Strengthening U.S. Coast Guard Oversight and Support of Recognized Organizations: The Case of the Alternate Compliance Program (2021)

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89 As part of its charge, the study committee is tasked with reviewing the U.S. Coast Guard’s (Coast Guard’s) marine safety workforce’s size, training, competency levels, and qualifications for performing duties related to con- ducting inspections and overseeing the performance of recognized organiza- tions (ROs). The Marine Electric tragedy in 1983 led to concerns about the Coast Guard’s deployment of an appropriately sized and proficient marine inspection workforce. Concerns were raised anew after the El Faro sinking in 2015. Reports by both the National Transportation Safety Board (NTSB) and the Coast Guard Marine Board of Investigation found shortcomings in the quality of Coast Guard oversight examinations and in the thoroughness of RO surveys and audits. To recap, these findings included the following: • Inconsistent Quality of Inspections and Oversight Examinations: A number of ACP vessels examined by traveling inspectors after the El Faro casualty were found to be substandard, yet they had been allowed to operate for prolonged periods. It was noted that field inspectors were sometimes unfamiliar with Alternate Compliance Program (ACP) requirements and not following the applicable U.S. Supplement, and that supplements were not being updated regularly. • Insufficient Competencies and Experience by Inspectors: Evalu- ations by Coast Guard traveling inspectors found that some field inspectors lacked significant maritime experience, which limited their ability to accurately assess vessel conditions during oversight examinations. The Coast Guard did not have training programs in 5 The Coast Guard Workforce for Alternate Compliance Program Support and Oversight

90 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs place or qualification levels for inspectors specific to ACP oversight and the kinds of vessels characteristic of the ACP’s older fleet. For example, the machinery inspector who examined the El Faro had not received steam qualifications. The Coast Guard’s National Center of Expertise that previously provided assistance and guid- ance on unique older vessels, including those with steam plants such as the El Faro, had been disbanded. • Lack of RO Oversight Capacity and Expertise: Coast Guard marine safety personnel conducting oversight of ROs were not trained and certified to conduct audits of RO quality manage- ment systems (QMSs) or sufficiently knowledgeable of auditing principles to ensure that ROs were conducting competent internal QMS audits and verifications of the safety management systems (SMSs) of vessels and their owners. Sector Commanders some- times lacked the prevention experience necessary for an Officer in Charge, Marine Inspections (OCMI) to make time-sensitive deci- sions about whether an ACP vessel should be cleared to operate in cases where the reports from ROs and Coast Guard inspections identified deficiencies of different types. In such cases, the OCMI was reliant on junior officers within their command to provide much of the context and expertise for such decisions. The Commandant responded to these findings, and subsequent recom- mendations by the NTSB and the Marine Board of Investigation, by agree- ing to take a series of actions. The actions are again reviewed in the next section accompanied by the committee’s judgment about their adequacy and possible opportunities to improve on them. IMPROVING THE CONSISTENCY AND QUALITY OF VESSEL INSPECTIONS AND OVERSIGHT EXAMINATIONS The Coast Guard has more than 650 marine inspector billets, including about 500 in the military and 150 in the civilian workforces.1 The military workforce consists of commissioned officers and chief warrant officers. They not only inspect commercial U.S. flag vessels, but also foreign vessels calling at U.S. ports, mobile offshore drilling units, and barges and towing vessels carrying hazardous cargoes. Indeed, most U.S. vessels subject to inspection are small passenger vessels and barges. Consequently, with such a large inspection workforce having a wide breadth of responsibility, the 1 Frittelli, J. 2019. The Coast Guard’s Need for Experienced Marine Safety Personnel. R45923. September 19. Congressional Research Service. https://sgp.fas.org/crs/homesec/R45923.pdf. The number of marine inspector billets has likely changed since 2019.

THE COAST GUARD WORKFORCE FOR ACP SUPPORT AND OVERSIGHT 91 Coast Guard faces an ongoing challenge in ensuring that inspections are carried out in a consistent and competent manner, especially for vessel types that are not seen very often, such as the El Faro with its legacy technologies and grandfathered regulatory requirements. While training to improve inspector knowledge and proficiency is essential to the Coast Guard’s marine inspection program, so too is sup- porting inspectors with needed tools and procedural guidance. Indeed, several of the actions taken by the Coast Guard in response to the findings and recommendations from the El Faro investigations were intended to provide marine inspectors with better tools and guidance for conducting inspections and oversight examinations of vessels that use ROs. They in- clude the following: • A mobile application for accessing vessel records in the field; • New work instructions (CVC-WIs) that include guidance for rec- ognizing possible shortcomings in a company’s and a vessel’s safety management system (SMS) through the establishment of objective evidence of nonconformities; • An ACP “Tactics, Techniques, and Procedures” manual that pro- vides guidance on preexamination, examination, and postexamina- tion activities for oversight of compliance and RO performance; • An annual inspector oversight workshop that provides a regular opportunity to inform inspectors about inspection programs hav- ing functions delegated to third parties; and • Development of a single U.S. Supplement. Fulfillment of the recommendations in the previous chapter to provide inspectors with more searchable, accessible, and accurate records of ves- sels would be particularly helpful to inspectors while also assisting other prevention personnel and CVC-4 in monitoring vessel compliance and RO performance. Part of that performance monitoring, in the committee’s view, should be an ongoing effort to assess the quality of inspections and examinations as a way to understand the skills and competencies needed for such work. As discussed in Chapter 3, certain field inspection reports are now being reviewed by third-party organization (TPO) coordinators for accuracy. When questionable reports are identified, the coordinator will initiate a process to document and ensure that appropriate corrective actions are taken. It may be desirable, however, for the Coast Guard to introduce a more formalized process for monitoring the consistency and quality of inspections. An example of formalized process for monitoring consistency and quality in the field is the Coast Guard’s own use of standardization teams (STAN Teams). For instance, a STAN Team is deployed to review each

92 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs Coast Guard small-boat unit on a biennial basis to assess compliance with current policy, configuration control, and standardization.2 Teams consist of three to five highly trained and experienced professionals specializing in the operational, deck, and engineering aspects of each boat platform. In addition to assessing the condition of the unit’s assigned boats, train- ing programs, and rescue and survival systems program, the STAN Team also conducts a full assessment of crew proficiency. The Coast Guard has instituted other STAN Teams, for example, for helicopter rescue swimmers. Such an external standardization team, perhaps augmented with travel- ing inspectors, could be charged with auditing and assessing the profession- alism, competence, and readiness of the marine inspector workforce at each sector, including competencies in ACP and RO oversight. An important role of the STAN Teams is to provide reports with constructive feedback. Although not generally considered to be trainers, the teams will use their visits as opportunities to share their knowledge and technical information with unit personnel. The teams would also support the development and enhancement of inspector proficiencies by providing feedback to training programs. At the conclusion to the chapter, the committee recommends that the Coast Guard consider creating similar highly experienced, external evaluation and standardization teams for marine inspectors. INCREASING INSPECTOR COMPETENCIES AND EXPERIENCE While El Faro investigators identified some specific gaps in inspector compe- tencies that were the subject of recommendations for new Coast Guard train- ing offerings (e.g., for steam propulsion coursework), the findings broadly suggested a need for a marine inspection workforce having more experi- ence as well as expertise. Indeed, both the NTSB and Coast Guard Marine Board of Investigation reports pointed to traveling inspector findings that some Coast Guard marine inspectors lacked significant maritime experience that limited their ability to accurately assess vessel conditions on the basis of inspections. In gaining knowledge and experience, Coast Guard marine inspectors proceed through three qualification levels: apprentice, journey- man, and advanced journeyman. Apprentices must pass an initial qualifica- tion process and then will spend 3 years in a large training, or “feeder,” port where they are required to earn four marine inspection qualifications to become a journeyman and be eligible for assignments at other locations. In the case of civilians, emphasis is placed on hiring individuals with past maritime and inspection experience; however, the Coast Guard also has a separate apprenticeship program for civilians, the Civilian Apprentice 2 See https://www.forcecom.uscg.mil/Our-Organization/FORCECOM-UNITS/TraCen- Yorktown/Training/Boat-Forces-Cutter-Operations.

THE COAST GUARD WORKFORCE FOR ACP SUPPORT AND OVERSIGHT 93 Marine Inspector Program. To facilitate hiring and retention, as well for ensuring long-term term continuity of operations, the Coast Guard civilian inspectors generally remain at a single location for their entire careers. According to the Congressional Research Service,3 military inspectors at the rank of Chief Warrant Officer (CWO) will normally remain marine inspectors until retirement, which averages between 8 and 9 years. Most CWOs complete one to three tours as a field-level marine inspector and rotate approximately every 3 years. They are subject to a reevaluation of competencies upon transfer to a new unit. When deciding to relocate (or transfer) inspectors in accordance with standard tour-of-duty rotations, and whether to add billets to the inspector workforce, the Coast Guard uses a tool called Sector Staffing Model. This workload model applies a standard time to complete each activity type as a means of determining re- quired work hours and thus staffing positions. While the model is updated annually, the Coast Guard indicated that it can be difficult to incorporate future efficiency improvements and new demands on inspectors’ time into the model. The staffing numbers generated by the model are thus treated as indicative of needs but are not definitive, and a fair amount of judgment is required in allocating inspectors among the sectors and field units. Training The Coast Guard makes periodic changes to the inspector training cur- riculum, including to the platforms used, which have increasingly become information technology based (i.e., e-learning) rather than resident based. Asked by the study committee to explain the training curriculum, the Coast Guard provided the following list of courses, some currently available and others that are developed, pending, or newly introduced: • Existing Courses — Introduction to Marine Inspections (e-learning) — Confined Space Entry Course (e-learning) — Marine Inspector Course (Coast Guard resident) — Port State Control Course (Coast Guard resident) — Liquefied Natural Gas Course (contracted for gas carrier quali- fication only) — Advanced Passenger Vessel Examiner (Coast Guard resident for foreign passenger vessel qualification only) — Outer Continental Shelf Inspector Course (contracted resident for mobile offshore drilling unit qualification only) 3 Frittelli, J. 2019. The Coast Guard’s Need for Experienced Marine Safety Personnel. R45923. September 19. Congressional Research Service. https://sgp.fas.org/crs/homesec/R45923.pdf.

94 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs — D9 Breakouts (concentrated, informal on-the-job training on deep-draft vessels breaking out of the ice in spring) — Fiberglass Reinforced Plastic/Wood Boat (contracted resident, small passenger vessel qualification only) — Tankship Inspector Course (contracted resident, optional for tankship qualification only) • New and Pending Courses — Steam propulsion vessels (Coast Guard blended learning) — Apprentice Systems Training (Coast Guard blended learning including 13 system e-learning courses) — Safety Management Systems including International Safety Man- agement, ACP, Marine Security Program, Streamlined Inspection Program (e-learning) — Ballast Water Management (e-learning) — Welding (e-learning) — Safe Work Practices (e-learning) — Automation/Dynamic Positioning (e-learning) — Verifying Officer: Train-the-Trainer (e-learning) — New Construction (e-learning) — Manning/Credentialing (App) — Alternate Fuels: LNG, Li-ion Battery (e-learning) — Journeyman Marine Inspector (JMI) Course (Coast Guard resident) — Advanced Journeyman Marine Inspector Continuing Education (Coast Guard resident) — Chief of Marine Inspections (Coast Guard resident) Note that among the new and pending courses is one on SMS and another on steam propulsion, which is in direct response to the recom- mendation of El Faro investigators and satisfies a congressional directive.4 The committee also observed that among the new course offerings are some that are intended to not only further career progression but also to ensure that inspectors continue learning after reaching the needed qualifications, including a continuing education for advanced journeymen. Recruitment and Retention Over the years, the Coast Guard has employed several methods to aid in the recruitment of inspectors. A marine safety curriculum has been established 4 As of July 2021, this was the only new completed course on steam propulsion vessels, but the Coast Guard anticipates that the other courses will be available in fall 2021 (CAPT M. Edwards, Coast Guard, presentation to the committee, July 15).

THE COAST GUARD WORKFORCE FOR ACP SUPPORT AND OVERSIGHT 95 at the Coast Guard Academy to introduce cadets to the challenges associ- ated with overseeing marine safety. In 2018 the Coast Guard established the Enlisted Marine Inspector Training Program to develop and train enlisted members as marine inspectors with the goal of becoming commissioned as CWOs to serve as technical experts. In addition to hiring civilians for apprenticeship training, the Coast Guard also seeks to bring credentialed merchant mariners into its military ranks under a direct commissioning program. The Maritime Academy Graduate Program also provides a way to commission maritime academy graduates to meet critical service needs in the prevention mission area. According to the Coast Guard, recruiting into the marine inspection program has been aided by these varied efforts. At the same time, the Coast Guard reported that retaining inspectors until they become advanced journeymen remains difficult. To fill workforce gaps and to build a larger cohort of inspectors who can develop the requisite experience to become advanced journeymen, the Coast Guard is requesting approximately 100 new inspector positions in the current budget cycle. In addition, the Coast Guard maintains that it is carrying out a holistic analysis of the existing marine inspection workforce, through the Marine Inspector Performance Support Architecture project, with the objective of delivering a roadmap for marine inspector development by the end of 2021. Career Paths and Advancement The Coast Guard explained that part of the challenge in retaining preven- tion officers until they become more experienced is that there may be a perception among junior officers that other Coast Guard specialties offer better career opportunities, including command assignments and other key leadership positions. The El Faro investigators observed, for instance, that the Sector Commander, whose position includes the authority and responsibility as the OCMI, lacked the prevention experience necessary to make time-sensitive decisions about when to detain substandard vessels.5 The Coast Guard has attempted to address this shortcoming by providing OCMI training that covers the ACP and other inspection programs that delegate functions to third parties (as discussed in Chapter 3). Moreover, the Coast Guard reported that if a Sector Commander does not have pre- vention experience, a Deputy Sector Commander will be assigned who has this background. In 2015, the Coast Guard published career path and progression guid- ance for Operations Ashore Prevention (OAP) Officers. OAP encompass the 5 Because Sector Commander staffs include subject-matter experts, the Sector Commander is not expected to have in-depth experience and expertise in all of the missions they oversee.

96 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs specialties of vessel and facility inspections, waterways management, and marine casualty investigation duties.6 The guidance explains how junior officers can build OAP career paths by achieving certain professional expec- tations (developing competencies, with specialties and subspecialties) and by seeking certain tour assignments. To build a strong technical founda- tion, the junior officer is advised to seek back-to-back 3-year field tours in vessel inspections and other prevention disciplines. After completing these initial operational tours, the guidance goes on to state that OAP officers should expect to achieve mastery of their specialties and go into staff and operational tour rotations for the remainder of their careers. The findings from the El Faro investigations that some marine inspec- tors lacked proficiency and experience in conducting inspections and per- forming other prevention duties suggest that Coast Guard efforts to ensure that its OAP career guidance can be pursued by junior officers would seem to be important. However, the guidance, which was developed before the El Faro investigations, acknowledges that some of the advised steps, including successful back-to-back assignments in prevention, cannot be guaranteed. An assessment of the record of junior officers successfully following the guidance would seem to be warranted and is thus the subject of a recom- mendation below. IMPROVING RECOGNIZED ORGANIZATION OVERSIGHT CAPACITY AND EXPERTISE The El Faro investigations revealed that the Coast Guard, after creating the ACP some 20 years earlier and having established other programs that delegated inspection functions to third parties, had been remiss in not establishing or maintaining oversight policies and procedures tailored to these programs. At the time of the El Faro sinking, the Coast Guard did not have a unit with staff dedicated to third-party oversight. Moreover, some program support and oversight measures that had been established when the ACP was created, such as RO liaison officer billets, had been allowed to atrophy. In establishing a Flag State Division (CVC-4) within the Office of Com- mercial Vessel Compliance (CVC), the Coast Guard has begun to rectify these shortcomings, and particularly by building a cadre of professionals proficient in third-party oversight. Much of the staffing for the CVC-4, which included 10 billets, was transferred from elsewhere in the Coast 6 Michel, C. D. 2015. Operations Ashore Junior Officer Career Guide. Deputy Com- mandant for Operations, U.S. Coast Guard. https://www.dco.uscg.mil/Portals/9/DCO%20 Documents/5p/5ps/Design%20and%20Engineering%20Standards/docs/Ops_Ashore_Junior_ Officer_Career_Guide_2015.pdf?ver=2017-06-16-142233-273.

THE COAST GUARD WORKFORCE FOR ACP SUPPORT AND OVERSIGHT 97 Guard while two new junior officer (Lieutenant Commander) billets were added. As discussed in Chapter 3, the Coast Guard created the new position of TPO coordinator. These coordinators are expected, among other quali- fications, to have experience and expertise in conducting inspections for a variety of vessels enrolled in alternative inspection programs, coordinating and managing audit processes, and providing technical expertise and train- ing to new inspectors. The Coast Guard explained to the study committee that it does not plan to train field inspectors in auditing because they are not expected to be auditors. The TPO coordinators, however, are expected to have subject- matter expertise for auditing vessels, operating companies, ROs, and other TPOs. As discussed in earlier chapters, a key role of the coordinators is to lead marine inspection teams during complex vessel exams and inspec- tions, train new inspectors on complex projects such as for reflagging Maritime Security Program (MSP) vessels, perform quality control and trend analysis on inspection data (e.g., Marine Information for Safety and Law Enforce ment [MISLE] records), and observe audits by ROs and other TPOs. Accord ing to the Coast Guard, the plan is to ensure that at least one TPO coordinator is stationed in each sector to provide these func- tions in support of field inspectors. Having the support of coordinators, it could be a concern that the field inspectors themselves are not expected to be sufficiently knowledgeable of auditing principles to ensure, for instance, that ROs are conducting competent audits of the SMSs of vessels and their owners. It is the committee’s understanding that a key role of TPO coordina- tors is to make determinations about when a vessel or company may not be properly implementing an SMS or when an RO is not performing delegated functions (including SMS audits) as consistently and effectively as required or as would be expected if adhering to a sound QMS. These determina- tions must be based largely on evidence and observations from inspections; hence, coordinators depend on marine inspectors to bring SMS issues to their attention on the basis of objective evidence. Consequently, the in- spector’s referral role is crucial to the coordinator in performing effective oversight. This importance suggests that marine inspectors, and particularly senior inspectors, should have a working understanding of the principles of SMS and the audit function. This knowledge should be sufficient for all inspectors to have the ability to recognize when an RO’s audit of an SMS may not have been carried out with due diligence. CONCLUSIONS AND RECOMMENDATIONS The El Faro investigations raised concerns about the guidance and resources available to Coast Guard inspectors to conduct high-quality inspections and

98 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs examinations of vessels in the ACP that use ROs, about shortcomings in inspector competencies and experience levels for this purpose, and about the lack of marine safety personnel charged with, and capable of, oversee- ing ACP compliance and RO performance generally. The Coast Guard has taken important steps to address these concerns, including the introduction of new work instructions and tools (e.g., a mobile app for inspectors), new training courses with relevance to ACP vessels and third-party oversight, and the creation of CVC-4 and TPO coordinators. Nevertheless, needs and opportunities remain for the Coast Guard to further strengthen the performance and capabilities of its marine safety workforce by • Actively monitoring the competencies that marine inspectors have and need for conducting vessel inspections and oversight exami- nations in order to determine where further improvements are warranted; • Verifying that Coast Guard guidance on the career progression paths for OAP Officers can be pursued without undue impediment, is indeed being pursued by sufficient numbers of junior officers, and aligns with the goal of ensuring that mastery of marine inspection specialties provides sufficient profile and opportunities for assign- ments that can lead to command and leadership positions such as OCMI; and • Ensuring that all marine inspectors, and particularly senior inspec- tors, have sufficient knowledge of SMS principles and purposes to make observations about whether vessel and company SMS plans are being followed. SMS training for senior inspectors, including training on the process and principles of SMS audits, would cre- ate a valuable skill set that could make this career path even more desirable. On the basis of these findings, the committee recommends the following: Recommendation 5: The Coast Guard should consider establishing a standardization team, modeled after similar teams in other Coast Guard domains, that visits marine inspection field units on a regular basis to assess inspector competencies, the consistency in following work instructions and protocols, and the quality of inspections. The team, whose role should also be to provide real-time, constructive feed- back to inspectors and to inform Coast Guard inspector training programs, could be created through augmentation of the Coast Guard’s traveling staff of senior marine inspectors.

THE COAST GUARD WORKFORCE FOR ACP SUPPORT AND OVERSIGHT 99 Recommendation 6: The Coast Guard should review its current career path progression guidance for Operations Ashore Prevention Officers, which was introduced before the El Faro investigations, with an eye to whether the guidance is being followed by sufficient numbers of junior officers, provides opportunities to master the marine inspection specialties, and ensures that mastery of those specialties provides ample career advancement opportuni- ties in the prevention field, including relevant leadership positions such as OCMI. While the Coast Guard has acknowledged the importance of ensuring that OCMIs have marine inspection expertise, it is an imperative for assign- ments in the country’s largest commercial and feeder ports. To meet this imperative, the Coast Guard must make sure that marine inspection career pathways exist that are attractive and are being pursued by officers quali- fied for these assignments. Recommendation 7: The Coast Guard should ensure that all marine inspectors have sufficient understanding of the purpose and components of an SMS and how adherence to it should be evident during an inspec- tion. Senior inspectors should have a strong understanding of how an RO conducts an SMS compliance audit to allow them to know when deficien- cies and nonconformities observed during vessel inspections and oversight exami nations may be indicative of substandard RO performance and war- rant referral to the Flag State Control Division (CVC-4) and third-party organization coordinators. Because the SMS audit function is a critically important role of the RO, the Coast Guard’s oversight of it must be robust and comprehensive, starting with ensuring that field inspectors have sufficient awareness and under- standing to observe compliance firsthand.