The National Transportation Safety Board today
determined that the probable cause of a fatal accident involving a Staten Island ferry
was the assistant captain's unexplained incapacitation and the failure of the New York City Department of Transportation (NYC DOT) to implement and oversee safe, effective operating procedures for its ferries.
On October 15, 2003, the Staten Island ferry Andrew J. Barberi, owned and operated by the NYC DOT, was at the end of a regularly scheduled trip from Manhattan to Staten Island when it struck 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 two months later as a result of injuries sustained in the accident.
"Our Nation's ferry system is a vital means of transportation for the general public in many of our major cities," said NTSB Chairman Ellen Engleman Conners
. "It is crucial that we maintain a safe operating system that
will prevent accidents like this from occurring."
The report states that at the time of the accident the assistant captain was at the controls, the senior mate was seated in the aftmost section of the pilothouse reading a newspaper, and no one else was in the pilothouse at the ferry's Staten Island end. The assistant captain was apparently upright but unresponsive to his surroundings and the visual cues of the impending allision for an estimated 1 to 2 minutes before the accident. However, the cause of the assistant captain's unresponsiveness to cues clearly indicating an impending impact could not be determined.
The assistant captain and his physician omitted critical information regarding details of the assistant captain's medical condition and treatment on the form used for Coast Guard medical evaluations. In his appearance before the federal judge over a year after the accident, the assistant captain pleaded guilty to knowingly submitting false medical information to the Coast Guard. Therefore, the Board concluded that the Coast Guard had no opportunity to evaluate his fitness to maintain his mariner's license.
Contributing to the cause of the accident, the Board said, was the failure of the captain to exercise his command responsibilities of the Andrew J. Barberi by ensuring the safety of its operations. Also, the NYC DOT failed to implement and oversee safe and effective operating procedures for its ferries.
As a result of the investigation, the Safety Board recommended
that the New York City Department of Transportation require
its licensed pilots to provide proof of compliance with Coast Guard medical certification requirements; also, adhere to its October 2005 target for implementation of a comprehensive safety management system, incorporating all matters recommended by the Global Maritime and Transportation School
assessment, and ensuring medical fitness oversight (requiring, minimally, assurance of compliance with Coast Guard requirements); and as part of its response to the Global Maritime and Transportation School assessment
, fully comply with the technology-related recommendations of the Global Maritime and Transportation School, and establish a recurrent evaluation process to assess the use of navigation technology
. To the Coast Guard, the Board recommended seeking legislative authority to require all U.S.-flag ferry operators to implement safety management systems, and once obtained, require all U.S.- flag ferry operators to do so. To the states operating public ferries and the Passenger Vessel Association, the Board recommended encouraging public ferry operators to voluntarily request application of the federal requirements for implementing a safety management system, if not already in place.