NTSB: Safer Seas Digest 2023

Safer Seas Digest 2023 detailed the lessons learned from tragedies involving capsizings, contact, collisions, fires, flooding and groundings. 

Among the investigations, the most sobering investigations NTSB conducted involve the loss of human life. In 2023, they completed their investigation of the fatal collision between the Coast Guard cutter Winslow Griesser and the center-console boat Desakata, which took the life ofone Desakata crewmember and seriously injured the other.

We found that neither vessel’s crew maintained a proper lookout, and we issued a Safety Alert encouraging small-vessel operators to improve their vessels’ detectability.

..NTSB stated.

Lessons learned

#1 Detecting Small Vessels 

Sometimes, mariners on board larger vessels cannot see small recreational or commercial vessels, increasing the risk of a collision. Fitting small vessels with equipment—such as radar reflectors or AIS— improves the opportunity for vessels with radar, when combined with a proper visual lookout, to detect these
smaller vessels and take action to avoid a collision.

#2 Effectively Communicating 

Effective communication—between firefighting teams and a unified command or between mariners making passing arrangements—is critical. Clear communication by the most prudent method, whether by radio or face-to-face, can be an effective measure in reducing damage or averting a casualty. Additionally, repeating orders or passing arrangements can help ensure everyone is on the same page.

#3 Proactively Inspecting Equipment 

Inspection programs can identify deficiencies before equipment fails. For example, conducting periodic inspections is prudent for equipment at high risk for corrosion—such as pierside bollards or wire ropes used on vessels—especially when their location is in or near saltwater environments, which can significantly affect service life. It is also good practice to develop a means to periodically inspect equipment and vessel systems that are difficult to access, such as those that run through tight spaces or are located near structures, other equipment, or materials that obstruct direct observation.

#4 Mitigating Fatigue 

Crew fatigue can increase the likelihood of a casualty, as it impacts all aspects of human performance. Inadequate sleep can lead to poor decision-making, decreased alertness, and slower reaction time. Mariners should understand the performance effects of sleep loss and recognize the dangers of fatigue. Company operational policies and requirements should incorporate and follow fatigue management best practices to ensure that crewmembers receive enough rest to adequately perform navigational, lookout, engineering, and other watchstander duties. Companies and vessel captains should also actively monitor watch schedules and any off-watch work performed by their crews to ensure adherence to fatigue mitigation policies. Further, they should adjust watch schedules to prevent crew fatigue.

#5 Anticipating Fire Hazards 

Fire is a serious threat—and, unfortunately, common occurrence—on board vessels. Fires can cause significant damage to a vessel or its cargo, equipment, and personnel. It is critical to ensure that combustible materials such as cardboard boxes or oily rags are properly stored (or disposed of). In addition, crewmembers involved in hot work should be trained to identify potential fire hazards, such as combustibles, and take action to remove or protect them from hot work.

#6 Improving Firefighting Training 

Firefighters or crews untrained in the complexities of managing fires on vessels can increase the chance that fires will damage or destroy vessels, or even lead
to injuries or deaths. To prevent engine room fires and ensure they are effectively contained, operators should provide mariners realistic scenario-based training, including training that covers engine room emergencies. This training should also cover procedures for effectively shutting down machinery, fuel oil, lube oil, and ventilation systems, as well as boundary monitoring. In addition, because mariners may need to work with shoreside firefighters to extinguish vessel fires, it is important to educate landbased firefighting teams that potentially respond to shipboard fires on marine vessel firefighting tactics, so they can avoid risks such as breaking a fire boundary or releasing accumulated firefighting water by opening watertight doors.

#7 Conducting Timely Hull Maintenance and Repair

To protect vessels and the environment, it is good marine practice for vessel owners to conduct regular oversight and maintenance of hulls, including between
drydock periods. An effective maintenance and hull inspection program should proactively address potential steel wastage, identify hull and watertight integrity deficiencies, and require the repair of corrosion issues in a timely manner by permanent means. Periodic out-of-water examinations and hull gauging by qualified individuals such as a marine inspectors or surveyors can help determine the material condition of the vessel’s hull and identify areas of corrosion and fatigue.

#8 Maintaining an Effective Watch 

Regulations and long-standing prudent maritime practice require a proper lookout for safe navigation. Maintaining a proper lookout, by sight and sound, is a fundamental rule of the Convention on the International Regulations for Preventing Collisions at Sea, 1972 (COLREGS) for vessels, regardless of their size or
activity, and is essential in determining the risk of collision. Operators and crews should ensure that vessel bridge teams are staffed with certificated/credentialed mariners who are familiar with all bridge navigation equipment and able to independently take immediate action when serving as lookout. In addition, repetitive operations, such as ferry transits—back and forth on the same route—require operators to sustain a high level of vigilance to prevent complacency. To combat complacency, operators should comply with procedures, such as operating checklists, that are in place to prevent single points of failure, and companies should train personnel on the importance of following procedures.

#9 Avoiding Nonoperational Cell Phone Use

Using cell phones and other personal electronic devices has been demonstrated to be visually, manually, and cognitively distracting. Nonoperational use of cell phones should never interfere with the primary task of a watchstander to maintain a proper lookout; personnel should follow established protocols regarding cell phone use. 

#10 Planning Appropriately 

Lack of planning can lead to a disaster on the water. All operations—no matter how routine—should be adequately planned and all risks assessed. Planning can help prevent mishaps related to unforeseen circumstances. Voyage plans should include every phase of the voyage—from the vessel’s starting port to its end port—including leaving the dock and mooring. The plans should account for any hazards, such as bridges, that pose a risk to vessels and tows with high air drafts.

#11 Properly Maintaining Vessel Equipment and Machinery

Many casualties can be traced back to imprecise, incomplete, incorrect, or improper maintenance practices. Vessel crews and equipment manufacturer technicians should follow manufacturer assembly procedures and guidance and ensure correct replacement parts are installed. Additionally, vessel operators and crews should identify possible hazards or risks to maintenance being conducted, such as the effect of ambient conditions on machinery or how working on one piece of equipment may affect other equipment.

#12 Reporting Chart Changes and Hazards

Accurate and up-to-date navigation charts are critical for crews to ensure the safe transit of a vessel while underway. Ports and terminals should immediately report significant modifications to port or terminal configurations to the appropriate hydrographic authority so charts can be updated and the changes
made readily available to chart users. In addition to marking hazards on their own charts and charting software, mariners can report issues (errors or omissions) with NOAA’s nautical charts and/or Coast Pilot through the Office of Coast Survey. 

#13 Avoiding Excessive Speed during Bow-to-bow Harbor-assist Operations

The risk of a casualty during bow-to-bow harborassist operations with ASD tugboats increases with increasing speed. Hydrodynamic forces around an assisted vessel’s bow increase exponentially with speed, while the amount of reserve propulsion power available to the tugboat operator decreases. Therefore, owners and operators of ASD tugboats that perform bow-to-bow harbor-assist operations should set speed limits for these maneuvers. Additionally, tugboat operators should communicate pre-determined speed limits to pilots and ship masters in command of the vessels that they are assisting before engaging in these maneuvers.

#14 Preventing Vessel Damage from the Risk of Thermal Runaway of Lithium-ion Batteries

The risk of fire from lithium-ion batteries is a growing concern as their use becomes more prevalent in handheld radios and other devices. A lithium-ion battery cell—if damaged, shorted, overheated, defective, or overcharged—can spontaneously experience a thermal runaway, a chemical reaction that can cause the cell
to ignite and explode. A cell that explodes can be propelled from its initial position within a battery and ignite combustible materials on a vessel. Due to the potential for rapid expansion of a lithium-ion battery fire, detection, containment, and extinguishment are essential to prevent damage to a vessel.

#15 Reporting Potential Damage from Dragging Anchors 

Underwater pipelines or other utilities can become damaged if anchorages are located too close and vessels drag anchor. Vessel crews should be aware of nearby underwater hazards while anchored and notify the appropriate authorities of an anchor-dragging event.

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