The following are the findings of the National Transportation Safety Board:

1. The master's decision to depart from the Traffic Separation Scheme to avoid ice was probably reasonable, even though it required a heading toward shoal water.
2. Navigating the EXXON VALDEZ between the ice field and Bligh Reef required a diligent, competent navigation watch capable of conning the vessel, watching for ice, and fixing the vessel's position frequently; hence, two officers were required on the bridge -- one with conning and shiphandling experience to conn the vessel and one to fix the vessel's position frequently -- to navigate the vessel safely.
3. The master's decision to leave the third mate in charge of the navigation watch was contrary to Federal regulations and Exxon policy and was improper given the course of the vessel, the uncertain extent of the ice conditions, the proximity of a dangerous reef and the fact that the third mate did not have the required pilotage endorsement.
4. The master's judgement was impaired by alcohol during the critical period when the vessel was transiting Valdez Arm.
5. The performance of the third mate was deficient, probably because of fatigue, when he assumed supervision of the navigation watch from about 2350.
6. The third mate's failure to turn the vessel at the proper time and with sufficient rudder was probably the result of his excessive workload and fatigued condition, which caused him to lose awareness of the location of Bligh Reef.
7. The vessel was in the red sector of Busby Island Light for several minutes before grounding, which afforded a warning of the reef that apparently was not noticed by the third mate or the lookout.
8. There were no rested deck officers on the EXXON VALDEZ available to stand the navigation watch when the vessel departed from the Alyeska Terminal.
9. Many conditions conducive to producing crew fatigue on the EXXON VALDEZ exist on other Exxon Shipping Company vessels because many are three-mate vessels and because the company has pursued reduced manning procedures.
10. The Exxon Shipping Company did not adequately monitor the master for alcohol abuse after his alcohol rehabilitation program.
11. Exxon Shipping Company did not have a sufficient program to identify, remove from service, if necessary, and provide treatment for employees who had chemical dependency problems.
12. Exxon Shipping Company manning policies do not adequately consider the increase in workload caused by reduced manning.
13. The Exxon Shipping company had incentives and work requirements that could be conducive to fatigue.
14. The Exxon Shipping Company had manipulated shipboard of crew overtime information that was to be submitted to the Coast Guard for its assessments of workloads on some tankships.
15. The Coast Guard was unduly narrow in its perspective when it evaluated reduced manning requests for the EXXON VALDEZ; it based manning reductions primarily on the assumption that shipboard hardware and equipment might reduce the workload at sea but did not consider the heavier workload associated with cargo operations in port and the frequency of such operations.
16. The Coast Guard was not adequately prepared to implement the requirement to obtain toxicology samples from mariners involved in marine accidents.
17. The Department of Transportation regulations for post-accident/incident drug testing of employees in safety-sensitive positions are not adequate.
18. Drug testing of Vessel Traffic Center watchstanders was not conducted in a timely manner in accordance with with Department of Transportation directives.
19. The Coast Guard needs to have access to National Driver Register information and other information regarding alcohol related traffic offences commited by licensed maritime officers in order to better determine a merchant mariner's fitness to hold a Federal license.
20. The Alyeska Pipeline Service Company failed to meet the expected response-time objective of its approved spill plan because it failed to have an oil spill cleanup barge loaded and ready for deployment.
21. The Alyeska Pipeline Service Company should have, at a minimum, a second barge that is loaded with additional cleanup and lightering equipment so that cleanup equipment will be ready for immediate deployment at all times.
22. The National Oil and Hazardous Substance Pollution Contingency Plan and Alaska Regional Oil and Hazardous substances Pollution Contingency Plan both lack adequate guidance for On-Scene Commanders about the use of dispersants and in-situ burning.
23. Requiring the On-Scene Commander to confer with the Regional Response Team before using dispersants or in-situ burning needlessly delays the use of these methods and complicates the decision process.
24. There was no evidence that the Federal Government (Coast Guard) or any other organization would have been capable of increasing the efforts under way during the first 34hrs of the spill.
25. The Alyeska Pipeline Service Company contingency plans lacked procedures that would allow individual companies transporting oil from the Valdez Terminal in Prince William Sound to relieve Alyeska of cleanup responsibilities in a manner that would prevent interruption.
26. The Alyeska Pipeline Service Company plan should include guidelines that describe the wind and sea conditions under which different types of skimmers, dispersants, and in-situ burning can be used most effectively for North Slope crude oil.
27. Ice in Valdez Arm is a significant hazard to navigation and requires closer monitoring and reporting.
28. The limited supervision of the Vessel Traffic Center probably contributed to the commanding officer's lack of awareness that tankships were departing from the traffic separation scheme to avoid ice and were passing close to Bligh Reef.
29. The Vessel Traffic Service radar was operating satisfactorily, and the detection range of the radar was not significantly reduced by weather or sea conditions while the EXXON VALDEZ was transiting Valdez Arm.
30. The Vessel Traffic Center lost radar contact with the EXXON VALDEZ about 7.7 miles from the radar site, which is about 5.5 miles from the northern part of Bligh Reef, because the Center's watchstander did not use a higher range scale and not because of any limitation of malfunction of the radar. Had he used a higher range scale, the vessel probably could have been tracked as far as the site of the grounding, but no firm policy required him to do so.
31. The monitoring of vessels in Valdez Arm was left to the discretion of the Vessel Traffic Center watchstander because the senior watchstander decided to allow the Center's watchstanders to monitor instead of plot the positions of vessels transiting Valdez Arm.
32. A firm policy requiring the Vessel Traffic Center to plot tankships transiting the full length of Valdez Arm could have alerted the commanding officer of the Marine Safety Office to the fact that tankships were departing from the traffic separation scheme, in the vicinity of Bligh Reef to avoid ice.
33. Monitoring the EXXON VALDEZ by radar as it transited Valdez Arm would have revealed to the Vessel Traffic Center watchstander that the vessel had changed course to 180, had departed the vessel traffic separation scheme, and was headed for shoal water east of Bligh Reef.
34. A query or warning from the Vessel Traffic Center might have alerted the third mate to the impending danger from Bligh Reef.
35. Ice reports issued by the Vessel Traffic Center frequently are neither sufficiently timely nor sufficiently accurate to enable masters to ascertain before leaving Port Valdez the ice conditions that will be encountered in Valdez Arm.
36. The policy adopted by the Coast Guard about 1985 to discontinue independent collection of ice information and statistics about vessel deviations from the traffic separation scheme probably contributed to the commanding officer and the operations officer not knowing that ice was causing vessels to depart from the traffic lanes and pass close to Bligh Reef.
37. A radar site near Bligh Reef would enable the Vessel Traffic Center to obtain current information on ice in Valdez Arm and to reliably track vessels in Valdez Arm
38. The communication and microwave systems for the Vessel Traffic Service, Prince William Sound, were not reliable owing to age, the scarcity of proper replacement parts, and improvised repairs.
39. The Coast Guard has not maintained an effetive vessel traffic service in Prince William Sound.
40. Although moving the pilot station to Rocky Point was apparently based on a consideration for pilot safety, the move also resulted in a reduction in pilotage services past Bligh Reef, where local knowledge is needed.
41. Moving the pilot station to a position south of Bligh Reef enhanced navigation safety by ensuring the presence of an officer with local knowledge of the area on the bridge of each vessel transiting Valdez Arm past Bligh Reef.
42. Former COTP Order 1-80, which included requirements for two officers on the bridge for plotting and position reporting by vessels, contributed to navigation safety.
43. Current monitoring of the amount and size of ice being calved from the Columbia Glacier is inadequate for the safety of tankships transiting Prince William Sound.
44. The EXXON VALDEZ met all U.S. and international segregated-ballast regulations.
45. Current standards for segregated ballast and cargo tank size do not provide sufficient protection against oil spills caused by groundings or collisions.
46. If the EXXON VALDEZ had been fitted with an 11-foot double bottom (based on the 1/15 of the beam criterion), the resulting oil spill would have been small, and possibly eliminated.
47. Double bottoms on all U.S. and foreign tank vessels (tankships and barges) that enter U.S. waters and have a capacity of more than 20,000 deadweight tons would minimize oil pollution in U.S. waters caused by groundings.