Wednesday, July 25, 2018

DUCK BOAT TRAGEDY.....A CASE FOR SMS.

DUCK BOAT TRAGEDY.....A CASE FOR SMS.

On July 19, A duck boat sightseeing vessel capsized and sunk on Table Rock Lake in Branson Missouri after a thunderstorm created turbulent waters and high winds. 17 people died. The duck boat industry is one of the few public transportation services that regulators do not require Safety Management Systems, SMS. If Ripley Entertainment, the company that owns the duck boat service, had SMS, this tragedy could have been avoided. Here is the evidence why: 
Duck boats in Branson Missouri 
SMS requires hazard identification, incident analysis and risk assessment. In this case here are the facts. 
Ignoring Risk Factor Data
A witness’s video of the Branson duck boat just before it capsized suggests that its flexible plastic windows might have been closed and could have trapped passengers as the hybrid boat-truck went down. It does not show passengers jumping clear. In 1999 the NTSB recommended that all Duck boat "...canopies be removed and mandatory use life vests for each passenger." NTSB went on to suggest that the canopies could entrap passengers if the boat sank. This was the major cause of deaths in the Branson tragedy. Duck boat companies chose not to take this risk factor seriously.

"There is always a trail of things going out-of-control before every accident." 

The Coast Guard prohibited the vessel from operating from January 2015 to April 2015, but the report does not state a reason other than "hazardous/unsafe condition." Another report from February 2015 cited leakage in a wheel well caused by sealant failure.

The owner of an inspection service in the St. Louis area said he issued a written report in August 2017 to the Branson duck boat operator, Ripley Entertainment, after inspecting two dozen boats. In the report, Steve Paul of Test Drive Technologies explained that the vessels' engines — and pumps that remove water from their hulls — might fail in inclement weather
Duck boats have a history of fatal and less serious accidents. It's often led to criticism about their design and use as tourist vehicles. For example, 13 people died after a duck boat sank on Lake Hamilton near Hot Springs, Arkansas in 1999.
The owner of the Branson Duck boat operation admits that the boat should have NOT been in the water. Andrew Duffy is an attorney whose firm represented victims of a deadly 2010 duck boat crash in Philadelphia. He and other lawyers with his firm have called duck boats "death traps" and called for them to be banned. They have specifically pointed to the canopies as problematic.
In 2015, five college students were killed and 69 others were injured in Seattle after a duck boat collided with a bus. Ride the Ducks International of Branson, which operated the Seattle boats, was fined $500,000.

In 2010, a barge plowed into a duck boat that had stalled in the Delaware River in Philadelphia.Two of the 37 people on board drowned. They were 16- and 20-year-old Hungarians visiting the United States through a church exchange program.

All these facts lead to Root Cause Analysis and subsequent Corrective Actions. Unfortunately the Corrective Action suggested by the NTSB were not implemented. 
Using the Deming “Interaction of Forces,” lets examine the facts.

The Machine....additional risk factors.....ignored. 

Duck boat design is inherently unsafe

Duck boats were designed for military use during WWII and never considered for private or commercial use. Here are some of the problems with Duck boats:

1. Tend to be top heavy which leads to easy capsizing. 

2. They take on water easily and require a fairly powerful bilge system.

3. Not designed to have ridged canopies or windows. 

In addition. In August 2017, mechanical inspector Steven Paul saw a glaring problem when he examined the duck boat.One of the most prominent things I found was the exhaust being in front of the vessel, which -- according to Department of Transportation standards -- would not pass regulation," he told CNN's "New Day" on Monday. "The exhaust has to come out past the passenger compartment.” When he saw footage of the boat sinking, Paul said "with the exhaust coming out the front and going down below the water line, the waves are obviously pushing water up in that exhaust." If water gets in the exhaust, he said, "the engine is eventually going to stop."

Methods...NOT following Procedures.

The amphibious vessel changed the route it took on Thursday, Missouri Attorney General Josh Hawley said Saturday. The boat capsized as a storm and high winds lashed the lake. Investigators want to know "when did the driver and (captain) of this vessel know about this storm forecast? When did they decide to alter the route of the boat?" he said. "Because they did alter the route of the boat. When did they decide that? Why?"

Environment ......Risk Factors ignored.

Severe storms were quickly approaching

The first storm warnings came the morning of the incident about 11:20 a.m., when the National Weather Service in Springfield issued a severe thunderstorm watch, which was scheduled to last until 9 p.m. A former president of the American Meteorological Society said the radar "clearly showed a very large complex of storms approaching the lake." Specifically, Branson straddles the line separating Stone and Taney counties.  A more serious alert, a severe thunderstorm warning, was issued for Stone County at 6:07 p.m., and was extended to including neighboring Taney County at 6:32 p.m., about the same time the duck boat is believed to have entered the water. That's also about the time the storm struck Table Rock Lake.

People and Methods…lack of Policy, Procedures and Training. 

Interviews with survivors indicate that there was mention of life jackets and where they were located. The decision to go ahead even though the wind had picked up to 45 miles an hour, indicated either a lack of policy or ignoring of policy. If the company had a proper safety risk profile, all the risk factors should have been mitigated. We will, of course, find out more as the investigation continues. 
Conclusion
Programs are created and put into place for a reason. SMS was implemented as a result of the Exxon Valdez accident. Unfortunately we are very good a reacting when a tragedy takes place. Hindsight is always 2020. In the world of Safety and Quality, we must study data. Not to merely record it but, to use it to develop and improve Safety and Quality. I am sure now, there will be changes in the regulation of this industry. We in the Aviation and other industries need to be reminded that what we do in SMS has life saving implications and we must never wane from our diligence in promoting and continuously improving it. 

Author: Mr. Dennis Taboada M.eng, CQE,CQM

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