Procedures were both not followed and not widely known due to there being no safety management system or training program. The lookout left the wheelhouse before the crash.
Thats not true. The two-pilot rule had been in existence for over 50 years. The Director of Ferry Operations admitted he knew it wasn’t being followed. He even had submitted a directive to the city re-enforcing the already existing rule but lied about actually distributing it to crew, and pled guilty himself to Seaman’s Manslaughter.
From the case:
Patrick Ryan, the City’s director of ferry operations at the time of the accident, conceded that he knew that the Staten Island Ferry’s Standard Operating Procedures (“SOP”) were not being followed:
[W]hen I was the director of Staten Island Ferry operations, I understood . . . that the ferry service had a written rule that generally required the captain and assistant captain to be together in the operating pilot house while the [ferry was] underway.
A rule that served to insure passenger safety by providing for at least two people in the operating pilot house aware of the navigational situation.
I knew that this rule was not always being observed by all captains and assistant captains in good weather. I drafted revised Staten Island Ferry Standard Operating Procedures between 2001 and 2002 that restated this rule but did not take appropriate steps to insure – did not take adequate steps to insure that the ferry’s captains and assistant captains received the new document, trained them on the rule nor insured that they were complying with it.
As a result, this rule was not followed at the time of the accident involving the Barberi on October 15, 2003 and no crew member noticed in time that the boat was far off course.