Marine Casualty Investigations – Information and analysis, not data, is needed

My friend Dennis Bryant (USCG-Ret) published an article on titled “Marine Casualty Reporting: Addressing the Coast Guard’s Processes” in which he discusses the current broken state of the Coast Guard’s marine casualty reporting and investigation system. I agree with Dennis that the system is broken – and has been for years.

In his article Dennis states:

“The Coast Guard is drowning in marine casualty reports.  The majority of its informal investigations are never closed.  Those that are closed are seldom read again.  Lessons that might have been learned from marine casualties are rarely shared with the maritime industry. It is time to go back to basics.”

Therefore, Dennis recommends that the types of accidents and injuries reported to the Coast Guard be scaled back and that sector commanders be given broad latitude to decide which casualties should be investigated.

Dennis also states that “In my opinion, there are far too many informal investigations and they generally provide no lessons learned.” If an investigation provides no less learned – then perhaps it is the fault of the investigator, the investigator’s training, and the quality of the report that has been prepared. The major purpose of these types of investigations is not to suspend or revoke the license of a mariner who may have made a mistake – but to learn from the casualty so that future accidents can be prevented and to help ensure that Coast Guard regulations are adequately addressing the root causes of a casualty.

Perhaps the Coast Guard should gather more information about a casualty – not just “data” about time, place, and who was involved. The National Institute for Occupational Safety and Health (NIOSH) has delved into the Coast Guard’s casualty reports and prepared an excellent analysis of casualties and injuries on commercial fishing vessels.  This information is then made publicly available at their site (see link). The Coast Guard has also used this information to help identify problems in the fishing vessel industry.  However, I understand that the data in the casualty reports were not particularly helpful in identifying the types of problems that should be addressed for towing vessels under the new Subchapter M regulations.

Congress agreed with Dennis that marine casualty reports should be made available to the public. Section 442 of the Maritime Transportation Security Act of 2002 amended section 6101(i) of title 46, United States Code States to require that:

 “(i) The Secretary shall, as soon as possible, and no later than January 1, 2005, publish all marine casualty reports prepared in accordance with this section in an electronic form.”

As Dennis points out, there were problems with privacy sensitive information being contained in certain data fields that should not be released (names, phone numbers, social security numbers, etc).  This made automation of the publishing of these reports a challenge. The Coast Guard scrubbed that information to ensure no privacy information was released and now makes all marine casualty reports available on line at: Incident Investigation Reports. The public and insurers can search this database based on the vessel’s name, owner, or other key words. It will also help the public see the quality of the investigation.

There are problems with the Coast Guard’s marine casualty reporting and investigation system – but the solution is not to give sector commanders broad discretion to decide what should and should not be investigated.  That lack of national uniformity will make the consistent gathering of casualty information impossible and of little value to those trying to use the information for regulatory purposes. A sector commander may not have any background in maritime safety and decide to allocate the limited sector resources to other purposes.

Much of the reporting that Dennis is concerned about is comparable to occupational safety reports other industries must submit regarding workplace injuries to agencies such as the Occupational Safety and Health Administration (OSHA).  However, OSHA does not generally have jurisdiction on Coast Guard inspected vessels – so this type of information is collected by the agency with jurisdiction – the Coast Guard.

The Coast Guard is drowning due to all types of resource constraints and it is affecting many programs – not just casualty investigations. If the Coast Guard does not have the resources necessary to collect the information necessary to prevent future casualties – the solution isn’t to stop gathering the information.  Perhaps the solution is to give this responsibility to a different federal agency that can perform this responsibility.


  • Reblogged this on Brittius.


  • It may be that they should also be more circumspect in the use of their resources. Not that long ago, a marine investigator read an article in the newspaper about an evacuation from a cruise ship, specifics unclear in the article. Contacted the company and told is was a heart atack – not reportable. He then demanded a formal report so that he could determine if it was or was not a reportable casualty! A report should not be required when a dancer dances herself off the stage as this has nothing to do with the ship operations. The idea should be to improve safety, not gather statistics that have nothing to do with vessel and operations safety. Better training is required. Better focus is required.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s