    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

      EXAMINATION OF REPORTS ON THE ``EL FARO'' MARINE CASUALTY AND COAST
                       GUARD'S ELECTRONIC HEALTH RECORDS

    =======================================================================

                                    (115-34)

                                    HEARING

                                   BEFORE THE

                                SUBCOMMITTEE ON
                    COAST GUARD AND MARITIME TRANSPORTATION

                                     OF THE

                                  COMMITTEE ON
                       TRANSPORTATION AND INFRASTRUCTURE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                JANUARY 30, 2018

                                   __________

                           Printed for the use of the
                 Committee on Transportation and Infrastructure

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

         Available online at: https://www.govinfo.gov/committee/house-
         transportation?path=/browsecommittee/chamber/house/committee/
                                 transportation

                                        ______

                             U.S. GOVERNMENT PUBLISHING OFFICE

    30-345 PDF                     WASHINGTON : 2018

                 COMMITTEE ON TRANSPORTATION AND INFRASTRUCTURE

                      BILL SHUSTER, Pennsylvania, Chairman
    DON YOUNG, Alaska                    PETER A. DeFAZIO, Oregon
    JOHN J. DUNCAN, Jr., Tennessee,      ELEANOR HOLMES NORTON, District of
      Vice Chair                             Columbia
    FRANK A. LoBIONDO, New Jersey        JERROLD NADLER, New York
    SAM GRAVES, Missouri                 EDDIE BERNICE JOHNSON, Texas
    DUNCAN HUNTER, California            ELIJAH E. CUMMINGS, Maryland
    ERIC A. ``RICK'' CRAWFORD, Arkansas  RICK LARSEN, Washington
    LOU BARLETTA, Pennsylvania           MICHAEL E. CAPUANO, Massachusetts
    BLAKE FARENTHOLD, Texas              GRACE F. NAPOLITANO, California
    BOB GIBBS, Ohio                      DANIEL LIPINSKI, Illinois
    DANIEL WEBSTER, Florida              STEVE COHEN, Tennessee
    JEFF DENHAM, California              ALBIO SIRES, New Jersey
    THOMAS MASSIE, Kentucky              JOHN GARAMENDI, California
    MARK MEADOWS, North Carolina         HENRY C. ``HANK'' JOHNSON, Jr.,
    SCOTT PERRY, Pennsylvania                Georgia
    RODNEY DAVIS, Illinois               ANDRE CARSON, Indiana
    MARK SANFORD, South Carolina         RICHARD M. NOLAN, Minnesota
    ROB WOODALL, Georgia                 DINA TITUS, Nevada
    TODD ROKITA, Indiana                 SEAN PATRICK MALONEY, New York
    JOHN KATKO, New York                 ELIZABETH H. ESTY, Connecticut,
    BRIAN BABIN, Texas                       Vice Ranking Member
    GARRET GRAVES, Louisiana             LOIS FRANKEL, Florida
    BARBARA COMSTOCK, Virginia           CHERI BUSTOS, Illinois
    DAVID ROUZER, North Carolina         JARED HUFFMAN, California
    MIKE BOST, Illinois                  JULIA BROWNLEY, California
    RANDY K. WEBER, Sr., Texas           FREDERICA S. WILSON, Florida
    DOUG LaMALFA, California             DONALD M. PAYNE, Jr., New Jersey
    BRUCE WESTERMAN, Arkansas            ALAN S. LOWENTHAL, California
    LLOYD SMUCKER, Pennsylvania          BRENDA L. LAWRENCE, Michigan
    PAUL MITCHELL, Michigan              MARK DeSAULNIER, California
    JOHN J. FASO, New York
    A. DREW FERGUSON IV, Georgia
    BRIAN J. MAST, Florida
    JASON LEWIS, Minnesota
                                    ------

            Subcommittee on Coast Guard and Maritime Transportation

                      DUNCAN HUNTER, California, Chairman
    DON YOUNG, Alaska                    JOHN GARAMENDI, California
    FRANK A. LoBIONDO, New Jersey        ELIJAH E. CUMMINGS, Maryland
    GARRET GRAVES, Louisiana             RICK LARSEN, Washington
    DAVID ROUZER, North Carolina         JARED HUFFMAN, California
    RANDY K. WEBER, Sr., Texas           ALAN S. LOWENTHAL, California
    BRIAN J. MAST, Florida               ELEANOR HOLMES NORTON, District of
    JASON LEWIS, Minnesota, Vice Chair       Columbia
    BILL SHUSTER, Pennsylvania (Ex       PETER A. DeFAZIO, Oregon (Ex
        Officio)                             Officio)

                                    CONTENTS

                                                                       Page

    Summary of Subject Matter........................................     v

                                   TESTIMONY
                                    Panel 1

    Rear Admiral John P. Nadeau, Assistant Commandant for Prevention
      Policy, U.S. Coast Guard.......................................     4
    Hon. Earl F. Weener, Ph.D., Board Member, National Transportation
      Safety Board, accompanied by Brian Curtis, Director, Office of
      Marine Safety, National Transportation Safety Board............     4

                                    Panel 2

    Rear Admiral Erica Schwartz, Director of Health, Safety, and
      Work-Life, U.S. Coast Guard....................................    19
    Rear Admiral Michael J. Haycock, Assistant Commandant for
      Acquisition and Chief Acquisition Officer, U.S. Coast Guard....    19
    David A. Powner, Director of Information Technology Management
      Issues, U.S. Government Accountability Office..................    19

              PREPARED STATEMENTS SUBMITTED BY MEMBERS OF CONGRESS

    Hon. John Garamendi of California................................    30

                   PREPARED STATEMENTS SUBMITTED BY WITNESSES

    Rear Admiral John P. Nadeau, Assistant Commandant for Prevention
      Policy, U.S. Coast Guard.......................................    33
    Hon. Earl F. Weener, Ph.D., Board Member, National Transportation
      Safety Board, accompanied by Brian Curtis, Director, Office of
      Marine Safety, National Transportation Safety Board............    52
    Rear Admiral Erica Schwartz, Director of Health, Safety, and
      Work-Life, U.S. Coast Guard \1\
    Rear Admiral Michael J. Haycock, Assistant Commandant for
      Acquisition and Chief Acquisition Officer, U.S. Coast Guard \1\
    David A. Powner, Director of Information Technology Management
      Issues, U.S. Government Accountability Office..................    66

                           SUBMISSIONS FOR THE RECORD

    U.S. Coast Guard, responses to questions for the record from Hon.
      John Garamendi, a Representative in Congress from the State of
      California.....................................................    36
    Hon. Earl F. Weener, Ph.D., Board Member, National Transportation
      Safety Board, responses to questions for the record from Hon.
      John Garamendi, a Representative in Congress from the State of
      California.....................................................    62
    David A. Powner, Director of Information Technology Management
      Issues, U.S. Government Accountability Office, responses to
      questions for the record from Hon. John Garamendi, a
      Representative in Congress from the State of California........    81

    ----------
    \1\ RADM Schwartz and RADM Haycock did not submit written statements
    for the record.
    Reports referenced in the Summary of Subject Matter on pages v-x:

        Coast Guard Marine Board of Investigation Recommendations \2\    86
        Action by the Commandant, U.S. Coast Guard, December 19,
          2017, ``Steam Ship El Faro (O.N. 561732) Sinking and Loss
          of the Vessel with 33 Persons Missing and Presumed Deceased
          Northeast of Acklins and Crooked Island, Bahamas, on
          October 1, 2015''..........................................    92
        National Transportation Safety Board Recommendations \3\.....   123

    ----------
    \2\ This is an excerpt from the 199-page U.S. Coast Guard Marine Board
    report entitled, ``Steam Ship El Faro (O.N. 561732) Sinking and Loss of
    the Vessel with 33 Persons Missing and Presumed Deceased Northeast of
    Acklins and Crooked Island, Bahamas, on October 1, 2015'' and available
    online at https://media.defense.gov/2017/Oct/01/2001820187/-1/-1/0/
    FINAL%20PDF%20ROI%2024%20SEP%2017.PDF.
    \3\ This is an excerpt from the 282-page National Transportation Safety
    Board report entitled, ``Sinking of U.S. Cargo Vessel SS El Faro,
    Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas,
    October 1, 2015'' adopted December 12, 2017, NTSB/MAR-17/01, PB2018-
    100342 and available online at https://www.ntsb.gov/investigations/
    AccidentReports/Reports/MAR1701.pdf.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      EXAMINATION OF REPORTS ON THE ``EL FARO'' MARINE CASUALTY AND COAST
                       GUARD'S ELECTRONIC HEALTH RECORDS

                                  ----------

                           TUESDAY, JANUARY 30, 2018

                      House of Representatives,
              Subcommittee on Coast Guard and Maritime
                                        Transportation,
                Committee on Transportation and Infrastructure,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10 a.m., in room
    2167, Rayburn House Office Building, Hon. Duncan Hunter
    (Chairman of the subcommittee) presiding.
        Mr. Hunter. Good morning. The subcommittee will come to
    order.
        The subcommittee is convening today to examine the fatal
    sinking of the U.S.-flagged cargo ship, SS El Faro and, on a
    second panel, the Coast Guard's failed efforts to implement an
    electronic health record system.
        On October 1, 2015, the 790-foot U.S.-flagged cargo ship SS
    El Faro sank in the Atlantic Ocean about 40 nautical miles
    northeast of Acklins and Crooked Island, Bahamas. An unusual
    storm path, reliance on outdated weather reports, and failure
    to implement proper bridge resource management techniques
    resulted in El Faro sailing almost directly into Hurricane
    Joaquin, a category 4 storm with an estimated sustained wind
    speed of 115 knots.
        The loss of the U.S.-flagged cargo vessel El Faro, along
    with its 33-member crew, ranks as one of the worst maritime
    disasters in U.S. history and resulted in the highest death
    toll from a U.S. commercial vessel sinking in almost 40 years.
        The last comparable U.S. maritime disaster was the sinking
    of the U.S. bulk carrier Marine Electric off the coast of
    Virginia in February 1983, in which all but 3 of the 34 persons
    aboard lost their lives. The Coast Guard instituted major
    changes following that tragedy to improve safety and prevent
    similar events from occurring in the future.
        Despite those efforts to improve safety, tragedy befell the
    El Faro.
        On October 31, 2015, a U.S. Navy vessel located the main
    wreckage of El Faro and the vessel's voyage data recorder was
    successfully recovered. It contained 26 hours of bridge audio
    recordings and other critical navigation data that were used by
    the Coast Guard and the NTSB investigators to understand the
    causes of this horrible incident and develop recommendations to
    prevent future tragedies.
        The Coast Guard Marine Board of Investigation made 31
    safety and 4 administrative recommendations to address the
    causes of the El Faro's sinking. In December 2017, the
    Commandant of the Coast Guard released his Final Action Memo on
    the Marine Board's recommendation. The Commandant concurred
    with 29 of 31 safety recommendations and 3 of 4 administrative
    recommendations.
        The National Transportation Safety Board launched an
    investigation as soon as the sinking of El Faro was confirmed,
    ultimately providing numerous recommendations for responsible
    entities, including the Coast Guard, the International
    Association of Classification Societies, and the owner of El
    Faro.
        The Nation relies on our merchant mariners and the U.S.-
    flagged ships they sail. It is critical that policies are in
    place and adopted as standard practice to ensure mariners'
    safety. In order to do so, we must learn from the loss of the
    El Faro. I look forward to discussing how this tragedy occurred
    and what steps are being taken to prevent another such incident
    from occurring.
        Notwithstanding the importance and gravity of the El Faro
    tragedy, on panel 2 we will examine the Coast Guard's apparent
    inability to implement an electronic health record system to
    manage data for its over 56,000 Coast Guard members and
    retirees.
        After wasting more than $66 million over a 5-year period,
    the Coast Guard canceled its electronic health records effort,
    referred to as the Integrated Health Information System
    project.
        The Service has nothing to show for the time and money
    expended and finds itself in a worse position than before it
    awarded the first contract almost 8 years ago.
        Today the Coast Guard is still handling all medical
    information using paper records, records that cannot be shared
    with the Department of Defense or the Department of Veterans
    Affairs system.
        Following a subcommittee request to review Coast Guard
    actions, the Government Accountability Office found that for
    nearly the entire span of the project, the Coast Guard allowed
    program managers to act without sufficient oversight by
    acquisition professionals. Even when the Coast Guard
    established its nonmajor acquisition process policies to
    provide oversight for information technology acquisitions,
    things like the Integrated Health Information System project,
    they did not implement any oversight.
        Despite chartering several oversight bodies for the
    project, GAO found that the Coast Guard, ``could not provide
    evidence that the boards had ever been active in overseeing the
    project prior to its cancellation.''
        Other than realizing they had been throwing away good money
    for years, the Coast Guard still cannot provide a solid
    explanation as to why it canceled the Integrated Health
    Information System project.
        The Coast Guard needs to show what it has learned and how
    things have changed as it works to finally implement an
    electronic health record system. We understand the Service is
    following its acquisition policies for the current effort and
    has conducted significant research which pointed to a
    recommended solution of using an existing Federal agency
    system. That is amazing.
        After a 5-year epic failure, these are positive steps.
    However, we need to hear more about the policies and procedures
    that are now in place to prevent the waste of taxpayer money in
    the future.
        I look forward to discussing how this debacle occurred,
    what steps the Coast Guard is taking to ensure nothing like
    this can happen again, and where the Coast Guard is in the
    process of finally acquiring an electronic health record
    system.
        I thank the witnesses for being here today, and I look
    forward to hearing all the various testimony on the various
    issues.
        And I yield to Ranking Member Garamendi. You are
    recognized.
        Mr. Garamendi. I yield to----
        Mr. Hunter. Yield to the ranking member of the full
    committee, Mr. DeFazio.
        Mr. DeFazio. Thank you, Mr. Chairman. And I thank the
    ranking member for that. I have to run to a press event and
    then I will be back.
        First off, I am concerned that we are merging two totally
    unrelated subjects here. Certainly, the acquisition failure is
    important. Whether it merits a hearing or not, I am not sure,
    but it certainly shouldn't be taking away from a focus on the
    El Faro tragedy.
        This was totally preventable. And I think there are a
    number of factors and things that require the attention of the
    subcommittee.
        First off, there are real questions about the Coast Guard,
    whether their budget is adequate to carry out this very, very
    important function. I think it is not. I think we have spread
    them too thin. And they are relying far too much on
    classification societies without any substantial oversight of
    those classification societies.
        And from some in the industry, I understand there are
    companies who do a good job and there are other companies, if
    you pay them, they will certify your rust bucket as seaworthy.
        Now, that is just not right, and that really requires some
    scrutiny. It also requires us to question how we got to that
    point, and what we can do to rectify that.
        I think that the Coast Guard should have resources adequate
    to, minimally, to oversee these classification societies.
    Perhaps we need to have some sort of a system where we either
    certify them or decertify them for U.S. certification.
        Now, they can go to these nonexisting countries with these
    registries and certify rust buckets. We can't control that, but
    we can control whose certifications we accept here in the
    United States of America, and that, I think, played a
    substantial role in this.
        Plus, real questions about, obviously, the management of
    TOTE and the training that TOTE provided, the adequacy of the
    lifesaving supplies on the ship, all the questions about when
    the ship had a major conversion, why it wasn't considered a
    major conversion, and, therefore, they didn't have to upgrade
    things, what brought that about, which might have saved lives
    in this case.
        There is just a host of questions. And I hope we can really
    drill down on that, and I hope we don't get distracted with the
    second panel.
        Thank you, Mr. Chairman.
        Mr. Hunter. I thank the ranking member.
        From I understand, too, it is hard to get committee time,
    because we won't do in this full committee multiple
    subcommittees at the same time. So we don't do freeways and
    Coast Guard, which enables the ranking member and others to
    attend, but we are out of days for stuff. So we are going to
    focus for the first hour on the El Faro, or however long it
    takes us, before we move on.
        Mr. Garamendi, you are recognized for your opening
    statement.
        Mr. Garamendi. Let's get on with the hearing. Without
    objection, my testimony will be in the record.
        Mr. Hunter. Without objection, so ordered.
        Mr. Garamendi. And I think I will just let it go at that,
    with a couple of very brief statements.
        It was 35 years ago that the Marine Board of Investigation
    made a report about the faults of two systems in the maritime
    safety programs. Here we are again, essentially the same report
    being issued, this time on the El Faro situation.
        The question is, why are we back with the same
    recommendations to address the tragedy of the El Faro? Bottom
    line is, why didn't we get it right in the last 35 years?
        With that, my testimony, my written, will be in the record.
        Mr. Hunter. I thank the gentleman.
        And I ask unanimous consent that members not on the
    subcommittee be permitted to sit with the subcommittee at
    today's hearing and ask questions. Without objection, so
    ordered.
        On the first panel we will hear from Rear Admiral John
    Nadeau, Assistant Commandant for Prevention Policy for the
    United States Coast Guard, and the Honorable Earl Weener,
    Member of the National Transportation Safety Board, accompanied
    by Mr. Brian Curtis, Director of the Office of Marine Safety
    for the NTSB.
        Admiral Nadeau, you are recognized to give your statement,
    and welcome back.

    TESTIMONY OF REAR ADMIRAL JOHN P. NADEAU, ASSISTANT COMMANDANT
       FOR PREVENTION POLICY, U.S. COAST GUARD; AND HON. EARL F.
      WEENER, PH.D., BOARD MEMBER, NATIONAL TRANSPORTATION SAFETY
    BOARD, ACCOMPANIED BY BRIAN CURTIS, DIRECTOR, OFFICE OF MARINE
              SAFETY, NATIONAL TRANSPORTATION SAFETY BOARD

        Admiral Nadeau. Good morning, Chairman Hunter, Ranking
    Member Garamendi, distinguished members of the subcommittee. I
    am honored to be here today.
        Mr. Chairman, I want to especially thank you for your
    leadership and enduring support to the Coast Guard.
        On behalf of all the men and women in the Coast Guard, I
    offer our deepest condolences to the families of the 33
    mariners lost onboard El Faro.
        As our Commandant noted in the Final Action Memo, the loss
    of the El Faro and everyone aboard was a tragic and preventable
    accident. This is a call to action for the entire maritime
    community. The Commandant is committed to making improvements
    within the Coast Guard and the maritime industry and has
    directed me to do so.
        The Marine Board of Investigation conducted an exhaustive
    2-year investigation in full view of the public. While the
    primary cause of the casualty was the decision to navigate El
    Faro too close to the path of Hurricane Joaquin, there were
    other contributing factors.
        These include, one, the failure of TOTE Services,
    Incorporated, to maintain an effective safety management
    system; two, the failure of the ship's classification society,
    ABS [American Bureau of Shipping], on multiple occasions to
    uncover or otherwise resolve longstanding deficiencies that
    adversely affected the safety and seaworthiness of vessels;
    and, three, failure of the Coast Guard to properly oversee the
    work conducted by ABS on our behalf.
        To determine if these issues revealed in the El Faro
    investigation are pervasive throughout the fleet, I directed a
    team of senior marine inspectors to closely examine more ships
    currently enrolled in the Alternate Compliance Program, or ACP.
    We have found additional evidence of breakdowns in the safety
    framework, and our findings confirm concerns raised in the
    investigation about the material condition of several other
    U.S.-flagged vessels.
        All elements of the safety framework--the vessel owners and
    operators, the class societies, and the Coast Guard--must all
    improve.
        The vessel owner is accountable for properly maintaining
    and ensuring the safe operations of the vessel.
        The class society plays a key role in ensuring safety by
    providing thorough and accurate surveys and compelling
    corrective actions when needed.
        The Coast Guard is the final element in the safety
    framework by verifying compliance with mandatory safety
    standards.
        As was noted in the Federal Register announcing the program
    more than two decades ago, ACP was created in response to the
    needs expressed by the U.S. maritime industry to reduce the
    regulatory burden and alleviate duplication of effort between
    the Coast Guard and class societies.
        Since day one, the Coast Guard has committed to providing
    oversight to ensure that vessels participating in ACP are
    maintained and operated to the same level of safety as vessels
    inspected by the Coast Guard under the traditional process.
        Today we remain committed to this goal and acknowledge we
    must do better.
        The U.S., like other flag states around the globe today,
    now relies far more heavily on third parties than ever before.
    In fact, the vast majority of the U.S. sealift fleet that DoD
    relies on to transport America's soldiers, Marines, and their
    equipment overseas, uses class societies for many of their
    compliance activities.
        Now, more than ever, we need to get this right. The Coast
    Guard must and will restore the safety framework with robust
    and thorough oversight and accountability.
        I am taking a number of steps to do so. I will lead the
    actions directed by the Commandant in response to this tragedy.
    I am reforming our oversight program and directing changes to
    the organization, the procedures, the policy, the training, and
    the capture and management of key information.
        These actions are needed to ensure accountability for the
    maritime industry, the authorized class societies, and the
    Coast Guard. The Coast Guard has the authority and the
    competency needed to successfully accomplish this. As I pursue
    these actions, I will be transparent and keep you all informed.
        At the end of the day, this is about the lives of the men
    and women who go to sea in support of the Nation's economic
    prosperity, in support of our military readiness, and in
    support of our national security.
        I recently had the opportunity to visit the El Faro
    Memorial in Jacksonville. I also met some of the mariners who
    had once sailed on the El Faro and now mourn the loss of their
    shipmates. It was a moving and humbling experience.
        This tragedy has shined a spotlight on failures of the
    safety framework. We must honor the 33 lost mariners with a
    strong bias towards action.
        The Coast Guard, after the vessel owner and the class
    society, is the final element in the safety framework
    responsible for ensuring compliance with mandated safety
    standards. The Coast Guard must and will restore the safety
    framework.
        Again, thank you for your strong support of the Coast
    Guard. Thank you for the opportunity to testify today. I ask my
    written statement be entered into the record. I look forward to
    your questions.
        Mr. Hunter. Without objection. Thank you, Admiral.
        Mr. Weener, you are recognized.
        Mr. Weener. Good morning, Chairman Hunter, Ranking Member
    Garamendi, and members of the subcommittee. Thank you for
    inviting the NTSB to provide testimony today.
        Mr. Hunter. Would you mind pulling the microphone a bit
    closer to you? Thank you.
        Mr. Weener. I am accompanied by Brian Curtis, the Director
    of our Office of Marine Safety.
        My testimony will discuss the NTSB's investigation into the
    sinking of the cargo ship El Faro and the loss of all 33
    crewmembers aboard.
        The NTSB-led investigation and was a joint effort with the
    United States Coast Guard. Four days after the sinking, the
    NTSB, Coast Guard, and many other organizations began a
    collaborative search of the ocean floor seeking the El Faro
    wreckage and in an effort to locate and retrieve the ship's
    voyage data recorder, or VDR.
        Data recorders are important investigative tools critical
    to many of our investigations. It took three missions to
    recover the VDR. Analysis revealed significant data, including
    26 hours of audio, which was crucial in determining the
    probable cause of El Faro's sinking.
        On September 29, 2015, at 9:48 p.m., the El Faro and its
    crew departed Jacksonville, Florida, for San Juan, Puerto Rico.
    Operated by TOTE Services, the U.S.-flagged ship was slated to
    arrive in the early morning hours of October 2. However, rather
    than routing around the approaching storm, the ship sailed
    directly----
        Mr. Hunter. Mr. Weener, I am sorry, there is wind going
    through here and I have bad ears. Do you mind pulling that
    thing really close, please, and speak louder if you could.
    There is like wind blowing through here behind us. And I have
    got artillery ears.
        Mr. Weener. On September 29, 2015, at 9:48 p.m., the El
    Faro and its crew departed Jacksonville, Florida, for San Juan,
    Puerto Rico. Operated by TOTE Services, the U.S.-flagged ship
    was slated to arrive in the early morning hours of October 2.
    However, rather than routing around the approaching storm, the
    ship sailed directly into the path of the hurricane and sank at
    approximately 8 a.m. on October 1.
        My written testimony provides more detail regarding what
    happened during the voyage that led to the ship's being in
    harm's way. For now, I will focus on major safety issues
    identified in our report.
        The NTSB's probable cause determination for this accident
    included the captain's decisionmaking and actions, which put
    the El Faro and its crew in peril. The captain did not divert
    to safer routes to avoid Hurricane Joaquin, failing to heed
    junior officers who suggested an alternate course was necessary
    to avoid the hurricane.
        We found that although the El Faro received sufficient
    weather information to facilitate appropriate decisionmaking by
    the captain regarding the vessel's route, the captain did not
    use the most current weather information available to him.
        In addition, the investigation revealed the captain's light
    regard for the crew's suggestions and the crew's lack of
    assertiveness in stating their concerns to the captain. The
    NTSB found that the bridge crew did not use all available
    resources, nor act effectively as a team to safely operate the
    ship.
        The El Faro, sailing on a collision course with Hurricane
    Joaquin, was further imperiled by the failure to maintain the
    ship's watertight integrity. Seawater entered a cargo hole
    through an open scuttle. The resulting flooding caused
    improperly secured automobiles to impact an inadequately
    protected fire pump supplied by piping carrying seawater.
        The damaged piping allowed seawater to flow unchecked into
    the ship. This exacerbated other flooding causes, caused by
    water entering through open, unsecured ventilation closures.
        In addition, the TOTE safety management system was
    inadequate. Its lack of oversight in critical aspects of safety
    management denoted a weak safety culture in the company and
    contributed to the sinking of the El Faro.
        Finally, the captain's decisions to muster the crew and
    abandon the ship were late and likely reduced the crew's chance
    of survival. The severe weather, combined with El Faro's list,
    made it unlikely that liferafts or lifeboats available on the
    ship could be launched or boarded by crewmembers once in the
    water. The lifeboats onboard would not have provided adequate
    protection, even if they had been launched.
        Coast Guard standards do not require older ships, such as
    the El Faro, to adhere to the latest safety standards.
        These are just a few of the issues identified out of a
    total of 81 findings and 53 safety recommendations. As with all
    investigations, our aim is to learn from this tragedy to
    prevent similar events from occurring again. We believe that
    the adoption of our recommendations will help improve safety
    for current and future generations of mariners.
        Thank you again for the opportunity to testify, and I am
    happy to take your questions.
        Mr. Hunter. Thank you, sir.
        Mr. Curtis, you are recognized.
        OK. You are just accompanying. So I will start out by
    recognizing myself. Thank you very much for being here.
        My question is pretty simple. If they would have closed the
    hatches or the ventilation systems, right, so the water could
    not get in, in the heightened sea states that they had, would
    they have been OK, if their engines would not have failed and
    they hadn't taken on water? Could they have sailed through?
        Mr. Weener. I think our investigation showed that this was
    a series of events, a chain of events that had it been
    interrupted at any point, the chain would not have been
    completed. So it started with a decision to not avoid the
    hurricane. Once they got into heavy weather, they had a scuttle
    that got flooding in one of the holes----
        Mr. Hunter. When you say an open scuttle, what is that? Can
    you tell the committee what that is?
        Mr. Weener. That is a hatch going between decks that for
    heavy weather should have been closed and locked, but it was
    left open. So they got down-flooding with that. Basically,
    there was a whole series of events.
        Mr. Hunter. Mr. Curtis? Admiral?
        Admiral Nadeau. Sir, I would add to that.
        In the Coast Guard's perspective, I think it is difficult
    to say. It is hard to simplify it to that level. It is a series
    of events that go on, that chain of events that occurred, and I
    think it would be very difficult for us to say with any degree
    of certainty whether or not simply closing vents would have
    prevented this casualty.
        Mr. Hunter. What I am trying to get at is you have all of
    these recommendations, right? And you can go through a ship or
    an airplane or anything, military or civilian, and say, this
    isn't up to code, or this is unsatisfactory, or we are going to
    allow this to slide because of the age of the vessel or the
    aircraft or whatever.
        But what I am trying to get at is, if all of those things
    were followed then the right decisions would have been made in
    the first place and the chain of events would not have
    happened.
        But it is not like the ship broke in half because the weld
    wasn't right or something or it passed an inspection where it
    failed on the structure of the ship. It was decisionmaking and
    not paying attention to detail that caused the initial stuff,
    right?
        I mean, the captain sailed into the hurricane, not around
    it, and they had basically open hatches on the ship that
    allowed water to get in, and then, boom, right? That is sort of
    the really fast chain of events, I am guessing.
        Is that correct, roughly?
        Admiral Nadeau. Sir, our investigation concluded that it is
    likely the material condition of the ship did contribute as
    well and that the watertight fittings that would be relied upon
    to prevent progressive flooding were not in the condition they
    should have been maintained.
        Mr. Hunter. Mr. Curtis.
        Mr. Curtis. Certainly, as you point out, that was a
    significant event in the series of events, having the hatch
    open. And our report made recommendations to that very point to
    hopefully prohibit it from happening in the future, with having
    alarms and notifications if a hatch is left open, that it
    should be closed.
        But it was, as you said, a significant----
        Mr. Hunter. To me, you had, when I was in Fallujah, you had
    M1 Abrams tanks every now and then that would roll over into
    ravines and the Marines would die. They would go over into
    irrigation canals, right?
        It wasn't anything wrong with the tank. They might have had
    some things that weren't up to code, but it is wartime, but
    there wasn't anything wrong with the tank, but they changed how
    they drove around irrigation canals. And I would guess that
    that is a lot of your recommendations that say, do this next
    time, don't do that, right?
        Mr. Curtis. Certainly in our report. Yes, sir.
        Admiral Nadeau. Sir, I would only add, during this
    investigation we went aboard the sister vessel, the El Yunque,
    which was in similar service, similar build date, maintained by
    the same company, and that ship ended up being scrapped after
    we went onboard based on the material condition.
        Mr. Hunter. And TOTE was in the process of rebuilding
    these--or building the new class of these anyway, right, as
    this happened.
        [Admiral Nadeau nods.]
        Mr. Hunter. This ship, the El Faro, was going to be pulled
    out of the line, I would assume, in the next couple--or now,
    right, if it had stayed afloat.
        Admiral Nadeau. Sir, I believe the intent was to shift the
    El Faro to the northwest so that it would go into trade back
    and forth to Alaska while they were still working to deliver
    the final two new containerships that were being built.
        Mr. Hunter. Thank you.
        Mr. Garamendi, you are recognized.
        Mr. Garamendi. I am not going to spend a lot of time
    focusing on the mistakes made by the captain and the crew along
    the way. Those are well documented in the report.
        Going forward, the utility of the National Transportation
    Safety Board report and the Coast Guard is really where I want
    to focus here. How can we prevent this kind of accident from
    occurring again?
        So to the Coast Guard who has oversight of the safety of
    ships and the associations that are specifically responsible
    for reviewing a ship, what are you doing to assure us that the
    various associations and organizations that review the safety
    of ships is actually taking place and is robust enough to
    assure that the ship is safe? Then there is a series of
    questions about the competency of the men and women on the
    ship.
        So, first, what are you doing to assure us that the
    organizations that review the safety of the ships actually do
    their job?
        Admiral Nadeau. Ranking Member Garamendi, for starters, we
    want to see how pervasive these conditions were throughout the
    fleet. So I have a team out visiting what we would view as the
    high-risk vessels that are enrolled in ACP, based on their age,
    based on their history, based on their casualties, et cetera.
    And the findings indicate that it is not unique to the El Faro,
    we have other ships out there that are in substandard
    condition.
        We have moved out to reform our oversight program. It
    starts with governance and having the proper people in place
    with the proper focus to call attention and hold others
    accountable. That also involves having the right policy and
    procedures in place, the right information management systems
    to capture the data, collect it, and then engage with our third
    parties and communicate to hold them accountable.
        So it is an ongoing effort. It will take us a little time.
    But we have launched and we are underway and committed to
    rectifying the problems that we are finding.
        Mr. Garamendi. Do you have a tracking system, a review
    system in place, so that you know what is actually taking place
    as you attempt to improve your oversight?
        Admiral Nadeau. We have a--it is called MISLE, it is an
    information management system we use for all of our marine
    safety activities and others. It has not been able to capture
    some of the information we want it to capture, so we are making
    changes now to improve that system.
        At this time it is difficult for our people in the field,
    when they do find things, to properly incorporate it into MISLE
    so we can roll up all that data, all that information, and then
    engage with our third parties to talk to them about the
    problems we are finding.
        Changes are underway, so we will have that capability and
    be able to make sure we have the information to engage with
    them.
        Mr. Garamendi. So there is a reporting system that has not
    worked well in the past when your people in the field find
    something is amiss. No reporting up the chain of command, and
    then no action by the chain of command. Is that what has
    happened in the past?
        Admiral Nadeau. The procedures, the processes, the
    training, and the information capture all need to be improved.
        Mr. Garamendi. Well, we are towards the end of January
    here, and I suppose you have a tracking system in place so that
    you know that there are improvements underway?
        Admiral Nadeau. We do, sir. We are working, have a team
    assembled that is working on this, and we have moved out to
    actually look at the ship.
        So I guess there are a couple efforts. One, again, is in
    the field, getting aboard the ships, and trying to call out
    those requirements and raise the condition of those ships that
    need it. And the second thing is to actually make structural
    changes within our processes and our procedures and those tools
    we use to better enable us to conduct the proper oversight.
        Mr. Garamendi. All right. I was just talking to our
    chairman and his staff. I am going to turn this back to the
    chairman about a request for a matrix on exactly what you are
    doing and timeframes.
        Mr. Hunter. Which you have, which you are going to give us,
    right?
        Admiral Nadeau. I can do that for you, sir.
        Mr. Hunter. We have already asked you for it.
        Admiral Nadeau. OK.
        Mr. Hunter. So somebody is working on it. Anybody here
    working on it who would know when it would be given to us?
        OK.
        Mr. Garamendi. Well, let me just take it up here.
        If you have a system in place to improve the review and
    oversight not only of the work you--that the Coast Guard is
    doing, but also of the various organizations to whom you have
    assigned responsibility, this committee would like to have that
    tracking system, that matrix, that reporting program, as to
    exactly how you are tracking the safety programs, and then an
    update, a report 6 months from now as to how it is going.
        Can you do that?
        Admiral Nadeau. Yes, sir.
        Mr. Garamendi. Good. Thank you.
        For the NTSB, with regard to the action in itself, you
    report you have, I don't know, I am trying to add up the number
    of at least 20 or 30 different recommendations. Do you ever go
    back and follow up on your recommendations as to whether they
    are actually done, Mr. Weener?
        Mr. Weener. Yes, we do. We make these recommendations,
    safety recommendations, to a variety of parties, but the
    majority in this case have gone to the Coast Guard. We send
    these recommendations off, we expect acknowledgment of receipt,
    and then we track them from that point on.
        We have some expectations of how long it is going to take
    to get a response. But we constantly keep track of the
    recommendations until such time as they are ``Closed
    Acceptable,'' in some cases ``Closed Unacceptable,'' but we
    track them all the way through.
        Mr. Garamendi. So your recommendations came out more than a
    month, almost 2 months ago now, the final version, I think that
    is the date. And have you had any success or have you seen any
    improvement, any action on your recommendations yet, some to
    the Coast Guard, some to the shipowners?
        Mr. Weener. At this point in time we would just expect to
    be getting an acknowledgment that they have the recommendation.
    At this point we would hope that they would give us some idea
    of what their plan was and how long it was going to take.
        Mr. Garamendi. Our role here with regard to the Coast Guard
    is to make sure they are doing their task of maritime safety.
    And for the NTSB, your work to report to us, Mr. Curtis, I
    think this is your specific responsibility.
        What is your timeframe on following up on the
    recommendations, both to the shipping industry as well as to
    the Coast Guard? We just asked the Coast Guard for their matrix
    for review, and I am asking you for your matrix for review,
    your timeframe, your schedule.
        Mr. Curtis. Yes, sir. So as you said, the recommendations
    would go out as the adoption date shortly after once they are
    forwarded to the parties, and they have 90 days to make their
    initial response to how they respond to the recommendation,
    what they would do. And TOTE has implemented some changes to
    those recommendations. There are about 10 recommendations to
    TOTE.
        But for all parties, whether they go to the Coast Guard,
    TOTE, other agencies, NOAA, some to NOAA, they have 90 days for
    the initial response. And then we have an office, Office of
    Safety Recommendations, which corresponds directly with them on
    an ongoing basis. And when they get a response back from those
    recipients of the recommendations, specific ones are forwarded
    back to our office to respond that we feel whether they are
    appropriate or not.
        And so we work through back to the Safety Recommendations
    Office and ultimately back to the recipient of the
    recommendation. So in this case there were 53 recommendations,
    so we will be very active and proactive in working with the
    Office of Safety Recommendations and the recipients.
        Mr. Garamendi. It seems to me that the committee should be
    aware of this response loop that you just described. I would
    appreciate it if you could provide to the committee a
    continuous update on the progress by both the Coast Guard and
    the shipping industry in addressing the multiple
    recommendations that you have made. When might you be able to
    provide that update to us?
        Mr. Curtis. Sir, we can provide that any time. I can work
    with through Office of Government Affairs to work with your
    folks to give you an update at any period you specify.
    Certainly we are available at any time to give those updates.
        Mr. Garamendi. I am going to yield back at this point, but
    before I do, for me and my particular role here, the NTSB's
    recommendations and the response of both the Coast Guard and
    the shipping industry generally, written large, is really
    important.
        So I would appreciate it if the NTSB, towards the middle of
    this coming year, like maybe June, report back to us on what
    progress has been made, what outreach you have done to NTSB
    with regard to the recommendations that you have made. They are
    of no value unless somebody follows up on them. So I would
    appreciate it, Mr. Curtis and Mr. Weener, if you would do that.
        And similarly the Coast Guard with regard to all of the
    recommendations and updating both with regard to the
    recommendations as well as with regard to the improvements on
    the oversight of the various organizations that do the safety
    reviews.
        And with that, I yield back. Thank you, Mr. Chairman.
        Mr. Hunter. I thank the ranking member.
        Quick question. Does every ship being built now have an
    indicator for the hatch being closed, the hatches around the
    ship, if they are below a certain----
        Admiral Nadeau. There are standards in place for newer
    ships that are being built, yes, sir.
        Mr. Hunter. So that is in effect now? So all big ships
    being built, cargo ships, have a little light with all the
    hatches that says that they are closed or open?
        Admiral Nadeau. They have indicators, as well as there is
    flooding detection in the hold spaces to alert them if there is
    water coming into that space. Yes, sir.
        Mr. Hunter. Thank you.
        I would like to yield to the ranking member, which we are
    honored to have here with us.
        Mr. DeFazio. Thanks, Mr. Chairman.
        Well, I read a lot about this, and I really don't like
    systems that foster preventable tragedies that take 33 lives.
        Admiral, the Coast Guard subsequently looked at the sister
    ship, El Yunque. What was the condition of that ship?
        Admiral Nadeau. It was in substandard condition.
        Mr. DeFazio. And so we can assume that El Faro was, as the
    sister ship, in similar substandard condition?
        Admiral Nadeau. The Coast Guard's Marine Board certainly
    made that same conclusion, sir.
        Mr. DeFazio. And was this boat certified by ABS?
        Admiral Nadeau. Yes.
        Mr. DeFazio. And what did they say about the boat? Did they
    note deficiencies? How recent was their inspection? Isn't it
    annual?
        Admiral Nadeau. Yes, they would be on there every year, as
    would the Coast Guard. I don't know when the last survey had
    been. I don't recall on the El Yunque when the last survey was.
    Certainly, we found things that should have been captured in
    the course of the normal routine of surveys and Coast Guard
    inspections.
        Mr. DeFazio. So things were omitted.
        Now, when is the last time that you are aware that one of
    these alternative compliance folks told a company they had to
    take a ship out of service and make very significant repairs or
    just retire it, as they did El Yunque once you looked at it?
        Admiral Nadeau. I am aware of others that have been in
    similar condition that have had to come out of service. But I
    would say probably--it is not frequent. It is not frequent.
        Mr. DeFazio. Right. I mean, it is a competitive industry,
    right? And so I hire you, I am hiring you to certify my rust
    bucket, I would rather not hear about it, or you tell me about
    it and then I am probably not going to hire you again, right? I
    mean, if they aren't being adequately overseen.
        What is the liability of the classification people in this
    case? Is there potential liability for them? Are they being
    sued because they overlooked things?
        Admiral Nadeau. That is a little bit outside my area of
    expertise regarding the liability. I can reassure you that
    certainly we recognize the importance of proper oversight over
    all classification societies, all third parties that we entrust
    to do our work, to help us. And we are committed, again, to
    trying to rectify that.
        Mr. DeFazio. Do you feel there is any conflict in your
    mission here where you are both to facilitate and promote
    seaborne commerce and at the same time you are supposed to
    protect the life and safety of the mariners?
        Many years ago, I offered an amendment in this committee
    where the FAA had that dual mandate, and I asked, is that a
    problem, and they said no.
        Then we had a tragic, totally preventable airplane crash.
    And after that came out, somehow my amendment got into the bill
    without having been passed on either side of the Hill, because
    people realized that this was a horrible problem for the FAA,
    to be both promoting an industry which is very mature and
    didn't need promotion and regulating safety, and I
    substantially took away the promotional aspects.
        Should we be moving the promotional aspects or mandate over
    to Commerce? It seems a more logical place than the Coast
    Guard.
        Admiral Nadeau. I don't know that I find my role as
    promotion. I think that we balance, we try and be practical and
    apply common sense when we apply the standards that are either
    developed by Congress or that industry has asked for. I think
    we rely more on the safety side of things and we try and ensure
    that there is a level playing field out there, that we equally
    apply the regulations.
        And I would offer also, sir, that we are not the only flag
    in the world, the only country in the world that relies on
    third parties. Virtually every flag state out there today
    relies on these classification societies in some way, shape, or
    form. It is just the way the system has evolved. But we need
    proper oversight in order to ensure that all parties are doing
    what they are responsible for doing.
        Mr. DeFazio. Yeah. And what would constitute proper
    oversight? I mean, in this case, let's just say had the Coast
    Guard had adequate staff, El Faro was surveyed, deficiencies
    were not noted. And if you had followed on with a comprehensive
    inspection and found deficiencies that weren't noted, what
    would be in consequences for that classification society?
        Admiral Nadeau. Well, first off, we would have made sure
    that the ship--should have made sure the ship is in proper
    condition and does not have the problems that were found.
    Secondly would be to have a scheme in place to make sure that
    we do hold those class societies accountable.
        So it starts at the basic level of getting onboard the ship
    to observe the standards onboard the ship to see if they are
    meeting the minimum standards.
        Secondly, it is digging into the safety management system
    aboard the ship and aboard that company that they have to make
    sure that they have the proper systems in place to maintain the
    ship.
        And, thirdly, it is looking at the quality system in place
    by those third parties to make sure that they have the proper
    training, the proper procedures in place to make sure they
    capture and resolve these things when they find them.
        Mr. DeFazio. Is there any way to assess a penalty against
    the classification society that does an inadequate survey that
    endangers life and safety or to suspend their capability to do
    alternate compliance?
        Admiral Nadeau. I don't know that we would pursue the
    penalty. I think probably the larger ramifications would be
    either preventing them from doing that work on our behalf. They
    all have a reputation they try and uphold. It is a competitive
    business. They are generally pretty responsive when we ask them
    to be. We need to make sure that we are on them, holding them
    accountable, and ensuring they take the proper response.
        Mr. DeFazio. I mean, it just all reminds me a little bit of
    the junk bonds on Wall Street that caused the worst economic
    collapse since the Great Depression where all of these bonds
    were given very high ratings because it was well known if you
    didn't give this junk high ratings, they wouldn't hire you to
    give the junk high ratings, and you lose business. I don't see
    how it is any different here.
        Admiral Nadeau. Sir, I would say, here the difference is we
    know how to do this work. I have asked myself over and over
    again, how did this happen? We learned this lesson, yes, with
    Marine Electric. Since then we have doubled down time and time
    again, investing more and more in third parties, whether it is
    through Congress or the industry asking us to push more and
    more through the third parties.
        And we have gone through changes in the Coast Guard where
    we stood up sectors. We used to have marine safety offices
    working for district M captains. Now we have sectors, which are
    very powerful, allow us to do things we could never do before,
    like we saw this summer in response to the hurricanes. But
    along the way I think we have lost a little bit of our focus
    and we are doubling down now to get that back.
        Mr. DeFazio. And you have got adequate resources to do
    that?
        Admiral Nadeau. As always, you could do more if you had
    more. But this is not strictly a capacity problem. There are
    elements to training. If you just gave me another 1,000 marine
    inspectors, it wouldn't solve this problem. This problem
    involves training. This problem involves getting the right
    information. This problem involves getting the right policy and
    procedures in place.
        Entry-level marine inspections is not what I am talking
    about. I need to have a small corps--it is not a lot--a small
    corps of people that can get out and are highly trained and
    proficient and stay focused on this area until we get it right.
        Mr. DeFazio. OK. All right. Thank you.
        Thank you, Mr. Chairman.
        Mr. Hunter. I thank the ranking member.
        Does anybody else have any questions for this panel? Any of
    my Republican colleagues? I will take that as a no.
        I thank you very much for being here and talking with us on
    this. And with that, we will move on to the next panel.
        Mr. Garamendi. Mr. Chairman.
        Mr. Hunter. Please.
        Ms. Garamendi. Before we move on, we have a series of
    questions that we would like to submit for the record. Many of
    these have already been discussed here. Let me just review very
    quickly and make sure that we cover what we want to cover.
        I want to specifically ask Admiral Nadeau, the
    recommendations from the NTSB, numerous as they are, I am just
    going through them, I think there are 20 or 30 of them, have
    you responded to those recommendations? Almost all of them are
    specific to the Coast Guard.
        Admiral Nadeau. Thank you for that question.
        We look forward to getting the entire report so we can go
    through them. We have seen the recommendations that were
    published, I guess a summary notice when the hearing was held.
        In looking at those, I can already tell, they are very
    close to the recommendations we made in our own Marine Board
    investigation, our own report. We had 36 recommendations. Many
    of those are very, very similar to what is coming from the
    NTSB.
        So, yes, I think that we will respond. We have a process in
    place to provide them feedback on each one of those, and we
    will carefully assess their information, the report, and each
    recommendation.
        Mr. Garamendi. When will you have your initial review and
    response to the recommendations?
        Admiral Nadeau. As soon as we get the report--as soon as
    the report is published, we will begin our review. And as I
    indicated, I think there is a timeline, I don't think it is
    laid out in our MOU, but there is a timeframe we meet. I don't
    know if it is 30, 60 or 90 days. But we will certainly meet
    that and do our best to meet the timeline that is established
    in the procedures.
        Ms. Garamendi. Mr. Curtis, when will it be finalized?
        Mr. Curtis. The report will be out mid-February, the 15th,
    and the recommendation letters right around that time.
        Mr. Garamendi. So the 90-day response cycle, is that----
        Mr. Curtis. The 90-day response cycle will start right
    around mid-February, maybe a little earlier, but soon. But they
    have been released in the abstract of the report.
        Mr. Garamendi. OK. And presumably, I can't count, there are
    53 specific recommendations. I lost count somewhere around 30.
    We will be interested in hearing the response from the Coast
    Guard.
        Also, does the shipping company or companies also respond?
        Mr. Curtis. Yes, it is the same process for all recipients
    of NTSB recommendations, sir.
        Mr. Garamendi. OK. We will await that. Thank you very much.
        I yield back and thank you. And I do have specific
    questions for the record.
        Mr. Hunter. Without objection, we will give the gentleman
    authority to submit questions for the record.
        So we are looking for from the Coast Guard and from NTSB
    the matrix that he is talking about earlier. I got those
    confused. He would like the types of ships--and correct me, Mr.
    Garamendi, if I am wrong--the types of ships that are like the
    El Faro that you have been looking at now, the same year range,
    I guess, that are out there.
        I think that is what he is asking for, not the matrix of
    recommendations and accomplishments, which is separate. So both
    of those things. But we would like to see all of those ships
    that you are out there looking at now, saying these could be at
    risk.
        In closing, I drive a 1997 Expedition. If you were to go
    through the check list on my truck, there is probably a lot of
    stuff on it that is not correct, like the middle seatbelt in
    the back doesn't work, the airbag is out on the passenger side.
        But if I take my seatbelt off, as a driver, when it is
    pouring down rain and go driving on the freeway at 90 miles an
    hour and crash it, you can look to all those things that
    weren't up to code in my truck, but the reason that it crashed
    and I died is because I drove it without my seatbelt in pouring
    rain at 90 miles an hour.
        In the end, you can make all the recommendations you want
    to, but if you leave hatches open in high sea states and drive
    into a hurricane, bad things could happen.
        I think at the end of this that is what I am kind of taking
    out of this, is all the structural issues, from the age of the
    ship and classifications and giving the ship approval to set
    sail, those are all good things, but if you drive at 90 miles
    an hour in an old truck with no seatbelt on in pouring rain,
    you might crash.
        So with that, yes, sir, closing statement, it is all yours.
        Admiral Nadeau. Sir, I could see why you draw that
    conclusion. But I guess we looked a little further beyond this
    particular incident, caused us to look at other vessels in the
    fleet, and did cause us concern about their condition.
        It is almost like your same old car. Some of our fleet--our
    fleet is almost three times older than the average fleet
    sailing around the world today. Just like your old car, those
    are the ones likely to break down. Those are the ones that are
    more difficult to maintain and may not start when I go out and
    turn the key.
        Our fleet is older than the average fleet. That presents
    some challenges. And some of our fleet, particularly the
    Military Sealift Command, where it is a Ready Reserve component
    that kind of sits idle for long periods of time, that presents
    challenges for us, sir.
        We are working very closely with partners at Military
    Sealift Command, Admiral Mewbourne, as well as MARAD Admiral
    Buzby, to make sure that we pay proper attention to that.
        Mr. Hunter. Thank you.
        Mr. Garamendi is recognized.
        Mr. Garamendi. Mr. Chairman, thank you for opening another
    avenue here that I had neglected. I know we are running up
    against the clock also.
        There is the ship and all of the adequacies or inadequacies
    of the ship itself. In this particular situation, as the
    chairman was saying, the driver on the freeway made a serious
    mistake.
        Are the men and women who are responsible for the safe
    operation of the ship, both from shore as well as on the ship
    itself, are they adequately trained? Are they over a period of
    time recertified? Are there questions that we should be raising
    about the adequacy of the men and women responsible for the
    ship itself? And is the Coast Guard also investigating that
    piece?
        Admiral Nadeau. Yes. There were recommendations related to
    training, both with respect to weather forecasting,
    meteorology, and also with bridge resource management, and
    other aspects that were highlighted here.
        Mr. Garamendi. OK. Obviously, we are not going to be able
    to question any of the personnel that were on the ship. But it
    appears that there were mistakes made in the operation of the
    ship, perhaps both from shore as well as from the ship itself
    while at sea.
        Does the NTSB or the Coast Guard have any concerns about
    the adequacy of training of the personnel that are on American
    ships that are currently on the oceans? Do we have any
    recommendations for upgrade, for continuing classification, and
    for review of their ability to properly conduct the ship?
        Mr. Weener. The NTSB has recommendations related to
    training and bridge resource management, both recurrent
    training as well as initial training, for things like heavy
    weather, for advanced meteorology, for deck crews. So that
    aspect of training has also been included in their assessment
    in our investigation.
        Mr. Garamendi. My final point is that the ability and
    capability of the men and women in charge of running the ship
    has to be continually observed and with a high level of
    assurance that they are competent and capable. In the NTSB
    report, among your 53 recommendations, there are several that
    speak to that issue. I would expect that in the responses, both
    from the shipowner as well as from the Coast Guard, that this
    will be an issue that will be taken up in the responses.
        My concern goes beyond this particular company and the men
    and women that are hired to operate the ships for this company,
    but rather to the entire U.S. Fleet and the adequacy of the
    training and the capability of the men and women that are
    responsible. So I would like the Coast Guard to also pick up
    that issue beyond just this one company.
        With that I will yield back. Thank you.
        Mr. Hunter. I thank the ranking member.
        Just in closing, you had two Navy ships crash last year,
    and it wasn't any mechanical anything. It was they took away,
    the last couple years, they took away surface warfare officer
    training, it became on-the-job training with a DVD. It used to
    be a 6-month school up until, I don't know, 4 or 5 years ago.
    They got rid of it. Training saves a lot of lives.
        And looking through everything, it looks like this was poor
    decisionmaking that exacerbated physical problems with the
    ship. And I think that is what we take out of this and we will
    keep drilling down.
        If we could get those matrixes of the ships, right, that
    you are looking at, so we can kind of see what is out there
    right now, and then the recommendations and what has actually
    been accomplished with those 53--52. The Commandant said, let's
    go with it two out of the three, the admin recommendations, he
    said, let's go with it. We would like to see what actions were
    taken that match those recommendations.
        And I think June 1. Is that too long? Could you get them
    before that? We can get the ship matrix before that probably.
    But as soon as you have it, we would like to see it.
        Mr. Garamendi. June 1 is good.
        Mr. Hunter. June 1 is good with the ranking member, so it
    is good with me.
        And with that, thank you all very much. And we will move on
    to the next panel.
        Lady and gentlemen, thanks for being here.
        We will move on to the second panel. We will hear from Rear
    Admiral Erica Schwartz, Director of Health, Safety, and Work-
    life with the United States Coast Guard; Rear Admiral Michael
    Haycock, Assistant Commandant for Acquisition and Chief
    Acquisition Officer with the United States Coast Guard; and Mr.
    David Powner, Director of Information Technology Management
    Issues with the Government Accountability Office.
        Admiral Schwartz, you are recognized.

     TESTIMONY OF REAR ADMIRAL ERICA SCHWARTZ, DIRECTOR OF HEALTH,
     SAFETY, AND WORK-LIFE, U.S. COAST GUARD; REAR ADMIRAL MICHAEL
      J. HAYCOCK, ASSISTANT COMMANDANT FOR ACQUISITION AND CHIEF
      ACQUISITION OFFICER, U.S. COAST GUARD; AND DAVID A. POWNER,
      DIRECTOR OF INFORMATION TECHNOLOGY MANAGEMENT ISSUES, U.S.
                    GOVERNMENT ACCOUNTABILITY OFFICE

        Admiral Schwartz. Chairman Hunter, Ranking Member
    Garamendi, honorable members of the subcommittee, good morning
    and thank you very much for your oversight and for your
    continued strong support of the United States Coast Guard. I am
    honored to testify before you today with my colleague, Rear
    Admiral Haycock.
        Let me state now, bottom line, upfront, we sincerely regret
    what happened with the Integrated Health Information System, or
    IHiS. The Coast Guard attempted to develop an electronic health
    record that was ultimately unsuccessful.
        What began as a project to develop a simple electronic
    health record increased in scope and expanded into a much
    larger concept, which added work-life and safety services.
    While well intentioned, this project lacked appropriate
    oversight and governance and resulted in a project that had
    significant mission creep, untimely delays and increased cost.
        Upon realizing that IHiS was not going to be completed in a
    reasonable time, at a reasonable cost, the Coast Guard made the
    decision to cancel IHiS.
        We are incorporating lessons learned as we move forward
    with our new electronic health record. Recognizing the
    criticality of the new electronic health record, it has been
    formally designed and designated with an acquisition with the
    necessary and appropriate level of governance and oversight
    that IHiS lacked.
        As the program sponsor representative, it is my highest
    priority to work alongside the chief acquisition officer, the
    chief information officer, and other members on the governance
    board to leverage lessons learned and to ensure that the best
    choice that meets service requirements is acquired and
    implemented as soon as possible.
        Since our outdated electronic health record had significant
    IT security concerns, we continued with just paper health
    records.
        As a physician, I know firsthand the risk of managing a
    medical program based on paper health records. Whether it is
    the challenges of scheduling an appointment, difficulty in
    reading handwritten clinical notes, storing volumes of
    information, or decreased productivity, the Coast Guard cannot
    continue without an electronic health record system long term.
        Our clinics and sick bays are managing with a paper health
    record system, but this is not a permanent solution. We must
    have an electronic health record system that is interoperable
    with the DoD and one that allows our members to officially
    transition to the Department of Veterans Affairs.
        As the Coast Guard's chief medical officer, I oversee the
    healthcare delivery and medical services for more than 48,000
    members of the Nation's fifth armed service. I have a passion
    for ensuring the Coast Guard has superior access to healthcare.
    It is my duty and responsibility to ensure that our healthcare
    system is able to serve our greatest asset, our people.
        As we continue to pursue the very best electronic health
    record solution for our members, the Coast Guard is thankful
    for your interest and assistance on this important issue.
    Supported by sustained internal governance and your continued
    support, I am confident that the Coast Guard will implement the
    finest electronic health record solution.
        Thank you.
        Mr. Hunter. Thank you, Admiral.
        Admiral, you are recognized.
        Admiral Haycock. Chairman Hunter, Ranking Member Garamendi,
    good morning.
        First, I would like to thank you for your continued support
    of the Coast Guard and the guidance that you provide to our
    military service. As my colleague has mentioned, the Coast
    Guard recognizes the critical need to move to an electronic
    health record system. And as the chief acquisition officer, I
    appreciate the opportunity to discuss the improvements that we
    have made over the last several years to apply disciplined
    governance to these types of investments throughout our
    Service.
        As you are well aware, over the last 15 years or so, with
    the tremendous assistance of this subcommittee, the Coast Guard
    has undertaken significant efforts to improve the oversight and
    the management of our major acquisitions, such as our vessels
    and our aircraft.
        Our acquisition framework is designed to constrain and
    validate requirements to provide checks and balances and
    provide continuous and effective oversight at all stages of the
    acquisition life cycle. Until recently, we did not use the same
    level of rigor to govern key decisions for our smaller
    investments.
        We have learned several lessons from our experience with
    the Integrated Health Information System. The most important of
    these lessons are related to oversight and program management.
        Without the oversight and guidance normally provided to our
    formal acquisition programs, well-meaning people were overcome
    by the task at hand and that program simply outgrew their
    capabilities. And as a result, we have made significant process
    improvements to manage all sizes of acquisitions, including
    nonmajor acquisitions.
        To that end, the Coast Guard overhauled its processes of
    our nonmajor programs. We established formal roles and
    responsibilities and requirements in the same manner that we
    use for major acquisition programs.
        These new processes established a governance framework and
    provided a roadmap for improving program execution and managing
    risk. This framework leverages the expertise of our technical
    authorities, including the chief information officer, to ensure
    that nonmajor programs remain on track and key decisions
    represent the priorities of all communities across the Coast
    Guard.
        Additionally, we recently instituted new processes to
    identify candidates for formal acquisition management and
    oversight which allows us to look out for those investments,
    like IHiS, to prevent them from falling through the cracks.
        We created an oversight council specifically to provide
    oversight and governance for nonmajor programs. This provides
    senior staff from across the Service a forum to regularly
    assess performance, raise issues, and address concerns, and it
    also ensures we have people with the right talents and skills
    managing our programs.
        Recognizing the continued urgent need to address our
    healthcare record system, in 2016 the Coast Guard established a
    formal nonmajor acquisition program to modernize the management
    of healthcare acquisition for approximately 50,000 Active Duty
    and Reserve members and improve the exchange of healthcare
    information with the Department of Defense, the Department of
    Veterans Affairs, and commercial care providers.
        We initiated activities to explore several possible
    alternatives and are in close contact with DoD and Department
    of Veterans Affairs to ensure the new solution is interoperable
    with their healthcare records systems.
        Last year, we initiated market research to gather data on
    cost, schedule, and performance capabilities, and potential
    solutions currently available in the commercial marketplace. We
    are evaluating the benefits and the risks associated with
    several approaches and are developing the best procurement
    strategy to expedite the acquisition.
        The Coast Guard recognizes the urgency to support the
    health of our most valuable asset--our people--and our current
    governance framework ensures that we have the processes and
    policies in place to oversee our current electronic healthcare
    acquisition program.
        We continue to incorporate the recommendations made as a
    result of the invaluable oversight of this subcommittee and the
    GAO. And I am committed, along with Admiral Schwartz, to the
    expeditious and responsible delivery of a high-quality
    electronic health record solution for our men and women in the
    field.
        Thank you again for the subcommittee's staunch support and
    your oversight of Coast Guard programs and for the opportunity
    to testify today. I look forward to answering your questions.
        Mr. Hunter. Thank you, Admiral Haycock.
        Now to Mr. Powner. You are recognized.
        Mr. Powner. Chairman Hunter, Ranking Member Garamendi,
    thank you for inviting GAO to testify on the Coast Guard's
    failed effort to acquire an electronic health record. This
    morning I will provide details of what went wrong with the
    acquisition and what needs to be done to manage this more
    appropriately in the future. This lookback is important to make
    sure that the Coast Guard corrects the management and
    governance flaws that led to about $60 million being wasted.
        This effort started in September 2010 and was to be a 5-
    year project and cost about $14 million. Due to growing scope
    and mismanagement, the cost grew to about $60 million before
    the project was terminated in October 2015 with nothing to show
    for it.
        There is a long list of things that went wrong that are
    laid out in great detail in the report we are releasing today.
    The highlights are:
        The project was behind schedule.
        There were questions about whether the Coast Guard was
    using appropriate funding sources to pay for it.
        Expected system capabilities were not being delivered.
        The system had limited security features, which is alarming
    given the sensitivity of the data residing in these electronic
    health records.
        The Coast Guard wasn't completely following its own
    processes to acquire a system. Examples include not involving
    users of the system and not testing it adequately.
        Executives who should have been involved were not, as
    several governance boards were established to oversee this and
    they were simply not active.
        I would like to highlight the words ``not active.'' We at
    GAO have reported on failed IT acquisitions over the years and
    the message is usually that executive boards were not effective
    or not involved enough, not ``not active.''
        Finally, post-cancellation, no equipment or software was
    delivered for reuse and the Coast Guard continued to pay
    millions to vendors after the cancellation to satisfy
    contractual commitments. In fact, our report highlights two
    payments scheduled for next month that collectively total more
    than $5 million. Yes, nearly 2\1/2\ years after cancellation,
    we are still paying contractors.
        Compounding the situation is the fact that 3 months after
    the October 2015 cancellation, the Coast Guard decommissioned
    its older existing legacy system because it was not complying
    with international medical coding requirements. This left the
    Coast Guard to predominantly use a paper process to maintain
    health records.
        To its credit, the Coast Guard is attempting to use some
    DoD applications and workarounds to supplements its paper
    process. But let's be clear, using paper is inefficient and
    dangerous.
        Coast Guard clinical staff reported major issues to us that
    include problems with incomplete records, issues with tracking
    medications, and challenges scheduling appointments.
        The Coast Guard is planning a new electronic health record.
    A request for information went out in April 2017, but the Coast
    Guard has yet to determine its specific electronic health
    record solution.
        Moving forward, we have five recommendations for the Coast
    Guard:
        Number one, make sure managers and executives with the
    right IT background are involved with this acquisition. Most
    importantly, this includes the chief information officer.
        Number two, executive governance needs to be active and
    frequent. This governance needs to be driven by the CIO and the
    witnesses here today.
        Number three, project management disciplines need to be
    carried out. This would include implementing the appropriate
    cybersecurity measures and involving the user community
    extensively, since business process change will be significant
    to effectively deploy commercial products in this area.
        Number four, the Coast Guard needs to consider adjustments
    or tailoring of its processes it uses to manage what it calls
    smaller or nonmajor acquisitions. Dollar thresholds alone
    shouldn't drive the rigor and attention projects get. Mission
    criticality should.
        And finally, the Coast Guard needs to strongly consider the
    EHR solution that DoD and the Department of Veterans Affairs
    are pursuing.
        Mr. Chairman, this concludes my statement. Thank you for
    your oversight of this important acquisition.
        Mr. Hunter. Thank you, Mr. Powner. And to the other
    witnesses, thank you very much.
        I guess let us go with what you were saying. What was your
    last recommendation?
        Mr. Powner. The last recommendation is you really need to
    look at what DoD and Department of Veterans Affairs are doing.
    I mean, we made a bold decision for VA to go with the solution
    that DoD was using. And I understand competition in this
    industry.
        Mr. Hunter. But is the Coast Guard DoD? The Coast Guard is
    a military service, right? Why wouldn't you go with DoD in the
    first place? Why not be interchangable with DoD? Why not save
    all that money and time and be efficient and use DoD's product?
        Admirals.
        Admiral Schwartz. The Coast Guard is looking with great
    interest at what DoD is doing and what the Department of
    Veterans Affairs is doing with regards to their new electronic
    health record system.
        Mr. Hunter. But why would you not use that?
        Admiral Schwartz. So, sir, as a military service we
    certainly are looking at what they are doing with respect to
    the new MHS GENESIS product. And what we are doing is looking
    at what their lessons learned are.
        Mr. Hunter. But why would you not use that? Why would you
    not use what DoD is already doing?
        Admiral Schwartz. As part of the acquisition process, which
    I will yield to my colleague here, we are looking at various
    GOTS [Government off-the-shelf] and COTS [commercial off-the-
    shelf] solutions.
        Mr. Hunter. I understand that you are doing that. Why would
    you not use DoD's solution?
        Admiral Haycock. Mr. Chairman, I can't speak to something
    that happened that long ago.
        Mr. Hunter. No, now. Why would you not use DoD's solution
    now?
        Admiral Haycock. That is our----
        Mr. Hunter. It is a waste of money and time going to look
    at stuff when it exists right now. I don't think you would say
    that the Navy is less complicated than the Coast Guard, right,
    or the Army. It is a lot more complicated, and larger and more
    spread out, and they are able to do it. So why wouldn't you
    just use that?
        Admiral Haycock. As you know, Mr. Chairman, when you start
    getting into major acquisitions of great scope and complexity
    there is discipline that we have to put in the process, and
    that is what prevents us from getting into trouble.
        We are going through that process. We have done an analysis
    of alternatives, which is looking at what exists out there for
    us to potential solutions.
        One of those solutions is using a Federal service provider.
    That is the solution that we would like to go for and that is
    what we are working with the Department of Veterans Affairs and
    DoD to make happen. We are in close conversation with them
    informally on probably a weekly basis and meeting with them
    formally on a monthly basis. We have been invited to be part of
    their executive steering group and we are participating in
    that.
        So we are tracking down that direction, but we need to
    follow the discipline of the acquisition process or we will end
    up in messes like other programs have seen in the past for not
    doing it.
        That is when gives me great confidence on eHRA [electronic
    health record acquisition] going forward, is that we have stood
    it up as a formal acquisition program and it is getting that
    discipline and the oversight. The very same people that oversee
    all of our major acquisitions, like ships and aircraft and
    such, they are providing the oversight for eHRa now, and that
    includes the chief information officer and every stakeholder
    and tech authority in the Coast Guard.
        Mr. Hunter. OK. I would highly encourage you guys to do
    what is easy and efficient and effective, especially when you
    have got really big services with lots of money doing it for
    you and you can just piggyback onto that.
        Let me switch over. There is no code, there is no software,
    there is no code and no machinery, right?
        Admiral Schwartz. Sir, IHiS is considered a software as a
    service product. And so what we did was we contracted with
    various software companies and they produced, developed modules
    for our safety program, for our health program, for our work-
    life program. But because it is a software as a service, once
    we stopped paying for those services we don't have a final
    product to show.
        Mr. Hunter. So you didn't have any intellectual property?
        Admiral Schwartz. That is correct, sir.
        Mr. Hunter. Whose decision was it to cancel it?
        Admiral Haycock. I guess it was probably three-quarters of
    the way through 2015 the Executive Oversight Committee, their
    counsel was sought out by the project. The executives on that
    team heard the brief, saw the risks involved, and recommended
    that the Coast Guard, the Vice Commandant, cancel the program.
        Mr. Hunter. I think it is very strange that there is
    nothing, that you got $60 million and you literally got nothing
    out of it.
        Is that usual, Mr. Powner, I mean, to retain no
    intellectual property?
        Mr. Powner. You know, I think you can write contracts in a
    way where you do maintain some of--I understand the software as
    a service concept, but you can write that in a way that you
    have some reusability.
        If you have nothing, that might even be more of a reason to
    go with what the Department of Veterans Affairs and DoD are
    already doing, because if we don't have anything to reuse--I
    agree with you on your comment about piggybacking on what is
    already there. And they are ahead of the game, so you can look
    at lessons learned and learn from that. That is what the
    Department of Veterans Affairs is doing with DoD right now.
        And there are lessons learned on the business processes and
    the like. To me, that makes sense, to go that route, especially
    given the fact that we have nothing.
        Mr. Hunter. My last question is to stress this point. Is
    there anything that makes coastguardsmen different from any
    other servicemember besides what they do in their specialty? Is
    there anything special about being in the Coast Guard that
    would not allow you to be in the Department of Defense's health
    record system?
        Admiral Haycock. No, Mr. Chairman. We are a military
    service, so our Active Duty coastguardsmen are just like all
    the other Active Duty military.
        I think some things that may play into it that make us a
    little unique is the size of our Service. So infrastructure is
    a little bit different, the types of patients that we see and
    that the Department of Veterans Affairs sees might be a little
    bit different. But for the most part there is nothing special
    there.
        Mr. Hunter. The Coast Guard has got a lot of missions that
    do a lot of totally different things. And I think what you are
    doing is complicating your own lives here. I mean, you can't
    have a core competency of everything.
        With that, I would like to yield to the ranking member. You
    are recognized, Mr. Garamendi.
        Mr. Garamendi. I think I have been through too many of
    these. Electronic health records are now standard in virtually
    every health system in the Nation. And every one of them have
    made mistakes and in most every system the first effort failed.
    But we have more than enough models in place so that this
    should not have happened. But it did.
        My real issue is, who was the contractor? I was looking
    through the report and never a name of the contractor.
        Admiral Schwartz. Sir, there were numerous contractors that
    supported the IHiS effort.
        Mr. Garamendi. Who are they?
        Admiral Schwartz. Sir, I don't have a list of the
    contractors with me today, but we certainly can make that list
    available to you.
        Mr. Garamendi. Somebody ought to be accountable here. We
    are holding the Coast Guard accountable, but the contractor
    also screwed up. I want to know who screwed up. Who is the
    contractor that screwed up here?
        Mr. Powner, do you know?
        Mr. Powner. We can get you a list of the contractors who
    were involved in that.
        Mr. Garamendi. I am sorry, this whistling behind just wiped
    you out. Could you say that again?
        Mr. Powner. Yes, we can get you a list of the contractors
    involved.
        I think you bring up a good point. I have testified in
    front of Congress on many failed acquisitions over the years.
    And is there mismanagement on the Government side? Yes. But
    there is also an obligation on the contractual side to work in
    partnership on this, and we need more of that going forward,
    clearly.
        Mr. Garamendi. I am just willing to bet, without knowing
    who they are, I will bet they have screwed up before and I will
    bet we have hired the same folks that screwed up before to do
    another screwup.
        Yes, I would like to know the name of the companies that
    failed to perform. That is the first issue.
        The second issue was the question raised by the chairman,
    Mr. Hunter, and that is, the Department of Defense is in the
    process of developing an electronic medical record. And if I
    recall correctly, they finally decided, out of a fit of wisdom,
    that it would also be the same records that the Department of
    Veterans Affairs used. In other words, they were transferrable
    one to another.
        That took about 10 years' fight between the two agencies,
    but I guess somewhere along the line both decided that an
    active member and reservist in the military, the Department of
    Defense, might at some time in the future become a veteran and
    that their medical records really ought to be available to the
    Department of Veterans Affairs.
        Does the Coast Guard also see the wisdom of this
    transferability of the medical records from the Coast Guard to
    the Department of Veterans Affairs? Are you taking that into
    account?
        Admiral Schwartz. Absolutely, sir. And just to be clear,
    right now, even though we are on paper health records, we do
    transfer our paper health records to the Department of Veterans
    Affairs. It is through a system called the Health Artifact and
    Image Management Solution, which is the same system DoD uses
    right now. We digitize our paper health records when a member
    leaves the Service, and that record is uploaded into HAIMS and
    the Department of Veterans Affairs can extract the record from
    HAIMS.
        Mr. Garamendi. So at least you are thinking about it with
    regard to paper. And you are going to do that with regard to
    the electronics if and when you ever get there?
        Admiral Schwartz. Absolutely, sir.
        Mr. Garamendi. The chairman was pushing the point, I think
    correctly, that you ought to be using the same system as the
    Department of Defense. Are you contemplating doing that? It
    wasn't quite clear to me in the responses, Admirals, that you
    are or are not.
        Admiral Haycock. The alternatives analysis is----
        Mr. Garamendi. Please really speak loud, this whistling
    behind us is most distracting.
        Admiral Haycock. So the alternatives analysis that we
    conducted, that is one of the preferred alternatives, and we
    are working through the details to make that happen.
        Mr. Garamendi. And when do you expect to make a decision?
        Admiral Haycock. We are approaching Acquisition Decision
    Event 2A/2B, which probably doesn't mean much. But we have a
    major acquisition decision coming up here probably end of
    February.
        Mr. Garamendi. I know of several clinics in California that
    have more than 50,000 lives in their clinics. They have
    established electronic medical records. I mean, some of this
    stuff is now off the shelf.
        Mr. Powner, you have been at this a long time. You have
    found more than enough problems. Your recommendations in your
    report are rather general. Do you have specific
    recommendations? And is one of those recommendations----
        Mr. Powner. Yes. I would say the key recommendation, and I
    have seen this, you can have the best project management on
    these technology projects, but if you don't have executives
    that are accountable and breathing down the neck of project
    managers, that is what makes this stuff work, when you get
    executives involved.
        Example, the U.S. Census Bureau, OK? Now we are going to
    spend $3 billion more on the Census Bureau. What happened?
    Secretary Ross is now involved with the Census Bureau and they
    set up adequate governance.
        The Coast Guard has a governance process in their policies,
    they just need to execute it. It starts with the admirals at
    this table, with the CIO, with the CFO, and they need to drive
    the delivery of this system.
        Good governance, that is what actually works in Government,
    when you have the executives accountable and pushing hard to
    make sure we get deliveries, not only from the Government but
    from contractors too. You sit down with contractors, you demand
    the A team.
        That is the stuff that has worked over the years, and I can
    give you positive examples, too, where it has worked.
        Mr. Garamendi. I agree entirely.
        So, Admirals, are you engaged?
        Admiral Haycock. Yes, Congressman. IHiS was kind of a
    watershed event, shook our foundations. It really caused us to
    kind of sit back on our heels and try to figure out what
    happened.
        IHiS did not have the appropriate executive oversight. That
    is probably the biggest problem. There are other things that
    complicate IHiS, but they all lead to this failed oversight on
    our part.
        So we have stood up a formal acquisition program for eHRa,
    and it has the right executives providing the oversight.
    Admiral Schwartz is a member of the EOC, the Executive
    Oversight Committee, our CIO is, and a host of others that have
    a stake in this.
        So I assure you, we have the right executives breathing
    down the neck.
        Mr. Garamendi. You just described everybody is responsible
    and therefore nobody is responsible. So which of the two of you
    are responsible?
        Admiral Haycock. I am responsible because I am the
    acquisition officer.
        Mr. Garamendi. Admiral Schwartz.
        Admiral Schwartz. Sir, I am responsible for ensuring the
    requirements document is delivered to our acquisition officer
    to delineate what we need and what we want for an electronic
    health record system.
        Mr. Garamendi. Isn't that readily available from a dozen
    different organizations that already have electronic medical
    records?
        Admiral Schwartz. We have completed the operational
    requirements document. We delivered it to the hands of our
    chief acquisition officer. And we are moving as quickly as we
    can to get this EHR out in the field.
        Mr. Garamendi. Have you consulted with Mr. Powner on his
    recommendations?
        Admiral Schwartz. Sir, we have read the GAO's draft report
    and we have taken them absolutely to heart.
        As Admiral Haycock mentioned, governance was a significant
    issue with IHiS. IHiS was stovepiped in the medical program. We
    did not involve the chief information officer. We did not
    involve the chief acquisition officer.
        No more. As we move forward, we have this cross-directorate
    governance that includes the CIO, that includes the chief
    acquisition officer and others on the governance board.
        Mr. Garamendi. You have developed an AOA?
        Admiral Haycock. An alternatives analysis, yes.
        Mr. Garamendi. Have you developed one?
        Admiral Haycock. We have.
        Mr. Garamendi. Have you presented that to the committee,
    us?
        Admiral Haycock. I don't----
        Mr. Garamendi. Well, why don't you do so? We have seen AOAs
    on God knows how many things under Defense on the House Armed
    Services Committee. I would love to see your AOA.
        Mr. Powner, have you reviewed the AOAs?
        Mr. Powner. No, I have not reviewed that in great detail.
        Mr. Garamendi. Should you?
        Mr. Powner. Yes. But I would say you could eliminate the
    AOAs down to--as was mentioned here, this is a robust area when
    you look at commercial products. So I don't know why we would
    look at anything beyond commercial products.
        And then I will narrow it further. Let's piggyback on DoD
    and the Department of Veterans Affairs. Let's make it simple.
    We are making it too complicated.
        I understand we have to follow the process----
        Mr. Garamendi. Admiral Schwartz, you heard what he said?
        Admiral Schwartz. Sir, as the chief medical officer, I
    absolutely would love to go with DoD and the Department of
    Veterans Affairs. I have provided my requirements. We worked
    very closely to look at what DoD was doing to ensure that the
    operational requirements documents that we provided to the
    acquisition officer was very similar to what the DoD system is.
        Mr. Garamendi. I find it astounding that--I mean, this is
    so--this is not complicated. There are commercial applications
    out there. I know four clinics that in the last 3 years have
    purchased off-the-shelf electronic medical records that also
    allow them the opportunity to convert their previous paper
    records to electronic records, all done. It is off the shelf.
    And they have more lives than the Coast Guard has.
        I guess one question is that the GAO comes in after there
    is a screwup. It seems to me that there ought to be an
    iterative process here.
        Mr. Powner, you have got a lot more knowledge than either
    of the two admirals here about these kinds of things. This has
    been your life or at least you more recent life's work. Maybe
    you ought to quit GAO and become a consultant. But stay where
    you are, we need you there.
        But it would seem to me that it would be worthwhile for the
    Coast Guard to consult with the GAO and to learn from their
    experiences. I know you have two different tasks.
        Mr. Powner. If I can add. So we do some postmortems at GAO
    on things that go wrong, but we also do a lot of work for the
    Congress when acquisitions are in flight. And that is when it
    is most effective, working alongside. We can still maintain our
    independence and work alongside while acquisitions are in
    flight to ensure that governance and project management,
    contractor oversight, and all those things are occurring.
        Mr. Garamendi. Well, given that, I have just requested an
    AOA--or the AOA. I would appreciate your review of the AOA,
    while it is in process. Postmortems are usually over dead and
    troubled projects. We can avoid that, I think, by working
    together here.
        I yield back.
        Mr. Hunter. I thank the gentleman.
        One thing we looked at, and I don't know if you have heard
    of this, Mr. Powner, but it is called the Distributed Common
    Ground System, DCGS, for the Army. It is like $4 billion they
    put into it.
        It never worked. They had about 30 nice contractors that
    all did modules and they could all plug and play theoretically,
    but nothing. It didn't work, period.
        And it was billions of dollars and it required the Chief of
    Staff of the Army now, General Milley, to kind of do what you
    are doing, Admiral Haycock, and taking a hard look at this, as
    a four-star. Because when you are spending billions of dollars
    or tens of millions of dollars for the Coast Guard, I mean, you
    have to make sure you have it right, especially with software.
        It would be nice to be a software contractor in town here.
    I can do stuff for you and never give it to you and you will
    pay me.
        Mr. Garamendi. I want to know who the contractor was.
        Mr. Hunter. I think it is absurd you are paying next month
    for this, even though the whole thing is over. But what is in
    the past is in the past. We don't want to beat on the Coast
    Guard too much right now. You have got things straightened up.
    And hopefully moving forward, Mr. Powner will have good things
    to say.
        And again, I am of the mind to make you get on DoD's thing
    no matter what you think. We ought to just tell you to do it.
    You don't need to be going off and doing your own thing when it
    comes to healthcare.
        I think that is not Mr. Garamendi and I or this committee
    micromanaging. It is saying you guys don't get to go off on
    your own and just use taxpayers' dollars because it is fun when
    you have the Department of Defense doing it.
        So I think that is something we ought to look at, is just
    telling you what to do, especially in this case. I think that
    would be a smart thing for us to look at and see if that is
    even possible.
        With that, thank you very much for being here. And
    hopefully we get this straight.
        With that, the hearing is adjourned.
        [Whereupon, at 11:36 a.m., the subcommittee was adjourned.]

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