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10 Conclusions and Recommendations Maneuvering ships safely through narrow, shallow, and often congested channels is a challenging task for even the most skillful shiphandler. The marine operating environment is a complex, highly interdependent system. It encom- passes waterways, vessels, human operators, navigational aids, and a supporting infrastructure for pilotage, vessel and port management, policy and regulation, and professional development. When the system performs well, the regional and national economies, the vessels and their crews, populations near ports and wa- terways, and the natural environment all benefit. But over the past decade, the safety, effectiveness, and efficiency of navigation and piloting have become ma- jor concerns. Although by many measures safety has improved over the past several decades, in the eyes of the public, major shipping-disasters resulting in extensive pollution have brought into question the merchant mariners' profes- sional capabilities to operate safely. Clearly, major marine accidents deserve attention, particularly in terms of prevention or mitigation measures. Public attention has opened a window for reasonable and positive changes in the marine navigation and piloting system. System improvements need to be carefully crafted and implemented to avoid unintended side effects. A steady hand at the helm is needed to steer implemen- tation through the changes projected in Chapter 9. The following recommenda- tions are intended to help chart a well-informed, prudent course. The Committee on Advances in Navigation and Piloting accepts and endors- es the traditional concept that pilots are local experts in whom special trust and confidence are placed for the safe navigation of the vessels they serve. Those whom society officially recognizes as pilots have a long history of dedicated and 311

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312 MINDING THE HELM expert service to uphold. By longstanding maritime tradition, they are held to high standards of professional competence and official accountability. This tra- dition should continue. The conclusions and recommendations expand on this fundamental view by prescribing a strategy for reducing operational and envi- ronmental risk and for improving safety performance, thereby enhancing public confidence in the marine navigation and piloting system and its pilotage compo- nent. Whether or not pilotage as practiced in the United Estates satisfies this fundamental view of the pilot is a central focus of this chapter. Recommenda- tions are numbered for convenience of reference; no priority order is implied. System organization, operation, and overall performance could be substan- tially improved to reduce operational risk by a more systematic accounting of interactions among system components. The marine navigation and piloting sys- tem is characterized by large disparities in its administration and standards of performance and by limitations in safety data that constrain intorrned oversight. The system is also characterized by considerable polarization over safety, eco- nomic, and jurisdictional issues that have prevented resolution of conflicts over marine pilotage and inhibited system-wide regulation of vessel traffic. Specific improvements can be made in system organization and integration, human sys- tems, marine pilotage, waterways management, navigation and piloting technol- ogy, and marine research and development, as described in following sections. MARINE NAVIGATION AND PILOTING: INTEGRATING THE SYSTEM The organizational structures within the marine navigation and piloting sys- tem range from a well-established hierarchy for decision making on a traditional ship's bridge to the more common, informal structure that prevails for system- wide decision making, including the organizational structure used for vessel traffic management. The loose nature of organizational structures contributes to lapses in human performance. These varying organizational structures, and the decision making that results from them, are proximate or contributing causes in many marine accidents. Little attention has been paid to marine navigation and piloting as a system; instead, previous assessments and investigations have focused principally on performance of specific vessels in specific circumstances. The systemic ele- ments navigation and piloting tasks, technology, human systems, governance, and the organizational environment in which they operate- have been assessed in varying degrees, but their interactions and relative importance in reducing operational and environmental risk are not well understood. Little organizational research has been conducted by the federal government and the marine industry that would improve the marine community's understanding of the system, its elements, and their interactions. This lack of understanding, together with the informal integration of the marine navigation and piloting system, inhibits re

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CONCLUSIONS AND RECOMMENDATIONS 313 auction in risk with respect to modern expectations for safety and environmental protection. Understanding Risk in the Marine Navigation and Piloting System Because of the interdependent nature of maritime navigation and piloting operations, these operations must be understood as a system. The understanding of risk in navigation and piloting can be improved by assessing system elements, their interactions, and their interactions with the environment in which they op- erate. Planning, management, administration, research activities, and recommen- dations for improvement must recognize the interdependence of system elements and take their interactions into account. RECOMMENDATION l: The Department of Transportation, in consulta- tion with the Department of Commerce and the Department of the Army, should sponsor a cooperative program of continuing risk assessment involv- ing the U.S. Coast Guard, Maritime Administration, National Oceanic and Atmospheric Administration, and U.S. Army Corps of Engineers. The pro- gram should include development of a standard methodology for assessing risk and safety performance (at the vessel, individual mariner, fleet, port, and regional levels) in order to improve understanding of risk in navigation and piloting. This methodology should include standard methods for data collection and normalization of data across port, waterway, and river sys- tems. (See also recommendation 37.J RECOMMENDATION 2: The Department of Transportation, in consulta- tion with the Department of Commerce and Department of the Army, should undertake a cooperative, multidisciplinary research program involving the U.S. Coast Guard, Maritime Administration, National Oceanic and Atmo- spheric Administration, and the U.S. Army Corps of Engineers, in order to better understand risk relationships. The research program should investi- gate the interaction of the essential elements of a highly reliable, complete, and safe marine navigation and piloting system. This research should in- volve subject matter experts from the marine community. (See also recom- mendation 37.) Casualty Reports and Safety Records Although marine accident investigations by the National Transportation Safety Board, the Coast Guard, and state boards and commissions often provide valuable information about particular accidents, available safety data are inade- quate for valid statistical evaluation and comparisons of pilotage systems, even those covering the same routes. This is a longstanding problem in marine-safety

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314 MINDING THE HELM analysis and should be corrected. An accepted methodology needs to be devel- oped for comparing safety records across pilot routes and piloting functions. RECOMMENDATION 3: The U.S. Coast Guard should review and im- prove its existing programs and capabilities for collecting and analyzing marine accident, incident, and near miss data; investigating groundings, collisions, and other marine accidents and incidents; and reporting these investigations and safety trends so that comprehensive safety-performance information becomes readily available. The U.S. Coast Guard should assign a high priority to data compatibility and sharing across existing and future marine safety data bases and should develop a sound methodology to enable comparison of safety data currently maintained in incompatible data bases. HUMAN SYSTEMS Professional Development Professional development programs for mariners and marine pilots need to be improved, and each individual's navigation and piloting knowledge and skills need to be periodically refreshed, upgraded, and confirmed. Professional weak- nesses and problems need to be identified and corrected before they become causal factors in marine accidents. After-the-fact official discipline, while an important tool, is only effective if it also leads to remedial action. Marine professional development programs are not generally assessed for their effectiveness. There is no official oversight in the development and valida- tion of practical skills in federal marine licensing for masters, mates, and pilots, except for radar observer certification. For state-licensed marine pilots, the de- velopment process varies among pilot systems but is primarily supervised by licensed pilots. There are no certification programs for navigation and piloting instructors or for marine licensing examiners to establish their professional and educational capabilities for guiding pilot development. Continuing professional development has not been guided by specific requirements or standards, not- withstanding growing efforts by some marine pilot organizations and shipping and towing companies to provide refresher and advanced training. The rapid evolution and introduction of advanced electronic navigation and piloting technology creates new knowledge and skill requirements, expanding the range of expertise required for effective operator performance. But the pro- fessional training base for mariners is not keeping pace with these changes. From a technical perspective, it is premature for U.S. training facilities to make major investments in advanced navigation aids until International Maritime Or- ganization (IMO) standards for Electronic Chart Display and Information Sys- tems (ECDIS) are finalized, other IMO equipment standards updated, and equip

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CONCLUSIONS AND RECOMMENDATIONS 315 ment is manufactured to them. Selective investment in advanced electronic chart- ing systems meeting the IMO's provisional ECDIS standards may, however, be appropriate and necessary to aid in familiarizing mariners with these new sys- tems. Near-term changes made in training facility resources will also need to be capable of incorporating revisions in IMO's Standards for Training, Certifica- tion, and Watchkeeping (STCW) when these revisions are finalized and imple- mented. Approaches to development of theoretical knowledge and entry-level navi- gation and piloting skills range from accredited undergraduate programs at mar- itime academies to on-thejob training in the shipping and towing industries, in ferry operation, and often in marine piloting. To build expert qualifications, marine pilots need a basic knowledge of nautical theory, practical navigation skills, local-area knowledge, broad-based shiphandling skills, and progressive advancement on routes and categories of ships. Shipboard responsibilities often do not allow masters and bridge teams to develop proficiency in piloting skills, shiphandling, and local knowledge. There are few checks and balances within the marine navigation and pilot- ing system, either human- or technology-based, for advance detection and cor- rection of problems in the professional competence or performance of mariners, including marine pilots. Few masters, mates, or pilots have been formally trained, such as through simulation exercises, to process information and make decisions in extreme situations that require spontaneous emergency shiphandling and com- munications. However, marine pilots may develop sufficient experience to react correctly through their apprenticeships and service. A consistent and thorough approach to professional development is needed. The core of a complete professional development program should involve: training and performance standards for professional mariners; accreditation of curricula and certification of instructors; development and validation of professional knowledge (theoretical and applied) and practical skills; development of special skills such as emergency decision making and shiphandling; continuing professional development; and periodic requalification. The committee's conclusions and recommendations concerning the profes- sional development of individuals piloting ships and towing vessels and barges are consolidated in the section entitled Marine Pilotage. Recommendations re- garding the professional development of mariners other than those piloting ves- sels involve economic, marine training, and education issues which were beyond the scope of this assessment. Training needs with respect to advances in technol- ogy are presented below.

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316 MINDING THE HELM RECOMMENDATION 4: Training programs should be developed concur- rently with the voluntary or mandatory introduction of new navigation and piloting technologies. Bridge personnel should be trained in the use of these new technologies, and associated changes should be made in organizational relationships before the equipment is applied to operations; these efforts are essential to ensure the effective and prudent use of this equipment consis- tent with safety needs and requirements. Continuing training should be available thereafter, as necessary, to maintain mariner proficiency and to train new operators. To aid in the use of new navigation and piloting tech- nologies in pilotage waters, provisions should also be made to familiarize marine pilots with the capabilities and general use of these technologies. The U.S. Coast Guard should encourage the International Maritime Orga- nization to adopt standard training procedures for the use of new naviga- tion and piloting technology. (See also recommendations 7-8, 10-11, 15-18, 21, and 24.) Marine Simulation Decade-old marine simulation research expanded fundamental knowledge about human factors. But this information base is incomplete and did not fully verify how well training results transfer to actual operations. Meanwhile, train- ing needs have expanded because of the ongoing rapid evolution of navigation and piloting technology, ship's systems, and operating practices. The simulation research literature needs to be updated to reflect current conditions within the marine industry and piloting profession. However, there is a sufficient basis to believe that computer-based and manned-model simulations can, in varying de- grees help individuals understand the limits of their knowledge and skills be- fore these factors become an issue in actual performance; demonstrate ship maneuvering theory; and assist in developing or refining basic, advanced, and emergency shiphan- dling and bridge team management skills. Marine simulation potentially can provide a general capability for validating skills and operational decisions without the risk that would be associated with similar efforts aboard real vessels. However, there are unresolved questions about: the accuracy of simulations for vessel operations in shallow and confined waters, especially where there are small under-keel clearances; how well simulation training experience transfers to actual operations; cost-effectiveness;

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CONCLUSIONS AND RECOMMENDATIONS 317 the basis for establishing the equivalency or relevance of marine simula- tion to sea service for licensing purposes; the relative value of computer-based and married physical scale-model simulations for various functions. and operations; validation of simulations; accreditation of simulators and simulations; training and certification of instructors; evaluation of trainee performance; and the high cost of the technology per individual trained (these costs could be especially burdensome if borne by individuals rather than operating compa- nies or licensing agencies, which is a major issue in the use of simulation in licensing). These issues, which are vital to improving the value of marine simulation in professional development, need to be resolved before simulation is broadly ap- plied in marine licensing or required for the licensing of marine pilots. Still, there is growing acceptance of marine simulation to selectively supplement, but not replace, more traditional means for the initial and continuing professional development of marine pilots. Simulations designed to improve shiphandling skills and to expose pilots to situations or vessels not routinely encountered can be especially useful if limitations in the simulation are clearly understood and conveyed to those trained. In this regard, marine pilots generally seem capable of making effective use of computer-based and manned-model simulations to re- fine generic and vessel-specific shiphandling skills. RECOMMENDATION 5: The U.S. Coast Guard and Maritime Adminis- trat~on should update and build on their earlier assessments of marine sim- ulation to determine the technology's capability and suitability for use in the initial training and qudlfflcation of pilots, in the continuing development of pilot skills in handling large vessels or complex operations, and for ma- rine licensing purposes. RECOMMENDATION 6: Marme pilot licensing authorities and marine pilot associations should encourage the selective use of marine simulation as one approach for meeting continuing professional development needs. MARINE PILOTAGE Debates over the safety performance of federally-licensed or state-l~censed pilots, especially over which of these categories of pilots has a better safety record, have generated considerable public attention but miss the mark. The pilotage services provided by independent state-licensed and federally-licensed pilots routinely exhibit professionalism and competence. The real issue is that

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318 MINDING THE HELM the national structure of marine pilotage and its administration, both federal and state, do not consistently ensure the completeness of professional development and adequate safety performance. Measures need to be improved to ensure the completeness of professional qualification and to identify for correction any train- ing deficits and degradations in knowledge and skills that may occur after train- ing or receipt of a license prior to any performance-related weaknesses becom- ing causal factors in marine accidents. The conclusions and recommendations that follow are designed to preserve and build on the strengths of key features found in the existing marine pilotage systems. The division of pilotage responsi- bilities between federal and state pilotage authorities would continue to be the centerpiece of pilotage nationwide, with certain refinements to achieve systemic Improvements. Safety Performance The Committee on Advances in Navigation and Piloting found no statistical evidence that professional competence varies according to the methodology used to train independent marine pilots nor was any statistical evidence found that the performance of pilots varies by the level or type of maritime expertise acquired prior to entering the pilot profession. There is some anecdotal evidence from experts that differences in professional backgrounds can affect the time required for pilot candidates to adapt to various aspects of marine pilotage. While the length of time required to qualify as a pilot may vary as a result, comparable levels of professional skill can be achieved, provided that individual strengths and weaknesses are accommodated in professional development. It is difficult to determine whether system-wide problems exist in marine pilotage, primarily because there is no standardized method for normalizing and ranking casualty data to support such determinations. The existing casualty data do not completely reflect the overall nature of safety problems in any one port area. There is also a general lack of understanding of the complexity of the port, waterway, and river operating environments; the nature and variability of risk factors that are present; and vessel behavior in shallow water and confined, asymmetrical channels. Careful and statistically valid assessments of safety performance will be important and should reflect substantial differences in marine safety, risk, and exposure, even within the same port and waterway complex. The committee reviewed and assessed available studies and research that examined the safety records of pilots. This literature provided general background, but because of questions regarding the data utilized, how it was manipulated, and how measures of safety and performance were constructed, no sound inferences could be drawn. The committee found no empirical evidence that safety performance varied by licensing authority. Nor was there evidence proving any difference in naviga- tional safety between marine pilots and docking masters or between the pilotage

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CONCLUSIONS AND RECOMMENDATIONS 319 of ships and of towing industry vessels. This is not to say that studies supporting particular points of view on these subjects could not be found; on the contrary, the committee reviewed several studies on each subject (Appendix D). However, the committee found no statistically sound basis that would indicate differences in performance among the various categories of federally- and state-licensed mariners who are providing pilotage services. At the same time, the committee heard considerable anecdotal testimony from representatives of all segments of the marine community offering ample evidence of a loosely integrated system with opportunities for error and incomplete measures for error detection and correction. Pilotage Administration and System Standards Pilotage regimes in the United States exhibit large differences in their ad- ministration. Considerable professional attention is given to pilotage administra- tion in most systems to satisfy user needs, although performance guidelines and standards to meet official requirements are often informal. Depending on the vessel's flag and the trade in which it is engaged, it might be piloted by an individual holding a state license, a federal pilot's license, or a federal pilot's endorsement to a master or mate's license. In each of these situa- tions, the pilot is subject to different qualifications and to either federal or state authorities. For some intraport movements, there is no official pilotage require- ment for foreign trade vessels, although the Coast Guard has proposed rules to begin closing these pilotage gaps. Pilotage administration in the United States needs to be improved, with the objective of providing a consistent approach to ensuring marine safety and envi- ronmental protection. The core of an improved system would involve: lion; 1es; professional standards for all aspects of piloting and pilotage administra administration of standards through existing licensing/administrative bod . consolidation of pilotage administration at the port or regional level; and accreditation of local programs. The recommendations that follow are related to features that the committee concludes are essential for a complete pilotage system (see Appendix E). Some of these features are already embedded in the professional development pro- grams or approaches used by most marine pilot and docking master associations and major U.S.-operating companies. Because the recommended systemic im- provements are based on the strengths found in many existing port-level pilotage systems, it is anticipated that such systems would be able to satisfy the guide- lines and standards that are envisioned by publishing existing processes and

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320 MINDING THE HELM procedures and by implementing selective improvements in features that may not have previously received complete attention. RECOMMENDATION 7: Nationally accepted baseline standards and guidelines should be established without delay in the following critical areas for state and federal pilot development, licensing, and administration, and to enhance pilot proficiency: . PILOT TRAINING Standards should be developed for training both state-licensed and federally-li- censed pilots, including any individuals that may be authorized to act as pilots under local, state, or federal regulations. Professional development should be supervised by pilot instructors qualified for this purpose. Qualification criteria or programs for pilot instructors should also be established. Training for decision making in emergency conditions should be a required ele- ment of pilot training. Programs should be developed for continuing professional development and for periodic evaluation of all those who perform under pilot licenses, endorsements, or other off cial credentials. Adequate requirements for recency of service or training should be established as prerequisites for the exercise and renewal of pilot licenses, endorsements, or other official credentials. . QUALIFICATION Standards should be developed to qualify individuals to pilot particular types of vessels and routes. Professional competence of prospective pilots should be determined through an assessment program involving qualified assessors, and should be based on observed performance as well as examinations. Qualif cation programs for pilot assessors should also be established. PILOTAGE BOARDS The provisions of state and local laws relating to pilotage boards should be re- viewed and strengthened, if necessary, as it relates to their staffs, proceedings, composi- tzon, and accountability. Members of pilot boards and commissions should be appointed by and account- able to state or local governing authorities. Membership should be balanced, with adequate representation of state pilot groups, vessel operators, others in the maritime industries, and the public. Boards should meet regularly and frequently. They should have adequate staff and other resources to administer pilotage and to conduct investigations. Their pro- ceedings should be recorded and open, and they should publish their reports. INVESTIGATION OF CASUALTIES INVOLVING PILOT PERFORMANCE. Issues of pilot performance as contributing or causal factors in marine casualties and incidents should be investigated promptly and completely by pilot boards and other

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CONCLUSIONS AND RECOMMENDATIONS 321 responsible authorities following standards and procedures developed for this purpose to guide individual and systemic corrective measures. Investigations should be objec- t7ve, effective, and timely. The results should be made available in a public report. (See also recommendation 3.J GAPS IN COVERAGE Standards of coverage are needed to ensure that all ships, regardless offlag, trade, or service, unless specifically exempted, are directed and controlled by an individual holding a valid state-issued marine pilot's license or a Federal First Class Pilot's Li- cense or Endorsement. The standards should be specifically designed to fill existing gaps in state and federal pilotage requirements to ensure that there is of ficial accountability for docking and moonng masters and for persons who direct in-port vessel movements. (See also recommendation 19.) Pilotage System Development and Oversight The following recommendations offer an approach for pilotage that the Com- mittee on Advances in Navigation and Piloting believes would enhance safety as well as the national-level credibility and accountability of local pilotage systems. The objective is to establish, for each port, a consolidated pilotage system that is subject to nationally acceptable and applicable standards and guidelines and which satisfies federal and state marine safety interests. At the same time, the recommendations are intended to preserve, enhance, and rely on strong local control of port-level pilotage systems. Under the supervisory and administrative umbrella of state authorities, pro- fessions in the United States generally have been allowed to regulate themselves to some degree. State regulation of pilotage for vessels in foreign trade generally follows this model. Another characteristic of state pilotage is a large measure of port-level control. The federal system, which has filled important needs for coast- wise vessels, has not ensured quality control for the professional development of federal pilots or docking masters, nor has it routinely monitored the provision of pilotage services, leaving this aspect of federal pilotage largely self-regulated. Port-region control is exercised by a regional Coast Guard official, but this offi- cial has little flexibility to modify pilot qualification requirements to address experience or skills necessitated by unique local operating conditions. The committee reached a consensus on the need for standards of the profes- sion, system accountability, and for a national commission to guide systemic improvements. There are, however, alternate views on the path to implement the national commission concept. One view is that safety performance in the marine community is substantially better than suggested by spectacular marine acci- dents, and that the piloting profession, leading shipping and towing companies, and unions are already responding vigorously and positively to public calls for improvements in the piloting performance of members and employees. This

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334 MINDING THE HELM RECOMMENDATION 23: The U.S. Coast Guard should operate VTS sys- tems where federal authorities employ these systems to govern or influence vessel movements or maneuvering. loins federal-private operation or cost sharing should also be considered for expanded VTS coverage, provided that suitable arrangements can be made for exercising federal authority where it is used in conducting VTS functions, such as in managing use of federal anchorages. All private operation of VTS-like services should be authorized by the Department of Transportation. RECOMMENDATION 24: The U.S. Coast Guard should establish or au- thorize a national training course that meets national criteria for local VTS instructors, and an entry-level course for VTS operators, to improve the quality and consistency of VTS systems and VTS-like operations, and to facilitate implementation of national VTS standards. Special Operational Considerations Access to channels by vessels that exceed channel design parameters and special operating criteria guiding their transit should be decided by port safety authorities based on consideration of operational risk, in consultation with af- fected and interested parties, marine pilots, and local advisory bodies (recom- mendation 91. Use of marine simulation should be considered when resolving uncertainties about the safety of such transits or for building a consensus con . . . . . cern~ng special operating criteria. RECOMMENDATION 25: When operations are proposed that present sig- nificant operational, environmental, or public health risk, they should be analyzed objectively to ensure that they can be performed safely. Special operational criteria should be set if needed to achieve levels of safety equiv- alent to that of routine vessel transits. These determinations should involve the U.S. Coast Guard, U.S. Army Corps of Engineers, and local advisory bodies. (See recommendation 9.) NAVIGATION AND PILOTING TECHNOLOGY Technology, along with training programs (recommendations 4 through 6, and recommendation 24) and organizational changes (recommendations 8 through 10, and 21 through 23), can be applied to mitigate human error and reduce operational risk in marine navigation and piloting. Emerging electronic, real-time positioning and charting technologies can offer several significant ben- efits: they can add precision to navigation, improve the clarity of information provided for decision making, allow the user additional time to consider infor

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CONCLUSIONS AND RECOMMENDATIONS 335 mation and alternatives, and may improve decision making and the safety of navigation and piloting overall. The emerging technologies require a shift from traditional human-intensive methods of navigation and piloting to new approaches incorporating both human and electronic elements, with the human assisted by the technology. However, the full prospective benefits of the new technologies, especially ECDIS, will not be gained in the near term unless measures are taken to: provide technical and operating standards for the new technologies; . develop organizational strategies for introducing new technology, includ- ing user training and changes in operating practices designed to enhance the technology's contribution to safety (see also recommendation 41; and update laws, regulations, and policies that are based on the use of tradi- tional methods and older technologies as standard practice. The introduction of new technology may result in incompatibility among systems that combine old and new technology. Thus, the development and pro- liferation of new technology must be handled carefully; requirements may be warranted for modular or compatible development and retrofit of existing ves- sels, and they may need to be addressed. Policies and procedures based on older systems and traditional navigation and piloting practices also will need to be modified to facilitate the introduction of new technology without compromising the levels of safety and accountability inherent in existing practice. The real-time, position-keeping benefits of advanced electronic navigation systems can be obtained through near-term installation of emerging and innova- tive electronic charting and precision navigation systems even though technical and operating standards need to be developed and implemented, legal issues resolved, and institutional impediments to their use removed. A concerted effort by vessel owners and operators and strong encouragement by marine safety au- thorities will probably be needed to accelerate the rapid introduction of advanced navigation technologies so that experience can be gained and mariner trust and confidence built in system capabilities through prudent use. Otherwise, it is like- ly that the integration of new technologies into routine operations and the poten- tial benefits they offer to improve operational safety will proceed at a less rapid pace. RECOMMENDATION 26: The U.S. Coast Guard should strongly encour- age the development and updating of international technical and perfor- mance criteria for advanced navigation systems with the objective of pro- viding a solid foundation for the systematic introduction of advanced navigation technologies and as a benchmark for national technical and per- formance criteria.

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336 MINDING THE HELM RECOMMENDATION 27: The U.S. Coast Guard and Maritime Adminis- tration should continue research directed at developing technical and oper- ating standards for new technologies. Research and development for ad- vanced marine navigation and piloting technology should be funded to a much greater extent than it is now. Furthermore, to obtain the maximum return on this investment, the U.S. Coast Guard, Maritime Administration, National Oceanic and Atmospheric Administration, and the U.S. Army Corps of Engineers should jointly develop research and development prior- ities based on risk assessments. RECOMMENDATION 28: Laws and regulations addressing operational requirements for navigation and piloting technology should be based on performance objectives rather than equip~nent-based criteria so that effec- tive use (and maximum benefit) of advanced navigation technologies and innovative research and development are not inadvertently constrained. The U.S. Coast Guard, Maritime Administration, National Oceanic and Atmo- spheric Administration, and U.S. Army Corps of Engineers should review existing laws, regulations, and policies to identify impediments to the devel- opment and introduction of promising navigation and piloting technologies. These agencies should recommend to Congress any changes to enabling leg- islation that may be indicated, and they should modify policies and regula- tions under their jurisdictions to the extent necessary. RECOMMENDATION 29: The following steps should be taken to acceler- ate the introduction of advanced navigation technologies into marine opera- tions: t The introduction of advanced technology should occur as soon as practical, consistent with the development of a supporting infrastructure that permits its effective use. Training should be provided concurrently with the introduction of the technology (See also recommendation 4.) Owners and operators of oceangoing vessels trading to U.S. ports, U.S. coast- wise vessels, any other vessel subject to federal or state pilotage requirements should take the initiative to install electronic charting and precision navigation devices that are suitable for their applications andfor navigation safety of their vessels. Owners and operators of inland towing vessels that operate in pilot waters should make a concerted effort to install equal or equivalent navigation devices as practical for each vessel's conf gyration and operation. Mariners and pilots aboard vessels with new technologies should take the ini- tiatzve to become familiar with these technologies and to learn how to use system capa- bilities. These technologies should be used carefully in conjunction with traditional navigation methods to ascertain the new technology's suitability and reliability for application in pilotage waters. The U.S. Coast Guard should encourage the introduction,field evaluation, and use of advanced navigation technologies by owners, operators, and mariners through

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CONCLUSIONS AND RECOMMENDATIONS 337 International Maritime Organization, national and local Department of Transporta- t~on-chartered advisory committees, and other media to which the agency has access (See also recommendation 9.J Traditional Aids to Navigation Mariners continue to rely heavily on traditional short-range aids to naviga- tion, especially buoys and ranges. These traditional aids often lose their benefit when most needed, that is, during heavy sea conditions and low visibility. Con- tinued efforts by the Coast Guard to improve the visibility of these aids are having positive effects, as are Coast Guard initiatives to advance the develop- ment and use of the Differential Global Positioning System (DGPS). But little effort is being made to develop improved voice radio communications capabili- ties, electronic data links, or electronic ranges such as localizer beams. Navigational information needs are not satisfied by existing waterways man- agement systems, including VTS systems. The reasons include inefficient com- munications and the uncertainty of VTS users about VTS operator capabilities, especially where operators lack merchant marine or pilot licenses and provide maneuvering guidance. To meet information needs, locally operated navigation systems will appear in some locations that will likely include the use of interac- tive, portable communications, navigation, and surveillance systems (PCNS). When mature, these systems have the potential to provide essential information on navigation and instantaneous position data for direct interpretation by marine pilots regardless of the equipment installed aboard a vessel, with or without secondary safety oversight by shore-based personnel. RECOMMENDATION 30: The U.S. Coast Guard should maintain, and when appropriate, enhance existing short-range aids to navigation that will support evolving technologies as well as traditional navigation technologies. In particular, the U.S. Coast Guard should continue efforts to improve visi- bility and electronic acquisition of buoys during adverse sea and weather conditions. The U.S. Coast Guard should also examine the feasibility of electronic ranges and distance-measuring equipment for specialized local use, which could be in the form of a local Differential Global Positioning System. Navigation Systems The Differential Global Positioning System (DGPS), when combined with ECDIS and when fully operational, will provide a substantial technological ca- pability for enhancing operational safety. Such a system will provide nearly instantaneous, accurate positioning information; steering guidance; and automat- ic hazard warnings. This technology has the potential to provide a more accurate and reliable automatic radar plotting aid function if it is integrated into periodic

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338 MINDING THE HELM broadcasts (automated dependent surveillance) of individual vessel position and velocity. An electronic charting system is the central feature of emerging onboard navigation systems. The effective use of electronic charting systems for real- time precision navigation depends on the completion and proper operation of DGPS. Completion of DGPS and development of a long-term commitment to maintain and operate it are critical to obtaining the potential benefits. Immediate and long-term measures must be taken by the Department of Defense and the Department of Transportation (through the Coast Guard) to achieve this objec- tive. Electronic charting systems, consisting of at least an electronic chart and real-time position data, and which meet legal requirements for navigation, will be the next type of navigation technology that has the potential to achieve uni- versal commercial use, following the example of radar and very high frequency radio. The capability to obtain instantaneous precision positioning information and display it on an electronic chart without loss of geographic detail due to weather and sea conditions, will constitute a great advance in navigation systems and will significantly improve navigational safety. RECOMMENDATION 31: The Department of Defense should fully estab- lish the Global Positioning System at the earliest opportunity, and the De- partment of Transportation, through the U.S. Coast Guard, should acceler- ate establishment of Differential Global Positioning System for marine navigation in U.S. navigable waters and the seaward approaches. The De- partment of Defense and the Department of Transportation should develop a plan and make a long-term commitment for the continued maintenance and operation of these systems. Modern hydrographic data coverage is inadequate for much of the nation's coastal waters. Mariners are notified of critical corrections to charts through weekly Coast Guard publications; required changes to charts aboard ship are done manually, if at all. New editions of charts with these corrections are not published by the National Oceanic and Atmospheric Administration until a sub- stantial number of critical corrections are accumulated. Publication of updated charts is constrained by a substantial backlog of reported but unsubstantiated discrepancies, and there are no operational risk analyses to guide prioritization of discrepancy correction. The result is chart data that are substantially less precise than what is technologically achievable. Legal issues concerning the electronic charting data and the legal standing of electronic charting systems are unresolved. RECOMMENDATION 32: The National Ocean Survey of the National Oce- anic and Atmospheric Administration should conduct modern and updated

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CONCLUSIONS AND RECOMMENDATIONS 339 surveys of all U.S. ports, waterways, and port approaches. Specifically, the Department of Commerce should obtain and allocate the necessary resourc- es to assure the timely collection of hydrographic data that are essential to enhancing the effectiveness of passage planning and the safety of vessel op- erations. RECOMMENDATION 33: The National Oceanic and Atmospheric Admin- istration should accelerate digitization of hydrographic and topographic data essential for producing nautical charts electronically. The agency also should lead an effort to resolve the legal status of electronic charts, includ- ing those provided by other vendors using agency-digitized hydrographic data. The Department of Commerce should obtain and allocate the neces- sary resources to facilitate the introduction and use of electronic charting systems. The integrated bridge concept may have potential to reduce operational risk through the consolidation of navigation, steering, planning, and communications functions at one workstation (as is done in aviation). Effective and reliable use of integrated bridge systems (IBS) has been demonstrated under very select condi- tions on set routes where repeat transits are frequent and piloting is accom- plished by permanently assigned mariners with expert piloting skills. These sys- tems have not yet been proven effective for universal use in piloting although locally specific successes have been reported. Pilot uncertainty about the maneu- vering behavior of unfamiliar ships and the pilot's general lack of familiarity with integrated bridge technology means that vessel- and route-specific valida- tion will be necessary to establish IBS reliability for even regular routes. How an independent marine pilot would interact with IBS is not certain; full use of system capabilities seems to require either integration of independent marine pilots into the bridge team, a nontraditional role, or redefined working relation- ships between the pilot and the individual operating the IBS. Physical data rele- vant to maneuvering that are needed to support decision aids in integrated sys- tems are limited. Real-time tide, current, and weather information is not available except in very select locations. Tide and current prediction tables, often derived from surveys conducted decades ago, need to be updated in the near term. The integrated ship control system (ISCS) may provide a means to reduce crew size and reduce human error in the performance of some navigational tasks. Piloting expert systems and other decision aids may be needed to enhance or facilitate operator use of automated systems. As hands-on experience is reduced through automation, additional professional training may be required to prepare vessel operators to determine when integrated systems are not performing within tolerances and to build skills for taking corrective action. While ISCS may be satisfactory for at-sea operations, reduction of bridge team size because of ISCS installation would reduce the onboard resources for traditional navigation meth

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340 MINDING THE HELM oafs, including hand steering. These traditional methods may be needed at times, especially during operating conditions for which use of rudder angles to control the vessel is more effective than for steering courses. Because it is difficult to obtain international standardization of navigation and communications systems, local electronic navigation systems may be need- ed to extend the benefit of DGPS positioning accuracy to the piloting of all ships in U.S. waters. A PCNS system may be needed for use aboard unequipped ves- sels that are required to have this capability. The PCNS also might be used as a primary navigational aid in lieu of, or to supplement, ship's equipment. For implementation of such a system as well as installed electronic charting systems DGPS coverage will need to be fully operational; electronic chart data bases will be needed for waters where portable sys- tems are used; . and chart updating and electronic chart correction capabilities will be needed; the legal status of electronic charts will need to be resolved. RECOMMENDATION 34: The U.S. Coast Guard and the Maritime Ad- ministration should leverage earlier and existing research and should em- pirically evaluate the impact of advanced electronic positioning systems, automated steering systems, and integrated bridge and ship-control systems (including artificial intelligence and neural networks) on: the safety of piloting and navigation; . the future; the future. the practice of piloting, particularly by ship's pilots and bridge watch teams of use of traditional aids to navigation; and organizational forms and practices that may be required for safe navigation in RECOMMENDATION 35: The Maritime Administration and the U.S. Coast Guard should encourage the development and enhancement of inte- grated navigation systems (including portable and hand-held units3. The U.S. Coast Guard, National Oceanic and Atmospheric Administration, and the U.S. Army Corps of Engineers should examine and encourage develop- ment of real-time environmental data systems as well as chart-updating and correction systems. Communications Effective exchange of information between vessels and with shore-based navigational support units is essential to navigation safety. Voice communica

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CONCLUSIONS AND RECOMMENDATIONS 341 lion is especially important for passing important and perishable information. However, use of voice communication is inefficient for passing general navigational information; introduces the potential for additional human error in acquiring, screen ~ . . . . . . sing, and interpreting navigational information; ~ can result in information overload of bridge teams and pilots; can interfere with onboard actions to resolve "close quarters" and "in extremis" situations; and is prone to interference from unauthorized or inappropriate use. VTS operations use voice radio communications intensively. The amount of information transmitted to a vessel represents a shore-based operator's estimate of that vessel's information needs. Reliance on overheard transmissions and gen- eral traffic broadcasts to provide a complete traffic picture leaves the acquisition of information to chance and introduces opportunities for human error. Adverse operating conditions, which increase the use of voice radio, further stress the capability for effective information exchange. Electronic data links and installed or portable communications systems inte- grated with electronic charts and DGPS positioning capabilities are feasible; prototypes are being introduced in marine navigation. Although not mature tech- nologies, these systems can potentially be used to provide substantially more data instantaneously to bridge teams and pilots than is now possible; moreover, it will be in a form that permits onboard interpretation. There are no technical or operating standards for marine data transmission systems, and changes to operat- ing practices would necessitate special training in system use (see recommenda- tion 43. The utility of electronic systems for information transfer and interpreta- tion has not been demonstrated in maneuvering situations that require the pilot's constant attention or where br~dge-team support is minimal. Improvements are needed in communications to enhance essenha1 voice communications and to provide a more efficient and effective means for dissem- inating essential operational information. RECOMMENDATION 36: The U.S. Coast Guard, in coordination with the Maritime Administration, the Federal Communications Commission, Na- tional Oceanic and Atmospheric Administration, Army Corps of Engineers, and the Radio Technical Commission for Maritime Services, should assess electronic data links as a primary means for transmitting and receiving information needed for safe and efficient navigation and piloting of com- mercial vessels. In particular, measures to reduce dependency on voice ra- dio communications in VTS operations should be assessed. The U.S. Coast Guard and Federal Communications Commission should also investigate and assess alleged unauthorized use of bridge-to-bridge voice radio frequen- cies and take such enforcement action as may be indicated.

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342 MINDING THE HELM MARINE NAVIGATION AND PILOTING RESEARCH NEEDS The extensive and rapid changes occurring in ship and navigation technolo- gies, manning and operating practices, and the nation's status as a port state and flag state, have created substantial uncertainties about the performance of virtu- ally all marine transportation systems. The limited research literature that is available focuses primarily on ships and technology. Coast Guard-sponsored research and development programs supporting the application of advanced elec- tronic navigation aids, while not addressing all application issues, are generally keeping pace with the development of these technologies. Past recommendations to improve safety data have had little effect except to motivate Coast Guard efforts to make its existing marine data bases compatible and to improve data collection on human systems. Available research on human systems and safety performance is often based on data that were not designed to answer questions about human performance. Also, the pioneering work in hu- man systems sponsored by the Mantime Administration and the Coast Guard has become dated, because of the absence of dedicated, continuing research to iden- tify trends and assess their effects and implications. These problems have coin- cided with the privatization of operations at the Mantime Administration's Com- puter Aided Operations Research Facility, a change in the facility's focus from fundamental to applied research and training, the closing of the National Man- time Research Center, and severe reductions in the Mantime Administration's research funds. Organizational research pertaining to marine transportation is virtually nonexistent. The Coast Guard's establishment of a human systems re- search staff is an important step in addressing the human dimension in marine accidents. Marine safety and economic efficiency would benefit from the program of dedicated fundamental research identified in Chapter 8. Research needs are sub- stantial and cross the missions of the Coast Guard, Mantime Administration, National Oceanic and Atmosphenc Administration, Army Corps of Engineers, and the National Transportation Safety Board. Therefore, a comprehensive co- operative research program is indicated. The Department of Transportation is an appropriate choice to coordinate the cooperative research program in marine transportation. RECOMMENDATION 37: The Department of Transportation, in consul- tation with the Department of Commerce and the Department of the Army, should establish a comprehensive, cooperative research program focusing on navigation safety and piloting. The program should be led by a Depart- ment of Transportation agency designated by the Secretary of Transporta- tion and should include participation by the U.S. Coast Guard, Maritime Administration, National Oceanic and Atmospheric Administration, U.S. Army Corps of Engineers, and National Transportation Safety Board. The

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CONCLUSIONS AND RECOMMENDATIONS 343 program should be designed to address the existing, substantial research needs in marine-systems safety, waterways management, navigation and pi- loting technology, port-state versus flag-state policy, navigation and piloting practices, and human systems. Research sponsored by the Department of Defense, especially the U.S. Navy, should be examined for relevance; insofar as practical, lessons from this research should be leveraged into the Depart- ment of Transportation cooperative research program. Research needs should be prioritized in each area according to their prospective contribu- tion to marine safety and economic efficiency. Congress should authorize the research program and appropriate funding for its execution.

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