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APPENDIX D A Review of Pilotage Studies Covering U.S. Navigable Waters Numerous navigation and piloting studies, analyses, and investigations have been undertaken in the past 50 years. Several of these studies addressed safety issues, state and federal piloting-safety records, pilot governance, and piloting practice, as well as developed empirical piloting-safety measures. A review of these piloting and navigation references is presented in this appendix (Box D-1 J. These studies were reviewed and considered by the committee. In some cases, the studies formed the historical context within which the committee conducted its work; in other cases, the studies represented current and recent past assess- ments that addressed issues of import to the committee. The reports reviewed have been grouped by general topic headings, although many topics and reports overlap. The topic groupings in this appendix include state and federal pilot issues, port-level safety analyses, pilot governance and administration, vessel safety, piloting practice, and analyses of marine accidents and incidents. Many of the studies are limited by their reliance on the data available to support these investigations- primarily from the Coast Guard's au- tomated main casualty (CASMAIN) data base. As has been noted before, these data are incomplete and inadequate for assessing the safety of navigation and piloting. (Research needs with respect to safety data are discussed in Chapter 8.) STATE AND FEDERAL PILOT ISSUES Comparisons of state and federal protege have been conducted for a number of years. For instance, in 1942, the U.S. Coast Guard, at the request of the Navy Department, conducted an analysis of pilotage in the United States that included 360

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A REVIEW OF PILOTAGE STUDIES 361

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362 APPENDIX D a comparison of state and federal pilots and piloting practices (USCG, 19423. The Committee on Advances in Navigation and Piloting reviewed a number of studies addressing federal and state pilot issues: the 1942 Coast Guard study, three different approaches to weighing state versus federal pilotage (Booz, Allen and Hamilton, 1991; Leis, 1989~; and a rebuttal to the Booz, Allen and Hamilton report, Leis (19921; a National Transportation Safety Board report (NTSB, 1988a), and a Coast Guard rebuttal to that 1988 report (USCG, 1993c). 1942 Coast Guard Study The 1942 Coast Guard study delineated the following assets and liabilities of the state and federal pilotage systems: Assets of the State Pilot Systems It has withstood the test of time. Since 1912, no attempt has been made to wrest control of pilotage of registered vessels away from the states (Ashe, 1984; Parks, 1988), and the 1942 attempt, as well as previous attempts, failed because it could not be demonstrated that such changes were either necessary or benefi- cial to commercial interests. State pilotage has been maintained at a generally high standard. The long record of state pilot associations, taken as a group, is better than good. The state-licensed pilots, as a class, are responsible, proud of their work, and proba- bly at least as capable as the pilots of any other country. Weaknesses of the State Pilot System Lack of uniformity. Variation in the administration and operation of pilot groups was cited as a weakness of the state pilotage system, particularly "in a war, where its outcome depends on the safe and speedy movement of shipping." Rotary system. The practice of designating a pilot for a particularly diffi- cult job because it is his turn, rather than because he is the best qualified pilot available, was in use in 1942, as it is today. Compulsory physical exams and compulsory retirement as not common. The fact that very few states mandated periodic physical examinations for pilots, and that very few pilot associations set a mandatory retirement age, was consid- ered to be a weakness. . . . Weak leadership in some ports. Lack of internal discipline was cited as a weakness; in some ports, "men are unable to maintain efficient organizations." . Failure of some states to make pilotage compulsory in certain dangerous waters. The fact that the federal government had left it to the states to designate waters for which pilotage was compulsory for registered vessels was an issue cited in the report.

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A REVIEW OF PILOTAGE STUDIES Weaknesses of the Federal Pilot System 363 Pilot licenses, or piloting endorsements on officers' licenses, are renewed every 5 years, regardless of the length of time the applicant has been away from the pilotage waters in question. Physical examinations are required only at 5-year intervals, and there is no upper age limit. This weakness was also identified as a weakness of the state pilotage system. Suspension of a pilot grievously at fault is not immediate. Federal control over state-licensed pilots is by agreement only and is not complete. The report stated that in 1937, all 32 state pilot groups of the Ameri- can Pilot's Association were parties to a written agreement to voluntarily submit to federal investigation and disciplinary action, even though pilots were acting under the authority of state rather than federal licenses. The report said, howev- er, that it was doubtful whether federal action against a pilot acting under his state license could be legally sustained. Many of the issues identified and considered by the committee with respect to state and federal pilotage issues have not changed substantially in the past 50 years. The 1942 piloting study provides a useful background context for the committee's work, as it places the issues, and discussions about them that have occurred over the years, in a historical perspective. 1989 Battelle/American Pilots' Association Study In this analysis, performed by Battelle's Columbus Division for the Ameri- can Pilot's Association (APA), Leis (1989) sought to develop a relationship between the safety performance of state pilots and non-state pilots, both per- forming pilotage in port areas. State pilots were those designated in Coast Guard casualty data as holding a state license, or both a state license and a federal license; non-state-pilots were those performing similar pilotage functions, but "not qualified" for a state license. The report examined comparative perfor- mance as represented by pilot-caused accidents for each pilot group during the conduct of equivalent pilotage tasks. CASMAIN records were used as the basis of this study. Methodology Because data were not available for direct measurement of relative safety performance, the report developed a surrogate measure that would permit the comparative accident rate to be inferred; this "key factor" was computed as accidents occurring per ton of cargo transported. In this measure, accidents were defined as those involving vessel motion (i.e., dynamic accidents), and tons were defined as the tons handled in port areas as derived from the U.S. Army Corps of

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364 APPENDIX D Engineers Waterborne Commerce data. Key factors were evaluated for different port areas for each pilot group, and the ratio of these key factors, or the "key factor ratio," was used to infer relative safety performance. That is, the ratio of non-state-pilot key factors to state-pilot key factors was used as an indicator of relative safety performance. Key factor ratios were computed for (1) coastal port areas of the contiguous United States, viewed as a single port area; (2) 10 high-activity ports, viewed as a single port area; and (3) eight ports (New York, Baltimore, Philadelphia, Hamp- ton Roads, Tampa, New Orleans/Baton Rouge, Galveston/Houston/Texas City, and Mobile), each viewed as a single port area. (No West Coast ports were included in the third category.) Assumptions made in the report that tended to favor the state pilots were reported to have been adjusted so as to favor the non- state pilot group; thus, the report was characterized as examining a "worst case" scenario for state pilots. The methodology classified pilots by licensing authority, rather than by func- tion performed (that is, docking evolutions and bar, river, and harbor pilotage). Professional qualifications, risk exposure, performance of ship systems, and per- formance of navigation technology were not assessed. Safety performance in different operating environments was not normalized to accommodate variations in exposure to risk. Data screening relied heavily on tonnages as the predomi- nant comparison measure. Findings Based on the key factor analysis, the report found that non-state pilot groups had experienced 10 to 20 times the number of pilot-caused accidents as had state pilots. Because of the definition of key factor ratios, this result suggested that, for equivalent task exposure (i.e., an equal number of similar trips in the same environment with equivalent ships), the accident rate for non-state pilots could be expected to be on the order of 10 to 20 times higher than that of state pilots. Analysis The study had a number of limitations that would inhibit any broad applica- tion of its results. In data comparisons, no tests of statistical significance were reported. For example, in the Key Factor Analysis Trend (Figure 15 in the Bat- telle report), the key factor trend is shown to be shown to be increasing, although no tests of statistical significance are reported. The committee's review of the study's methodology showed that the num- ber of trips and tonnages accrued to the non-state pilot group had been reduced. For instance, the report assumed that in-port trips related to cargo movement (including trips to and from sea, dock shifts, and movements to and from anchor- ages) occurred in some proportion to the trips to and from sea and that this

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A REVIEW OF PILOTAGE STUDIES 365 proportion for in-port moves was the same for both pilot groups. This assump- tion is problematic, as there is no clear relationship between seagoing and non- seagoing trips (including anchoring, mooring, and docking evolutions). Further- more, non-state pilots handle the bulk of such intraport transits. Inclusion of this data would have favored the federal pilots, increasing the number of tons carried, with no change in the number of accidents. The report assumes that pilot task demands involved in movement of an average ton of cargo are the same for both state and non-state pilots. However, as the report notes, a transit is a combination of values and factors that determine the task demands of piloting. A measure of risk exposure for each pilot group would have provided a better assessment of safety and accidents per risk-expo sure mile. Although screening of casualty data was intended to favor pilots not holding state licenses, the approach appears to have substantially favored state pilots, as Alaskan oil movements were not included in the analysis. The stated reason was that inclusion of the data would have skewed the analysis because of the large tonnage of oil moved in that trade. However, ship's officers with Federal First Class Pilot's Licenses or endorsements for pilotage routes used by the Alaskan oil coastwise trade, state pilots in Alaska and in West Coast ports, and indepen- dent marine pilots holding only federal pilot credentials but who pilot foreign trade ships in certain California ports (Chapters 2 and 3) all are involved in piloting ships carrying Alaskan oil to U.S. ports. In addition, the report did not credit East Coast docking masters with the transport of substantial tonnages. This is relevant, because docking masters were assigned casualties but were not given credit for all transits in which no casual- ties occurred. Docking masters in some ports, by the nature of their work, would have been exposed to a significantly higher potential for groundings and alli- sions than state-licensed pilots, yet a full representation of their successful tran- sits was not included (see Chapters 2 and 3~. Additionally, the substantial num- ber of intraport movements under the sole control of docking masters was not credited to their performance. The "most influential and error-prone assumption," as characterized by the report, concerned the algorithms selected to allocate the Coast Guard's casualty data and the U.S. Army Corps of Engineers' tonnage data between the pilot groups. Casualty data were allocated on the basis of the information in the "pilot type" field in the CASMAIN records. If the pilot type was designated as state, the data was so directed. All other pilot types, including casualties in which the presence of a licensed pilot was not indicated (shown as "none" in the data field), were directed to the non-state pilot group, an approach the report said penalized this group. Subsequent analyses were performed in the report in which the "none" cases were distributed equally between state and non-state pilots. Another problem concerned the allocation of all foreign tonnage data to state pilots and all domestic, waterborne tonnage to the non-state pilots. In fact,

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366 APPENDIX D state pilots handle a large portion of domestic waterborne commerce. This data allocation penalized the state pilots. In view of these problematic assumptions, Leis (1989) recommended that state pilots, singularly or as a group, monitor and collect relative safety-perfor- mance data. Improved safety data would overcome the basic deficiency of the report's analysis the need to infer relative trips on the basis of tons. 1991 American Institute of Merchant Shipping Study The objective of this study, conducted by Booz, Allen and Hamilton in 1991 for the American Institute of Merchant Shipping (AIMS), was to comparatively assess state and federal pilot safety performance between 1983 and 1988. Safety levels for each group were developed using the ratio of the number of dynamic casualties involving pilots to the relative risk faced by pilot group. Although addressing one of the limitations of the Leis (1989) analysis lack of risk expo- sure as a normalizing factor this analysis still relied on two surrogate measures to approximate risk: cargo tons moved by each group, and number of trips made by each pilot group within U.S. coastal ports. These denominators involve many of the limitations discussed in Leis (19891. Professional qualifications and per- formance of navigation technology were not assessed, nor were exposure to risk, performance of ship systems, or pilot performance in the towing industry. Methodology Marine pilots were divided into state and federal groups. Docking masters, although not technically operating under Federal First Class Pilot's Licenses or Endorsements while aboard foreign-flag ships or U.S.-flag ships under registry, were considered federal pilots for the purpose of the analysis. Results with and without docking-master data are presented. Data were not available that would permit a more definitive allocation of tonnages or trips between federal pilots and state-licensed pilots operating on a federal license. Docking-master exposure was estimated based on tonnages and operating practices in pertinent East Coast ports. The methodology defined pilot groups by licensing authority and function performed. The report described and analyzed the differences among pilot types and accommodated these variations in the analysis. Both tonnages and trips were used in the comparisons; however, differences in operating environments were not considered. All casualty data used in the analysis were provided as appendi- ces to the report. Only casualties where pilot error was a contributing factor were included, as determined by individual review of each casualty report on file with the Coast Guard.

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A REVIEW OF PILOTAGE STUDIES I- 7 r Inalngs 367 The report contained two types of findings: those stemming from the com- posite analysis of federal and state safety performance nationwide and those resulting from port case studies. In the former analysis, the report found the following: Despite similar objectives, state and federal pilot systems exhibit major systemic differences. These include differences in minimum pilot qualification requirements, as well as in system oversight and governance. The number of dynamic vessel casualties involving all pilots decreased 21 percent (5 percent per year) between 1983 and 1988. The levels of risk exposure for both groups were constant with respect to vessel trips and increased with respect to cargo tons. The safety of both pilot groups improved measurably over the study peri- od. By 1988, the overall U.S. pilot system (federal and state) was reported to be 40 percent safer than in 1983. By 1988, a dynamic vessel casualty involving a pilot aboard a self-propelled vessel occurred once every 10.5 million tons of cargo moved, or once in every 1,700 vessel trips, which accounted for the report- ed 40 percent safety improvement. Over the study period, the relative safety levels of the federal pilots were found to be greater than those of state pilots. The findings in the individual-port case studies provided similar results: Varying levels of pilotage difficulty, rather than systemic differences between state and federal pilot systems, appear to be the primary reasons for differences in pilot safety performance across the studied ports. Relative to the national average, pilots operating in the port systems of New Orleans/Baton Rouge, Tampa, San Francisco, and Houston were more like- ly to be involved in a dynamic vessel casualty. In Houston, this ratio was slightly greater than the national average; in San Francisco, Tampa, and New Orleans/ Baton Rouge, respectively, the ratios were two, three, and four times greater. However, the report noted that several factors affecting the difficulty of pilotage tasks (such as pilotage distance, channel width and depth, tidal currents, and traffic levels) were not accounted for in the measure of risk exposure employed. Analysis of pilot performance in port regions that were less safe than the national average indicate that both federal and state pilot groups contributed to the safety deficit. For instance, in Houston, Tampa, and New Orleans/Baton Rouge, pilots in both systems had poorer safety records than the national aver- age. The report said these findings reflected heightened difficulties in pilotage tasks, rather than systemic problems. Comparative assessments of federal and state pilot safety performance at the port level produced mixed results. In New York and the Delaware River, the .

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368 APPENDIX D reported data showed comparable safety performance between the two groups; in San Francisco, federal pilots were reported to be safer when tons moved was the measure of risk exposure (although this finding was complicated by the fact that domestic trip data appear to have been severely underreported in waterborne commerce data bases); and in Houston, Tampa, and New Orleans/Baton Rouge, state pilots were reported to have safer records. However, the report noted that 50 percent of the dynamic vessel casualties in the Gulf Coast were attributed to state pilots acting on federal licenses, thus doubling the number of dynamic vessel casualties in the federal pilot group and skewing the findings. Analysis The report provides a general baseline for assessing pilot performance and reasonably establishes that marine-pilot performance is improving and that fed- eral and state pilots have comparative safety records. The report does not distin- guish between marine pilots and ship's officers piloting under a Federal First Class Pilot's License or Endorsement. Nor does it provide means to identify and determine universal and port-specific needs and alternatives for improving safe- ty performance. Perhaps the most useful finding of the AIMS report is buried in Appendix A, the port case studies, where the report concedes that "no uniform conclusions can be drawn from this analysis." This is, perhaps, the finding that can be drawn from all previous state and federal pilot comparative safety analyses. Because of the lack of readily available and thoroughly reliable safety performance data, no uniform conclusions can be drawn. 1991 Battelle Rebuttal to the 1991 AIMS Study This 1992 report (Lets, 1992) attempted to resolve discrepancies between the findings of the 1989 APA report and the 1991 AIMS report with respect to federal and state pilot safety. In this study, Leis corrected a number of the diffi- culties noted for the 1989 report. Corrections were made with regard to the characterization of pilot groups; use of CASMAIN data; assignment of pilot error; inclusion of the Alaska and Hawaii oil trade; and use of a "trips" measure- ment to represent federal and state piloting exposure. Nevertheless, discrepan- cies between the two reports remained; even the 1989 data were reassessed with assumptions and definitions similar to those in the Booz, Allen and Hamilton/ AIMS study. The differences are primarily due to varying interpretations of missing or incomplete data in the CASMAIN data base, as well as to differing philosophical approaches to data analysis. The overall result is a more cogent explanation of the rationale and data analysis in both the 1989 and 1992 reports; however, the rebuttal does not definitively resolve the safety debate. Instead, it

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A REVIEW OF PILOTAGE STUDIES 369 illuminates the issues and data interpretations used in two prominent piloting safety studies, greatly assisting safety analyses to follow. 1993 U.S. Coast Guard Rebuttal to National Transportation Safety Board Petersfield/Bayou Boeaf Recommendations The National Transportation Safety Board (NTSB, 1988a) recommended that the Coast Guard seek legislation to require all pilots aboard vessels engaged in commerce (foreign or domestic' on the navigable waters of the United States to have a federal pilot's license, which would be legally superior to all state- issued documents. In response, the U.S. Coast Guard initiated a review of marine casualties to determine the extent of pilot-related casualties. The Coast Guard sought to determine whether a relationship existed between the frequency of marine casualties and the license under which a pilot was operating. Marine casualties were defined as collisions, allisions, and vessel groundings occurring while a vessel was under the direction and control of a pilot. CASMAIN data for vessel casualties between 1984 and 1987 were used as the basis for this six page report. Methodology The analysis focused on self-propelled passenger, tank, or freight vessels greater than 1,600 gross tons that had been involved in a collision, allision, or grounding in a 10-port-area sample. The port areas used were Baltimore/Annapolis; Galveston/Texas City; Houston; lower Mississippi River (New Orleans, Baton Rouge, Port Sulphur, Avon- dale, Destrehan, Gramercy, St. Rose, and Good Hope); . the Port of New York and New Jersey (New York, Port Elizabeth, New- ark, Bayonne); Sabine River (Port Arthur, Sabine, Orange, and Beaumont); Delaware Bay and River (Philadelphia, Chester, Wilmington, Paulsboro, Camden, Gloucester City, and Marcus Hook); Columbia River (Portland "Oregon], Astoria, Longview, Kalama, and Vancouver); Puget Sound/Strait of Juan de Fuca region (Seattle, Tacoma, Blaine, Bell- ingham, Everett, Port Angeles, Port Townsend, Anacortes, Friday Harbor, Olym pia, and Neah Bay); and San Francisco Bay region (San Francisco, Stockton, Oakland, Richmond,

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370 APPENDIX D Alameda, Crockett, Sacramento, Martinez, San Joaquin River, San Pablo Bay, and Carquinez Strait). Examination of 516 marine casualty records for the 10-port-area sample indicated that in 130 cases listed the pilot's license was listed as "none" or "unknown." Further analysis allowed 91 of these 130 to be classified with re- spect to the type of pilot aboard. The Coast Guard's Exposure Analysis Project, which combines Army Corps of Engineer data for domestic U.S. trade and Cen- sus Bureau data for foreign trade, was used to determine the number of transits for the 10-port sample, for the years 1984 through 1987. (These transit numbers do not include shifts from piers and berths to other piers and berths within the same port.) Findings An analysis of the number of casualties per number of transits indicated that pilots operating under their state licenses are involved in 2.9 times more casual- ties than are pilots operating under their federal licenses. However, the report notes that pilots operating under the authority of their state license made more than 2.7 times more transits than did pilots operating under the authority of a federal license. Overall, pilots operating under their federal license experienced one casualty for every 851 transits, while pilots operating under their state li- censes experienced one casualty for every 797 transits. Usefulness The Coast Guard found no statistically significant difference between the safety performance records of state- and federally licensed marine pilots. The report concludes that the ratios of casualties per number of transits are virtually the same, and that "regardless of the type of license under which a pilot operates, the likelihood of experiencing a casualty is the same. ETherefore, a] pilot operat- ing under one license type is not inherently safer than a pilot operating under another license type." Thus, this report uses CASMAIN data to support the argument that there is no difference in safety performance between state- and federally licensed pilots. The report fills some of the important gaps in the CAS- MAIN data (e.g., pilot aboard, type of license held), performs an analysis based on adjusted CASMAIN data, and develops a simple exposure index (number of casualties over the number of vessel transits) for the 10 selected ports. The report provides a useful exposure baseline against which related statistical safety analy- sis can be compared.

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386 APPENDIX D tional equipment and operational requirements for ships operating in the ap- proaches to and within pilotage waters. A public notice of the project was published in the Federal Register on 26 July 1989, and in all Local Notice to Mariners. The study group received numer- ous telephone calls, over 200 letters, three studies, and two videotapes in re- sponse to the notice. The majority of these responses were from state pilots and federal pilots. Other responses came from pilot associations, tug and barge com- panies, associations of ship owners and operators, oil companies, individual ship masters, other licensed officers, and state pilot commissions and boards. Findings The findings of the study group were divided into the eight study areas as defined in the group's objectives. Pilotage Waters The group found that all large self-propelled vessels, vessels restricted in their movements (large freight or tank barges), and vessels carrying a large number of passengers should have a licensed pilot aboard. Thus, the group recommended that a legislative change be made to allow the Coast Guard to require pilots within the recently proclaimed 12 mile territorial sea rather than the former territorial sea limit (nominally 3 miles offshore). Further, the group "recommended tthat] a pilot licensed for Prince William Sound be aboard every ship from a point somewhat offshore Cape Hinchinbrook and Seal Rocks through the entire length of the pilot waters" (USCG, 19894. In effect, a pilot would be required to be aboard from just seaward of the passages into Prince William Sound. The study group recommended that the Secretary of Transportation: use the authority of 46 U.S.C. 8502(g) to designate all waters of Prince William Sound as an area on which a vessel must be under the direction and control of a pilot licensed under 46 U.S.C. 7101; and use the authority in 46 U.S.C. 8503 to require a pilot licensed under 46 U.S.C. 7101 to be on board vessels in those areas of Prince William Sound where a pilot is not required by the state of Alaska. Small Vessel Pilotage The study group recommended that an amendment to 46 U.S.C. 8502 be made to allow the Coast Guard to develop regulations addressing small passenger vessels, where the requirement for all U.S.-inspected self-pro- pelled coastwise seagoing vessels to carry a federal pilot had been "overlooked or unknown." Small passenger vessels, which can be over 200 feet in length and carry up to 1,400 passengers, are generally not required by their Certificates of Inspection to carry federally-licensed pilots. The study group recommended that tonnage or length, or other criteria, be

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A REVIEW OF PILOTAGE STUDIES 3S7 used to determine the requirement for pilotage of these vessels. The group fur- ther recommended that passenger vessels greater than 100 feet in length or carry- ing more than 149 passengers be required to carry a pilot. The study group recommended that the same requirement hold for small cargo ships of over 15 gross tons; this would include offshore supply vessels, some of which exceed 200 feet in length and have displacements of approximately 2,000 tons. Because of the additional hazard to ports, facilities, and the environment that are posed by tank vessels simply by nature of the cargo carried, the study group recommended that self-propelled tank vessels over 50 meters (164 feet) in length be required to carry a pilot when underway in pilotage waters. The study group also recommended that regulations be further amended to clarify the status of docking pilots, specifying that docking pilots be required to have a pilotage endorsement for the appropriate route. Requirements for Pilots' Licenses The study group recommended that service requirements for an original license or endorsement as a first class pilot be exam- ined. The group found that the requirements in 46 CFR 10.703 allow applicants to qualify who have never supervised a navigating watch or conned a vessel. The holder of a master or mate license of inspected vessels and the holder of an Operator of Uninspected Towing Vessels (OUTV) license who has 18 months' service in the wheelhouse are also qualified after obtaining the required round trips. The study group believed that additional sea service would be a valid requirement and would not impose a heavy burden on any officer or operator who is qualified to be a pilot. The group found that it would be reasonable to require proof of six months' sea service under the authority of a mate's license or experience in a formal pilot's apprentice program. For the OUTV license, simi- lar service requirements were recommended. The study group further recommended that the Coast Guard not issue a pilotage endorsement to any license without a written test, including a chart sketch, and that the regulations in 46 CFR 15.812(g) be amended to require mariners to keep records to establish their service qualifications. These records were to be equivalent to the documentation of service required in 46 CFR 10.205(e)~15. Requirements for Recertification and Familiarization The study group recom- mended that the provision for recency of service over a route be changed. Provi- sions in 46 CFR 10.713 allow certification on review of publications and charts to be accepted for "long or extended" routes in lieu of actual transits. The group believed that consideration should be given to amending the regulations to re- quire at least one round trip over the pilotage route within the previous 12 months, either to retain license validity on that route, or to act as a pilot on that route. The group recommended deletion of the regulation allowing certification on review of charts and publications in lieu of actual transits.

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3S8 APPENDIX D Pilot's Responsibility Aboard the Vessel The study group concurred with sev- eral centuries of English and U.S. law on the subject of pilot responsibility aboard vessels, concluding that "the pilot is in full charge of the navigation of the ship, yet the master retains his overall responsibility." The study group also held that any pilot on a large ship should not be expected to perform both the navigation and watch officer functions; the group found that there should be both a pilot and a qualified watch officer on the bridge at all times when the ship is in pilotage waters. It was recommended that regulations be amended to include this requirement for self-propelled vessels over 1,600 gross tons. The group acknowledged that small vessels following regular routes could be an exception to this rule, as these vessels traditionally have operated with one watch officer who also has pilotage endorsements for the waters travelled. The study group recommended that the pilot's share of responsibility for master- pilot conferences (which were deleted in 33 CFR 164) be reinstated; specifically, the group recommended the following language: The master or person in charge of the vessel Should be] informed by the pilot of any abnormal characteristics of the area to be transited and of non-routine maneuvers before the pilot makes them. (USCG, 1989) Proper Roles for Federal and State Governments The study group did not concur with the National Transportation Safety Board in its recommendation to make the federal pilot license legally superior to any state license or commis- sion. Instead, the group recommended that legislation be sought to extend the Coast Guard's authority over licenses it issues to any employment directly relat- ed to the qualification of that license. "While not making one license superior to another, it would remove the anomaly that when a state sees fit to discipline a pile+, perhaps even revoking his/her license, the federal license is untouched and remains valid." The study group recommended that the Coast Guard open discussions with various state pilot commissions and pilot groups concerning revisiting the use of federal-state agreements for cooperative measures on pilot matters. The study group also proposed that state waters where state pilotage is not required be identified in each Marine Inspection Zone and that the Coast Guard require a licensed pilot in areas where the state has chosen not to act. This proposal would cover pilotage requirements for vessels shifting from an anchor- age to a berth, or between berths within a port complex, as well as occasions when a pilot is required but not taken. The group proposed that the regulation should require either a state- or a federally licensed pilot. Navigation Equipment and Operational Requirements in Pilotage Waters Be- cause several ships have gone aground inbound to U.S. ports while enroute to the

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A REVIEW OF PILOTAGE STUDIES 3S9 pilot station, the study group recommended that the Loran C coordinates of each pilot station be listed in the Coast Pilot. In addition, there have been a few casualties that, upon review, showed that a tug was ill-equipped to navigate properly or did not have access to recent information on the area being transited, presumably because the Navigation Safety Regulations contained in 33 CFR 164 apply to self-propelled vessels of 1,600 or more gross tons (the regulations do not normally apply to tugs, because they are usually less than 1,600 gross tons). However, tug and barge combinations of well over 1,600 gross tons could be operated legally without any required navigation equipment, charts, Coast Pilot, or Notice to Mariners. The study group recommended that consideration be given to amending the regulations in 33 CFR 164 to make at least some of them applicable to tug-barge combinations of 1,600 gross tons and over. Additional Issues During visits to Regional Examination Centers and in dis- cussions with Coast Guard officers serving as an OCMI, the study group found that the local knowledge questions in pilot's examinations were usually based solely on information contained in the Coast Pilot. Further, they appeared to be so general that they were poor indicators of actual familiarity with the port or place. It was recommended that these questions be reviewed and expanded to cover topics such as areas with unusual currents, changes of current during dif- ferent tidal current stages, areas of frequent shoaling, and unusual local practic- es. It was recommended that each OCMI have a role in the development of such questions. Usefulness of the Results The requirements for this study group parallel the task of the National Re- search Council's Committee on Advances in Navigation and Piloting. The same eight issues are being examined. The background information contained in the Bauman report, tracing the history of pilotage, as well as the findings and con- clusions are of interest to the committee. (Regarding pilotage jurisdiction, the National Research Council committee sought to determine whether there are waters for which pilotage should be required that currently are not subject to pilotage requirements. No problem areas were identified by the Committee on Advances in Navigation and Piloting aside from gaps in official accountability for docking and mooring masters and approach concerns raised by the Bauman Report and various NTSB accident investigations.) 1992 American Waterways Operators (AWO) Report to Committee on Advances in Navigation and Piloting The U.S. barge and towing industry, comprising some 800 companies that operate a fleet of approximately 6,000 tugs and towboats and more than 30,000

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390 APPENDIX D barges, is far from homogeneous. With operations along the Atlantic, Pacific, and Gulf coasts, as well on the nation's inland waterways, the various elements of the towing industry differ significantly in the types of vessels utilized, the geographic areas served, the cargoes carried, and the backgrounds of people employed. The American Waterways Operators' report (AWO, 1992b) focuses on pi- lotage aboard towing vessels, "which has been shaped by operational character- istics and a regulatory framework distinct in many ways from those which im- pact upon ship pilotage." Pilotage in the towing industry, explained as being quite different from ship's pilotage, is then explored. The report describes existing procedures and policies for ensuring personnel competence in the towing industry. These include requirements for Coast Guard licensing, company criteria for selection to captain, the value of round trips in acquiring local knowledge, and the relative safety records of towing vessel cap- tains and licensed pilots. In this last category, the report cites a 1985 study conducted by Temple, Barker, and Sloane (TBS) for Maritrans (then operating as Sonat Marine; TBS, 1985~. The TBS study compared oceangoing barges of 5,000 gross tons or more (operating without pilots) with oceangoing ships of 1,000 gross tons or more (with federal pilots), analyzing collisions and ground- ings attributed to the personal fault of the pilot, master, or mate directing the movement of the vessel. The TBS report, which covered the period 1972 to 1982, is reviewed later in this appendix. In comparing safety records of tug captains and state pilots, the AWO report cited an analysis of navigational safety on the Hudson River, conducted by AWO in October 1991, comparing the safety performance of state-licensed pilots and federally licensed vessel operators (towing vessel captains and federal first class pilots) on the Hudson River between 1981 and 1989. Also cited were Army Corps of Engineer data and Coast Guard statistical analyses of collisions, alli- sions, and groundings involving state and federal pilots in selected U.S. ports. In each of these cases, the safety records of tug captains compared favorably with those of ship's pilots. Findings The report maintains that upgrading and maintaining marine safety neces- sarily involves ensuring that all those who navigate the nation's waterways are competent to perform their jobs safely. The report also asserts that there is a place in marine transportation for qualified navigators of all kinds: tug captains, ship masters, federal pilots, and state pilots. The report holds that no single class of mariner is a safety panacea; rather, navigational safety would best be served not by attempting to impose an artificial equivalency on mariners with such diverse functions, but by ensuring that each group is well-equipped to perform its particular job safely.

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A REVIEW OF PILOTAGE STUDIES 391 The report holds that "human factors are clearly a critical link in the marine safety nexus." Remedying the underlying cause of human error remains difficult, however. Simulator training is mentioned as being helpful, although "the towing industry's experience with simulator training is not yet far enough along for us to say without equivocation that this is the best means to assure proficiency." The report echoes a suggestion made to the committee by F. Eugene Guest of Marine Safety International/Computer Aided Operations Research Facility, that research be conducted to determine what constitutes mariner proficiency, how this level of proficiency can be attained, how proficiency can be validated or demonstrat- ed, and whether demonstrations of proficiency required of airline pilots should be required of mariners. Usefulness The report provides an overview of variations in towing industry pilotage practice, with appropriately cited supporting data for its conclusions and recom- mendations. The report provided useful background information for the commit- tee in its examination of pilotage practice in the towing industry. 1985 Temple, Barker, and Sloane Report Temple, Barker, and Sloane (TBS) was retained by Sonat Marine to evalu- ate casualties of large (over 5,000 gross registered tons EGRTjJ oceangoing tank barges, compared with those of ships over 1,000 GRT moving within U.S. har- bors. The report (TBS, 1985) also provides an economic analysis of the addition- al costs of pilots compared with the cost structure of tank barge operations. Data The report is based on an analysis of collisions and groundings with damage involving vessels in waters where the Inland Rules of the Road applied, and where the personal fault of the master, mate, or pilot aboard caused the incident. This study covered the 11-year period between 1972 and 1982, examining Coast Guard casualty records for all types of vessels. The casualty files of 93 tank barge incidents identified by the Coast Guard were reviewed at Coast Guard Headquarters. The files also were checked to find additional incidents. Each case was analyzed and then included in the data base if the following criteria were met: the barge was greater than 10,000 GRT, identifying the barge as primari- ly engaged in the coastwise trade; damage was sustained; the cause or fault was due to human, not equipment or material, failure;

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392 APPENDIX D the incident was located within the jurisdiction of the Inland Rules of the Road, where pilotage applies; . the incident was not a collision with an aid to navigation, as many of these are unreported and cannot provide a relevant comparison,; the incident was not administratively closed by the Coast Guard (that is a Coast Guard investigation of the incident was still in progress); and the incident was not a duplicate report for a case already in the data base. In addition to the 93 cases identified by the Coast Guard, 14 additional cases were identified and 74 other cases in the Coast Guard's files were excluded by TBS. Traffic information was calculated from waterway commerce data collect- ed and maintained by the U.S. Army Corps of Engineers. Findings Evaluation of the Coast Guard data indicated that oceangoing tank barges over 10,000 GRT that had no pilots had a significantly lower incidence of colli- sions or groundings than did ships with pilots. In addition, tank barges greater than 10,000 GRT had equal or lower rates of incidents than did barges between 5,000 and 10,000 GRT. The report found that the economic consequences of requiring pilots on tank barges would be to increase annual operating costs for typical tugs and tank barges by 1.7 to 7.1 percent, depending on the average voyage length and the number of port entrances and exits. It concluded, therefore, that one impact of pilotage would be to significantly reduce the net earnings of tank barge opera- tors. Findings of the report were divided into four categories: casualty data, incident rates, costs of incidents, and costs of pilotage. Casualty Data The report found that oceangoing tank barges over 5,000 GRT were involved in a total of 30 collisions and groundings between 1972 and 1982. Six of these barges were over 10,000 GRT. None of the tank barge incidents caused any fatalities or injuries, and the 30 tank barge incidents without pilots resulted in five pollution cases. In contrast, ships over 1,000 GRT were involved in 1,007 incidents during the same period, resulting in 51 fatalities, 67 injuries, and 19 pollution cases. No tests of statistical significance were run on these data. Incident Rates The report found that tank barges greater than 10,000 GRT had about one-third the probability (0.0324) of U.S.-flag tankers (0.0895) of being involved in incidents when the exposure to risk is measured by the available years of service for each fleet. Tank barges between 5,000 and 10,000 GRT were found to have about two-thirds the probability (0.0588) of U.S.-flag tankers (0.0895) of incidents using the same measure of exposure to risk. In the report, tank barges between 5,000 and 10,000 GRT and those greater

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A REVIEW OF PILOTAGE STUDIES 393 than 10,000 GRT have about the same probability (0.00052 and 0.00050) of incidents. This level is reported to be approximately 25 percent lower than the probability for all ships (0.00069) when the exposure to risk is measured by the number of port sorties for each type of vessel. The report found that the average number of incidents during a 30-year life span is 1.7 for tank barges between 5,000 and 10,000 GRT, 1.0 for tank barges greater than 10,000 GRT, and 2.7 for U.S.-flag tankers. Costs of Incidents The $52,742 average cost of damage from incidents involv- ing tank barges greater than 10,000 GRT is less than half the $120,764 average cost of ship incidents. Further, the report found that the $117,253 average cost for incidents of tank barges between 5,000 and 10,000 GRT is nearly equal to the $120,764 average cost for ship incidents. The $26.58 average cost of incidents per port sortie for tank barges greater than 10,000 GRT is one third the $83.79 average cost per port sortie for ships. Costs of Pilotage The report found that the annual cost of pilotage for a tug- tank barge combination ranged from $72,750 to $289,500, depending on average voyage length and the number of port entrances and exits. These estimates as- sumed the average $750 pilotage rate per movement estimated by the Coast Guard. Actual annual costs of $96,738 to $350,520 were calculated by Sonat Marine. The additional expense for pilots was forecasted to increase total annual costs for a typical tug-barge combination by 1.3 to 5.5 percent based on the $750 Coast Guard estimated rate, and 1.7 to 7.1 percent based on actual cost data. The report found that the annual pilotage cost for a 10,000-GRT barge would be 11 to 43 percent of the total annual crew costs of a tug-barge combination at the $750 rate. For a 90-mile voyage (about 45 percent of the company's long- haul voyages at that time), the annual cost of pilotage equals 43 percent of the annual crew cost, but pilots provide service during only 9 percent of the vessel's operating hours. Finally, the report found that The cost to the barge industry of pilots on board tank barges greater than 10,000 GRT during 1972 to 1982 could have been between 42 and 204 times the cost in damages suffered by those vessels during the eleven year period. (TBS, 1985) Usefulness There are three particularly useful parts to this report. The first is the Section 2 discussion of misuses of statistical measurements by the U.S. Coast Guard; the second is the Section 3 discussion of excessive costs of pilotage; and the third is the inclusion of all the data used in the analysis. The section on alleged misuse of statistical measurements by the Coast Guard centers on the methodology used

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394 APPENDIX D to calculate the relationship between the size of a tank barge and the probability of a casualty. The calculation was reported to be based on the number of tank barges in each size classification as the measure of potential exposure to the incidents. The report noted two deficiencies in this approach. First, the method- ology misrepresented the total number of barges that were in service during each of the years that the casualties were reported. A measure evaluating the number of years of barge service was suggested as an alternative. Second, the methodol- ogy misrepresented important facts affecting a vessel's exposure to incidents relevant to pilotage. The report proposed a different measure, employing the total number of port entrances and exits to establish exposure as the denominator of the risk-measuring statistic. The section on the excessive costs of pilotage is of interest to the committee, as it is one of the few quantitative discussions of an often-cited criticism of the requirement for pilots aboard tank barges. In this analysis, the cost to the barge industry of pilots aboard tank barges greater than 10,000 GRT between 1972 and 1982 could have been between 42 and 204 times the cost in damages incurred by those vessels. The report held that, based on an average pilotage fee of $750 per movement, the industry would have incurred an annual pilotage bill of approxi- mately $811,636 and would have paid $8.9 million during the period from 1972 to 1982. This estimate was said to understate the actual cost, because some ports established as many as three different pilotage segments, and the $750 per-call estimate did not include any costs for delays to the pilots or to the tugs and barges that had to wait for pilots. The $8.9 million pilotage cost was weighed against the total $316,450 cost of damages related to tank barges over 10,000 GRT and the fact that no injuries or loss of life occurred. This discussion quanti- fied the costs involved and made no qualitative estimates of the costs or benefits. Inclusion of the actual data used in the report's analysis facilitates replica- tion of the study methodology as well as development of generalized actions based on the study's findings. ANALYSES OF MARINE ACCIDENTS AND INCIDENTS As early as 1972, the National Transportation Safety Board identified a number of factors that have played a role in collisions in the navigable waters of the United States (NTSB, 19723. Although human error is frequently cited as a probable cause in collisions, the board found that the underlying reasons for the error, the causal factors, are of greater importance when prescribing preventive measures. The board found that "there is a need for providing more effective assistance and tools to the mariner to enable him to cope with the increasingly complex decisions he must take." As a result, "multiple solutions" to the prob- lems leading to collisions are necessary, as "no one particular solution will work in every location." However, the board found that the United States had lagged behind other countries in developing, experimenting with, and evaluating shore

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A REVIEW OF PILOTAGE STUDIES 395 based collision avoidance systems. The 1972 report also cites shipboard colli- sion avoidance systems, traffic separation schemes, traffic control systems with mandatory participation, position determination systems, and offshore marine terminals as having potential for increasing the safety of navigation. A general overview of the role of the human element in shipping casualties is provided by Bryant (19911. The U.K. Department of Transport commissioned this effort by the Tavistock Institute of Human Relations to address "not just the immediate subject of errors but. . .the whole human element in accidents to ships." The findings, although not earthshaking, do clarify the issues involved in considering why the oft-quoted 80-percent human error rate occurs in shipping incidents and accidents. A few reports have examined the task-performance problems of shipboard personnel in order to assess their contribution to vessel safety. Some of these studies found that different task-performance problems can be associated with different types of marine accidents (Cahill, 1983, 1985; Gates, 1989; NAS, 1976; Paramore et al., 1979; Smith et al., 1976~. Many of these reports are dated. particularly with respect to navigation and piloting technology and bridge watch- standing practices. In short, there have been no systematic attempts to incorporate the human element into the factors considered by those in charge of marine casualty investi- gations (Bryant, 1991~. Bryant's analysis and suggestions are conventional. They include a systematic approach to identifying human error elements and interac- tions in accident reporting; near-miss reporting requirements; new approaches to files and records, as well as to the management of casualty information; and use of standard methodologies and checklists, as well as distributing "best practices" case studies. 1972 National Transportation Safety Board Report Analyses of marine accidents and incidents, and recommendations for pre- ventive measures, have been proposed and pursued for as long as ships and people have been going to sea. The National Transportation Safety Board (NTSB, 1972) described the marine environment and the need for safe navigation of vessels, relating the following: Progressive changes in the marine industry have triggered the introduction of new methods and equipment to assist mariners in safely navigating ships. . .The sheer number of vessels has increased significantly. . .fand] the size of vessels has increased sharply. . . Design characteristics have changed considerably dur- ing the past 10 years. The speeds of vessels have increased, and have reduced reaction times in dangerous situations. The higher speeds, in combination with improved loading and offloading capabilities, have reduced turnaround and tran- sit times, which allow a vessel to complete a greater number of voyages within a specified time frame. Changes in traffic patterns. . .caused by variancefs) in

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396 APPENDIX D the size and speeds of vessels and by the nature of (different ship types are also of concern). In the marine transportation field, the risk levels have risen during the past 10 years and probably will continue to rise in the future if no action is initiated to curb or reduce the causes of this rise. There are numerous factors which have caused the increase in risk levels. Many of these factors, such as increased speeds, higher traffic density, limited maneuverability, increased size, and great- er numbers of vessels have already been mentioned. Another very important factor is the recent increase in types and quantities of hazardous and dangerous cargoes. (NTSB, 1972) In short, the environment in which maritime navigation and piloting occur has not changed much in the past 20 years. The economic, political, environmen- tal, professional, and safety concerns may have intensified, but the environment itself is as accurately described in that 1972 NTSB report as in any more current documents. In its 1972 analysis, the NTSB described two facets to the problem of colli- sions of vessels: the number of collisions and the magnitude of potential losses resulting from the collisions. Solutions to the problem that were offered by the board, therefore, focused on attempting to eliminate or significantly reduce the number of collisions, the potential losses involved, or both. This report provides a useful primer for the committee for two reasons: it provides an overview of the committee's tasks, and it demonstrates that these issues, and approaches to their solution, have not changed dramatically in 20 years. Shipboard and shore-based automatic navigation systems, overloading of communications channels, VTS participation, VTS administration, position-determination systems, traffic sepa- ration schemes, and personnel training are all identified as issues in need of resolution.