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April 2012 www.sname.org/sname/mt west, its crew responding to a reported non- emergency vessel grounding. e CG 33118 struck and overran the Sea Rays stern near the west end of Harbor Island. As a result of the collision, an 8-year-old boy onboard the Sea Ray was fatally injured and 4 other people on board sustained serious injuries. No CG 33118 crewmembers were injured in the accident. e NTSB determined that the proba- ble cause of the collision between the CG 33118 and the Sea Ray was the failure of the CG 33118 crew to see and avoid the Sea Ray because of the excessive speed at which the coxswain operated the CG 33118 , given the prevailing darkness, background light- ing, and high vessel density. Also deemed causal, however, was the coast guards lack of e ective oversight of its small boat oper- ations both nationally and at Coast Guard Station San Diego. Coast guard coxswains at all stations are trained through standardized instruc- tional methods?including passing an oral examination on such topics as situational judgment, rules of the road, piloting and navigation, and risk assessment. Despite this standardized training, as well as a standing operating speed limit at Station San Diego of 4,200 rpm, or 35 knots, the crew of the CG 33118 operated their vessel at speeds as high as 42 knots in a crowded and dark environment on the night of the acci- dent. Nevertheless, coast guard managers told NTSB investigators that their oversight provided sufficient information to deter- mine whether crews followed policies and rules such as these. Interviews with Station San Diego coxswains and crew indicated that they considered 4,200 rpm to be a normal tran- sit speed for the SPC-LE in the bay during the day and night. Station command appeared to have accepted this speed as normal. Indeed, the coxswain serving as ocer of the day aboard CG 33118 ?and therefore a direct representative of the sta- tions senior management?on the night of the accident voiced no objections to the speeds at which the vessel was operated. Further, following the accident, witnesses stated that coast guard boats often oper- ated at high speeds in the bay. While some coast guard high-speed operations observed may have been for valid reasons, the evidence suggested that high-speed operations were routine, rather than iso- lated, events. Data collection and quality control program Organizations navigating the course towards safety culture have e ective means of keeping their ngers on the pulse of their operations. This can be done by using a number of varied data collection and anal- ysis programs, such as internal and external safety audits and confidential incident reporting systems. One of the best sources of safety- related information is employees. ey are out there doing the jobs every day so they know what works and what doesnt, and they know the workarounds. Experience has shown that employees will report safety problems if they receive assurances that the information will be acted upon, that the data will be kept con- dential or de-identied, and they will not be punished or ridiculed for reporting. Many organizations have non-reprisal policies that are signed by the CEOs. Non- reprisal policies put actions behind the words, reassuring employees that the company will not use the reporting sys- tem to initiate disciplinary proceedings against an employee who discloses, in good faith, a hazard or occurrence involv- ing safety that is the result of inadvertent or unintentional conduct. Further Reading For more information on the topics and incidents explored here, check out the following resources. United States Nuclear Regulatory Commission Safety Culture Policy Statement, 76 Fed. Reg. 34,773 (June 14, 2011). J. Reason, Managing the Risks of Organizational Accidents (Ashgate, 1997). Lautman, L. & Gallimore, P. Control of the crew caused accidents.? Boeing Airliner (Boeing Commercial Airplane Company, 1988.) D. Zohar, Safety Climate in Industrial Organizations: Theoretical and Applied Implications,? Journal of Applied Psychology , vol. 65 (1980); A Group-level Model of Safety Climate: Testing the E ect of Group Climate on Micro-accidents in Manufacturing Jobs,? Journal of Applied Psychology , vol. 85 (2000); and The E ects of Leadership Dimensions, Safety Climate, and Assigned Priorities on Minor Injuries in Work Groups,? Journal of Organizational Behavior , vol. 23 (2000). Sinking of U.S. Fish Processing Vessel Alaska Ranger, Bering Sea , Marine Accident Report NTSB/MAR- 09/05 (National Transportation Safety Board, 2009). Grounding of U.S. Passenger Vessel Empress of the North, Intersection of Lynn Canal and Icy Strait, Southeast Alaska , Marine Accident Report NTSB/MAR- 08/02 (National Transportation Safety Board, 2008). Collision Between U.S. Coast Guard Vessel CG 33118 and Sea Ray Recreational Vessel CF 2607 PZ, San Diego Bay, California , Marine Accident Report NTSB/MAR-11/03 (National Transportation Safety Board, 2011). e CG 33118 struck and overran the Sea Rays stern near the west end of Harbor Island.