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Audit: U.S. Coast Guard falls short in its casualty investigation role

Oct 2, 2013 11:49 AM
A Coast Guard boat patrols alongside the damaged Cosco Busan after the ship struck a bridge in 2007. The casualty probe, which resulted in guilty pleas and medical reforms, illustrates both the Coast Guard’s strengths and shortcomings.

Courtesy U.S. Coast Guard

A Coast Guard boat patrols alongside the damaged Cosco Busan after the ship struck a bridge in 2007. The casualty probe, which resulted in guilty pleas and medical reforms, illustrates both the Coast Guard’s strengths and shortcomings.

The U.S. Coast Guard does not develop enough qualified people to investigate maritime accidents, resulting in a backlog of 6,000 open cases awaiting action, according to a federal audit.

The report by the Department of Homeland Security (DHS) said inadequate policies and career development ultimately mean that the maritime industry waits too long to receive casualty analysis and safety lessons.

In May, DHS’s Office of Inspector General issued an 18-page audit on the Coast Guard accident investigations function. The review included visits to about 12 of the busiest Coast Guard marine casualty investigations offices plus other sites.

Auditors reviewed whether personnel meet the Coast Guard’s own qualification standards. About two-thirds of the inspectors and investigators didn’t meet the standards. The Coast Guard reported that the shortage will be exacerbated when the Subchapter M towing vessel inspection rules go into effect.

“The USCG does not have adequate processes or sufficient personnel to investigate, take corrective actions and enforce regulations related to the reporting of marine accidents as required,” the auditors concluded.

“These conditions exist because the USCG has not developed and retained sufficient personnel, established a process with dedicated resources to address corrective actions and provided adequate training,” they wrote. “As a result, the USCG may be delayed in identifying the causes of accidents ... and providing the findings and lessons learned to mariners, the public and other governmental entities.”

The audit further said the backlog “may also delay the development of new standards that could prevent future accidents.”

The audit urged the Coast Guard to do more to promote the casualty-investigation specialty as a more attractive career commitment. In a written response, the Coast Guard agreed with the audit’s recommendations and promised corrective action.

The problems ring familiar to mariners who study maritime casualties. The Coast Guard’s military structure, officers’ path to promotion and expansion of the agency’s role during an era of federal budget cuts pose challenges to improvement.

“The findings are completely correct,” said Joseph Murphy, professor of marine transportation at Massachusetts Maritime Academy. “It does highlight a deficiency that the Coast Guard has. Coast Guard inspectors relocate every couple of years, and once they’re up to speed, they go somewhere else and have to start all over again.”

Bob Couttie, a seafarer-education developer and founder of Maritime Accident Casebook, said the U.S. Coast Guard ranks “near the top” of the world’s coast guards that have casualty investigation duties. The rotation of personnel in and out of the safety role, however, stymies the agency’s ability to develop competencies to aid the industry.

“This is part of the militarized style,” said Couttie. “In a military context, it may very well be the right thing to do, whereas when it comes to maritime accident investigation, how committed can somebody be? Guys are getting trained and then they move on to something else. So that’s a lowering of institutional experience.”

The U.S. Coast Guard ranks below the U.K. Marine Accident Investigation Branch, the Australian Transport Safety Bureau and other civilian-based casualty investigators, in Couttie’s opinion. That’s because the non-military, non-punitive agencies are structurally in a better position to zero in on facts that can lead to better prevention analysis. The educational aspect is made more difficult when the investigators know they could end up in a courtroom.

“The Coast Guard is an enforcement agency, so it’s not really an independent investigation,” Couttie said. “If you’re talking to a seafarer, you want to get the truth out of him. You’re likely to get much better insight in the dynamics of a situation than if you’re acting as a policeman.”

Top Coast Guard brass have known for years that their casualty-investigations function was substandard. Industry criticism grew more vocal in the years following 9/11, after which the Coast Guard was tasked with a deeper security role at the nation’s ports. Service to the maritime industry declined.

In response to that criticism, in 2007, then-Commandant Thad Allen promised to bolster the uniformed Coast Guard marine safety ranks by hiring hundreds of civilian casualty investigators. Allen called for the “blended work force” and a renewed respect for commercial mariners as partners instead of targets.

“The Coast Guard acknowledges the concerns of industry and others that our operations in the wake of these (9/11) events have placed greater emphasis on our security missions, sometimes at the expense of marine safety activities,” Allen told Congress.

In 2009, the Marine Safety Enhancement Plan was issued, with a framework for additional hiring and training for inspectors and investigators. That same year, however, came the Great Recession, followed by the recent federal sequester and military spending cuts. Allen’s successor, Adm. Robert Papp, is managing a Coast Guard with tighter resources.

The recent Inspector General’s audit said an “absence of dedicated resources” has caused a backlog of more than 6,000 open investigations.

“If there are 6,000 outstanding, it’s a situation there that certainly needs looking at,” Couttie said.

The audit offered seven recommendations to improve personnel training and retention and to adopt policies that enhance the development of expertise and track results better. In a written response, the Coast Guard agreed with all the recommendations and said it would implement them in the 2014 fiscal year or sooner.

The Coast Guard has “initiated a prevention curriculum at the U.S. Coast Guard Academy to bring new officers into the program, and issued career guides to assist personnel in planning their careers, as well as showing junior officers that repeated tours in inspections and investigations may lead to positions of progressively greater responsibility within the program,” according to the written response.

“The Coast Guard is currently developing a Maritime Prevention Enhancement Plan that will ... refine our improvement efforts, including a consistent focus on retaining prevention professionals,” the Coast Guard wrote.

An example that illustrates both the Coast Guard’s investigative deficiencies and also its good work on lessons learned is the Cosco Busan accident in 2007. The containership struck the San Francisco-Oakland Bay Bridge and spilled 53,000 gallons of heavy fuel. Couttie said the Coast Guard initially didn’t gather data from the navigation electronics and onboard computers, leaving open the opportunity for the ship manager to falsify evidence. The activity eventually was discovered and the management company pleaded guilty to two misdemeanors.

“It’s a case where the Coast Guard did not secure certain documents — like charts — and the plots were added later,” Couttie said. “If the documents had been secured, or at least copied, that would never have happened.”

From an industry safety standpoint, Murphy said a positive outcome from the same investigation resulted from the uncovering of issues with the Cosco Busan bar pilot’s health and medications. The Coast Guard tightened its merchant mariner medical reviews at the National Maritime Center.

Murphy said he would like to see the Coast Guard focus more on prevention rather than so often catching up with hazards after a bad accident has occurred. “They’ve made some progress on medical standards, and they have been able to improve safety,” said Murphy, author of a biennial study guide for deck officers.

In an era of austere federal budgets, the Coast Guard’s ability to improve its investigative performance and reduce the backlog may prove acutely challenging, the audit acknowledges.

“Safety recommendations cannot be addressed until the Coast Guard closes the associated investigations,” the auditors wrote. “Therefore, the USCG will be unable to address these safety recommendations in a timely manner without dedicated resources.”

Whatever the funding level, the key to improvement will be convincing Coast Guard personnel that becoming an inspector or investigator will be an attractive future career track worthy of their aspirations, Murphy said.

“Investigations does not have the promotion path for them, and they avoid it, and I think they put lesser-quality people in there,” Murphy said. “They’ve got to get away from the desire of their people to have their foot in every piece of Coast Guard operation. Today’s world is too technical, and they have to have the expertise to do the job.”

Nov 11, 2013 11:11 pm
 Posted by  The Hook

As a maritime academy grad I took a CG commission and did a tour at an MSO in late 70's including investigations. Even then CG academy officers avoided MSO duty as not in the path. Maritime Academy grads should be encouraged to look into these opportunities and the Coast Guard should actively recruit this shipboard expertise.

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