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Executive Summary INTRODUCTION The marine transportation system has come under intense public scrutiny as a result of recent marine accidents involving substantial spillage of oil and dam- age to the marine environment. This report focuses on the role of marine naviga- tion and piloting) in minimizing the number of accidents. It examines what can be done to reduce operational, economic, and environmental risks through im- provements to navigation and piloting technology and practices in the nation's ports and waterways and their coastal approaches. Overview of Marine Navigation and Piloting Marine navigation and piloting involve complex, interdependent operations in a large sociotechnical system that encompasses waterways, vessels, naviga- tion aids, and human operators. System elements are supported by an infrastruc- ture for vessel and port management, pilotage, pilotage regulation, and profes- sional development. Marine navigation and piloting occur in an operating environment characterized by extreme reliance on human performance, consid- erable diversity in geographic and hydrographic features, and great variability in operating conditions. How well this system performs in U.S. waters affects the nation's economy, the safety of vessels and their crews, the well-being of inhab- itants near ports and waterways, and the natural environment. However, the ~Pilotage terms used in this report are found in Chapter 1.

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2 MINDING THE HELM system's structure and operation have not been extensively studied; moreover, interactions of its component elements are decentralized and highly localized. Efficient and effective interaction of these elements is essential for a highly reliable marine navigation and piloting system, which, in turn, is a key to en hanced maritime safety. National and international authorities have worked for many years to im- prove safety in marine transportation. Improvements have been made in vessel design and construction, navigation aids, watchkeeping guidelines, professional training, and marine traffic regulation. Some of these advances have been volun- tarily implemented by some operating companies either to reduce perceived op- erational and environmental risks or to improve economic performance. But in order to achieve universal adoption of these advances, establishment and en- forcement of international conventions and national shipping laws and regula- tions is usually necessary. National requirements specify maintenance, outfit- ting, and crowing requirements for vessels flying the nation's flag. Nations have taken actions under the terms of international treaties and standards as port states to motivate improvements in the operating practices of foreign-flag ships. Nations have also used unilateral measures to exert direct influence over foreign-flag ships operating in their territorial waters. Port-state control actions and unilateral measures will become increasingly important inso- far as the small size and economic competitiveness of the U.S. merchant fleet provide more limited leverage than in the past for negotiating improvements in international marine safety measures. Nevertheless, questions remain as to how well modern ships, advances in navigation and piloting technologies, professional training, and official oversight have enhanced safety performance and met contemporary navigational, public, and environmental safety needs. By many measures, operational safety has im- proved over the past several decades, yet other indicators suggest that safety issues requiring resolution remain. Despite continuing efforts to improve opera- tional safety, major shipping accidents involving all categories of commercial vessels continue to occur, some with great spillage of oil. Most of these acci- dents have been attributed to human causes rather than purely mechanical, envi- ronmental, or other causes. Public attention to safety in shipping has intensified in recent years, driven in part by major marine accidents resulting in oil pollution in ecologically sensitive areas. Public concern has also been heightened by the increased potential for damage inherent in increasingly larger ships and barges, the toxic nature of hazardous and dangerous cargoes originating in both foreign and domestic trade that are carried in bulk or in containers, and cargo volume. Although marine transportation entails risks, "acceptable" levels of opera- tional risk have not been established by marine safety authorities. Nevertheless, the contemporary public has demonstrated a strong lack of tolerance for marine accidents that result in major spillage of petroleum and hazardous cargoes or substantial loss of life. Laws and regulations aimed at curbing risks to the envi

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EXECUTIVE SUMMARY ronment have in turn stimulated considerable operating company interest in re- ducing economic risk through changes that improve operating practices and hu- man performance. Synopsis of Major Findings and Recommendations The marine navigation and piloting system is for the most part safe, but it can be made safer. There are urgent and compelling reasons to do so. Reasons include (1) the potential consequences and costs of vessel accidents, (2) the accountability of carriers and mariners, and (3) the need to bring substandard ships up to acceptable operating conditions. The marine navigation and piloting system could be enhanced substantially through specific improvements in marine pilotage and waterways management, as well as through maritime research and development, all of which would im- prove the safety performance of human systems. In particular, requirements and standards for pilotage of vessels, pilot development, and pilotage administration across the nation need to be addressed. In addition, the lack of pilotage require- ments for harbor transits of foreign-flag ships in some ports and an absence of official accountability for some pilot services provided to such vessels are gaps that need to be addressed. Pilotage would benefit greatly from improvements in professional development programs, official oversight, and pilotage system ad- ministration. Constructive changes in each of these areas, designed to reduce operational and environmental risk, are needed to ensure full public confidence . . . In potage. Strong action by federal and, in the case of pilotage, state-level authorities is needed to improve: the capability to determine and correct systemic problems underlying human causal factors in marine accidents; the organizational structure for interdependent decision making through measures that include application of vessel traffic services and other technologi- cal aids to marine traffic regulation; the quality, integrity, and consistency of pilot development programs and associated marine licensing; the accountability of pilotage systems and individual pilots, by closing gaps in official oversight and other measures; and the introduction and use of advanced navigation technologies. Timely international action, which includes port-state control measures to en- force international standards, is needed to motivate action by flag states to cor- rect substandard operating and manning practices for merchant vessels operating under each country's registry. One set of steps toward a safer system is to develop formal professional standards for the provision of pilotage services and for the qualification and

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4 MINDING THE HELM performance of pilots. This report recommends immediate action by all pilotage authorities to strengthen the existing federal and state pilotage requirements with- in their jurisdictions. It also recommends fundamental change in the federal and state pilotage systems, drawing on positive aspects from each approach, that would ultimately lead to a single pilotage system, encompassing both federal and state elements, for each local pilotage region. Fundamental to improving safety in marine navigation and piloting is atten- tion to human performance, new technology, and vessel traffic services (VTS). The report addresses each of these areas and contains recommendations for re- search and for application of new technologies to improve operational safety. Major recommendations are presented here in summary format. Chapter 10 con- tains the committee's complete conclusions and recommendations. RISK IN THE MARINE OPERATING ENVIRONMENT Major Findings Although marine transportation entails risks, acceptable levels of operation- al risk have not been established by marine safety authorities. Risk factors are numerous and complex and their interactive effects are poorly understood; con- sequently, acceptable levels of risk are determined subjectively and vary widely among localities. Furthermore, because of the complexity of the marine operat- ing environment, there are substantial differences in operational risk and expo- sure among vessels, even within the same port and waterways complex. Im- proved safety depends on understanding and effectively addressing these risk factors. The available marine safety data are insufficient for quantitative assess- ments of risk and safety performance. The problem is exacerbated by the lack of an acceptable methodology for normalizing data across ports or regions to en- able comparative analysis. For these reasons, casualty rates are imperfect indica- tors of safety performance. Few statistically valid assessments are publicly avail- able about the probable contributions of various measures intended to improve navigational safety. Nevertheless, existing safety data, together with anecdotal information and expert opinions, provide a reasonable basis for informed prob- lem identification and decision making. The impressions of marine pilots nationally and internationally and some data suggest that the numbers of substandard foreign-flag ships and crews are increasing and that some classification organizations (the bodies that establish and enforce standards for ship construction and maintenance on behalf of many flag states) are not applying adequate construction standards and are not ensur- ing adequate maintenance. However, there are no systematic national or interna- tional monitoring programs to detect vessels that increase risk. The full extent and effects of these safety hazards can only be surmised, but the evidence is

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EXECUTIVE SUMMARY s sufficient to have stimulated national and international consideration of correc- tive measures. Solutions that reduce risk in one operating environment may not achieve equivalent results in another. Inappropriately applied solutions can increase risk, as can a proliferation of marine equipment without technical or performance standards to guide their manufacture, configuration, and use. Although such risks can be reduced by establishing standards, by using ergonomic designs, and by educating and training mariners, it is more difficult to deal with unforeseen and unintended consequences of implemented solutions. Consequently, system-wide remedies to problems identified in marine navigation and piloting need to look beyond intended effects in order to identify and address the broader array of effects that might also result from the proposed solution. The Oil Pollution Act of 1990 and subsequent rules and legislation substan- tially increased the economic cost of marine pollution incidents to polluters and provided for other measures intended to enhance marine safety and environmen- tal protection. These changes have produced substantial incentives for shipping companies to reduce operational risk through improved ship construction, navi- gational procedures and equipment, and professional development. However, there is no systematic program to monitor shipping, economic, and safety perfor- mance trends or their relationship to marine safety laws and regulations or other options for improving marine safety. Such monitoring and assessment programs are essential. Summary Recommendations The U.S. Coast Guard, National Oceanic and Atmospheric Administration, Maritime Administration, and U.S. Army Corps of Engineers should cooperate in developing a standard methodology for assessing risk and safety performance and establish a continuing risk assessment program. They also should undertake a cooperative, multidisciplinary research program to investigate the interaction of the essential elements of a highly reliable, complete, and safe marine naviga- tion and piloting system in order to better understand risk relationships. The Coast Guard should review and improve its capability to collect, analyze, and publish marine safety data on casualties, accidents, incidents, and near misses so that comprehensive safety performance data are available to guide improvements in marine navigation and piloting. HUMAN SYSTEMS Major Findings Because human error is a major causal factor in marine accidents, counter- measures must focus on areas in which human actions are paramount: navigation

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6 MINDING THE HELM and pilotage. Human performance can be improved by combining improvements in professional development, the organizational structure for decision making, and technology. There is growing concern over the professional development of ship's offic- ers and pilots, especially those who direct and control the movements of tankers, and over the qualifications of licensed operators and pilots of coastwise towing vessels, especially tank barges. Programs for acquisition of theoretical knowl- edge and entry-level navigation and piloting skills range from training provided through accredited undergraduate programs at maritime academies to appren- ticeships and on-thejob training. The last two play a major role in the shipping and towing industries, in ferry operation, and in marine piloting. The proficiency of crews of foreign-flag ships varies and is less certain than that of U.S.-flag crews. One consequence is that public safety and environmental protection au- thorities, especially at the state level, increasingly rely on the services provided by marine pilots to reduce operational (and environmental) risk. This is done through the presence of the pilots and through the application of their expertise. The expertise needed to serve as a marine pilot includes basic maritime theoretical knowledge and practical skills; local knowledge (such as routes, traf- fic conditions, seasonal variations); shiphandling skills; familiarity with techni- cally advanced equipment; and the ability to assess the capabilities of masters, mates, and bridge personnel and to interact effectively with them. On-thejob training usually consists of progressive advancement in knowledge about routes and categories of ships. Although U.S. merchant marine officers are generally well qualified for navigation at sea, their capabilities for navigation and piloting in pilotage waters vary considerably based on navigation and bridge team expe- rience, shiphandling opportunities, and continuing professional development op- portunities. Modern shipboard responsibilities often do not allow masters and mates to develop the broad-based proficiency in vessel maneuvering needed to serve as independent marine pilots without an apprenticeship designed for this purpose. Towing industry experience normally provides extensive opportunities to handle vessels and to become familiar with local routes, but it does not pro- vide shipboard experience. Therefore, an apprenticeship program is required even for seasoned mariners wishing to enter the marine pilot profession. Standards for entry-level education, training, and continuing professional development for all pilots have tended to be more informal than formal, although well-developed curricula are used by some state pilot associations. Periodic re- fresher training has been gaining momentum, particularly with respect to ship- handling in special conditions. The number of pilot associations that have estab- lished continuing professional development programs for their members has increased considerably in recent years. Some pilot associations have made substantial investments in continuing professional training programs (generally funded through pilotage fees) to en- hance member proficiency and have used these programs for some time. Interest

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EXECUTIVE SUMMARY 7 in such programs is growing throughout the piloting profession as a response to public concern over the safety of marine transportation. Although informal monitoring of pilot performance is provided to some extent by colleagues, there is no systematic recertification or professional moni- toring that could detect or prevent substandard performance in pilotage. Defi- ciencies in pilot knowledge and skills, or personal problems that adversely affect performance, are often identified only after a marine casualty occurs. U.S. shipping companies and large towing industry companies generally have continuing professional development programs, as do a growing number of marine pilot associations. These programs, in the absence of standards to guide their development and use, vary in format and function. Most are not accredited or assessed for effectiveness. Marine simulation training is used in some pro- grams to refine navigation and piloting skills, to promote and improve bridge team management, and to develop and practice emergency shiphandling proce- dures in a benign environment. Computer-based and manned-model simulation training technologies are widely considered useful, but their use in marine li- censing currently is limited and evolving. Official oversight of practical skill development is lacking in the federal marine licensing regime for masters, mates, and pilots. Professional develop- ment programs for mariners and marine pilots need to be improved, and each individual's navigation and piloting knowledge and skills need to be periodically refreshed, upgraded, and confirmed. Professional weaknesses and problems need to be identified and corrected before they cause or contribute to marine acci- dents, but formal advance detection measures are meager. Ship bridge simula- tion to detect weaknesses in professional abilities has been used to a limited extent by a few operating companies. After-the-fact official discipline by the Coast Guard or state pilotage authorities, while currently an important tool, is only effective if it also leads to remedial action. Roles and functions are relatively well defined for masters, mates, and pilots on the traditional ship bridge. Although bridge-to-bridge radio communications have improved the coordination of vessel interactions, the lack of a formalized organizational structure for interdependent decision making in ports and water- ways creates opportunities for human error. Complicating factors are the rapid advent of new ship-bridge configurations, navigation equipment, steering equip- ment, and integrated systems, all of which are beginning to appear aboard some new ships. The rapid evolution of advanced electronic navigation and piloting technology calls for new knowledge and skills, in turn increasing the need for continuing professional development, and perhaps for new organizational struc- tures on ships. Acquiring the requisite skills can be especially difficult for ma- rine pilots who are presently exposed to these new technologies on the job rather than through training programs. Although advanced navigation and vessel-control technology may provide improved means to navigate and maneuver in pilot waters, training in using a

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8 MINDING THE HELM resew technology often lags behind its introduction aboard ships. This weakness in training opportunities is especially true for many independent marine pilots who may not have occasion to use a new technology in their work or may use it too infrequently to ensure familiarity and proOcier~.cy. Since pilots may en.coun- ter an advanced technology for the first time while providing p~lotage, it is im- portant that entry-level. and continuing professional development programs ac- con~modate technological changes soon. These programs also need to continue to build and refine traditional skills that remain essential to piloting. Also needed are examinations of changes in organizational structures necessitated by these new technologies.. As navigators attempt to become familiar with advanced technologies on the job, there is the potential for technology assisted marine accidents. Such a phe- nomenor~ occurred in the form of radar assisted collisions in an earlier era. The potential for human error cart be aggravated by the introduction of new technol- ogy and by bridge configurations that force the use of this technolo~v before its reliability and accuracy are confirmed. Summary Recommendations Training programs should be developed. concurrently with the introduction of new technology, and mariners should be trained in the use of this technology. These technologies should be carefully used in conjunction with traditional nav- igation methods to ascertain the new technology's suitability and reliability for application in pilotage waters. Mariners should also be apprised of changes In roles, functions, and organizations that can result from introduction of this tech- nology. Pilotage authorities and marine pilot associations should make provi- sions to familiarize marine pilots with the capabilities arid general use of flew navigation technologies and with any new organizational forms that result. The Coast Guard should encourage the International Maritime Organization to adopt standard training procedures to facilitate the introduction of new navigation and piloting technologies into pilotage practices. The Coast Guard and the Maritime Administration should: update prior assessments of marine simulation to deter- m~ne the technology's capability and suitab~.~.ty for marine training and lacers ing. All pilotage authorities and marine pilot associations should consider the use of marine simulation as a means for improving pilot professional knowledge and skills, consistent with the current level of capabilities and instructional de- sign.

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EXECUTIVE SUMMARY Pilotage Practice 9 MARINE PILOTAGE Major Findings Marine pilotage in the United States has been the source of much controver- sy for many years. Although the operational performance of pilots is an impor- tant consideration, safety is sometimes a surrogate for economic issues that often underlie and stimulate controversy in pilotage. Particularly contentious issues are the form and manner of pilotage administration. Well-defined battle lines have been drawn between advocates of state and federal pilotage, yet there is no common reference for comparative analysis. Effective piloting is essential for navigational and environmental safety. A pilot provides expert knowledge about ship behavior; local operating conditions; limitations of other traffic; and local procedures in the pilotage area for which the pilot is licensed, because a master's corresponding knowledge of these ma- neuvering [actors is normally limited. The pilot normally directs and controls the vessel's maneuvering and is subject only to the overriding command authority of the master. When tugboats have to be used to assist with maneuvering, the pilot provides the necessary understanding of local operating practices and knowledge about tug performance and limitations Traditionally, these services are provided by independent marine pilots, although in the United States the master or a mate aboard a U.S.-flag coastwise vessel may serve as pilot if licensed by the Coast Guard to do so. Ship masters and senior mates serving permanently aboard the same vessel or sister vessels on regular routes can potentially achieve high levels of piloting expertise for their vessel over these specific routes. Under these select operating conditions, these individuals may be more familiar with the vessel's behavior than a marine pilot, although the pilot would have more extensive knowledge of local operating conditions. This must be balanced against shipping practices that over the past several decades have eroded the potential for masters and mates to acquire port-specific and vessel-specific pilotage expertise, except for on some coastwise vessels such as U.S.-flag tankers operating between U.S. ports. In order to reduce exposure to risk, some operating companies obtain marine pilots' services as an additional resource to enhance the overall safety of the passage even when officers aboard U.S.-flag ships are licensed to provide own-ship pi- lotage. A combination of professional licensing, professional discipline, profession- al and official oversight, and responsiveness to vessel operator interests in reduc- ing risk is necessary to achieve effective and efficient pilotage and full account- ability to the pilotage profession, users of pilotage services, and the public. Yet, significant gaps exist in official accountability. These gaps are particularly ap

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10 MINDING THE HELM parent with regard to docking, undocking, mooring, and intraport transits for some foreign trade ships in some localities. Furthermore, there is considerable variability with regard to the features and functioning of pilotage systems in different localities in the United States. Despite these gaps, however, pilotage in the United States is for the most part safe. Formal requirements and informal professional development policies vary considerably for individuals providing pilotage services. Professional develop- ment of marine pilots holding only federal licenses and of docking masters is an individual responsibility, although development criteria often are established in- formally by associations or companies with which pilots are affiliated. The Coast Guard, as licensing authority, has not provided oversight or monitoring of pro- fessional development and performance; these functions are left to the discretion of operating companies. Accountability with respect to pilot performance has been achieved through Coast Guard disciplinary proceedings following marine accidents. In most state pilotage jurisdictions, the professional development of marine pilots is the responsibility of pilot associations, although training and qualifica- tion requirements usually are set by a pilotage board or sometimes through legis- lation. Competence and proficiency are enhanced in varying degrees through selection, training, licensing, official discipline, and administrative organization. The dual system of federal and state pilotage and pilot professional develop- ment programs are not designed or organized to ensure equivalent competence and proficiency within each pilotage area. In practice, however, marine pilots and docking masters who are members of pilot or docking master associations generally achieve equivalent expertise through the combined effect of pilotage administration, professional development, and operating practices. There are no adequate data or methodologies for comparing safety perfor- mance for different pilotage functions, categories of pilots, or pilotage systems across localities. However, the committee found no compelling evidence to sug- gest wide disparities in safety performance among organized associations of marine pilots and docking masters. This finding also applies to those U.S.-flag ship's officers who possess a federal First Class Pilot's License or endorsement. Pilotage Standards There is an urgent need in pilotage for consistent application of high profes- sional standards in every pilotage area as a defense against substantial variability in master and bridge team qualifications of foreign-flag ships. Although marine pilots, docking masters, and mooring masters typically provide effective pilotage services, there is considerable variability in the development of requisite skills and local knowledge. There is also considerable variability in the provision of professional and official oversight across all pilotage jurisdictions. It is possible for degraded piloting skills or other problems affecting individual performance

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EXECUTIVE SUMMARY 11 to go unrecognized until an accident occurs. Nationally accepted guidelines or baseline standards are needed to guide and assist pilot associations and pilotage authorities in pilot selection, training, licensing, professional oversight, and pro- fessional and official discipline. Nationally accepted standards for the composi- tion and accreditation of pilotage boards are also needed to assure that appropri- ate interests and subject matter expertise are represented. Notwithstanding the need for highly specific local requirements for pilot qualification and perfor- mance, a national approach to upgrading pilotage systems with respect to the central features of complete pilotage systems (see Chapter 3) is needed to pro- vide a solid foundation for pilotage performance in each port and between ports. Such an approach can acknowledge, through establishment of an "own-ship" pilotage option for U.S.-flag ships only, that given certain operating conditions and individual experience levels, masters and experienced mates of U.S.-flag ships may be suitably qualified to pilot their vessels. Effective use of the own- ship pilotage option relies on both the vessel and the person piloting the vessel being directly subject to U.S. flag-state authority and U.S. port-state control. This pilotage option would address both the public needs for safety and the economic concerns of operators of U.S.-flag ships. Jurisdiction and Licensing The division of pilotage jurisdiction in the United States is the product of the political and legislative processes. Although safety considerations are associ- ated with decisions to require pilotage, jurisdiction is determined by a vessel's trade (domestic or foreign, based on cargo source and destination) rather than according to safety needs or the capability of governing authorities to satisfy them. State pilotage applies to all vessels in foreign trade. Federal pilotage ad- ministered by the Coast Guard applies to U.S.-flag vessels in domestic trade (referred to as "under enrollment") and can be applied to foreign trade vessels if a state does not exercise primary jurisdiction. As a result, there are substantial differences in pilotage requirements and administration, as well as duplication of staff and other costs. At the same time, the pilotage infrastructure has difficulty in adjusting to rapid change. This is the result of the long time required to build pilots' expertise, the limited access nature of port-level pilotage that constrains relocation of pilots to other pilotage jurisdictions, and the lack of other work that is suitable for pilots displaced by economic and technological changes in ship- ping. The federal pilotage program has important features but lacks key elements that would make it a comprehensive pilotage system. Its important assets are its consistent nationwide organizational structure; basic, albeit minimal standards for licensing; approval processes for professional development programs de- signed to satisfy criteria for an original First Class Pilot's License; and a disci- plinary process. But the federal program lacks quality assurance in training,

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4 MINDING THE HELM public interests. It should also develop accreditation procedures for marine pilot- age and for vessel traffic services (discussed later). Periodic performance review should be conducted to ensure that goals and objectives for the commission are being met. The Department of Transportation, through the Coast Guard, should convene navigation and piloting safety advisory committees in each port com- plex or region if they are not already in place. These committees should provide expertise in support of marine traffic regulation by the Coast Guard and pilotage administration by pilotage authorities. Pending development of nationally accepted standards for the piloting pro- fession, all pilotage authorities should examine and improve their pilotage pro- grams with respect to professional development, professional and official ac- countability, standards of the profession, and infrastructure. Action on the aforementioned recommendations should proceed without delay. The pilotage recommendations in the following paragraph also represent a consolidated approach that must not be implemented separately. The order in which these recommendations are implemented is also important. The recom- mendations contained in the following paragraph should be implemented only after the preceding pilotage recommendations which address the essential ele- ments necessary for an effective single marine pilotage system in the United States, are in place and functioning to expectations. This approach and imple- mentation timing are necessary to ensure (1) harmony and fair treatment in the recommended approach, (2) comprehensive and consistent application of pilot- age policy, and (3) the effective integration of all essential pilotage system fea- tures. After a national commission is in place and functioning to expectations, and after universal standards of the profession, pilotage system accreditation, and port-level navigation and pilotage safety advisory committees are established, then a single marine pilotage system should be established for each port and waterway system. The system should be guided by national standards and ac- credited under procedures of the national commission but overseen locally by a nonfederal public organization with balanced membership representing the pan- oply of interests in pilotage. This organization should have authority to shape pilotage rules to meet regional and local needs. The system should include provi- sions for the master and mates of U.S.-flag ships to qualify for route-specific and vessel-specific pilotage credentials, federal or state, authorizing them to pilot the vessels on which they serve but making them subject to rigorous local require- ments. Ultimately, the own-ship pilotage option should be consolidated under the single port-area pilotage system and made subject to rigorous local stan- dards, but it should be accredited to national criteria to ensure fair treatment. Independent marine pilots that hold only federal licenses should be brought into the port-level pilotage system as it is established. Federal requirements for a First Class Pilot's License or endorsement should be converted into a Coast Guard-administered national entry-level certification program that prospective

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EXECUTIVE SUMMARY 15 marine pilots must satisfactorily complete as a prerequisite to further pilotage . . training. Coastwise Tugs and Tows Pilotage in the towing industry should be part of the fabric of the national port-level system. However, official oversight and administration should remain the responsibility of the Coast Guard. The Coast Guard should collect empirical data that are needed to assess the effectiveness and safety of navigation and piloting, with attention to pilotage in the towing industry. The Coast Guard should periodically use these data to evaluate program effectiveness. Adminis- tration and standards of pilotage for towing industry vessels should be strength- ened with regard to individuals who by federal regulation may "act as" pilots without a pilot's license. The Coast Guard should establish and enforce proce- dures to ensure compliance with applicable requirements and standards. Stan- dards that should be strengthened include the amount and recency of experience in the actual handling and navigation of towing vessels and barges under varying conditions and on specific routes. The towing industry should examine the feasi- bility of establishing an industry-sponsored, accredited training program as a means to ensure competence and proficiency of towing vessel operators. WATERWAYS MANAGEMENT Major Findings Port State Control The volume of foreign-flag ships is of particular concern in improving safe- ty performance, as there is growing evidence for some foreign-flag vessels of substandard conditions with respect to maintenance, bridge team composition and professional qualifications, and navigation and safety equipment. These con- ditions increase the risk to life, property, and the environment. The United States does not oversee the construction or maintenance of for- eign-flag ships or the qualifications and performance of their masters and bridge teams. Further, the United States lacks a large merchant marine that could be used to force change in foreign-flag merchant fleets through competitive forces. However, the construction, outfitting, and operation of foreign-flag vessels are strongly influenced by enforcement of international standards, insofar as these standards are incorporated into national laws. Unilateral measures, such as spe- cial construction or equipment requirements as a prerequisite for entry into U.S. waters, also are used to satisfy national interests in marine safety. International efforts to counter substandard conditions rely on consultative relationships and enforcement of international protocols by flag-states and port

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16 MINDING THE HELM states. The United States can enhance this effort by exercising its port-state prerogatives strongly, including use of new port-state authority for the inspec- tion of crews that is being promulgated by the International Maritime Organiza- tion. The United States, through unilateral measures, can also profoundly influ- ence change in ship structures (for example, by requirements for double hulls), material condition, and operating practices of foreign-flag vessels. Both the fed- eral and state governments have a direct and compelling interest in the require- ments for, and effectiveness of, the navigation and piloting of foreign-flag as well as U.S.-flag vessels in U.S. navigable waters. Marine Traffic Regulation Management of U.S. ports and waterways systems consists of overlapping and informally coordinated functions. The movement of a vessel is an indepen- dent action that is largely uncoordinated with other marine traffic operating in a particular area. Advisory committees, chartered locally or by the Department of Transportation, are available in a few ports, and they have provided for informal coordination and improved working relationships in terms of waterways man- agement issues. No single organization has the responsibility for either coordi- nating vessel operations and movements to enhance safety or for improving efficiency within each port area. A major benefit of VTS applications within the VTS service area-improve- ment in general order and predictability is realized through the establishment of area-wide standard operating procedures and communications protocols. These features also help establish radio discipline. The U.S. Coast Guard has substantial authority for marine traffic regulation, including time and space management and direction of specific actions by ves- sels, such as those carrying certain hazardous or dangerous cargoes. This author- ity is applied sparingly and selectively to promote safety, even where the Coast Guard operates VTS systems. Ensuring economic efficiency is not an agency . . mlsslon. A small number of East and West Coast marine pilot associations and at least one marine exchange also operate VTS systems or VTS-like services with voluntary participation. Some of these systems provide navigational information only, while others sometimes provide maneuvering assistance to association members (for pilot-operated systems) and occasionally to inbound or outbound vessels. Two pilot associations on the Gulf Coast coordinate the movement of large vessels under operating agreements with local maritime interests. Although there are no national standards or protocols to guide VTS opera- tions and administration, the Coast Guard conducts internal reviews of its VTS operation manuals and regulations to ensure consistency with the International Maritime Organization's VTS guidelines. However, the Coast Guard does not

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EXECUTIVE SUMMARY 17 oversee, or set standards for, VTS systems or VTS-like services that it does not operate. Bridge-to-bridge voice radio communications is widely acknowledged as a major factor in improving operational safety in ports and waterways. The inten- sive use of voice radio in VTS operations for communicating transit and traffic data between and among vessels and to and from a VTS is inefficient, except for the most important and perishable of information. Such use of voice radio intro- duces the potential for additional human error through information overloading of bridge teams and pilots, and it can potentially interfere with bridge-to-bridge communications initiated to resolve emergency situations. VTS-user interac- tions can be facilitated by adaptation of electronic data transmission technolo- gies that provide essential information in a form conveniently used aboard each vessel. With adoption of such technology, a VTS system could serve more as a safety observer than as a traffic regulator, unless traffic management were re- quired specifically as a routine VTS function or indicated by urgent circumstances. Air traffic control is not analogous to marine traffic regulation; there are major differences in the operating environments. Yet, many features of the avia- tion model are adaptable to marine conditions. A national marine traffic regula- tion system could be established generally using the linked network concept found in the aviation sector. Introduction of most features that could be adapted from the National Airspace System would require the widespread introduction of new operating procedures and highly advanced technology, and are thus suited to international implementation to achieve universal application. Summary Recommendations Port-State Control The Coast Guard should continue to augment its efforts to identify substan- dard vessels and take whatever action is necessary to enforce compliance with applicable international guidelines and U.S. requirements. Procedures should be established for reporting observed or suspected substandard conditions or inade- quately crowed vessels that pose unacceptable operating risks. Provisions should be made to improve cooperation among the U.S. coastal states and the federal government in reducing risks that involve foreign-flag shipping. Marine Traffic Regulation All VTS systems and VTS-like services (including vessel information sys- tems) should be accredited to international and national operational and perfor- mance standards. A national commission on pilotage, navigation, and waterway safety should be responsible for developing and promulgating standards and for accreditation. Government-operated and privately operated VTS systems and

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IS MINDING THE HELM VTS-like services should be expanded and improved to reduce operational and environmental risk. This effort should be promoted by the Department of Trans- portation. VTS operations should extend seaward of pilot boarding areas, where feasible, to guard against navigation and operational errors when approaching piloting waters. The Coast Guard should operate VTS systems where these systems are used as the means to execute or enforce federal marine traffic regulations. All private- ly operated VTS systems and VTS-like services should be authorized by the Department of Transportation. The Coast Guard should establish or authorize a national training course for VTS instructors and an entry-level course for VTS personnel. The Coast Guard, Army Corps of Engineers, and local advisory bodies should participate in determining special operational criteria for proposed vessel operations that present significant operational, environmental, or public health risks. The Coast Guard should assess the application of interactive electronic data transfer in VTS operations to reduce reliance on voice radio for information transfer and to improve VTS-user interactions and onboard interpretation of traffic information. This assessment should be coordinated with the Maritime Administration, the Federal Communications Commission, Army Corps of En- gineers, and the Radio Technical Commission for Maritime Services. NAVIGATION AND PILOTING TECHNOLOGY Major Findings Introduction of New Technology and Performance Criteria Innovations in navigation technology hold significant potential for reducing operational risk and improving safety performance. However, significant imped- iments exist that constrain full beneficial application of emerging high-technolo- gy navigation systems. The structure and process for introducing and using new technologies need to be modernized rapidly to accommodate improvements in operational capabilities. Electronic charting systems are rapidly being introduced for marine use and will be an essential part of integrated bridge systems. Electronic charting sys- tems have the potential to improve navigational safety and to significantly re- duce operational risk through the accurate and instantaneous display of a ves- sel's position. Electronic charting systems that consist of at least an electronic chart and real-time position data, and which meet legal requirements for naviga- tion, could achieve universal.commercial use following the examples of radar and very high frequency radio, although international action may be required for this to occur. Electronic Chart Display and Information Systems (ECDIS) will have the essential features to achieve real-time position-keeping benefits and by

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EXECUTIVE SUMMARY 19 international and national definition be considered equivalent to paper charts for . . . use in navigation. Although some advances in operating practices and technology can be intro- duced by operating companies and professional associations, there are few obvi- ous economic incentives for doing so. Furthermore, the existing marine naviga- tion and piloting system does not facilitate the introduction and use of new technologies. The operating practices, laws, regulations, and legal precedents that form the organizational structure in which change occurs are based princi- pally on older practices and technologies. This structure evolved; it was not designed nor is it well suited to foster or support the introduction of new and innovative approaches and technologies. Further, new technologies are being developed faster than are the technical and performance standards needed to guide and facilitate their use. The introduction of new technologies likely will be uncoordinated unless systematically guided at the international level through technical and perfor- mance criteria. It will be complicated by competitive factors and operating prac- tices. Technology introduction will also be complicated by existing institutional and legal requirements for use of traditional charts and navigation practices. The existence of numerous manufacturers will result in a proliferation of electronic charting systems that may or may not meet ECDIS standards and configurations. Such equipment, when introduced into the world's merchant fleets, will compli- cate greatly the efforts of marine pilots to familiarize themselves with, much less operate, these systems. Marine pilots may have to rely to a much greater extent on the watch officer to set up and manipulate the display. This situation may reduce safety, especially if there are language difficulties. The full prospective benefits of the new technologies, especially ECDIS, are not likely to be gained in the near term unless deliberate measures are taken to promote the introduction of these technologies. Such measures must include establishment of technical and operating standards, as well as professional train- ing for those that will be expected to utilize fully the systems' capabilities. Pilots are expected to work safely and efficiently with shipboard navigation equipment that reflects the full spectrum of available technologies. Marine pilots can play an important role in the introduction and use of today's advanced navi- gation technologies by becoming familiar with and validating their capabilities for application in piloting waters. As new systems are developed, the demands on pilots increase. It is therefore desirable to put all ships on an equal technolog- ical "footing," at least in U.S. pilotage waters. This can be accomplished by onboard installation of suitable technologies that meet appropriate performance objectives, by developing hand-carried systems for use by pilots, or by a combi- nation of the two approaches.

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20 Hydrographic and Topographic Data MINDING THE HEEM Tide, current, and weather information are not available in real time except in select locations, nor have techniques been perfected for sensing changes in marine weather conditions. Tide and current prediction tables often are derived from survey data that are decades old. Hydrographic data for much of the na- tion's coastal waters were collected using single-position measurements of depth (i.e., lead line soundings) rather than modern marine surveying equipment that provides comprehensive bottom profiles. The result is that chart data are sub- stantially less precise than are modern electronic positioning systems. Shipboard updating of charts is done manually using the changes published weekly by the Coast Guard and by the U.S. Army Corps of Engineers for inland waterway systems. Publication of updated charts by the National Oceanic and Atmospheric Administration is constrained by a substantial backlog of discrep- ancies, and there are no guidelines for setting priorities for making these correc- tions. Digital formats and procedures are available for preparing digital data for use with electronic charts, but digitizing the full chart portfolio will take 5-10 years at present resource levels. The legal status of electronic charting systems has not been resolved and may impede their wide-scale introduction. Positioning Systems A combination of Differential Global Positioning System (DGPS J technolo- gy and electronic charting systems appears to be the best available technical means for enhancing safety. This technology can provide instantaneous and ac- curate positions, steering guidance, automatic hazard warnings, and a permanent navigation record. ECDIS holds considerable potential for adding to this capa- bility. Improved accuracy and reliability of Automatic Radar Plotting Aid (ARPA) functions is possible though integration with automated periodic broad- casts of position, course, and speed by individual ships, referred to as automatic dependent surveillance (ADS). However, DGPS is not completely implemented. As previously observed, adoption of electronic charting systems is likely to oc- cur rapidly. However, universal adoption of combined systems that incorporate DGPS, ECDIS, ARPA, and ADS is not an immediate prospect. Integrated Bridge and Control Systems Effective use of an integrated bridge consistent with the practice of good seamanship may reduce operational risk. It consolidates the navigation, steering, lookout, and communications functions at one workstation, as is done in avia- tion. The traditional allocation of tasks and the nature of their interrelationships in the functioning of a traditional ship bridge seem straightforward, but the pro- cesses are complex, human-resource intensive, and can be error inducing. The

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EXECUTIVE SUMMARY 21 way these tasks are assigned leads to a dependence on voice communication and reliance on others to share functional responsibilities. Each of these factors pro- vides opportunities for error to occur. This is offset to some extent by monitoring and cross-checking that has evolved as a practice of good seamanship. Integrated bridge and control systems replace hu~nan-resource-intensive tasks with a sys- tem requiring fewer operators in the extreme, only one. However, the new bridge also requires new operating skills. Monitoring and cross-checking must be accomplished through technological means to offset the potential for "single person error." The integrated bridge has proved effective where (1) the person directing and controlling the vessel has expert knowledge of the system and the ship, (2) frequently pilots the ship on a route for which the individual is qualified as a pilot, and (3) a full bridge team is present. The suitability of one-person bridges for large ships operating in pilotage waters has yet to be proven. How an inde- pendent marine pilot would interface with this new bridge system is not certain. Full use of the system's capabilities seems to require either the integration of independent marine pilots into the bridge team, a non-traditional role, or a rede- fined working relationship between the pilot and the individual operating the integrated bridge. Integrated control systems may serve to reduce human error in the perfor- mance of many navigation tasks, as well as provide the means to reduce crew size. As automation decreases opportunities for hands-on experience, additional training may be required for the operators, so they can determine when integrat- ed systems are not performing within tolerances. Training may also be required to build skills for taking corrective action. While reduced crew size may be satisfactory for operations on the open sea, decrements in already small bridge teams reduce the onboard resources for use in traditional navigation tasks, in- cluding hand steering. Hand steering is especially important, because when ma- neuvering, it may be more effective under certain operating conditions for the pilot or master to give rudder commands to a helmsman than to indicate a course to steer by autopilot. Traditional Aids to Navigation Navigators continue to rely heavily on traditional short-range aids to naviga- tion, principally buoys and ranges. The usefulness of these aids often is compro- mised when most needed, that is, during heavy sea conditions and low visibility. The problem is being addressed by Coast Guard efforts to improve visibility of these aids and to advance the development and use of DGPS. There is little effort to develop electronic ranges that are similar in concept to the localizer systems that are used in aviation for approaches to airports. Traditional aids to navigation will continue to play a central role for the foreseeable future, particularly for pilots. While the degree of reliance on these

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22 MINDING THE HELM aids depends on the operating environment, pilots will find them essential, as points of comparison, for determining the reliability of advanced navigation sys- tems in piloting waters. Visual and lighted ranges will continue to be particularly important in restricted waters; enhancements to improve the ability of mariners to discern ranges are needed. Summary Recommendations Introduction of New Technology The Coast Guard should strongly encourage the development and updating of international technical and performance criteria and corresponding national standards and criteria for advanced navigation systems. This is needed to pro- vide a solid foundation for the systematic introduction of these new systems. The Coast Guard should evaluate empirically the impact of advanced electronic posi- tioning systems, automated steering systems, and integrated bridge and ship con- trol systems on marine safety, piloting practices, use of traditional aids to navi- gation, and organizational forms and practices that may be required for safe navigation in the future. The Coast Guard and the Maritime Administration should encourage the development and enhancement of integrated navigation systems. These two agencies, the National Oceanic and Atmospheric Adminis- tration, and the Army Corps of Engineers should also examine and encourage development of improved environmental information systems as well as chart updating and correction systems. Institutional Considerations Laws and regulations addressing operational requirements for navigation and piloting technology should be based on performance objectives rather than equipment-based criteria, so the full operational benefit of the technologies can be obtained and innovative research and development are not inadvertently con- strained. The Coast Guard and the Maritime Administration should continue research to identify technical and operating standards for new navigation and piloting technologies. These agencies should be joined by the National Oceanic and Atmospheric Administration and the Army Corps of Engineers in reviewing laws, regulations, and policies that are impediments to the introduction and ef- fective use of promising navigation and piloting technologies. The agencies should modify policies and regulations under their jurisdictions to remove im- pediments and should recommend to Congress any changes necessary in en- abling legislation.

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EXECUTIVE SUMMARY Hydrographic and Topographic Data 23 The National Ocean Survey should improve its capability to conduct sur- veys with modern equipment in all U.S. ports, waterways, and port approaches. The Department of Commerce should fund this effort at a level that would rem- edy current shortcomings in hydrographic and topographic data that inhibit the full implementation of electronic navigation systems. The National Oceanic and Atmospheric Administration should accelerate efforts to digitize these data for producing electronic nautical charts and should lead an effort to resolve the legal status of electronic charts provided by either the agency or vendors using agency data. Positioning Systems The introduction of electronic charting and precision navigation systems suitable as onboard aids to enhance navigation safety should occur as soon as practical, consistent with the applications for which this technology is appropri- ate and with the development of the supporting infrastructure that is necessary to enable its effective use. Training should be provided concurrently with the intro- duction of the technology, as discussed earlier. The Department of Defense should establish fully the Global Positioning System (GPS) at the earliest oppor- tunity, and the Coast Guard should accelerate establishment of DGPS. The De- partment of Defense and the Department of Transportation should develop a long-term operating and maintenance plan for GPS to ensure its continued avail- ability once it is fully established. Traditional Aids to Navigation The Coast Guard should maintain and enhance shore-range aids to naviga- tion that support traditional and evolving navigation technologies and should continue efforts to improve visual and electronic acquisition of buoys during unfavorable operating conditions. The feasibility of electronic ranges and dis- tance-measuring equipment for specialized local use should be examined. MARITIME RESEARCH AND DEVELOPMENT Major Findings The substantial and rapid changes in ship and navigation technologies, man- ning, and operating practices have created uncertainties about the performance of virtually all systems in marine transportation. The available research literature is limited and primarily focuses on ship construction and technology. The Coast Guard's applied technology research is current with technologi

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24 MINDING THE HELM cat developments, but there has been little practical improvement in safety dat except to make the agency's existing marine data bases internally compatible. Although human error is a major factor in accidents, very little research is avail- able on maritime human systems and safety performance. The studies that do exist are often based on data not designed to answer questions about human performance. The Coast Guard's vastly improved data-collection program for human causes of marine accidents is ongoing, but the availability of human- systems data to support empirical analysis is at least several years in the future. Pioneering work in human systems that used marine simulation, that was spon- sored by the Maritime Administration and the Coast Guard, has become outdat- ed in the absence of dedicated, continuing research to identify trends and assess their effects and implications. At the same time, operation of the Maritime Ad ministration's Computer Aided Operations Research Facility has been priva- tized, resulting in a change in focus from fundamental research to training and applied research. There also have been severe reductions in the agency's re- search funds. The overall result is that research pertaining to the organizational structure and culture of marine transportation is very limited. Summary Recommendations A program of dedicated fundamental research is needed to address marine systems safety, waterways management, navigation and piloting technology, port-state versus flag-state policy, navigation and piloting practice, and human systems. Such a program would generate great benefits in terms of marine safety and economic efficiency. The research needs are substantial and, as they span the missions of the Coast Guard, the Maritime Administration, the National Oce- anic and Atmospheric Administration, Army Corps of Engineers, and the Na- tional Transportation Safety Board, a comprehensive cooperative research pro- gram is recommended. In view of the Department of Transportation's responsibilities for marine safety, and the research capabilities of its agencies and their ongoing navigation technology research programs, an appropriate agen- cy from the department should coordinate federally-sponsored marine naviga- tion and piloting research.