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From page 1...
... 1 Executive Summary On October 1, 2015, the U.S. flag cargo ship El Faro sank during a hurricane en route to Puerto Rico from Florida, leading to the death of all 33 crew members.
From page 2...
... 2 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs surveys of ships and audits of the management systems of ship owners to verify compliance with the safety requirements and other demands of international conventions.
From page 3...
... EXECUTIVE SUMMARY 3 functions delegated by the Coast Guard. CVC-4 has issued new policies, procedures, and guidance for marine inspectors in conducting vessel oversight examinations and making observations relevant to assessing the quality of RO surveys and audits.
From page 4...
... 4 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs CONCLUSIONS AND RECOMMENDATIONS Building a Database for Vessel Compliance Verification and Recognized Organization Oversight The Coast Guard's progress in instituting a more data-driven and risk-based approach to overseeing ROs has not kept pace with the strides it has made in establishing an organizational and procedural oversight framework.
From page 5...
... EXECUTIVE SUMMARY 5 Absent better data systems and tools for data extraction and analysis, the Coast Guard's intentions to be more risk based and data driven are not likely to be fulfilled. The following four recommendations pertaining to data, metrics, and risk-based tools are offered with the needs, constraints, and time dimensions identified above: Recommendation 1: In the near term, the Coast Guard should collaborate with ROs and vessel owners to develop and execute a plan to share and validate information for the purpose of ensuring that records derived from MISLE of vessels and vessel owners who use RO services are complete, accurate, and current with respect to compliance history.
From page 6...
... 6 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs will be important for efforts to get under way to introduce this more functional, stand-alone data system as soon as possible.
From page 7...
... EXECUTIVE SUMMARY 7 • Ensuring that all marine inspectors, and particularly senior inspectors, 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 create a valuable skill set that could make this career path even more desirable.
From page 8...
... 8 STRENGTHENING U.S. COAST GUARD OVERSIGHT AND SUPPORT OF ROs 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 understanding to observe compliance firsthand.
From page 9...
... EXECUTIVE SUMMARY 9 and tools needed to ensure that resources are devoted to mitigating the highest consequence risks. Having several years of experience with the implementation of its new organizational and procedural framework for RO oversight, the Coast Guard can now take stock in whether its elements are designed and being implemented in a manner that reinforces a safety partnership.

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