NATIONAL TRANSPORTATION SAFETY BOARD
Public
Meeting of June 9, 2015
(Information
subject to editing)
March 22,
2014
This is a
synopsis from the NTSB’s report and does not include the Board’s rationale for
the conclusions, probable cause, and safety recommendations. NTSB staff is
currently making final revisions to the report from which the attached
conclusions and safety recommendations have been extracted. The final report
and pertinent safety recommendation letters will be distributed to
recommendation recipients as soon as possible. The attached information is
subject to further review and editing.
Executive
Summary
On March 22,
2014, about 1235 central daylight time, the 607-foot-long bulk carrier Summer
Wind with a Houston pilot on board collided with the 670-foot-long Miss
Susan tow (a 70-foot-long towing vessel and two 300-foot-long tank barges
loaded with fuel oil) in the Houston Ship Channel, Lower Galveston Bay, Texas.
The visibility was restricted at the time due to fog. The bulk carrier was
inbound to Houston, traveling in a north direction. The tow was bound for Port
Bolivar on the east side of the Houston Ship Channel, traveling in an east
direction.
The collision
breached the hull of the forward tank barge in the Miss Susan tow, and
about 168,000 gallons of fuel oil spilled into the waterway. Two crewmembers on
board the Miss Susan sustained minor injuries related to inhalation of
fuel vapor. The total estimated damage was nearly $1,378,000 (excluding oil
response and recovery efforts).
The National
Transportation Safety Board determines that the probable cause of the collision
was the Miss Susan captain’s attempt to cross the Houston Ship Channel
ahead of the Summer Wind, thereby impeding the passage of the bulk
carrier, which could transit only within the confines of the channel.
Contributing to the accident was the failure of the Houston pilot and the Summer
Wind master to set a safe speed given the restricted visibility and nearby
towing vessel traffic, and the failure of the Miss Susan captain and the
Houston pilot to establish early radio communication with one another. Also
contributing to the accident was the failure of Vessel Traffic Service
Houston/Galveston to interact with the two vessels in a developing risk of
collision, and the lack of a Coast Guard vessel separation policy for the
Bolivar Roads Precautionary Area.
The report
identifies the following safety issues:
Lack of
vessel separation in Houston Ship Channel precautionary areas with intersecting
waterways: The NTSB has previously noted that insufficient distance between
vessels when they turn, pass, and overtake one another near intersections can
create unsafe situations. This accident once again highlights the need for
separation between vessels in such areas of the Houston Ship Channel.
Inadequate
oversight and training related to the safety and health of uninspected towing
vessel crews responding to hazardous materials releases: In assessing why
two Miss Susan crewmembers suffered inhalation injuries when responding
to the oil spill, the NTSB found that both federal oversight and company
training of personnel exposed to hazardous materials were insufficient.
Findings
1. Vessel
propulsion and steering systems, medical conditions and medication use, alcohol
and illegal drug use, and distraction from personal electronic devices were not
factors in this accident.
2. The Miss
Susan captain should not have attempted to cross the Houston Ship Channel
ahead of the Summer Wind’s passage, especially given the restricted
visibility and the bulk carrier’s ability to navigate only within the confines
of the channel.
3. Given the
restricted visibility and the towing vessel traffic in the Bolivar Roads
Precautionary Area at the time, the pilot on the Summer Wind should not
have given an order for the bulk carrier to transit at full-ahead speed.
4. The Summer
Wind master should have questioned the pilot’s decision to transit at
full-ahead speed given the restricted visibility and nearby towing vessel
traffic.
5. Sufficient
information existed via radar, automatic identification system, and radio
communications from both the Miss Susan and the Summer Wind for
the vessel operators to know of each other’s intended passages, but despite the
availability of this information neither the Miss Susan captain nor the pilot
on the Summer Wind took early action to avoid the collision.
6. Vessel
Traffic Service Houston/Galveston did not effectively follow its own internal
operating procedures to guard channel 13.
7. In the
minutes leading up to the collision, Vessel Traffic Service Houston/Galveston
did not maintain an effective watch, diminishing its ability to recognize a
developing risk of collision and to interact with the vessel operators.
8. With
several intersecting waterways, high-density vessel traffic, and diverse types
of vessels with differing speeds and maneuvering characteristics, the Bolivar
Roads Precautionary Area is a high-risk section in Vessel Traffic Service
Houston/Galveston’s area of responsibility, and the Coast Guard’s failure to
develop and implement a vessel separation policy for this section contributed
to the collision.
9.
Consistently entering the complete dimensions of tow configurations for
individual transits into automatic identification systems would alleviate
misinterpretation and possible confusion from inaccurate information, and thus
enhance safety.
10. In response
to the oil spill, effective communications and coordination were established
and maintained between the responsible parties, the Coast Guard, local and
state response agencies, and oil spill removal organizations.
11. The
actions taken to recover spilled oil to minimize further environmental damage
were timely and appropriate.
12. Because
of the Miss Susan crewmembers’ incomplete assessment of the material
safety data sheet, lack of being provided required direct-reading testing
equipment, and their assumptions about the nature of the cargo, the Miss
Susan crewmembers did not fully assess the need for respiratory protection
during their emergency response following the collision.
13. The Miss
Susan crewmember training did not adequately prepare them to safely respond
to the hazardous materials release.
14. The
inadequate federal oversight of mariner work safety on board uninspected towing
vessels places crewmembers at greater risk of injury from exposure to hazardous
materials and other safety hazards.
PROBABLE
CAUSE
The National
Transportation Safety Board determines that the probable cause of the collision
was the Miss Susan captain’s attempt to cross the Houston Ship Channel
ahead of the Summer Wind, thereby impeding the passage of the bulk carrier,
which could transit only within the confines of the channel. Contributing to
the accident was the failure of the Houston pilot and the Summer Wind master
to set a safe speed given the restricted visibility and nearby towing vessel
traffic, and the failure of the Miss Susan captain and the Houston pilot
to establish early radio communication with one another. Also contributing to
the accident was the failure of Vessel Traffic Service Houston/Galveston to
interact with the two vessels in a developing risk of collision, and the lack
of a Coast Guard vessel separation policy for the Bolivar Roads Precautionary
Area.
New
Recommendations
To the
United States Coast Guard:
1. Include in
your new towing vessel inspection regulations requirements for (1) availability
and use of personal protective equipment, (2) hazardous materials training, and
(3) identification and mitigation of health and safety hazards posed by
exposure to hazardous materials. (M-15-XX)
To
Kirby Inland Marine:
2. Provide
direct-reading air monitoring equipment and applicable training to your towing
vessel crews that transport hazardous materials, so that crews can identify
combustible or explosive atmospheres, oxygen deficiency, and toxic substances
that may present risk of serious injury. (M-15-XX)
3. Revise
your initial and refresher Hazardous Waste Operations and Emergency Response
training to include demonstration of competence, and ensure that crewmembers
complete this training before serving on vessels that transport hazardous materials.
(M-15-XX)
To the
American Waterways Operators:
4. Inform
your members of the circumstances of this accident and the need for towing
vessels that transport hazardous materials to carry direct-reading air
monitoring equipment, so that crews can identify combustible or explosive
atmospheres, oxygen deficiency, and toxic substances that may present risk of
serious injury. (M-15-XX)
Previously
Issued Recommendation Reiterated in this Report
To the
United States Coast Guard:
Finalize and
implement the new towing vessel inspection regulations and require the
establishment of safety management systems appropriate for the characteristics,
methods of operation, and nature of service of towing vessels. (M-07-6)
Previously
Issued Recommendations Reiterated and Reclassified in this Report
As a result
of this accident investigation, the National Transportation Safety Board
reiterates and reclassifies from “Open―Acceptable Response” to
“Open―Unacceptable Response” the following two safety recommendations:
To the
United States Coast Guard:
Develop and
implement a policy to ensure adequate separation between vessels operating in
the Bayport Channel and Bolivar Roads Precautionary Areas and any other
similarly configured precautionary areas in the Houston Ship Channel. (M-12-6)
Graphically delineate precautionary areas on appropriate Houston Ship
Channel nautical charts so they are readily identifiable to mariners. (M-12-7)