PB96-916402

NTSB/MAR-96/01/SUM

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

MARINE ACCIDENT/INCIDENT

SUMMARY REPORT

CAPSIZING OF QUESTAR MOTORBOAT AND

DROWNING OF OPERATOR SOUTH OF SHELTER

ISLAND NEAR JUNEAU, ALASKA

AUGUST 21,1994

6746
Abstract: This summary report discusses a 1994 fatal accident in which a disabled 18-foot

Questar motorboat with the vessel’s owner and one passenger aboard capsized while being towed

by the Coast Guard Auxiliary vessel PUPPET near Juneau, Alaska.

The safety issues discussed in this report are communications during the 1994 Golden

North Salmon Derby, policy on the use of Coast Guard Auxiliary resources in hazardous weather

and sea conditions, policy on removal of passengers from towed vessels, risk assessment training

of Coast Guard Auxiliary personnel involved in search and rescue operations, and policy on

postaccident toxicological testing of Coast Guard Auxiliary personnel involved in marine

accidents.

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.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
National Transportation

Safety Board

Washington, D.C. 20594

MARINE ACCIDENT/INCIDENT SUMMARY

Accident Number: DCA-95-MM-032

Accident Vessel Owner/Operator: Kirby G. Dale

Vessels: Questar motorboat, 18 feet 6 inches long, Alaska State No. 

AK 9955K, fiberglass hull and deckhouse, built in 1987

Coast Guard Auxiliary Vessel PUPPET, O.N. 681658,

48 feet long, 36 gross tons, built in 1985, uninspected

Accident Type: Capsizing

Location: Immediately south of Shelter Island on Lynn Canal near 

Juneau, Alaska

Date: August 21, 1994

Time: 1433 (Local)

Property Damage: Approximately $10,000

Injuries: 1 Death

Accident Vessel Complement: 1 Operator

1 Passenger

On August 21, 1994, a disabled 18-foot Questar motorboat with the vessel’s owner and

one passenger on board capsized while being towed by the Coast Guard Auxiliary vessel

PUPPET immediately south of Shelter Island, Lynn Canal, near Juneau, Alaska. The Questar’s

owner, who was mildly disabled, was trapped inside the vessel’s cabin and was drowned. The

passenger was not injured.

In examining the Coast Guard’s safety management during the 1994 Golden North

Salmon Derby and the incident involving the Questar, the Safety Board identified five significant

safety issues: communications during the derby, policy on the use of Coast Guard Auxiliary

resources in hazardous weather and sea conditions, policy on removal of passengers from towed

vessels, risk assessment training of Coast Guard Auxiliary personnel involved in search and

rescue operations, and policy on postaccident toxicological testing of Coast Guard Auxiliary

personnel involved in marine accidents.

INVESTIGATION AND ANALYSIS

THE ACCIDENT

uring the morning and early afternoon

of August 21, 1994, two men, the

owner/operator, 45, and his passenger,

26, aboard an 18-foot Questar motorboat (see

figures 1 and 2), were participating in the

Golden North Salmon Derby south of Shelter

Island, Lynn Canal, near Juneau, Alaska (see

figure 3). The derby is an annual 3-day fishing

tournament held in the Juneau area to raise

scholarship funds. The Coast Guard estimated

that up to 1,000 vessels would participate in the

derby. The weather was overcast with showers,

the wind was out of the south at 25-30 knots,

and the seas were 3-5 feet. Sea water

temperature was about 55 °F. The National

Weather Service in Juneau had issued a small

craft advisory1

 for the Eastern Gulf Coast of

Alaska, including the Lynn Canal and area

around Juneau.

Shortly after noon, the operator of the

Questar tied the motorboat to the fish packing

vessel KAMILAR, anchored near the south end

of Shelter Island, to discharge his catch of fish.

While next to the KAMILAR, the Questar took

on water over its side from boarding seas. About

1230, as the Questar was pulling away from the

KAMILAR, the outboard engines stopped. The

motorboat drifted southwesterly toward

Admiralty Island for 30-45 minutes as the crew

made numerous unsuccessful attempts to restart

the engines. The Questar’s operator did not have

a radio and flagged down a nearby recreational

boat, the IDLE HOURS, to ask for help. The

Questar’s operator asked the IDLE HOURS’

operator to call the Coast Guard for assistance.

The IDLE HOURS was unable to reach the

Coast Guard by VHF/FM radio because of the

volume of traffic on channel 16, the VHF

 1

A small craft advisory is a notice that alerts mariners

to sustained weather or sea conditions that might be

hazardous to small vessels.

calling and distress frequency monitored by the

Coast Guard.

The Coast Guard Auxiliary vessel PUPPET,

a 48-foot Nordic fiberglass motorboat, was

standing by in the Saginaw Channel on the west

side of Shelter Island. The PUPPET was under

the tactical control of Coast Guard Station

Juneau in support of the 1994 Golden North

Salmon Derby. The PUPPET was under the

command of a Coast Guard Auxiliary operator,

whose wife, an Auxiliary Boat Crew Member,

comprised the crew. Both individuals, who were

the vessel’s owners, had 17 years of experience

in the Coast Guard Auxiliary and, together,

almost 350 patrols and 30 towing assists. Also

aboard the PUPPET that day were four guests: a

Coast Guard Chief Radioman assigned to the

Coast Guard 17th District Communication

Center in Juneau, his wife, and their two

children.

The Chief Radioman overheard the IDLE

HOURS’ radio call to the 17th District

Communication Center relaying the Questar’s

request for assistance. He helped the two parties

shift their radio conversation to a Coast Guard

working frequency, channel 22, normally used

by the 17th District Communication Center. The

PUPPET’s operator was fishing off the stern of

his vessel at the time and was unaware of these

radio conversations.

The operator of the IDLE HOURS indicated

to the Coast Guard that his vessel did not have

sufficient power to tow the Questar to Auke

Bay, a small harbor about 5 nautical miles

southeast of the south end of Shelter Island. The

Coast Guard Chief Radioman aboard the

PUPPET radioed the 17th District

Communication Center and stated that he was

familiar with the Questar and that the PUPPET

would be on-scene within the hour to assist. The

Chief Radioman informed the PUPPET’s

operator that he had just committed the

D


4

PUPPET to a case, and the vessel got under way

shortly thereafter.

As the PUPPET motored toward the south

end of Shelter Island, the operator directed that

the towline and bridle be laid out on the

afterdeck. He discussed the upcoming tow with

the Coast Guard Chief Radioman, who

mentioned that he had seen the Questar before.

The operator stated that he believed his

guest, the Chief Radioman, was experienced in

small boat search and rescue (SAR) and that he

therefore did not question him about picking up

the Questar. The Chief Radioman later told

investigators that his career was in the

communications field and that he had little

practical seamanship experience in small boat

SAR operations. In effect, the operator of the

PUPPET allowed the Chief Radioman to assume

the responsibilities assigned to the PUPPET’s

Auxiliary crewmember. Coast Guard policy

prohibits guests’ involvement in Auxiliary

patrol activities.

Meanwhile, the IDLE HOURS had towed

the Questar back to the KAMILAR and secured

the vessel alongside, initially tying it to the

weather side of the KAMILAR. The Questar’s

low freeboard and open decks allowed seas to

flood the vessel, requiring that the crew bail out

the water and run the bilge pump. The Questar

was eventually moved to the leeward side of the

KAMILAR to await the arrival of the PUPPET.

About 1425, the PUPPET arrived on scene

and prepared to take the Questar in tow. The

PUPPET’s operator did not discuss alternatives

to being towed, the Questar’s condition, or the

physical condition of the Questar’s operator and

passenger. The Auxiliary operator of the

PUPPET was unaware that the Questar had

flooded and was susceptible to flooding from

rough seas and that the Questar’s operator had

medical disabilities.2

 After advising the vessel’s

occupants to don their personal flotation devices

 2

The Questar’s operator had mild cerebral palsy, was

under medication for epileptic seizures, and had a left

clubfoot.

(PFDs), the PUPPET’s operator and the Chief

Radioman passed the towline to the passenger

on the Questar’s bow, directing him to tie the

towline around the anchor windlass. They did

not consider the stem padeye of the Questar’s

trailer hitch as an alternate attachment point for

the towline. The operator of the PUPPET then

directed the Chief Radioman to advise the

Questar’s two occupants to go to the stern of the

vessel; they were to wave their hands to

communicate with the crew of the PUPPET if a

problem developed during the tow. The

PUPPET’s operator did not set a towing watch.

The Chief Radioman recalled that as the tow

was getting under way, he looked back on the

Questar and determined that everything looked

“OK” to him. He admitted that he had difficulty

seeing what was happening on the Questar at the

end of a 150-foot towline. He did notice that

only one of the Questar’s crewmembers was still

at the vessel’s stern. He stated that the second

crewmember might have moved into the vessel’s

cabin, a box-like structure fitted with smoked

glass windows. The cabin was fitted with an

accordion-style fiberglass (folding) door that

provided access to the bow area and a second

door (sliding glass) that opened to the stern. The

afterdoor was open when the vessel was taken in

tow.

At 1430, the PUPPET’s operator reported to

the 17th District Communication Center that he

had taken the Questar in tow heading for Auke

Bay and that he would relay an estimated time

of arrival when he had determined what speed

he was able to make. He did not provide a

situation report to Station Juneau, his patrol

commander.

The PUPPET and tow initially steered a

southeasterly course toward Auke Bay through

an area marked by the confluence of Favorite

and Saginaw Channels. Sea conditions in this

area were confused, with chop and breaking

waves. When the Questar was about 150 feet

from the KAMILAR, the PUPPET’s Auxiliary

crewmember noticed that the Questar was down

by the bow and alerted the operator to slow

down. After a wave suddenly broke over the
5

Questar’s bow, the vessel assumed a bow-down

attitude, flooding the foredeck.

The passenger, who was sitting at the stern

of the Questar, stated that he shouted to the

operator to get out of the cabin and reached out

to grab his wrist. Before the operator could exit

the cabin, a second wave broke over the bow,

causing the bow to submerge. Water swept aft,

collapsing the deckhouse front accordion door

and flooding the cabin. The passenger later

stated that he tried unsuccessfully to pull the

operator out of the cabin and that the next thing

he knew, he was floating in the channel. Shortly

thereafter, he observed the Questar, now full of

water, slowly roll to starboard and capsize. The

passenger was rescued within minutes by one of

the boats that had been discharging fish to the

KAMILAR at the time of the accident.

When the PUPPET’s operator, who was

steering from the flying bridge, realized what

had happened to the Questar, he reversed

engines, causing the towline to become fouled

in one of the propellers. The maneuverability of

the PUPPET was thereby restricted, and it was

unable to participate in the rescue effort. The

PUPPET, with one shaft, later proceeded to

Auke Bay.

The master of the KAMILAR stated he had

observed the events that occurred between the

time the Questar was taken in tow and the

subsequent attempt to rescue the operator

trapped in the vessel’s cabin. The master noticed

the PUPPET’s operator turn the tow in the

direction of Auke and increase speed. He further

stated that when the PUPPET increased speed,

he became concerned and tried to contact the

vessel using VHF/FM radio (channel 16) to

advise the operator that he needed to slow down.

Before the master could get through, the Questar

capsized. At 1434, the KAMILAR’s master

radioed the 17th District Communication Center

to advise them what had happened and that

assistance was needed. The 17th District

Communication Center immediately issued a

PAN3

 on channel 16 describing the incident and 3

A voice communication practice indicating that the

calling station has a very urgent message to transmit

requesting that any vessel in the area help with

the rescue.

Shortly after notifying the Coast Guard of

the accident, the KAMILAR’s master launched

one of his small boats to try to right the Questar

and extract its operator. When the master

realized that efforts to right the vessel would not

be successful, he weighed anchor and

maneuvered the KAMILAR alongside the

Questar so that he could use the KAMILAR’s

seine winch to lift the Questar’s bow out of the

water. He was able to raise the Questar far

enough out of the water to allow crewmembers

from the KAMILAR to remove the operator

from the Questar’s cabin. About 25 minutes

after the initial capsizing of the Questar, the

unconscious operator was carried to the deck of

the KAMILAR, where one of the crewmen who

was a certified emergency medical technician

(EMT) immediately initiated CPR. According to

the EMT, the Questar’s operator was not

breathing and had no pulse; his skin color was

blue.

Station Juneau’s 25-foot patrol boat,

responding to the PAN, arrived at this point, and

a Coast Guard EMT joined the attempt to revive

the operator. The Coast Guard EMT provided a

medical kit from the patrol boat containing a

positive-pressure oxygen delivery system used

for CPR, but the system’s oxygen tank was

empty and the EMTs continued with manual

CPR.

At 1507, the unconscious operator was

transferred to Station Juneau’s 25-foot patrol

boat and taken to Auke Bay, where he was

transferred to a waiting ambulance and

transported to Bartlett Memorial Hospital. CPR

was administered continuously during the trip to

the hospital. He was pronounced dead at 2141

that evening. An autopsy indicated drowning as

the cause of death.

No evidence indicated fatigue, alcohol, or

drug involvement in this accident. Except for

 concerning the safety of a ship or person.
6

the autopsy on the Questar’s deceased operator,

no toxicological testing was conducted.

SAFETY ISSUES

In examining the Coast Guard’s safety

management during the 1994 Golden North

Salmon Derby and the incident involving the

Questar, the Safety Board identified five areas

of concern: communications during the derby,

policy on the use of Coast Guard Auxiliary

resources in hazardous weather and sea

conditions, policy on removal of passengers

from towed vessels, risk assessment training of

Coast Guard Auxiliary personnel involved in

SAR, and policy on postaccident toxicological

testing of Coast Guard Auxiliary personnel

involved in marine accidents.

Coast Guard Communications

The Safety Board found deficiencies in

Coast Guard communications during the 1994

Golden North Salmon Derby that compromised

the Coast Guard’s ability to effectively

discharge its SAR mission responsibilities in the

Juneau area.

The Coast Guard estimated that

approximately 1,000 vessels participated in the

derby, yet discipline over the use of VHF/FM

radio channel 16 was minimal. Legitimate

traffic, such as the IDLE HOURS’ initial call for

assistance to the Coast Guard, was suppressed

by the sheer volume of radio operators using

channel 16 and by operators with more powerful

radios. The Coast Guard made no attempt to

minimize inappropriate use of channel 16 on

August 21, 1994. Planning for the use of one or

more public working frequencies during special

events such as the derby could have alleviated

the congestion on channel 16, the Coast Guard’s

distress, safety, and calling frequency.

During the 1994 derby, a period of highvolume VHF/FM traffic, the 17th District

Communication Center became a choke point

for the flow of radio communication

information. When reports of the Questar’s

capsizing were being radioed, a second Coast

Guard Auxiliary vessel, the FAERING, also

assigned to Station Juneau for patrol during the

derby, was responding to a medical case in the

Shelter Island area. The FAERING reported to

the 17th District Communication Center that it

was under way to Auke Bay with a patient. This

report was the first one indicating that a second

Auxiliary vessel was responding to an assist

case, and the Coast Guard did not quickly

resolve the confusion among SAR personnel

over which victim was associated with which

incident. In addition, more than 2 hours passed

before SAR controllers realized that the

Questar’s passenger had not been accounted for

after the Questar capsized. In fact, the passenger

had already been transported to Auke Bay and

questioned by Station Juneau personnel. Station

Juneau did not inform Group Ketchikan or 17th

District SAR personnel of this fact.

During its review of communication

records, the Safety Board found that SAR

personnel accepted and passed on inaccurate

information without question or verification. At

one point, Group Ketchikan, the SAR mission

coordinator, briefed 17th District SAR personnel

that a helicopter from Coast Guard Air Station

Sitka, Alaska, was on the way to the accident

site, that the FAERING was transporting the

Questar’s passenger to rendezvous with an

ambulance, and that Station Juneau’s 25-foot

patrol boat was en route to Auke Bay to pick up

a dive team, none of which was accurate. No

one individual in the SAR communication

network verified and assessed the streams of

information for quality or significance during

the Questar’s response.

Coast Guard Group Ketchikan had issued a

1994 Golden North Salmon Derby operational

order that assigned Coast Guard Station Juneau

as patrol commander of all support units,

including four Coast Guard Auxiliary vessels, in

its area of tactical control. Station Juneau’s

primary means of communication with units

under its control was VHF/FM radio. However,

Station Juneau was unable to communicate with

its units reliably because of poor VHF/FM radio

reception attributable to the location of its
7

antenna and high mountains in the area that

blocked radio signals. For all practical purposes,

Station Juneau was unable to exercise command

over resources responding to marine incidents in

its area.

Before the Questar capsized, Station Juneau

was unaware that two of its Auxiliary vessels,

the PUPPET and the FAERING, were

proceeding with assist cases. Moreover, the

PUPPET’s operator did not confirm with Station

Juneau, the patrol commander, his intention to

tow the Questar, although both the 1994 Golden

North Salmon Derby operational order and a

directive issued by the derby’s Juneau Auxiliary

Flotilla Commander required that he do so. The

operator of the FAERING, also attached to

Station Juneau, failed on several occasions to

obtain authorization from Station Juneau before

providing assistance to boaters in distress.

The Safety Board believes that had Station

Juneau been provided with reliable radio

communication capability, allowing it to talk

with units in its patrol area, the Coast Guard’s

confusion in responding to the Questar’s request

for assistance and subsequent capsizing could

have been minimized.

Policy on Use of Auxiliary Resources in

Hazardous Conditions

The Safety Board found that the Coast

Guard 17th District does not have a policy on use

of the Auxiliary in assist cases involving

hazardous weather and sea conditions. The

Executive Petty Officer at Station Juneau stated

that the station limits such assist operations to

calm seas and daylight hours. The Coast

Guard’s Auxiliary Boat Crew Qualification

Guide, COMDINST M16798.21, defines calm

seas as waves of 1 foot or less. It defines heavy

seas as waves of 4 feet or more. At the time of

the accident, Group Ketchikan had a draft

document4

 specifying that under no 4

Appendix 8 to annex E from Group Ketchikan’s

standard operating procedure, which was in draft at the

time of the Questar accident, reflected Group Ketchikan’s

policy for use of the Auxiliary. Since the accident, the 17th

Coast Guard District has reorganized, and Group Ketchikan

has been eliminated.

circumstances should Auxiliary vessels be used

in severe or adverse conditions. Neither adverse

nor severe were defined.

The National Weather Service in Juneau

was predicting winds up to 25 knots and seas as

high as 5 feet, for the Juneau area on the day of

the accident. Before the capsizing of the

Questar, Station Juneau had reminded Group

Ketchikan that the station’s 25-foot boat was on

patrol near Shelter Island and was available for

use. Coast Guard boat crews are regularly

trained and tested in towing under hazardous

conditions. Auxiliary operators, on the other

hand, meet a much less demanding training

requirement to maintain qualification.

Nonetheless, the Auxiliary vessel PUPPET

was allowed to respond to the Questar’s request

for assistance without SAR personnel having

made a proper assessment of the Auxiliary

operator’s capabilities and limitations, the risks

involved, or other response options available, as

is required under Coast Guard SAR procedures.5

The PUPPET's operator stated that the decision

whether or not to tow was entirely his to make.

He was unaware that Station Juneau and Group

Ketchikan had policies restricting his authority

to accept assist cases.

The Coast Guard, responding to downsizing

pressure, plans to shift more of its small boat

operational workload from regular Coast Guard

units to Auxiliary resources. The Safety Board

believes that this accident demonstrates a need

to clearly define limits in the use of Auxiliary

resources when weather and sea dictate the use

of better trained and equipped regular Coast

Guard units.

 5

Coast Guard National Search and Rescue Manual,

COMDTINST M16120.5A.
8

Policy on Removal of Passengers from

Towed Vessels

The Safety Board is concerned that existing

Coast Guard policy on removal of passengers

before towing allows on-scene response

personnel too much discretion. Although its

SAR towing doctrine gives primacy to the safety

of passengers during a towing operation, the

Coast Guard does not have a policy for

mandatory removal of passengers from towed

vessels, assuming conditions are safe to do so.

Rather, its policy6

 is to remove all occupants

from the disabled boat, if necessary.

The Auxiliary operator of the PUPPET

assumed he had been directed to tow the

Questar to Auke Bay. He discussed the

upcoming tow with his guest, the Chief

Radioman, and, based on the information

available to him, decided not to remove the

operator and passenger. The PUPPET’s operator

believed the tow was routine and that the

Questar’s operator and passenger were in no

danger if they remained on their vessel during

the operation. He neither determined the

physical condition of the Questar or its crew nor

asked the Questar’s crew whether they had any

concerns about being towed.

Safety considerations did not preclude

removal of the Questar’s crew. The Questar was

moored in the lee of the KALIMAR, and

transferring personnel from the Questar to the

PUPPET would have been routine. In fact, little

benefit was to be gained from leaving the

Questar’s crew on their vessel during the tow.

The PUPPET lacked an effective means of

communicating with the Questar. Additionally,

the crew of the Questar, which was at the end of

150 feet of towline, would have been unable to

rapidly alert the PUPPET’s crew to an

emergency on the Questar or to assist the

PUPPET’s operator in managing the tow by, for

example, adjusting the length of the towline (the

adjustable end of the PUPPET’s towline was

tied around the Questar’s anchor windlass).

 6

Boat Crew Seamanship Manual, Commandant

Instruction M16114.5A.

The Safety Board believes that the

occupants of a disabled vessel should be

removed, if removal can be done safely, before

the vessel is towed and that the Coast Guard

needs to revise its policies on removal of

occupants during towing operations to reduce

the risk associated with on-scene response

personnel making decisions based on

incomplete information.

Risk Assessment Training of Auxiliary

Personnel Involved in SAR Operations

The Safety Board is concerned that the

PUPPET’s operator failed to properly assess the

risk to the Questar’s operator and passenger in

attempting to tow the motorboat. The Safety

Board has addressed the issue of risk assessment

by Coast Guard SAR personnel in its

investigations of the capsizing and sinking of

the SEA KING, RITE OF PASSAGE, and BIG

ABALONE (see appendix A). Although the

Coast Guard is training its active duty SAR

personnel in risk assessment, Coast Guard

Auxiliary personnel are not receiving this

training. The Safety Board believes that the

Coast Guard should have applied the lessons

learned from the above accidents to its response

in the Questar incident. It is critical to the

success of any SAR mission that on-scene

response personnel determine the nature of the

problem, do a risk assessment, and decide on a

course of action that minimizes the risk to life

and property. The Auxiliary operator of the

PUPPET, in responding to the Questar’s request

for assistance, conducted operations that

exposed the Questar’s crew to unnecessary risk.

The PUPPET’s operator also allowed a

guest aboard his vessel to become involved in

Auxiliary patrol activities, contrary to Coast

Guard Auxiliary operational policy.7

 While his

guest, a Coast Guard Chief Radioman assigned

to the 17th District Communication Center, was

experienced in communications, he had no

practical experience in SAR and towing

operations. Even if the operator thought that the

 7

Coast Guard Auxiliary Operations Policy Manual,

COMDTINST M16798.3C.
9

Chief Radioman was experienced in small boat

SAR, the Safety Board believes that he should

not have allowed a guest on his vessel to assume

the responsibilities properly assigned to the

PUPPET’s Auxiliary boat crewmember.

The PUPPET’s operator did not ask about

the physical condition of the Questar’s operator

and passenger, in particular, whether anyone

had special health problems or medical

disabilities. Had he done so, he probably would

have determined that the Questar’s operator had

mild cerebral palsy, was under medication for

epileptic seizures, and had a left clubfoot.

In addition, the operator failed to ascertain

the condition of the Questar, what the original

problem was, and what other problems the crew

were experiencing with the vessel while waiting

for assistance. The Questar had initially taken

on water after unloading fish next to the

KAMILAR, and the operator had been unable to

start either engine. After the Questar was towed

back to the KAMILAR by the IDLE HOURS,

the motorboat continued to take waves over the

side, requiring the operator and passenger to run

the bilge pump and bail out water. The

Questar’s open fore and aft decks had minimal

drainage, and the vessel had a low freeboard in

relation to the waves it was encountering.

Moreover, the Questar’s high wind profile in

relation to her shallow draft made her

susceptible to wind loading. Had the PUPPET’s

operator examined the Questar more closely and

talked to her crew, he may have determined that

the vessel’s seaworthiness in the prevailing sea

conditions was questionable.

Proper trimming of a vessel to be towed is

one of the Coast Guard’s principal towing safety

precautions taught to SAR personnel. The

PUPPET’s 150-foot 5/8-inch double-braided

nylon towline, connected to the Questar’s

anchor windlass on the main deck, created a

downward force that may have prevented the

Questar’s bow from riding over waves

encountered during the tow. A shorter towline

with less catenary may have reduced the

downward force on the bow of the Questar

during the tow. The PUPPET’s operator did not

consider using the Questar’s trailer hitch stem

padeye, which would have been a better

connection point for the towline because of its

lower position on the vessel.

Exacerbating the Questar’s trim condition

was the operator’s move into the cabin as the

tow was getting under way. Although the

PUPPET’s operator asked the Questar’s crew to

remain at the stern of the vessel, he did not

monitor the crew’s activities once the PUPPET

was under way. The Questar operator’s

relocation into the deckhouse created a forward

moment that increased the bow-down trim of the

vessel. The PUPPET’s operator did not set a

towing watch that could have detected this

condition. Setting an alert, dedicated towing

watch that will maintain a constant watch and

frequently account for all occupants on the

towed vessel is critical during any towing

operation and is recommended under Coast

Guard towing doctrine.8

 The Chief Radioman

aboard the PUPPET noticed that one of the

Questar’s crew had moved away from the

vessel’s stern, but the significance of the move

was not apparent to him. The PUPPET’s

operator had not instructed the Chief Radioman

in any towing safety precautions before getting

the tow under way.

When the PUPPET began its tow of the

Questar, the PUPPET’s operator did not

evaluate the motorboat’s response to being

towed in the prevailing seaway at low speeds.

When he looked back at the Questar, after being

prompted by his boat crewmember to slow

down, the Questar was already being dragged

under the first wave. By the time he was able to

reverse his engines, the Questar was capsizing.

If the PUPPET’s operator had observed how the

Questar was responding at slow towing speeds,

he may have noticed that the Questar was not

riding over the waves but into them.

The Safety Board believes that had the

operator of the PUPPET evaluated the risk more

thoroughly than he did, he would not have

 8

Coast Guard Boat Crew Seamanship Manual,

COMDINST M16114.5.
10

towed the Questar with its crew aboard.

However, unlike their counterparts in the regular

Coast Guard, neither he nor his crewmember

had received Human Error Accident Reduction

Training (HEART) or similar risk assessment

training. The Safety Board believes that had the

Auxiliary crew of the PUPPET been trained in

SAR risk assessment, this accident may not have

happened.

The Safety Board also investigated the issue

of crew survivability during this capsizing. Had

the PUPPET’s operator monitored the actions of

the Questar’s operator and passenger and

restricted their movements to the stern of the

vessel, the Questar’s operator may not have

been trapped in the cabin when the motorboat

capsized. In its investigation of the capsizing

and sinking of the U.S. fishing vessel SEA

KING, the Safety Board determined that the

people who had remained on board in the cabin

during the tow could not safely exit when the

vessel capsized. Using lessons learned from the

SEA KING and Questar accidents, the Coast

Guard Auxiliary needs to revise its towing

policies to ensure that people who remain on

board a towed vessel are situated so as to ensure

their safe exit in the event of an emergency.

Toxicological Testing of Coast Guard

Auxiliary Personnel

During its investigation, the Safety Board

found that Coast Guard SAR personnel involved

in the Questar’s capsizing, including the

PUPPET’s Coast Guard Auxiliary crew, were

not toxicologically tested. The Coast Guard

designated this accident a class A mishap and

invoked the provisions of its Safety and

Environmental Health Manual, COMDTINST

M5100.47, by convening a vessel mishap

analysis board. The medical officer assigned to

that board is responsible for ensuring that

appropriate examinations and laboratory

procedures, including complete physical

examinations and toxicological tests, are

conducted to establish which human factors

were relevant to the accident. While

toxicological testing after a class A mishap is

routine for active duty personnel, the Coast

Guard does not have a policy to require

toxicological testing of Auxiliary personnel

involved in vessel mishaps, even if they are

operating under Coast Guard orders. The Coast

Guard justifies this position on the grounds that

Coast Guard Auxiliary personnel are volunteers

and the “Good Samaritan Law” should apply.9

The Secretary of Transportation has

published a directive (DOT Order 3910.1C)

prescribing the department’s policy and

procedures for implementing Executive Order

12564, Drug-Free Federal Workplace. The

directive calls for testing each employee, if his

or her work performance may have contributed

to an accident, for the presence of drugs

following an accident involving one or more

deaths. This policy applies to the Coast Guard.

The Safety Board believes that members of the

Coast Guard Auxiliary, while operating on

Coast Guard orders, also have significant

responsibilities affecting public safety and

should meet the same standards as full-time

Coast Guard personnel.

 9

Telephone conversation with COMMANDANT (GHSE-4) on April 28, 1996.
PROBABLE CAUSE

The National Transportation Safety Board

determines that the probable cause of the

Questar’s capsizing was the flooding of the

vessel due to use of improper towing procedures

by the Coast Guard Auxiliary operator of the

PUPPET. Contributing to the capsizing was the

failure of the PUPPET’s operator to properly

assess risk before deciding to tow the vessel in

hazardous sea conditions. Contributing to the

loss of life was the failure of the PUPPET’s

operator to remove the Questar’s operator and

passenger before towing the vessel.
RECOMMENDATIONS

As a result of its investigation, the National

Transportation Safety Board makes the

following recommendations to the U.S. Coast

Guard:

Improve Station Juneau’s radio

reception capability commensurate with

its tactical responsibilities in the

mission area. (M-96-11)

Develop written policies that set limits,

based on clearly defined weather and

sea conditions, on the use of Coast

Guard Auxiliary resources. (M-96-12)

Revise Coast Guard search and rescue

policy to require or recommend removal

of occupants from towed vessels before

beginning the tow if it is safe to do so.

(M-96-13)

Provide risk assessment training to all

Coast Guard Auxiliary personnel

involved in search and rescue missions.

(M-96-14)

Revise Coast Guard Auxiliary policies

on units rendering assistance to vessels

to ensure that all people who remain on

board a towed vessel are situated so as

to ensure their safe exit in the event of

an emergency. (M-96-15)

Revise Coast Guard regulations to

require mandatory postaccident toxicological testing of Coast Guard Auxiliary

personnel involved in marine accidents

while operating under Coast Guard

orders. (M-96-16)

Incorporate the lessons learned from

this accident into a case study training

exercise for Coast Guard search and

rescue units, including Coast Guard

Reserve and Auxiliary commands.

(M-96-17)

Publicize the circumstances of this

accident to all Coast Guard units

responsible for search and rescue.

(M-96-18)

Disseminate a copy of this report to all

Coast Guard Auxiliary personnel

involved in search and rescue missions.

(M-96-19)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

November 26, 1996 Member
13

APPENDIX A

SAFETY BOARD’S APRIL 13, 1994, RECOMMENDATION LETTER

TO COMMANDANT, U.S. COAST GUARD

CONCERNING RITE OF PASSAGE, BIG ABALONE, DUKE LUEDTKE

Appendix A 15

National Transportation Safety Board

Washington, D. C. 20594

Safety Recommendation

Date: April 13, 1994

In Reply Refer To: M-94-7 through -9

Admiral J. William Kime

Commandant

U.S. Coast Guard

Washington, DC. 20593-0001

The National Transportation Safety Board has investigated three rescue efforts conducted

by the U.S. Coast Guard during August 1993. The vessels in distress were two pleasure craft

and one tugboat. Four persons died, three civilians and one Coast Guardsman. As a result of

investigating these accidents, the National Transportation Safety Board determined that some of

the Coast Guard personnel involved in each search and rescue (SAR) operation did not properly

assess the risks. The Safety Board makes the following findings and recommendations:

The first accident involved a disabled 27-foot sailing vessel near Charleston, South

Carolina. At 0058,1

 on August 4, 1993, the operator of the vessel, the RITE OF PASSAGE,

used VHF-FM channel 16 to call Coast Guard Group Charleston, South Carolina. He said that

he was about a mile east of Breaches Inlet, near Isle of Palms, South Carolina, and that he

needed help because his vessel was disabled by engine problems. The Coast Guard

communications watchstander questioned the operator and learned that he was the only person

on the vessel and that the vessel was not aground but anchored. Believing that the operator was

in no immediate danger, the watchstander classified the case as a “non-distress”2

 one and issued

a Marine Assistance Request Broadcast (MARB). 3 A local, privately owned commercial towing

1 Eastern daylight time, based on a 24-hour clock.

2 A SAR case is classified as a non-distress one if it does not constitute a threat to life or property.

3A message broadcast on VHF/FM channel 16 asking anyone who is interested to help a vessel. Such a

message is broadcast only about a vessel in a “non-distress” situation. Responders are supposed to reply on

VHF/FM channel 22A.

6299
16 Appendix A

company responded and offered to help. The watchstander told the operator of the RITE OF

PASSAGE that the towing company was coming.4

At 0100, the Isle of Palms police department telephoned the Coast Guard to report

spotting a sailing vessel in trouble. The watchstander immediately dispatched the CG 41428,

a 41 -foot utility boat (UTB). Neither the police nor the watchstander realized that the distressed

vessel was the RITE OF PASSAGE.

About 0120, a representative of the towing company informed the watchstander that his

company did not have sufficient personnel available to assist the RITE OF PASSAGE. At 0125,

the watchstander told the operator of the RITE OF PASSAGE that the towing company could

not help him, but that the UTB was proceeding to assist a second vessel in distress and would

come to his assistance as soon as it was available. The operator replied that the RITE OF

PASSAGE was dragging its anchor, had drifted near the beach, and was encountering heavy

surf.

The towing company notified the watchstander that it was now able to provide assistance

to the RITE OF PASSAGE. The watchstander granted permission for the company to respond.

Within minutes, the company vessel was underway. In the meantime, the UTB continued

toward what was assumed to be the second vessel in distress but was actually the RITE OF

PASSAGE.

As the UTB approached the vessel, the coxswain observed the vessel’s operator moving

around the deck. The UTB’s crew passed a towline to the operator, who secured it to his

vessel. The operator then attempted to release his anchor line, apparently in an attempt to

facilitate the towing operation. The coxswain, using a loudhailer, instructed him to go to the

stern and put on a personal flotation device (PFD). Whether the operator heard the coxswain

is unknown.

Shortly thereafter, the UTB took the vessel in tow. The operator was last seen moving

toward his vessel’s stern, apparently in compliance with the coxswain’s instructions. The

operator was not wearing a PFD, and the vessel was pitching and rolling violently in the surf.

Meanwhile, about 0240, the boat sent by the towing company arrived on scene. Its

operator tried to establish radio contact with the operator of the RITE OF PASSAGE. When

his attempts failed, he maneuvered the company vessel alongside the RITE OF PASSAGE and

placed a crewman aboard.

Once on board, the crewman discovered that the operator of the RITE OF PASSAGE

was no longer aboard. The towing company personnel reported to the Coast Guard that no one

was aboard the RITE OF PASSAGE. The coxswain of the UTB released the towline and began

searching for the missing operator.

4

For more detailed information, read Marine Accident Brief No. DCA-93-MM-023 (attached).
Appendix A 17

At 0550, a local rescue squad recovered the body of the operator from the surf and

transported himto anearby hospital, where he was pronounced dead. The official cause of

death was drowning.

The Safety Board believes that both the watchstander and the coxswain made mistakes

in handling the case. The watchstander should have classified the incident as a distress case.

The coxswain should, when he arrived on scene, have evaluated the situation more thoroughly

and accurately than he did.

According to Group Charleston policy , when prosecuting the SAR, the communications

watchstander should have used a check-off list with criteria for deciding whether the call for

assistance constituted a distress or a non-distress situation. The watchstander should have

determined whether anyone on board the vessel had special problems or problems related to age

or health and whether the vessel was at anchor or had a drift rate.

The watchstander did not ask the operator of the RITE OF PASSAGE all of the questions

on the check-off list. Had he asked the questions, he likely would have determined that the

operator was 67 years old, had a heart condition that required medication, and had had a heart

attack within the last year. He would then have had a sufficient basis for classifying the case

as a distress one and, consequently, for immediately dispatching a SAR vessel.

When the operator of the RITE OF PASSAGE told the watchstander that the vessel was

dragging its anchor, was near the beach, and was encountering heavy surf, the watchstander had

a second chance to decide the situation was a distress case. He should have immediately

changed the status of the case and dispatched a SAR unit. Instead, he gave the towing company

permission to handle the situation.

Under Coast Guard policy, as stated in the National Search and Rescue Manual (the SAR

manual), the safety of people is always more important than the safety of property.

Accordingly, the Coast Guard specifically requires its personne15 to assess a situation before

making any attempt to take a distressed vessel in tow. By that assessment, personnel should

establish and maintain communications with the people on the distressed vessel, ensure that they

are wearing PFDs, and evaluate the risks that towing the vessel might pose to either Coast Guard

personnel or civilians.

Nevertheless, as soon as the UTB arrived on scene, the coxswain tried to take the RITE

OF PASSAGE in tow despite the fact that the vessel’s anchor was deployed, the operator was

not wearing a PFD, and the operator was moving about on a deck that was pitching and rolling

wildly. The coxswain did not pause to determine whether the operator or the vessel was in such

immediate danger that he should be removed before any attempt was made to tow the vessel.

5

A11 personnel involved in a SAR case.
18 Appendix A

The second accident involved the sinking of a 25-foot pleasure craft in Coos Bay,

Oregon. About 1500,6 on Friday, August 20, 1993, the pleasure craft BIG ABALONE, with

five persons on board, departed the Charleston Marina, Coos Bay, Oregon, for a day of

recreational crabbing in the bay. Three of the people on board were older than 65. After a

couple of hours of crabbing, the BIG ABALONE began having engine trouble and became

disabled and adrift.7

Meanwhile, the charter fishing vessel BETTY KAY was returning to Charleston Harbor.

The operator saw someone from the BIG ABALONE waving for attention. When he brought

the BETTY KAY alongside the BIG ABALONE, he was told by the boat’s operator of the

engine problem and was asked to call the Coast Guard. The operator called Coast Guard Station

Coos Bay via VHF-FM channel 16 (at 1719), reporting that the BIG ABALONE was disabled

in Coos Bay with five persons on board.

At 1721, a four-man crew, consisting of a coxswain, an engineer, and two crewmembers,

got underway aboard the CG 44373, a 44-foot motor life boat (MLB). Shortly thereafter, the

operator of the BETTY KAY advised the Coast Guard that the BIG ABALONE was slowly

taking on water.

The coxswain of the MLB decided

watered and towed. He told the engineer

pump.

en route that

to prepare to

the pleasure craft needed to be deboard the pleasure craft with a P-5

The coxswain later stated that because the pleasure craft had not been reported as being

in imminent danger of sinking, he had assumed that the flooding was probably minor.

Consequently, he had decided before he arrived at the accident scene that there was no need

to expose the pleasure boat’s passengers to the dangers involved in transferring them to the

MLB.

The MLB arrived on scene at 1730. Winds were from the south at 10 knots, seas were

3 to 5 feet and choppy, and visibility on the bay was about 100 to 150 yards. The temperature

of the water was 57° F.

At 1732, the engineer boarded the BIG ABALONE and reported that there were about

6 inches of water in the engine casing bilge. He could not determine the source of the leak.

The coxswain noticed the sea conditions were deteriorating rapidly and began

maneuvering the MLB so that a towline could be attached to the BIG ABALONE. As the MLB

approached the starboard bow of the vessel, an 8- to 10-foot swell broke over the starboard

quarter of the BIG ABALONE. Almost immediately, another 8- to 10-foot swell broke over the

stern, swamping the pleasure craft. Two of the passengers were trapped on the sunken vessel

and could not be rescued. The other three persons on the boat and the MLB engineer

6

Pacific daylight time, based on a 24-hour clock.

7

For more detailed information, read Marine Accident Brief No. DCA-93-MM-029 (attached).

were able
Appendix A 19

to jump clear of the vessel and were rescued by the MLB. They were transferred to a 20-foot

rigid-hull inflatable boat from Station Coos Bay and transported ashore.

While it is a sound practice for rescuers to make plans before they arrive on scene, the

Safety Board believes that the coxswain should have reevaluated the situation when he arrived.

The actual sea conditions were much more severe at the bar than indicated in earlier weather

reports. In addition, the BIG ABALONE had drifted, and continued to drift, dangerously close

to the bar.

Had the coxswain reevaluated the situation, he might have realized that it was much more

serious than he had thought and that transferring the engineer would do nothing more than

increase the number of people who were about to be endangered by the sinking of the BIG

ABALONE and, ultimately, the number of people who would have to be rescued. If after his

reevaluation, he still believed that it was too dangerous to remove the passengers from the BIG

ABALONE, he could have attempted to tow the vessel into quieter waters. The engineer could

have then boarded the BIG ABALONE while the UTB continued towing the vessel back to Coos

Bay.

The third accident involved the sinking of a harbor tug on Lake Erie, Ohio. The DUKE

LUEDTKE was a typical Great Lakes Harbor tug: 68.7 feet long, 17 feet wide, and 11 feet

deep. Three persons were on board, the captain and two deckhands. After getting underway

at 19308 on September 20, 1993, en route to Ashtabula, Ohio, the captain had checked the

engineroom every hour to ensure that everything was operating properly. At 2300 he noted that

there was 3 feet of water in the engineroom, whereas he had observed no water there during his

previous check at 2200. He could not determine the source of the flooding.

The wind was coming out of the west at 6 knots, and the seas were 2 to 4 feet. The air

temperature was 63° F, the water temperature was 70° F, and visibility was 4 miles.

At 2337 the operator of the tug called Coast Guard Station Cleveland Harbor, Ohio,

on VHF/FM channel 16. He said he needed help because the water in the engineroom was

about 3 feet deep. He gave his position as approximately 13 miles north of Avon Point on Lake

Erie. About 8 minutes later, about 2345, he told the watchstander that the level had increased

to about 5 feet.9

At 2340, Coast Guard Station Cleveland Harbor dispatched a 41-foot UTB, CG 41487,

with a coxswain, an engineer, and three crewmembers. Before the coxswain got underway, the

watchstander briefed him, telling him the vessel’s identity, type, location, and problem.

The UTB arrived on scene at 0323, September 21, 1993, and secured the UTB to the

forward port side of the tug. Two of the UTB crewmembers immediately boarded the tug and

entered a compartment above the engineroom through a watertight door on the port side, slightly

8

Eastern daylight time, based on the 24-hour clock.

9

For more detailed information, read Marine Accident Brief No. DCA-93-MM-030 (attached).
20 Appendix A

aft of amidships, closing the door behind them. They intended to determine the source of the

flooding, stop the flooding, if possible, with repairs, and use a portable pump to evacuate the

water.

About 90 seconds after the UTB arrived on scene, the tug suddenly rolled to port and

sank, stern first. The two UTB crewmembers were still inside the area above the engineroom.

One of them managed to make his way to the wheelhouse through an interior forward bulkhead

door leading through the galley and up to the wheelhouse. He then escaped through a window

and swam to the surface, where he was rescued by the UTB. The other crewmember was

trapped inside the tug. Divers from a civilian salvage company recovered his body the next day.

All three crewmembers of the DUKE LUEDTKE survived.

The Safety Board believes that the Coast Guard’s response to this incident demonstrated

a clear lack of risk assessment, particularly by the watchstander and the coxswain. When the

watchstander received the call for assistance, he was supposed to fill in a Search and Rescue

Incident Summary form. 10 He did not fill in the part of the form labeled “Initial Severity. ” He

said that he had not sensed any urgency in the voice of the tug captain and that he therefore had

not considered the situation to be life threatening. The Safety Board believes that the

watchstander should not have based his assessment solely on his perception of the stress in the

captain’s voice. Because the watchstander misjudged the severity of the situation, he briefed the

coxswain inaccurately, telling him that the tug was underway and taking on water, not that it

was in danger of sinking.

The coxswain stated that he believed that the case would be routine and could be resolved

by putting two of his crewmembers on board to assess the situation, stop the flooding, if

possible, and pump out the flooded compartment with a portable pump. He said that when he

arrived on scene, the tug was riding smoothly, rolling slowly, and not listing. Therefore, he did

not think it was likely to sink.

However, with over 5 feet of water in the engineroom, the tug’s stability had reached a

critical point: the tug would ride smoothly and roll slowly until it was about to capsize and sink.

The Safety Board believes that a properly trained coxswain would have known that the slow

rolling of the tug was an indication that it was very unstable and ready to capsize. A properly

trained coxswain would also have known that a vessel does not necessarily list before it capsizes

or sinks.

According to the surviving Coast Guardsman, when he and the other crewmember

boarded the tug, he noticed there was about a foot of water on the after main deck. He said that

when they entered the engineroom, the other crewmember closed the door so that the water on

deck would not enter the engineroom. The Safety Board believes that the two crewmembers did

not understand the severity of the flooding that had taken place before and during the time they

10A form used to record important data and information about the vessel in distress. The form is vital for

ensuring that SAR cases are properly assessed and prosecuted.
Appendix A 2 1

were on the vessel. The tug had already sunk to a point where the water level was above the

freeing ports11 aft, allowing water to accumulate on the main deck. 

The Officer-in-Charge of the Station stated that over 90 percent of all SAR cases handled

by his unit involve assisting recreational boats 19 to 25 feet in length. (The DUKE LUEDTKE

was about 69 feet long.) Therefore the Station does not train its personnel in on-scene

evaluation of a commercial vessel’s condition or on the differences between assisting commercial

vessels and recreational boats.

The Safety Board believes that the coxswain in this case, lacking such training, was not

able to recognize the risks involved in placing his crewmembers aboard the DUKE LUEDTKE

or in allowing people to enter a closed space. Nor did he recognize the need to seek advice

about the dangers of a flooded engineroom or the need to consult with licensed crew before

taking action. Had he done a proper risk assessment, he would have known that everyone

should have been removed from the tug immediately and that no one should have been allowed

to go inside the deckhouse.

The Safety Board also addressed the issue of risk assessment in its investigation of the

January 11, 1991, capsizing and sinking of the fishing vessel SEA KING. 12 As a result of that

accident, the Board issued Safety Recommendation M-92-54 on November 17, 1992, asking that

the Coast Guard:

Incorporate into the training of search and rescue (SAR) personnel

procedures to ensure the gathering and dissemination of pertinent

information by all appropriate SAR personnel to facilitate a

thorough assessment of the potential risks to persons involved in

a SAR mission.

In its June 21, 1993, response the Coast Guard said that it concurred with the intent of

the recommendation and planned to revive its on-scene commander’s course, which had been

discontinued in 1988. The Board consequently classified the safety recommendation “Open--

Acceptable Response,12 pending implementation of the course. In a November 15, 1993, letter,

the Safety Board asked the Coast Guard for an update on the status of this project and is

awaiting the reply.

The Safety Board is concerned that the Coast Guard’s reviving the course will not satisfy

the need for risk assessment training at the Group and Station levels. As illustrated in the

Board’s investigations of the three accidents described in this letter, the communications

watchstander in two of the three cases and the boat coxswain in all three cases failed to

adequately assess the risks to the lives of the people on the distressed vessels.

110penings in the side plating of a vessel. The openings are close to the main deck so that if there is any

water on deck, it can drain overboard.

12Marine Accident Report--Capsizing and Sinking of the U. S. fishing Vessel SEA KING near Astoria,

Oregon, January 11, 1991 (NTSB/MAR-92/05).
22 Appendix A

The SAR manual explains how SAR missions should be conducted. Chapter 4,

“Awareness and initial Action,” states:

. . the information collected and the initial action

to SAR success. Information must regathered

determine the nature of the distress... and what

taken . . . . [section 400]

taken are critical

and evaluated to

action should be

The risks inherent in any SAR response must be carefully weighed

against the mission’s chances for success, that is, the saving of life

or, to a lesser extent, property . . . . [section 446]

The Safety Board believes that had the watchstanders and the coxswains involved in these

accidents been more aware of the importance of following the guidance in the above sections of

the SAR manual and had they done a better job of assessing the risks that the people on the

distressed vessels were facing, they would have decided to remove them from the vessels as soon

as possible.

Because of its high freeboard, the MLB involved in the BIG ABALONE accident had

great difficulty in retrieving one of the survivors. The Safety Board found the same problem

in a previous accident, the December 2, 1989, sinking of the small passenger vessel BRONX

QUEEN13 in Lower New York Bay, New York. As a result of that accident, the Safety Board

issued Safety Recommendation M-90- 111, asking that the Coast Guard:

Develop new methods and or equipment for use aboard the 44-foot

motor life boat to expedite the retrieval of survivors from the

water during search and rescue operations.

In its March 22, 1991, response, the Coast Guard agreed with the Safety Board on this

matter and said that it would direct the National Motor Lifeboat School and the UTB System

Center to investigate alternative methods of recovering people from the water. The Safety Board

had asked that the Coast Guard not only investigate, but also develop alternative methods.

Pending the Coast Guard’s further reply to this recommendation, it was classified “Open--

Acceptable Response. ”

On October 10, 1993, the Coast Guard stated that it had bought and tested four different

inflatable “rescue ramp” prototypes and that after it made some minor modifications, the testing

would continue. The Coast Guard said that once the design was acceptable, it would seek funds

for outfitting selected Coast Guard units with the ramps. The Board continues to hold this safety

recommendation in an “Open--Acceptable Response” status.

13For more information, see page 57 of the Safety Board’s Marine Accident Brief NTSB/MAB-92/01, a

compilation of accident briefs.
Appendix A 23

In view of the BIG ABALONE accident, the Safety Board reiterates Safety

Recommendation M-90-1 11 and asks that the Coast Guard expedite its testing of the rescue

ramps and supply them to the Coast Guard’s fleet of 44-foot MLBs as soon as practicable. If

the Coast Guard determines that the ramps are unsuitable, the Safety Board strongly urges the

Coast Guard to provide a suitable alternative.

And lastly, as a consequence of the Board’s investigation of the three accidents described

in this letter, the Safety Board recommends that the Coast Guard:

Provide risk assessment training to all Coast Guard personnel

directly involved in search and rescue missions. (Class II, Priority

Action) (M-94-7)

Review search and rescue procedures to ensure that all search and

rescue personnel are trained to recognize the differences between

assisting commercial vessels and recreational boats. (Class II,

Priority Action) (M-94-8)

Publicize the circumstances of these accidents to all Coast Guard

search and rescue units. (Class II, Priority Action) (M-94-9)

Chairman VOGT, Vice Chairman COUGHLIN, and Members LAUBER,

HAMMERSCHMIDT, and HALL concurred in these recommendations:

By: Carl W. Vogt

Chairman
24 Appendix A

Vessel:

Accident Type:

Location:

Date:

Time:

Owner:

Property Damage:

Injuries:

Deaths:

Complement:

NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

Marine Accident Brief No. DCA-93-MM-023

Adopted March 25, 1994

27-Foot-Long Sailing Vessel RITE OF PASSAGE, State

Registration No. NJ629CP

Fall Overboard

Isle of Palms near Charleston, South Carolina

Latitude 34°59.75’ N, Longitude 92°45.75’ W

August 4, 1993

Approximately 0200, Local

James Jackson

Whiting, New Jersey

None

0

1

1

Description of the Accident

At 00581 on August 4, 1993, Coast Guard Group Charleston received a call on VHF-FM

channel 16 from the operator of the sailing vessel RITE OF PASSAGE. The operator stated that

the vessel was disabled with engine problems about 1 mile east of Breaches Inlet near Isle of

Palms, South Carolina, and that he needed assistance. He told the Coast Guard communications

watchstander that he was the only person on the vessel, that the vessel was not aground but

anchored, and that the vessel was a 27-foot white-hulled sloop. Believing that the operator was

in no immediate danger, the watchstander classified the incident as a “non-distress” situation and

issued a Marine Assistance Request Broadcast (MARB). 2 A local towing company responded

l

A1l times are Eastern daylight time based on a 24-hour clock.

2

A radio broadcast on VHF/FM channel 16 to anyone interested in providing assistance to a vessel in a

“non-distress” situation, e.g., out of fuel with no existing threat to life or property. Responders are asked by

the Coast Guard to call back on VHF/FM channel 22A.
Appendix A 25

to the MARB and advised the Coast Guard that it would help the RITE OF PASSAGE. The

Coast Guard then passed this information to the operator of the RITE OF PASSAGE.

Thecommunications watchstander, contrary to Group Charleston policy, did not ask the

operator all of the questions on the search and rescue (SAR) check-off list. Had he asked the

questions he would have learned that the operator was a 67-year-old man with a heart condition

that required medication and that he had had a heart attack within the last year. Such

information would have allowed the watchstander to classify the case as a distress one and

consequently dispatch a SAR unit.

At 0100, the Coast Guard received a telephone call from the Isle of Palms Police

Department reporting that a sailing vessel (identity unknown) was aground and listing badly

about 100 yards off the beach near the north end of Isle of Palms. About 0106, the Coast Guard

dispatched the C 41428, a 41-foot utility boat (UTB), to respond to what was apparently a

second vessel in distress. 3

About 0120, a representative of the towing company told the watchstander that his

company did not have sufficient personnel available to assist the RITE OF PASSAGE. At 0125,

the watchstander told the operator of the RITE OF PASSAGE that the towing company was

unable to assist him but that a UTB was proceeding to help a second vessel in distress and would

come to his assistance as soon as it was available. It was at this time that the operator of the

RITE OF PASSAGE reported that his vessel was dragging its anchor, was located near the

beach, and was encountering heavy surf. The wind on scene was about 25 knots, and the seas

were between 3 and 4 feet in height. Shortly thereafter, the towing company notified the

watchstander that it was now able to help the RITE OF PASSAGE. The watchstander granted

permission for the company to respond. Within minutes, a privately-owned commercial vessel

got underway to render assistance to the RITE OF PASSAGE.

About 0155, the coxswain of the UTB reported that he had spotted a white-hulled sailing

vessel in the surf off Isle of Palms and that he was maneuvering the UTB inshore, toward the

vessel. He made several attempts to contact the operator of the RITE OF PASSAGE vessel on

VHF-FM channels 16 and 22A but was unsuccessful.

As the UTB approached the stricken vessel, the coxswain observed the vessel’s operator

moving around the deck. The crew of the UTB passed a towline to the operator, who secured

it to his vessel. He then attempted to release his anchor line, apparently in an attempt to

facilitate the towing operation. The coxswain, using a loudhailer, instructed him to proceed to

the stern of the RITE OF PASSAGE and to don a personal flotation device (PFD). It could not

be determined whether the operator heard the instructions.

3

1n fact, the vessel that the Isle of Palms Police Department had sighted was the RITE OF PASSAGE, but

this was not known at the time.
26 Appendix A

Shortly thereafter, the UTB took the vessel in tow. The operator was last seen moving

toward his vessel’s stern, apparently in compliance with the coxswain’s instructions. He was

not wearing a PFD, and the RITE OF PASSAGE was pitching and rolling violently in the surf

at this time.

Meanwhile, the boat dispatched by the towing company arrived on scene. Its operator

attempted to establish radio contact with the operator of the RITE OF PASSAGE. About 0245,

when these attempts proved unsuccessful, the operator of the towing company vessel maneuvered

alongside the RITE OF PASSAGE and placed a crewman aboard.

When the crewman got on board, he discovered that the vessel’s operator was no longer

aboard. The towing company personnel reported to the Coast Guard that no one was aboard the

RITE OF PASSAGE. The coxswain of the UTB released the towline and began searching for

the missing operator.

At 0550,

transported it to

wearing a PFD.

Probable Cause

a local rescue squad recovered the operator’s body from the surf and

a nearby hospital, where the operator was pronounced dead. He was not

The official cause of death was determined to be drowning.

The National Transportation Safety Board was unable to determine the probable cause

for the operator of the RITE OF PASSAGE falling overboard. Contributing to the loss of life

was the failure of the Coast Guard communications watchstander and coxswain to properly

assess the risk to the operator of the RITE OF PASSAGE and the failure of the coxswain of the

CG 41428 to remove the operator before attempting to tow the vessel.
Appendix A 27

Vessel:

Accident Type:

Location:

Date:

Time:

Owner:

Property Damage:

Injuries:

Complement:

NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

Marine Accident Brief No. DCA-93-MM-029

Adopted March 25, 1994

BIG ABALONE, a25-Foot-Long Fiberglass Pleasure Craft,

Registration No. 0R176KD

Sinking

Coos Bay, Oregon(Latitude 43’’21.16’N, Longitude 124°

21.36’W)

August 20, 1993

Approximately 1734, Local

Mr. Clair Irwin, Myrtle Creek, Oregon

$10,000

2 Fatalities

5

Description of the Accident

About 1500,1 on Friday, August 20, 1993, the pleasure craft BIG ABALONE departed

the Charleston Marina, Coos Bay, for a day’s recreational crabbing in the bay. The vessel had

five passengers: the 67-year-old owner/operator of the pleasure craft, his 68-year-old wife,

another couple ages 66 and 58, and a 46-year-old woman. The owner had bought the boat in

April 1993 and put it in the water in June. He had owned and operated other smaller boats but

had never taken courses from any organization in either boat or marine-radio operation. This

outing was the fourth or fifth time he had taken this boat away from the pier.

The group baited and set crab traps within the protective jetty entrance at Coos Bay,

between buoys G5 and G5A. After the traps were checked for catch, the BIG ABALONE began

having engine trouble. Because of the engine trouble, the BIG ABALONE was disabled and

adrift in Coos Bay.

Meanwhile, the charter fishing vessel BETTY KAY, which was returning to Charleston

Harbor, was proceeding inbound approaching buoy G5A. Its operator saw someone waving for

attention from the drifting pleasure craft. When he brought the BETTY KAY alongside of the

BIG ABALONE, he was told by that boat’s operator of the engine problem. Even though the

BIG ABALONE’s operator stated that his CB and VHF radios were on and tuned to channel 11

and channel 16, he asked the operator of the BETTY KAY to call the Coast Guard and tell them

1

All times in this report are Pacific daylight time based on a 24-hour clock.
28 Appendix A

of his problem.

At 1719, the operator of the BETTY KAY contacted the communications center at USCG

Station Coos Bay, via VHF-FM radio channel 16. He reported that the BIG ABALONE was

disabled and adrift in Coos Bay, between buoys G5 and G5A, with five persons on board. The

communications watchstander told the operator to instruct all persons on board the BIG

ABALONE to don personal flotation devices (PFDs). The BETTY KAY’s operator passed on

the Coast Guard’s instructions, and all persons on board the BIG ABALONE complied.

The BETTY KAY remained within shouting distance of the BIG ABALONE while

awaiting the arrival of the Coast Guard. According to the BETTY KAY’s operator, after a short

while, he noticed that the pleasure craft appeared a little low in the water. He asked the BIG

ABALONE’s operator whether his vessel was taking on water. The operator of the BIG

ABALONE said it was not. The BETTY KAY operator asked a second time, and after

checking his boat, the BIG ABALONE operator confirmed that his vessel was slowly taking on

water. The BETTY KAY relayed this information to the Coast Guard. He also informed the

Coast Guard that all persons on the disabled boat were now wearing PFDs. The Coast Guard

instructed the BETTY KAY’s operator to switch his VHF radio to channel 22A for all further

communications with the Coast Guard.

At 1719, when the BETTY KAY’s initial call was received at Station Coos Bay, the

watchstander sounded the alarm to activate the duty boat crew. At 1721, a four-man crew,

consisting of a coxswain, who was in command, an engineer, and two crewmen, got underway

aboard the CG 44373, a 44-foot motor life boat (MLB). Among the MLB’s standard equipment

were a VHF-FM radio, radar, Loran, towing lines, and a P-5 gas-engine-driven portable pump.

According to the morning (0855) weather report, conditions at Coos Bay Bar were as

follows: southerly winds at 10 knots, swells of 3 to 5 feet occasionally running to 6 feet,

choppy, with a 2-knot ebbing current, The morning weather report also contained a rough bar

warning because of “extremely hazardous bar conditions, ” which restricted recreational boats

less than 20 feet long from crossing the bar at the entrance to Coos Bay. The rough bar warning

and restriction were issued by Station Coos Bay and broadcast on the radio regularly by the

Coast Guard.

The coxswain stated that, based on the morning weather report and rough bar warning,

the position of the BIG ABALONE (inside the jetty), and radio-transmitted information

concerning the pleasure craft (disabled, adrift, and taking on water), he decided while he was

en route to de-water and tow the pleasure craft to shore. The coxswain further stated that he

was aware the pleasure craft was taking on water, but it was his understanding that the boat was

not in danger of sinking. To this end, the coxswain told the MLB engineer to prepare to board

the pleasure craft with a P-5 de-watering pump.

When the coxswain saw the pleasure craft, he released the BETTY KAY to return to

port. As the coxswain brought the MLB close to the BIG ABALONE, he noticed two women

in the forward portion of the pleasure craft, outside the small cabin, but protected by a canvas

cover. They were sitting on a bench facing forward at the boat’s control console. The two
Appendix A 29

women waved calmly to the crew as the MLB approached the BIG ABALONE. The two male

occupants were standing in the stern of the pleasure craft, along with the 46-year-old female.

According to the coxswain, the people in the pleasure craft showed no signs of panic or fear.

The coxswain stated that because the pleasure craft did not appear to be in imminent danger of

sinking, he believed that the reported flooding was probably minor.

He later stated that the conditions on the bar were more severe than the early weather

report had indicated. The ebb tide appeared to be about 4 to 5 knots with seas of about 7 to 8

feet. He therefore saw no need to expose the pleasure boat’s passengers to possible injury by

attempting to transfer them to the MLB in the rough sea.

He observed that the BIG ABALONE was setting seaward toward the bar with the ebbing

tidal current. And he believed that the transfer of his engineer and a P-5 pump to the pleasure

craft would not endanger the vessel or the people on board. The coxswain maneuvered along

the BIG ABALONE’s port side, and about 1732, the engineer boarded the pleasure craft. The

P-5 pump was then transferred to him. Once on board, the engineer reported to the coxswain

about 6 inches of water in the engine casing bilge. He also reported that the water around the

engine was calm and flat and that he could not determine the source of the leak.

After transferring the engineer, the coxswain maneuvered the MLB aft along the port side

of the pleasure craft, turned around the stern, and proceeded up along the starboard side to

position the MLB ahead of the BIG ABALONE to facilitate towing. About 1734, as the MLB

neared the starboard bow of the pleasure craft, an 8- to 10-foot swell broke over the stern of the

BIG ABALONE. The coxswain yelled, “Get all the people out on deck. ” But his warning was

too late. By then another 8- to 10-foot swell had broken over the stern again, swamping the

pleasure craft.

Suddenly, the open stern of the vessel was under water, and the forward half of the

pleasure craft pointed up out of the sea at about a 45-degree angle. The coxswain clearly saw

the two women sitting on the front bench seat at the boat’s control console as the pleasure craft

slipped beneath the sea stern first. Only about 2 minutes had passed since the engineer had

boarded the pleasure craft. The coxswain yelled to his remaining crew to get a count of all

people in the water.

Following the swamping of the BIG ABALONE, the coxswain radioed Station Coos Bay

and reported that the pleasure craft had capsized and there were four people visible in the water,

including his engineer. All of the BIG ABALONE’s occupants still had on their PFDs. By this

time, the bow of the pleasure craft was protruding only about 1.5 feet above the surface of the

sea.

An MLB crewmember requested permission to enter the water and assist in retrieving

the people. The coxswain immediately granted permission, and the crewmember jumped into
30 Appendix A

the 57° F sea water.2

The crewmember (rescue swimmer) assisted the survivor nearest the

MLB, the 46-year-old woman, who weighed about 270 pounds, Another crewmember threw

the rescue toss line to the rescue swimmer, and together they maneuvered the woman toward

the side of the MLB. After numerous attempts, the two MLB crewmen on board the MLB,

with the help of the two crewmembers who were in the water, succeeded in getting the woman

on board the MLB.

The coxswain threw a life ring to the engineer, who held onto the BIG ABALONE’s

operator. The boat operator was holding onto the P-5 pump, which was still afloat in its

buoyant drum-like container. The engineer and the operator were pulled to the side of the MLB

with the life ring retrieving line. The operator held on until the 46-year-old woman was

removed from the water. Then the operator was lifted on board the MLB.

The last survivor, a male, was observed clinging to the bow of the pleasure craft. The

nearly submerged pleasure craft was drifting toward the MLB, and the survivor was between

the two vessels and in danger of being injured between them. The MLB engineer swam to him

and pulled him free of the pleasure craft bow. A crewmember reached over the side of the

MLB, while the coxswain held onto his belt, and together all four crewmen pulled and pushed

the survivor onto the MLB. Then the coxswain and a crewmember lifted their shipmate (rescue

swimmer) into the MLB. The engineer pulled himself on board the MLB.

According to the MLB crew, the three survivors appeared to be in various stages of

shock. One of the elderly men was dazed and sobbing and very depressed. Another survivor

appeared to have a bluish or purplish complexion and was complaining of chest pains, and the

third survivor had bruised or broken ribs. At that time the MLB was rolling through an 80-

degree arc (40 degrees to each side) when a 20-foot rigid hull inflatable boat (RHIB) from

Station Coos Bay came alongside. The coxswain decided to transfer the survivors to the RHIB,

while the MLB continued the search for other possible survivors. The survivors were

transported ashore to a waiting ambulance. They were taken to local hospitals, where they were

treated and released.

During the transfer of the survivors, the MLB crew lost sight of the bow of the BIG

ABALONE. Following the transfer, the MLB coxswain returned to the accident site and began

a search from that location, accounting for the ebb tide. About 25 minutes later, he was joined

by the Station’s 30-foot patrol boat. Shortly after that, a helicopter from USCG Air Station

North Bend and the 52-foot MLB INTREPID joined in the search. An air and sea search for

the two missing women continued for a day and a half with negative results. The bodies of the

two victims were never found.

Probable Cause

2The estimated survival time in 57° F water is 1 to 6 hours. However, a person may become exhausted or

unconscious within 1 to 2 hours as a result of hypothermia and may drown while afloat in a PFD. A person’s

age is also a factor in his/her ability to survive.
Appendix A 31

The National Transportation Safety Board determines that the probable cause of the

sinking of the BIG ABALONE was the swamping of the drifting and disabled pleasure craft

because of the heavy seas at Coos Bay Bar. Contributing to the loss of life was the failure of

the coxswain of the CG 44373 to remove the passengers before attempting to tow the vessel into

safer waters.
32 Appendix A

NATIONAL TRANSPORTATION SAFETY BOARD

Vessels:

Accident Type:

Location:

Date:

Time:

Owner:

Property Damage:

Injuries:

Deaths:

Complement:

WASHINGTON, D.C. 20594

Marine Accident Brief No. DCA-93-MM-030

Adopted March 25, 1994

U.S. Tug DUKE LUEDTKE, O.N. 216022, 68.7 Feet Long, 73

Gross Tons, Built in 1917, Uninspected

Coast Guard Utility Boat, CG 41487, 41

Feet Long

Sinking

Lake Erie, about 13 Miles North of Avon Point, Cleveland,

Ohio(Latitude 41 °43.6’N, Longitude 81 °58.6’W)

September 21, 1993

Approximately O033, Local

Luedtke Engineering Company, Frankfort, Michigan

In Excess of $250,000.00 (Total Loss)

3 (Minor)

1

3 (Tug), 5 (Coast Guard Boat)

Description of the Accident

At 19301 on September 20, 1993, the commercial tug DUKE LUEDTKE departed West

Harbor, Ohio, en route to Ashtabula, Ohio. It was a typical Great Lakes harbor tug, steel

hulled, and of both riveted and welded construction.

The wind was coming out of the west at 6 knots, and the seas were 2 to 4 feet. The air

temperature was 63° F, and the water temperature was 70° F. Visibility was 4 miles.

Three persons were on board, the operator and two deckhands. After getting underway,

the operator made routine hourly checks of the engineroom to ensure that everything was

operating properly. At 2300 he noted 3 feet of water in the engineroom, whereas he had

observed no water during his previous check at 2200. He looked for but could not determine

the source of the flooding.

l

A1l times are Eastern daylight time and are based on the 24-hour clock.
Appendix A 33

At 2337, the DUKE LUEDTKE was about 13 miles north of Avon Point, Ohio, when

the operator transmitted a distress call on VHF/FM channel 16, reporting his vessel was taking

on water and required assistance. The distress call was immediately answered by the

communications watchstander at Coast Guard Station Cleveland Harbor, Ohio. The tug operator

told the watchstander that the water in the engineroom at that time was about 3 feet deep. Later,

at 2355, he advised the watchstander that the level had increased to 5 feet.

At 2340, Coast Guard Station Cleveland Harbor dispatched the 41-foot utility boat (UTB)

CG 41487 with a crew of five (a coxswain, an engineer, and three crewmembers) to render

assistance. Before getting underway, the coxswain reported to the watchstander for a briefing.

The watchstander advised him of the vessel’s identity, type, and location and that the vessel was

taking on water.

The coxswain did not talk to the tug operator while en route, nor did the coxswain talk

to the operator when the UTB arrived on scene. The tug operator stated that as soon as the

UTB was alongside, it was secured to the forward port side of the tug.

Unknown to the operator, two Coast Guard crewmembers immediately boarded the tug

and asked one of the tug’s deckhands for directions to the engineroom. The crewmembers

entered the compartment above the engineroom through a watertight door on the port side,

slightly aft of amidships, closing the door behind them.

About 90 seconds after the UTB came alongside, the tug heeled to port and sank stern

first. Both of the crewmembers who had boarded the tug were trapped in the area above the

engineroom when the tug sank.

Earlier, the tug operator had instructed his two deckhands to don their survival suits and

stay on the main deck. Both were on the port bow of the tug when the UTB came alongside.

As the tug started to sink, one of the deckhands jumped from the tug to the bow of the UTB and

was helped aboard. The other deckhand jumped into the water and was rescued shortly

thereafter by the UTB. The tug operator escaped through a window of the wheelhouse into the

water and was rescued by the CG 41391, a UTB from Coast Guard Station Lorain, Ohio, that

had also responded to the incident. He was transferred to the Cleveland Harbor UTB and later

taken to a Cleveland hospital, where he was admitted and treated for chest pains.

One of the UTB crewmembers who had boarded the tug managed to escape from the

engineroom area through a forward bulkhead door leading through the galley and up to the

wheelhouse. He escaped by breaking out a window in the wheelhouse and swimming to the

surface. He was rescued by the Cleveland Harbor UTB and transported to the Lorain County

Hospital by a Coast Guard helicopter from Coast Guard Air Station, Detroit, Michigan. The

other Coast Guardsman remained missing. Searches were conducted by various Coast Guard

units, civilian helicopters, and civilian agency vessels throughout the night. Additional Coast

Guard helicopters joined the search at daybreak and continued the search for him throughout the

day with no success. On September 22, 1993, his body was recovered from the tug in the area

above the engineroom by divers from a civilian salvage company. They were helped by divers
34 Appendix A

from the Cleveland and Lorain police departments.

The Cleveland Harbor Station’s communications watchstander was responsible for

executing a search and rescue (SAR) Incident Summary form2 when he received the tug’s call

for Coast Guard assistance. The form has a case data section that includes information to be

obtained and entered under the heading “Initial Severity.” The SAR Incident Summary form

executed during this case had no entry under “Initial Severity. ” The watchstander stated that

there was no sense of urgency in the voice of the tug operator when he was talking on the radio;

therefore, the watchstander did not consider the situation to be life threatening. Consequently,

when the coxswain reported to the watchstander for a briefing of the accident, the coxswain was

not made aware that the tug was in danger of sinking, only that it was underway and taking on

water.

The coxswain stated that he initially believed that he was on a routine case that could be

resolved by putting two of his crewmembers on board to assess the situation, stop the flooding

if possible, and pump out the flooded compartment with a portable pump.

The coxswain stated that when the UTB arrived on scene, the tug did not appear to him

to be in danger of sinking. When questioned about how he made this assessment, he stated that

the vessel was riding smoothly and rolling slowly. He further stated that because the vessel was

not listing, he did not think it was in danger of sinking.

When the two crewmembers boarded the tug, the surviving crewmember stated, he

noticed there was about a foot of water on the after main deck of the tug. He said that when

they entered the engineroom, the other crewmember closed the door so that the water on deck

would not enter the engineroom. The tug had already sunk to a level above the freeing ports3

aft, allowing water to accumulate on the main deck.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the

sinking of the tug boat DUKE LUEDTKE was the flooding of the vessel’s engineroom from an

unknown source. Contributing to the loss of life was the Coast Guard’s failure to provide

proper risk assessment training to Station Cleveland Harbor search and rescue personnel.

2 A form used to record important data and information about the vessel in distress. The form is vital for

ensuring that cases are properly assessed and prosecuted.

3

An opening in the side plating of a vessel close to the main deck that allows water washing on deck to run

freely overboard.