Captain’s Corner: The Role of a CG Investigator

U.S. Coast Guard photo of CAPT Tom Allan taken by Petty Officer 2nd Class Timothy TamargoHappy New Year! Hope 2014 provides you the promise and energy to fulfill new goals for your organization and you personally. For the crew of Sector Jacksonville, the recent holidays provided us a great opportunity to recharge, reflect on a busy 2013 and look forward to the bright future of the Port of Jacksonville. This month’s Captain Corner is provided by LT John Nee our Senior Investigation Officer. His article provides information on how and why we conduct investigations. Our program goal for investigations is to reduce future incidents and at Sector Jacksonville we strive to do this by ensuring our investigators complete their work professionally and thoroughly in coordination with the professional mariners we help serve. Looking forward to seeing you in the port.
– CAPT Tom Allan

The Role of a Coast Guard Marine Casualty Investigator

By LT John Nee, USCG Sector Jacksonville, Senior Investigating Officer

The Coast Guard’s marine safety mission has been instrumental in promoting safe transportation of passengers and cargo since 1838 when the Steamboat Inspection Service was formed. At the heart of the marine safety mission is the Coast Guard’s marine casualty investigator who determines the cause of marine accidents and initiates corrective measures to reduce the likelihood of future occurrences. It is also the role of the investigator to determine if laws or regulations were broken and recommend new laws or policy to enhance the safety of navigation. Every year the Coast Guard investigates approximately 4,500 reports of marine casualties ranging from minor equipment failures to major casualties such as the sinking of the tall ship HMS Bounty in 2012.

The Coast Guard’s investigative process is a multi-step process that is flexible in its ability to scale up and down depending on the complexity of the accident. The first two steps include gathering facts, classifying facts into conditions, actions or events, and then placing the facts in a timeline. Investigators must act quickly to gather essential information that can be permanently lost such as electronic charting data, drug and alcohol testing results, and other crucial voyage planning data; otherwise the integrity of the investigation could be jeopardized. In addition, investigators must conduct thorough interviews of witnesses immediately following the incident as this aids in putting together a detailed timeline of events and facilitates the identification of any pre-existing latent unsafe conditions and the initiating event leading up to the incident.

The primary focus of the investigation is centered on the initiating event, which is the first unwanted action or event. This event might be an occurrence that took place minutes or in some cases years before the accident. For example, the Coast Guard’s investigation into the USNS Martin allision with the Mathews Bridge identified several latent unsafe conditions related to the vessel and bridge measurement plans. After the fact finding, timeline development and latent unsafe conditions are identified, the investigator must explore the human aspect of the case. In other words, the actions or decisions that may have contributed to the accident. Often times the human error analysis will raise more questions and the process starts all over again!

During the final stages of the process, the investigator draws conclusions and makes safety recommendations to prevent the occurrence from happening again. In the case of the USNS Martin, investigators identified a number of procedural safety recommendations related to the review and use of bridge and vessel plans aimed towards ensuring critical measurement data is both timely and accurate. Once the casualty investigation is complete and recommendations are made, final analysis is conducted to determine if any laws or regulations were violated. Similar to the National Transportation Safety Board, the role of the Coast Guard investigator is to respond to accidents, gather the facts, determine the contributing factors of the accident, and develop recommendations on how to prevent future occurrences.

The marine transportation system is a complex and multi-layered entity that involves multiple levels of defense strategies to prevent accidents from occurring. Thus an investigator must conduct a systematic review of the entire maritime transportation system to effectively reduce the likelihood of future occurrences.