NTSB Reflects on Lessons Learned from Marine Investigations in 2023

The National Transportation Safety Board (NTSB) has published its Safer Seas Digest 2023, a comprehensive collection of crucial lessons learned from marine investigations completed last year.

The digest encapsulates safety recommendations and insights from 31 investigations concluded in 2023.

One of the highlighted investigations pertains to the release of 588 barrels of crude oil into San Pedro Bay due to an anchor strike on an underwater pipeline. In response, the NTSB urged the Coast Guard to reshape federal anchorages in San Pedro Bay, among other preventative measures.

The report also delves into investigations concerning life-threatening incidents. One such event was the engine room fire on the Spirit of Norfolk, where 108 individuals were successfully evacuated. The NTSB found that the absence of a fire-detection system in the engine room delayed fire detection. Consequently, the NTSB pushed for the elimination of regulatory gaps that permit certain small passenger vessels to function without engine-room fire-detection systems.

The fatal collision between the Coast Guard cutter Winslow Griesser and the center-console boat Desakata, which resulted in one casualty and one serious injury, was also examined. The NTSB determined that neither crew maintained an adequate lookout. The board issued a Safety Alert advising small-vessel operators to enhance their vessels’ detectability.

The publication underscores several overarching safety risks and challenges, including vessel stability, engine room fire containment, severe weather, risk management, cargo preparation, teamwork, communication, standard operating procedures, narrow channel transit, distress communication, and navigational hazards identification.

“The NTSB will advocate tirelessly for our safety recommendations because we know from our investigations what’s at stake,” NTSB chair Jennifer Homendy writes in the publication’s opening message.

This year’s issue was dedicated to Captain Morgan Turrell, NTSB Director of Marine Safety, who passed away in March at the age of 58. “He was a proud graduate of the US Merchant Marine Academy; served as a licensed deck officer, including Master, on a variety of commercial vessels; and was a strong advocate for improving safety on our waterways,” wrote Homendy.

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