Proceedings magazine is a communication tool for the Coast Guard's Marine Safety & Security Council. Each quarterly magazine focuses on a specific theme of interest to the marine industry.
Issue link: http://uscgproceedings.epubxp.com/i/617100
20 Proceedings Winter 2015–2016 www.uscg.mil/proceedings and the National Transportation Safety Board to ensure a complete and thorough investiga- tion. 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 inter- views 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 offcer 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 offcer 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 strat- egy. 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 tech- niques. Mr. Nick Parham is a former USCG lieutenant commander who completed Offcer Candidate School in February of 2002 and served in the Coast Guard for 13 years. He began his feld 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 Tennes- see River Near Aurora, Kentucky, on January 26 th , 2012 (draft report not yet publicly available nor fnalized). 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 tran- sit, 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 person- nel 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 dimen- sional properties. After the on-scene joint investigation concluded, NTSB per- sonnel 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 investiga- tors reconciled all the exhibits to ensure that each member of the hearing understood the various deliverables and expec- tations as the investigation moved forward. During the months following the incident, there was a con- stant furry 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.