NATIONAL

TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT REPORT

7009B

PB2000-916401

NTSB/MAR-00/01

Ramming of the Eads Bridge by

Barges In Tow of the M/V Anne Holly With

Subsequent Ramming and Near Breakaway

of the President Casino on the Admiral

St. Louis Harbor, Missouri

April 4, 1998

Marine Accident Report

Ramming of the Eads Bridge by 

Barges in Tow of the M/V Anne Holly With 

Subsequent Ramming and Near Breakaway 

of the President Casino on the Admiral

St. Louis Harbor, Missouri 

April 4, 1998

NTSB/MAR-00/01

DCA98MM027

PB2000-916401 National Transportation Safety Board

Notation 7009B 490 L’Enfant Plaza, S.W.

Adopted September 8, 2000 Washington, D.C. 20594

E P L U R IB U S U N U M

N AT I O N A L T R A S PO R TA T IO N

B O A R D

SA F E T Y

N
National Transportation Safety Board. 2000. Ramming of the Eads Bridge by Barges in Tow of the

M/V Anne Holly With Subsequent Ramming and Near Breakaway of the President Casino on the

Admiral, St. Louis Harbor, Missouri, April 4, 1998. Marine Accident Report NTSB/MAR-00/01.

Washington, DC.

Abstract: On April 4, 1998, a tow of the M/V Anne Holly, which was traveling northbound on the

Mississippi River through the St. Louis Harbor, struck the Missouri-side pier of the center span of the Eads

Bridge. Eight barges broke away and drifted back through the Missouri span. Three of these barges drifted

toward the President Casino on the Admiral (Admiral), a permanently moored gaming vessel below the

bridge on the Missouri side of the river. The drifting barges struck the moored Admiral, causing most of its

mooring lines to break. The Admiral then rotated away from the Missouri riverbank. The captain of the

Anne Holly disengaged his vessel from the remaining barges in the tow and placed the Anne Holly’s bow

against the Admiral’s bow to hold it against the bank. No deaths resulted from the accident; 50 people were

examined for minor injuries. Of those examined, 16 were sent to local hospitals for further treatment.

The safety issues discussed in the report are: the advisability of the Anne Holly captain’s decision to make

the upriver transit and the effectiveness of safety management oversight on the part of American Milling,

L.P.; the effectiveness of safety measures provided for the permanently moored vessel President Casino on

the Admiral; and the adequacy of public safety for permanently moored vessels.

As a result of this investigation, the National Transportation Safety Board made safety recommendations to

the U.S. Coast Guard, the Research and Special Programs Administration, the States of Missouri and

Illinois, the cities of St. Louis and East St. Louis, the National League of Cities, the American Association

of Port Authorities, the American Gas Association, the American Public Gas Association, President

Casinos, Inc., Laclede Gas Company, and American Milling, L.P.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation,

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L'Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical

Information Service. To purchase this publication, order report number PB2000-916401 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
iii Marine Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

President Casinos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Police . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Fire Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Coast Guard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Other Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Crew and Staff Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Anne Holly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

President Casino on the Admiral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Anne Holly Tow and Barges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

President Casino on the Admiral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Conditions, Traffic, and Accident History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Bridges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Upbound Transit of the Eads Bridge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

St. Louis Harbor Tow Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

American Milling, L.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

President Casinos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

President Casinos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

MSO St. Louis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

St. Louis Harbor Emergency Response Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Drills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Patron Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Safety Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Inspections and Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Permanently Moored Vessels and Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Boats in a Moat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Passenger Vessels in St. Louis Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Contents iv Marine Accident Report

Responsible Carrier Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

1994 New Orleans Search and Rescue Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Developments Since the Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

President Casino on the Admiral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Laclede . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

NFESC Mooring Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Striking of the Eads Bridge by the Anne Holly Tow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Captain’s Decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Navigation Task . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Factors That Could Have Affected the Captain’s Performance . . . . . . . . . . . . . . . . . . 55

Striking and Near Breakaway of the President Casino 

on the Admiral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Public Safety of Permanently Moored Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Owner’s Safety Management of the President Casino on the Admiral . . . . . . . . . . . . 69

Local and State Oversight of Permanently Moored Vessels 

in St. Louis Harbor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Role of the Coast Guard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Previously Issued Recommendations Classified in This Report . . . . . . . . . . . . . . . . . . . . . 85

Appendixes

A: Investigation and Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

B: Damage to Anne Holly Barges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

C: Characteristics of Barges in Anne Holly Tow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

D: Mooring Wires for the President Casino on the Admiral . . . . . . . . . . . . . . . . . . . . . . . . 90

E: Coast Guard List of PMVs in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

F: Coast Guard February 17, 2000, Letter to the Safety Board on PMVs . . . . . . . . . . . . . 94

G: Coast Guard PMV Initial Risk Assesment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

H: Conclusions and Recommendations of the QAT for PMVs . . . . . . . . . . . . . . . . . . . . . 100

 I: Draft Coast Guard Marine Safety Manual Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
v Marine Accident Report

Acronyms and Abbreviations

ABS American Bureau of Shipping

Admiral President Casino on the Admiral

AM American Milling

AWO American Waterways Operators

BOCA Code Building Officials and Code Administrators Basic Fire 

Prevention Code

CFR Code of Federal Regulations

COTP Coast Guard Captain of the Port

ERT Emergency Response Team

hp horsepower

LMR Lower Mississippi River

MLK Martin Luther King

MSM U.S. Coast Guard Marine Safety Manual

MSO Coast Guard Marine Safety Office

NFESC Naval Facilities Engineering Service Center

NFPA National Fire Protection Association

OCMI Officer in Charge of Marine Inspection

PARI Port Activity Risk Index

PMV permanently moored vessel

PVA Passenger Vessel Association

RCP Responsible Carrier Program

RSPA Research and Special Programs Administration

SLFD St. Louis Fire Department

U.S.C. United States Code

UMR Upper Mississippi River

USACE U.S. Army Corps of Engineers

vii Marine Accident Report

Executive Summary

About 1950 on April 4, 1998, a tow of the M/V Anne Holly, comprising 12 loaded

and 2 empty barges, which was traveling northbound on the Mississippi River through the

St. Louis Harbor, struck the Missouri-side pier of the center span of the Eads Bridge. Eight

barges broke away from the tow and drifted back through the Missouri span. Three of

these barges drifted toward the President Casino on the Admiral (Admiral), a permanently

moored gaming vessel below the bridge on the Missouri side of the river. The drifting

barges struck the moored Admiral, causing 8 of its 10 mooring lines to break. The Admiral

then rotated clockwise downriver, away from the Missouri riverbank. The captain of the

Anne Holly disengaged his vessel from the six remaining barges in the tow and placed the

Anne Holly’s bow against the Admiral’s bow to hold it against the bank. About the time

the Anne Holly began pushing against the Admiral, the Admiral’s next-to-last mooring line

parted. The Anne Holly and the single mooring wire that remained attached to the

Admiral’s stern anchor held the Admiral near the Missouri bank. No deaths resulted from

the accident; 50 people were examined for minor injuries. Of those examined, 16 were

sent to local hospitals for further treatment. Damages were estimated at $11 million.

The National Transportation Safety Board determines that the probable cause of

the ramming of the Eads Bridge in St. Louis Harbor by barges in tow of the Anne Holly

and the subsequent breakup of the tow was the poor decision-making of the captain of the

Anne Holly in attempting to transit St. Louis Harbor with a large tow, in darkness, under

high current and flood conditions, and the failure of the management of American Milling,

L.P., to provide adequate policy and direction to ensure the safe operation of its towboats.

The National Transportation Safety Board also determines that the probable cause

of the near breakaway of the President Casino on the Admiral was the failure of the

owner, the local and State authorities, and the U.S. Coast Guard to adequately protect the

permanently moored vessel from waterborne and current-related risks. 

The Safety Board’s investigation identified the following major safety issues:

• the advisability of the Anne Holly captain’s decision to make the upriver transit

and the effectiveness of safety management oversight on the part of American

Milling, L.P., 

• the effectiveness of safety measures provided for the permanently moored

vessel President Casino on the Admiral, and 

• the adequacy of public safety for permanently moored vessels.

As a result of this investigation, the Safety Board made safety recommendations to

the U.S. Coast Guard, the Research and Special Programs Administration, the States of

Missouri and Illinois, the cities of St. Louis and East St. Louis, the National League of
Executive Summary viii Marine Accident Report

Cities, the American Association of Port Authorities, the American Gas Association, the

American Public Gas Association, President Casinos, Inc., Laclede Gas Company, and

American Milling, L.P.
1 Marine Accident Report

Factual Information

The Accident 

The towboat Anne Holly, owned by American Milling, L.P., (AM) began its 1998

operating season on the Upper Mississippi River (UMR)1 on March 9, 1998. According to

its log, the Anne Holly transited southbound through St. Louis Harbor about 08502 on

April 4 and arrived at the Eagle fleeting area3

 at mile 177.6 UMR at 0930. (See figure 1.) 

About 1710 on April 4, the Anne Holly’s captain4 relieved the pilot on watch. At

this time, the tow was being made up and the barges were being secured to each other with

extra rigging because of the prevailing river conditions. About 1830, the Anne Holly got

underway from the fleeting area, heading upstream for St. Paul, Minnesota, (mile 839.0)

pushing 12 loaded and 2 empty barges. 

The tow was five barges long in the port side or string, five barges long in the

center string, and four barges long in the starboard string.5 Except for the two empty

barges on the forward end of the starboard string, all the barges contained dry cargo

(mostly fertilizer) and carried 981 to 1,696 tons of cargo each. All 14 barges were 35 feet

wide; 11 barges were 200 feet long, and the remaining 3 barges were 195 feet long. The

complete tow, including the 154-foot-long towboat (secured at the after-center of the tow),

was 1,149 feet long and 105 feet wide. (See figure 2.)

The river current at St. Louis was running about 6 mph at a river gage of 31.6 feet. 

1 For navigation purposes, the Mississippi River is divided into the Lower Mississippi River (LMR) and

the UMR. The LMR extends from the Gulf of Mexico to the confluence of the Ohio and Mississippi Rivers,

near Cairo, Illinois. The UMR extends north from the Ohio River to the head of navigation at Minneapolis,

Minnesota. All river miles along the UMR are measured in statute miles northbound from mile 0 near Cairo to

mile 857.6 at Minneapolis. 

2 Unless otherwise noted, all times are central standard and are based on the 24-hour clock. Daylight

savings time began at 0200 on April 5, 1998.

3 A fleeting area is where barges are kept until picked up by tows. Barges are dropped off and picked up

by line-haul towboats at these locations. The areas consist of an anchor barge to which the other barges are

moored. Small towboats, also known as harbor or fleet boats, shift the barges around to make them

accessible for making up tows. 

4 The terms captain and pilot are routinely used on river towboats, and here they are used to differentiate

between the Anne Holly’s two operators. The captain was the senior licensed operator and was in charge of

the vessel. Each operator had, and was required to have, a Coast Guard license as an operator of uninspected

towing vessels. 

5 Due to the size of locks (110 feet wide by 600 feet long) on the UMR, the sizes of dry cargo tows tend

to be limited to a maximum of about 15 barges (5 barges long and 3 barges wide). Because barges are about

35 feet wide and 195 or 200 feet long, such a tow would measure about 1,000 feet long and 105 feet wide.

Such a tow would have to make a double lockage to pass a lock. In this procedure, the tow is split at nine

barges and locked through; then the remainder of the tow goes through the lock. After both segments lock

through, the tow is reconnected to continue its trip.
Factual Information 2 Marine Accident Report

The captain said that, after leaving the Eagle fleeting area, he radioed the fleet to

request a helper boat6 to assist the Anne Holly through the four upcoming bridges. The

only Eagle fleet boat working that evening was carrying out other activities, and the Anne

Holly captain was told that a fleet helper boat was not available. Around 1900, the tow

passed under the Douglas MacArthur and Poplar Street Bridges, miles 179.0 and 179.2

UMR, respectively. The captain said the passings were uneventful and the equipment on

the vessel was operating satisfactorily. 

With respect to the transit of St. Louis Harbor, the captain told investigators,

“Once I cleared Poplar Street [Bridge], I didn’t think I’d have no problem at all.” He also

said, “If you can shove up these two bridges [MacArthur and Poplar] in high water like we

Figure 1. Map showing accident area

6 A helper boat is a harbor or fleeting towboat that can either be secured to the forward or aft part of the

tow, wait ahead of the tow, or follow alongside the tow to assist, if needed, in controlling the tow. 
Factual Information 3 Marine Accident Report

have now, the rest of the bridges are simple.” When investigators asked the captain

whether he had thought he needed a helper boat in making this passage, he stated that he

might have needed one for the MacArthur and Poplar Street Bridge transits but not after

he had cleared the Poplar Street Bridge.

The captain told investigators that he had maneuvered the tow northbound through

St. Louis Harbor at full engine throttle (about 900 rpm on both engines), making about 3

mph against the river current. According to the chief engineer, the captain asked him to set

the fuel rack to provide the maximum engine power before the Anne Holly got near the

bridges. The engineer complied with the request, and the captain made no comments

about inadequate engine power. 

The Anne Holly’s chief engineer testified that he was in the engineroom during the

transit through St. Louis Harbor (including the passage under the Eads Bridge), and that

the two propulsion engines, the electrical generators, the steering gear, and other

engineroom equipment experienced no problems. The chief engineer testified that the

readings shown on the engineroom log for April 4, 1998, which recorded engine rpms,

fuel rack settings, and temperatures and pressures for engine cooling water and lubricating

oil, were normal. He also stated that since he had come aboard the vessel on March 8,

1998, he had not experienced any problems with the propulsion engines; he had performed

only routine maintenance. 

A little before 1950 on April 4, 1998, the tow approached the Eads Bridge, mile

180.0 UMR. The captain later recalled, “Everything was looking good. Everything was

under control. The boat was doing well.” The captain said that he did not have any trouble

seeing the dayboards7

 and the fixed green light at the center of the Eads Bridge. He said he

illuminated the dayboards with his searchlight.

The captain told investigators that he directed the tow to the right of the center of

the Eads Bridge center span.8 According to the Anne Holly’s first mate (non-navigating

Figure 2. Schematic of the Anne Holly tow barges

7 A dayboard is an unlighted aid to navigation designed primarily for daytime use; dayboards are coated

with retroreflective material for nighttime use (with searchlights). 

8 The bridge’s three spans, facing north, are the Missouri (left side, 498 feet wide), the center (517 feet

wide), and the Illinois (right side, 498 feet wide).
Factual Information 4 Marine Accident Report

person in charge of the deck), the vessel’s steering light9 was not lit. The captain said that

by using visual “marks” (the Eads and Martin Luther King Memorial Bridge lights and

other visual points), he maneuvered the Anne Holly close to the middle of the arched

center span because the arch apex could best accommodate the towboat’s height. He said

he thought the vessel had about 8 feet of vertical clearance. The captain testified that when

300 to 400 feet of the tow had passed under the Eads Bridge, he could feel the tow begin to

slow. He said he continued to use the vessel’s full power to move the tow through the

bridge.

The captain said that as the eight forward barges (three port, three center, and two

starboard), which comprised about 600 feet of the tow, passed under the center span, the

Anne Holly “stalled” (the tow’s forward movement was halted by the river current). When

asked by investigators about the reason for the halt, the captain said that he believed a

“pop rise”10 had occurred, which impeded the vessel’s forward progress. The captain said

that the towboat was using its maximum engine power of 900 rpm, but it could not

overcome the current in the bridge span. He said that, with the headway stopped, a current

then caused the tow to drift sideways toward the Missouri shore. Within 30 seconds, the

tow’s port side (between the third and fourth barge from the tow’s head) struck the

Missouri-side pier of the Eads Bridge center span. 

About 1950, just after the tow struck the bridge, the forward eight barges broke

away from the tow and drifted back down through the Missouri span. Three of these

barges began drifting toward the 380-foot-long President Casino on the Admiral

(Admiral), which is a gaming vessel and attached entry barge11 permanently moored by

10 mooring wires below the Eads Bridge on the Missouri side of the river.12 (See figure 3.

See figure 4 for a schematic of the Admiral complex.) The captain of the Anne Holly

immediately notified the Coast Guard Group UMR in Keokuk, Iowa, on VHF-FM radio of

the accident. He also attempted to call the Admiral on VHF-FM radio to warn it of the

loose barges, but he received no response. 

Across the river, the master on watch on the M/V Casino Queen (a passenger

vessel that periodically gets underway for gaming) overheard the Anne Holly’s radio

9 A steering light is a small blue light installed on a pole placed on the centerline at the head of the tow

facing aft. The operator may use the light to detect heading changes and to align the tow with respect to a

bridge or other restricted navigation area during periods of darkness.

10 The Anne Holly captain said, “there are two types of rises, the slow rise [in river stage or level], you

don’t have as much current. You have a more steady current. A pop rise is a rise [in river stage or level] that

comes up a lot swifter...it brings gushes of water at time.” A pamphlet on the “Language of the Western

Rivers,” published by the U.S. Coast Guard in the early 1970s, defines a pop rise as “a fast rise (usually not

a great one) in the river generally caused by flash flood.”

11 The Admiral’s owner told the Safety Board that the entry barge was actually two custom-built barges

connected end to end. For the purposes of this report, we refer to this unit as the entry barge.

12 The floating entry barge has three gangways to shore; the center gangway is for passengers, while the

forward and aft ones are for services. The passengers move from shore over the gangways onto the entry

barge and then onto the Admiral. The Admiral and the entry barge are physically secured to each other. For

the purposes of this report, the whole complex, including entry barge and vessel, will be generally

considered the Admiral. 
Factual Information 5 Marine Accident Report

Figure 3. Photo of the Admiral

Figure 4. Schematic of the Admiral complex
Factual Information 6 Marine Accident Report

attempts to contact the Admiral. He called the captain of the Anne Holly and advised him

that the Admiral did not have a radio and that people were on the vessel.

Shortly thereafter, the three barges from the Anne Holly drifted toward the Admiral

and severed or severely damaged mooring line numbers 8, 9, and 10 at the Admiral’s bow,

before colliding with the Admiral. At least two of the three barges struck the Admiral, and

two barges drifted downriver. The third barge drifted toward shore and struck the sidewalk

protection guards and the north gangway between the shore and the entry barge. The

impact to the Admiral caused wire rope numbers 1, 2, 3, 4, and 5 to break. (Figure 5 details

the mooring arrangement. Figure 6 shows two views of the complex.)

Almost immediately, the Admiral began moving offshore and slowly rotated with

the current clockwise downriver, away from the Missouri shoreline. The three gangways

(which remained attached to the entry barge) were damaged, and the Admiral’s electrical,

natural gas, telephone, and water service lines parted about 1954.13

The Casino Queen master on watch radioed the Anne Holly captain and told him

that the Admiral was drifting. After receiving the radio call, the captain of the Anne Holly

disengaged his vessel from the six remaining barges in the tow. He then moved his vessel

downriver to the Admiral and, about 1959, placed the Anne Holly’s bow against the

Admiral’s bow to keep it near the bank. According to the chief engineer on the Admiral,

wire rope number 6 broke about the time the Anne Holly began pushing against the

Admiral. 

After being notified of the emergency by President Casinos14 personnel, about

1957, a St. Louis Fire Department (SLFD) team arrived at the scene at 2005. The SLFD

deputy chief assumed responsibility as the incident commander and found that the

Admiral appeared to be “stable.” He ordered Admiral engineering personnel to inspect the

hull; they subsequently told him that the Admiral was not taking on water. 

Once the Admiral was stabilized against the bank, patrons from the Admiral were

evacuated to the Anne Holly. At first, the evacuation took place over a foot-wide plank

between the two vessels. Later, the people evacuated to the towboat using a ramp provided

by the SLFD. From the Anne Holly, the patrons transferred to two excursion vessels, the

Becky Thatcher and the Tom Sawyer, and subsequently to shore. The evacuation process

took about 3 1/2 hours. 

Upon hearing the radio transmissions from the Anne Holly, at least seven towboats

from various fleeting areas south of the MacArthur Bridge responded to the scene to

capture the loose barges drifting down the river. By 2050, all 14 barges had been retrieved

and secured to fleeting areas. 

13 Times for events occurring after the Admiral was struck were derived by investigators using President

Casinos, Inc.’s onboard security videos and electric company records. Electrical power was partially

restored within 5 seconds, when the Admiral’s emergency generators activated.

14 The Admiral is owned by President Riverboat Casino-Missouri, Inc., which is a subsidiary of President

Casinos, Inc. For the purposes of this report, we will generally use the term “President Casinos” to refer to

the ownership of the Admiral, unless a distinction between the two firms seems necessary.
Factual Information 7 Marine Accident Report

Figure 5. Schematic of the Admiral mooring arrangement
Factual Information 8 Marine Accident Report

Figure 6. Two views of the Admiral complex
Factual Information 9 Marine Accident Report

Emergency Response

President Casinos

About 1951 on April 4, 1998, a night security officer assigned to President Casino,

Inc.’s, main office on North 1st Street (a few blocks upriver of the Admiral) heard a

towboat blowing its whistle. He went to a nearby office with a view of the harbor, from

which he observed sparks caused by the Anne Holly’s barges striking against the concrete

pier of the Eads Bridge. He immediately telephoned the Admiral’s security office. 

The Admiral’s senior shift manager received the warning telephone call from

shore. He left the security office on the entry barge and went down one deck to the north

(employee) gangway. Looking northward, he saw three barges about 50 yards upstream

heading downriver and directly toward the Admiral. Realizing that impact was imminent,

he sent a warning message by walkie-talkie to all Admiral security personnel, who were

equipped with walkie-talkies, that loose barges were heading toward the Admiral and to

prepare for impact. The senior shift manager stated that, after giving the warning, he ran

down the north gangway onto some nearby scaffolding (which had been used during the

high water as a temporary means of access to the entry barge gangway) and began

ushering people toward shore.15

As soon as they were aware of the approach of the breakaway barges, center

gangway security personnel16 began ushering patrons back down the gangway and up the

temporary scaffolding along L.K. Sullivan Boulevard. Testimony indicated that at least

two elderly individuals among the patrons near the center gangway were using walkers

and required security officer assistance to get them off the gangway. 

At some time during this activity, the barges struck the Admiral. About 1957, the

President Casinos shoreside office took action to notify the SLFD and the St. Louis City

Police Department of the accident.

As he ushered patrons up the scaffolding, the senior shift manager used his walkietalkie to tell the Admiral’s security dispatch office (on the north gangway) to call 911. The

dispatcher told the senior shift manager that the vessel’s telephone lines were dead. 

Following the barge strikes, vessel engineering personnel closed all watertight

doors below deck, inspected all compartments below deck for leaks, and ensured that the

emergency generators were operating properly. When the Anne Holly arrived and pushed

against the Admiral to hold it in place near the riverbank about 1959, security personnel

began moving patrons from the “B,” “C,” and “D” decks down to the “A” deck and

toward the starboard forward doors. 

15 Admiral security personnel estimated that about 100 people had been on the center gangway and

nearby scaffolding before the initial impact.

16 Five security personnel were assigned to the center gangway. Their primary responsibilities were to

check patron ages, prevent unruly people from boarding, and control the crowd.
Factual Information 10 Marine Accident Report

When the Admiral began to break away from shore, the senior shift manager was

on shore. He returned to the Admiral about 2145, transferring from the Becky Thatcher.

Admiral security personnel told investigators that they carried out at least five

deck-by-deck security sweeps of the Admiral in the hours following the accident, looking

for stray, lost, or injured patrons. 

Police

City. St. Louis police personnel arrived on the scene about 2000 and saw the Anne

Holly holding the Admiral in place. About 30 additional St. Louis police officers were

dispatched to the scene.

State. When he saw the accident sequence begin, a Missouri State police gaming

officer assigned to the Admiral,

17 who was ashore at the time of the accident, ran to a

parking garage about 1/4 mile away and asked the attendant to call 911. (The attendant

was unable to complete the call.) The gaming officer then ran to the State Gaming

Commission’s patrol car, which was parked on the upper level of the garage, to use his

department’s cellular phone. He was unable to do so because he did not have the cellular

phone password. He then drove another patrol car out of the garage (for better radio

reception) and, at 2002, used the car’s radio to notify the Missouri State police dispatcher

of the accident and of possible people in the water. The Missouri State police dispatcher

notified the State Water Patrol, the Coast Guard, the SLFD, the St. Louis City Police

Department, and local State police units. Shortly thereafter, the Missouri State police

dispatched a police helicopter and six crowd management personnel to the scene. 

Fire Department

An SLFD deputy chief and SLFD personnel and equipment (a marine task force,

five quint firefighting apparatuses,18 one heavy rescue squad, and two battalion chiefs)

arrived on the scene at 2005 and established an incident command post and a medical

triage area. Rescue squads and 12 ambulances arrived shortly thereafter. More than

48 units (including 15 ambulances) and 65 people (including 35 medics and technicians

and 1 medical physician) ultimately responded to the emergency. 

The fire department also provided a 32-foot-long fire and rescue boat. This boat

was later used to transport SLFD personnel to the Admiral and to move patrons with

medical complaints and injuries ashore. According to SLFD logs, responders examined

50 people who had medical complaints and transported 16 to area hospitals for further

treatment of disorders including chest pains, dizziness, lumbar strain, and abdominal pain.

Most were released shortly thereafter. (One person remained in the hospital because of a

pre-existing heart condition.) 

17 A State gaming officer is a Missouri State trooper on board the vessel to ensure that the State receives

its proper tax revenues. The trooper can arrest patrons if they become unruly or a public nuisance.

18 A fire truck with multiple-feature firefighting capabilities. 
Factual Information 11 Marine Accident Report

SLFD personnel were told that people were trapped in elevators on the Admiral.

They checked this report and found that no one was in the Admiral elevators. The SLFD

also responded to two incidents involving people trapped in elevators at a nearby National

Park Service parking garage.19 Regarding the first incident, one person had been released

from an elevator before the SLFD arrived at the garage. At the second incident, the SLFD

removed one person who had been trapped in an elevator. 

The safety coordinator for the National Park Service Gateway Arch facility

reported that the elevator power failure at the parking lot was related to the Admiral

accident. He said that when the Admiral broke its moorings, electrical power was lost to

the Arch parking garage and caused the Arch garage elevators to shut down and the doors

to remain closed. The elevators had no emergency power backup. (The safety coordinator

told Safety Board investigators that a fail-safe system has since been installed and that if

power is lost now, battery power will activate, the elevator cars will go to the lowest

garage level, and the doors will open. The system was tested and found satisfactory on

February 15, 2000.)

Coast Guard

At 2000, Group UMR notified the duty officer at the Coast Guard Marine Safety

Office (MSO) St. Louis that the Anne Holly had lost power and collided with the Eads

Bridge. At 2004, Group UMR issued an urgent marine information broadcast about the

drifting barges.20

At 2014, the Coast Guard (at the request of the SLFD) closed the river between

miles 178 and 180 UMR to all vessel traffic. The Eads, Poplar Street, and MacArthur

Bridges were also closed until all barges could be recovered and the bridges inspected for

damage. At 2030, a team of MSO St. Louis personnel, consisting of the Captain of the

Port (COTP),21 the executive officer, a public affairs officer, an inspector, and an

investigating officer, arrived at the scene to assist fire and police services. The COTP

joined the SLFD deputy chief at the incident command post. State bridge inspectors

reopened the Eads, Poplar Street, and MacArthur Bridges at 2216. 

At 2228, the Coast Guard buoy tender Cheyenne received reports that a person

may have fallen into the water. The Coast Guard began a search using the Cheyenne, three

Missouri water patrol boats, and a St. Louis police helicopter. They searched 8 miles

downstream for anyone in the water. The Coast Guard issued an urgent marine

information broadcast requesting all vessels in the vicinity of the Admiral to report any

19 The garage provides parking for the St. Louis Gateway Arch. 

20 The broadcast was “PAN PAN, PAN PAN, PAN PAN. This is the United States Coast Guard Upper

Mississippi River, Keokuk, Iowa. The Coast Guard has received a report of 14 barges adrift in vicinity of

mile 180 Upper Mississippi River. All vessels in vicinity are requested to transit with caution and assist if

possible. Signed, Commander Coast Guard Group, Upper Mississippi River.” 

21 In St. Louis, the person in charge of the MSO has three titles; commanding officer (for carrying out

military duties), officer-in-charge (for regulating the commercial marine industry by conducting inspections

and investigations), and COTP (for conducting pollution control and port safety duties). In this report,

we will refer to the highest official in the St. Louis MSO as the COTP. 
Factual Information 12 Marine Accident Report

sightings of people in the water and to assist, if possible. At 2310, the search ended, and

no one had been found. A vessel in the area, the M/V Janie Charlie, continued to watch

for anyone in the water. No reports of a missing person were received in the aftermath of

the accident, and authorities received no other evidence indicating that anyone had fallen

into the water.

At 0148 on April 5, the Coast Guard reopened the river to light boat traffic (vessels

with no tows). About 0930 on April 5, the river was reopened to all traffic. (See table 1 for

notification sequence of initial emergency responders.)

Other Responders

Gateway Riverboat Cruises. Two nearby Gateway Riverboat Cruises excursion

vessels, the Becky Thatcher and the Tom Sawyer, both of which had moorings at the

Gateway barge, south of the Admiral, assisted in the emergency response. The master of

the Becky Thatcher, hearing the danger signal from the Anne Holly and seeing the Admiral

swing around, disembarked his vessel’s passengers and got underway to assist. According

to the Becky Thatcher’s logbooks, the vessel got underway at 2040, arrived along the port

side of the Anne Holly at 2045, and began boarding Admiral patrons from the Anne Holly.

The first load of 302 patrons evacuated from the Anne Holly to the Becky Thatcher about

Table 1. Approximate initial notification and response sequence

Times 

(some estimated) Actions

1950 Barges break loose from the Anne Holly. 

Anne Holly captain makes emergency call to Coast Guard Group UMR.

1951 President Casinos, Inc., watchman notifies the Admiral senior shift manager of 

problem at Eads Bridge.

1952 to 1954 Barges strike the Admiral; moorings begin to break; the Admiral begins to swing 

away from shore; power fails and emergency power activates.

1957 to 1958 The SLFD and the St. Louis City Police are notified.

1959 The Anne Holly pushes against the Admiral’s bow.

2000 to 2001 Coast Guard Group UMR notifies MSO St. Louis that the Anne Holly has collided 

with Eads Bridge and lost tows. 

St. Louis City police personnel arrive on scene.

2002 Gaming officer notifies Missouri State police of accident.

2003 Missouri State police dispatcher notifies the State Water Patrol, the Coast Guard, 

the SLFD, the St. Louis City Police, and local State police units. 

2004 Coast Guard Group UMR issues urgent marine information broadcast about 

breakaway barges. 

The Missouri State police dispatch a helicopter and personnel to the scene.

2005 SLFD team arrives on scene. 

2014 Coast Guard closes river between miles 178 and 180 UMR to all vessel traffic.

2030 MSO St. Louis personnel arrive on scene.
Factual Information 13 Marine Accident Report

2100. By 2355, the Becky Thatcher had offloaded 927 people from the Admiral to the

Gateway barge.

Gateway Riverboat Cruises called in a crew for the Tom Sawyer, which had been

moored at the Gateway barge. The vessel came alongside the Anne Holly and began

offloading patrons at 2105. The first load of 288 patrons left the Anne Holly for the Tom

Sawyer at 2130. The Tom Sawyer had offloaded 787 people from the Admiral by 0030 on

April 5, 1998.

Utilities. The electrical power and natural gas lines attached to the Admiral from

shore parted when the vessel rotated after being struck by the barges. Shoreside electric

power to the Admiral was lost when the power supply line shorted as it parted. Emergency

generators on the Admiral restored emergency electrical power on the vessel within

5 seconds. 

When the Admiral lost power, the Arch parking garage and three other buildings in

the area served by the same power line that served the Admiral also lost electric power. At

1954, the electric company received an alarm in its distribution dispatch office indicating

that the power line was open to the waterfront area. The company sent personnel to the

substation22 responsible for the power line and began checking circuits at 2037. The

problem circuit was isolated at 2107. The technicians then had to go to each building to

isolate the affected circuit and activate reserve circuits to carry the electric power.

Between 2145 and 2200 on April 4, power was restored to the parking lot garage and

downtown buildings. The line to the Admiral had to be repaired. Full power was restored

to the Admiral at 1430 on April 30, 1998. 

After the lines parted following the accident, natural gas continued to leak from the

natural gas line at 5 psi. Because natural gas is lighter than air, the natural gas rose and

dispersed into the atmosphere. The wind hastened this process. Soon after arriving on

scene, the SLFD incident commander had water sprayed on the escaping natural gas. No

fire or explosion occurred.

At 2028, the SLFD dispatcher requested assistance from the Laclede Gas

Company, and a seven-person emergency repair team was on the scene by 2105. Laclede

Gas responders located the regulator pit in the flooded sidewalk near the Admiral. The pit

was under temporary scaffolding that had been erected for passengers to use when

boarding the Admiral, so that they would not have to walk through the flood water in the

street leading to the boarding ramp. The Laclede team removed the scaffolding so they

could access the steel coverplate of the pit. Once they had removed the plate, the Laclede

team could not locate the shut-off valves within the pit, which was filled with muddy river

water. When they could not turn off the natural gas from the pit, the Laclede personnel

made two unsuccessful attempts to close off the natural gas hose with clamps supplied by

a fire truck. About 2300, the team put a heavy-duty Laclede clamp on the ruptured hose

and tightened it until the natural gas flow stopped. 

22 The substation, which supplied the electrical power to the Admiral, reduced the incoming voltage from

138 to 13.8 kilovolts.
Factual Information 14 Marine Accident Report

Federal regulations (49 Code of Federal Regulations [CFR] 192.365 [b] and [c])

make the following requirements regarding the location of valves for service lines:

(b) Outside valves. Each service line must have a shut-off valve in a readily

accessible location that, if feasible, is outside of the building. 

(c) Underground valves. Each underground service-line valve must be located in a

covered durable curb box or standpipe that allows ready operation of the valve

and is supported independently of the service lines.

Injuries

* Table is based on the injury criteria of the International Civil Aviation Organization (49 CFR 830.2), which the Safety Board

uses in accident reports for all transportation modes. The table contains injuries sustained by those persons involved in this 

accident who were treated at local hospitals within 24 hours of the accident.

** President Casinos estimated through ticket counts that the Admiral had about 2,100 people, including 250 staff 

members, on board at this time. 

Damage

Anne Holly and barges $485,000

Admiral $10 to 11 million

Total Approximately $11 million

The Anne Holly and 9 of its 14 barges were undamaged. See appendix B for the

details about the towing company’s damage estimate for the remaining five barges and the

cargo.

The Admiral’s bow received damage above the waterline. Also, two of the four

universal-type joint connection devices (upriver and downriver ends) that connected the

vessel and its entrance barge were damaged. The Admiral’s entrance barge was damaged

when it was dragged from its shoreside position. All three gangways had to be replaced.

Electrical, natural gas, and water lines that parted during the accident had to be replaced or

repaired. The Admiral and its entry barge were repaired and back in full operation on

April 30, 1998. 

Table 2. Injuries sustained in the Admiral accident*

Injuries Anne Holly Admiral Total

Fatal 0 00

Serious 0 11

Minor 0 15 15

None 10 2,084 2,094

Total 10 2,100** 2,110
Factual Information 15 Marine Accident Report

Except for some scraping on the Missouri-side pier of its center navigation span,

the Eads Bridge did not sustain any damage.

Crew and Staff Information

Anne Holly

Crew. The Anne Holly had a crew of 10, including the captain, the pilot, two

engineers, a mate, four deckhands, and a cook. Both the captain and pilot held valid Coast

Guard licenses as operators of uninspected towing vessels. No other people on board were

required to have Coast Guard licenses.

Chief engineer. The chief engineer of the Anne Holly said that he had 23 years of

experience on the river as a towboat engineer, had been employed with the company as

chief engineer for 7 1/2 years, and had served as the chief engineer of the Anne Holly for

about 4 1/2 years. 

Captain. The captain, 54, said that he had begun working on vessels as a deckhand

when he was 15. He had obtained his first license as an operator of uninspected towing

vessels upon the Great Lakes and inland waters in 1973. Since 1985, most of his

experience had been operating towing vessels on the UMR through St. Louis Harbor. He

said that he had made numerous trips through St. Louis Harbor at various river stages. He

told investigators that he had had one other accident in 1986 or 1987, when he was

pushing a tow downstream near Huntington Point, Mississippi; his towboat’s starboard

engine failed, and the tow struck a dock. 

The Coast Guard told the Safety Board that it had no record of any actions taken

against the captain before the April 4, 1998, accident at the Eads Bridge. Following the

accident, the captain was charged with negligence; he entered a “no contest” plea. All the

valid licenses and documents issued to the captain by the Coast Guard were suspended for

2 months, remitted on 6 months probation, effective July 27, 1998.

Winterville Marine, of Greenville, Mississippi, a personnel agency that provides

crews to operate towboats, employed the captain. He worked sporadically for Winterville

Marine during the 1980s. The captain had worked the Anne Holly for Winterville Marine

since March 1993. Winterville Marine paid his health care benefits and salary. AM paid

Winterville Marine a monthly fee for towboat personnel services. Although the captain

was paid by Winterville Marine, AM was responsible for all operational matters on

the tow.

The captain’s physical exam for renewal of his operator of uninspected towing

vessels license took place in November 1993. His hearing, vision, and color acuity were

normal, and his visual acuity was uncorrected 20/20. His blood pressure was 150/90. The

physician certified the captain physically competent to perform duties aboard a U.S.

merchant vessel. 
Factual Information 16 Marine Accident Report

The captain had a physical examination, including referral for an exercise stress

test, administered by his private physician in February 1998. No problems were noted. In

August 1998, the captain underwent a physical exam for renewal of his operator’s license,

conducted by his private physician. The physician certified the captain physically

competent to perform duties aboard a U.S. merchant vessel.

The captain had been prescribed three medications at the time of the accident:

nifedipine for high blood pressure; glyburide for noninsulin-dependent diabetes; and

sertraline, an antidepressant (beginning in December 1997). The captain told Safety Board

investigators that he had been taking the nifedipine and glyburide for years (the Board was

able to document use since December 1996) and was not suffering from any side effects.

The captain’s blood pressure in February 1998 was 150/90, and his estimated average

blood glucose in August 1998 (after the accident) was 227. The captain did not mention

use of sertraline, which was discovered by Safety Board investigators upon review of

subpoenaed personal medical records. 

During postaccident interviews, the captain told Safety Board investigators that he

was not a drinker. He told Coast Guard investigators under oath that he did not drink

alcohol. 

As of April 4, 1998, the captain and the pilot had worked about 26 days of a

30-days-on, 30-days-off rotation that began on March 9, 1998. The captain and pilot

shared navigation responsibilities for the Anne Holly on a 6-hour alternating watch

schedule, which is commonly used in the UMR towboat industry. The captain’s watch

times, by agreement with the pilot, were about 0500 to 1100 and 1700 to 2300.

The captain said he generally slept 4 to 5 hours per off-duty period, when not in the

pilothouse, and he felt that this sleep schedule was adequate for him. He chose to use some

of his off-watch time to eat, see to his personal hygiene, and relax. 

The captain testified that on April 4 he was relieved at 1115 from his morning

watch (which began that day at 0500). He then went below, ate lunch, and went to bed. He

said that he slept 3 1/2 to 3 3/4 hours, got up, and took a shower. After showering, he went

down to the galley, visited, drank coffee, and ate supper. The captain said that he relieved

the watch in the pilothouse about 1705.

When Safety Board investigators asked him what he thought would make

transiting St. Louis Harbor safer under high-water conditions, the captain replied, “I’d like

for them to put a restriction on these bridges northbound as well as southbound....

It would be a lot safer if everybody could run in the daylight.” He also stated:

Daytime you can see up above. You can tell about how your set is. At nighttime,

you can’t tell that. You go by feel, you go by experience, you know. You know

what this stage of river was last year, 30 foot on the gage, you know. You held up

this much from the bridge.

But daytime, you can see all this as well as your experience, and that’s the same

reason they have it, you know, southbound at night for 25 foot.
Factual Information 17 Marine Accident Report

The captain testified:

The biggest difference in daytime you can see your current, you can see your

setting. At nighttime the only thing you have to rely on is your radar and your

searchlight. Which the radar doesn’t pick up current. It doesn’t pick it up, and

your searchlight you can’t see it... . But on the Eads Bridge in particular you have

no way of, you know, other than common knowledge, of what the current is going

to do.

President Casino on the Admiral

At the time of the accident, the Admiral had a staff of about 250 people on board,

serving in the security, casino or gaming, food service, and maintenance departments.

About 15 people were on the security staff. None of the Admiral staff members were

required to have Coast Guard marine licenses. The Admiral normally employed about

900 people (three daily 8-hour shifts of about 250 to 300 people per shift). The Admiral

was open to patrons 22 hours a day.

The facility had a 10- to 20-percent turnover in personnel each month. Company

management told the Safety Board that more than 250 of the Admiral’s staff members

were original employees who had been with the casino since it began gaming operations

in 1994. 

Vessel Information 

Anne Holly Tow and Barges

The Anne Holly, O.N. 553021, was an uninspected, diesel-driven, push-type river

towboat built on January 1, 1973, at the Mississippi Marine Corporation, Greenville,

Mississippi. For the next 20 years, the vessel had various owners and was used as a towing

vessel on the Mississippi River. On October 6, 1989, AM’s parent company (the American

Milling Company) purchased the vessel from River Carriers, Inc. 

The Anne Holly was equipped with two 645 EMD–E7 propulsion diesel engines at

2,800 horsepower (hp) each, driving two propellers through reduction gear drives. The

Anne Holly was equipped with navigation and communication devices, including radar,

radiotelephone equipment, and searchlights. The vessel had pilothouse control of engines

and rudders, and was equipped with twin propellers, twin rudders, and flanking or backing

rudders.23

The Anne Holly’s operator directed the towboat by manipulating two parallel,

horizontally arranged, 3-foot-long metal rudder control handles that were in the control

console in the forward center of the pilothouse. The operator stood between the two

handles and shifted them from side to side as needed to control the rudders. The radar

23 A set of rudders forward of the propellers, designed to assist in controlling the towboat’s movement at

very low speeds, particularly when backing down.
Factual Information 18 Marine Accident Report

console was to the operator’s right as he stood his watch at the control console.

(See figure 7 for the Anne Holly pilothouse interior.) 

The Anne Holly’s principal characteristics were:

Length 154 feet

Beam 40 feet

Depth 9.3 feet

Draft 8.8 feet

Gross tonnage 1,099

Hp 5,600

Air draft24 46 feet (approximate)

The 14 barges in the Anne Holly’s tow were of double-hull construction. Their

cargo areas were surrounded on both sides, on the bottom, and at each end by void spaces

to protect the cargo and limit flooding in case of outer hull damage. Because these were

dry cargo barges and operated solely on U.S. inland waters, they were not required to be

inspected by the Coast Guard. (Appendix C shows the characteristics of each barge.)

Figure 7. Anne Holly pilothouse interior

24 Distance from the vessel’s waterline to the highest point on the vessel. 
Factual Information 19 Marine Accident Report

President Casino on the Admiral

History. The Admiral was built in 1907 as a side-paddlewheeled steam-driven

railroad transfer and passenger ferry. At that time, it was called the Albatross. In 1926, the

vessel was lengthened by 50 feet. About 1939, it was bought by Streckfus Steamers, Inc.,

which converted it into an excursion passenger vessel in St. Louis Harbor and renamed it

the Admiral. About 1973, the steam-powered paddlewheels were replaced by three diesel

engines with outboard propellers, one in place of each paddlewheel and one on the stern.

The Admiral continued to operate as an excursion passenger vessel in St. Louis Harbor

until 1978, when it was taken out of excursion passenger service and sold. 

Between 1978 and 1983, the vessel was moved from St. Louis and its engines were

removed. The Admiral’s entry barge, however, remained permanently moored at mile

179.9 UMR throughout this period.25 In 1983, the Admiral returned to mile 179.9 UMR in

St. Louis Harbor and became a permanently moored vessel (PMV) with its barge at that

location. 

The Coast Guard classifies the Admiral as a permanently moored shoreside structure

or floating building, not an inspected passenger vessel. As a building, it must meet the

regulatory requirements of the local authority, in this case, the city of St. Louis. The Coast

Guard no longer inspects the Admiral, issues it certificates of inspection, or requires drills of

any kind to be conducted on it. 

A city of St. Louis occupancy permit allowed the Admiral to carry 5,625 people.

Structure. At the time of the accident, the Admiral was secured26 to a boarding or

entry barge that was also a permanently moored facility. The entry barge had three

gangways that led to shore. The north and south gangways, each of which was 12 feet

wide and 125 feet long, were used to embark and disembark casino employees and to load

supplies. The center gangway, 20 feet wide and 135 feet long, was covered by an awning

9 feet, 6 inches, high. The center gangway was designed for two-way patron traffic on and

off the vessel via the entry barge. Due to changing river levels, the center gangway

sometimes became so steep that wheelchairs were kept at hand to assist elderly and

disabled patrons on and off the vessel.27 (See figure 8 for a photograph of the center

gangway of the Admiral.)

At the time of the accident, the vessel and the entry barge were secured by

10 mooring wires (or combinations of wires and chains). The 10 lines comprised the bow

and stern anchor wires (attached to the entry barge) and 8 lines secured to the shore. The

25 This was not the entry barge in place at the time of the April 4, 1998, accident. The barge had been

replaced in the mid-1980s. 

26 The Admiral was secured to the entry barge by four universal couplings in addition to wires that held

the vessels together. Each coupling was welded to the hulls of both vessels and allowed for limited

movement to accommodate differences in vessel drafts as patrons moved from the entry barge to the

Admiral and vice versa, as well as other small differences in vessel movements.

27 According to Admiral management, many of the vessel’s patrons are elderly, rely on walkers, have

breathing problems, have had recent surgery, or have some other physical condition hampering their ability

to move up and down the gangway. 
Factual Information 20 Marine Accident Report

mooring wires for the Admiral and the entry barge were routinely adjusted as the facility

was moved toward (during high water) and away from (during low water) shore. President

Casinos informed the Safety Board through a January 25, 1999, letter that:

The authorized mooring arrangement, including location and size of mooring

wires, was designed by P.H. Weis and Associates, Professional Engineers. The

moorings are designed using conventional design and analysis methods with loads

determined using recognized codes, such as the Uniform Building Code and the

American Association of State Highway and Transportation Officials. The

mooring lines are sized for various combinations for all forces acting on the

Admiral and Support Barges, such as wind and stream flow.

(See appendix D for additional information about the mooring wires.)

The Ameren-Union Electric Company and the Laclede Gas Company supplied

electricity and natural gas, respectively, to the vessel through individual lines that came

from shore along the gangways. The natural gas was transported from the 12-inch main

line beneath L.K. Sullivan Boulevard to the Admiral via a 4-inch line leading to a concrete

regulator pit on the boulevard’s eastern sidewalk. The opening to the pit, covered by steel

plates, was at sidewalk level. A 2-inch service line that extended from the regulator pit to

the Admiral was installed in April 1986. The service line, which ran from the regulator pit

and emerged into a shallow concrete trough (about 12 inches wide and 6 inches deep) led

to a quick-disconnect fitting. The quick-disconnect fitting was 35 to 50 feet from the

Figure 8. Center (passenger) gangway to the Admiral
Factual Information 21 Marine Accident Report

street. A steel grating also protected that portion of the concrete trough housing the service

line in the street before the line emerged and was attached to the Admiral’s gangway.

The Admiral’s principal characteristics were:

Length 380.0 feet

Beam 89.5 feet

Depth 7.6 feet 

Draft 6.0 feet (estimated)

Gross tonnage 1,599

Hp N/A

Air draft 62.5 feet (estimated)

The entry barge’s principal characteristics were:

Length 265.0 feet

Beam 60.5 feet

Depth 6.6 feet (estimated)

Draft 5.0 feet (estimated)

Gross tonnage N/A

Hp N/A

Waterway Information

Conditions, Traffic, and Accident History

Conditions. According to the U.S. Army Corps of Engineers (USACE), St. Louis

District, the river stage at mile 179.6 UMR on the Missouri side of the river was 31.6 feet

on the St. Louis gage at 2000 on April 4, 1998. Flood stage is 30.0 feet in St. Louis.

USACE does not designate an official “high-water” level for St. Louis Harbor, but the

region’s operators generally consider high water to be about 20 feet or more on the

St. Louis gage. From 1987 through 1997, St. Louis averaged 22.8 days per year

(6.2 percent) with the river stage at 30 feet or more and 69 days (18.9 percent) at 20 feet or

more. USACE estimated the current at the time of the Anne Holly’s allision28 with the

Eads Bridge to be about 6 mph. 

USACE obtained river stage information from an automatic stage gage on the

Eads Bridge (which records river stage every hour) and a flow gage on Poplar Street

Bridge. The chief of the potamology29 section of the St. Louis District USACE indicated

28 An allision is the striking of an object that is stationary (such as a bridge or moored vessel) by a

moving vessel.

29 Potamology is the study of rivers. 
Factual Information 22 Marine Accident Report

that from 0100 through 2400 on April 4, 1998, the river was rising and the river stage

increased from 30.7 to 31.6 feet, while the flow increased from 515,000 to 538,000 cubic

feet per second. Between 1900 and 2000, the river stage rose from 31.4 to 31.6 feet.

During this same period, the flow increased from 533,000 to 536,000 cubic feet per

second. During his testimony, the USACE chief of potamology stated that the river’s rise

in St. Louis Harbor on April 4, 1998, could be characterized as “gradual.” 

When he was asked if there had been “any unusual precipitation or additions to the

base flow rate upstream of the St. Louis Harbor that could have resulted in an unexpected

‘wall of water’ between the Martin Luther King, Jr., and the Eads Bridges,” the USACE

representative’s reply was negative. He said that if there had been a “wall of water”

coming down the river, it would have appeared in the data, and the data did not reveal such

a phenomenon.

According to records kept by USACE, from 1970 to mid-1997, minimum water

temperatures in St. Louis Harbor occurred from December to February and ranged from

32° to 36° F. The average annual water temperature was about 56° F. On April 4, 1998, the

water temperature was about 53° F.

Traffic. According to an estimate made by the lock keeper at lock 27, mile 185.5

UMR, which is the first lock northbound above St. Louis, about 8,000 tows pass through

the harbor each year, transporting 80,000 to 85,000 barges. The USACE records from lock

27 show that from April 6 to April 30, 1998, 27 tows of a size or tonnage similar to that of

the Anne Holly successfully made upbound trips in darkness through St. Louis Harbor. Of

the 27 upbound tow transits:

• 9 were made at river stages between 32.0 and 30.8 feet;

• 5 were made at river stages between 29.9 and 28.5 feet; and 

• 13 were made at river stages between 27.8 and 25.5 feet.

On the morning of April 4, 1998, one tow of comparable size to the Anne Holly

transited upbound through the harbor. (The tow had 16 barges, 16,500 short tons30 of

cargo, and 4,300 hp.) No problems were reported with the transit. No other upbound

transits of similar tows were recorded that day by USACE. After the Anne Holly accident,

no other upbound tows transited the harbor in darkness on the night of April 4 through

5, 1998. The river was closed to traffic from about 2014 on April 4 until 0930 on

April 5, 1998.

According to USACE “Waterborne Commerce of the United States” statistics for

1998, the metropolitan St. Louis area (mile 138 to 208 UMR) had a 21.9 percent increase

in total tonnage from 1989 through 1998. In 1998, the total tonnage was 31.758 million

short tons, of which about 5.710 million short tons (18 percent) were petroleum or

hazardous materials.

30 A short ton is 2,000 pounds.
Factual Information 23 Marine Accident Report

Accident History. According to Coast Guard data, from January 1, 1989, through

June 30, 1999, a total of 18 accidents (1.6 per year) classified as casualties31 took place in

St. Louis Harbor. Twelve accidents occurred when the river was in high-water stage

(20 feet or higher on the St. Louis gage). Of the 18 accidents, 12 were allisions and

occurred in high water, 2 were collisions, 2 were of unknown cause, and 2 were

groundings in low water when the gage read 2 feet.

During this 11-year period, 29 breakaway accidents occurred (2.6 per year). Of the

29 breakaways, 4 took place above the location of the Admiral. Three of these four

breakaways occurred at river stages between 10.2 and 13 feet on the gage. The fourth took

place when a moored tow was dragged in ice at a river stage of -5 feet.32

The 25 breakaways occurring below the location of the Admiral affected fleeting

areas but no publicly accessed PMVs. Of the 25 breakaways, 10 occurred in high-water

river stages. Of the 10 high-water breakaways, 1 was considered a case of sabotage, and

1 was caused by vandalism. In 1993, four breakaways took place, three of which occurred

during river stages of 35, 43, and 49 feet on the gage (respectively, 5, 8, and 19 feet above

flood level in St. Louis Harbor). The breakaway that occurred at 49 feet on the gage

occurred at mile 179.8, or 0.1 mile below the Admiral.

Bridges

Four fixed-span bridges are within the recreational and tourist area of the St. Louis

waterfront. They are:

Douglas MacArthur Highway and Railroad Bridge mile 179.0 UMR

Poplar Street Highway Bridge mile 179.2 UMR

Eads Highway and Railroad Bridge mile 180.0 UMR

Martin Luther King, Jr., Memorial (MLK) Highway Bridge mile 180.2 UMR

The Poplar Street Bridge is on the interstate highway system and is a principal

vehicular roadway between St. Louis, Missouri, and East St. Louis, Illinois. 

On its lower level, the Eads Bridge supports a tramway that operates between St.

Louis, Missouri, and East St. Louis, Illinois. The upper-level highway portion of the

bridge is in disrepair and is not used for vehicular traffic. The Eads Bridge bears fixed

markers that indicate to mariners the center of the arched span (a green square dayboard

for daylight and a green light for darkness) and the two low points on either side of the

span (red triangular dayboards) to be cleared.

Between the Poplar Street and Eads Bridges on the Missouri side of the river are,

in addition to the Admiral, the Gateway Riverboat Cruises permanent floating barge, the

31 The Coast Guard considers a marine casualty to be an accident that results in damage in excess of

$25,000. (46 CFR 4.05-1)

32 According to the USACE in St. Louis, zero gage means that the river channel has about 12.5 feet of

water in it. At -5 feet on the gage, St. Louis Harbor would have a water depth of about 7.5 feet.
Factual Information 24 Marine Accident Report

permanently moored Robert E. Lee restaurant (not operating), and a permanently moored

McDonald’s restaurant (permitted to hold 400 people). On the Illinois side between the

two bridges are a permanent floating mooring for the Casino Queen (a casino vessel that

gets underway periodically and is certified to carry 3,000 people) and, south of this vessel,

fixed mooring cells for grain and coal facilities. 

Below the Poplar Street Bridge, on both sides of the river, are barge terminals,

fleeting areas, and other industrial facilities. (See figure 9.)

Except for the MLK Bridge, the main navigation spans for all four bridges are

centered at mid-river.33 Information on the widths and vertical clearances of the various

bridges appears in table 3.

All the bridges except the Eads Bridge provided a vertical clearance under all

spans of at least 61.1 feet at the time of the accident. The Eads Bridge’s symmetrical main

navigation arch provided 57 feet of vertical clearance at the center; this clearance tapered

Figure 9. Schematic view of the accident area

33 The left descending pier of the MLK Bridge center span is almost in line with the left descending pier

of the Eads Bridge’s center span. The right descending pier of the MLK Bridge center span is near the

Missouri shore, almost in line with the right descending pier of the Eads Bridge’s Missouri span. 
Factual Information 25 Marine Accident Report

down proportionately on each side of the arch. The bridge’s red day markers were each

150 feet from the center of the bridge, leaving a horizontal space of 300 feet between

them. At the time of the accident, 42.2 feet was between each marker and the river surface.

Given its air draft, the Anne Holly required a minimum of 46 feet of vertical clearance.

The flood conditions reduced the vertical clearance under the side portions of the Eads

Bridge main arch so that a center navigation area of about 270 feet had 46 feet or more of

vertical clearance. (See figure 10.)

Upbound Transit of the Eads Bridge

For an operator conducting an upbound transit of the Eads Bridge, lighting sources

in the area immediately preceding the bridge included rotating colored lights from the

Table 3. Bridge widths (by span) and vertical clearances, in feet

Bridge Missouri Span Center Span Illinois Span Vertical Clearance*

MacArthur 645 647 645 71.9

Poplar Street 480 580 480** 61.1

Eads 498 517 498 57.0

MLK 450*** 940 450 64.8

* At 31.6 feet gage in St. Louis.

** Mooring cells riverside of the Illinois pier reduce this navigable width to about 420 feet. These cells were in place before

the bridge was constructed.

*** Not navigable.

Figure 10. Schematic view of the Anne Holly tow under the Eads Bridge. (This figure is 

not representative of the actual path taken by the Anne Holly. The figure is used for illustrative purposes only, to show the heights of the bridge and the Anne Holly.)
Factual Information 26 Marine Accident Report

Casino Queen (moored on the Illinois shore opposite the Admiral), street lighting, and

traffic headlights from cars on the St. Louis side of the river. The Admiral had a string of

lights around its top deck and lighted letters spelling “Admiral” on the top deck. During

the Safety Board’s public hearing on the Admiral accident, a towboat captain who testified

as an expert in towing operations in St. Louis Harbor stated:

Let’s take St. Louis Harbor here, for instance, at nighttime, when you are coming

southbound through the bridges and the Casino Queen is lit up with all its highintensity lights and different colors, it really distracts—first of all, it impedes your

night vision... .

North of the MLK Bridge, the current flows approximately parallel to the

riverbanks. Between the MLK and Eads Bridges, the current flows toward the Illinois side

at various angles. 

According to one experienced towboat operator, to complete a transit of the Eads

Bridge, the operator of an upbound tow follows the procedure outlined below: 

• The operator may use radar to identify riverbanks and other objects in or near

the waterway, such as bridges, other vessels, piers, etc., in darkness and in

restricted visibility. Use of the radar can help the operator to orient the tow

with respect to fixed objects and, if need be, to compare the radar image to

river charts.

• To begin the transit, the operator approaches the bridge with the tow to the left

(Missouri side) of the river centerline and with the tow’s head aimed at the

Illinois (right side) bridge pier of the center span. During the approach, the tow

is held at a slight angle to the axis of the river, so that the stern of the tow is

angled slightly toward the Missouri side of the river. In this position, the tow

presents its port side to the current. 

• On nearing the Eads Bridge opening, the operator applies left rudder to turn the

tow to the left so that it will head directly into the current and line up for

passage through the center bridge opening. 

• Once the tow is aligned for passage and heading directly into the current, the

operator pushes the tow into the bridge opening. 

• When the tow and towboat are almost through the Eads Bridge center span, the

operator turns the tow slightly to the right for passage through the MLK

Bridge.

St. Louis Harbor Tow Restrictions

The MSO St. Louis tow restrictions for the high-water river stage of 25 feet or

more are based on a power and tonnage formula. The local marine industry, the Coast

Guard, and USACE cooperatively developed the formula, using their experience in this

area. Upbound (against the current) and downbound (with the current) towboats are
Factual Information 27 Marine Accident Report

required to have a minimum of 250 hp per 1,500 tons of cargo. During high water of

25 feet or more, downbound tows longer than 600 feet are restricted to daylight operation.

MSO St. Louis advised the Safety Board in June 2000 that, since late 1998, during

flood stages of 30 feet or more, “All line boat traffic [is] limited to daylight transit only

with the exception of northbound tows with helper boats.” (A line boat is a relatively large

towboat that pushes large tows over long distances, as opposed to a harbor or fleet boat

that moves one or two barges at a time in a local area.)

Operations Information

American Milling, L.P.

AM is a small towboat business that operates nine towboats on the inland

waterways. The company contracts for additional boats and operators as its workload

requires. AM is not a member of the American Waterways Operators (AWO), the inland

towing industry’s primary trade association. (The AWO is a national trade association for

the inland and coastal barge and towing industry. About 375 companies are AWO

members; of these, about 200 are tug/towboat companies. AWO members account for

about 85 percent of the tonnage that moves on U.S. waterways.)

AM policy is that the captain is responsible for crew welfare and all operational

obligations associated with running the towboat. In addition, the captain is responsible for

the tow configuration and the security and fastness of the tow’s barges. At fleet operations,

the captain determines the arrangement of the barges in the tow and whether he can safely

move the tow as configured. The captain is responsible for ensuring that logbooks are

properly maintained and that associated paperwork is completed. (The captain can

perform some or all of these duties while on watch.)

The company provides no safety guidance to its operators concerning high-water

operations, night operations, use of helper boats, required equipment, or halting operations

when safety concerns may warrant such action. AM does not have written procedures on

how to identify or respond to potential emergency shipboard situations, such as an allision

and loss of tow. AM does not have written policies or procedures to ensure that its

towboats and equipment are adequately maintained and appropriate for their assigned

tasks. AM does not designate anyone on shore to assist the captain to make decisions

concerning the safety of navigation.

The company relies on its towboat operators to use their own skill and experience

and maintains that the captain is responsible for all aspects of the towing operation. When

investigators asked the Anne Holly captain whether the company responded unfavorably

to a captain’s decision to make changes to the company-assigned schedule or load for

safety reasons, the Anne Holly captain replied, “Only if you do it all the time... .” 

AM provides no training to its crewmembers, nor does Winterville Marine. 
Factual Information 28 Marine Accident Report

The following is a brief description of the duties of the captain and pilot during a

routine day while working the Anne Holly for AM. The captain and pilot would each stand

two watches a day. The watch times might be varied by the captain (with agreement by the

pilot), but the schedule followed would be 6 hours off watch succeeded by 6 hours on

watch. During the watch, any navigation or maneuvering of the vessel or tow would be the

responsibility of the person on watch (the captain or the pilot). On watch, the pilot would

handle all operational and administrative matters arising, in the same manner that the

captain would. If a problem that the pilot could not or desired not to handle arose, he could

call the captain. 

Generally, the captain would fulfill his administrative duties, such as ordering

food, fuel, or other supplies, while on watch. The captain would typically take care of

personnel administration or engineering matters while on-watch, but, if necessary, he

could deal with them while off-watch. Such off-watch work, however, would not occur on

a routine basis.

The captain, after being relieved by the pilot about 2330, would go to bed and

sleep for about 5 hours before being awakened to have breakfast before going on watch at

about 0530. After being relieved about 6 hours later, the captain would, about 1130, eat

lunch, watch TV, talk, read, do laundry, or carry out other personal tasks. He might also

make a round of the boat or check the tow before going to bed. He generally would get

3 to 4 hours sleep before being called to prepare for the evening watch. He might take a

shower and eat dinner before going on watch about 1730. The pilot would usually follow a

similar routine on his off-watch periods.

President Casinos

The Admiral is owned by President Riverboat Casino-Missouri, Inc., which also

owns and operates the Becky Thatcher and the Tom Sawyer excursion vessels, through

Gateway Riverboat Cruises. President Riverboat Casino-Missouri, Inc., is owned by

President Casinos, Inc., which is a Passenger Vessel Association (PVA)34 member. 

Admiral engineering personnel were responsible for vessel operations, including

managing the mooring and utility lines between the vessel and shore and ensuring the

hull’s integrity. Security personnel were responsible for safety on the vessel. They were

not trained in crowd management techniques. None of the security or engineering

personnel were required to be licensed or to have any other formal certification of

competency.

34 The PVA is a trade organization that focuses on the U.S. domestic passenger vessel industry. PVA

membership represents about 65 percent of the industry owner-operators nationwide, comprising more than

1,100 vessels, which carry approximately 85 million passengers annually. 
Factual Information 29 Marine Accident Report

Meteorological Information

At the time of the accident, the weather was clear, with visibility of at least 2 miles

in darkness. The wind was from the southwest at 5 mph. The air temperature was 42° F. 

Toxicological Information

About 3 1/2 hours after the accident, when the evacuation of the Admiral was

almost complete, the St. Louis Police Department, at the request of the Coast Guard,

administered a breathalyzer alcohol test to the Anne Holly captain. (The Anne Holly

captain was engaged in the emergency response for the Admiral until this time.) Test

results were negative. Immediately following the breathalyzer test, the captain gave a

videotaped sworn interview to the Coast Guard in which he stated that he did not drink

alcohol. Safety Board investigators reviewed the videotape and found no apparent

evidence of impairment, such as slurred speech, in the captain’s behavior.

According to 46 CFR 4.06–1, “Responsibilities of the marine employer,” a marine

employer must establish and maintain procedures to conduct drug and alcohol testing in

the event that one of its crews is involved in an accident. According to 46 CFR 4.06–20,

“Specimen collection requirements,” a marine employer must ensure that specimens

required are collected “as soon as practicable” following the occurrence of a serious

marine incident. AM defers all personnel matters to Winterville Marine. After being

notified of the accident by AM, Winterville Marine arranged for medical technicians from

West Kentucky Drug and Alcohol Screen Specialists of Paducah, Kentucky, to board the

Anne Holly in St. Louis Harbor at 1620 on April 5, 1998, to conduct crew breath tests for

alcohol. They also collected urine for drug testing. The specimens were tested at Lab One

in Overland Park, Kansas. Negative results were reported by Medical Review Services,

Inc., of Belle Chase, Louisiana, serving as the medical review officer for Winterville

Marine.

Emergency Preparedness

President Casinos

The company provided the Safety Board with a copy of its Emergency Evacuation

Procedures for the Admiral, dated February 21, 1997. The procedures specified that

Admiral security personnel are responsible for ensuring that patrons leave the facility in an

emergency. The document essentially stated that staff should conduct the evacuation by

directing patrons and employees to the nearest exit and assembling them at a prearranged

staging area on shore. The procedures did not include specific duties for managing patrons

and employees. Most of the staff members were instructed to assist patrons as they

themselves were exiting the vessel. The procedures did not indicate how assistance was to

be provided. All evacuation procedures presupposed that those on the vessel would
Factual Information 30 Marine Accident Report

proceed to shore via the standard entry barge gangways. The Admiral staff members had

not received crowd management training before the accident, and they were not required

to take such training. 

The Admiral management considered its security force to have primary

responsibility for patron safety during an emergency. President Casinos, Inc., had

developed a St. Louis Emergency Plan, dated January 1994. The stated purpose of the plan

was to:

Minimize the effects of a major emergency or disaster by prompt treatment of

injuries, prevention of additional injuries, reduction in property damage, and

provision for continuity and expeditious resumption of operations.

President Casinos, Inc., designed the plan to activate whenever a situation

occurred that “threatens the well-being of more than a few people at any of the

[company’s] St. Louis-based facilities.” (The plan’s scope included the corporate

headquarters building, the Admiral, the two Gateway Riverboat Cruises vessels, and the

Robert E. Lee floating restaurant.) The emergencies specifically cited in the plan were air

or water pollution incident, civil disorder or riot, earthquake, explosion, fire, flood,

tornado, and utility failure. 

Each company facility had a designated Emergency Response Team (ERT). The

chain of command and responsibilities for the Admiral’s ERT were dependent on the time

the event occurred and the availability of personnel. According to President Casinos, the

assigned duties and responsibilities of the Admiral personnel were as follows:

General manager: Responsible for directing emergency operations on site. Is

also in charge of the ERT and other duties and responsibilities that include:

contacting members of senior management and outside authorities as necessary,

overseeing rescue operations, and directing the return of facilities to normal

operations. 

Director of security: Responsible for alerting Federal, State, and local agencies

for assistance; controlling the flow of foot and vehicle traffic to and from the

Admiral; securing and policing the damaged areas and facilities; and controlling

the evacuation and movement of patrons and employees to a safe area. When the

director of security is not on board, the senior security supervisor assumes these

duties. 

Director of casino operations: Responsible for coordinating casino operations

and activities, including securing all gaming equipment, rendering aid to the

injured, and assisting all other departments in dealing with patrons and employees

on an as-needed basis. 

Director of surveillance: Responsible for monitoring and videotaping all areas of

the casino. 

Director of marine operations: Responsible for all marine operations for the

company’s vessels (Admiral, Robert E. Lee, Becky Thatcher, and Tom Sawyer).
Factual Information 31 Marine Accident Report

MSO St. Louis

According to its 1997 annual report, MSO St. Louis has a complement of about

30 people attached to it. The office has one small harbor patrol boat that can be used to

assist in local search and rescue activities in St. Louis Harbor. The geographic area of

responsibility for this office includes all or parts of 12 States and more than 2,000 miles of

navigable waterways. In covering this area, MSO St. Louis is assisted by its Marine Safety

Detachments in St. Paul, Minnesota, and Quad Cities, Illinois. Together, these two

detachments have about 40 employees.

St. Louis Harbor Emergency Response Plan

MSO St. Louis had a St. Louis Harbor Emergency Response Plan, most recently

issued in October 1996. The plan covered the area between miles 160.7 and 195.0 UMR.

The St. Louis COTP developed the plan with the cooperation of St. Louis Harbor area fire

departments, river industry representatives, and local law enforcement agencies. The plan

stated that it was intended to facilitate:

Effective marine emergency response operations through the establishment of

mutually agreed upon operating guidelines and the compilation of pertinent

reference materials needed during response operations.

The St. Louis Harbor Emergency Response Plan specifically stated “the COTP

does not have firefighting or search and rescue capabilities... .” [Emphasis appears in

original.] 

The plan also stated that the St. Louis COTP would monitor all emergencies and

dispatch a Coast Guard representative to the incident’s command post to coordinate

Federal and local response activities. It made Coast Guard Group UMR, in Keokuk, Iowa,

responsible for notifying the appropriate COTP and local fire department of a marine or

shoreside emergency.

The St. Louis Harbor Emergency Response Plan specified that firefighting and

search and rescue operations fell under the jurisdiction of local and State fire and rescue

services. The plan called for the senior fire department official on scene to become

incident commander for riverfront emergencies within the department’s jurisdiction.

A unified command system, consisting of the fire chief (incident commander), the owner

of the facility involved, and the COTP representative, was to be established at the incident

command post.

The St. Louis Harbor Emergency Response Plan also identified the agencies that

would participate in the response to marine emergencies in St. Louis Harbor and listed the

names and telephone numbers of critical responders. The plan identified the interagency

command and control responsibilities of the various agencies and designated the radio

frequencies to be used during the response. 
Factual Information 32 Marine Accident Report

Survival Aspects

Admiral patrons indicated that they experienced some panic and confusion during

the emergency. Some stated that the initial impact of the barges caused them to fall against

slot machines and to the floor. No patrons entered the water due to the barge strikes.

Several patrons commented on minor injuries they had sustained because of the press of

other patrons attempting to exit. They also recalled concerns about the smell of natural gas

and the fact that patrons were allowed to continue smoking. They indicated that the large

numbers of people attempting to push through the single exit leading to the Anne Holly

caused some discomfort. Several also stated that some patrons were disorderly.

Drills

The Fire Prevention Code of the city of St. Louis required fire drills to be held at

least every 90 days in accordance with evacuation plans. Fire drills were not required to be

documented on the Admiral. According to an SLFD official, fire department personnel

visited the Admiral annually to conduct fire code inspections and to familiarize

firefighters with the Admiral’s layout. 

President Casinos made conducting fire drills aboard the Admiral the

responsibility of the facility’s security staff. Security personnel were also responsible for

securing cash and chips in the casino in an emergency. Fire drills on the Admiral were

conducted similarly to fire drills from a building and included the sounding of on-board

alarms and exiting of occupants. The Admiral had last conducted an on-board fire drill at

0700 on June 9, 1997. The fire drill involved those employees normally on the vessel at

that time. 

According to the Admiral’s chief security supervisor, two power outages had taken

place on the vessel between January 1994 and the day of the allision. The last outage had

occurred in December 1996. To deal with these power problems, the Admiral established a

power outage procedures review program. The purpose of the reviews was to establish

means to stop casino operations and evacuate patrons from the vessel in an expeditious

and organized manner. Vessel personnel conducted reviews (question and answer

sessions) to ensure that employees understood their individual duties in a power outage.

The Admiral’s security manual detailed the procedures and each employee’s duties and

responsibilities. Each Admiral employee had to sign a statement verifying that he or she

had read the security manual. 

Communications

With Emergency Responders. Admiral security personnel had walkie-talkies by

which they could communicate with each other. On the accident night, when the shore

lines’ breaking interrupted the hard-wire telephone service, the Admiral staff did not

establish direct communications with shoreside responders until SLFD personnel came on

board.
Factual Information 33 Marine Accident Report

With Patrons. Before the accident, no Admiral staff member issued any statement

or warning to patrons of the impending allision. After the impact, some Admiral staff

members gave patrons oral instructions. The instructions were not consistent or

coordinated. 

The Admiral had a public address system capable of transmitting messages

throughout the vessel. The company had no formal policies governing the use of the

public address system in an emergency. Three telephones on the vessel could operate the

public address system. One telephone was on either side of the center gangway. The third

telephone was at the Captain’s Club, on the vessel’s “B” deck (port side) near the top of

the escalators. Captain’s Club personnel carried out various administrative tasks (selling

tickets, voiding passes, stamping parking vouchers, and handling food and beverage

charges). They also made announcements concerning lost and found items. 

On the night of the accident, Admiral staff did not initially use the public address

system because they believed it was inoperable. According to the Admiral’s senior shift

manager, he used the public address system to make several announcements to patrons and

staff after he had returned to the vessel via the Becky Thatcher (around 2145). He recalled

that he told patrons that “the vessel was not taking on water... [it] was being held in place

by a tugboat.” He said he also told them that everything was fine and that, because of the

size of the Becky Thatcher and the Tom Sawyer, only 300 patrons could be disembarked at

a time. He said he told them that fire and rescue personnel had arrived and that patrons

with medical problems should go to the gift shop (on the “A” deck) for treatment. 

Patron Questionnaires

Following the accident, the Safety Board sent 251 questionnaires to Admiral

patrons.35 Among other inquiries, the questionnaires asked patrons to characterize the

amount, type, and usefulness of information they received from the Admiral’s staff during

the emergency. The Board received 74 responses. Asked whether they had received

information about the nature of the emergency, 38 respondents stated that they received no

useful information from the Admiral’s staff about the emergency’s nature. Four of the

74 respondents said that they first learned of the nature of the emergency more than an

hour after the accident occurred. Forty-five respondents reported that the oral instructions

they received from the staff about the need to evacuate and the procedures for doing so

were either nonexistent or of little use.

One respondent stated that the vessel staff made no effort to calm the crowd, and

she observed that some staff members rushed to get off the vessel before patrons. Another

stated that the staff “appeared to be just as confused as we were.” One respondent stated

35 President Casinos does not maintain patron lists. To obtain names and addresses of patrons on board

the Admiral on the night of the accident, the Safety Board requested assistance from President Casinos.

President Casinos provided the Safety Board with a list of patrons who had made claims concerning the

accident against President Riverboat Casino-Missouri, Inc. The Safety Board sent its questionnaires to these

patrons. The information from the questionnaires used in this report is not intended to represent a statistical

sample of passengers’ experiences; instead, it served as a preliminary indicator of areas to be pursued in the

investigation. 
Factual Information 34 Marine Accident Report

that, during the emergency, one of the vessel cashiers ran by yelling, “Get off this boat, it’s

sinking.” 

Safety Equipment

Coast Guard regulations at 46 CFR Parts 70 through 78 require inspected

passenger vessels to carry life preservers and survival craft (lifeboats, life rafts, buoyant

apparatus, life floats, etc.). The Coast Guard does not extend lifesaving equipment

requirements to permanently moored public structures like the Admiral, and the Admiral

carries no life preservers or survival craft. 

At the July 23, 1998, Safety Board hearing session on this accident, the former

MSO St. Louis COTP stated that, during his 3 years in St. Louis, people who entered the

river at St. Louis rarely survived, even if they were wearing lifejackets. He stated,

“I would not do anything to encourage people to think that they could jump in the river

with a lifejacket on and have a very good chance of surviving.” 

The Casino Queen, an inspected casino vessel that may carry 2,775 passengers and

225 crewmembers, is moored across from the Admiral along the Illinois bank. The vessel

gets underway periodically for gaming and is required to have a life preserver for every

person on board. The Coast Guard also requires the vessel to carry life floats or buoyant

apparatus or both (for 10 percent of the people carried), ring buoys, and two rescue vessels

(one forward and one aft). 

Inspections and Tests

On April 8, 1998, Safety Board investigators rode the Anne Holly northbound from

the Eagle fleeting area through St. Louis Harbor and past the Eads Bridge; the vessel had a

15-barge tow (5 barges comprising the port string, 5 the center string, 4 the starboard

string, and 1 empty barge on the starboard side by the towboat). During the trip, the river

stage was 30.2 feet on the St. Louis gage. The trip was uneventful, and no problems were

noted.

A Safety Board investigator examined the operation of the Anne Holly’s steering

gear, its propulsion engines, and its other engineroom equipment during the test trip.

He found no problems. According to the company, no repairs had been made to the

steering gear or propulsion engines since the accident. 

Other Information

Permanently Moored Vessels and Structures

General. PMVs are used for a wide variety of purposes, including serving as

casinos, museums (or other tourist attractions), entertainment facilities, restaurants, or
Factual Information 35 Marine Accident Report

mooring barges. Because they frequently involve significant public use, PMVs often have

relatively high patron occupancy levels. According to the Coast Guard, 162 PMVs were

on U.S. waterways as of November 20, 1998. (See appendix E.) The Coast Guard

estimated that about 30 of them were permanently moored gaming vessels in Mississippi

and Missouri. In all, these 30 vessels had a carrying capacity of more than 50,000 people.

St. Louis Harbor contained five PMVs, the Admiral vessel, the Admiral support barge, the

McDonald’s restaurant barge, the Robert E. Lee restaurant barge (not operating), and the

Gateway Riverboat Cruises support barge. 

Coast Guard Authority. The Coast Guard’s authority to regulate the design,

construction, equipment, staffing, and inspection of vessels derives from its enabling

statute, 46 United States Code (U.S.C.), Subtitle II. With respect to the definition of the

term vessel, Section 2101[45] of Subtitle II refers to 1 U.S.C., Chapter 1, Section 3, which

states that vessel “includes every description of watercraft or other artificial contrivance

used, or capable of being used, as a means of transportation on water.” Section 3301(4) of

46 U.S.C., Subtitle II, states that passenger vessels are among the categories of craft that

are subject to Coast Guard inspection. 

The U.S. Coast Guard Marine Safety Manual (MSM),36 Volume 2, Chapter 10,

Section I, states that:

a. Introduction. A floating fuel dock, showboat, theater, hotel, restaurant,

museum, etc., is not a ‘vessel’ for inspection purposes if it is permanently moored

and thus taken out of navigation. In this manner, the entity is ‘substantially a land

structure’ and not subject to the [Coast Guard] inspection laws. However, it may

be subject to other regulations, such as those promulgated under the Ports and

Waterways Safety Act of 1972. The following criteria should be used in

determining whether an entity is ‘substantially a land structure.’

(1) It must be securely and substantially moored as approved by the Officer in

Charge of Marine Inspection [OCMI].

(2) The mooring must be so rigged that its lines cannot be inadvertently or

accidentally cast off, it is unlikely to break away from its mooring, and it

cannot be moved away from the mooring without special effort (i.e., the use

of tools).

(3) Permanent connection to shoreside facilities is evidence of being a ‘land

structure.’ The nature and use of the entity may also be considered.

The Coast Guard has other responsibilities concerning waterway safety that are not

necessarily related to vessel inspection. The Coast Guard has extensive authority under the

Ports and Waterways Safety Act of 1972 (PWSA) to act to safeguard navigation and

protect waterfront facilities and the marine environment. Under the PWSA, as amended,

the Coast Guard:

36 The MSM sets forth Coast Guard policy and guidelines for use by Coast Guard personnel and the

marine industry. It explains the Coast Guard’s authority and rationale for various marine safety activities. 
Factual Information 36 Marine Accident Report

May take such action as is necessary to–(1) prevent damage to, or the destruction

of, any bridge or other structure on or in the navigable waters of the United States,

or any land structure or shore area immediately adjacent to such waters; and

(2) protect the navigable waters and the resources therein from harm resulting

from vessel or structure damage, destruction, or loss. Such action may include, but

need not be limited to– (A) establishing procedures, measures, and standards for

the handling, loading, unloading, storage, stowage, and movement on the

structure (including the emergency removal, control, and disposition) of

explosives or other dangerous articles and substances, including oil or hazardous

material as those terms are defined in section 2101 of title 46; (B) prescribing

minimum safety equipment requirements for the structure to assure adequate

protection from fire, explosion, natural disaster, and other serious accidents or

casualties; (C) establishing water or waterfront safety zones, or other measures for

limited, controlled, or conditional access and activity when necessary for the

protection of any vessel, structure, waters, or shore area; and (D) establishing

procedures for examination to assure compliance with the requirements

prescribed under this section. [33 U.S.C. 1225]

With respect to the application of the PWSA as it may concern PMVs, the Coast

Guard stated, in a February 17, 2000, letter to the Safety Board:

The PWSA has generally not been interpreted and applied to expand the Coast

Guard’s regulatory authority over construction, manning, equipment or operations

on vessels other than tank vessels.... If the issue is how ingress and egress from

the PMV is provided in an emergency, the authority is more likely the vessel

inspection laws and regulations, as opposed to the PWSA, at least as it has been

traditionally applied.

This letter further stated that:

[T]he broad language of the PWSA can provide additional regulatory authority to

address new risks to port safety presented by vessels other than tank vessels, or to

facilities in U.S. ports, or protection of the marine environment on the navigable

waters of the United States. In fact, the language of the PWSA, authorizing the

Secretary to regulate with respect to facilities and vessels in the ports of the U.S.,

is very broad.

(See appendix F for the full text of the Coast Guard’s February 17, 2000, letter.)

USACE Authority. USACE is authorized to regulate activities on the Nation’s

waters according to 33 CFR Parts 320 through 330, which establish the Department of the

Army permit process. USACE permits are required for dams or dikes in U.S. navigable

waters and other structures or work, including excavation and dredging or disposal

activities (or both), in U.S. navigable waters (33 CFR 320.1[b]). PMVs are considered

structures under this definition and are required to have USACE permits. The USACE

permit program is not concerned solely with safety; it involves “consideration of the full

public interest by balancing the favorable impacts against the detrimental impacts”

(33 CFR 320.1[a][1]). Permit review processes do not require that USACE assess the

effect on vessel traffic or the risks to public safety posed by the structure. USACE often
Factual Information 37 Marine Accident Report

consults with Federal (particularly Coast Guard), State, and local government agencies

before issuing a permit; but USACE is not required to conduct such a consultation before

it issues a permit.

Federal Oversight of the Admiral. In July 1983, the S.S. Admiral Ltd. company

applied for a USACE permit to permanently moor a floating showplace family

entertainment and dining center at mile 179.9 UMR. In conjunction with the permit

application, the company installed “deadmen”37 to secure the floating showplace

structures to shore.

USACE asked the Coast Guard to review the permit request. In an advisory

capacity, the St. Louis COTP conducted the review. In a letter dated September 22, 1983,

he stated that “I have no objection to this proposal; however, I would be interested in

reviewing any major changes to the plan.” USACE issued the requested permit on

October 5, 1983. The showplace operated from March 1987 until summer 1988, when it

closed. In 1992, President Casinos purchased the floating showplace structures at mile

179.9 UMR.

In 1992, President Casinos applied for a modification to the USACE permit for the

Admiral because the entry barge facility was 25 feet wider than the barge cited in the

1983 permit. (The unit extended 25 feet further into the river.)38

USACE requested that the Coast Guard review the permit revision request. After

reviewing the public notice of permit, the St. Louis COTP wrote a letter to USACE dated

June 22, 1994. The letter included the following statements:

A recent towboat casualty in St. Louis Harbor involving the ‘permanently

moored’ gaming boat Admiral [

39] indicates the vulnerability of that vessel to

possible future casualties. The presence of large numbers of patrons raises similar

considerations to those discussed during the review of the Casino Queen’s

application. In that case, a protection cell was required to deflect and slow down a

barge which might otherwise strike the vessel with high and destructive energy.

Accordingly, I request a review of the Admiral’s permit to determine if additional

conditions are necessary to assure public safety. I have verbally discussed this

with [a named individual], the director of marine operations for the parent

company, President Casinos. [40] I request that he be included in the review effort.

On November 23, 1994, USACE advised President Casinos that it had modified

the Admiral’s October 1983 permit to accommodate the existing mooring configuration.

37 Deadmen are mooring anchoring devices sunk into the riverbank from which anchor chains or mooring

wires may be attached to a floating structure.

38 The wider entry barge was necessary to comply with shore-to-entry gangway slope boarding

requirements in the Americans With Disabilities Act of 1990.

39 Coast Guard St. Louis case MC95005051, allision of the Admiral by the two-barge (empty) tow of the

harbor towboat M/V Robert Y. Love on May 5, 1994.

40 The President Casinos representative to whom the Coast Guard officer spoke was actually the director

of the subsidiary, President Riverboat Casino-Missouri, Inc., not the parent company, President Casinos, Inc.
Factual Information 38 Marine Accident Report

USACE also stated that a USACE district engineer “deemed it necessary that the

S.S. Admiral must emplace a protection cell to provide protection from ice flow, debris,

and breakaway tows.” 

President Casinos hired a professional engineering consulting firm to conduct a

risk assessment (completed March 9, 1995) concerning drifting vessels affecting the

Admiral and the possible location of a protection cell. The consultant reported that

breakaway upbound tows had struck the vessel three times while it had been moored in

this location.41 The consultant’s report stated that placing a protection cell upstream and to

the starboard of the Admiral could redirect loose barges toward the Admiral and was not in

the best interests of public safety. President Casinos did not install a protection cell.

On July 10, 1995, the St. Louis COTP42 sent a letter to the St. Louis District

USACE. A portion of the letter read:

This addresses a previous request filed by this office for consideration of a

protection/deflection cell upstream of the Admiral Casino on the St. Louis

waterfront. Since that request was filed I have had several meetings with

representatives of the lease holder, your office, the River Industry Action

Committee, and the St. Louis Harbor Association. Casualty scenarios were

examined and assessed; protection cells and other measures were discussed; and

future move from the site now under review by the port authority is considered

likely. [43]

I believe the allision risks associated with continued operations at the site are such

that a deflection cell would not significantly improve the public’s safety. This

conclusion is particularly valid given the probability of a change in the vessel’s

location in the near future.

Local Requirements. The city of St. Louis owns the waterfront area in St. Louis

Harbor where the Admiral is moored; the city leases the area to President Casinos. The

city of St. Louis has procedures that its Port Commission and the Board of Public Service

must follow when the owners of a structure, like the Admiral, request a lease to moor the

structure along city-owned land within the port district. These procedures involve review

41 Coast Guard records provided one instance of the Admiral being struck, by tows from the towboat

Robert Y. Love in May 1994. On June 5, 2000, AM representatives provided the Safety Board evidence of

other occasions on which the Admiral was struck by tows/barges. AM provided a copy of a February 13,

1995, memo from the Admiral’s (then) director of marine operations to the President Casinos, Inc.,

engineering consultant. The 1995 memo stated that the Admiral had been struck three times since 1988. The

three incidents to which the memo referred were an April 23, 1991, incident involving the towboat Wendy

Ann, during which the operator lost tow control while passing through the MLK Bridge and the tow struck

the Admiral, a second for which no details were provided, and the Robert Y. Love accident. AM also gave

Board staff a copy of a Coast Guard accident investigation report of the “M/V Crescent City allision with the

Eads Bridge, Mile 180, Upper Mississippi River on 23 February 1985, with no personnel injuries or loss of

life.” The report indicated that breakaway barges from the tow struck the Robert E. Lee, the Admiral, the

Golden Rod Showboat, and the St. Louis Visitors Center.

42 The COTP in this case was the same individual who had sent the June 22, 1994, letter.

43 In 1995, interested parties had discussed the possibility of moving the Admiral upstream when it

obtained the new permit. No action was taken until after the accident. 
Factual Information 39 Marine Accident Report

and approval by the Board of Public Service, the port administrator,44 the Department of

Public Safety, and other city agencies. If the Board of Public Service ultimately approves

the application, it recommends a lease ordinance to the Board of Aldermen. If the Board

of Aldermen and the mayor approve the lease ordinance, they make it a lease agreement.

President Casinos went through this approval procedure to obtain a lease for the Admiral

on the St. Louis waterfront.

As substantially land structures or floating buildings, PMVs are subject to local

ordinances and building codes. The codes require that the “building” have adequate

electrical, mechanical, and plumbing arrangements, as well as appropriate exits, lighting,

emergency lighting, power ratings, sprinkler systems, etc., for a facility of its size. The

city of St. Louis has adopted the Building Officials and Code Administrators Basic Fire

Prevention Code (BOCA Code)45 for its buildings. Through a December 6, 1999, letter,

the SLFD deputy chief informed the Safety Board that pertinent provisions of the code

had been applied to the Admiral.

The Department of Public Safety for the city of St. Louis reviewed the Admiral’s

design plans to ensure that the PMV met the applicable building codes for fire safety

(according to the BOCA Code), electrical, mechanical, and plumbing requirements. The

department also approved the Admiral’s design and evacuation plan for compliance with

requirements for emergency exits, emergency lighting, and fire sprinklers, as they would

apply to buildings. According to a Department of Public Safety representative, the agency

was not required to review the Admiral for marine safety aspects, nor did the city consider

the need for lifesaving equipment because such factors are not considered during the

approval processes for buildings.

Missouri Gaming Commission Requirements. Permanently moored casinos in

Missouri must have a license from the Missouri Gaming Commission. In a July 9, 1998,

letter to the Safety Board, the Missouri Gaming Commission stated: 

The Commission’s rules mandate that the licensee meet the minimum standards

for safety and environment established by the U.S. Coast Guard, the Army Corps

of Engineers, and the Environmental Protection Agency. 

The Commission’s safety rules require that permanently moored vessels meet:

(1) The fire safety standards of the Missouri Law and Rules; (2) The fire safety

standards contained in the National Fire Protection Association (NFPA), NFPA

Standard 307 Standard for the Construction and Fire Protection of Marine

Terminals, Piers, and Wharfs; and (3) The NFPA Life Safety Code.

44 The port administrator is responsible for monitoring any lease and for requesting the assistance of

appropriate city agencies when it is necessary to fulfill city ordinances or State or Federal regulations that

might apply to the transaction or that might be needed to protect the life, health, or property of citizens or to

further the city’s economic development. 

45 The BOCA is one of three major national model building code groups that publish a building code.

Each code group is a consensus body. There is some uniformity among the model codes, although the groups

meet different regional and geographical needs. 
Factual Information 40 Marine Accident Report

The acting executive director of the Missouri Gaming Commission also informed

the Safety Board in the July 1998 letter that: 

The Commission does not employ safety experts but instead relies on other

government agencies with expertise in safety standards and inspections. 

The Commission required that, before it would license the Admiral, the vessel be

inspected by American Bureau of Shipping (ABS) Marine Services, Inc.,46 for stability

and integrity. Before it would relicense the Admiral in 1995 and 1997, the Commission

required that ABS Marine Services reinspect the vessel to ensure that it continued to be fit

to serve as a permanently moored casino in Missouri. 

Boats in a Moat

“Boat in a moat” is a term used to describe a vessel that is restricted from leaving a

waterway (lake, pond, or basin) by natural or man-made obstructions. Such a vessel

cannot float into a river or be subject to collision or ramming by other vessels. If a boat in

a moat breaks away from its mooring for any reason (such as weather), it will not be

subject to the dangers of vessel traffic. The moat is generally shallow, so if the vessel

should sink, people on board will not be endangered.

The Eighth (Gulf Coast and Central Western Rivers District) and Ninth (Great

Lakes District) Coast Guard Districts contain 9 and 11 boats in a moat, respectively.

Thirteen of these vessels are inspected by the Coast Guard and issued certificates of

inspection. State and local authorities regulate the other seven. Four of the 11 boats in a

moat in the Ninth District are attempting to give up their Coast Guard certificate status and

be regulated by State and local governments.

Passenger Vessels in St. Louis Area

The St. Louis Harbor area contains four vessels that are inspected by the Coast

Guard for compliance with passenger vessel safety requirements. They are the Casino

Queen (capacity 3,000), the Tom Sawyer (capacity 375), the Becky Thatcher

(capacity 350), and the Alton Belle II (capacity 1,500).

Risk Assessment

General. “Risk” may be defined as a combination of the probability of an accident

occurring together with its consequences.47 “Risk assessment” is an organized and

systematic search for high-risk conditions in a system; through this process, the hazards in

a system are identified and prioritized. Through risk assessment, risk management

46 ABS Marine Services, Inc., is a for-profit corporation that provides consulting, survey, engineering and

training services. It is separate from ABS, Inc., a non-profit vessel classification society. 

47 National Transportation Safety Board. Fire Aboard the Tug Scandia and the Subsequent Grounding of

the Tug and the Tank Barge North Cape on Moonstone Beach, South Kingston, Rhode Island, January 19,

1996. Marine Accident Report NTSB/MAR-98/03. (Washington, DC: National Transportation Safety

Board, 1998).
Factual Information 41 Marine Accident Report

strategies can be developed. System stakeholders can then select certain risk management

strategies over others, based on the level of risk they are willing to accept.48

The MSM defines the waterway elements to be considered during the risk

assessment process as vessel properties, waterway properties, cargo properties, and

environmental conditions. Port risk management is the responsibility of the Coast Guard’s

Office of Marine Safety and Environmental Protection, which is charged with protecting

the public, the environment, and U.S. economic interests by preventing or mitigating the

effects of marine accidents and incidents. According to the “Program Principles” section

of the Office of Marine Safety and Environmental Protection’s 1996 Performance

Report,

49 risk management is the “business” of the office. The report states:

Preventing low probability-high consequence events, such as major loss of life on

passenger vessels, and medium and major oil spills, is a cornerstone of our risk

management approach. To improve our decision making, we need to strike a

balance, allowing field commanders to employ existing risk analysis tools for

routine risk management decisions, while establishing a formal program policy

for high level risk analysis projects, such as comprehensive port risk models.

According to the operations manager of the St. Louis City Port Authority, neither

Federal, State, nor local authorities conducted a formal risk assessment of waterfront

operations in St. Louis Harbor. 

The PVA maintains a Risk Management Manual for Passenger Vessels. The

document addresses such topics as providing safety audits, meetings, and announcements;

reducing various types of accidents; managing hazardous waste; maintaining logbooks;

and conducting fire drills and contingency planning. In 1995, a President Casinos

employee drafted the chapter “Emergency Drills and Contingency Planning” that appears

in the PVA manual. Using St. Louis Harbor as its model, the chapter discusses developing

passenger vessel marine risk contingency plans to address various types of emergencies

involving collisions, taking on water, losing propulsion and requiring harbor tug

assistance, moving injured people ashore, and transferring firefighters from shore to

vessel. 

Risk Assessment Methods Used by the Coast Guard. Pursuant to the Coast

Guard’s 1996 Performance Report objectives of employing risk-based tools for routine

field use and port risk management, the Coast Guard contracted with George Washington

University to develop a Port and Waterways Risk Assessment Guide.

50 The guide was

48 For more information on risk assessment as it applies to marine vessel operations, see National

Transportation Safety Board, Allision of the Liberian Freighter Bright Field with the Poydras Street Wharf,

Riverwalk Marketplace, and New Orleans Hilton Hotel in New Orleans, Louisiana, December 14, 1996.

Marine Accident Report NTSB/MAR-98/01. (Washington, DC: National Transportation Safety Board,

1998).

49 The Coast Guard’s 1996 report on the office’s progress toward goals listed in Commandant Instruction

16000.2 (series), Business Plan for Marine Safety and Environmental Protection. 

50 George Washington University. Port and Waterways Risk Assessment Guide. (Washington, DC: George

Washington University, 1996).
Factual Information 42 Marine Accident Report

published for Coast Guard field personnel to use in evaluating and managing risk in

U.S. ports and waterways. Appendix A of the guide contains a 12-step program that

provides “a structured format for gathering and analyzing the necessary information and

professional knowledge required to evaluate and manage risk in U.S. ports and

waterways.” The Coast Guard Proceedings of the Marine Safety Council, July–September

1999, contains several articles about how the Coast Guard is applying risk management

approaches similar to those described in the guide.

The Proceedings outline how MSO Jacksonville, Florida, has developed vessel

risk measures for the different types of vessels (deep-draft, fishing, towing, and passenger)

operating in its port. MSO Jacksonville has also developed facility risk measures to

manage the risk of oil spills at cargo oil transfer facilities in its port, as well as a port

activity risk measure that gauges the relative risk levels for waterway segments according

to each segment’s traffic density, geographic features, importance, other unique factors,

and high-risk activities such as dredging, bridgework, etc. The risk profile for the port is

updated and monitored weekly, allowing the COTP to target risk management resources

optimally. 

The MSO at Los Angeles/Long Beach, California, refined and expanded MSO

Jacksonville’s risk model by including as many as 16 parametric measures of risk to

develop an overall Port Activity Risk Index (PARI). Examples of risk parameters include

cruise ship activity, vessel movements, status of aids to navigation, weather, and special

operations in the port. The PARI is updated daily and provides the COTP with an overall

indicator of the relative port risk for that day, so the COTP can implement appropriate risk

reduction measures.

Following the December 1996 collision of the M/V Bright Field with a pier in the

Port of New Orleans,51 the February 1998 breakaway of the casino barge Jubilee near

Greenville, Mississippi,52 and the April 1998 near breakaway of the Admiral, the Coast

Guard established a Quality Action Team (QAT) in April 1998 to identify risks to PMVs

that carry passengers. The goals of the team were to establish Coast Guard involvement in

the siting and mooring of PMVs and to develop measures for reducing the risk of

accidents affecting PMVs.

On December 7, 1999, the Coast Guard issued the final report of its QAT for

PMVs.53 The report provided a simplified methodology by which Coast Guard field units

might assess risks to PMVs. The risk assessment methodology is based on six parameters:

PMV location, vessel traffic, adequacy of emergency maritime assistance to disabled

vessels, anticipated environmental factors, unpredictable environmental factors, and

exposure (presence) of PMV passengers. (See appendix G for the Coast Guard’s PMV

51 NTSB/MAR-98/01. 

52 On February 10, 1998, the PMV Jubilee Casino, carrying nearly 1,000 people, broke loose from its

moorings on an inlet of the Mississippi River near Greenville, Mississippi, during a severe thunderstorm

with high winds. No injuries or damage resulted, and river vessels pushed the PMV back into place. 

53 U.S. Coast Guard. Permanently Moored Vessel QAT: A Site Selection and Risk Mitigation Model: Final

Report, December 7, 1999. (Washington, DC: U.S. Coast Guard, 1999).
Factual Information 43 Marine Accident Report

initial risk assessment form.) The QAT developed the methodology using expert opinion,

experience, and local knowledge from Coast Guard field units. The team developed the

method by assigning risk scores between 1 and 5 to each risk parameter (1 being the

greatest risk and 5 being the least risk). 

Next, the QAT examined accident data comprising 295 accidents (including

groundings, collisions, allisions, and breakaways) that occurred between 1992 and 1997

within 1/2 mile upstream of PMVs. The QAT included data on 162 PMVs in the study.

The QAT found that the accident data generally validated the methodology54 developed

through field experience and expert opinions. The accident statistics were used to establish

acceptable risk scores to be used with the method. (The published QAT report did not

disclose the actual risk scores and rankings for individual PMVs, or determinations of

whether the PMVs met acceptable risk criteria as defined by the report.)

The QAT found that barge breakaways, collisions, and high water were the main

causes of PMVs breaking their moorings.55 The team also found that accident statistics

showed that most (68 percent) of the accidents occurred at high-risk locations, making

location the single most important parameter in predicting risk to a PMV. The QAT report

concluded that site selection was the most effective way of managing PMV risk. The

report stated that, where site selection options are limited, the next option could be to

modify the site by adopting measures such as the installation of protective cells.

In addition, the QAT report stated that, although the methodology that the QAT

constructed for assessing PMV risks was developed using only PMV data, this risk

assessment system is applicable to other vessel types and mooring sites.56

The Coast Guard adopted the QAT report’s recommendations and used them as the

bases for changes in Coast Guard policies applicable to PMVs. (See appendix H for a full

list of the report’s conclusions and recommendations.) The policy changes are explained

in the Coast Guard’s 1999 update to its MSM, which the Coast Guard issued for field use.

(See appendix I, Draft U.S. Coast Guard Marine Safety Manual Change, MSM Vol. II:

Material Inspection, Chapter 10.) 

The revised MSM makes a number of new requirements regarding PMVs. For

example, before the Coast Guard will formally acknowledge a vessel as a PMV, the vessel

must undergo a risk assessment based on the methodology described in the QAT report. If

a PMV fails to meet the risk criteria, the COTP has “articulable grounds” for calling safety

into question. In such a case, the COTP can require the vessel owner or operator to

develop a formal risk assessment and mitigation plan. 

With respect to the USACE permit process, the new Coast Guard policy requires

that the simplified risk assessment be an integral part of USACE permit reviews. The

Safety Board understands that, as part of the Coast Guard’s involvement in the site

54 Permanently Moored Vessel QAT: Final Report, December 7, 1999, appendix C. 

55 Permanently Moored Vessel QAT: Final Report, December 7, 1999, appendix F, p. 2. 

56 Permanently Moored Vessel QAT: Final Report, December 7, 1999, p. 13, conclusion 6. 
Factual Information 44 Marine Accident Report

approval process, the COTP will advise USACE whether the PMV under consideration

meets the acceptable risk criteria.

On June 2, 2000, USACE and the Coast Guard signed a Memorandum of

Agreement regarding the new process for evaluating risks to PMVs. According to the

Coast Guard’s media advisory concerning this action, the agreement establishes “a formal

process whereby the Coast Guard will provide input into [USACE’s] evaluation process

for issuing permits related to these types of fixed or floating structures.” The release

further stated: 

The new process elevates the attention given to port and waterway safety issues

associated with a structure’s location during [USACE’s] public interest review

process, and provides for periodic review of existing permits as a result of

waterway changes. 

The Coast Guard continues to require that PMVs be immobilized and removed

from navigation but, under the revised MSM, the local COTP must now require that a

professional engineer evaluate each PMV’s mooring arrangements. Further, the standard

to which the mooring is evaluated must be developed during the initial risk assessment

process and take local conditions into account. 

Under the new procedures, once the COTP determines that the PMV meets the risk

criteria and the USACE provides a site permit, the Coast Guard will transfer the

responsibility for future safety regulation of the PMV to local authorities. The transfer will

be designated in writing. Because some local authorities may not be well versed in marine

issues, the COTP will meet with the local authorities to ensure that they have satisfactorily

addressed hull integrity, mooring arrangements, emergency egress, lifesaving appliances,

and navigation-related operational issues.

The Coast Guard will continue to be involved in the PMV’s safety after its

jurisdiction is transferred to local authorities. The COTP must re-evaluate the risks to the

PMV at least every 2 years (and when pertinent local conditions change), using the QAT

report’s risk method. (The Memorandum of Agreement being developed between the

Coast Guard and USACE is to include a provision for periodic permit reassessments.)

Further, if the PMV is moved to a site that already has a USACE permit, the Coast Guard

is responsible for determining whether that vessel qualifies as a PMV at that location. 

The Coast Guard has initiated a review of all PMVs based on the new policy and

expects to complete the assessment of risk for all 162 PMVs in 2000. (The results of this

review are not yet available.)

Responsible Carrier Program

Through the AWO, the inland towing industry has developed and adopted a safety

management system called the Responsible Carrier Program (RCP). The RCP is modeled

after the International Maritime Organization’s International Safety Management Code.57

The RCP provides member companies with recommended policies and practices
Factual Information 45 Marine Accident Report

concerning the management, administration, maintenance, inspection, and use of

equipment and human factors affecting the safe and efficient operation of towing vessels

under varying conditions (such as high water, low water, restricted visibility, and so forth). 

All AWO members are required to develop and implement the vessel operating

policies and procedures outlined in the RCP to retain their AWO membership. The RCP

system is intended to document and define the responsibilities of shoreside management

and tow crews, to enhance safety and environmental protection for vessel operations. All

AWO members were required to develop and implement the vessel operating policies and

procedures outlined in the RCP by 2000 to retain their AWO membership. AWO has

reported that 11 companies have been removed from AWO membership because they did

not fully comply with the RCP requirements.

1994 New Orleans Search and Rescue Exercises

On January 30, 1994, Coast Guard Group New Orleans, Louisiana, conducted a

series of search and rescue exercises with local emergency groups on the LMR, between

the Crescent City connection bridges and Algiers Point. The purpose of the exercises was

to determine the capability of the Coast Guard, city, and commercial interests to locate and

rescue large numbers of people in the river. The exercise simulated a collision between a

passenger vessel with 1,400 people on board and a 700-foot freighter. In the staged

incident, the passenger vessel sank quickly, causing 1,400 “people” to go in the water.

Wooden blocks represented people in the water.

In the response to the scenario, responders recovered less than 20 percent of the

1,400 wooden blocks. The Coast Guard found that the conditions of the Mississippi River

in the vicinity of New Orleans severely limited the survivability of people in the water.

These conditions included cold water temperatures (34° F) and swift and treacherous

currents, eddies, and undertows. The Coast Guard determined that, under prevailing

conditions, a large percentage of people entering the water would have soon succumbed to

hypothermia. The Coast Guard on-scene commander concluded that, should such an

accident actually occur, he could not guarantee the rescue of passengers forced into the

Mississippi River. 

Developments Since the Accident

President Casino on the Admiral

The Admiral’s 10 mooring wires have been replaced with new wires. The stern

anchor weight has been increased from 6,000 to 12,000 pounds. President Casinos has

57 The International Safety Management Code recognizes and codifies the responsibilities of shipping

company management in ensuring adherence to marine safety guidelines and environmental protection

standards. The Code provides member companies with recommended policies and practices concerning the

management, administration, maintenance, inspection, and use of equipment and human factors affecting

the safe and efficient operation of vessels under varying operating conditions. 
Factual Information 46 Marine Accident Report

added an auxiliary anchor and chain to the Admiral’s bow; they can be released should the

other two anchors (bow and stern) or anchor mooring wires break or become dislodged.

Since the accident, the company has purchased two cellular phones for the

Admiral; one is kept in the security shift office and the other in the general manager’s

office. President Casinos has also installed a marine radio scanner and a marine radio in

the Admiral’s security shift office. The radio can be used to communicate with the Casino

Queen and other navigating vessels in the area. The company has made provision for an

Admiral employee to monitor the marine radio 24 hours a day, 7 days a week. 

On March 16, 1999, three Admiral security staffers participated in a 6-hour

“Crowd Management for Passenger/Casino Vessels” training session conducted by a

commercial training center. The course was designed to help participants develop the

knowledge and skills to control and direct passengers in emergency situations.

On May 24, 1999, at the request of President Casinos, USACE issued a permit to

move the Admiral complex to mile 180.3 UMR, above the MLK Bridge, and to place four

protection cells around it. President Casinos has until December 31, 2003, to complete the

action and is expected to move the vessel by fall 2000. 

Laclede

According to a December 9, 1999, letter from the Laclede Gas Company to the

Safety Board, when the Admiral is moved to mile 180.3 UMR, Laclede will install a new

service line and meter station to serve the vessel. The company stated that:

The new meter station, with accessible shutoff valves, will be located at 802 N.

First Street. This location was chosen by Laclede because it is remote from areas

affected by flooding. This new service line will be approximately 750 feet in

length and will terminate in a custody transfer vault located on the riverfront.

Considering the Admiral’s new location, and its readily accessible valving which

would be available in the event of an emergency, Laclede feels that an automatic

shutoff device is not necessary for this installation.

When the Safety Board expressed its concern about the other PMVs on the St.

Louis waterfront to which Laclede supplies natural gas, the company stated, in a

December 28, 1999, reply, that:

Laclede has tested and found the Fisher 299H w/VSX module regulator to be an

acceptable automatic shutoff device for the service to the St. Louis Concessions

[

58] and McDonald’s riverboats. Installation of a Fisher 299H w/VSX module

regulator and necessary service line modifications for both of these customers is

planned by Laclede [ ]... .

Laclede subsequently informed the Safety Board that it will install these lowpressure shutoff devices in fall 2000.

58 Gateway Riverboat Cruises support barge. 
Factual Information 47 Marine Accident Report

In a January 7, 2000, letter to the Safety Board, Laclede stated that, with respect to

“providing ready access, in the event of flooding, to the natural gas service shutoff valves

for floating customers on the St. Louis riverfront,” the company was continuing its

actions. Specifically, Laclede stated that:

A [ ] guide is being designed for these service valves so that a valve key can be

easily placed on a service valve from over head in the event of high water on the

St. Louis riverfront. These guides will be installed on the remaining active

customers [St. Louis Concessions, McDonald’s, and Robert E. Lee] during the

Spring of 2000 when additional work is planned.

Laclede has since informed the Safety Board that valve key guides have been

installed on the St. Louis Concessions, McDonald’s, and Robert E. Lee PMVs, as well as

the Admiral, in its current location. 

NFESC Mooring Study

After the accident, the Safety Board contracted with the Naval Facilities

Engineering Service Center (NFESC), East Coast Detachment, to conduct an engineering

analysis of the mooring of the Admiral and its entry barge as it was at the time of April

1998 accident. The purpose of the analysis was to help determine what factors may have

contributed to the mooring failure.

The NFESC evaluated the effect on the mooring caused by impact on the

Admiral’s bow from one and three loose barges, loaded as they were at the time of the

accident. The mooring wire strengths, diameters, and arrangements used in the NFESC’s

calculations were based on those used to moor the Admiral.

In summary, the NFESC found that:

• the Anne Holly’s runaway barges probably badly damaged or severed mooring

wires 8, 9, and 10 by drifting into them before the barges struck the Admiral

itself;

• the impact of the runaway barges on the Admiral caused peak acceleration of

the Admiral of approximately 0.1 g or less;

• more than one runaway barge probably struck the Admiral and/or the wire

ropes may not have had their full new-break strength at the time of the

accident;

• a runaway group of three barges would have broken the mooring wire rope

numbers 1 through 6 at a speed as low as 4 feet per second (2.7 miles per hour);

• the mooring wire rope numbers 1, 2, 3, 4, 5, and 6 likely failed because wire

ropes are stiff (do not stretch much), and the wire rope winches were locked

tight, so the wire rope could not “pay out” in case of overloading;
Factual Information 48 Marine Accident Report

• after wire rope numbers 1 through 6 and 8 through 10 broke, the river current

acted on the Admiral and the entry barge to make them swing slowly in a

clockwise direction and end up near the riverbank downstream; and 

• the final remaining mooring wire, number 7, would likely have held even

without the Anne Holly’s assistance.
49 Marine Accident Report

Analysis

Exclusions

Based on the statements of the Anne Holly’s chief engineer, the Safety Board’s

examination of the towboat’s machinery and steering, and the trial trip taken on the Anne

Holly on April 8, 1998, the Safety Board found no evidence of loss of engine power, loss

of steering, or of any other mechanical or electrical malfunction that could have caused or

contributed to this accident. The Anne Holly had nearly twice the minimum horsepower

required by the Coast Guard for upbound towboats during high-water conditions, and the

vessel successfully navigated the area a few days after the accident with a similar tow

under similar conditions. The Safety Board therefore concludes that the Anne Holly had

sufficient horsepower to successfully navigate upbound through St. Louis Harbor on the

night of the accident, and the vessel did not experience any propulsion or steering system

failure.

Nifedipine and glyburide do not typically impair performance, although some

individuals may experience side effects, including dizziness and nausea. The Anne Holly

captain had used both of these medications on a regular and continuing basis at least since

December 1996, and he testified that he did not experience any side effects. In controlled

medical studies, sertraline did not cause sedation and did not interfere with psychomotor

performance,59 and may actually improve performance in patients with depression.60

The Safety Board reviewed the report of a medical examination of the captain

performed several weeks before the accident (in late February 1998) and a medical

examination for Coast Guard licensing done in August 1998, after the accident. The

review of the two examinations indicated that the captain’s physician had found the

captain physically fit for duty on board the Anne Holly. He was receiving appropriate

treatment for his diabetes and elevated blood pressure, and no side effects were reported

for any of his medications.61

The Anne Holly captain had more than 25 years of experience as a towing vessel

operator, was properly licensed, and had routinely transited the river through St. Louis

Harbor many times both upbound and downbound under many different circumstances,

including high-water conditions. Moreover, he had operated tows through the St. Louis

Harbor area without an accident for the previous 4 years. He was thus qualified and

59 See, for example, Doogan, D.P., and Caillard V. “Sertraline, A New Antidepressant.” J Clin Psychiatry.

Aug: 49. Suppl: 46-51. 1988.

60 See, for example, Finkelstein, S.N., Berndt, E.R., Greenberg, P.E., Parsley, R.A., Russell, J.M., and

Keller, M.B. “Improvement in Subjective Work Performance After Treatment of Chronic Depression: Some

Preliminary Results.” Psychopharmacol Bull. 32(1): 33-40. 1996.

61 Postaccident drug and alcohol testing and fatigue, as they relate to the Anne Holly captain, will be

addressed in a later section of the analysis. 
Analysis 50 Marine Accident Report

adequately experienced and skillful to serve as captain of the Anne Holly in St. Louis

Harbor. Therefore, the Safety Board concludes that the captain of the Anne Holly was

sufficiently qualified, experienced, and skillful to serve as captain on the night of the

accident, and his prescription medication did not negatively affect his performance. 

Although it was dark when the Anne Holly’s transit began, the weather was clear,

with good visibility (of at least 2 miles) in darkness. The wind was from the southwest at

5 miles per hour. The Safety Board therefore concludes that weather was not a factor in

this accident.

After the accident, the Anne Holly captain said that his tow’s forward movement

was affected by a river phenomenon that he described as a “pop rise” between the MLK

and Eads Bridges. A review of the USACE hourly river stage data, however, indicated a

gradual rise of about 0.9 foot in 24 hours in the river stage in St. Louis Harbor. USACE

data showed about 0.2-foot rise between 1900 and 2000 on April 4, 1998. 

Testimony from the chief of the potamology section of the St. Louis District

USACE indicated that the rise in river level that day had been gradual. When he was asked

if a condition “that could have resulted in an unexpected ‘wall of water’ between the MLK

and the Eads Bridges” had been present on the day of the accident, the USACE official

replied that it had not. The USACE findings suggest that the Anne Holly tow experienced

no anomalous river conditions as it moved between the MLK and Eads Bridges.

Consequently, the Safety Board concludes that no sudden rise in river level interfered with

the forward movement of the Anne Holly tow. 

The major safety issues identified in this investigation and discussed below are:

• the advisability of the Anne Holly captain’s decision to make the upriver transit

and the effectiveness of safety management oversight on the part of AM, 

• the effectiveness of safety measures provided for the PMV Admiral, and 

• the adequacy of public safety for permanently moored vessels.

This accident comprises two separate accident sequences: 1) the striking of the

Eads Bridge, with the break up of the Anne Holly tow, and 2) the subsequent striking of

the PMV Admiral by barges from the Anne Holly tow and the PMV’s near breakaway. The

analysis that follows considers each sequence separately.

Striking of the Eads Bridge by the Anne Holly Tow

Captain’s Decision-making

On the night of the accident, the principal task of the Anne Holly captain was to

navigate the 14-barge tow upriver from the Eagle fleeting area past four bridges. Under

normal river stage (less than 20 feet on the St. Louis gage) and in daylight, someone with
Analysis 51 Marine Accident Report

experience and skills similar to the captain’s could routinely accomplish this task.

Conditions, however, were unfavorable in that the river was in flood and it was dark.

The captain’s decision to proceed with the transit under the prevailing conditions

of darkness and flood (which resulted in minimal vertical clearance at the Eads Bridge and

a swift current of 6 mph) is critical to understanding the probable cause of this accident.

On the night of the accident, the Anne Holly captain was aware of the difficult navigation

task that he was undertaking; once he left the fleeting area, he requested a helper boat to

assist him in taking his tow through the St. Louis Harbor bridges. When he learned that no

helper boat was immediately available, he chose to attempt the transit without one. Other

options, however, were open to him. He could have:

• returned to the fleet to await the availability of a helper boat; 

• returned to the fleet, dropped off part of his tow, and then proceeded with a

partial tow through St. Louis Harbor62 (he would then have had to return to the

fleet to retrieve the remainder of the tow and make a second trip through the

harbor or had another towboat bring the remaining barges upriver for him); or 

• returned to the fleet and remained there until daylight so that he could make the

transit through St. Louis Harbor in daytime. 

Despite these options, the captain decided to continue with the transit without a

helper boat. 

The transit of this tow under the prevailing conditions was a difficult task and

presented risks that increased the likelihood of an accident. The captain, although

experienced and familiar with the navigational demands of the area, decided on the

evening of April 4, 1998, to move the Anne Holly tow through the area under recognizably

adverse conditions. The Safety Board concludes that, given the difficult navigation task,

the darkness, the flood conditions (which resulted in a swift current and minimal vertical

clearance at the Eads Bridge), and the lack of a helper boat, the captain should have

chosen to pursue another option on the evening of April 4, 1998. 

Role of Company. Although the immediate cause of the accident was the Anne

Holly captain’s operational error or errors (to be discussed in the next section), the

underlying cause was the owner’s lack of effective safety management of its towing

operations. The absence of corporate management input into the captain’s strategic

decision-making process about whether to proceed with the transit of St. Louis Harbor that

night placed an unreasonable burden on the captain and forced him to make unilateral

safety-critical decisions from the narrow perspective of the pilothouse.

As a small business, AM often contracts for boats and operators as its workload

requires and does not maintain an extensive shoreside operations infrastructure.

62 By making the transit with a shorter tow, the captain would have made the navigation task less

challenging because it would have reduced the tow’s tonnage, increased the Anne Holly’s control over the

barges in the tow and the tow’s maneuverability, and lessened the effect that the current had on the tow by

reducing the surface area of the tow that was exposed to the current.
Analysis 52 Marine Accident Report

According to AM management, the company relies on the captain to make all decisions

regarding the tow’s operation. The company does not have written policies that its

captains should follow to consistently ensure safe towing operations or procedures to

assist the captains in choosing the proper course of action in safety-critical situations. The

company has not established policies that address high water, nighttime transit, and other

conditions that might affect the safety of towing operations. In addition, AM has provided

no written guidance to its captains describing situations in which they may be justified in

recessing operations for safety reasons. Nor does the company provide basic guidance

concerning the proper way to make up a tow or use the tow’s equipment when underway.

Company officials told the Safety Board that they rely exclusively on the knowledge,

experience, and discretion of the individual captain to decide what is safe and proper

under the prevailing circumstances.

In the Safety Board’s view, the company’s comparatively small size does not

justify AM’s attempt to place sole responsibility for safe operation of its vessels on the

captain. Regardless of corporate size, management retains responsibility and

accountability for its vessels’ operations and accidents. The Safety Board realizes that the

captain is on board the vessel and is making decisions and taking actions for which he, and

only he, can be responsible. Nevertheless, shoreside management shares or owns the

responsibility for many of the operational decisions and actions affecting vessel safety.

AM, which is not an AWO member, did not participate in the RCP and did not

have a similar safety management system. The absence of such a system meant that AM

had no comprehensive method to provide effective management oversight of safety

operations, a responsibility that the company should have proactively pursued. This

responsibility is not one that can be delegated to the towboat captain. The lack of an

effective safety management system that provided procedures governing the safe

operation of the Anne Holly was substantially responsible for creating an environment that

increased the likelihood that this accident would occur. 

Night operation increases the risk of accidents, and AM should have developed

night operations procedures for its captains. Operations during high water also pose

greater risks, and AM should have addressed them through management instruction and

policy. Certain areas of operation, such as the transit through St. Louis Harbor, present

unique risks that likewise should have been the subject of management policy and

oversight. The procedures should have anticipated the need for a helper boat and should

have delineated alternative actions that the captain might take under various foreseeable

circumstances. Moreover, the risk of collision with other river traffic is always present.

Had the Anne Holly’s tow struck and ruptured other barges loaded with petroleum

products or hazardous materials, the resulting spill could have seriously harmed the

environment. The captain should have been provided guidance concerning such an

eventuality. 

By not providing guidance through a comprehensive safety management system,

AM left the captain of the Anne Holly to his own devices to make safety-critical decisions,

increasing the likelihood that the captain would make an inappropriate decision.

Consequently, the Safety Board concludes that the captain of the Anne Holly would have
Analysis 53 Marine Accident Report

been better able to make prudent decisions concerning the operation of his tow, and this

accident might thereby have been prevented, had AM developed and implemented an

effective safety management system. The Safety Board therefore believes that AM should

develop and implement a safety management system similar to the RCP used by the

AWO; the system should establish effective policies and procedures to enhance the safety

of vessel operations.

The Safety Board has previously addressed the need for safety management

systems in the U.S. towing industry and has recommended that the Coast Guard require

such systems. As a result of its investigation of the 1996 accident involving fire aboard the

tug Scandia and the subsequent grounding of the tug and the tank barge North Cape,

63 the

Safety Board issued the following safety recommendation to the Coast Guard:

M-98-104

In conjunction with the towing vessel industry, develop and implement an

effective safety management code to ensure adequate management oversight of

the maintenance and operation of vessels involved in oil transportation by barges.

In its November 5, 1998, reply to the Safety Board, the Coast Guard stated that it

concurred with the intent of the recommendation, that it believed use of safety

management systems would result in significant benefits, and that it supported the

development of such programs. However, the Coast Guard’s letter also stated that

46 U.S.C. 3202, which affirms that U.S. domestic vessels may voluntarily meet the

requirements of the chapter, does not provide the Coast Guard with statutory authority to

require safety management systems on domestic vessels. The Coast Guard further stated

that it had issued Navigation and Vessel Inspection Circular 2–94, providing “Guidance

Regarding Voluntary Compliance with the International Management Code for the Safe

Operation of Ships and for Pollution Prevention,” and that it had worked with the AWO in

developing the RCP. The Coast Guard considered that these actions fulfilled the intent of

Safety Recommendation M-98-104 and requested that it be closed. 

In a September 22, 1999, reply, the Safety Board stated that because not all U.S.

towing companies are AWO members, some may not use the RCP, so a safety

management system remains necessary for the industry. Further, the Safety Board found

the Coast Guard’s efforts insufficient to fulfill the recommended action. Consequently, the

Safety Board classified the recommendation “Open–Unacceptable Response.”

This accident demonstrated that the Safety Board’s concern regarding the lack of

safety management systems for towing industry companies that are not AWO members

was well founded. AM was not an AWO member and had no safety management system.

Approximately 15 percent of the tonnage that is moved on U.S. waterways is transported

by towing companies that are, like AM, not AWO members. These non-AWO members

are not required to follow a safety management system similar to the RCP and therefore

may not benefit from the organized safety procedures that such systems provide. The

Safety Board concludes that the lack of a safety management system requirement for all

63 NTSB/MAR-98/03. 
Analysis 54 Marine Accident Report

U.S. towing industry companies represents a threat to waterway safety. Consequently, the

Safety Board reclassifies Safety Recommendation M-98-104 “Closed–Unacceptable

Action/Superseded” and believes that the Coast Guard should seek authority to require

domestic towing companies to develop and implement an effective safety management

system to ensure adequate management oversight of the maintenance and operation of all

towing vessels. 

Navigation Task 

Once he was committed to transiting St. Louis Harbor on the evening of April 4,

1998, the captain faced the challenging task of navigating past the MacArthur, Poplar

Street, Eads, and MLK Bridges. The captain successfully brought the Anne Holly tow

through the MacArthur and Poplar Street Bridges. Then he faced the Eads Bridge transit.

The passage of a tow through the Eads Bridge required the operator to approach

the bridge with the tow positioned to the left of the river centerline and with the tow’s head

aimed at the Illinois (right side) bridge pier of the center span. Operators of multi-barge

tows must head their tows directly into the current to navigate the Eads Bridge

successfully during high water. On nearing the Eads Bridge opening, the operator turns the

tow to the left so that it will be aligned with the current for passage through the navigation

span. Upon exiting the span, the operator moves the tow back to the right to align it for

passage through the MLK Bridge.

This steering task cannot be completed by the operator establishing the tow’s

course while he is still some distance from the bridge and driving the tow straight through

the opening. The maneuver requires that the operator begin the turns at the proper

locations, at the proper times, and with the proper amounts of rudder. The operator also

has to complete the turns appropriately by reducing the rudder angle or applying counter

rudder in the opposite direction, at the correct locations and times. According to the

testimony of the Anne Holly captain, which the Safety Board verified through discussions

with other Mississippi River towing vessel operators, these types of maneuvers are made

by sight and “feel,” based on years of experience in handling tows in a particular area.

The center of the navigation span for the Eads Bridge was marked by a fixed green

dayboard for daytime use and a fixed green light for nighttime use. The horizontal limits

of the recommended 300-foot-wide navigable channel under the bridge were marked by

two red dayboards. The Anne Holly’s captain stated that he clearly saw the center green

light and that he illuminated the red dayboards on the bridge arch with his searchlights so

that he could use them as visual cues. He also indicated that he used these visual aids, the

lights on the MLK Bridge, and his radar to align the tow for passage under the Eads

Bridge. 

The value of the radar information, however, would have diminished as the tow

approached the bridge, especially once the radar return from the bridge began to degrade

the radar screen picture. Despite the captain’s initial use of the radar, the execution of the

transit under the bridge remained essentially a visual task.
Analysis 55 Marine Accident Report

The Anne Holly captain was attempting to perform a critical visual task under less

than ideal circumstances. To complete the task successfully, he had to be in peak

physiological and mental condition. The task required that the captain remain attentive to

the headway (speed and distance traveled), feel, and handling of the tow, as well as be

ready to react quickly if he perceived that the tow was not in alignment to pass the Eads

Bridge safely. Lacking daylight visual cues, the captain would have had to rely on his

piloting skills, knowledge, experience, and memory of the currents around the Eads

Bridge to make the transit successfully. His ability to predict headway, distances, current

speed and direction, and other conditions, as well as his ability to make the most of

degraded visual cues, would factor into the task. 

A momentary lapse in attention, a slight error in estimating speed or distance, or a

minor misjudgment of the current speed or direction on the part of the captain could have

caused the accident. The path available under the bridge with sufficient vertical clearance

(of 46 feet or more) to accommodate the 105-foot-wide Anne Holly tow was only 270 feet

wide. Thus, the captain had little margin for error. Most probably, he misjudged the

alignment of his tow during the approach to the bridge and did not detect the misalignment

in time to correct it before his tow struck the bridge. The Safety Board therefore concludes

that the tow struck the Eads Bridge because of an error in judgment or a lapse of attention

on the part of the Anne Holly captain, which resulted in the tow’s misalignment. 

Factors That Could Have Affected the Captain’s Performance 

Visibility. The maneuvering of inland river towboats relies heavily on the

operator’s visual acuity and ability to make accurate visual estimates of speed and

distance. The operator not only needs to judge the speed of the tow correctly, but also to

assess the speed and effect of the currents that the tow encounters. Much of this

proficiency is developed through experience and practice. However, the towboat

operator’s ability to make accurate velocity and spatial estimations also depends on his

ability to see visual cues, in particular, changes in the current direction and tow

movement. 

Naturally, this ability is diminished when visibility is limited. The operator’s task

on the night of the accident was made unusually difficult by the darkness, particularly

given the high current speed and the tow’s length.

To provide a reference point for nighttime operations, many inland towboat

operators rig a steering light at the heads of their tows. According to the Anne Holly’s

mate, a steering light had not been lit for the tow on the night of the accident. The Coast

Guard or AM did not require use of a steering light, and use of such a light would not

necessarily have prevented this accident. Nevertheless, a steering light would have

provided an additional visual cue to help the captain judge the alignment and angular

movement of the tow.

The length of the Anne Holly tow also limited the visible cues available to the

captain. On the night of the accident, the captain’s vantage point was more than 1,000 feet
Analysis 56 Marine Accident Report

aft of the tow’s head, and the physical presence of the tow blocked his view of the water

ahead of the tow. 

Such visibility-limiting factors also would have made it more difficult for the

captain to determine the direction of the river’s current and negatively affected his ability

to perceive the tow’s headway and to estimate distances. Although darkness alone did not

cause the Anne Holly captain to strike the Eads Bridge, limited visibility of navigational

cues due to darkness made the transit through St. Louis Harbor more difficult than it

would have been in daylight. 

In maneuvering the tow through St. Louis Harbor, the captain would have

experienced background illumination from shoreside lighting and shadows near bridge

structures and a general lack of visual cues due to darkness. The Safety Board previously

investigated an accident in St. Louis Harbor in which the glare from lighting was a safety

issue.64 In that instance, the accident occurred in high water while the tow was downbound

in St. Louis Harbor at night because the operator failed to identify the navigation span of

Poplar Street Bridge in time to align the tow for safe transit. Through its investigation, the

Safety Board surmised that the background lighting in St. Louis Harbor hampered the

operator’s ability to distinguish the navigation lights on the bridge and resulted in the

operator’s misaligning the tow. In its report on this accident, the Safety Board

recommended that the Coast Guard:

M-85-23

Conduct a comprehensive review of shore lighting in St. Louis Harbor to

determine which lights adversely affect identification of bridge span navigation

lights and take action to minimize the effect of the shore lights that interfere with

bridge light identification.

The Coast Guard concurred with Safety Recommendation M-85-23. It conducted a

harbor survey and met with towboat operators to identify troublesome shore lighting so

that these lights might be altered or screened to limit their interference with safe

navigation. The Coast Guard made changes to the bridge navigation lights in St. Louis

Harbor to make them easier to distinguish from the background lights. On December 23,

1993, the Safety Board classified Safety Recommendation M-85-23 “Closed–Acceptable

Action.”

In the years since the Coast Guard conducted its survey, both the Admiral and the

Casino Queen, which are brightly lit at night, began operating in St. Louis Harbor. Given

the combined effect of the city lights along the waterfront, the lights from area marine

facilities, and the lights on the bridges, the ambient light level may be high enough to

impair the night vision of towboat operators. During the Safety Board’s public hearing on

the Admiral accident, a towboat captain who testified as an expert in St. Louis Harbor

64 National Transportation Safety Board. Ramming of the Poplar Street Bridge by the Towboat M/V Erin

Marie and Its Twelve-Barge Tow, St. Louis, Missouri, April 26, 1984. Marine Accident Report

NTSB/MAR-85/02. (Washington, DC: National Transportation Safety Board, 1985).
Analysis 57 Marine Accident Report

towing operations stated that he thought the high-intensity lights in the harbor could be

distracting and could impede night vision.

The Anne Holly captain testified that he had no trouble seeing the navigation

markers on the Eads Bridge. Nevertheless, the fact that the captain could see the

navigation markers on the bridge does not necessarily mean that he had no night vision

problems. The Safety Board, therefore, concludes that glare from shoreside lighting may

have impaired the Anne Holly captain’s night vision and may have been a factor in his

failure to align the tow properly for transit through the Eads Bridge. Consequently, the

Safety Board believes that the Coast Guard should conduct a study of the lighting in

St. Louis Harbor to determine whether the light level impairs nighttime navigation and

take corrective action as necessary. 

Postaccident Drug and Alcohol Testing. Although the results of postaccident

alcohol and drug testing for the Anne Holly captain were negative, the Safety Board is

concerned about the timeliness of the postaccident collection of testing samples. Blood or

breath and urine samples for postaccident testing must be collected before any impairing

or suspected substances are metabolized and eliminated from the body. Alcohol

metabolizes much faster than the drugs listed for postaccident testing in 46 CFR 16.350,

“Specimen analysis”; thus, a lower time limit is required for alcohol testing. Failure to

collect specimens promptly for testing will likely yield inconclusive results.

In this instance, postaccident alcohol testing was not done sooner because the Anne

Holly captain was engaged in the emergency response for the Admiral. Over a period of

hours, the Anne Holly served as a platform to hold the Admiral against the shore and to

off-load the Admiral’s patrons. Federal regulations (46 CFR 4.06–20) stipulate that

postaccident testing is to be done as “soon as practicable.” Once all the Admiral’s patrons

had been off-loaded, the Anne Holly captain was breath-tested for alcohol. Therefore, the

Safety Board concludes that, because alcohol testing could not be accomplished until

rescue operations were complete, the Safety Board is not able to eliminate the possibility

that alcohol use may have contributed to the accident. Nevertheless, the Anne Holly

captain stated under oath that he did not drink alcohol, and his videotaped interview with

the Coast Guard, taken just after the breathalyzer test, showed no evidence of impairment. 

As a marine employer, Winterville Marine is responsible for having procedures in

place for conducting drug and alcohol testing in the event that its marine employees are

involved in an accident (46 CFR 4.06–1). Following the accident, AM contacted

Winterville Marine. Winterville Marine, in turn, arranged for the dispatch of medical

technicians to St. Louis Harbor on the day after the accident.

In its May 1998 Special Investigation Report, Postaccident Testing for Alcohol

and Other Drugs in the Marine Industry and the Ramming of the Portland-South Portland

(Million Dollar) Bridge at Portland, Maine, by the Liberian Tankship Julie N on

September 27, 1996, the Safety Board issued the following safety recommendation to the

Coast Guard:
Analysis 58 Marine Accident Report

M-98-79 

Establish a requirement that postaccident testing for drugs begin within 4 hours of

a serious marine incident and postaccident testing for alcohol begin within 2 hours

of a serious marine incident, with attempts to test for alcohol ceasing after 8 hours,

and establish a requirement that the marine employer document any testing delays

or failures.

The Coast Guard responded to this recommendation on November 4, 1998, and

stated “the Coast Guard intends to initiate a regulatory project to review, and revise as

necessary, the drug and alcohol testing regulations and will include this issue in that

review.” In its July 28, 1999, reply to the Coast Guard, the Safety Board classified the

recommendation “Open–Acceptable Response.” Safety Board staff has been informed

that the Coast Guard is contemplating issuance of a notice of proposed rulemaking on this

matter sometime in fall 2000. 

The Anne Holly captain’s urine sample for drug testing was collected the day after

the accident, well beyond the 4-hour limit recommended by the Safety Board in the

Julie N report. Therefore, the Safety Board concludes that, because postaccident testing

for illicit drugs did not take place until the day following the accident, the Safety Board is

not able to eliminate the possibility that illicit drug use may have contributed to the

accident. 

Nonetheless, the captain’s medical records indicated no history of alcohol or illicit

drug abuse, and his behavior following the accident did not indicate impairment.

Therefore, the Safety Board concludes that, given the results of postaccident testing,

together with the review of the captain’s videotaped interview, and the review of his

medical records, the Safety Board found no evidence that the Anne Holly captain was

impaired by drugs or alcohol at the time of the accident. 

Fatigue. Sleep loss can result in performance degradation or variability (or both),

affecting decision-making ability, vigilance, reaction time, memory, psychomotor

coordination, and information processing.65 If the Anne Holly captain was sleep-deprived

at the time of the accident, he may have been less alert than he would have been had he

fulfilled his normal sleep requirement. Reduced vigilance could have caused him to miss

normal landmarks or other cues to navigation that he may have needed. The Safety Board

considered whether sleep loss as a consequence of the captain’s watch schedule affected

his performance. In particular, the Safety Board considered whether the captain had

adequate opportunity to obtain about 8 hours of sleep in every 24-hour period. 

During interviews with both Coast Guard and Safety Board investigators, the

captain stated that he had been operating on a standard watch schedule of 6 hours on,

65 A general description of classic research and findings on sleep deprivation and loss and human

performance can be found in sections 10.801-806 and 10.809-811 of the Engineering Data Compendium,

Human Perception and Performance, Volume III, edited by Kenneth R. Boff, Human Engineering Division,

Armstrong Aerospace Medical Research Laboratory, and Janet E. Lincoln, University of Dayton Research

Institute. Published by the Armstrong Aerospace Medical Research Laboratory, Wright-Patterson Air Force

Base, Ohio, 1988.
Analysis 59 Marine Accident Report

6 hours off in the Anne Holly pilothouse. The captain’s watch schedule shows that before

beginning the 0500 watch on April 4, 1998, he would have been off watch for 6 hours

after completing his 2300 watch on April 3.

On April 4, the captain was relieved from his 0500 morning watch at 1115. He then

went below, ate lunch, and went to bed. He said that he slept 3 1⁄2 to 3 3⁄4 hours. He got up,

took a shower, went down to the galley, visited, drank coffee, ate supper, and relieved the

pilothouse watch about 1705. While at the Eagle fleeting area, the captain had no

collateral duties during his off-watch period.

According to this schedule, in the best of circumstances, absent any emergencies

or collateral activities when off watch, the captain had about 2 1⁄4 to 2 1⁄2 hours in which to

eat two meals, shower, dress, and so forth. This time allotment is reasonable if we allow

45 minutes for each meal (including socializing with crewmembers), 30 minutes for

getting undressed and dressed, and 15 to 30 minutes for ancillary activities. Therefore, he

had about 4 hours available per off-watch period for sleep. Consequently, in the 24 hours

preceding the accident, the captain had the opportunity to obtain about 8 hours of sleep. 

Given that the captain had the opportunity to obtain about 8 hours of sleep each

day of the 26 days that he had been aboard the Anne Holly, the Safety Board could find no

clear evidence of sleep loss. However, because of the 6-on, 6-off watch schedule, the

captain’s sleep would have been split into two periods. That is, the captain could not

possibly have gotten 8 hours of continuous sleep, given the demands of his work schedule.

Therefore, the Safety Board concludes that, although the Anne Holly captain had the

opportunity to obtain about 8 hours of sleep in a 24-hour period, the sleep would

necessarily have been obtained on a split schedule. 

In 1995, the Safety Board conducted a study on factors that affect fatigue in heavy

truck accidents,66 which considered the effects of split-sleep patterns on the accident rates

for truckdrivers. The study stated:

The findings of this study show that truckdrivers with split sleep patterns were

obtaining about 8 hours of sleep in a 24-hour time period; however, they obtained

it in segments, on average of 4 hours at a time. While the research is not clear

whether split sleep constitutes or contributes to sleep loss, research has shown that

sleep accumulated in short time blocks is less refreshing than sleep accumulated

in one long time period.67 [68]

66 National Transportation Safety Board. Factors That Affect Fatigue in Heavy Truck Accidents,

Volume 1. Safety Study NTSB/SS-95/01. (Washington, DC: National Transportation Safety Board, 1995).

67 Dinges, D.F. “The Nature of Sleepiness: Cases, Contexts, and Consequences.” In: Stunkard, A.J.;

Baum, A. Perspectives in Behavioral Medicine: Eating, Sleeping, and Sex. (Hillsdale, NJ: Lawrence

Erblaum Associates, 1989) p. 147-179. 

68 NTSB/SS-95/01. p. 46.
Analysis 60 Marine Accident Report

The Safety Board’s 1995 study drew upon research69 that indicated “decrements in

performance occur earlier for drivers using sleeper berths (or drivers with split-sleep

patterns) than for other drivers.”70 The Safety Board’s truckdriver fatigue study showed a

correlation between split-sleep schedules and fatigue-related accidents. The Safety Board is

not aware of any similar studies correlating split-sleep schedules for towing vessel operators

and the towing vessel accidents in which fatigue caused or contributed to the accident.

Relatively little research exists to establish the physiological and performance

implications of the 6-on, 6-off watch schedule widely used in the towing industry.

Although the Safety Board’s 1995 study on factors affecting fatigue among drivers of

heavy trucks correlated split-sleep schedules with accident occurrences, the precise nature

of split sleep and its specific effects on performance need further research. Therefore, the

Safety Board concludes that insufficient research is available on the effects of split-sleep

schedules on the performance of inland towing industry operators for the Safety Board to

determine whether the Anne Holly captain was appropriately rested. 

As a result of its 1999 evaluation of U.S. Department of Transportation efforts to

address operator fatigue, the Safety Board made the following recommendation to the

Coast Guard:

M-99-1

Establish within 2 years scientifically based hours-of-service regulations that set

limits on hours of service, provide predictable work and rest schedules, and

consider circadian rhythms and human sleep and rest requirements.71

The Coast Guard replied to the recommendation on October 8, 1999, stating that:

While the complexities of the maritime transportation system preclude the Coast

Guard from establishing scientifically based hours of service at this time, progress

is being made on multiple levels, internationally as well as domestically, to

rationally frame and address the fatigue issue on commercial vessels. The Coast

Guard intends to continue sponsoring research domestically, and leading efforts

internationally, with the aim of identifying and promoting the best practices and

most effective countermeasures to control fatigue.

The Safety Board classified Safety Recommendation M-99-1 “Open–Acceptable

Response” on December 9, 1999. This classification anticipates that the Coast Guard will

establish, in the course of completing compliance with Safety Recommendation M-99-1,

the physiological and performance implications of various marine watchstanding

schedules currently in use, including the 6-on, 6-off watch schedule, and examine the

precise nature of split sleep and its specific effects on performance. 

69 Hertz, R.P. “Tractor-Trailer Driver Fatality: The Role of Nonconsecutive Rest in a Sleeper Berth.”

Accident Analysis and Prevention. 20(6): 431-439. 1988.

70 NTSB/SS-95/01. p. 46.

71 National Transportation Safety Board. Evaluation of U.S. Department of Transportation Efforts in the

1990s to Address Operator Fatigue. Safety Report NTSB/SR-99/01. (Washington, DC: National

Transportation Safety Board, 1999). 
Analysis 61 Marine Accident Report

Striking and Near Breakaway of the President Casino 

on the Admiral

When the Anne Holly struck the Eads Bridge, its eight lead barges broke free from

the rest of the tow and were cast adrift in the river. When three of these barges drifted near

the Admiral, they severed or severely damaged the three mooring lines at the Admiral’s

bow. The force of the impact of the barges on the Admiral resulted in the rest of the

remaining lines breaking, except for line number 7, which held. Two of the three barges

continued downriver. The third barge headed toward shore and struck, in succession, the

levee wall, the access walkway from shore, and the north (employee) gangway to the

Admiral. 

The 1999 NFESC study of the Admiral’s mooring indicates that the final mooring

line (number 7) probably would have kept the PMV from breaking away even if the Anne

Holly had not assisted the Admiral. Given the range of conditions present when the

accident occurred and the number of unknown factors that could have influenced the

outcome of the event, however, the validity of the NFESC’s supposition cannot be

guaranteed. The fact remains that only 1 of the 10 lines that moored the Admiral held

when the PMV was struck by a few relatively small vessels. Had the allision been more

severe, or had the drifting vessels been heavier or larger, a less favorable outcome could

have occurred.

The Admiral had more than 2,000 people on board and was unpowered and without

a marine crew or emergency equipment. Had the Admiral broken free from its moorings

without intervention, it would have entered a flood current and been forced downbound on

the Mississippi. The swift current would have carried the Admiral downstream where it

might have collided with the Poplar Street Bridge, which did not have sufficient vertical

clearance for the Admiral to pass underneath it in the existing flood conditions. The Safety

Board concludes that, had the Admiral broken free as a result of the allision, the

consequences could have been catastrophic, because it could have resulted in the sinking

or capsizing of the vessel, which would have placed more than 2,000 lives in jeopardy.

Survival Aspects

Drills. Although the Admiral security personnel were responsible for ensuring the

safety of patrons in an emergency, they had no training in crowd management techniques.

During the emergency response, the security personnel did not keep vessel patrons from

becoming agitated and disorderly. Respondents to the Safety Board’s postaccident

questionnaire reported that some minor injuries and considerable anxiety resulted from

people shoving them and crowds attempting to push through the single exit leading to the

Anne Holly. Had the accident been more severe, this unruly conduct might have increased

to the point of causing serious injuries or even deaths.

The fire drills held on the Admiral essentially addressed the procedures for

securing the casino and evacuating a building-type structure, rather than for assembling

and managing crowds to make an orderly evacuation. The drills did not provide alternative

actions for personnel to take if the main avenues of egress were blocked or not available.
Analysis 62 Marine Accident Report

Further, although the local fire prevention code required that fire drills be held every

90 days on the Admiral, the last such drill before the April 1998 accident was held in

June 1997. 

Clearly, local authorities did not provide adequate oversight of the company’s

responsibility to conduct periodic fire drills. Because the city of St. Louis did not require

owners to keep records of drills that had been conducted, the city was unaware that the

Admiral had gone almost 9 months between the last fire drill and the accident. In the

Safety Board’s opinion, frequent drills would have helped prepare the Admiral’s staff to

deal with a real emergency. The Safety Board concludes that President Casino’s failure to

conduct fire drills and the city of St. Louis’s failure to enforce fire drill requirements for

the Admiral contributed to a lack of casino staff preparedness to deal with emergency

situations. Therefore, the Safety Board believes that the city of St. Louis should establish

and implement oversight procedures to ensure that owners of operational PMVs

accessible to the public in St. Louis Harbor conduct and document fire drills. 

Communication. Once the Admiral’s ship-to-shore telephone lines parted during

the near breakaway, vessel personnel could not communicate with on-shore emergency

personnel. None of the emergency rescue organizations were notified from the Admiral

because the vessel had no means of communicating externally after it was struck and its

phone lines parted. Since the accident, the Admiral has installed a marine radio scanner

and a marine radio in the security office, and personnel now have access to cellular phones

that are kept in the security shift and general managers’ offices. The Safety Board is

pleased that President Casinos has installed this important communication equipment.

Another element of a successful on-board emergency response is authoritative and

helpful communication to vessel patrons and staff about the nature, scope, and status of

the emergency. During the Admiral’s near breakaway, internal communication

deficiencies were evident. President Casinos had no formal policies governing the use of

the public address system in an emergency. On the night of the accident, use of the public

address system was delayed because the staff mistakenly thought the system was

inoperable until about 2145, when the security shift manager returned to the PMV from

the shore. Thus, no use was made of the public address system until the emergency on the

Admiral had gone on for about 1 hour and 45 minutes. 

In their responses to postaccident questionnaires, a significant proportion of the

Admiral patrons who responded stated that, despite some public address announcements

and instructions from staff, patrons generally found the staff’s communication of

information not useful. They also reported that many people on board did not know what

had happened or what they should do in the accident aftermath. Respondents said that

panic and confusion may have been encouraged by the scarcity of information. Some

respondents further claimed that they incurred minor injuries caused by other patrons’

panicked attempts to evacuate the Admiral following the barge strikes. Therefore, the

Safety Board concludes that patrons on board the Admiral did not receive sufficient safety

information in the aftermath of the barge allisions to help prevent panic and confusion. To

resolve this problem, the Safety Board believes that President Casinos should develop
Analysis 63 Marine Accident Report

guidelines for making periodic public address announcements during emergencies to

provide direction and ensure patron safety. 

Crowd Management. The Admiral often accommodates thousands of patrons and

hundreds of staff members at a time. All would have to be evacuated safely in an

emergency. Such evacuations are best conducted by trained personnel who are assigned,

and trained in carrying out, specific responsibilities during an evacuation. As a result of its

investigation of a 1994 fire aboard the Argo Commodore,

72 the Safety Board issued the

following recommendation to the PVA:

M-95-43

Develop and provide to your members crew drills for on-board crew emergency

procedures/standards that include pre-incident planning for a variety of shipboard

emergencies, including fires, and the deployment of crew resources for proper

response to the emergency without compromising passenger safety.

The PVA developed a section for its Training Manual for Passenger Vessel Safety

entitled “Non-marine Crew Training” that outlines a comprehensive training program for

nonoperating crewmembers. The introduction to this section states that specialized safety

training for nonoperating employees “makes sense when management realizes that, more

often than not, [these employees] will be the first person[s] on the scene in any kind of

emergency.” Based on the PVA’s support for comprehensive training for nonoperating

employees and the organization’s development of the training manual, the Safety Board

classified Safety Recommendation M-95-43 “Closed–Acceptable Action” on July 21,

1997.

As an operator of several passenger vessels on the Mississippi River, President

Casinos, Inc., is a PVA member. Personnel on the PMV Admiral face many of the same

emergency response challenges as crewmembers of other types of large passenger vessels. 

The Safety Board understands that, since the accident, President Casinos has had

three Admiral security employees trained in crowd management techniques. The Board

considers that this effort, if continued, will improve the vessel’s on-board emergency

response capability. To ensure the development of crowd management capabilities

throughout the organization, the training should include all Admiral personnel. Such broad

provision of training is prudent because even those vessel employees who do not have

safety-related duties in an emergency can affect the response either positively or

negatively. The Safety Board noted as a result of the Bright Field investigation73 that

nonoperating crewmembers on both the Queen of New Orleans and the Creole Queen had

not received training covering the full range of emergency scenarios and were unprepared

to properly carry out their responsibilities.

72 National Transportation Safety Board, Fire Aboard U.S. Small Passenger Vessel Argo Commodore in

San Francisco Bay, California, December 3, 1994, Marine Accident Report NTSB/MAR-95/03.

(Washington, DC: National Transportation Safety Board, 1995).

73 NTSB/MAR-98/01.
Analysis 64 Marine Accident Report

According to a comment made by a patron after the Admiral allision and near

breakaway, some Admiral staff members “appeared to be just as confused as we were.”

One cashier even shouted that the vessel was sinking. Staff confusion and inflammatory

remarks can only increase the level of panic on board a vessel or a permanently moored

casino during an emergency. Training in crowd management would help staff understand

the importance of maintaining calm and order. The Safety Board concludes that Admiral

security personnel and other staff members were not adequately trained and drilled in

crowd management techniques and therefore were not successful in ensuring that the

vessel’s patrons and staff behaved in a calm and orderly fashion in the aftermath of the

April 4, 1998, accident. Therefore, the Safety Board believes that President Casinos

should require and document that all Admiral personnel receive formal training in crowd

management techniques and conduct periodic drills to reinforce this training so that vessel

staff can perform effectively in an emergency. Also, President Casinos should amend the

Admiral’s Emergency Evacuation Procedures to reflect crowd management techniques. 

St. Louis Harbor contains three PMVs in addition to the Admiral and its support

barge—the McDonald’s restaurant barge, the Robert E. Lee restaurant barge, and the

Gateway Riverboat Cruises support barge. The Robert E. Lee is not operating, but the

other two PMVs face some of the same safety challenges as the Admiral. Both are

accessible to the public, so the personnel that staff them need the same type of crowd

management training as Admiral personnel. The Safety Board concludes that formal

training in crowd management techniques for staff on all operating PMVs that are

accessible to the public would enhance safety on board PMVs. The city of St. Louis does

not require crowd management training for the staff members of any PMVs within its

jurisdiction. Because the city of St. Louis has primary enforcement responsibility for

PMVs in St. Louis, it should ensure that all operating PMVs accessible to the public have

staff trained in crowd management techniques. Therefore, the Safety Board believes that

the city of St. Louis should take the following three actions: a) require that the owners of

all operating PMVs that are accessible to the public in St. Louis Harbor provide and

document formal training in crowd management techniques for all personnel on such

vessels; b) require that periodic drills be conducted to reinforce the crowd management

training; and c) require that the vessel owners amend their emergency plans to reflect

crowd management techniques. In view of the need to ensure that such measures are

applied to all PMVs and the fact that the Coast Guard is best positioned to establish

uniform crowd control requirements, the Safety Board believes that the Coast Guard

should take the following three actions under its PWSA authority: a) require that the

owners of all operating PMVs that are accessible to the public provide and document

formal training in crowd management techniques for all personnel on such vessels;

b) require that periodic drills be conducted to reinforce the crowd management training;

and c) require that the vessel owners amend their emergency plans to reflect crowd

management techniques. 

Means of Egress. When the Anne Holly barges struck the Admiral, the standard

gangways almost immediately dropped into the water. Together, the Admiral staff, the

Anne Holly crew, and the Gateway Riverboat Cruises personnel improvised means to

evacuate patrons and staff, but they were following no directions from President Casinos
Analysis 65 Marine Accident Report

about how to do so. Also, the makeshift evacuation was a slow process, taking more than

3 hours to complete. Had the Admiral caught fire or begun to sink, such a lengthy

evacuation would have placed patrons and staff at considerable risk. 

In addition to strikes by barges or vessels, other emergency situations, such as

fires, floods, severe winds, etc., that might make the Admiral’s standard gangways

dangerous or unavailable can easily be envisioned. Nevertheless, President Casinos did

not have contingency plans for such events, and the company did not train or instruct its

personnel in how to conduct an evacuation that would not involve use of the standard

gangways. Therefore, the Safety Board concludes that the evacuation of the Admiral was

jeopardized by the lack of contingency plans for an emergency egress when the standard

gangways were not available. The Safety Board believes that President Casinos should

develop and exercise contingency plans for emergency egress from the Admiral to ensure

that occupants can exit the vessel in a timely and orderly manner when the standard means

of egress become unusable and amend the Admiral’s Emergency Evacuation Procedures

to reflect the new procedures. 

Emergency Response

After the accident, the SLFD had personnel on the scene within 15 minutes. Coast

Guard MSO St. Louis and other resources arrived shortly thereafter. The SLFD incident

commander worked effectively with the Coast Guard to halt river traffic and close bridges

during the emergency. The SLFD provided a rescue boat and medical personnel who

examined patrons with medical complaints and transported some patrons to local

hospitals.

When the Admiral’s gangways collapsed, however, SLFD rescue personnel could

not immediately board the Admiral. The lack of available means of boarding and leaving

the vessel delayed the evacuation of the Admiral, which ultimately took more than 3 hours

to complete. Therefore, the Safety Board concludes that, although local emergency

response agencies arrived on the scene in a timely manner, they were not prepared to

rescue patrons and staff from the Admiral after the standard gangways to the vessel

became unusable, which delayed the evacuation and could have put patrons and staff in

jeopardy. Consequently, the Safety Board believes that the city of St. Louis should ensure

that harbor emergency responders develop, in conjunction with local PMV owners,

including President Casinos and the McDonald’s Corporation, contingency plans for

boarding and exiting the vessels when the standard means of egress become unusable and

amend the St. Louis Harbor Emergency Response Plan to reflect the new procedures. 

Emergency Preparedness

The Coast Guard coordinated the development of the St. Louis Harbor Emergency

Response Plan in cooperation with State and local fire and rescue services and the local

marine industry. The intent of the plan was to allow the emergency response agencies, the

industry, and the Coast Guard to achieve coordinated and effective use of public and

private response resources during an emergency. Although the Coast Guard has Federal

responsibility for the overall safety of the port during an emergency, the responsibility for
Analysis 66 Marine Accident Report

emergency response rests with local fire and rescue services and State response services.

While, as a policy matter, the Coast Guard responds to emergencies to the extent that its

resources allow, it does not have primary search and rescue responsibility in inland areas,

such as St. Louis Harbor. The Coast Guard does not have firefighting or search and rescue

capabilities in St. Louis Harbor, yet its personnel helped coordinate the plan, participated

in drills, and provided information about marine risk mitigation measures to the incident

commander. The COTP also assisted in crises by restricting vessel movements on the

Mississippi River.

The Safety Board evaluated the St. Louis Harbor Emergency Response Plan and

found that it adequately identified the agencies that would participate in marine

emergency responses in St. Louis Harbor and provided a comprehensive contact listing for

critical responders. The plan further identified the interagency command and control

responsibilities of the various agencies and designated the radio frequencies to be used

during responses. 

The response plan, however, did not take into account the various types of

accidents that might occur in the harbor. For instance, the plan did not anticipate an

accident similar to that involving the Admiral on April 4, 1998—the breakaway or near

breakaway of a high-capacity PMV. The possibility of such an accident, especially during

a period of high water, was reasonably foreseeable. The St. Louis Harbor Emergency

Response Plan did not identify all foreseeable emergencies or create strategies to deal with

them. Without identifying the types and magnitudes of the possible emergencies for which

St. Louis Harbor authorities would have to be prepared, response planners could not

determine the amounts, types, and sources of emergency equipment and other resources

that would be needed to conduct a successful response. 

The 1994 exercise sponsored by the Coast Guard in New Orleans, Louisiana,

revealed that local contingency plans and responses for the New Orleans area were

inadequate for rescuing large numbers of people from the Mississippi River. The exercise

illustrated that responding to emergencies requiring the rescue of large numbers of people

from the Mississippi River can overwhelm local resources, even in municipalities that

may have greater marine resources than St. Louis.

It is conceivable that, had the Anne Holly not held the Admiral against the

riverbank on April 4, 1998, the Admiral might have broken free of its last mooring wire

and floated downriver, possibly causing collisions and sinking or capsizing under one of

the lower bridges. The risk to the Admiral and its more than 2,000 occupants would have

been high in such a scenario because the Admiral did not have means of propulsion or

navigational control, marine lifesaving equipment (such as life floats or personal flotation

devices), or an experienced marine crew.

Therefore, the Safety Board concludes that the St. Louis Harbor Emergency

Response Plan did not sufficiently prepare emergency response agencies to deal with an

emergency involving the rescue of a large number of people on or in the Mississippi River.

Consequently, the Safety Board believes that the Coast Guard should take the lead, in

cooperation with appropriate port and waterways stakeholders, to develop contingency
Analysis 67 Marine Accident Report

plans to assist in marine-related incidents, such as search and rescue operations, fires,

capsizings, or sinkings involving passenger vessels or permanently moored public

facilities within St. Louis Harbor. Also, the Coast Guard should amend the St. Louis

Harbor Emergency Response Plan to reflect these changes. 

The Safety Board also believes that the Coast Guard should conduct, in

cooperation with the States of Missouri and Illinois and the cities of St. Louis and East

St. Louis, regular drills to exercise the contingency plans for a variety of different marine

scenarios, such as stopping breakaway vessels or rescuing large numbers of people from

the Mississippi River. 

Laclede Gas Company. The severing of the natural gas supply line to the Admiral

resulted in a natural gas leak. When the line broke, natural gas began escaping. Although

the escaping gas did not ignite, one of the first priorities in any situation during which

natural gas is released should be to curtail the escape of product. 

An emergency repair team was summoned from the Laclede Gas Company to deal

with the situation. The Laclede team could not shut off the natural gas from the regulator

pit because, due to high water, the pit had filled with muddy water that prevented them

from reaching the shutoff valves. The team was able to clamp off the ruptured natural gas

hose, but by then, the leak had continued for about 3 hours.

High water is not particularly unusual in this area; on the average, the river stage at

St. Louis is 30 feet or higher more than 20 days a year. The river stage is 20 feet or higher

nearly 70 days a year, on the average. Given this environment, the designers of this system

should have considered that a facility set so close to the river might be difficult to access,

depending on the river level. Laclede should have been aware of this design weakness and

of the need to prepare its personnel to respond to emergencies affecting this regulator pit

(and others on the waterfront) under all river conditions. But the Laclede response team

had received no special preparation for responding to an emergency during high water and

had to take a trial-and-error approach to shutting off the broken line. Therefore, the Safety

Board concludes that Laclede Gas Company’s emergency responders had not been

adequately prepared to stop the uncontrolled flow of natural gas resulting from this

accident. To enable Laclede personnel to become more familiar with the special

challenges associated with riverside emergency responses, the Safety Board believes that

Laclede Gas Company should require that its emergency response teams participate in

port contingency plan drill exercises involving PMVs that are supplied with natural gas.

Because inadequate emergency response preparation may be a concern for natural gas

providers to PMVs in other jurisdictions, the Safety Board believes that the American Gas

Association and the American Public Gas Association should advise their members of the

natural gas leak that resulted from the April 4, 1998, accident affecting the Admiral in

St. Louis Harbor, and recommend that they participate in port contingency plan drill

exercises involving PMVs that are supplied with natural gas.

Federal regulations (49 CFR 192.365) require that natural gas service line valves

be placed in “a readily accessible location.” Based on the Laclede responders’ inability to
Analysis 68 Marine Accident Report

reach the valve, the Safety Board concludes that, at the time of the accident, the Admiral’s

natural gas shutoff service valve was not readily accessible. 

Laclede has taken actions to provide the Admiral and its other floating facility

customers in St. Louis Harbor with improved means of stopping the flow of gas in

emergencies. In the case of the Admiral, Laclede intends to provide a new service line and

meter station with accessible shutoff valves when the Admiral relocates to a position north

of the MLK Bridge in 2000. Laclede informed the Safety Board that it selected the new

meter station location specifically because it is removed from areas affected by flooding.

Laclede has also informed the Safety Board that it has installed valve key guides that

allow service valves to be readily accessed and operated, even during periods of highwater conditions, for the Admiral (in its current location) and the other floating facilities in

St. Louis Harbor. 

Natural gas lines serve other PMVs in U.S. ports, so inaccessible shutoff valves

may be a safety hazard common to pipelines that supply natural gas to PMVs during highwater conditions. In the case of the Admiral, it took about 3 hours to stop the escape of gas

from the service line. The delay in this instance did not have serious consequences, but a

future incident involving release of gas could have far more unfortunate results. The

Safety Board concludes that the flow from the Admiral’s ruptured natural gas supply line

was not secured in a timely manner, and such a delay could be hazardous should such an

incident recur. The Research and Special Programs Administration (RSPA) is the Federal

agency with the responsibility for ensuring that local gas companies comply with the

requirements of 49 CFR 192.365. The Safety Board believes that RSPA should require

corrective action as appropriate to ensure that pipeline operators have the means to shut

off the flow of natural gas to PMVs in a timely manner, even during periods of high-water

conditions. In the interim, the Safety Board believes that the American Gas Association

and the American Public Gas Association should urge their members to take corrective

action as appropriate to ensure that they can shut off the flow of natural gas to PMVs in a

timely manner, even during periods of high-water conditions.

Public Safety of Permanently Moored Vessels 

PMV safety falls under the purview of many entities, from the owner and local

jurisdictions, such as the fire department and the city building commissioner, to State and

Federal authorities, including the Coast Guard and USACE. The overlapping of these

authorities’ responsibilities can result in confusion or worse. In some instances, gaps in

safety have resulted because authorities have assumed that another entity is administering

PMV safety oversight. Under this assumption, these authorities have then allocated their

own limited resources to other priorities rather than using them to provide PMV oversight. 

The Coast Guard has traditionally described the system for providing marine

safety as a series of “safety nets.” The primary safety net is provided by the owner as the

entity responsible for ensuring that a safe environment is provided to its customer, the

public. The next two in the series of safety nets are provided by the owner’s flag State
Analysis 69 Marine Accident Report

(or its representative when the vessel is foreign) and by the public safety representative(s),

such as the Coast Guard. In the case of the Admiral, the Safety Board reviewed the safety

net system in a similar fashion, considering that the primary safety responsibility lies with

the owner, that the next levels of safety are provided by the local jurisdiction and the State,

and that the remaining safety assurances are provided by the Federal authorities (the Coast

Guard and USACE). This investigation looked at the safety of these vessels in a

hierarchical format, starting with the responsibilities of the owner and ending with an

assessment of the Coast Guard’s policy on PMVs from a national perspective. 

Owner’s Safety Management of the President Casino on the Admiral

President Casinos, as the owner of the Admiral, had the fundamental responsibility

to ensure the safety of the PMV and all people on board it. President Casinos also had the

corporate control, knowledge, and resources to provide an effective safety management

system but failed to do so, unnecessarily exposing the Admiral and people on board to

waterborne and current-related risks that none of the stakeholders were prepared to meet.

President Casinos was the entity most knowledgeable about its business and the

unique aspects of operating a casino on a floating platform in the Mississippi River and

was, therefore, best placed to provide the primary safety net for the PMV and its

occupants. President Casinos, Inc., operated other passenger vessels in St. Louis under the

same environment and river conditions and was knowledgeable about and experienced

with Coast Guard inspection and certification requirements for passenger vessels,

including the provisions concerning such safety features as lifesaving equipment, staffing

requirements, marine crew qualifications, and vessel operational requirements. President

Casinos was more knowledgeable than any other organization about the operation of the

Admiral, including its history of accidents and near misses while located in St. Louis

Harbor. President Casinos was also familiar with the local and State jurisdictional

authorities and the local codes and standards with which the Admiral had to comply.

President Casinos, Inc., had the corporate responsibility to establish risk reduction

measures to provide a safe operation. President Casinos, Inc., was in the best position to

understand the risks associated with marine operations because the company operated

several passenger vessels and was involved with the daily operation of the Admiral.

President Casinos, Inc., also had access to the appropriate resources (such as capital,

personnel, PVA membership, and so forth) to help mitigate the risks, and the company

controlled the corporate decision-making process. President Casinos, Inc., however, did

not take any safety action beyond complying with the regulatory requirements.

An effective safety management system is essential for the safe operation of a

high-capacity passenger vessel (regardless of whether it is in permanently moored status).

Such a system should, at a minimum:

• Describe the functions of the staff during an emergency,

• Require staff training in their respective emergency functions,

• Provide adequate fire and lifesaving equipment for passengers and staff,
Analysis 70 Marine Accident Report

• Provide appropriate shore notification,

• Provide internal communication with staff and passengers,

• Provide the capacity for communication with emergency responders,

• Provide for the safe evacuation of occupants or an adequate area of safe refuge

aboard the vessel,

• Include regular drills, and 

• Provide management oversight of the process to ensure compliance and system

viability.

President Casinos did not have a safety management system to ensure that

company responsibilities and authority were defined, risks were identified, contingency

plans were prepared, staff emergency training was provided, proper safety and response

equipment was available, and local responders were involved. A safety management

system would have also provided for a designated individual to oversee and coordinate

emergency training drills and for an audit to be conducted to ensure compliance with

company safety policies and procedures. The company did not have an effective safety

management system in place before it put the Admiral in service, nor did it implement one

once the PMV was in operation.

Risk assessment is an essential part of any effective safety management system.

President Casinos, however, did not conduct a comprehensive risk assessment before

placing the vessel in service. The owner conducted only a limited risk assessment to

evaluate the possibility of locating a protective cell upstream of the Admiral. USACE,

urged by the Coast Guard, had required during the site permit review process that such a

protective cell be installed because of concern that the Admiral had previously been struck

by tows while at that location.

The professional engineering firm hired by President Casinos determined that a

protective cell placed at the bow of the Admiral on the outboard side would present a

safety problem; that is, the firm’s report stated that, under such a cell arrangement, loose

barges would be directed into the vessel rather than away from it. Neither the owner nor

the engineering firm (which had cited three previous allisions of the Admiral by upbound

tows) then considered what type of protection would be necessary to keep loose barges

from striking the Admiral. Instead, President Casinos simply decided that because the

engineer’s report found that the proposed solution of using a single protective cell had

negative safety implications, the requirement should be rescinded.

Therefore, despite its knowledge of previous allisions, President Casinos made no

effort to mitigate the risk to the Admiral from breakaway tows or even from debris or ice

flows. Had President Casinos employed risk reduction measures, the Admiral’s ability to

survive waterborne and current-related risks would have increased. Possible risk reduction

methods included: 
Analysis 71 Marine Accident Report

• Relocating the vessel to an area that eliminates the chance of collisions,

• Installing barriers, such as fendering or crush zones, to absorb the dynamic

loading from collisions with other vessels or floating debris,

• Restricting vessel operations during high-risk conditions,

• Developing alternate escape routes for use in emergencies, and 

• Training the staff in crowd management, as is done on large cruise liners.

The operation of a high-capacity floating casino like the Admiral shares many

operational elements and safety concerns with high-capacity passenger vessels that

operate in the same area. President Casinos, Inc., was a member of the PVA and had

access to the PVA’s experience and support in the safe operation of high-capacity

passenger vessels. A President Casinos employee, in fact, drafted the chapter on

“Emergency Drills and Contingency Planning” for the PVA’s Risk Management Manual

for Passenger Vessels. The chapter cites specific examples of conditions in St. Louis

Harbor for use in developing passenger vessel marine risk contingency plans covering

events such as collisions, taking on water, losing propulsion and requiring harbor tug

assistance, moving injured people ashore, and transferring firefighters from shore to a

vessel. The Admiral is subject to the same types of risks. President Casinos developed a

contingency plan for the PMV (the Admiral’s Emergency Evacuation Procedures).

However, the risks identified in the plan did not include all the waterborne and currentrelated risks and factors cited in the PVA Risk Management Manual for Passenger Vessels.

The Safety Board concludes that President Casinos had the responsibility,

knowledge, and experience with passenger vessel operations, previous accident history,

and contingency planning, as well as the necessary management control and opportunity,

to provide an effective safety management system for the Admiral but failed to do so.

Therefore, the Safety Board believes that President Casinos should develop and

implement a safety management system for the Admiral that anticipates and provides

appropriate means of responding to all foreseeable emergencies. 

The Safety Board also believes that President Casinos should site the Admiral in a

location in which it is protected from waterborne and current-related risk events, including

breakaways, allisions, sinking, capsizing, etc. 

Local and State Oversight of Permanently Moored Vessels 

in St. Louis Harbor

The local and State jurisdictional authorities for St. Louis Harbor did not provide

adequate marine safety oversight of the owners’ responsibility to assess and mitigate

waterborne and current-related risks to the local PMVs and all people on board them.

At the time of the Admiral accident, local jurisdictional authorities, such as the

city’s public safety and fire departments, had immediate oversight responsibility for the

PMVs in St. Louis Harbor. The local authorities provided the first level of regulatory

oversight for PMV owners and the first safety net under PMV operations. The St. Louis
Analysis 72 Marine Accident Report

Department of Public Safety believed that it had met its obligation to ensure public safety

by reviewing the Admiral’s design plans to ensure that the PMV met the applicable

building codes for certain aspects of building structures, such as fire safety (according to

the requirements of the BOCA Code), electrical, mechanical, and plumbing requirements.

The St. Louis Department of Public Safety also approved the Admiral’s design and

evacuation plan for compliance with requirements for emergency exits, emergency

lighting, and fire sprinklers, as they would apply to buildings. However, the department

did not require the equivalent of below-ground structural elements, such as would be

required of a land-based structure, or any additional structural elements to protect the

Admiral from the risk of collision. Buildings, when they are designed for public

occupancy, are required to have fixed fire exits with clear access to areas of safety. The

city required no added features to ensure the long-term integrity of the Admiral’s fire exits.

According to its representative, the St. Louis Department of Public Safety was not

required to address the siting of the Admiral or marine safety aspects, such as the

possibility of the PMV’s breaking away or sinking or whether it might require flooding

alarms or emergency pumps and generators. Nor did the city consider the need for

lifesaving equipment, because such aspects are not considered during the approval

processes for buildings.

After the Coast Guard designated the Admiral as a PMV, the city of St. Louis

assumed responsibility for its safety. In the absence of Coast Guard involvement, the city

had general oversight responsibility for public safety for the entire operation. Yet city

authorities did not have a mechanism for regulating the marine safety aspects of the

operation of PMVs located in St. Louis Harbor. Local building and safety codes did not

address the waterborne and current-related risks and risk reduction measures associated

with PMVs in the harbor. The Safety Board therefore concludes that the city of St. Louis

did not exercise effective marine safety oversight for the Admiral because the city treated

the Admiral as a commercial building on land.

The State of Missouri Gaming Commission also placed safety requirements on the

operation of the Admiral. In a July 9, 1998, letter to the Safety Board, the Commission

stated that it requires its licensees to meet the minimum standards for safety and

environment established by the Coast Guard, the USACE, and the Environmental

Protection Agency. It also requires that licensed casino PMVs meet Missouri’s fire safety

standards, the NFPA’s fire safety standards for the construction and fire protection of

marine structures, and the NFPA Life Safety Code.

In addition, the Commission requires that the vessel comply with all local fire and

safety codes. However, because the Coast Guard did not impose any safety requirements

beyond “secure and substantial mooring” of the vessel and because none of the other

authorities or standards addressed all the waterborne and current-related risks to which the

Admiral was exposed, the Commission’s actions fell short of its intended purpose. 

The Commission also said in the July 1998 letter that it does not employ safety

experts but relies on government agencies with safety standard and inspection expertise.
Analysis 73 Marine Accident Report

The Commission recognized that it does not possess the requisite expertise to establish

safety standards or to provide safety oversight of the Admiral’s operations. 

Although the State Gaming Commission required the owner to contract with ABS

Marine Services to assess the stability of the Admiral and to periodically inspect its hull

and watertight closures to ensure their integrity, ABS Marine Services did not, nor was it

requested to, assess the adequacy of the mooring design, fire safety, lifesaving, or any

other marine safety systems related to the Admiral’s operation. The Safety Board therefore

concludes that the oversight provided by the State of Missouri, as represented by the State

Gaming Commission, did not address marine safety systems, such as the PMV’s mooring

design, fire safety, and lifesaving capabilities, and did not protect the safety of people on

board the Admiral.

In the Safety Board’s opinion, city and State authorities should recognize their

limitations in marine safety expertise. The Coast Guard is the primary recognized marine

safety regulatory authority and should regulate the operation of floating casinos exposed

to waterborne and current-related risks. The Safety Board therefore believes that the Coast

Guard, the city of St. Louis, and the State of Missouri should either require owners of

PMVs to protect their vessels from waterborne and current-related risks so that their

PMVs are, in fact, equivalent to buildings or require that the owners obtain Coast Guard

certificates of inspection for their PMVs. 

Also, to ensure that other jurisdictions benefit from information gained during this

investigation, the Safety Board believes that the National League of Cities and the

American Association of Port Authorities should inform their members of the April 4,

1998, near breakaway of the permanently moored Admiral in St. Louis Harbor and of the

waterborne and current-related risks associated with similarly located PMVs. 

Role of the Coast Guard 

Tows regularly pass the Admiral’s site on the Mississippi River. In an average year,

about 8,000 tows pass through St. Louis Harbor, transporting 80,000 to 85,000 barges.

Between January 1989 and April 1999, about 30 barge breakaways took place in St. Louis

Harbor. The Admiral, sited below the Eads Bridge, had been struck three times by upriver

tows before it was struck by barges from the Anne Holly tow. Thus, based on experience, a

future strike was a predictable event. In fact, during the USACE site permit process, the

Coast Guard correctly predicted that the Admiral would be struck again. As previously

stated, however, when President Casinos subsequently argued that a protective cell was

unnecessary, the Coast Guard agreed. Neither the Coast Guard nor President Casinos took

any further action to assess and mitigate the risk to the Admiral from a future allision. 

The fact that the Admiral was hit on April 4, 1998, by barges from the Anne Holly

was merely a function of circumstance; any number of breakaway or wayward vessels or

objects traveling with the river current could have struck it. The overriding consideration

is that the Admiral, as it is currently sited below the Eads Bridge, is vulnerable to allision

from breakaway tows and other vessels or objects due to its location. 
Analysis 74 Marine Accident Report

At the time of the April 1998 accident, Coast Guard policy did not provide local

Coast Guard representatives with adequate practical guidance for determining whether a

PMV was safely sited. Guidance on PMV siting could provide information on the relative

risks of various types of site locations. Such risks might include those associated with the

outside and inside bends of rivers, obstructions such as bridge piers, the water depth, and

the natural and artificial protective barriers in the vicinity. At its location directly below

the Eads Bridge in the busy Mississippi River, the Admiral was at risk from an allision and

the potential consequences of that event. Therefore, the Safety Board concludes that the

Admiral should not have been sited in a location where it was subject to waterborne and

current-related risk events, including breakaways, which could have put more than 2,000

lives in jeopardy. 

PMVs, as they are treated in existing Coast Guard policy, are unique in that they

possess certain characteristics of both vessels and buildings, so their risks do not fall

entirely into either category. A vessel, as the term is used in the Coast Guard’s enabling

statute, 46 U.S.C. Subtitle II, is defined as a craft “used or capable of being used as a

means of transportation on the water” (46 U.S.C. 2101[45], citing 1 U.S.C. 3). The Coast

Guard’s authority to regulate design, construction, equipment, staffing, and inspection of

vessels derives from Subtitle II. Most vessels, because they are subject to waterborne and

current-related risks, require Coast Guard inspection and certification under 46 U.S.C.

Subtitle II. Thus, according to the Coast Guard, if a craft is no longer “used or capable of

being used as a means of transportation on the water,” it is not subject to this Coast Guard

inspection authority.

Under such a flexible, fact-bound test, and given the wide disparity of judicial

precedent on the subject, the Coast Guard had considerable discretion in its categorization

of PMVs. The Coast Guard chose to treat all PMVs, including the Admiral, as

“substantially land structures,” which, once sited, were the regulatory responsibility of the

land jurisdiction to which they were moored. And, although the Coast Guard has extensive

and broad authority under the PWSA to act to safeguard navigation and protect waterfront

facilities and the marine environment, the Coast Guard did not exercise its authority to

protect PMV occupants. Therefore, the Safety Board concludes that the Coast Guard has

extensive discretionary authority over PMVs in navigable waters, such as the Admiral, but

has chosen not to fully exercise it. 

It is noteworthy that several large casino boats have been placed in moats in

shallow water, where they are in no danger of sinking or capsizing, and are surrounded by

enclosures so that other vessels could never allide with them. These “vessels” are not used

in transportation but are nonetheless considered “vessels” under the Coast Guard’s

inspection authority and are required to meet Coast Guard safety standards, including the

carriage of life preservers for all people on board. It is completely incongruous that these

PMVs, which are not vulnerable to waterborne and current-related risks, are under Coast

Guard safety oversight while the Admiral, which is vulnerable to such risks, is not.

The policy issued by Coast Guard headquarters regarding PMVs—the Coast

Guard’s PMV safety net—not only failed to recognize the risk to the Admiral from

breakaways, it failed to recognize that the Admiral and similar vessels would be exposed
Analysis 75 Marine Accident Report

to other serious waterborne and current-related risks. Because the Admiral was exposed to

many of the same risks as vessels in navigation, it was also vulnerable to being struck by

passing marine traffic, to sinking, and to capsizing. The Admiral, in effect, fell through the

safety nets on April 4, 1998. A major disaster may have been narrowly averted by the

Admiral’s last mooring line holding and the Anne Holly captain acting to help stabilize the

Admiral against the riverbank.

The Safety Board considers that the Coast Guard PMV policies, and the decisions

that were made based on those policies, failed to adequately protect the Admiral from the

risk of a marine accident. In essence, the Coast Guard PMV policy stated that removing

the vessel from active navigation and attaching it to land by mooring lines changed the

basic character of the Admiral so that it was no longer a vessel and ceased to be subject to

Coast Guard inspection jurisdiction. The Safety Board questions the wisdom of this policy

and of its application to the Admiral in particular. The Coast Guard was the only public

safety organization in St. Louis Harbor with the knowledge and experience to regulate the

public safety of PMVs at risk from waterborne and current-related events. 

Although the Admiral was moored in a stationary position, it was still exposed to

many of the same hazards to which it would have been exposed were it a vessel in active

navigation. Hundreds of towboats and thousands of barges passed close by the Admiral

every year. These passings were made in all weathers and at all times of the day and night.

Further, when changing conditions made navigation riskier, as when the river reached

flood stage, the risks to the Admiral likewise increased. The Admiral was vulnerable to

being struck by a passing vessel, and, if holed as a result, it could have flooded, sunk,

capsized, or broken away.

An accident involving the Admiral caused by a waterborne or current-related risk

could easily endanger 2,000 or more lives. Yet the Coast Guard PMV policy at the time of

the Admiral accident did not consider anything other than the mooring system in

determining whether the vessel would be granted PMV status. 

Instead of protecting PMVs from waterborne and current-related risk events, the

Coast Guard’s policy focused on the adequacy of the mooring arrangement. However, a

mooring system, no matter how well engineered, cannot compensate for the consequences

of locating a PMV at a risky site. As the accident demonstrated and the NFESC mooring

study confirmed, the Admiral’s mooring system, which was designed by a professional

engineer, was, as a consequence of the allision with the Anne Holly’s barges, unable to

keep the Admiral and its entry barge secure in position against the riverbank. After the

allision, without the gangways in place, emergency egress from the PMV was jeopardized.

Had the circumstances of this accident been different and had the Admiral been set adrift

in the river during flood stage, the risk to the Admiral and the people on board could have

been extreme. 

As the Coast Guard determined in its review of PMV safety, 68 percent of

waterway accidents occurred at high-risk locations, making location the single most

important factor in PMV waterborne and current-related risk. Nevertheless, the Coast

Guard PMV policy failed to account for and remedy the Admiral’s risky location through
Analysis 76 Marine Accident Report

site selection or other means. The Safety Board therefore concludes that the Coast Guard

PMV policy, as it existed at the time of the accident, did not adequately provide for the

safety of the Admiral or its patrons. 

As a result of the Bright Field, Admiral, and less prominent accidents involving

PMVs, the Coast Guard reviewed its PMV policy. In 1999, the Coast Guard revised the

policy to improve and standardize the way the Coast Guard treats PMVs. The new policy

requires all local Coast Guard OCMIs to re-evaluate the safety of all existing PMV

designations within their zones, using the risk assessment and reduction methodology

developed by the Coast Guard’s QAT for PMVs.

The Safety Board reviewed the new Coast Guard policy on PMVs and found it to

be an improvement over the policy used at the time of the Admiral accident. The Safety

Board is pleased with this Coast Guard action but considers it does not go far enough to

ensure the safety of PMV operations in U.S. navigable waters. The new policy does not

change the basic premise of the Coast Guard’s treatment of PMVs at risk from waterborne

and current-related events—that local and State authorities will eventually have safety and

enforcement responsibility over these vessels. Expecting local and State authorities to

adequately oversee and regulate PMV safety regarding waterborne and current-related

risks is unrealistic because building safety considerations do not address issues such as

collision potential, mooring requirements, or waterway safety factors. Therefore, the

Safety Board concludes that the Coast Guard’s new policy on PMVs is inadequate because

it still fails to provide for the safety of people on PMVs subject to waterborne and currentrelated risk events, including breakaways, allisions, sinking, and capsizing. Consequently,

the Safety Board believes that the Coast Guard should not allow PMVs to be sited in

locations in which they are not protected from waterborne and current-related risk events,

including breakaways, allisions, sinking, capsizing, etc. 
77 Marine Accident Report

Conclusions

Findings

1. The Anne Holly had sufficient horsepower to successfully navigate upbound through

St. Louis Harbor on the night of the accident, and the vessel did not experience any

propulsion or steering system failure.

2. The captain of the Anne Holly was sufficiently qualified, experienced, and skillful to

serve as captain on the night of the accident, and his prescription medication did not

negatively affect his performance. 

3. Weather was not a factor in this accident. 

4. No sudden rise in river level interfered with the forward movement of the Anne Holly

tow.

5. Given the difficult navigation task, the darkness, the flood conditions (which resulted

in a swift current and minimal vertical clearance at the Eads Bridge), and the lack of

a helper boat, the captain should have chosen to pursue another option on the evening

of April 4, 1998.

6. The captain of the Anne Holly would have been better able to make prudent decisions

concerning the operation of his tow, and this accident might thereby have been

prevented, had American Milling, L.P., developed and implemented an effective

safety management system.

7. The lack of a safety management system requirement for all U.S. towing industry

companies represents a threat to waterway safety.

8. The tow struck the Eads Bridge because of an error in judgment or a lapse of

attention on the part of the Anne Holly captain, which resulted in the tow’s

misalignment. 

9. Glare from shoreside lighting may have impaired the Anne Holly captain’s night

vision and may have been a factor in his failure to align the tow properly for transit

through the Eads Bridge.

10. Because alcohol testing could not be accomplished until rescue operations were

complete, the Safety Board is not able to eliminate the possibility that alcohol use

may have contributed to the accident. 

11. Because postaccident testing for illicit drugs did not take place until the day

following the accident, the Safety Board is not able to eliminate the possibility that

illicit drug use may have contributed to the accident. 
Conclusions 78 Marine Accident Report

12. Given the results of postaccident testing, together with the review of the captain’s

videotaped interview, and the review of his medical records, the Safety Board found

no evidence that the Anne Holly captain was impaired by drugs or alcohol at the time

of the accident. 

13. Although the Anne Holly captain had the opportunity to obtain about 8 hours of sleep

in a 24-hour period, the sleep would necessarily have been obtained on a split

schedule. 

14. Insufficient research is available on the effects of split-sleep schedules on the

performance of inland towing industry operators for the National Transportation

Safety Board to determine whether the Anne Holly captain was appropriately rested.

15. Had the President Casino on the Admiral broken free as a result of the allision, the

consequences could have been catastrophic, because it could have resulted in the

sinking or capsizing of the vessel, which would have placed more than 2,000 lives in

jeopardy.

16. President Casinos’s failure to conduct fire drills and the city of St. Louis’s failure to

enforce fire drill requirements for the President Casino on the Admiral contributed to

a lack of casino staff preparedness to deal with emergency situations.

17. Patrons on board the President Casino on the Admiral did not receive sufficient

safety information in the aftermath of the barge allisions to help prevent panic and

confusion.

18. President Casino on the Admiral security personnel and other staff members were

not adequately trained and drilled in crowd management techniques and therefore

were not successful in ensuring that the vessel’s patrons and staff behaved in a calm

and orderly fashion in the aftermath of the April 4, 1998, accident. 

19. Formal training in crowd management techniques for staff on all operating

permanently moored vessels that are accessible to the public would enhance safety

on board permanently moored vessels.

20. The evacuation of the President Casino on the Admiral was jeopardized by the lack

of contingency plans for an emergency egress when the standard gangways were not

available. 

21. Although local emergency response agencies arrived on the scene in a timely manner,

they were not prepared to rescue patrons and staff from the President Casino on the

Admiral after the standard gangways to the vessel became unusable, which delayed

the evacuation and could have put patrons and staff in jeopardy. 

22. The St. Louis Harbor Emergency Response Plan did not sufficiently prepare

emergency response agencies to deal with an emergency involving the rescue of a

large number of people on or in the Mississippi River.
Conclusions 79 Marine Accident Report

23. Laclede Gas Company’s emergency responders had not been adequately prepared to

stop the uncontrolled flow of natural gas resulting from this accident. 

24. At the time of the accident, the President on the Admiral’s natural gas shutoff service

valve was not readily accessible.

25. The flow from the President Casino on the Admiral’s ruptured natural gas supply line

was not secured in a timely manner, and such a delay could be hazardous should such

an incident recur.

26. The President Casino on the Admiral should not have been sited in a location where

it was subject to waterborne and current-related risks, including breakaways, which

could have put more than 2,000 lives in jeopardy.

27. President Casinos had the responsibility, knowledge, and experience with passenger

vessel operations, previous accident history, and contingency planning, as well as the

necessary management control and opportunity, to provide an effective safety

management system for the President Casino on the Admiral but failed to do so. 

28. The city of St. Louis did not exercise effective marine safety oversight for the

President Casino on the Admiral because the city treated the President Casino on the

Admiral as a commercial building on land.

29. The oversight provided by the State of Missouri, as represented by the State Gaming

Commission, did not address marine safety systems, such as the permanently moored

vessel’s mooring design, fire safety, and lifesaving capabilities, and did not protect

the safety of people on board the President Casino on the Admiral. 

30. The U.S. Coast Guard has extensive discretionary authority over permanently

moored vessels in navigable waters, such as the President Casino on the Admiral, but

has chosen not to fully exercise it.

31. The U.S. Coast Guard permanently moored vessel policy, as it existed at the time of

the accident, did not adequately provide for the safety of the President Casino on the

Admiral or its patrons.

32. The U.S. Coast Guard’s new policy on permanently moored vessels is inadequate

because it still fails to provide for the safety of people on permanently moored

vessels subject to waterborne and current-related risk events, including breakaways,

allisions, sinking, and capsizing.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the ramming of the Eads Bridge in St. Louis Harbor by barges in tow of the Anne Holly

and the subsequent breakup of the tow was the poor decision-making of the captain of the
Conclusions 80 Marine Accident Report

Anne Holly in attempting to transit St. Louis Harbor with a large tow, in darkness, under

high current and flood conditions, and the failure of the management of American Milling,

L.P., to provide adequate policy and direction to ensure the safe operation of its towboats.

The National Transportation Safety Board also determines that the probable cause

of the near breakaway of the President Casino on the Admiral was the failure of the

owner, the local and State authorities, and the U.S. Coast Guard to adequately protect the

permanently moored vessel from waterborne and current-related risks. 
81 Marine Accident Report

Recommendations

New Recommendations

As a result of its investigation, the National Transportation Safety Board makes the

following safety recommendations:

To the U.S. Coast Guard:

Seek authority to require domestic towing companies to develop and

implement an effective safety management system to ensure adequate

management oversight of the maintenance and operation of all towing

vessels. (M-00-10)

Conduct a study of the lighting in St. Louis Harbor to determine whether

the light level impairs nighttime navigation and take corrective action as

necessary. (M-00-11)

Take the following three actions under your Ports and Waterways Safety

Act authority: a) require that the owners of all operating permanently

moored vessels that are accessible to the public provide and document

formal training in crowd management techniques for all personnel on such

vessels; b) require that periodic drills be conducted to reinforce the crowd

management training; and c) require that the vessel owners amend their

emergency plans to reflect crowd management techniques. (M-00-12)

Take the lead, in cooperation with appropriate port and waterways

stakeholders, to develop contingency plans to assist in marine-related

incidents, such as search and rescue operations, fires, capsizings, or

sinkings involving passenger vessels or permanently moored public

facilities within St. Louis Harbor. Also, amend the St. Louis Harbor

Emergency Response Plan to reflect these changes. (M-00-13)

Conduct, in cooperation with the States of Missouri and Illinois and the

cities of St. Louis and East St. Louis, regular drills to exercise the

contingency plans for a variety of different marine scenarios, such as

stopping breakaway vessels or rescuing large numbers of people from the

Mississippi River. (M-00-14)

Either require owners of permanently moored vessels to protect their

vessels from waterborne and current-related risks so that their permanently

moored vessels are, in fact, equivalent to buildings or require that the

owners obtain U.S. Coast Guard certificates of inspection for their

permanently moored vessels. (M-00-15)
Recommendations 82 Marine Accident Report

Do not allow permanently moored vessels to be sited in locations in which

they are not protected from waterborne and current-related risk events,

including breakaways, allisions, sinking, capsizing, etc. (M-00-16)

To the Research and Special Programs Administration:

Require corrective action as appropriate to ensure that pipeline operators

have the means to shut off the flow of natural gas to permanently moored

vessels in a timely manner, even during periods of high-water conditions.

(P-00-14)

To the State of Missouri: 

Conduct, in cooperation with the U.S. Coast Guard, the State of Illinois,

and the cities of St. Louis and East St. Louis, regular drills to exercise the

contingency plans for a variety of different marine scenarios, such as

stopping breakaway vessels or rescuing large numbers of people from the

Mississippi River. (M-00-17)

Either require owners of permanently moored vessels to protect their

vessels from waterborne and current-related risks so that their permanently

moored vessels are, in fact, equivalent to buildings or require that the

owners obtain U.S. Coast Guard certificates of inspection for their

permanently moored vessels. (M-00-18)

To the State of Illinois:

Conduct, in cooperation with the U.S. Coast Guard, the State of Missouri,

and the cities of St. Louis and East St. Louis, regular drills to exercise the

contingency plans for a variety of different marine scenarios, such as

stopping breakaway vessels or rescuing large numbers of people from the

Mississippi River. (M-00-19)

To the City of St. Louis:

Establish and implement oversight procedures to ensure that owners of

operational permanently moored vessels that are accessible to the public in

St. Louis Harbor conduct and document fire drills. (M-00-20)

Take the following three actions: a) require that the owners of all operating

permanently moored vessels that are accessible to the public in St. Louis

Harbor provide and document formal training in crowd management

techniques for all personnel on such vessels; b) require that periodic drills

be conducted to reinforce the crowd management training; and c) require

that the vessel owners amend their emergency plans to reflect crowd

management techniques. (M-00-21)
Recommendations 83 Marine Accident Report

Ensure that harbor emergency responders develop, in conjunction with

local permanently moored vessel owners, including President Casinos,

Inc., and the McDonald’s Corporation, contingency plans for boarding and

exiting the vessels when the standard means of egress become unusable

and amend the St. Louis Harbor Emergency Response Plan to reflect the

new procedures. (M-00-22)

Conduct, in cooperation with the U.S. Coast Guard, the States of Missouri

and Illinois, and the city of East St. Louis, regular drills to exercise the

contingency plans for a variety of different marine scenarios, such as

stopping breakaway vessels or rescuing large numbers of people from the

Mississippi River. (M-00-23)

Either require owners of permanently moored vessels to protect their

vessels from waterborne and current-related risks so that their permanently

moored vessels are, in fact, equivalent to buildings or require that the

owners obtain U.S. Coast Guard certificates of inspection for their

permanently moored vessels. (M-00-24)

To the City of East St. Louis:

Conduct, in cooperation with the U.S. Coast Guard, the States of Missouri

and Illinois, and the city of St. Louis, regular drills to exercise the

contingency plans for a variety of different marine scenarios, such as

stopping breakaway vessels or rescuing large numbers of people from the

Mississippi River. (M-00-25)

To the National League of Cities (M-00-26): 

To the American Association of Port Authorities (M-00-27):

Inform your members of the April 4, 1998, near breakaway of the

permanently moored President Casino on the Admiral in St. Louis Harbor

and of the waterborne and current-related risks associated with similarly

located permanently moored vessels. 

To the American Gas Association (P-00-15 and P-00-16):

To the American Public Gas Association (P-00-17 and P-00-18):

Advise your members of the natural gas leak that resulted from the April 4,

1998, accident affecting the President Casino on the Admiral in St. Louis

Harbor and recommend that they participate in port contingency plan drill

exercises involving permanently moored vessels that are supplied with

natural gas. 

Urge your members to take corrective action as appropriate to ensure that

they can shut off the flow of natural gas to permanently moored vessels in a

timely manner, even during periods of high-water conditions. 
Recommendations 84 Marine Accident Report

To President Casinos, Inc.:

Develop guidelines for making periodic public address announcements

during emergencies to provide direction and ensure patron safety.

(M-00-28)

Require and document that all President Casino on the Admiral personnel

receive formal training in crowd management techniques, and conduct

periodic drills to reinforce this training so that vessel staff can perform

effectively in an emergency. Also, amend the President Casino on the

Admiral’s Emergency Evacuation Procedures to reflect crowd management

techniques. (M-00-29)

Develop and exercise contingency plans for emergency egress from the

President Casino on the Admiral to ensure that occupants can exit the

vessel in a timely and orderly manner when the standard means of egress

become unusable and amend the President Casino on the Admiral’s

Emergency Evacuation Procedures to reflect the new procedures.

(M-00-30)

Develop and implement a safety management system for the President

Casino on the Admiral that anticipates and provides appropriate means of

responding to all foreseeable emergencies. (M-00-31)

Site the President Casino on the Admiral in a location in which it is

protected from waterborne and current-related risk events, including

breakaways, allisions, sinking, capsizing, etc. (M-00-32)

To the Laclede Gas Company:

Require that your emergency response teams participate in port

contingency plan drill exercises involving permanently moored vessels that

are supplied with natural gas. (P-00-19)

To American Milling, L.P.: 

Develop and implement a safety management system similar to the

Responsible Carrier Program used by the American Waterways Operators;

the system should establish effective policies and procedures to enhance

the safety of vessel operations. (M-00-33)
Recommendations 85 Marine Accident Report

Previously Issued Recommendations Classified in This Report

To the U.S. Coast Guard:

In conjunction with the towing vessel industry, develop and implement an

effective safety management code to ensure adequate management

oversight of the maintenance and operation of vessels involved in oil

transportation by barges. (M-98-104)

Safety Recommendation M-98-104 (previously classified “Open–Unacceptable

Response”) is classified “Closed–Unacceptable Action/Superseded” in the “Captain’s

Decision-making” section of this report. It is superseded by Safety Recommendation

M-00-10, issued in this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

James E. Hall

Chairman

John A. Hammerschmidt

Member

John J. Goglia

Member

George W. Black, Jr.

Member

Carol J. Carmody

Member

Adopted: September 8, 2000

87 Marine Accident Report

Appendix A

Investigation and Hearing 

The National Transportation Safety Board was notified of this accident early in the

morning of April 5, 1998, and launched a four-person investigative team that arrived in St.

Louis, Missouri, in late afternoon. The team consisted of an investigator-in-charge and

survival factors, human performance, and engineering factors investigators. That evening,

the Captain of the Port of the U.S. Coast Guard Marine Safety Office in St. Louis briefed

the team. A Board Member arrived on scene on April 7. 

The Safety Board investigated the accident under the authority of the Independent

Safety Board Act of 1997, according to Safety Board rules. Team members conducted

interviews from April 7 through 10, and on April 15. The team viewed the damage on the

President Casino on the Admiral and interviewed crewmembers of the towing vessel Anne

Holly, including the captain, pilot, mate, deckhands, and chief engineer. The team

interviewed representatives from the U.S. Army Corps of Engineers and the Coast Guard,

the master on watch of the Casino Queen, St. Louis emergency response personnel, and an

American Bureau of Shipping surveyor. Safety Board investigators also spoke with

personnel from the President Casino on the Admiral, including the Missouri State gaming

officer, the senior shift manager who had been on duty when the accident took place, the

vessel’s former marine manager, and the casino manager.

The designated parties to the Safety Board’s on-scene investigation were the Coast

Guard; President Casinos, owner of the Admiral; and American Milling, L.P., owner of the

Anne Holly. A public hearing on this accident was held in St. Louis, Missouri, on July 23

and 24, 1998. The parties to the public hearing were the Coast Guard; President Casinos;

the city of St. Louis, Missouri; and the U.S. Army Corps of Engineers. 
88 Marine Accident Report

Appendix B

Damage to Anne Holly Barges

Barge Hull Damage Cargo Damage

SB 15B $35,000 $30,000

CGB 219B $20,000 -0-

PIN 348 $100,000 $125,000

ABC 767 $150,000 $15,000

MWO 211 $10,000 -0-

Total $315,000 $170,000
89 Marine Accident Report

Appendix C

Characteristics of Barges in Anne Holly Tow

*In order, forward to aft. 

NAME

LENGTH 

(feet) BEAM (feet)

DRAFT 

(estimated)

CARGO 

TONNAGE CARGO TYPE

Port Position*

ABC 767 195 35 6 ft., 6 1/2 in. 981 Cottonseed

PIN 348 200 35 9 ft., 5 in. 1,638 Fertilizer

SUN 363 200 35 9 ft., 3 in. 1,638 Fertilizer

SB 15B 200 35 9 ft., 5 in. 1,643 Clay

RM 41 200 35 9 ft., 8 1/2 in. 1,696 Fertilizer

Center Position

MWO 211 195 35 6 ft., 9 1/2 in. 1,037 Cottonseed

CGB 277 200 35 9 ft. 1,553 Fertilizer

CSV 9605 200 35 9 ft., 1 1/2 in. 1,575 Fertilizer

CMM 2 200 35 9 ft., 4 in. 1,626 Fertilizer

PMC 8101 200 35 9 ft., 7 1/2 in. 1,682 Fertilizer

Starboard Position

ITEL 206 200 35 1 ft., 9 in. empty N/A

CGB 219B 200 35 1 ft., 9 in. empty N/A

FIC 526 195 35 8 ft., 11 in. 1,476 Fertilizer

TCKM 1 200 35 9 ft., 1/2 in. 1,563 Fertilizer

Total

Total Cargo 18,108
90 Marine Accident Report

Appendix D

Mooring Wires for the President Casino on the Admiral

The President Casino on the Admiral (Admiral) was moored with 10 mooring

wires: 

• Number 1 wire: (11⁄2 inch diameter) Attached to the facility’s entry barge and

to the anchor upstream of the structure. This wire was put into service 23

months before the accident. 

• Number 2 wire: (11⁄4 inch diameter) Attached to a deadman upstream from the

entry barge. This wire was put into service 55 months before the accident. 

• Number 3 wire: (11/8 inch diameter) Attached to a deadman at the forward end

of the entry barge, forward of the employee gangway. This wire was put into

service 22 months before the accident. 

• Numbers 4 and 5 wires: (11/8 inch diameter) Attached to a deadman on the

levee parallel to the center gangway with one wire on each side. These wires

were put into service 26 and 2 months, respectively, before the accident. 

• Number 6 wire: (11/8 inch diameter) Attached to the entry barge and a

deadman downstream of the entry barge. This wire was put into service 55

months before the accident. 

• Number 7 wire: (11⁄2 inch diameter) Attached to the entry barge and the

anchor downstream of the structure. This wire was put into service 14 months

before the accident. 

• Numbers 8 and 9 wires: (11/8 inch diameter) Attached to the Admiral bow and

deadmen upstream of the Eads Bridge. These wires were put into service 12

and 24 months, respectively, before the accident. 

• Number 10 wire: (11/8 inch diameter) This was a breast wire attached to the

Admiral’s bow and to a deadman upstream of the Eads Bridge. This wire was

put into service 48 months before the accident. 

Before the “Great Flood of 1993,” the Admiral had eight mooring wires. During

the first rise of the 1993 flood waters, the chief engineer on the Admiral and the Chief of

Marine Operations decided to add the head and bow wires to the Admiral mooring. The St.

Louis gage reached 49.5 feet on August 1, 1993. From the beginning of April through

early October 1993, St. Louis experienced flood waters (over 30 feet on the gage) except

for a period from the end of May to the end of June when the river stage was at high water.

A permanently moored heliport, the permanently moored Burger King barge, and a

minesweeper were damaged and broke away from their moorings in 1993. The Admiral,

the Gateway Riverboat Cruises barge (and the two small passenger vessels moored to it),

the Robert E. Lee, and the McDonald’s riverboat remained secure to their moorings.
91 Marine Accident Report

Appendix E

Coast Guard List of PMVs in the United States

List of Permanently Moored Vessels as of November 20, 1998

PORT VNAME MAX PAS LATITUDE LONGITUDE RIVER MILE

1 BALTIMORE EX USCGC TANEY NA PATAPSCO RIVER

2 BALTIMORE TORSK NA PATAPSCO RIVER

3 BALTIMORE CHESAPEAKE NA PATAPSCO RIVER

4 BALTIMORE CONSTELLATION NA PATAPSCO RIVER

5 BOSTON MAYFLOWER II (FRAZIER PIER) 75 PLYMOUTH, MA

6 BOSTON DISCOVERY (LONG WHARF) 1500 BOSTON, MA

7 BOSTON MERRIMAC QUEEN (BURROUGH’S) 150 BOSTON, MA

8 BOSTON FORT WARREN (LONG WHARF) 342 BOSTON, MA

9 BUFFALO USS CROAKER 40 BUFFALO RIVER 0.9

10 BUFFALO USS SULLIVANS 150 BUFFALO RIVER 0.9

11 BUFFALO USS LITTLE ROCK 600 BUFFALO RIVER 0.9

12 CHICAGO COLUMBIA YACHT CLUB 500 N415303 W0873635

13 CHICAGO USS SILVERSIDES 40 N431348 W0862000

14 CHICAGO IDLER 150 N422418 W0861626

15 CLEVELAND USS COD 72 N413038 W814130

16 CLEVELAND S/S/WILLIAM G MATHER 125 N413040 W814147

17 CLEVELAND HORNBLOWERS 225 N413038 W814129

18 CORPUS CHRISTI LANDRY’S RESTAURANT 200 N27477 W097235

19 DULUTH S/S WILLIAM A IRVING 100

20 DULUTH M/V LAKE SUPERIOR 40

21 DULUTH S/S EDNA G 40

22 GUAM ASHORE RESTAURANT SAIPAN

23 GUAM REEF WALKER GUAM

24 HAMPTON ROADS DISCOVERY 25 N37125 W76468 JAMESTOWN ISLAND

25 HAMPTON ROADS JAMES RIVER RESERVE FLEET UNK N3768 W76389 JAMES RIVER

26 HAMPTON ROADS HUNTINGTON 10 N36506 W76176 ELIZABETH RIVER

27 HONOLULU FALLS OF CLYDE 300 HONOLULU, HI

28 HONOLULU USS BOWFIN 70 PEARL HARBOR

29 HONOLULU BRIG CARTHAGINIAN 50 LAHAINA, MAUI, HI

30 HUNTINGTON W.P. SNYDER <50 MUSKINGUM RIVER 0.5

31 HUNTINGTON BECKY THATCHER <350 MUSKINGUM RIVER 0.3

32 HUNTINGTON SHOWBOAT MARINA <100 N38241 W082333 OHIO RIVER 305

33 JACKSONVILLE LLOYD’S RESTAURANT 30 CAPE CANAVERAL

34 JACKSONVILLE PROFESSIONAL OFFICE COMPLEX 50 TAVARES, FL

35 LA/LB NAUTICAL HERITAGE MUSEUM 150 NEWPORT HARBOR

36 LA/LB SCORPION (RUSSIAN SUB) 100

37 LA/LB QUEEN MARY 1000 SAN PEDRO BAY

38 LONG ISLAND REGINA MARS 50 GREENPORT, NY

39 LONG ISLAND NANTUCKET 40 BRIDGEPORT, CT

40 LONG ISLAND CHARLES MORGAN 100 MYSTIC, CT

41 LONG ISLAND JOSEPH CONRAD 50 MYSTIC, CT

42 LONG ISLAND L.A. DUNTON 50 MYSTIC, CT

43 LONG ISLAND GOV BRYANT (INACTIVE) 30 N4139 W070165

44 LOUISVILLE SHOWBOAT MAJESTIC 233 OHIO RIVER 470

45 LOUISVILLE TOW BOAT ANNIES 400 OHIO RIVER 603.8

46 LOUISVILLE HARVEY’S ON THE RIVER 150 OHIO RIVER 589.9

47 LOUISVILLE FORE & AFT RESTAURANT 300 OHIO RIVER 484

48 LOUISVILLE STAR OF LOUISVILLE LANDING 350 OHIO RIVER 603.7

49 LOUISVILLE THE WHARF 130 OHIO RIVER 558

50 LOUISVILLE MIKE FINK’S 450 OHIO RIVER 470.5

51 LOUISVILLE SLOPPY JOES 233 OHIO RIVER 470

52 LOUISVILLE HOOTER’S 354 OHIO RIVER 470

53 LOUISVILLE REMINGTON’S 350 OHIO RIVER 469.5

54 LOUISVILLE RIVERSIDE 4 60 OHIO RIVER 469

55 LOUISVILLE FOUR SEASONS 250 OHIO RIVER 464

56 LOUISVILLE ANCHOR INN 250 OHIO RIVER 465.5

57 LOUISVILLE BARLEYCORN’S 784 OHIO RIVER 470

60 LOUISVILLE WATERFRONT RESTAURANT 1700 OHIO RIVER 471

61 LOUISVILLE COVINGTON’S LANDING (CLOSED) OHIO RIVER

62 MEMPHIS LAS VEGAS CASINO 1132 N33250 W091040 UMR

63 MEMPHIS JUBILLEE CASINO 1500 N33251 W091040 UMR

64 MEMPHIS LIGHTHOUSE POINT CASINO 1800 N33252 W091040 UMR

65 MIAMI WATERWAY CLIPPER 53 N26500 W080044

66 MIAMI LOBSTER WALK (INACTIVE) 40 N24517 W0804365

67 MIAMI CAPTAIN RUNAGROUND 50 N24335 W0814715

68 MILWAUKEE USS COBIA 35 MANITOWOC RIVER 0.2
Appendix E 92 Marine Accident Report

69 NEW ORLEANS CASINO MAGIC BAY 5000 N30170 W089260 BAY ST LOUIS

70 NEW ORLEANS SHREVE STAR 1925 RED RIVER 277

71 NEW ORLEANS LADY OF THE ISLE 1925 RED RIVER 276

72 NEW ORLEANS QUEEN OF THE RED (INACTIVE) 1850 RED RIVER 276

73 NEW ORLEANS LADY LUCK CASINO 2000 N41322 W090310 UMR 485.5

74 NEW ORLEANS ISLE OF CAPRI 2000 N32200 W090550 LMR 436

75 NEW ORLEANS KING OF THE RED 2930 RED RIVER 276

76 NEW ORLEANS MARY’S PRIZE 1925 RED RIVER 275

77 NEW ORLEANS AMERISTAR CASINO 2000 N32200 W090550 LMR 436

78 NEW ORLEANS RAINBOW CASINO 2000 N32150 W090533 YAZOO RIVER 1

79 NEW ORLEANS HARRAH’S CASINO 2000 N32300 W090124

80 NEW YORK LEHIGH VALLEY RR BRGE79 100 N40403 W074011

81 NEW YORK USS SLATER 0 N42383 W073450

82 NEW YORK BARGE MUSIC 140 N40421 W0730595

83 NEW YORK USS GROWLER 15 N40456 W074001

84 NEW YORK USS INTREPID 3500 N40456 W074001

85 NEW YORK USS EDSON 250 N40456 W074001

86 NEW YORK 3 UNNAMED BARGES 150 N40456 W074001

87 NEW YORK PEKING 200 N40222 W074001

88 NEW YORK AMBROSE LIGHT SHIP 125 N40222 W074001

89 PADUCAH QUEEN OF CLARKSVILLE BRD BRG CUMBERLAND RIVER 125.5

90 PADUCAH CHATTANOOGA STAR BRD PLAT TENNESSEE RIVER 464.5

91 PADUCAH THE STAR BRD PLAT TENNESSEE RIVER 648.3

92 PADUCAH SOUTHERN BELLE BRD BRG TENNESSEE RIVER 464

93 PADUCAH PLAYER’S ISLAND CASINO OHIO RIVER 943.7

94 PADUCAH OPRYLAND RIVER TAXIS BRD BRGE CUMBERLAND RIVER 191

95 PHILADELPHIA OLYMPIA 350 N39565 W075085 DELAWARE RIVER

96 PHILADELPHIA BECUNA 100 N39565 W075085 DELAWARE RIVER

97 PHILADELPHIA HOOTER’S 500 N39575 W075082 DELAWARE RIVER

98 PHILADELPHIA MOSHULU 490 N39564 W075085 DELAWARE RIVER

99 PHILADELPHIA AMERICANA 110 N38570 W074546 CAPE MAY

100 PITTSBURGH REGATTA BEER BARGE 400 OHIO RIVER 0

101 PITTSBURGH SCIENCE CENTER SUB 300 OHIO RIVER 0.5

102 PITTSBURGH GATEWAY CLIPPER 810 MONONGHELA RIVER 0.5

103 PITTSBURGH CAPT ED’S DOCK 650 OHIO RIVER 0.93

104 PITTSBURGH CREWSER’S DOCK 3000 ALLEGHENY RIVER 1.5

105 PORTLAND USS BLUEBACK 100 WILLIAMETT RIVER 13.5

106 PORTLAND DIMILLO’S FLOATING RESTAURANT 700 PORTLAND, ME

107 PORTLAND JOHN WANNAMAKER 200 PORTSMOUTH HARBOR, NH

108 PORTLAND PORTLAND 100 WILLIAMETT RIVER 12.5

109 PORTLAND COLUMBIA 25 WILLIAMETTE RIVER 15

110 PROVIDENCE BIG BOB’S BARGE

111 PROVIDENCE NEW BEDFORD

112 PROVIDENCE LION FISH

113 PROVIDENCE JOE KENNEDY

114 PROVIDENCE HIDDEN SEA

115 PROVIDENCE GOV BRANT (INACTIVE) N4139 W070165

116 PROVIDENCE USS MASSACHUSETTS (INACTIVE) 30 N4139 W070165

117 PUGET SOUND WAWONA 100 N47376 W122202

118 PUGET SOUND COEUR D’ALENE FLOATING GREEN 15 N4741 W11645

119 PUGET SOUND CHALLENGER 12 N47389 W122198

120 PUGET SOUND SKANSONIA 150 N47389 W122198

121 PUGET SOUND USS TURNER JOY 300 N4733 W12239

122 PUGET SOUND EMERALD QUEEN 400 N47158 W122233

123 SAN FRANCISCO CGC RELIEF PORT OF OAKLAND

124 SAN FRANCISCO TELCO HYDE ST PIER

125 SAN DIEGO STAR OF INDIA 450 N32432 W117105

126 SAN DIEGO BERKLEY 1400 N32433 W117105

127 SAN DIEGO CHARLEY BROWN’S 640 N32435 W117113

128 SAN FRANCISCO USS HORNET ALEMADA

129 SAN FRANCISCO ALAMAR SACRAMENTO RIVER

130 SAN FRANCISCO FRESNO PORT OF RICHMOND

131 SAN FRANCISCO RED OAK VICTORY PORT OF RICHMOND

132 SAN FRANCISCO VIRGIN TURGEON SACRAMENTO RIVER

133 SAN FRANCISCO SAN JOAQUIN YACHT CLUB 184 N380100 W1213850

134 SAN FRANCISCO S/V BALCLUTHA 100 N374836 W1222523

135 SAN FRANCISCO M/V EPPLETON HALL 5 N374845 W1222520

136 SAN FRANCISCO S/V C.A. THAYER 50 N374834 W1222518

137 SAN FRANCISCO S/V ALMA 40 N374838 W1222524

138 SAN FRANCISCO M/V HERCULES 20 N374836 W1222522

139 SAN FRANCISCO M/V EUREKA 100 N374833 W1222519

140 SAN FRANCISCO USS PAMPANITO (SS383) 70 N374830 W1222506

141 SAN FRANCISCO M/V DELTA KING 1250 N383430 W1213030

142 SLT ST MARIE MAPLE 23 N45 52 W084 43

143 ST LOUIS RIVERPORT PLAYER’S ISLAND MISSOURI RIVER 32

List of Permanently Moored Vessels as of November 20, 1998 (cont.)

PORT VNAME MAX PAS LATITUDE LONGITUDE RIVER MILE
Appendix E 93 Marine Accident Report

144 ST LOUIS GOLDENROD THEATRE BOAT MISSOURI RIVER 29

145 ST LOUIS ST CHARLES CASINO SPT BRGE N37032 W089231 UMR 29.5

146 ST LOUIS PRESIDENT CASINO SPT BRGE N41308 W090332 UMR 482.5

147 ST LOUIS LACROSSE QUEEN PASS BRGE UMR 888

148 ST LOUIS LONGNECKER RESTAURANT N40235 W091225 UMR 364

149 ST LOUIS CADIE HOOPER RESTAURANT N40380 W089400 ILR 162.5

150 ST LOUIS MISSISSIPPI BELLE SPT BRGE N41501 W090110 UMR 518

151 ST LOUIS ARGOSY V SPT BRGE MISSOURI RIVER 731.8

152 ST LOUIS CATFISH BEND SPT BRGE N40363 W091161 UMR 383

153 ST LOUIS PADDLEFORD OFFICE N44560 W093050 UMR 840

154 ST LOUIS NO WAKE CAFE N44560 W093050 UMR 839.8

155 ST LOUIS ROBERT E LEE RESTAURANT N38374 W090106 UMR 179.6

156 ST LOUIS CASINO VESSEL ADMIRAL N38366 W090110 UMR 179.9

157 ST LOUIS ADMIRAL SUPPORT BARGE N38366 W090110 UMR 179.9

158 ST LOUIS GATEWAY SUPPORT BARGE N38374 W090106 UMR 179.6

159 ST LOUIS MACDONALD’S RESTAURANT N38366 W090110 UMR 179.3

160 ST LOUIS CASINO ROCK ISL SPT BRGE N41308 W090332 UMR 482.5

161 TAMPA BAY “SUBMARINE” 60 ST PETE PIER, ST PETE

162 TOLEDO SS WILLIS BOYER 1000 MAUMEE RIVER 5.16

List of Permanently Moored Vessels as of November 20, 1998 (cont.)

PORT VNAME MAX PAS LATITUDE LONGITUDE RIVER MILE
94 Marine Accident Report

Appendix F

Coast Guard February 17, 2000, Letter to 

the Safety Board on PMVs
Appendix F 95 Marine Accident Report
Appendix F 96 Marine Accident Report
Appendix F 97 Marine Accident Report
Appendix F 98 Marine Accident Report
99 Marine Accident Report

Appendix G

Coast Guard PMV Initial Risk Assesment Form
100 Marine Accident Report

Appendix H

Conclusions and Recommendations 

of the QAT for PMVs
Appendix H 101 Marine Accident Report
Appendix H 102 Marine Accident Report
Appendix H 103 Marine Accident Report
104 Marine Accident Report

Appendix I

Draft Coast Guard Marine Safety Manual Change
Appendix I 105 Marine Accident Report
Appendix I 106 Marine Accident Report
Appendix I 107 Marine Accident Report
Appendix I 108 Marine Accident Report