Marine Accident Report MAR-05-01

164 Pages·2005·2.86 MB·English

Allision of Staten Island Ferry Andrew J. Barberi
St. George, Staten Island, New York
October 15, 2003
Marine Accident Report
NTSB/MAR-05/01
PB2005-916401
Notation 7628A

National

Transportation
Safety Board
Washington, D.C.

Marine Accident Report
Allision of Staten Island Ferry Andrew J. Barberi
St. George, Staten Island, New York
October 15, 2003
NTSB/MAR-05/01
PB2005-916401 National Transportation Safety Board
Notation 7628A 490 L(cid:146)Enfant Plaza, S.W.
Adopted March 8, 2005 Washington, D.C. 20594
National Transportation Safety Board. 2005. Allision of Staten Island Ferry Andrew J. Barberi,
St.George, Staten Island, New York, October 15, 2003. Marine Accident Report NTSB/MAR-05/01.
Washington, DC.
Abstract: This report discusses the allision of the passenger ferry Andrew J. Barberi with maintenance
pier B-1 at the Staten Island ferry terminal on October 15, 2003. The ferry carried an estimated 1,500
passengers and 15 crewmembers. Ten passengers died in the accident and 70 were injured. An eleventh
seriously injured passenger died 2 months later. Damages totaled more than $8 million, with repair costs of
$6.9 million for the Andrew J. Barberi and $1.4 million for the pier.
From its investigation of the accident, the Safety Board identified the following safety issues: actions of
the assistant captain and captain, oversight of ferry operations by the New York City Department of
Transportation, medical oversight of mariners, safety management systems, and the potential contribution
of navigation technology to the safety of ferry operations.
On the basis of its findings, the Safety Board made recommendations to the New York City Department of
Transportation, the U.S. Coast Guard, the States that operate public ferries, and the Passenger Vessel
Association.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.
Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also
may be obtained from the Web site or by contacting:
National Transportation Safety Board
Public Inquiries Section, RE-51
490 L(cid:146)Enfant Plaza, S.W.
Washington, D.C. 20594
[phone] or [phone]
Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2005-916401 from:
National Technical Information Service
5285 Port Royal Road
Springfield, Virginia 22161
[phone] or [phone]
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
iii MarineAccidentReport
Contents
Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Regulatory Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Assistant Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Construction and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Propulsion System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Certification and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Operations of New York City Department of Transportation . . . . . . . . . . . . . . . . . . . . . . .24
Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Passenger Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Crew(cid:146)s Emergency Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Shoreside Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Emergency Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Emergency Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Communication System Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Propulsion System Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Staten Island Ferry Rules and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Coast Guard Oversight of Staten Island Ferries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Medical Oversight of Mariners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Safety Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Other Ferry Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Passenger Vessel Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Actions Since Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Assistant Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Contents iv MarineAccidentReport
Medical Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
New York City Department of Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Safety Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Response to Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
On Board Andrew J. Barberi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
Shoreside . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Navigation Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
Appendixes
A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
B: Standard Operating Procedures, Staten Island Ferry . . . . . . . . . . . . . . . . . . . . . . . . . . . .76
C: Memorandum of Understanding Between New York City Department
of Transportation and U.S. Coast Guard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
D: Contents Pages from Safety Management System Manuals,
Washington State Ferries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88
E: Example Procedures from Safety Management System,
British Columbia Ferries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
F: Assessment of Staten Island Ferries by Global Maritime and
Transportation School, U.S. Merchant Marine Academy . . . . . . . . . . . . . . . . . . . . . .126
v MarineAccidentReport
Acronyms and Abbreviations
AIS automatic identification system
APTA American Public Transportation Association
ARPA automatic radar plotting aid
CFR Code of Federal Regulations
COI certificate of inspection
CPR cardiopulmonary resuscitation
EMS emergency medical services
EMT emergency medical technician
FDNY New York City Fire Department
GMATS Global Maritime and Transportation School
GPS global positioning system
ICAO International Civil Aviation Organization
IMO International Maritime Organization
ISM International Safety Management [code]
MOU memorandum of understanding
NVIC Navigation and Vessel Inspection Circular
NYC DOT New York City Department of Transportation
NYPD New York City Police Department
OCMI Officer in Charge, Marine Inspection
PCP phencyclidine
PDR Physicians(cid:146) Desk Reference
PVA Passenger Vessel Association
REC regional examination center
SOLAS International Convention for Safety of Life at Sea
STCW International Convention on Standards of Training, Certification
and Watchkeeping
TIA transient ischemic attack
U.S.C. United States Code
VTS Vessel Traffic Service
vi MarineAccidentReport
Executive Summary
About 1520 on October 15, 2003, the Staten Island Ferry Andrew J. Barberi,
owned and operated by the New York City Department of Transportation, was near the
end of a regularly scheduled trip from Manhattan to Staten Island when it allided with a
maintenance pier at the Staten Island Ferry terminal. Fifteen crewmembers and an
estimated 1,500 passengers were on board. Ten passengers died in the accident and 70
were injured. An eleventh passenger died 2 months later as a result of injuries sustained in
the accident.
Hundreds of emergency personnel and dozens of emergency vehicles, including
several vessels, responded to the accident, dispatched by the New York City Police
Department, the New York City Fire Department (including emergency medical services),
the U.S. Coast Guard, and the U.S. Army Corps of Engineers. Damages totaled more than
$8 million, with repair costs of $6.9 million for the Andrew J. Barberi and $1.4 million for
the pier.
The National Transportation Safety Board determines that the probable cause of
this accident was the assistant captain(cid:146)s unexplained incapacitation and the failure of the
New York City Department of Transportation to implement and oversee safe, effective
operating procedures for its ferries. Contributing to the cause of the accident was the
failure of the captain to exercise his command responsibility over the vessel by ensuring
the safety of its operations.
The Safety Board(cid:146)s investigation of this accident identified safety issues in the
following areas:
(cid:149) Actions of assistant captain and captain.
(cid:149) New York City Department of Transportation oversight of ferry operations.
(cid:149) Medical oversight of mariners.
(cid:149) Safety management systems.
(cid:149) Potential contribution of navigation technology to the safety of ferry
operations.
As a result of its investigation, the Safety Board makes recommendations to the
New York City Department of Transportation, the U.S. Coast Guard, the States that
operate public ferries, and the Passenger Vessel Association.
1 MarineAccidentReport
Factual Information
Accident Narrative
About 1500 on October 15, 2003, the Staten Island Ferry Andrew J. Barberi
(figure 1) departed Whitehall, at the south tip of Manhattan, on a regularly scheduled,
approximately 22-minute trip to St. George, Staten Island (figure 2). The Andrew J.
Barberi was a large passenger vessel owned and operated by the New York City
Department of Transportation (NYC DOT) and certificated by the U.S. Coast Guard. The
ferry had a maximum capacity of 6,000 passengers but carried a smaller load, estimated at
1,500 people, on the accident trip.1 The vessel was under the command of a captain and
was staffed with an assistant captain, two mates, a chief engineer, an assistant engineer,
two oilers, and seven deckhands. A ladies(cid:146) room attendant and two New York City Police
Department (NYPD) uniformed officers were also on duty but were not part of the crew.
Figure 1. Andrew J. Barberi in New York Harbor after passing Statue of Liberty en route to
St. George terminal. The ferry(cid:146)s symmetrical design allows it to approach and leave its
berth without turning around. The end that docks in Manhattan is known as the New York
end, and the end that docks in Staten Island is called the Staten Island end. The sides of
the ferry are referred to as the Brooklyn side and the New Jersey side. The starboard side
on the trip to Manhattan is the Brooklyn side, while on the trip to Staten Island, the New
Jersey side is starboard.
1 After the Staten Island Ferry stopped charging passengers in 1997 (see (cid:147)Additional Information(cid:148)
section), the number of people riding the ferry was determined by rough estimation. The method, according
to a police officer assigned to the ferry, was to watch the passengers boarding the vessel and observe the
extent to which they filled the accommodation areas. The officer told investigators that ferries later in the
afternoon (4 o(cid:146)clock and after) might reach the maximum load.
Factual Information 2 MarineAccidentReport
er MANHATTAN
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Ellis Island
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Kill Van Kull
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STATEN ISLAND
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Figure 2. Route of Andrew J. Barberi in New York Harbor from Manhattan to accident site
at Staten Island.
En route to St. George, the assistant captain was operating the controls in the
pilothouse on the Staten Island end of the ferry. The navigation watch also included a
deckhand who served as lookout. The lookout told Safety Board investigators that he sat
on a stool next to the assistant captain and that they engaged in casual conversation. (cid:147)He
told me some tugboat stories,(cid:148) said the lookout. (cid:147)We were just having a regular