Coast Guard maritime casualty investigations hindered by poor management, IG finds

For more than six decades, the Coast Guard has been charged with investigating maritime accidents that result in death, injury or substantial property or environmental damage. The primary objective of a maritime casualty investigation, which can range in scope from preliminary information gathering to a formal inquiry depending on the severity of the accident, is to identify safety issues (other agencies are responsible for determining civil or criminal liability). But a new report raises serious questions about the Coast Guard's ability to adequately carry out this mission.

While the investigations are considered an essential element of the service's safety program, investigators more often than not fail to meet the agency's own qualification standards. A new report by the Homeland Security Department's inspector general suggested the Coast Guard was missing opportunities to issue safety alerts or recommendations that could prevent or minimize similar casualties.

During site visits to Coast Guard stations, auditors found that 68 percent of investigators did not meet the agency's qualification standards. In addition, the Hampton Roads sector in Virginia had established its own criteria for qualifying investigators based on knowledge of local industry, waterways and jurisdictions, as well as interviewing techniques and chemical testing. The New York sector had adopted a similar training and qualifications program modeled after the Hampton Roads criteria, but neither sector had received headquarters' approval to use the revised standards, which contributed to inconsistency across the service.

In September 2007, the Coast Guard issued a plan to improve the maritime safety program, including revised qualification standards for investigators, "which both added to and detracted from the qualifications for marine casualty investigators," the auditors found. The new standards updated tasks investigators must perform, but they removed a pre-qualification for working with hulls or machinery and small vessels. Knowledge of these areas is essential to correctly identify the causes of accidents and to issue appropriate alerts and recommendations, the report said.

Auditors also reported that investigations were conducted improperly and a substantial backlog of cases was closed by headquarters without proper review. "As a result, the Coast Guard may not be able to determine the causal factors of accidents and, therefore, prevent or minimize the effects of similar casualties," the IG reported.

The Coast Guard concurred with the IG's findings and generally accepted the auditors' recommendations. Central to the plan is a 2009 budget request to hire 276 additional maritime safety employees, which represents a 40 percent increase in inspectors and investigators.

On Thursday, the Coast Guard released its five-year Marine Safety Performance Plan outlining the service's goals. The document details links between the mission, strategic goals, objectives and performance. Tellingly, it identifies the "need to increase the competency of inspectors and investigators as well as their knowledge of actual industry practices beyond that taught through normal training opportunities." The Coast Guard will accept public comments on the document during the next 60 days. "The most significant threat to the Coast Guard's Marine Safety professionalism is insufficient human resource capacity to be responsive to the regulated marine industry," the plan noted, adding that "capability in the Marine Safety mission area has declined while the complexity, novelty and technological advancements used in the design, construction, and operation of ships and offshore systems have grown rapidly." According to the IG report, between Jan. 1, 2003, and Oct. 31, 2006, the Coast Guard conducted 15,327 investigations, but the majority -- 93 percent -- never progressed beyond the data collection stage. There are four levels of investigation: preliminary information gathering, data collection, informal investigation, and formal investigation. The highest level is required when accidents result in two or more deaths, property damage exceeds $1 million, or there is a major oil spill, defined as 10,000 gallons in inland waterways and 100,000 gallons in coastal waters.

The Coast Guard commandant could convene a Marine Board of Investigation if a marine accident is of such significance that a detailed formal investigation is in the public interest. While the service has conducted 282 Marine Boards since 1947, only two have been convened since 2001. After the Alaska Ranger fish processing vessel sank on March 23, resulting in four deaths and one missing sailor, Commandant Adm. Thad Allen convened a Marine Board. Prior to that, the most recent board was convened in April 2001 after the Arctic Rose sank in the Bering Sea. The decline in convening Marine Boards is due primarily to the extensive resources needed to support them, the IG found.