[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


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

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  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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