dr. Dobbins further noted, “In recent years location accuracy has significantly improved in U.S. Coast Guard marine 

casualty files.” 4 With an eye toward continuous improvement, Coast Guard personnel have developed new information quality guidelines, policies, and job aids and stressed 

the need for improved data entry during marine casualty 

investigator training at U.S. Coast Guard Training Center 

Yorktown.

Moving Forward

It’s impossible to engineer a system that will prevent all 

marine casualties. As defined, marine casualties are 

Case Study, Morgan City

For many years, ships navigating in 

southern Louisiana along the lower 

section of the Atchafalaya River had to 

take special precautions when transiting 

the “horseshoe,” a compact river bend. 

The water slows in this area and drops 

sediment. As the sediment built up, the 

charted channel narrowed, groundings 

became more frequent, and the channel 

required frequent dredging. 

A Money-Saving Project

To remedy these problems, the Port 

of Morgan City approached the U.S. 

Army Corp of Engineers and the U.S. 

Coast Guard to move the channel. The 

$4 million project took several years to 

complete and involved armoring one 

side of the river against erosion due to 

the increased wave action from traf-

cking vessels. 

While $4 million may seem like a lot of 

money, the project will save much more 

than that down the road. According 

to Raymond Wade, Port of Morgan 

City’s executive director, it cost nearly 

$10 million to dredge and maintain the 

horseshoe during the 7-year period 

immediately preceding the project. 

Further, the resultant channel reduces 

the trip from offshore to and from 

Morgan City by approximately three 

miles, which saves transiting ships both 

fuel and time.

In more good news, Wade noted no 

new vessel groundings in the area, and 

the new portion of the waterway is selfscouring, so it maintains itself without 

any required regular dredging.

accidents — and accidents happen every day. But through 

conducting simple trend analysis studies and seeking to 

identify and eliminate hazardous conditions that lead to 

marine casualties, we can realize a significant decrease in 

accidents.

Acknowledgement:

Special thanks to Mr. Paul Ledoux, senior investigating officer, Sector 

Hampton Roads, for his assistance.

About the author:

CDR Blake Welborn is a 1993 graduate of the Coast Guard Officer Candidate School. A career prevention officer, his service includes command cadre 

positions at marine safety units and training tours in vessel inspections, 

casualty investigations, and incident response management. CDR Welborn 

holds a master’s degree in quality systems management. 

Endnotes: 1. John Bender (performed by Judd Nelson), “The Breakfast Club,” Universal Pictures, 1985.

2. Dr. James Dobbins, personal communication, Mar. 16, 2015.

3. Ibid.

4. Ibid.

Graphics provided courtesy of Mrs. Cindy Cutrera, Port of Morgan City.
60 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

The report of investigation (ROI) following a marine incident is the primary communication method connecting all 

involved stakeholders. It delivers a coherent event timeline 

regarding actions surrounding the marine casualty and 

describes why the event occurred. Once completed, a report 

of investigation contains a wealth of knowledge to: 

• help prevent casualties, 

• base safety alerts upon, and 

• make appropriate changes to policy and regulations. 

Coast Guard personnel use the ROI to evaluate existing 

programs, regulations, and policy and incorporate changes 

as deemed necessary. Private industry corporations may 

also adjust their internal safety and operating procedures 

based on report results. With so much follow-up at stake, 

it’s important to get these reports right. Fortunately, the 

Investigations National Center of Expertise (INV-NCOE) 

provides a wide range of experience and technical advice 

to help investigating officers complete their investigations 

thoroughly and accurately for the benefit of the entire maritime community.

Vessel Electronic Analysis Expertise

Today’s investigation challenges include increasingly complex vessel electronics and the resulting volume of information investigating officers must review. The INV-NCOE 

ensures that field units have access to investigative and technical expertise for different types of vessel fleets as well as 

for the various types of onboard electronics.

For example, the voyage data recorder (VDR), typically 

located on the vessel bridge, is considered the nautical 

“black box.” Some of the VDR’s capabilities include ship’s 

position, speed, heading, bridge audio, very high frequency 

(VHF) radio communications, radar data, depth under keel, 

rudder order and response, and engine order and response. 

INV-NCOE personnel can download VDR data and enter it 

into a proprietary program that translates it all into a legible 

format for the investigations team.

For example, VDR causal analysis of a 2012 bridge allision 

revealed that the bridge’s navigational span should have 

been illuminated by three vertical white lights, indicating 

the main channel span. But VDR audio recorders revealed 

various inactions of the crewmembers on watch, including no verification of bridge lighting and no questioning of 

improper characteristics. 

Additionally, the vessel’s Automatic Identification System, 

which is incorporated into the vessel’s electronic chart system, identified a towing vessel that had recently moored 

Coast Guard Reports 

of Investigation

The Investigations National Center of Expertise’s role.

by LCDR BARBARA WILK

Marine Casualty Program Manager

U.S. Coast Guard Investigations and Analysis

Communicate

Inspections officer Chief Warrant Officer Jeff Gradel responds to a bridge 

allision. U.S. Coast Guard photo.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 61

just upriver of the bridge due to prevailing weather conditions. The bridge audio revealed no communication with 

that moored vessel, which could have revealed the lighting 

scheme of the bridge and the local notice to mariners, giving 

warning of the lighting scheme.

Thus, VDR information provides real-time overlay of the 

bridge crew actions as a marine casualty unfolds, so investigating officers can verify the facts via this VDR view of the 

incident in real time.

INV-NCOE Experience

When a mobile offshore drilling unit grounded in the Arctic, the INV-NCOE investigation highlighted industry towing standards, lack of government towing oversight, shackle 

design and strength, and crew competencies for Arctic towing.

The interest for oil exploration in the Arctic will continue 

to grow. Since the final report of this investigation covered 

a vast amount of information in great detail due to INVNCOE technical and investigative support, it is hoped it will 

be referenced to help industry develop adequate operating 

procedures for the harsh Arctic environment. 

One-Stop Shop

Whether an investigation yields an overwhelming amount 

of information or not enough, the INV-NCOE provides 

investigative expertise to ensure investigating officers have 

asked and answered all the necessary questions. They then 

apply their technical expertise to provide in-depth analysis and get the trickiest questions answered. Lending such 

quality and accuracy to the investigative process, the Investigations National Center of Expertise helps to make ROIs 

better products in the public interest and within the Marine 

Safety mission for the Coast Guard. 

About the author: 

LCDR Wilk is a 2001 U.S. Coast Guard Academy graduate. She has spent 

the majority of her time stationed in the Gulf, conducting vessel inspections, 

waterways management, and marine casualty and suspension and revocation investigations. She most recently completed a tour at U.S. Coast Guard 

headquarters in the Office of Marine Casualty Investigations and Analysis, 

where she provided program oversight for marine casualty and suspension 

and revocation investigations.

The General Slocum

The rst ocial report of investigation was written upon 

conclusion of the United States Commission of Investigation into the disaster to the steamship General Slocum on 

October 8, 1904. 

The General Slocum was chartered by a church group to 

transport approximately 1,300 individuals along the East 

River in New York. When a re started in the poorly organized forward cabin, it quickly spread among the steam 

steering gear, lamps, table, four barrels of oil, paint pots, 

life jackets in varying conditions, charcoal, glasses, hay, 

and various other ship’s stores, ultimately consuming the 

vessel.

The Commission

Following the disaster, the Secretary of Commerce and 

Labor convened a commission to investigate the incident. The commission members held an array of experience and knowledge, and included the Commissioner of 

Corporations, the Supervising Inspector General of the 

Steamship Inspection Service, and members of the War 

Department and Department of the Navy. 

The Report of Investigation

After countless hours reading regulations, scouring vessel 

and inspection documents, and interviewing witnesses, 

the commission produced its report regarding the General 

Slocum. Among various deciencies, the report noted:

•	 lack	 of crew proficiency with regard to fire and

abandon-ship procedures; 

•	 lack	of	a	licensed mate, as required by certificate;

•	 lack	of	operational	firefighting equipment; and

•	 lack	of construction regulation of	the	steamship.	

The commission also identied the lack of inspection 

oversight (due to a shortage of inspectors) and deviation 

from inspection regulations. 

Bibliography:

Report of the United States Commission of the Investigation upon 

the Disaster to the Steamer “General Slocum,” October 8, 1904. 

Washington: Government Printing Oce, 1904.
Fire or Explosion Concerns:

Nickel ore is non-combustible and presents a low fire risk. 

What is the Coast Guard doing about it?

The International Maritime Solid Bulk Cargoes Code 

specifies how nickel ore should be loaded, unloaded, and 

transported on a cargo vessel for international shipments. 

Domestic nickel ore shipments require a special permit 

issued in accordance with regulations found in 46 CFR 

Part 148.

Prior to a nickel ore shipment, the shipper must provide 

a signed certificate of the transportable moisture limit as 

well as a signed certificate or declaration of the moisture 

content to the vessel’s master or his/her representative. 

Additionally, the competent authority of the port of loading must approve the testing procedures for sampling, 

testing, and controlling the nickel ore cargo’s moisture 

content.

About the author:

Ms. Amy Parker is a lead chemical engineer in the Hazardous Materials Division at U.S. Coast Guard headquarters. She develops domestic 

and international regulations for hazardous material and solid bulk cargo 

marine transport and represents the U.S. at the meeting of the International Maritime Organization’s Sub-Committee on Carriage of Cargoes 

and Containers. 

Endnote:

1. Baltic and International Maritime Council, “Why is Nickel Ore so Hazardous?” 

Available at https://www.bimco.org/en/Education/Seascapes/Questions_of_

shipping/2014_03_07_Why_is_nickel_ore_so_hazardous.aspx.

References: 

The Nickel Institute website, www.nickelinstitute.org, accessed March 4, 2015.

U.S. Geological Survey, 2015, Mineral Commodity Summaries 2015: U.S. Geological Survey, p. 108-109. Available at http://dx.doi.org/10.3133/70140094.

What is it?

Nickel ore, a naturally occurring metal ore of varied composition and color, is the fifth most abundant element on 

Earth. While nickel has many applications, it’s primarily 

used in stainless steel and alloy steel production. 

Historically, stainless steel has accounted for nearly twothirds of nickel use worldwide. In 2014, the U.S. and China 

produced 18.34 million tons of austenitic (nickel-bearing) 

stainless steel.

Nickel is also used in the more specialized aerospace, 

military, and power-generating industries. Applications 

include metal plating, electronics, and batteries for hybrid 

vehicles and portable equipment.

Why should I care?

Shipping Concerns:

The primary concern with nickel ore shipment is its potential to liquefy. Over a three-year period from October 2010 

to October 2013, six bulk carrier vessels carrying nickel 

ore capsized, with 81 seafarers losing their lives.1 Cargo 

liquefaction was the root cause of these casualties. 

Liquefaction occurs in cargoes comprised of fine particles 

that also contain some moisture. Conversely, liquefaction 

will not occur in cargoes comprised of large particles or 

lumps, or when the cargo has a low moisture content. During liquefaction, water within the cargo separates from the 

solid particles, resulting in the cargo behaving more like a 

liquid than solid, which can cause significant cargo shift 

and decrease ship stability.

Health Concerns:

There are no known health concerns associated with 

nickel ore; however, dust may be generated from its processing, transporting, or handling. Shippers should use 

appropriate protective equipment to minimize exposure. 

Understanding Nickel Ore

by MS. AMY PARKER

Lead Chemical Engineer 

U.S. Coast Guard Hazardous Materials Division

62 Proceedings Winter 2015–2016 www.uscg.mil/proceedings Chemical of the Quarter
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 63

Prepared by NMC Engineering

Examination Team

Nautical

Engineering

Queries

Nautical

Engineering

Queries

1. When a megohmmeter is being used to test insulation resistance, current leakage along the surface of the insulation 

is indicated by the megohmmeter’s pointer responding in a very unique way. What would be the response of the 

pointer?

A. dipping toward zero, then raising slowly

B. continually rising as test voltage is applied

C. kicking slightly down scale as voltage is applied

D. fluctuating around a constant resistance reading

2. The quantity or condition which is measured and controlled is known as the .

A. controlled variable

B. manipulated variable

C. set point

D. control point 

3. Excessive side clearance between a piston ring and its groove will cause the ring to .

A. expand excessively under operating temperatures

B. scuff the cylinder liner excessively

C. hammer the piston land above the ring

D. hammer the piston land below the ring

4. The horizontal fore and aft movement of a vessel is called .

A. yaw

B. sway

C. heave

D. surge

Questions
64 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Answers

Engineering

1. Note: A hand-cranked analog megohmmeter is used to evaluate insulation resistance by imposing a relatively high DC voltage across a conductor and 

the framework of the apparatus (ground). The response of the pointer while performing this nondestructive test is used to determine the condition of the 

insulation. Assuming that constant DC voltage is applied while cranking, the measured resistance is inversely proportional to the leakage current. 

A. dipping toward zero, 

then raising slowly

Incorrect answer. This response pattern is the result of the capacitance of good, dry insulation and is especially seen when testing the insulation of large machines. 

B. continually rising as 

test voltage is applied

Incorrect answer. This response pattern is seen when testing good, dry insulation, and the 

resistance will continue to climb to the true resistance value. 

C. kicking slightly down 

scale as voltage is 

applied

Correct answer. This response pattern is caused by leakage of current along the surface 

of dirty insulation. 

D. fluctuating around a 

constant resistance 

reading

Incorrect answer. This is not a typical response pattern.

2. Note: Using a steam-heated fuel oil heater and associated control system as an example, the fuel oil heater fuel oil outlet temperature is the quantity or 

condition being measured and controlled, and is known as the controlled variable. 

A. controlled variable Correct answer. The controlled variable is that quantity or condition that is being measured and controlled, as explained in the note above. 

B. manipulated variable Incorrect answer. The manipulated variable is the variable of the process acted upon to 

control the output (controlled variable) at the desired value. In the example cited in the 

note, this would correspond to the fuel oil heater steam inlet flow. 

C. set point Incorrect answer. The set point is the desired value of the controlled variable. 

D. control point Incorrect answer. The control point is the actual value of the controlled variable at any 

given time.

3. Note: The side clearance between a piston ring and its groove should be sufficient to allow for thermal expansion but not so great as to allow the ring to 

reciprocate within its groove excessively and cause pounding. 

A. expand excessively 

under operating 

temperatures

Incorrect answer. The thermal expansion rate of piston rings is a function of ring metallurgy and the piston operating temperature, not piston ring side clearance. 

B. scuff the cylinder liner 

excessively

Incorrect answer. Excessive scuffing of the cylinder liner is primarily the result of inadequate cylinder liner, piston, and piston ring lubrication.

C. hammer the piston 

land above the ring

Incorrect answer. Though excessive side clearance does cause the ring to reciprocate within 

its groove excessively, due to firing pressure, the resulting pounding causes the piston land 

below the ring to be hammered, not the land above. 

D. hammer the piston 

land below the ring

Correct answer. Excessive side clearance causes the ring to reciprocate within its groove 

excessively. Due to firing pressure exerting downward, the resulting pounding causes the 

piston land below the ring to be hammered.

4. Note: A vessel is subject to six freedoms of movement, three of which are linear motions and the other three rotational motions about a specific axis of rotation. 

A. yaw Incorrect answer. The yaw motion is a rotational motion where the vessel rotates about a vertical axis. 

B. sway Incorrect answer. The sway motion is a linear horizontal motion where the direction of movement is to port 

or starboard.

C. heave Incorrect answer. The heave motion is a linear vertical motion where the direction of movement is up or 

down. 

D. surge Correct answer. The surge motion is a linear horizontal motion where the direction of movement is forward 

or aft.
www.uscg.mil/proceedings Winter 2015–2016 Proceedings 65

Prepared by NMC Deck

Examination Team

Nautical

Deck

Queries

Nautical

Deck

Queries

1. INTERNATIONAL ONLY: Your vessel is backing out of a slip in a harbor. Visibility is restricted. Which signal are 

you required to sound?

A. one prolonged blast only

B. one prolonged blast followed by three short blasts when the last line is taken aboard

C. one prolonged blast followed by three short blasts when leaving the slip

D. the danger signal

2. Which statement regarding the free surface correction is TRUE?

A. It is added to GM at light drafts and subtracted at deep drafts.

B. It is increased if the slack tank is not on the centerline.

C. It is decreased if the slack tank is below the KG of the vessel.

D. The correction decreases as the draft increases.

3. You are steering 125° PGC. The wind is southwest by south, causing a 3° leeway. The variation is 6°E, the deviation 

is 2°W, and the gyro error is 1°W. What is the true course made good?

A. 121°T

B. 123°T

C. 127°T

D. 129°T

4.	 Which statement is true when the captain of the port or officer in charge, marine	inspection issues an order of suspension to the operator of a vessel concerning oil transfer operations?

A. It is always effective immediately.

B. It includes a statement of each condition requiring corrective action.

C. It must be in writing before it takes effect.

D. All of the above.

Questions
66 Proceedings Winter 2015–2016 www.uscg.mil/proceedings

Answers

Deck

1. A. one prolonged blast only Correct answer. “A power-driven vessel making way through the water shall 

sound at intervals of not more than 2 minutes one prolonged blast.”

Reference: International Rule 35(a)

B. one prolonged blast followed by three short 

blasts when the last line is taken aboard

Incorrect answer.

C. one prolonged blast followed by three short 

blasts when leaving the slip

Incorrect answer.

D. the danger signal Incorrect answer.

2. A. It is added to GM at light drafts 

and subtracted at deep drafts.

Incorrect answer.

B. It is increased if the slack tank 

is not on the centerline.

Incorrect answer.

C. It is decreased if the slack tank 

is below the KG of the vessel.

Incorrect answer.

D. The correction decreases as the 

draft increases.

Correct answer. The free surface correction will decrease as displacement increases; 

this can be demonstrated by the following formula: 

GGo = Free surface constants/Displacement

Where: GGo = Virtual rise of the center of gravity 

Free surface constants = Free surface constant for all of the slack tanks 

Displacement = Vessel displacement 

Reference: Stability and Trim for the Ship’s Officer, Fourth Edition, William E. George, 

p. 170-171.

3. A. 121°T Correct answer. Correct the Gyro Compass Heading as follows: 

125° PGC - 1°W GE = 124°True 

Apply leeway to the true course in the direction the wind is setting to obtain the CMG. 

124°True - 3° of leeway = 121°True 

Reference: The American Practical Navigator, 2002 Edition, p. 97, p. 102, and p. 785. 

Where: T = True; PGC = Per Gyro Compass; GE = Gyro Error; CMG = Course Made Good

B. 123°T Incorrect answer.

C. 127°T Incorrect answer.

D. 129°T Incorrect answer.

4. A. It is always effective 

immediately.

Incorrect answer.

B. It includes a statement of 

each condition requiring 

corrective action.

Correct answer. “A suspension order: 

(a) May be effective immediately; 

(b) Is issued in writing unless it is effective immediately and then it may be issued orally and followed 

up in writing; 

(c) Includes a statement of each condition requiring correction to-”

Reference: 33 CFR 156.112(c)

C. It must be in writing 

before it takes effect.

Incorrect answer.

D. All of the above. Incorrect answer.
If your command is interested in 

“Championing” a Proceedings edition, 

contact the executive editor at 202-372-2315.

Champion’s Guidelines are available on 

the Proceedings website, 

www.uscg.mil/proceedings.

Mailing Address: 

U.S. Coast Guard, 

Proceedings Magazine, 

2703 Martin Luther King Jr. Ave. S.E.

Mail Stop 7318

Washington, DC 20593-7318

Phone: 

202-372-2316

Email: 

HQS-DG-NMCProceedings@uscg.mil

Website: 

www.uscg.mil/proceedings

Safety Management Systems

Waterways: America’s 

Economic Engine

Recreational Boating Safety

Safety Management Systems

Waterways: America’s 

Economic Engine

Recreational Boating Safety
COMMANDANT (CG-DCO-84)

ATTN: PROCEEDINGS

US COAST GUARD STOP 7318

2703 MARTIN LUTHER KING JR AVE SE

WASHINGTON, DC 20593-7318

Official Business

Penalty for Private Use, $300

FORWARDING SERVICE REQUESTED

PRSRT STD

POSTAGE & FEES PAID

U.S. COAST GUARD

PERMIT NO.G-157