The independent review of the Steamship Authority looked at five major areas of SSA operations and found serious deficiencies in four (the report on communications has been delayed), painting a picture of an organization lacking strong management, consistent procedures and effective planning.

The four topics covered in the report are:

• Vessel operations. Management of the fleet includes navigation, passenger management, deck operations, engineering and scheduling both trips and crew, along with associated policies and procedures, according to HMS.

• Fleet maintenance. This area covered both scheduled maintenance and unexpected situations, from routine work performed by staff to shipyard projects outsourced to contractors.

• Information technology systems. Consultants reviewed internet-based services and internal computer systems, including the SSA’s website and its reservations, emails and alerts, finances, telephones and asset maintenance systems.

• Management structure. HMS defines this as “the relationship between organizational culture and organizational structure that results in the overall organizational climate. This relationship determines the effectiveness of management to perform well and meet its objectives.”

On Monday afternoon in Falmouth, Mr. Sainsbury delivered a slide-assisted presentation of the findings and recommendations. The slideshow is available on the Steamship Authority website.

While the HMS review was spurred by a series of emergencies, the study aimed to take a longer view by examining and analyzing the root causes of the recent problems, he said.

In the end consultants recommended systemic changes throughout the boat line’s operations.

Vessel Operations

Steamship Authority ferries operate under a split chain of command, with engineers reporting up to the director of engineering — who reports directly to general manager Robert Davis — while crews, vessel masters and port captains answer to the operations manager, who also reports to Mr. Davis.

Along with the conflicts in authority this structure presents, SSA vessel operations are not represented at the executive level, according to the HMS consultants.

The report recommends resolving these conflicts by adding two new positions: a chief operations officer who reports directly to Mr. Davis, and a director of marine operations reporting to the new chief operations officer.

The current director of engineering and operations manager, the latter responsible for reservations, terminals, parking and security, would also report to the new COO.

Fleet Maintenance

The Steamship Authority lacks standardized policies and procedures that should have prevented “blackouts” like the St. Patrick’s Day breakdown, consultants said.

More than 70 passengers spent five hours aboard the ferry Martha’s Vineyard that night, after what the HMS report said was an avoidable generator fire that could have been caused by one or more of “21 individual issues with the vessel plant and the way it was operated,” consultants found.

“The net result of all of these issues was an unsafe condition on the vessel that led to the incident,” the report says.

“While the blackout did not result in any serious casualties, had it occurred minutes later, while the vessel was maneuvering into the dock, the consequences could have been dire.”

The SSA has no system in place to address the problems behind the March 17 breakdown and existing procedures vary markedly from vessel to vessel, the report says.

“For example, inconsistencies in the vessel startup and securing procedures were observed between M/V Martha’s Vineyard and M/V Woods Hole,” consultants wrote. “The Martha’s Vineyard procedures were highly descriptive and provided familiarization information, which may be useful to new and inexperienced crew members, but reduce the value of the procedure as a working checklist.

“The Woods Hole procedures were written much more like a working checklist, but lacked instructive information for new and inexperienced crew members.

“In both cases, the procedures were written in an informal, conversational tone, and lacked document control.”

HMS recommends establishing and standardizing shipboard procedures using a controlled-document system.

“It is unlikely that the SSA will be able to prevent future occurrences of the kinds of casualties that were experienced in the spring of 2018 without making a cultural and managerial shift from informal policies and procedures that rely on the judgment of individuals to a formalized management system that prescribes procedures,” consultants wrote.

Information Technology Systems

The collapse of a single line of code — one that had handled SSA website database connections for nearly five years — led to a website slowdown and frustrated consumers in early January when the 2018 reservation season opened, HMS found. The consultants recommended load testing and a backup website and noted a lack of procedures for making sure the SSA website can handle all the traffic it receives.

In a follow-up statement, Mr. Davis said the boat line has upped load testing for its website and is designating different days for 2019 online reservations to ease online congestion.

Responding to a slowdown of its email alerts in March, the SSA changed email vendors. The boat line is also working on a smartphone application, Mr. Davis said.

Consultants also uncovered a critical problem with the boat line’s reservation system, which they found is “entirely owned, managed and maintained by a single individual operating remotely.” The code that the system is written in is “dangerously outdated,” consultants found. Further, SSA managers have no access to the code and no knowledge of how it works, creating the potential for a single point of failure if the proprietor of the software becomes unavailable for any reason. HMS consultants said the SSA’s IT systems are “mission critical” to the boat line.

Management Structure

Enmeshed with the culture and structure of the SSA itself, the boat line’s management structure needs “right-sizing,” consultants wrote. “Adding key positions with critical skills will increase capabilities.”

The report continues: “SSA is over-reliant on a small number of individuals who hold inordinate amounts of knowledge and power, resulting in an executive team that is stuck in a perpetual mode of day-to-day firefighting.”

One of the report’s chief recommendations, opening management recruiting to outside applicants, runs counter to the longstanding SSA tradition of seeking job candidates within the organization. The current general manager Mr. Davis, for example, began his Steamship Authority career in 1986 as an auditor and became treasurer-comptroller before ascending to the top position in 2016. His predecessor, longtime general manager Wayne Lamson, similarly rose through the ranks, moving up from treasurer-comptroller to general manager.

The report also advises a significant transition from what it calls the boat line’s “firefighting” stance to what HMS terms a process-based culture.

“The SSA operates almost entirely reactively, rather than actively identifying and attempting to mitigate risks,” consultants wrote. “The SSA’s reactive culture is designed to address the immediate cause, but not the root cause” of emergencies and other problems.

Mr. Sainsbury said the boat line has achieved remarkable results without government subsidies, which make up a significant part of the funding for most regional ferry services.

“With the resources they have, they do a pretty good job,” he said. “We’re looking at how they can improve a pretty good system.”