Marine Accident Report

Collision Between the U.S. Coast Guard Patrol

Boat CG242513 and the U.S. Small Passenger

Vessel Bayside Blaster, Biscayne Bay, Florida

January 12, 2002

National 

Transportation

Safety Board

Washington, D.C.

A

A

N TION

L TRA SPOR

ATIO

N

B OARD

SAF E T Y

N

T

E PLURIBUS UNUM 

NTSB/MAR-02/05

PB2002-916405

Marine Accident Report

Collision Between the U.S. Coast Guard Patrol 

Boat CG242513 and the U.S. Small Passenger 

Vessel Bayside Blaster, Biscayne Bay, Florida 

January 12, 2002

NTSB/MAR-02/05

PB2002-916405 National Transportation Safety Board

Notation 7454A 490 LíEnfant Plaza, S.W.

Adopted December 17, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2003. Collision Between the U.S. Coast Guard Patrol Boat

CG242513 and the U.S. Small Passenger Vessel Bayside Blaster, Biscayne Bay, Florida, January 12, 2002.

Marine Accident Report NTSB/MAR-02/05. Washington, DC.

Abstract: This report discusses the collision that occurred on the evening of January 12, 2002, between the

U.S. Coast Guard patrol boat CG242513, which was on a routine patrol of Biscayne Bay, Florida, and the

small passenger vessel Bayside Blaster, which was on a sightseeing tour of the area. The accident resulted

in no deaths or serious injuries. However, both Coast Guard crewmembers and 2 of the Bayside Blaster's

passengers were taken to a hospital for examination. Damages to the patrol boat (which was a total loss),

the Bayside Blaster, and a moored recreational boat totaled $184,722.

From its investigation of the accident, the National Transportation Safety Board identified safety issues

regarding the adequacy of the following: operation of the Coast Guard patrol boat; operation of the

Bayside Blaster; Coast Guard oversight of routine patrols; Boatrides International, Inc. (owner of the

Bayside Blaster) management oversight; kill switch operation on Coast Guard nonstandard boats;

lifejacket stowage on the Bayside Blaster; and Coast Guard safety oversight of small passenger vessels in

Miami.

On the basis of its findings, the Safety Board made recommendations to the U.S. Coast Guard, to Boatrides

International, Inc., and to the Passenger Vessel Association.

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 LíEnfant 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 PB2002-916405 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Marine Accident Report

Contents

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

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

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

Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Bayside Blaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Coast Guard Patrol Boat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Crew Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Coast Guard Patrol Boat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Bayside Blaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Coast Guard Patrol Boat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Bayside Blaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Meteorology Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Coast Guard Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Coast Guard Nonstandard Boat Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Recreational Boating Safety and Manatee-Zone Enforcement Patrols . . . . . . . . . . . . 20

Island Queen Sightseeing Tours Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Coast Guard Patrol Boat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Bayside Blaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Emergency Systems/Survival Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Kill Switch Attachments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Coast Guard Patrol Boatís Navigation Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Postaccident Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Passenger Vessel Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Collision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Operation of the Coast Guard Patrol Boat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Operation of the Bayside Blaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Navigation Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Contents iv Marine Accident Report

Coast Guard Oversight of Routine Patrols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Boatrides International, Inc., Management Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Kill Switch Operation on Coast Guard Nonstandard Patrol Boats . . . . . . . . . . . . . . . . . . . 41

Lifejacket Stowage on the Bayside Blaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Coast Guard Safety Oversight of Small Passenger Vessels in Miami . . . . . . . . . . . . . . . . . 44

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Appendix

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
v Marine Accident Report

Acronyms and Abbreviations

AOR area of responsibility

CFR Code of Federal Regulations

COI certificate of inspection

DOT U.S. Department of Transportation

FWC Florida Fish & Wildlife Conservation Commission

ICAO International Civil Aviation Organization

MLB motor lifeboat

OOD Officer of the Day

PQS personnel qualification standard

SAR search and rescue

UTB utility boat
vi Marine Accident Report

Executive Summary

About 2013 on January 12, 2002, the 24-foot Coast Guard patrol boat CG242513,

with two crewmembers on board, was on a routine recreational boating safety and

manatee-zone patrol in Biscayne Bay, Florida, when it collided with the small passenger

vessel Bayside Blaster, carrying 2 crewmembers and 53 passengers. Both Coast Guard

crewmembers were ejected from their boat. The patrol boat continued running, circled to

port, and struck the Bayside Blaster again. The unmanned Coast Guard patrol boat

continued to circle for 10 to 15 minutes, striking a moored recreational boat two times and

pilings near the shore. Police officers responding to the scene pinned the Coast Guard

patrol boat to the pilings and shut off the engines. Five passengers who reported being

injured were taken to the Coast Guard Station, where they were triaged. After triage, two

passengers were transported to a hospital, and the others did not request further medical

treatment. The two Coast Guard crewmembers were triaged by paramedics on Palm

Island, taken to a nearby hospital for further examination, and released the morning of

January 13. As a result of the accident, the Coast Guard patrol boat, valued at $80,000,

was declared a total loss. The damage to the Bayside Blaster was estimated at $80,000,

and the damage to the moored recreational boat was $24,722. Damages from the accident

were estimated at $184,722.

The Safety Board's investigation of the accident identified the adequacy of the

following as major safety issues: 

ï Operation of the Coast Guard patrol boat;

ï Operation of the Bayside Blaster;

ï Coast Guard oversight of routine patrols; 

ï Boatrides International, Inc., management oversight; 

ï Kill switch operation on Coast Guard nonstandard patrol boats;

ï Lifejacket stowage on the Bayside Blaster; and

ï Coast Guard safety oversight of small passenger vessels in Miami.

The National Transportation Safety Board determines that the probable cause of

the collision between the Coast Guard patrol boat CG242513 and the small passenger

vessel Bayside Blaster was the failure of the coxswain of the Coast Guard patrol boat to

operate his vessel at a safe speed in a restricted-speed area frequented by small passenger

vessels and in conditions of limited visibility due to darkness and background lighting.

Contributing to the cause of the accident was the lack of adequate Coast Guard oversight

of nonstandard boat operations.

As a result of the investigation, the Safety Board makes recommendations to the

U.S. Coast Guard, to Boatrides International, Inc. (owner of the Bayside Blaster), and to

the Passenger Vessel Association.
1 Marine Accident Report

Factual Information

Accident Narrative

Bayside Blaster

The U.S. small passenger vessel Bayside Blaster (see figure 1) left Bayside

Marina, Miami, Florida, on an excursion to Biscayne Bay about 19301

 on January 12,

2002, with a master, a deckhand, and 53 passengers on board. 

The Bayside Blaster followed its normal route from the marina, under the bridge

on the west side of Dodge Island, eastward through the main channel along Dodge Island,

and under the MacArthur Causeway Bridge. North of the causeway, the vessel

maneuvered around the north end of Star Island and then south along its west side,

traveling at idle speed (3 to 4 knots), while the master and deckhand alternated providing

bilingual (English and Spanish) narration of the sights in the area (see figure 2).

1 All times in this report are Eastern Standard Time, based on the 24-hour clock.

Figure 1. The Bayside Blaster.
Factual Information 2 Marine Accident Report

From the south end of Star Island, the Bayside Blaster traveled west to Palm Island

at a slow speed of 6 to 8 knots. Arriving at a point about 100 feet from the island, the

master again slowed the vessel to idle and resumed the narrated tour. About 2010, the

master began to round the east end of Palm Island, with the intention of touring between

Palm and Hibiscus islands. The master and the deckhand were at the center steering

station. The deckhand had just completed a narration describing a house on Palm Island

when he noticed a commotion from the passengers seated in the bow area. Looking off the

starboard bow, the deckhand saw the running lights and bow wave of an oncoming boat

approaching at high speed. 

The deckhand alerted the master and told him, ìGo.î The master applied right

rudder and increased the throttle in an attempt to avoid the approaching boat.

Coast Guard Patrol Boat

About 1940, a Coast Guard petty officer at Coast Guard Station Miami Beach

sought out the station Officer of the Day (OOD) and requested permission to undertake a

recreational boating safety patrol of the north part of Biscayne Bay. According to the

OOD, the coxswain requested, ìto get under way for recreational boating safety . . . and

while in the area go see [another Coast Guardsman] at a private residence on Palm Island.î

The OOD granted permission for the patrol and the visit to the private residence, but

cautioned the petty officer ìto complete some boardings around their visitî [that is, to

board recreational boats and conduct safety checks on them while in the area of their

visit].

Figure 2. Bayside Blaster route.

BISCAYNE

BAY

CLAUGHTON

ISLAND

MIAMI

MIAMI

BAYSIDE

BISCAYNE

BAY

(DODGE ISLAND)

PORT OF MIAMI

(LUMMUS ISLAND)

Scale Approximate

YARDS

0 100 500

MAC ARTHUR

CAUSEWAY

PALM ISLAND

HIBISCUS ISLAND

ACCIDENT 

SITE

MAC 

ARTHUR

CAUSEWAY 

BRIDGECOAST GUARD

BASE

BELLE

ISLAND

MIAMI 

BEACH

RIVO

ALTO

ISLAND

DILIDO

ISLAND

SAN

MARINO

ISLAND

SAN MARCO

ISLAND BISCAYNE ISLAND

WATSON

PARK

N

MONUMENT

ISLAND

STAR

ISLAND
Factual Information 3 Marine Accident Report

About 2005, the petty officer got under way on the 24-foot Coast Guard patrol boat

CG242513 from Coast Guard Station Miami Beach for the recreational boating safety

patrol, to enforce safe recreational boating rules and proper speeds in manatee-protection

zones in Biscayne Bay (see ìWaterway Informationî section for more information). On

board the patrol boat were two Coast Guardsmen: a coxswain (the petty officer who had

requested the patrol) and a crewmember (also a petty officer). While the 24-foot patrol

boat was departing the station at slow speed (about 6 knots), a crewmember on a nearby

Coast Guard 41-foot utility boat (UTB) informed the coxswain of the patrol boat that his

port navigation light (red sidelight) was out. The patrol boatís coxswain said that he

tapped the light and it came back on. 

The patrol boat then traveled north under the MacArthur Causeway Bridge. After

clearing the bridge, the coxswain accelerated to full speed2 (about 4,000 rpm, or 32 knots)

and steered around the north end of Star Island and along the north shore of Hibiscus

Island. After traversing about halfway along the north side of Hibiscus Island, the

coxswain reversed course and headed toward the east end of the island (see figure 3).

2 The manufacturerís operating limit for the outboard engine is 4,400 rpm. Coast Guard Station Miami

Beach had established 4,000 rpm as the maximum throttle setting for operations to reduce stress on the

engines. 

Figure 3. Manatee-protection speed zones in the accident area, with Coast Guard 

patrol boat route.

BISCAYNE

BAY

CLAUGHTON

ISLAND

Land

Slow Speed Areas (includes Some Idle Speed Areas)

30-35 Mph Areas

(DODGE ISLAND)

PORT OF MIAMI

(LUMMUS ISLAND)

Scale Approximate

YARDS

0 100 500

MAC ARTHUR

CAUSEWAY

PALM ISLAND

HIBISCUS ISLAND

ACCIDENT 

SITE

MAC 

ARTHUR

CAUSEWAY 

BRIDGECOAST GUARD

BASE

BELLE

ISLAND

RIVO

ALTO

ISLAND

DILIDO

ISLAND

SAN

MARINO

ISLAND

SAN MARCO

ISLAND BISCAYNE ISLAND

WATSON

PARK

N

MIAMI

MIAMI

BAYSIDE STAR

ISLAND

TO ATLANTIC OCEAN

MONUMENT

ISLAND

MELOY

CHANNEL MIAMI 

BEACH

IDLE 

SPEED

BISCAYNE

BAY

BISCAYNE

BAY

Bridge

Approximate Track of Coast Guard Patrol Boat
Factual Information 4 Marine Accident Report

Still traveling about 32 knots, the patrol boat rounded the east end of Hibiscus

Island and proceeded south in the waterway between Hibiscus and Star islands, heading

toward the east end of Palm Island. The coxswain testified that ìknowing [he] was going

too fast in the manatee areaî as the patrol boat approached Palm Island, he ìstarted

bringing the throttle back.î The crewmember confirmed that the coxswain had his hands

on the throttle as they entered the manatee zone. At the same time, both crewmembers saw

a silhouette directly ahead and heard people screaming. The coxswain turned sharply to

port and applied full starboard throttle in an attempt to avoid the obstacle.

About 2013, the patrol boat struck the Bayside Blasterís starboard quarter,

sideswiping it with the patrol boatís starboard bow. According to the crewmember, at or

immediately after the impact, both she and the coxswain were ejected over the starboard

side of the boat and into the water. With the patrol boatís engines still running about full

throttle, the boat continued in a left-hand (counterclockwise) turn. 

In the water, both Coast Guard crewmembers removed their automatically inflated

lifejackets to more easily swim to nearby Palm Island; they did not remove their law

enforcement equipment. Both were forced to dive under the water at least once to avoid

the circling patrol boat. During one pass, the coxswain, while underwater, was struck in

the back by the patrol boatís hull but not its propellers. As the crewmembers swam toward

Palm Island, they called for help to people they saw on the island. Two people entered the

water from a residence on Palm Island, swam to the crewmembers, and helped them to

shore.

The master of the Bayside Blaster slowed his boat after the impact to determine

whether the passengers were all right. The deckhand also looked over the side of the

vessel to see whether any passengers were in the water, to check for damage, and to

determine whether the vessel was taking on water. As the Bayside Blaster slowed, the

unmanned patrol boat circled back and struck the Bayside Blaster again on the starboard

side (see figure 4). After the patrol boat struck the Bayside Blaster the second time, the

deckhand went to the helm console, where the master was calling the Coast Guard to

report the accident. Coast Guard records show that the call was made at 2015. After the

second impact, the master of the Bayside Blaster increased his speed and headed the

vessel north to avoid being struck again by the circling boat. He maneuvered the Bayside

Blaster toward the northwest side of Monument Island, about 800 yards north of the

accident site, and beached the vesselís bow on the sandy beach.

En route to the island, lifejackets were distributed to the passengers, first by the

deckhand and then by the passengers. Once the master beached the boat, the deckhand

directed everyone to the forward end of the vessel. He then jumped off the bow and began

to help the passengers disembark onto the beach. All passengers received a lifejacket

either while on the Bayside Blaster or while on the island. 

The Bayside Blasterís uninjured passengers were ferried from the island by

another company boat to Bayside Marina, their departure point. Five people who reported

they were injured were taken with others in their group in Coast Guard vessels to the

Coast Guard station, where medical technicians were waiting to triage them and where
Factual Information 5 Marine Accident Report

ambulances were on hand to transport them to local hospitals. According to Coast Guard

Station Miami Beach, two passengers with injuries were transported to South Shore

Hospital. The other three injured passengers declined transport to a hospital and were

taken to Bayside Marina by government vehicle.

Figure 4. Approximate collision angles between the Coast Guard patrol boat and 

the Bayside Blaster.

CG242513

CG242513

FIRST COLLISION

BAYSIDE BLASTER

N

SECOND COLLISION

N

Black circles

indicate crew
Factual Information 6 Marine Accident Report

Meanwhile, the Coast Guard patrol boat continued turning in counterclockwise

circles toward the east side of Palm Island. Twice, the Coast Guard patrol boat struck a 46-

foot recreational boat moored bow-out at a dock on Palm Island. The Coast Guard patrol

boatís T-top struck the bow pulpit of the recreational vessel during the first collision. The

T-top was knocked over and dragged on the port side of the Coast Guard patrol boat.

According to witnesses on shore, the patrol boat began making very small left-hand circles

with the T-top dragging (attached to the boat by engine control cables and electrical

wiring) in the water. At 2035, about 20 minutes after it first collided with the Bayside

Blaster, the Coast Guard patrol boat hit pilings on the northeast side of Palm Island. It was

wedged into the pilings by a Florida Fish & Wildlife Conservation Commission (FWC)

boat and a Miami Beach Police Department boat that had responded to the emergency (see

figure 5). The officers managed to shut down the patrol boatís engines (figure 6 shows the

patrol boat after the accident). See ìEmergency Responseî section for further details.

Injuries

The two Coast Guard crewmembers suffered bruises, and five of the Bayside

Blasterís passengers reported injuries as a result of the accident. After triage at the Coast

Guard station, two passengers were transported to a hospital and three declined further

treatment. The two Coast Guard crewmembers were taken to a nearby hospital for further

examination and released early on the morning of January 13. The injuries sustained in the

accident are shown in table 1.3

Table 1. Injuries sustained

Bayside Blaster CG242513

Injuries Crew Passengers Crew Total

Fatal 00 0 0

Serious 0 0 0 0

Minor 0 5 2 7

None 2 48 0 50

Totals 2 53 2 57

Title 49 Code of Federal Regulations (CFR) 830.2 defines a fatal injury as any injury that results in death within 30 

days of an accident. It defines serious injury as that which requires hospitalization for more than 48 hours, 

commencing within 7 days from the date the injury was received; results in a fracture of any bone (except simple 

fractures of fingers, toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon damage; involves any 

internal organ; or involves second- or third-degree burns, or any burn affecting more than 5 percent of the body 

surface.

3 Injuries are categorized according to the injury criteria of the International Civil Aviation

Organization (ICAO). The Safety Board uses the ICAO injury criteria in all its accident reports, regardless

of transportation mode.
Factual Information 7 Marine Accident Report

Figure 5. Possible track of the Coast Guard patrol boat from the time it collided with the 

Bayside Blaster to the time it was secured to pilings on Palm Island (for illustrative purposes only).

PALM 

ISLAND

STAR

ISLAND

LEGEND

(LOCATIONS ARE APPROXIMATE)

HIBISCUS

ISLAND

BRIDGE

MAC ARTHUR CAUSEWAY

Scale Approximate

YARDS

200 100 0

#1- First collision between 

 Bayside Blaster and CG242513

Number and diameter 

of left-hand turns 

(counter clockwise) 

are unknown

Bayside Blaster en route to

Monument Island 

after collisions #1 and #2

#2- Second collision between 

 Bayside Blaster and CG242513

#3- Location of two collisions between 

 moored recreational

 boat and CG242513

#4- Location of CG242513

 pinned in pilings

#1

#3

#4

#2

N
Factual Information 8 Marine Accident Report

Damages

The Coast Guard patrol boat, valued at $80,000, was declared a total loss. The

damage to the Bayside Blaster was also estimated at $80,000. The damage to the moored

recreational boat was $24,722 (see ìWreckageî section for more information). The

Bayside Blaster returned to service on April 21, 2002.

Crew Information

Coast Guard Patrol Boat 

Coxswain. The coxswain, a petty officer second class (E-5), age 24, had served in

the Coast Guard for 4 1/2 years at the time of the accident. Before being stationed at Coast

Guard Station Miami Beach, he served on the Coast Guard cutter Long Island. He reported

to Station Miami Beach in July 2000 and was qualified as a coxswain of 41-foot UTBs in

February 2001, which automatically qualified him to coxswain nonstandard Coast Guard

boats (those 30 feet or less in length), which included the 24-foot patrol boat. According to

the Coast Guard, while it had not yet established servicewide training standards for

nonstandard boats, Station Miami Beach had generated a personnel qualification standard

(PQS) checklist for its nonstandard boats, a common practice throughout the Coast Guard.

The qualification review board for the stationís UTB served as the review board for all

Figure 6. Damaged Coast Guard patrol boat.
Factual Information 9 Marine Accident Report

station boats. Some questions asked during the qualification review pertained to

nonstandard boats, though a check ride on a nonstandard boat was not required for

qualification. The Coast Guard has since issued nonstandard boat PQS certification and

check ride requirements, which are distinct for each type of nonstandard boat in addition

to being separate from the requirements for standard boats. 

At the time of the accident, the coxswain had been operating the 24-foot patrol

boat for 11 1/2 months as a qualified coxswain. He stated that he had been through the

accident area many times during his tour at Coast Guard Station Miami Beach. Coxswains

were required to conduct at least one day trip and one night trip on any type of boat every

6 months through all designated areas of interest in the Station Miami Beach area of

responsibility (AOR), which included the location of the accident. According to the

coxswainís individual training record, which covered June 1, 2001, to January 11, 2002,

he had accumulated 6 hours of night operation time in the stationís AOR over two separate

trips. The coxswainís training record also revealed that he had practiced boat-handling

skills, specifically, maneuvering in tight quarters on Coast Guard Station Miami Beachís

41-foot UTB, and that he had spent 8.2 hours practicing piloting and navigation onboard

the same boat. Station records showed that he had a total of 49 hours of operating

experience on the accident boat and nearly 34 hours of operating experience on the other

24-foot patrol boat at the station. The coxswainís personnel file contained no record of any

reprimands or anything else negative.

The coxswain had 8 hours of sleep two nights before the accident and 11 hours of

sleep the night before it. Station policy allows the boat crewmen the day off on the day

before their scheduled duty period begins. Therefore, the coxswain did not work the day

before the accident. He began his duty at 0700 on the day of the accident and operated the

41-foot UTB from approximately 0840 to 1200. About 1330, he ate lunch and then

reviewed PQSs with the OOD. The rest of the afternoon, he watched a televised football

game, which started at 1630, in the station crew lounge with other Coast Guardsmen.

Alcoholic beverages are not permitted in the lounge. According to the station log, the 24-

foot patrol boat got under way on the accident voyage about 2005. 

During the Safety Board interview, the coxswain rated his overall health as good

and indicated that he was not taking any prescription or nonprescription medication. 

Crewmember. The crewmember, a petty officer third class (E-4), age 23, joined

the Coast Guard on February 1, 2000. After completing basic training, she was assigned to

Coast Guard Station Miami Beach on July 7, 2000. She also attended a specialty training

school for a machinery technician rating at the Coast Guard Training Center in Yorktown,

Virginia. She had been qualified as a boat engineer for about a year at the time of the

accident. According to the crewmemberís individual training report, which covered the

period June 1, 2001, through January 11, 2002, she had accumulated 2 hours of night

operation time in the stationís AOR during one trip. She had also participated in 16 hours

of team coordination training in October 2001. The training report revealed that the

crewmember had had no specific training in the operation of nonstandard boats, although

she had completed the stationís PQS to qualify as a boat crewman and engineer on
Factual Information 10 Marine Accident Report

nonstandard boats. The crewmemberís personnel file contained no record of any

reprimands or other negative items.

The crewmember indicated that she stood day work duty, 0700 to 1500, on January

10, 2002. She had gotten 7 1/2 hours of sleep on January 10. On January 11, she was off

duty and ate dinner about 1900. That night she slept for 8 hours. On January 12, the day of

the accident, she began her duty at 0700 and ate lunch about 1300. She got under way to

escort cruise ships out of Miami Harbor about 1600 and returned to the station about 1730. 

The crewmember reported that her overall heath was good. Although she had a

history of hypertension, no medication was currently prescribed for the condition. 

Bayside Blaster

Master. The Master, age 49, worked part-time on the Bayside Blaster one day a

week, on Saturdays, and only during the second shift (1600 to 2400). He had worked for

Island Queen Sightseeing Tours, Inc., the parent company of Boatrides International, Inc.,

the owner and operator of the Bayside Blaster, for about 3 years as a deckhand before

receiving a Coast Guard masterís license in October 1998. Previously, he had worked as a

deckhand on a 75-foot vessel and as a mate on several fishing vessels in Key West,

Florida, for a year. The owner of the Bayside Blaster indicated that there had never been

any reprimands or other negative items in the masterís personnel file. 

On October 9, 1998, the master completed a Coast Guard-approved Master of

Passenger Vessels training course at Sea School in Fort Lauderdale, Florida. On October

21, 1998, he received a Coast Guard masterís license as a master of near-coastal steam or

motor vessels of not more than 100 gross tons.

The master of the Bayside Blaster said that on January 9 through 11, he slept about

6 hours each night. From 0700 to 1800 on January 11, he was at his other job, and that

night he slept for about 9 hours. On the day of the accident, January 12, he went to his

other job from 0700 to about 1100. He reported eating lunch about 1200 and taking a nap

from 1300 to 1500. At 1650, he started his shift on the Bayside Blaster. About 1715, he

began loading passengers for the 1730 trip, which returned to the dock about 1845. He

took a few minutes to relax, drank some coffee, and about 1915, began loading passengers

for the second trip. About 1930, he got under way on the accident trip. 

The master reported that his overall health was good and that he was not taking

any prescription or nonprescription medication. 

Deckhand. The deckhand, age 25, had worked for Island Queen Sightseeing Tours

for about 3 years. He had left their employment to work for other companies and had been

back working for Island Queen Sightseeing Tours for 4 or 5 months before the accident. In

the previous 3-year period, he had worked on all four boats owned by the company,

including the Bayside Blaster. Since returning to the company, he had worked solely on

the Bayside Blaster as a deckhand. He had not completed any formal maritime training,
Factual Information 11 Marine Accident Report

nor was any required. The owner of the Bayside Blaster indicated that there were no

reprimands or anything else negative in the deckhandís personnel file.

The deckhand reported sleeping about 7 1/2 hours on the night of January 9. He

slept for approximately 11 hours on the night of January 10. He spent January 11 shopping

with his family and slept about 10 1/2 hours the night before the accident. He started work

at 1030 on January 12, washing down the boat for the afternoon cruise. Before the

accident run, he worked on three tripsóat 1330, 1530, and 1730. Between trips, he stood

by at the dock and waited for the next trip.

Vessel Information

Coast Guard Patrol Boat

The Coast Guard patrol boat was a fiberglass-reinforced plastic Boston Whaler

Guardian, 24 feet long by 8 feet 3 inches wide, built in 1997 and powered by two 200-

horsepower Mercury outboard engines. The coxswainís control/console station was in the

center of the boat, with a leaning post behind it. The console was covered by an overhead

T-top made of canvas stretched over a metal framework. Radio and radar antennas were

mounted on the T-top. The boat was equipped with separate red and green sidelights and a

white all-around light. The vertical separation between the sidelights and the white allaround light was about 1 foot.4

The red and green sidelights were moved from the bow area to the forward outside

corners of the T-top when it was installed in 2001. The white all-around light was also

moved to the T-top and installed on top of a 1-foot extension aft of the radar antenna.

Safety Board investigators examined the boat involved in the accident and found that the

radar antenna partially blocked the white all-around light for about 10° on either side of

dead ahead (see ìOther Informationî section for further discussion of navigation lights on

Coast Guard patrol boats).

The manufacturerís operating limit for each outboard engine is 4,400 rpm. Coast

Guard Station Miami Beach had established a 4,000-rpm limit for normal (nonemergency)

high-speed operations. Depending on sea state and vessel load, 4,000 rpm on both engines

produced speeds of about 32 knots. 

The steering wheel was offset left of center on the console. Immediately right of

center were the engine controls, which consisted of a single lever control (shift and throttle

on the same lever) for each engine, mounted together (see figure 7). Two separately keyed

ignition switches (one for each engine) were mounted under the wheel. The steering wheel

had a knob attached to ease turning (see figure 8).

4 The Inland Navigation Rules stipulate that the minimum vertical separation between sidelights and

the white all-around light will be 1 meter (3.3 feet).
Factual Information 12 Marine Accident Report

The Coast Guard patrol boat was equipped with a toggle-style engine kill switch

(see figure 9), provided by MerCruiser, the engineís manufacturer. The kill switch was

mounted on the aft vertical face of the center console, to the right of the engine ignition

Figure 7. Postaccident photograph of Coast Guard patrol boat console.

Figure 8. Patrol boat steering wheel, with steering-assist knob.

1. Kill switch location

2. Engine ignition keys

3. Throttles

4. Damaged steering wheel

1 2

4

3
Factual Information 13 Marine Accident Report

switches and about 1 1/2 feet lower than the engine control levers (see figure 7). A plastic

loop on one end of a coiled lanyard (about 1 foot long, it could be stretched to about 4 feet)

fit over the kill switch, where it was held in place by a plastic cover. The other end of the

lanyard was connected to a plastic handcuff key clip on the coxswainís belt (see figure

10). About three months before the accident, Coast Guard Station Miami Beach had

changed to a coiled lanyard because the straight one used previously had interfered with

work, according to the commanding officer of the station.

The system is designed so that if the plastic loop and lanyard are pulled in any

direction from the kill switch (when, for example, the operator inadvertently moves away

from the console), the engines should stop. In such a system, the kill switch maintains an

open circuit while the engines are operating. When the lanyard-and-loop assembly is

pulled from the switch, the toggle closes the switch, which grounds the ignition circuits

and shuts down the engines. When the kill switch is in the on position, the engines can be

started regardless of whether the lanyard-and-loop assembly is in place. 

The handcuff key clip was connected to a loop on the coxswainís web belt. The

crewmember confirmed during her interview that the kill switch was connected by the

lanyard to the coxswainís belt. After the accident, the handcuff key clip was found broken

(figure 10). A Safety Board investigator took possession of the handcuff key clip and kill

switch lanyard from the commanding officer of Coast Guard Station Miami Beach and

delivered them to the Safety Boardís Materials Laboratory for examination (see ìTest and

Researchî section for more information). 

Engineering staff at Coast Guard Station Miami Beach completed a daily

examination of each boat at the station, following a checklist. At the time of the accident,

the list did not include checking the kill switch operation. However, the stationís standing

orders required the kill switch to be checked daily. The station duty engineer stated that he

Figure 9. Kill switch with lanyard attached.
Factual Information 14 Marine Accident Report

had checked the kill switch on the morning of the accident and that it had operated

properly. 

The checklist also included a visual examination of the engines, with a check of

fuel and oil levels, and operational tests of engines, navigation lights, searchlight,

worklights, and bilge pumps. The only deficiency noted on the January 12, 2002, checklist

for the CG242513 was that the starboard worklight was inoperative.

After Safety Board investigators viewed the salvaged Coast Guard patrol boat,

located part of the kill switch, and viewed the damaged steering wheel and the broken

plastic clip hook from the coxswainís belt used to attach the kill switch lanyard, they

interviewed a Miami Beach police officer about the kill switch. The officer reported that

the kill switch lanyard was hanging from the switch when he leaned into the patrol boat.

After wedging the boat into pilings at Palm Island, he and the FWC officers shut off the

engines by pulling on the consoleís wiring harness and hitting the console with a baton.

After the patrol boat was salvaged and T-top placed upright, the kill switch and lanyard

were found in the deck drain. (The lanyard was not connected to the switch.)

At the request of Safety Board investigators, the Station Miami Beach

commanding officer polled his coxswains about the kill switch lanyard becoming fouled

with the steering wheel during turns. The coxswains universally reported having

experienced the problem more than once.

Figure 10. Belt loop with broken clip (left) and lanyard with metal clip and plastic loop 

(right).
Factual Information 15 Marine Accident Report

Safety Board investigators advised the Coast Guard team conducting an internal

investigation of the accident and Coast Guard Headquarters Office of Boat Forces5

 that the

kill switch did not activate in the accident. As a result, a safety advisory regarding engine

kill switches was sent out by the Coast Guard Assistant Commandant for Operations, in

ALCOAST6

 message 038/02 on January 30, 2002: 

Crews operating non-standard boats and cutterboats are at significantly higher risk

for ejection from their boat than their counterparts operating larger standard boats.

In FY 2001 alone, over 70 Coast Guard members had unplanned departures from

their boats. . . . As a result of these mishaps, two Coast Guard members lost their

lives and one was seriously injured.

The Coast Guard message also stated that kill switches must be used at all times

while such boats are under way, and that kill switch lanyards must be attached to a metal

D-ring on the coxswainís lifejacket or survival vest. The Coast Guard message equated the

wearing of the kill switch lanyard to putting on a seat belt when operating an automobile.

Further, the message required that the kill switch and lanyard be inspected daily,

incorporated into a daily checklist, and tested weekly. It also stated that Coast Guard

headquarters intended to have kill switches installed on all nonstandard boats, and that

boats less than 40 feet long are to have kill switches installed within 24 months. Finally,

the message mandated inspecting kill switch and lanyard configurations for condition and

switch location, and making changes if necessary. 

The Coast Guard reported that its inspection of the kill switch wiring inside the

console after the accident revealed a disconnected wire. The report indicated that the

disconnected wire would have kept a ground from being completed in the ignition circuits

when the toggle switch was closed, thereby preventing the engines from stopping.

Possible explanations offered by the Coast Guard report for the disconnected wiring are,

first, that the boat was used earlier in the day to respond to a boat taking on water offshore

about 10 miles from Coast Guard Station Miami Beach. The coxswain in the case stated

that he had run the boat at high speed in moderate seas, causing moderate to severe

pounding of the boat. Such pounding, according to the Coast Guard report, could have

disconnected the wiring. Second, the report stated that the wiring could have been

disconnected by one of the police officers who boarded the boat and tried to stop the

engines by pulling wires in the console. Third, the Coast Guard report stated that the

wiring could have been disconnected when the console was torn loose from the deck. 

Bayside Blaster

The Bayside Blaster, O.N. 1033547, was a fiberglass-reinforced plastic, 65-footlong by 18-foot-wide, 54-gross-ton small passenger vessel, built by the Defender Yacht

5 The office functions in the Coast Guard Headquarters Operations Directorate and is responsible for

planning coordination and facility management for Coast Guard groups, stations, aids to navigation teams,

port security units, and all small boats less than 65 feet long (standard and nonstandard). The office also

develops boat crew survival equipment standards and requirements, provides for their acquisition and

maintenance, and coordinates small boat training.

6 Message sent by U.S. Coast Guard headquarters to all Coast Guard units.
Factual Information 16 Marine Accident Report

Company in 1995. The Bayside Blaster was powered by two 1,600-horsepower diesel

engines. It was owned and operated by Boatrides International, Inc., Miami, Florida, a

subsidiary of Island Queen Sightseeing Tours, Inc., a company that operated three other

vessels. According to the companyís website, Island Queen Sightseeing Tours is a familyowned business that has operated for over 50 years. 

Passenger seating in the Bayside Blaster was on fixed benches, divided by a center

walkway. Eight rows of benches were aft of the raised operatorís station (see figure 11)

and three rows of benches were forward of the station. A canvas awning covered the rear

passenger area, and a separate canvas awning covered the operatorís steering station.

The Bayside Blaster was equipped with separate red and green sidelights, a white

masthead light, and a stern light. The red and green sidelights were installed on the side

bulkheads, at the forward corners of the operatorís raised station in the center of the

vessel. Postaccident examination of the Bayside Blasterís navigation lights by the Coast

Guard in Miami showed that the sidelights were not properly screened, that the arc of

visibility of the sidelights was approximately 30° greater than it should have been, and that

the vertical separation between the masthead light and the gunwale was less than the

required minimum of 2 1/2 meters (8.2 feet). The masthead light was mounted on the

forward bulkhead of the operatorís station, near the top edge, and the lightís arc of

visibility terminated at the port and starboard beams. Safety Board investigators found the

stern light mounted on the top of the canopy, at its rearmost edge. The light fixture was

designed to be an all-around white light, but the forward half of the lens was covered with

duct tape to make it a stern light.

Figure 11. Bayside Blaster seating, looking aft from steering station.
Factual Information 17 Marine Accident Report

The Bayside Blaster was inspected by Coast Guard Marine Safety Office Miami

and was issued a certificate of inspection (COI)7

 on August 20, 2001, permitting the vessel

to carry 83 passengers, with a minimum crew of a master and two deckhands, on a limited

coastwise route on the Atlantic Ocean and the Gulf of Mexico between Melbourne, Key

West, and Cape Romano, Florida, not more than 3 miles from shore. The Coast Guardís

inspection for certification of the Bayside Blaster included approval of the navigation

lights and lifejacket locations. The Bayside Blaster provided 90-minute sightseeing

cruises along Millionaireís Row, the Port of Miami, and Miami Beach, usually only on

weekends.

Waterway Information

Miami Harbor is a deepwater port on the east coast of Florida. It is principally a

consumer port (most imported cargo is consumed in the area rather than transshipped

elsewhere) and is of great importance as a cruise port. Two unmarked jetties protect the

harbor entrance, known as Government Cut. Miami Beach is the barrier island that

separates Biscayne Bay from the ocean. Causeways and bridges connect a series of islands

throughout Biscayne Bay to Miami Beach and the city of Miami on the mainland. A Coast

Guard complex, including Coast Guard Station Miami Beach, is on the north side of the

main ship channel at the east end of the MacArthur Causeway, and a large cruise ship

complex and container port are on the south side of the main channel. The MacArthur

Causeway forms the north shore of the main ship channel. North of the causeway, in

Biscayne Bay, are Palm, Hibiscus, and Star islands.

The area of the bay where the accident occurred has background lighting from

various sources in the Miami harbor area, including downtown office buildings to the west

and private residences around Biscayne Bay. The MacArthur Causeway and the brightly

lit container port are located south of the accident site, and an area of white and red lights

on the islands and bridges is located to the north. The lights are generally at the same level

as the navigational lights of vessels on the water.

The coxswain reported that in Miami, the background lights are always a ìbigî

visibility factor, and that on nights when the causeway has more traffic, it is more difficult

to operate. The coxswain also stated that he knew there was a blind spot coming around

the end of Hibiscus Island, and that he made a wide turn at 4,000 rpm. 

Most of Biscayne Bay has low-speed restrictions on vessels, imposed by the State

of Florida to protect manatees, a marine mammal that is covered by the Federal Marine

7 Small passenger vessels carrying more than six passengers for hire may not operate without a valid

Coast Guard COI, which is issued by the Coast Guard Officer in Charge, Marine Inspection, for the zone.

The COI, among other conditions, stipulates minimum firefighting, lifesaving, and staffing requirements.

When determining the number and competencies of the crewmembers, the Officer in Charge, Marine

Inspection, considers many factors, including the size of the vessel, its route, the type and horsepower of the

vesselís propulsion machinery, the number of passengers, the type and location of lifesaving equipment, and

the hazards peculiar to the route and service. 
Factual Information 18 Marine Accident Report

Mammal Protection Act of 1972 and the Endangered Species Act of 1973. The Florida

Manatee Sanctuary Act was passed in 1978 to regulate motorboat speeds and operations in

critical areas of manatee concentration. In those zones, boats must operate at idle or slow

speeds (the designation can vary by time of year). Idle speed is defined as the minimum

speed that will maintain the steerageway of a vessel while producing no wake. Slow speed

is defined as the speed at which a vessel is off plane, has settled into the water, and is

proceeding without a wake or with a minimal wake. In the area of the accident, slow speed

is the maximum allowed year-round.

The area immediately north of Star Island and northeast of Hibiscus Island has a

vessel speed limit of 35 mph. Two signs mark the boundary of the manatee-protection

zone where the accident occurred. One sign is on the northwest corner of Star Island and

the other is on the northeast corner of Hibiscus Island. A boat rounding Hibiscus Island

and heading south immediately enters the State-designated slow-speed zone. The distance

from where the Coast Guard patrol boat made the turn at Hibiscus Island to the area of the

accident is about 400 yards (see figure 5).

Meteorology Information

Hourly observation tables from the National Weather Service for Miami

International Airport, approximately 8 miles west of the accident site, show that at the

time of the accident, there were broken clouds, with a visibility of 10 miles and a

temperature of about 67o F. The winds were 6 knots from the south-southeast. According

to the Coast Guard, the seas were calm and there was no precipitation in the vicinity at the

time of the accident. 

Sun and moon data provided by the U.S. Naval Observatory Astronomical

Applications Department for Miami, Dade County, Florida, for January 12, 2002, list the

sunset at 1750 and the end of twilight at 1815. Moonrise occurred at 1827. The moon was

in a waning crescent phase, with 1 percent of its visible disk illuminated.

Operations

Coast Guard Operations

Coast Guard Station Miami Beach is a multimission boat station. Its primary duties

are search and rescue (SAR), law enforcement, and port security. It has a response

requirement of providing two boats and crews on 30-minute standby, 24 hours a day, 365

days a year. To maintain daily control of the response duties, senior second-class or firstclass petty officers rotate as OOD. At the time of the accident, the OODs stood a 24-hour

duty period on a 5- to 7-day rotation and were not part of the boat crews. The boat crews

for the standby operations were organized into four duty sections. Each section had at least

two complete boat crews (two each of the following: coxswain, engineer, and

crewmember) and a boarding team (boarding officer and boarding team member). The
Factual Information 19 Marine Accident Report

senior coxswain in each duty section was responsible for the overall mission-readiness of

his section.

Guidelines from the command structure to the OODs and duty sections were

provided by verbal direction and the stationís standing orders. The duty coxswain was

responsible for the overall mission-readiness of all SAR resources under his or her control,

and while under way had overall responsibility for the operation of the vessel. The main

duties of the duty boat crewmember while under way were to follow the directions of the

coxswain and to act as primary lookout. The standing order that covered the operation of

small boats required the OOD to give permission for all boat launches. The order also

provided operating limitations for each type of boat based on seas, wind, and visibility.

The standing order did not mention specific speed or nighttime limitations for any patrol.

Coast Guard Group Miami is the supervising unit for Station Miami Beach. Group

Miami is responsible for coordinating the operations of 16 separate units, which include

four small boat stations, among them Station Miami Beach. The Seventh Coast Guard

District, headquartered in Miami, is the supervising unit for Group Miami and is the

program manager for nonstandard boats at Station Miami Beach.

Coast Guard Nonstandard Boat Oversight

According to the Coast Guard, small boat operations are divided into two

categoriesóstandard and nonstandard boats. Standard boats are those more than 30 feet

long and include the 41-foot UTBs and the 47-foot motor lifeboats (MLBs). Standard

boats are designed and procured by Coast Guard headquarters. For standard boats, crew

training, crew qualifications, vessel outfitting, and vessel operating limitations are set by

Coast Guard headquarters. In addition, a 41-foot UTB standardization team from the

Coast Guard Training Center and a 47-foot MLB team from the National Motor Lifeboat

School at Cape Disappointment, Washington, biannually visit every boat station that has

standard boats to inspect the standard boats and check the standardization of crew

qualification. During the years when the national visit is not made, the group office that

supervises the station conducts a ready-for-operations inspection for the same purpose.

Both inspections concentrate solely on standard boats. The Boat Crew Training Manual

(Commandant Instruction M16114.9C), issued by Coast Guard headquarters in May 1998,

contains guidance for training and certifying personnel to operate Coast Guard boats.

Nonstandard boats, those measuring 30 feet or less in length, compose the

remainder of the small boats at stations. The local Coast Guard district office has

procurement authority. Thus, the manufacturer, size, and equipment of nonstandard boats

vary widely, depending on the operating region and the conditions at individual stations.

Nonstandard boats are typically highly maneuverable, lightweight vessels that have a

greater speed, a shallower draft, and require fewer crewmembers than standard boats.

Nonstandard boats make up 53 percent of the boats operated by Coast Guard station boat

crews and carry out 3 percent of SAR missions.8

8 U.S. Department of Transportation (DOT), Audit of the Small Boat Station Search and Rescue

Program, Office of Inspector General, report MH-2001-094, September 14, 2001 (Washington, DC: DOT,

2001).
Factual Information 20 Marine Accident Report

According to Coast Guard officials, at the time of the accident, no formal training

or certification requirements existed for operating nonstandard Coast Guard boats. When

someone was qualified on standard boats at a Coast Guard station, he or she was

automatically considered qualified to operate nonstandard boats, although qualification on

a particular type of vessel did not automatically qualify an individual on all types of

vessels. As noted earlier, the Coast Guard has since issued nonstandard boat PQS

certification and check ride requirements, which are distinct for each type of nonstandard

boat in addition to being separate from the requirements for standard boats.

During his interview, the coxswain stated that all the qualification requirements to

become a coxswain at Station Miami Beach were carried out on the 41-foot UTB. He also

reported that during the coxswain qualification process, he was asked only ìa couple of

questionsî about nonstandard boats and did not have to complete any qualification

standards specific to the operation of nonstandard boats. The crewmember also stated that

Coast Guard personnel are qualified on the 41-foot UTB, but noted that they do some

drills and familiarization exercises on nonstandard boats. 

An addendum to the Coast Guard Station Miami Beach nonstandard boat

qualification guide for coxswains, engineers, and boat crewmen contains qualification

requirements regarding the nonstandard boats used at the station. One section on boat

handling contains an eight-item checklist. Three items assess operator proficiency in

mooring and anchoring the boat, in the proper use of tilt/trim controls, and in maneuvering

the boat in tight quarters. The remaining items require the operator to explain different

aspects of boat handling, but they do not require an individual to demonstrate skill in boat

handling. A review board consisting of the unitís department heads recommends qualified

personnel to the commanding officer, who approves and designates them as qualified.

Recreational Boating Safety and Manatee-Zone Enforcement Patrols

Undertaking a routine patrol is left to the discretion of the OOD or coxswain.9

 No

specific patrol routes or minimum number of patrols per day were required at the time of

the accident. The OOD had final authority in the duty section and approved the areas to be

patrolled, the boat to be used, and the crew. According to the coxswain, he decided to go

on the patrol, with permission from the OOD. He further stated that he intended to conduct

a patrol of the manatee-protection zone near Palm Island because of the high incidence of

high-speed operation of personal watercraft in the area.

According to Coast Guard officials, station management learns of improper

operation of its patrol boats (personnel not obeying speed limits or operating recklessly)

from other crewmembers, from citizen complaints, or from postaccident or incident

investigations. The commanding officer of Station Miami Beach stated that he had not

received any complaints about the manner in which his coxswains had operated their boats

before the accident. The marine patrol unit of the Miami Beach Police Department

reported that no previous complaints had been filed against Coast Guard Station Miami

9 The Coast Guard defines a routine patrol as a random-timed patrol in the AOR in support of Coast

Guard missions.
Factual Information 21 Marine Accident Report

Beach personnel for operating at high speeds in restricted zones. The FWC also reported

that it had not received any complaints from the public or reports from its personnel about

Coast Guard boats speeding in the restricted zones. 

A Florida statute (68C-22.003(2) and (3)) exempts law enforcement officers from

speed restrictions when entering a ìmotorboats prohibitedî or ìno entryî area in the

performance of their duties if the entry is reasonably warranted, is conducted to directly

protect manatees, or is necessary to prevent the loss of life or property or to render

emergency assistance. Because the Coast Guard personnel involved in the accident were

conducting a routine patrol, they were not exempt from the Stateís manatee-zone speed

restrictions.

Island Queen Sightseeing Tours Operations 

According to the procedures and policy manual of Island Queen Sightseeing

Tours, which lists duties of the companyís employees, the vessel master is responsible for

the operation and maintenance of company vessels and for supervising deckhands while

under way. He is also responsible for reporting deficiencies in policies, equipment,

procedures, or personnel to the operations manager.

Island Queen employees were responsible for completing the deck assignment

checklist for their assigned deck while under way, unless they were attending to

passengers (for example, narrating). The checklist included cleaning the vessel and

restocking the refreshments sold to passengers. When they were not attending to the

checklist or other shipboard duties, the crewmembers were required to monitor passengers

for safety and for enforcement of the alcoholic beverage policy. 

The procedures and policy manual states, ìEmployees shall not operate any

company vehicle or crew any vessel when taking any type of drug (prescribed or over the

counter) that affects faculties in any way contrary to safety.î The company is a member of

the American Professional Captains Associationís Maritime Drug Consortium.10 The

consortium conducts drug testing for preemployment, for periodic testing, for random

testing, for postaccident testing, and for reasonable cause. It also provides medical review

officer services and an employee assistance program for employees with substance-abuse

problems. 

Boat crews for all four Island Queen Sightseeing Tours vessels were drawn from

the same staffing pool and scheduled in advance by the Island Queen operations manager.

Typically, the day crews and evening crews changed about 1730. The Bayside Blaster was

required to have a crew consisting of a licensed master and two deckhands. The operations

manager said that two deckhands were scheduled for the 1930 trip on the Bayside Blaster

on the evening of the accident. However, the second deckhand for the 1930 trip did not

report for work the day of the accident. The master stated that he decided it was safe to sail

with only one deckhand and that he had done it before, although infrequently. The

10 Title 46 CFR 16.201-260 (subpart B) requires marine owners to have an approved drug-testing

program for their employees involved in vessel operations.
Factual Information 22 Marine Accident Report

operating manager said that he was not informed that the Bayside Blaster was short one

deckhand before the trip started. He indicated that it was not the first time the Bayside

Blaster had sailed shorthanded, but that it did not typically do so.

Medical and Pathological Information

Two marine casualty investigators from the Coast Guard Marine Safety Office,

Miami, conducted Breathalyzer tests for alcohol on the crewmembers of the Bayside

Blaster immediately after the accident, while they were on Monument Island. The results

were negative. Between 0405 and 0420 on January 13, urine samples were taken by a

contractor to test for the presence of drugs. The master of the Bayside Blaster tested

negative. The deckhand tested positive for cannabinoids/THC (marijuana). Witnesses

stated that the deckhand performed his duties in a seamanlike manner and did not appear

to be impaired. After the accident, the owner reported that he had suspended the deckhand

from his safety-sensitive position as deckhand but had continued to employ him. The

deckhand was placed in the Maritime Drug Consortiumís drug rehabilitation and

monitoring program for at least 1 year. He was drug-tested on February 27, 2002, with

negative results. His latest drug test, on October 15, 2002, was also negative. He was

reinstated to a safety-sensitive position on May 1, 2002.

Postaccident blood samples were taken from the Coast Guard coxswain and the

crewmember at Mount Sinai Medical Center, Miami Beach, to test for the presence of

drugs and alcohol. The coxswainís sample was taken about 4 hours after the accident, and

the other crewmemberís was taken approximately 5 hours after the accident. The results

for both coxswain and crewmember were negative for drugs and alcohol.

Wreckage

Coast Guard Patrol Boat

The bow section of the Coast Guard patrol boat was crushed back about 4 feet,

with evidence of buckling on the inside and outside of the hull (see figure 6). The stainless

steel trailer eyebolt was broken and bent downward. The T-top and center console

assembly was torn loose from the deck plate mounting attachments. The aft mounting

plates were torn upward, and the forward mounting plates were bent forward and torn out.

The port forward frame of the T-top was crushed rearward. The starboard engine propeller

shaft was broken, as evidenced by the freely rotating propeller. The starboard side of the

outboard engineís lower gear housing and one of the propeller blades had fresh contact

marks. The red plastic assembly of the port running light was missing, but the starboard

running light was present and undamaged. A Safety Board investigator took possession of

both lights from the commanding officer of Coast Guard Station Miami Beach and

delivered them to the Safety Boardís Materials Laboratory for examination (see ìTest and

Researchî section for more information). 
Factual Information 23 Marine Accident Report

The ignition switches on the center console were found in the off position, with the

keys inserted in the switches. The kill switch assembly was destroyed. The actual switch

was found in the deck drain on the port side, along with, but not connected to, the kill

switch lanyard. Inspection of the wiring harnesses inside the console showed that a

connection was pulled apart. The connection was traced to the remains of the wiring to the

kill switch. The steering wheel was broken and about a third of its circumference was

missing, along with the knob on the wheel used for steering.

Bayside Blaster

Damage to the starboard side of the hull began about 20 feet forward of the

transom. A series of scrapes and gouges originated in that area and extended aft, toward

the stern and up to the deck. The gunwale aft was buckled inward above its joint with the

main deck. The gunwale cap was torn loose and shifted rearward. The aft starboard

canopy stanchion was torn away from the gunwale.

Three bench seats on the starboard side aft were torn from the deck. They had been

mounted to the deck with wood screws. The screws had left gouges in the deck, indicating

that the seats had been displaced to the port side across the center aisle and against the

seats on the port side. A canopy stanchion attached to one of the seats was torn loose and

bent.

Other Damage

The Coast Guard patrol boat struck a moored 46-foot fiberglass recreational boat,

damaging the boatís bow pulpit area and the forward section of its port side. 

Survival Aspects

Emergency Response

At 2015, the master of the Bayside Blaster notified Coast Guard Station Miami

Beach of the accident via VHF-FM radio channel 16. According to the recorded radio

communication, he reported that a runaway vessel with no one on board had ìbroadsidedî

his vessel. Simultaneously, a witness on Palm Island telephoned Coast Guard Station

Miami Beach to report the collision.

An operator of a private vessel also notified Coast Guard Station Miami Beach of

the accident on VHF-FM radio after the Bayside Blaster had left the scene. He confirmed

the location of the Coast Guard patrol boat and stayed in the area, remaining clear of the

patrol boat until it hit the pilings and stopped.

At 2017, Coast Guard Station Miami Beach dispatched two boats to the scene. The

Coast Guard station notified the city of Miami emergency dispatcher, who passed the

information to the Miami Beach Police Department marine unit and the FWC. Both units

dispatched patrol vessels to the scene. A boat from Miami Fire-Rescue also responded. A
Factual Information 24 Marine Accident Report

Coast Guard Auxiliary vessel and a commercial towing company, Seatow Miami,

overheard the VHF radio traffic and responded to the scene. Island Queen Sightseeing

Tours also responded with another of the companyís small passenger vessels, the Island

Queen.

At approximately 2025, the first response vessels on scene were two Coast Guard

boats, followed shortly by the other vessels noted above. At that point, the Coast Guard

patrol boat was still running in circles. About 2035, when the patrol boat collided with the

shore pilings on Palm Island, the FWC and Miami Beach Police Department marine unit

vessels came alongside the patrol boat. A Miami Beach officer reached for the ignition

switches and observed that the kill switch lanyard was hanging from the kill switch. He

pulled the lanyard off, then tried to reach the ignition switches, ultimately striking them

with his baton. 

At the same time, two FWC officers boarded from the starboard side of the Coast

Guard patrol boat. One officer tried to pull the throttles to neutral but could not stop the

engines or slow their speed. The other FWC officer reached into the console interior and

began pulling at the wiring harness in an attempt to shut off the engines. The engines

subsequently shut down. A search of the vessel by the responding officers confirmed that

no one was on board.

After the Bayside Blaster beached on Monument Island, most of the passengers

disembarked off the bow onto the island. The master accounted for all passengers by

asking each group to check for all its people. FWC officers directed Coast Guard and

Miami Beach Police Department personnel to make a passenger list. After the list was

complete, passengers not going to the Coast Guard station for triage were transported on

the Island Queen to the Bayside Marina. Coast Guard boats transported people reporting

injuries and others in their group to Coast Guard Station Miami Beach, where ambulances

were standing by for triage. Five passengers complained of minor injuries and two

passengers were transported to the hospital by local emergency medical services. Three of

the passengers did not request any further medical care and were transported to the

Bayside Marina by government vehicle. 

The Coast Guard crewmembers reached shore with the help of two people from

Palm Island who swam out to render aid. An ambulance called by the Palm Island security

force transported the two Coast Guard crewmembers to Mount Sinai Hospital, Miami

Beach, for examination. The crewmembers were released from the hospital early on the

morning after the accident and returned to Coast Guard Station Miami Beach. 

The master and deckhand brought the Bayside Blaster, under its own power, back

to Bayside Marina, escorted by a Coast Guard Auxiliary vessel. The Coast Guard patrol

boat was towed by Seatow Miami to a nearby boat ramp, put on a highway boat trailer,

and transported to Coast Guard Station Miami Beach.
Factual Information 25 Marine Accident Report

Emergency Systems/Survival Equipment

Coast Guard Patrol Boat. The crewmembers on board the Coast Guard patrol

boat were wearing automatically inflating lifejackets that had been provided to station

personnel about 6 months earlier. They were also wearing web belts with law enforcement

equipment attached (9-millimeter pistol, magazines, baton, and handcuffs). The lifejackets

are worn uninflated during routine underway operations. When needed, a carbon dioxide

cartridge inflates a bladder in the lifejacket. The cartridge is activated by a manual pull

toggle, or it activates automatically after being immersed in water for about 4 seconds. In

all previous training with the inflatable lifejackets, station personnel had used a mouthinflation tube to inflate them. Crewmembers had received no training in which the

lifejackets were inflated using the carbon dioxide cartridge.

When the crewmembers were ejected into the water, the lifejackets inflated

automatically. The crewmembers found that the lifejackets constricted their necks and

made it hard to breathe. They also had difficulty turning their heads and found it hard to

swim because the buoyancy of the lifejackets rolled them onto their backs. The

crewmembers said that they removed their lifejackets to make it easier for them to swim,

to allow them to look out for the circling patrol boat, and to enable them to dive under the

boat to keep from being hit.

Since the accident, Coast Guard Station Miami Beach has instituted annual

training in the use and operation of the inflatable lifejackets, including in-water training,

inflation by mouth tube, and manual and automatic carbon dioxide inflation. The training

includes swimming with lifejackets inflated.

Bayside Blaster. The Bayside Blaster was equipped with 90 Coast Guardapproved adult-size lifejackets stowed in lockers at the bow (see figure 12). The

lifejackets could be reached through two vertical hatches at the forward edge of the

forward passenger seating area. The hatches were not labeled. The owner reported that the

signs had been removed during ongoing refinishing of the decks and bulkheads. Fourteen

Coast Guard-approved child-size lifejackets were stored in a compartment at the

operatorís station. The compartment was labeled ìChilds Lifejackets,î but the lockerís

opening mechanism was broken. Safety Board investigators observed that opening the

compartment required prying the latch with a knife or similar object.

Small passenger vessels such as the Bayside Blaster that carry 150 or fewer

passengers or have overnight accommodations for 49 or fewer passengers are required by

46 CFR part 180.78 to have lifejackets ìstored in convenient places distributed throughout

accommodation spaces.î11 The CFR further requires that ìeach life jacket kept in a storage

container must be readily available.î Federal regulations (46 CFR part 185.604(f)) also

require that each container for lifejackets be marked with the number and identification of

the items stowed inside. The Coast Guard last inspected the Bayside Blaster on August 20,

2001, and found no deficiencies in lifejacket stowage, although the inspection required

11 The same regulation is found at 46 CFR 117.78 for small passenger vessels that carry more than 150

regular passengers or more than 49 overnight passengers.
Factual Information 26 Marine Accident Report

replacing the reflective tape on some lifejackets. The Bayside Blaster was certified for

service as a result of the inspection.

In a recent accident on the small passenger vessel Port Imperial Manhattan

investigated by the Safety Board,12 lifejacket stowage was identified as a problem. The

Safety Board concluded, ìIf the lifejacket stowage had been more evenly distributed

throughout the passenger cabin of the Port Imperial Manhattan, the lifejackets would

have been more accessible to the passengers.î After the accident, the owners voluntarily

made changes to improve the stowage and distribution of lifejackets on this vessel and on

another company vessel with similar lifejacket stowage problems. As a result of the Port

Imperial Manhattan investigation, the Safety Board issued the following Safety

Recommendation to the Coast Guard on July 3, 2002:

M-02-13

Issue a directive to small passenger vessel operators to review the

distribution of lifejackets on board their vessels and to ensure that the

lifejackets are accessible and segregated.

Figure 12. Bayside Blasterís forward lifejacket stowage lockers.

12 National Transportation Safety Board, Fire On Board the Small Passenger Vessel Port Imperial

Manhattan, Hudson River, New York City, New York, November 17, 2000, Marine Accident Report

NTSB/MAR-02/02 (Washington, DC: NTSB, 2002). 
Factual Information 27 Marine Accident Report

On November 19, 2002, the Coast Guard responded, stating that it ìwill issue a

Safety Alert reminding small passenger vessel operators of the requirements and suggest

that they review the stowage arrangements on their vessels to ensure compliance with the

regulations.î

Tests and Research

Kill Switch Attachments 

The Safety Boardís Materials Laboratory examined the following kill switch

attachments from the Coast Guard patrol boat: a curled nylon lanyard (about 3/16 inch in

diameter by about 1 foot long curled, or about 4 feet long stretched), with a plastic loop

(about 1 3/4 inches long by about 5/8 inch wide by 5/32 inch thick) on one end and a metal

clip (1 7/8 inches long by 1/2 inch wide by 5/32 inch thick) on the other. The end of the

plastic loop fit into the kill switch on the boat console. The metal clip end was attached to

a plastic clip of about the same size, on a nylon loop (about 2 1/2 inches long [1 1/2 inches

in diameter] by about 1 inch wide by about 1/8 inch thick) that had been attached to the

coxswainís belt. The end of the plastic clip on the belt loop was broken off (see figure 10).

The end of the plastic clip was not found. 

The inside surface of the recovered part of the plastic clip from the belt loop

showed several areas of damage and two smeared surface areas, each displaying a similar

arced shape that matched the end of the lanyardís metal clip. A V-shaped impression was

observed where material had been displaced upward and outward. The V-shaped

impression was deepest at the edge, and its direction was across the width of the clip,

stopping just past the center. The edges of the fracture face were sharp and well-defined.

The fracture intersected a void containing a series of surface lines emanating from the

void. The void was located at the maximum material thickness of the section of the clip.

According to the Materials Laboratory, the void was typical of a shrinkage void in an

injection-molded product.

The inner surface of the kill switch loop attachment, which would normally

contact the kill switch toggle, appeared to be disturbed by a rubbing action. There were no

indications of severe deformation.

Coast Guard Patrol Boatís Navigation Lights 

The Safety Boardís Materials Laboratory examined the Coast Guard patrol boatís

port and starboard running lights. The port running light assembly was damaged. It

consisted of the base with the bulb, but the red lens was missing. The bulbís glass

envelope was removed from the port running light assembly for examination under a

scanning electron microscope. One end of the filament end was fractured in a brittle

manner, typical of the fracture of a cold filament (no electrical flow through the filament).

The other filament end was fractured in a globular fashion, typical of the fracture of a hot

element (with electrical flow). 
Factual Information 28 Marine Accident Report

According to the Materials Laboratory, to produce these fracture features, the

sequence of events must have been as follows: (1) the globular fracture and bending of

the filament were produced first, while electricity was flowing, and (2) the brittle fracture

was produced later, when the filament had cooled. The starboard running light assembly

was undamaged and consisted of the base, the green lens, and the bulb. The Materials

Laboratory determined that the filaments of the port and starboard running lights

displayed stretching and deformation features consistent with being illuminated at the

time of impact.

Other Information

Postaccident Developments

Nonstandard Boat Program. The DOT Inspector Generalís report, Audit of the

Small Boat Station Search and Rescue Program, made recommendations to the Coast

Guard concerning nonstandard boats. As noted in the report, a Coast Guard risk analysis

was conducted in July 2000 as a result of the increase in accidents involving nonstandard

boats. Improper operation of nonstandard boats was identified as the highest concern.

Since then, the Coast Guard has made a number of changes in the nonstandard boat program. Some were already under development when the accident occurred; some were

instituted as a result of the accident. 

The audit recommendations concerned developing and implementing a strategic

plan for improving SAR readiness. The report found that oversight at the Coast Guard

headquarters level is needed to ensure standardization of nonstandard boats and rigid-hull

inflatable boats in all aspects of their use, including operational doctrine, training, and

boat design and configuration (there are about 293 different nonstandard boats of varying

types and designs among the 554 Coast Guard rescue boats). The report found that

commanding officers should give safety and training precedence over less urgent or less

important command or program operational goals to ensure that units will be ìalways

readyî for more urgent or more important operations. The report also indicated that Coast

Guard headquarters involvement is needed to assure the implementation of Coast Guard

risk analysis recommendations.

On March 11, 2002, the Office of Boat Forces and the Office of Safety jointly sent

a mishap trend message from Coast Guard headquarters to 384 Coast Guard units

operating nonstandard boats or having support responsibility for nonstandard boats. The

message challenged leaders involved with small boat operations to reverse the trend of

mishaps involving small boats. Specifically, it suggested training in operational risk

management and team coordination as a way of reducing small boat mishaps. The

message emphasized that human errors were causing a high number of the recent mishaps

involving nonstandard boats. In the message, the Chief of Boat Forces encouraged boat 
Factual Information 29 Marine Accident Report

force leaders13 to ìimpress upon all hands that throttles have more than two [stop and full]

operational positions.î He emphasized that ìnormal operating speeds must be something

less than maximum speeds, and coxswains must have time to see, react, and avoid

obstacles.î He continued, ìThe image of the young Coastie zipping along at max throttle

is becoming a stereotype, reflects poorly upon out [sic] professionalism, and encourages

reckless behavior in our developing boat crews.î 

A draft nonstandard boat operations manual that had been available to units on the

Coast Guard web site for over a year was in the final phases of revision when the accident

occurred. On April 3, 2002, the Non-standard Boat Operators Handbook (Commandant

Instruction M16114.28) was published. The manual covers basic boat operation and

provides sample preventive maintenance and boat outfitting checklists. Chapter 5, section

A, ìOperating Parameters,î addresses speed: ìA high number of small boat mishaps can

be attributed to excessive speed.14. . . As a crewmember, never hesitate to ask the coxswain

to SLOW DOWN or take up a more forgiving heading. There is no justification for

navigating recklessly or fatiguing crews unnecessarily. . . . Safe operating speed is an

element of prudent seamanship.î

On April 25, 2002, the Commandant of the Coast Guard issued a final action

letter15 to all Coast Guard stations regarding a March 2001 accident involving a Coast

Guard small boat. The Coast Guard boat had deviated from its intended patrol route and

had capsized in Lake Ontario, resulting in the deaths of two Coast Guardsmen. The

Commandant found that ìthe deaths resulted from a series of equipment and experience

shortfalls, as well as a number of mistakesî by Coast Guard personnel on the water and on

shore. The Commandant specifically found that administration, supervision, and training

related to nonstandard boats was inadequate and ìthat the normal boat tracking and

mission monitoring process failed.î

As a consequence of the Coast Guardís internal investigation of the March 2001

accident in Lake Ontario, the Commandant directed several actions related to nonstandard

boat support, training, and operation. Among other things, he instructed the Assistant

Commandant for Operations to ensure that small boat coxswains provide the unit

maintaining their radio guard with a ìfloat planî and that they notify the guarding unit of

any significant changes in their projected movements. Furthermore, he required each

Coast Guard area and district commander to publish operating limits for each nonstandard

boat under their responsibility and to reexamine each boatís suitability for its purpose.

13 A boat force leader is anyone who oversees boat operations or is in the coxswainís chain of

command, such as a station commanding officer or officer-in-charge.

14 The DOT Inspector Generalís audit reported that there had been a 225-percent increase in accidents

in FY 2000 over FY 1998 and that ì56 percent of the [FY 2000] accidents were caused by poor judgment, or

navigation and operational errors and hence, were preventable.î 

15 U.S. Coast Guard, Final Action on the Administrative Investigation into the Boat Mishap and the

Resulting Deaths and Injuries to Station Niagara Crewmen That Occurred on 23 March 2001, file 5100,

April 25, 2002, signed by Admiral James M. Loy, Commandant.
Factual Information 30 Marine Accident Report

On April 29, 2002, the Coast Guard issued a revision to the Boat Crew Training

Manual (Commandant Instruction M16114.9D, replacing M16114.9C). The revised

manual gives more emphasis to nighttime training operations, specifically mandating that

every 6 months, at least 10 percent of coxswainsí minimum required underway time

should be at night. New requirements to perform drills once at night and once during the

day every 6 months will take effect in January 2003.

The Coast Guard Headquarters Chief of the Office of Boat Forces advised the

Safety Board on May 14, 2002, that training teams for nonstandard boats were established

in the spring of 2002. The teams became operational in the summer of 2002, and began

making training visits to Coast Guard stations throughout the nation to assess the

adequacy of nonstandard boat operations. 

On June 13, 2002, the Chief of the Office of Cutter Forces at Coast Guard

headquarters issued a new Coast Guard Navigation Standards Manual (Commandant

Instruction M3530.2A) that sets forth navigation policies and procedures for all cutters

and shore-based boats. The section of the manual that discusses unit command

responsibilities16 states that commanding officers shall: 

Identify specific areas within the unitís Area of Responsibility (AOR) that pose

significant navigational or environmental risks to boats. The CO shall mitigate

these risks by imposing specific operating restrictions such as speed limits,

establishing safe operating distances from known hazards, increasing frequency of

fixes, and restricting operating areas for specific boat types. Each unit shall

maintain a chart on display in the operations/planning space that highlights known

hazardous and special operating areas within the unitís AOR.

Navigation Lights on Coast Guard Patrol Boats. During the inspection of the

damaged Coast Guard patrol boat, Safety Board investigators observed that the boatís

white all-around light was blocked for about 10° each side of dead ahead by a radar

antenna dome that had had been installed about 1 month before the accident. As a result of

Safety Board investigatorsí conversations with the commanding officer, the all-around

light on the stationís other 24-foot patrol boat was inspected and found to be similarly

obstructed. The light was correctly repositioned on January 15, 2002. 

On January 29, 2002, the station sent a message to Coast Guard headquarters that

outlined the obstructed-light problem so that other stations might learn about the issue. On

two separate occasions in August 2002, one of the Safety Board investigators

investigating this accident advised Coast Guard Headquarters Office of Boat Forces that

he had observed two nonstandard boats (not in the Miami AOR) whose all-around white

navigation lights were obscured by radar domes in front of the light. Those observations

prompted Coast Guard Headquarters Office of Safety to send an ALCOAST message on

September 5, 2002, to all stations having nonstandard boats. The message acknowledged

that the obscuration of masthead lights on Coast Guard nonstandard boats by installed

equipment was a problem of national scope that had been identified during the Bayside

16 Page 2-3, item c.
Factual Information 31 Marine Accident Report

Blaster accident investigation. Consequently, Coast Guard headquarters required that all

boats display proper unobscured all-around white lights, in accordance with the Inland

Navigation Rules. 

Passenger Vessel Association

The Passenger Vessel Association is an association of small passenger vessel

owners and operators in the United States. The organization serves the interests of more

than 350 vessel owners and operators in the domestic passenger vessel industry, which

represents about 65 percent of the industry nationwide. Association members operate

more than 1,100 passenger vessels in the United States, carrying up to 200 million

passengers annually. Members offer services including dinner cruises, tour and excursion

services, car and passenger ferries, private charters, whale-watching trips, overnight

cruises, and riverboat gaming. The association has a committee responsible for reviewing,

developing, and implementing programs to encourage enhanced training and safety

among its members. The associationís Risk Management Manual contains a section on

signage for lifesaving equipment that covers marking lifejacket lockers, but not the

Federal requirement for storing lifejackets in convenient places and distributing them

throughout accommodation spaces.
32 Marine Accident Report

Analysis

General

The analysis first identifies factors that can be readily eliminated as causal or

contributory to the accident. The major safety issues identified during the investigation are

then discussed, regarding the adequacy of the following:

ï Operation of the Coast Guard patrol boat;

ï Operation of the Bayside Blaster;

ï Coast Guard oversight of routine patrols;

ï Boatrides International, Inc., management oversight;

ï Kill switch operation on Coast Guard nonstandard patrol boats;

ï Lifejacket stowage on the Bayside Blaster; and

ï Coast Guard safety oversight of small passenger vessels in Miami.

Exclusions

The weather on the night of the accident was mild, with calm seas and a clear

visibility of 10 miles. Such conditions should not and did not interfere with either vessel

operatorís ability to detect the other vessel. Both vessel operators were in generally good

health and were not taking any prescription or nonprescription medications.

The master of the Bayside Blaster reported his rest history for the 72 hours before

the collision. He indicated that he had slept 6 hours each night on January 10 and 11 and 9

hours the evening before the accident, and that he had taken a 2-hour nap before reporting

for work at 1650 the day of the accident. His deckhand had slept about 10 hours the two

nights before the accident. He had reported to work at 1030 and completed three tripsóat

1330, 1530, and 1730óbefore the accident trip. The Coast Guard coxswainís 72-hour

sleep history included 11 hours of sleep the previous two nights and 8 hours of sleep the

night before the accident. The Coast Guard crewmember had obtained 7 1/2 and 8 hours of

sleep the two nights preceding the accident. The coxswain and crewmember both reported

to work at 0700 on the day of the accident. All four individuals reported obtaining

adequate sleep on the days preceding the accident and were not affected by fatigue.

The Coast Guard crewmembers provided blood samples for alcohol and drug

testing between 4 and 5 hours after the accident. The results for both crewmembers were

negative for alcohol and drugs. Because testing for alcohol did not take place within the

optimal 2-hour period after the accident, the test does not conclusively eliminate the

possibility that alcohol was a causal factor in the accident. However, the crewmembers
Analysis 33 Marine Accident Report

spent more than 2 hours before the accident with other Coast Guardsmen in the crew

lounge, where alcohol is not permitted.

Tests of the Bayside Blaster crew for alcohol immediately after the collision were

negative. Urine samples were taken about 8 hours after the accident to test for drugs. The

result was negative for the master of the Bayside Blaster but was positive for the deckhand

for cannabinoids/THC, indicating that he had used marijuana sometime before the

collisions.

The deckhand had been on duty since 1030 that morning and had served on three

cruises that day; thus, any incapacitation should have been detected by coworkers or

passengers. Witnesses said that the deckhand performed his duties in a seamanlike manner

and did not appear to be impaired by drugs. The deckhand was placed in a drugmonitoring program and his subsequent test results were negative. Because the deckhandís

performance did not indicate that he was impaired at the time of the accident, the use of

drugs is not discussed further in this report.

Therefore, the Safety Board concludes that the crewmembers of both vessels were

well rested and not impaired by drugs or alcohol, and that the weather and sea conditions

were not factors in this accident.

Collision

The Bayside Blaster, with 2 crewmembers and 53 passengers on board, was on a

routine evening tour in Biscayne Bay and was idling off Palm Island when the sightseeing

vessel was sideswiped by Coast Guard patrol boat CG242513. The Coast Guard patrol

boat, with two crewmembers on board, was traveling at an excessive speed for the

restricted zone. The impact caused the Coast Guard crewmembers to be thrown

overboard. The kill switch system to the patrol boatís engines failed to operate, and

CG242513 proceeded to run in circles. The circling occurred because the coxswain had

made a hard turn to port in an effort to avoid hitting the sightseeing vessel, and the steering

wheel remained in the turned position. The patrol boat subsequently struck one of the

Coast Guard crewmembers in the water, the Bayside Blaster a second time, and another

recreational boat before it came to rest against pilings near Palm Island. As a result of the

accident, the two Coast Guard crewmembers sustained minor injuries requiring

hospitalization, and five Bayside Blaster passengers reported injuries requiring treatment.

Operation of the Coast Guard Patrol Boat

There was no safety or law enforcement reason for the coxswain to operate his

vessel at 32 knots while conducting a routine patrol at night in restricted waters close to

shore. The coxswain knew he was nearing a no-wake, manatee-protection zone as the

patrol boat rounded Hibiscus Island and that the area had strict speed restrictions, which
Analysis 34 Marine Accident Report

he claimed to be enforcing on the patrol. High-speed operations reduce the reaction time

for collision avoidance and require the utmost vigilance on the part of the coxswain and

crew. Such high speeds should be reserved for emergency responses, such as distress calls

or pursuit of lawbreakers. According to the OOD, the coxswain asked ìto get under way

for recreational boating safety . . . . and while in the area, go see [another Coast

Guardsman] at a private residence on Palm Island.î The OOD agreed to the boating safety

patrol and the residential visit.

Coast Guard patrol boats are not exempt from the no-wake speed restrictions in

Floridaís manatee-protection zones. The CG242513 was on a routine, nonemergency

boating-safety patrol the night of the accident. The coxswain testified that he knew he was

approaching a no-wake zone. Yet, he entered the no-wake zone, about 400 yards from the

accident location, at full speed. At 32 knots,17 the boat would take about 22 seconds to

cross the distance from the turn around Hibiscus Island to the collision point. The

coxswain stated that he knew there was a blind spot coming around the end of Hibiscus

Island but that he took the turn at nearly full throttle. Even in daylight, the speed at which

the coxswain was operating would have been illegal and inappropriate in the area. The

Safety Board, therefore, concludes that the coxswain of the Coast Guard patrol boat was

operating his vessel in excess of Florida speed restrictions for no safety or law

enforcement reason in a no-wake, manatee-protection zone.

The coxswain stated that he was familiar with the Bayside Blaster and had seen it

operating in the area before. He acknowledged that background lighting in the area

commonly interfered with visibility at night. A highway causeway and a brightly lit

container port are located south of the accident site, and white and red lights on islands

and bridges are west and north of the accident site. The darkness also limited the

coxswainís ability to clearly see and distinguish other vessels that could have been

operating in the vicinity of his vessel.

Knowing that passenger vessels like the Bayside Blaster routinely operated in this

area at night and that visibility could be a problem should have prompted the coxswain to

enter the turn around Hibiscus Island at a much slower speed. Had he done so, he or his

crewmember would probably have sighted the passenger vessel in ample time to avoid a

collision. The high speed of the Coast Guard patrol boat reduced the time the coxswain

had to sight the Bayside Blaster, to evaluate the situation, and to take effective action to

avoid the collision. It likewise severely limited the time available for the crewmember,

who was acting as lookout, to see and evaluate the developing situation. Both the

coxswain and the crewmember reported seeing the Bayside Blasterís silhouette mere

seconds before impact. Therefore, the Safety Board concludes that even if there were no

speed restrictions, the coxswainís speed was imprudent for the prevailing conditions of

darkness, background lighting, and potential for encountering passenger and recreational

vessels in the area of the accident.

High-speed operations at night in nonemergency situations, particularly in

restricted waters, needlessly endanger the safety of other users of the waterway, as well as

17 At 32 knots or 36.8 mph, the boat would travel 54.0 feet per second.
Analysis 35 Marine Accident Report

Coast Guard personnel. That sentiment was emphasized in a March 11, 2002, message

from Coast Guard headquarters that encouraged boat force leaders to ìimpress upon all

hands that throttles have more than two [stop and full] operational positionsî and that

ìnormal operating speeds must be something less than maximum speeds, and coxswains

must have time to see, react, and avoid obstacles.î 

At the time of the accident, no guidance mandated that commanding officers

mitigate the risks in small boat operations by imposing specific operating restrictions such

as speed limits and safe operating distances from known hazards.This lack of Coast Guard

policies and procedures regarding operating speeds for nonstandard boats at the time of

the accident gave wide latitude to Coast Guard personnel undertaking routine patrols

using small, high-powered vessels. Consequently, the Safety Board concludes that the lack

of Coast Guard speed restrictions for conducting routine patrols allowed coxswains too

much latitude in selecting patrol speeds, which could endanger other boaters as well as

Coast Guard crewmembers. Appropriately, the new Coast Guard Navigation Standards

Manual, which was issued after the accident, requires the commanding officers of Coast

Guard stations to establish speed limits in specific areas of the AORs ìthat pose

significant navigational or environmental risks to boats.î (For further discussion, see

ìCoast Guard Oversight of Routine Patrolsî section.)

Operation of the Bayside Blaster

The master of the Bayside Blaster operated the vessel over the same route it

normally took for conducting sightseeing tours in Miami Harbor, a route on which it was

permitted to operate under the terms of its COI. Thus, at the time of the accident, the

Bayside Blaster was operating on the waters where it was authorized to be, and the local

Coast Guard station personnel were aware of the routes of the Bayside Blaster and other

small passenger vessels. The master of the Bayside Blaster was operating his vessel at idle

speed, about 3 to 4 knots, while conducting a boat tour of the area. Idle speed was correct

and appropriate in a no-wake zone and close to shore. The vessel probably could not have

gone much slower and still maintained steerage. The Safety Board, therefore, concludes

that the Bayside Blaster was on an appropriate route for its service, and that the master

was operating his vessel at a safe and prudent speed for the conditions and circumstances.

The Coast Guard patrol boat was moving at 32 knots, or 54.0 feet per second. At

such a high speed, the boat would have covered the 400 yards from the turn around

Hibiscus Island to the position of the Bayside Blaster in seconds. Under the

circumstances, the master of the Bayside Blaster had little or no time to react to avoid a

collision. Because the Bayside Blaster was operating at an appropriate speed in the nowake zone, the master could logically expect that other vessels operating in the same area

would also be operating within the mandated speed restrictions. He therefore had no

reason to anticipate that he would encounter a craft operating at high speed in the area

where he was operating, especially in the darkness.
Analysis 36 Marine Accident Report

Despite the nighttime darkness and background lighting, the master and deckhand

observed the approaching Coast Guard vessel from their vantage point; however, they

sighted the patrol boat only seconds before the collision. Consequently, the Safety Board

concludes that the master and deckhand of the Bayside Blaster were maintaining a proper

lookout.

The master of the Bayside Blaster had no options for avoiding a collision after

sighting the oncoming patrol boat. Even if the master had sighted the patrol boat the

instant it rounded Hibiscus Island, he would have had only 22 seconds to evaluate the

situation and to select and execute an avoidance action. The master sighted the oncoming

patrol boat only after the deckhand brought it to his attention, giving him less than the full

22 seconds in which to react. He could not turn left without grounding his vessel on the

rocky shore of Palm Island. He could not turn right without steering into the probable path

of the patrol boat. He could not accelerate rapidly without endangering the passengers or

possibly increasing the speed and severity of the impact. Consequently, the Safety Board

concludes that the Coast Guard patrol boatís high rate of speed, combined with its sudden

appearance close to the Bayside Blaster, precluded the master of the Bayside Blaster from

being able to take any effective action to avoid the collision.

After the second collision with the patrol boat, the master of the Bayside Blaster

accelerated his vessel and headed north to Monument Island. If he had remained in the

immediate area of the accident, he would have risked being struck again by the circling

patrol boat. Monument Island was only 800 yards away and afforded a convenient soft,

sandy bottom on which the master could ground his vessel without damaging it more. In

addition, immediately after the second impact, the master did not know the full extent of

his vesselís damage. For the safety of the passengers, he needed to make sure his vessel

would not sink before they could disembark. Further, if the collision had ruptured a fuel

tank, there could have been the added danger of fire.

The master beached the Bayside Blaster on the sandy shore of Monument Island,

where he could safely disembark his passengers and examine his vessel. If he had not

taken that action and the hull had been breached, the vessel might have been in danger of

flooding and sinking. The Safety Board, therefore, concludes that it was appropriate for

the master of the Bayside Blaster to beach his vessel on Monument Island to ensure the

safety of his passengers, given the circumstance that he did not know the full extent of the

damage to the vesselís hull and fuel tanks.

Navigation Lights

Boaters depend on other vessels to properly display navigation lights at night to

help them visually detect other vessels and provide a reference to adjust their course or

speed to avoid a collision. For this reason, the Safety Board reviewed the evidence related

to the operation of the navigation lights on both vessels to assess their visibility on the

night of the accident.
Analysis 37 Marine Accident Report

The Coast Guard patrol boat was showing all the navigation lights that it was

required to display (although with some technical deficiencies, as discussed below). The

navigation lights had been found operational the day of the accident during the daily check

by the station engineering staff. However, the coxswain did not check the navigation lights

before leaving the dock. When the patrol boat got under way from Coast Guard Station

Miami Beach, the crew of another Coast Guard boat informed the coxswain that the boatís

port navigation light was not operating. After being notified that the light was not lit, the

coxswain tapped the light fixture with his hand, and it came on, indicating that the light

might be sensitive to jarring forces. In the Safety Boardís opinion, the coxswain should

have realized that the port navigation light might have been subject to intermittent

operation due to the jarring effects of high-speed operations, and he should not have taken

the vessel on a nighttime patrol without ensuring that the light was showing steadily.

Rather than proceeding with the patrol, he should have returned to the station and either

requested that the stationís engineers examine and repair the light or taken another boat on

the patrol.

The deckhand on the Bayside Blaster stated that he saw the sidelights and

masthead light of the Coast Guard patrol boat before the collision. A passenger also said

that he saw the sidelights of the Coast Guard patrol boat before the collision. Further, the

Safety Boardís Materials Laboratory examined the patrol boatís sidelights and determined

that the filaments of the port and starboard running lights displayed stretching and

deformation features consistent with their being illuminated at the time of the accident.

The Bayside Blaster was showing all the navigation lights that it was required to

display (although also with some technical deficiencies, as discussed below) and had

decklights on as well. Four passengers stated that the navigation lights on the Bayside

Blaster were on, and FWC officers tested the lights the evening after the collision and

found them to be operating properly.

Although the deckhand on the Bayside Blaster recalled seeing the white masthead

light on the approaching patrol boat, postaccident examination of the vessel by the Safety

Board revealed that it was partially obscured by a radar dome. Further postaccident

examination of the patrol boat by the Coast Guard revealed that the vertical separation

between the sidelights and the masthead light was less than the minimum required under

the Inland Navigation Rules. However, because the masthead light was sighted from the

Bayside Blaster before the collision, the partial obscuration and inadequate separation of

the masthead light and the sidelights apparently had no effect on the accident. 

Partially obscured or inadequately separated navigation lights make vessels more

difficult to see at night and constitute a hazard to safe operations. When Safety Board

investigators checked the masthead light on the other nonstandard boat assigned to Station

Miami Beach, they found the same condition. Later, a Safety Board investigator observed

a similar problem on two separate occasions involving nonstandard boats operating in a

different AOR and reported his observations to Coast Guard headquarters. As a direct

result of information provided by the Safety Board, Station Miami Beach corrected the

light problem on its remaining nonstandard boat, and Coast Guard headquarters mandated

action to correct the problem nationwide.
Analysis 38 Marine Accident Report

Postaccident examination of the Bayside Blaster by the Coast Guard in Miami

showed that the sidelights were not properly screened, resulting in arcs of visibility

approximately 30° greater than required; that the arc of visibility of the masthead light was

somewhat less than required; and that the vertical separation between the masthead light

and the gunwale was less than the required minimum. Nevertheless, the Bayside Blaster

was showing lights that were visible from the direction of the approaching patrol boat and

that were sufficient to warn the patrol boat of its presence. The Safety Board, therefore,

concludes that although both vessels had technical deficiencies in the configuration of

their navigation lights, they were sufficiently lighted to alert other mariners of their

presence, and the deficiencies did not contribute to the cause of the accident.

Coast Guard Oversight of Routine Patrols

Recent accidents involving Coast Guard patrol boats, as well as cautionary

messages from the Coast Guard Commandant, indicate that station commanders are not

exercising adequate oversight of small boat operations. Patrols should not be undertaken

without an in-depth predeparture briefing in which the OOD and the coxswain review

operational details of the intended patrol. The details should include the intended purpose

of the patrol, the intended route (float plan), the communications schedule for checking in

with the station, and any operating restrictions on the patrol. The coxswain involved in the

accident provided no detailed float plan, and the duty officer did not request one. He

merely knew that the coxswain was going to operate in the north part of Biscayne Bay and

that the coxswain would, at some time, end up at a private residence on Palm Island.

Further, there was no discussion of speed issues or of the condition of the boat that was to

be used for the patrol. Consequently, the Safety Board concludes that the coxswainís being

allowed to undertake the patrol without completing a thorough predeparture check of the

patrol boat or without ensuring that critical navigation equipment was fully functional

indicates a lack of effective oversight of patrol operations at Coast Guard Station Miami

Beach. 

The problem of safety in the operation of Coast Guard small boats goes beyond the

collision in Miami. Serious accidents involving Coast Guard nonstandard boats in FY

2001 resulted in more than 70 Coast Guardsmen having ìunplanned departuresî from

their boats, with two deaths and one serious injury resulting. In response to those

accidents, on April 3, 2002, Coast Guard headquarters issued a Non-standard Boat

Operators Handbook that covers basic boat operation and cautions against operating

vessels at excessive speed. The Coast Guard has also acted to improve equipment

outfitting, maintenance, and training in the nonstandard boat program. For example, the

Commandant issued a directive for area and district commanders to publish operating

limits for their nonstandard boats and reexamine each boatís suitability for its purpose. In

the Safety Boardís opinion, those actions are warranted by the recent accident history of

these vessels and should help improve the safety of nonstandard boat operations. 

In his April 25, 2002, final action letter to, among others, all area and district

commanders and all Coast Guard boat stations, the Coast Guard Commandant mandated
Analysis 39 Marine Accident Report

that district commanders and station commanding officers ensure compliance with all

policies pertaining to filing and adhering to small boat operational patrol plans, including

the requirement that the coxswain file a float plan with his station indicating the location

of intended operations before departing on patrol. Further, coxswains are required to

notify their controlling station if they deviate in any way from the filed plan. The float

plan requirements resulted from a nonstandard boat accident in which a Coast Guard

patrol boat capsized in Lake Ontario after the boat had deviated from its intended patrol

route, resulting in the deaths of two Coast Guard crewmembers. In his final action letter

concerning that accident, the Commandant found ìthat the normal boat tracking and

mission monitoring process failed.î In other words, there was a failure in overseeing small

boat operations by the responsible Coast Guard station. The float plan requirements, in the

Safety Boardís opinion, will provide a measure of oversight over small boat operations,

but by themselves, still fall short of the degree of oversight necessary to ensure operational

safety. 

Station officials (commanding officers, executive officers, and OODs) are in the

best position to provide continuing oversight of day-to-day operations at Coast Guard

stations. Station level oversight of Coast Guard small boat operations could be improved

by various means, including direct observation of coxswain performance by station

officials and solicitation of feedback from waterway users. In addition, technological

advances in transponder technology may provide an additional oversight tool if applied to

station operations. Further, greater formality in the conduct of routine patrols would

enhance oversight. For example, if coxswains were required to complete a written

checklist before getting under way, they might be more likely to conduct thorough

predeparture checks. If detailed predeparture briefings were held, as outlined above,

coxswains might be more mindful of operational restraints. And if detailed postpatrol

debriefings were held, coxswains might be less likely to take actions they could be held

accountable for. Consequently, the Safety Board concludes that Coast Guard oversight of

nonstandard boat operations was less than adequate at the time of the accident. 

The Coast Guard policy reflected in the Navigation Standards Manual places the

responsibility for safe operation of Coast Guard small boats on station commanding

officers. However, without some means of oversight, commanding officers cannot know

that the speed limits are being followed or that other safety requirements are being met.

Station commanding officers provide overall supervision to boat coxswains and are

responsible for ensuring that coxswains perform their duties safely. An effective oversight

program would make unsafe operation less common, and monitoring of coxswain

performance, as part of that oversight, would make coxswains less likely to operate their

vessels unsafely. The Safety Board, therefore, believes that the Coast Guard should

establish oversight procedures for use by the commanding officers or officers-in-charge of

Coast Guard stations to improve the safety of Coast Guard routine small boat operations,

including the institution of in-depth predeparture briefings, thorough predeparture checks

of boats, monitoring of coxswain performance, and thorough postpatrol debriefings. 

As noted earlier, the Coast Guard has issued a Non-standard Boat Operators

Handbook that covers basic boat operation and cautions against operating vessels at
Analysis 40 Marine Accident Report

excessive speed. The Coast Guard has also acted to improve equipment outfitting,

maintenance, and training in the nonstandard boat program. Requirements for nighttime

training of crews have been revised in the new edition of the Boat Crew Training Manual;

training teams for nonstandard boats have been established; and commanding officers are

required by the new Navigation Standards Manual to impose specific operating

restrictions (speed, distance from hazards, frequency of fixes, operating area). Such

changes should help improve the safety of nonstandard boat operations. Ongoing

evaluation and the establishment of verification procedures are, however, essential to

ensure compliance with the policies and procedures. The Safety Board, therefore, believes

that the Coast Guard should evaluate on an annual basis its program for reducing

nonstandard boat accidents and for ensuring compliance with Coast Guard policies and

procedures related to those vessels, and should publish the results annually for use by

Coast Guard stations. 

Boatrides International, Inc., Management Oversight

The Bayside Blaster departed on the accident voyage without one of the two

deckhands required by its COI. Despite the specific requirement of the companyís

procedures and policy manual to report deficiencies, the master did not notify company

management that he did not have the required crew before departing on the accident

voyage. The master stated he made the decision that it was safe to sail with only one

deckhand and that he had done so in the past, although infrequently. The operations

manager stated that he was not informed the Bayside Blaster was short one deckhand

before the vessel departed on the accident voyage. He also indicated that he was aware it

was not the first time the Bayside Blaster had sailed shorthanded, but that it did not

typically do so. 

The owner of the Bayside Blaster indicated that the master had never been

reprimanded and that nothing negative had ever been noted in the masterís personnel file.

The master was required to report the number of passengers on board before leaving the

dock. It would have been a simple matter for management to require him at the same time

to report whether he had a full crew on board. Moreover, because the Bayside Blaster had

departed without a full crew in the past, company management should have been aware

that it was possible for the vessel to be shorthanded and should have established

procedures to arrange for backup crewmen so that such incidents did not occur in the

future. 

In assessing the impact on safety of the lack of the second deckhand on the

Bayside Blaster, the Safety Board considered the opinions of the vessel master. The master

stated that if the second deckhand had been present, he would have been selling drinks and

film to the passengers and would not have been serving as a dedicated lookout. The lack of

the required second deckhand did not affect the ability of the Bayside Blaster to maintain a

proper lookout. The impact of the lack of the second deckhand was that one less person

was available to assist the passengers in the emergency. The second deckhand could have

been helpful in handing out lifejackets to passengers, in helping passengers don and secure
Analysis 41 Marine Accident Report

their lifejackets, and in helping the passengers disembark at Monument Island after the

accident. 

Had the accident been more serious, however, the need for the second deckhand

could have been critical. If, for example, passengers had been seriously injured or thrown

into the water and in danger of drowning, the second deckhand would have been needed

for such duties as providing medical assistance or handling the boat while the master

rendered medical assistance. If the boat had been more seriously damaged and in danger

of sinking, the second deckhand would have been needed to help with damage control, to

help distribute lifejackets, or to help the passengers safely abandon the vessel. The Safety

Board, therefore, concludes that operating the Bayside Blaster without the required

number of crewmembers could have had a negative impact on the safety of the passengers,

although it did not in this accident. The Safety Board believes that Boatrides International,

Inc., should establish procedures to prohibit its small passenger vessel from leaving the

pier with passengers on board unless the vessel has the crew required by the vesselís COI.

Kill Switch Operation on Coast Guard Nonstandard Patrol Boats 

If the kill switch lanyard and clips had operated properly, the engines on the Coast

Guard patrol boat would have shut down as soon as the coxswain was ejected from the

boat. And if the Coast Guard patrol boat engines had stopped when the coxswain was

ejected, the boat would not have struck the Bayside Blaster the second time. Further, the

other property damage resulting from the accident would not have occurred, and the Coast

Guard crewmembers would not have been placed in jeopardy of being run over by their

own vessel. According to the coxswain, he was struck by the boat but sustained only

minor bruising. If the runaway vesselís hull had struck him at a different angle or if the

propellers had struck him, he could have been seriously injured or killed.

Given that more than 70 Coast Guard crewmembers were ejected from

nonstandard boats in FY 2001,18 ejection is a hazard in the operation of such boats.

Automatic shutdown of the main engines in such circumstances is essential for the safety

not only of the Coast Guard personnel involved but also of other waterway users. The

Coast Guard sent a safety advisory to all Coast Guard units warning that crews operating

nonstandard boats and cutter boats are at significantly higher risk for ejection from their

boat than their counterparts operating larger, standard boats. The message required that

Coast Guard small boat operators use kill switches at all times while such boats are under

way and that kill switch lanyards be attached to a metal D-ring on the coxswainís

lifejacket or survival vest. Further, the message required that kill switches and lanyards be

inspected daily, incorporated into a daily checklist, and tested weekly. It also stated that it

was Coast Guard headquartersí intention to have kill switches installed on all nonstandard

boats, and that boats less than 40 feet long are to have kill switches installed within 24

months. 

18 Coast Guard headquartersí ALCOAST message, January 30, 2002.
Analysis 42 Marine Accident Report

The kill switch lanyard and connections were examined at the Safety Boardís

Materials Laboratory. The features on the belt clip fracture face were consistent with

bending overload, and indicate that the belt clip was the weak link in the lanyard

assembly. In a kill switch system, the weakest link should be the force required to operate

the switch. Either the belt clip was the wrong attachment, or the lanyard may have been

wrapped around another item in the console, thereby transferring all the force to the belt

clip and not the kill switch. 

It is possible that when the coxswain turned the steering wheel hard to the left to

avoid striking the Bayside Blaster, the lanyardís position was such that it became fouled

on the wheel or the steering knob. The coxswain said that he could not remember having

any problems with the coiled lanyard snagging on anything. The Safety Board could not

determine the most probable scenario. The two Coast Guard crewmembers confirmed that

the kill switch lanyard was connected both to the kill switch and to the coxswain, and the

police saw the lanyard connected to the kill switch when the patrol boat came to rest

against the pilings on Palm Island. The Safety Board concludes that why the kill switch

did not activate when the coxswain was ejected or whether fouling of the kill switch

lanyard on the steering wheel was a factor in the enginesí failure to stop cannot be

determined.

The Coast Guard action and policy statement of January 30, 2002, appears to

address most of the problems inherent with kill switch malfunction. However, the

individual Coast Guard units are being tasked with conducting evaluations of the proper

location and operation of kill switches, which may be beyond the technical qualifications

of some units. The ALCOAST message does not discuss the role of the kill switch

manufacturer. Because the placement and arrangement of kill switches may require

special knowledge of ergonomics and human engineering, engineers and technicians with

those skills should be part of any effort to redesign the kill switch system. The Safety

Board concludes that the actions by the Coast Guard to improve kill switch use could be

enhanced by including kill switch manufacturers and ergonomic/human engineering

experts in the redesign process. 

The kill switch system involves not only the toggle switch, the wiring, and the

lanyard-and-loop assembly, but also the person at the controls who is connected to the

switch by the lanyard. All these elements must operate correctly for the kill switch to

perform as intended. Therefore, the Safety Board believes the Coast Guard should

evaluate the adequacy of the design of present or future kill switch systems on Coast

Guard small boats, giving full consideration to ergonomic/human engineering factors.

Lifejacket Stowage on the Bayside Blaster

The adult- and child-size lifejackets on the Bayside Blaster were stowed so that

they were properly segregated from each other. However, all the lifejackets of each size

were stowed in one location, the adult jackets at the bow and the child jackets near the

operatorís station. Stowing lifejackets in one location on board a vessel can make them
Analysis 43 Marine Accident Report

inaccessible during an emergency. Lifejackets are essential safety appliances that should

be available to passengers in the earliest moments of an emergency. If a vessel is carrying

a large number of passengers who must retrieve lifejackets from a central location, the

crush of people all heading to the same location at the same time can incite panic, cause

injury, or delay distribution of lifejackets to all passengers. Title 46 CFR 180.78 requires

that lifejackets be ìstored in convenient places distributed throughout accommodation

spacesî and that ìeach life jacket kept in a storage container must be readily available.î

The Coast Guard approved the Bayside Blasterís lifejacket stowage arrangements when it

inspected the vessel in August 2001.

Passengers rely on the vessel crew to advise them when to retrieve and don

lifejackets in an emergency. Because of the few crewmembers relative to the number of

passengers carried on small passenger vessels, the crew may not have time to advise

passengers of what they should do in a rapidly developing emergency. Further, during an

emergency, crewmembers can become preoccupied with saving the vessel, leaving the

passengers to fend for themselves. Lifejackets must be readily available throughout the

accommodation spaces so that, if the lifejackets are needed, the passengers can retrieve

them. 

On the Bayside Blaster, the lifejackets were difficult to retrieve from the bow

locker, and no lifejackets were stowed in the aft accommodation area. Further, the opening

mechanism to the child-size lifejacket stowage compartment at the operatorís station was

broken and had to be pried open. Both the single stowage location of adult lifejackets and

the broken opening mechanism on the child lifejacket stowage compartment delayed the

distribution of lifejackets to all passengers. Fortunately, the delay did not affect the

outcome of the accident. However, under different circumstances, the delay in distributing

lifejackets could have had serious consequences. Therefore, the Safety Board concludes

that if lifejackets had been stowed throughout the accommodation space on the Bayside

Blaster, they would have been more readily accessible to the passengers. 

Stowage of lifejackets on small passenger vessels was also an issue in the Safety

Boardís recent investigation of the November 2000 fire on board the Port Imperial

Manhattan. Following that accident, the owner of the Port Imperial Manhattan, New York

Waterway, voluntarily elected to modify lifejacket stowage on its vessels. Lifejackets on

New York Waterway vessels are now stowed under the passenger seats. While the Coast

Guard approved the original stowage arrangements for lifejackets on all these vessels, the

owner of the Bayside Blaster should consider voluntarily reconfiguring the stowage of

lifejackets to make them readily available to passengers. Therefore, the Safety Board

believes that Boatrides International, Inc., should revise the stowage of lifejackets on

board its vessel so they are located throughout the passenger areas for immediate use in

case of emergency. 

In its report of the Port Imperial Manhattan investigation, the Safety Board

expressed concern that lifejacket stowage may be a widespread problem on small

passenger vessels throughout the industry and issued Safety Recommendation M-02-13,

asking that the Coast Guard:
Analysis 44 Marine Accident Report

Issue a directive to small passenger vessel operators to review the distribution of

lifejackets on board their vessels and to ensure that the lifejackets are accessible

and segregated.

On November 19, 2002, the Coast Guard responded, stating that it ìwill issue a

Safety Alert reminding small passenger vessel operators of the requirements and suggest

that they review the stowage arrangements on their vessels to ensure compliance with the

regulations.î 

The Safety Board considers the issue of proper lifejacket stowage on small

passenger vessels to be of the utmost importance, and that the primary responsibility for

the safety of passengers rests with the small passenger vessel operating companies.

Because the Passenger Vessel Association represents 65 percent of the small passenger

vessel operating companies, action taken by this organization can affect most of the

industry. The association has established its Safety and Loss Control Committee, which

reviews, develops, and implements programs to encourage enhanced training and safety

among its members. The Safety Board believes that the association should include in its

Risk Management Manual the information that lifejackets on small passenger vessels

should be evenly distributed throughout passenger areas for immediate use in an

emergency, as prescribed by 46 CFR 117.78 or 180.78. 

Coast Guard Safety Oversight of Small Passenger Vessels in 

Miami

For the Bayside Blaster to receive a COI to carry passengers, the Coast Guard must

inspect and certify that the vessel meets the small passenger regulations at 46 CFR 175-

185. The Bayside Blaster was deficient in at least three respects:

ï In the accident, Safety Board investigations found that lifejackets were not

readily available to passengers in the aft part of the vessel. However, the

Bayside Blaster had recently been inspected and approved for operation by the

Coast Guard. As the oversight authority for marine safety, Coast Guard

inspectors should not permit such arrangements. They should use inspections

as an opportunity to review the purpose of the regulations with vessel owners

and to improve the safety of passengers by ensuring that lifejackets are readily

accessible in an emergency.

ï After the accident, the Coast Guard in Miami advised the Safety Board that the

navigation lights of the Bayside Blaster were not configured in accordance

with the Inland Navigation Rules. The measurements taken by the Coast Guard

after the accident should have been taken during its 2001 inspection, and

corrections should have been made to ensure regulatory compliance.
Analysis 45 Marine Accident Report

ï The statements of the master and operations manager that the Bayside Blaster

had repeatedly, even if infrequently, operated shorthanded indicate that a

continuing safety deficiency regarding small passenger vessel operations in

Biscayne Bay remained undetected by the Coast Guard. While the owner of the

vessel has a primary responsibility for safety oversight, the Coast Guard has an

equally important responsibility to maintain oversight of the operations of all

small passenger vessels under its inspection authority. 

That the Bayside Blaster operated repeatedly with improper lifejacket stowage,

improper navigation lights, and without a full crew indicates that Coast Guard oversight of

small passenger vessel operations in the Miami area may be less than adequate. Although

it is the responsibility of the owners of the Bayside Blaster and other small passenger

vessels to maintain their vessels in compliance with the rules and regulations, it is also the

responsibility of the Coast Guard Marine Safety Office to ensure that a vessel is in

compliance before the Coast Guard issues a COI. In view of the noted deficiencies, the

Safety Board concludes that the Coast Guardís marine safety inspection program for small

passenger vessels in the Miami area may be less than adequate. The Safety Board,

therefore, believes that the Coast Guard should evaluate the adequacy of the marine safety

inspection program in the Miami area to ensure that small passenger vessels are in

compliance with applicable regulations, including the requirements for lifejacket stowage,

navigation lights, and manning. 
46 Marine Accident Report

Conclusions

Findings

1. The crewmembers of both vessels were well rested and not impaired by drugs or

alcohol, and the weather and sea conditions were not factors in this accident.

2. The coxswain of the Coast Guard patrol boat was operating his vessel in excess of the

Florida speed restrictions for no safety or law enforcement reason in a no-wake,

manatee-protection zone. 

3. Even if there were no speed restrictions, the coxswainís speed was imprudent for the

prevailing conditions of darkness, background lighting, and potential for

encountering passenger and recreational vessels in the area of the accident.

4. The lack of Coast Guard speed restrictions for conducting routine patrols allowed

coxswains too much latitude in selecting patrol speeds, which could endanger other

boaters as well as Coast Guard crewmembers.

5. The Bayside Blaster was on an appropriate route for its service, and the master was

operating his vessel at a safe and prudent speed for the conditions and circumstances. 

6. The master and deckhand of the Bayside Blaster were maintaining a proper lookout.

7. The Coast Guard patrol boatís high rate of speed, combined with its sudden

appearance close to the Bayside Blaster, precluded the master of the Bayside Blaster

from being able to take any effective action to avoid the collision.

8. It was appropriate for the master of the Bayside Blaster to beach his vessel on

Monument Island to ensure the safety of his passengers, given the circumstance that

he did not know the full extent of the damage to the vesselís hull and fuel tanks.

9. Although both vessels had technical deficiencies in the configuration of their

navigation lights, they were sufficiently lighted to alert other mariners of their

presence, and the deficiencies did not contribute to the cause of the accident.

10. The coxswainís being allowed to undertake the patrol without completing a thorough

predeparture check of the patrol boat or without ensuring that critical navigation

equipment was fully functional indicates a lack of effective oversight of patrol

operations at Coast Guard Station Miami Beach.

11. Coast Guard oversight of nonstandard boat operations was less than adequate at the

time of the accident.
Conclusions 47 Marine Accident Report

12. Operating the Bayside Blaster without the required number of crewmembers could

have had a negative impact on the safety of the passengers, although it did not in this

accident.

13. Why the kill switch did not activate when the coxswain was ejected or whether

fouling of the kill switch lanyard on the steering wheel was a factor in the enginesí

failure to stop cannot be determined. 

14. The actions by the Coast Guard to improve kill switch use could be enhanced by

including kill switch manufacturers and ergonomic/human engineering experts in the

redesign process.

15. If lifejackets had been stowed throughout the accommodation space on the Bayside

Blaster, they would have been more readily accessible to the passengers. 

16. The Coast Guardís marine safety inspection program for small passenger vessels in

the Miami area may be less than adequate.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the collision between the Coast Guard patrol boat CG242513 and the small passenger

vessel Bayside Blaster was the failure of the coxswain of the Coast Guard patrol boat to

operate his vessel at a safe speed in a restricted-speed area frequented by small passenger

vessels and in conditions of limited visibility due to darkness and background lighting.

Contributing to the cause of the accident was the lack of adequate Coast Guard oversight

of nonstandard boat operations.
48 Marine Accident Report

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the

following safety recommendations:

To the U.S. Coast Guard:

Establish oversight procedures for use by the commanding officers or officers-incharge of Coast Guard stations to improve the safety of Coast Guard routine small

boat operations, including the institution of in-depth predeparture briefings,

thorough predeparture checks of boats, monitoring of coxswain performance, and

thorough postpatrol debriefings. (M-02-25)

Evaluate on an annual basis your program for reducing nonstandard boat

accidents and for ensuring compliance with Coast Guard policies and procedures

related to those vessels; publish the results annually for use by Coast Guard

stations. (M-02-26)

Evaluate the adequacy of the design of present or future kill switch systems on

Coast Guard small boats, giving full consideration to ergonomic/human

engineering factors. (M-02-27)

Evaluate the adequacy of the marine safety inspection program in the Miami area

to ensure that small passenger vessels are in compliance with applicable

regulations, including the requirements for lifejacket stowage, navigation lights,

and manning. (M-02-28)

To Boatrides International, Inc.:

Establish procedures to prohibit your small passenger vessel from leaving the pier

with passengers on board unless the vessel has the crew required by the vesselís

certificate of inspection. (M-02-29)

Revise the stowage of lifejackets on board your vessel so they are located

throughout the passenger areas for immediate use in case of emergency.

(M-02-30)

To the Passenger Vessel Association:

Include in your Risk Management Manual the information that lifejackets on

small passenger vessels should be evenly distributed throughout passenger areas

for immediate use in an emergency, as prescribed by 46 CFR 117.78 or 180.78.

(M-02-31)
49 Marine Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

CAROL J. CARMODY JOHN A. HAMMERSCHMIDT

Acting Chairman Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: December 17, 2002

Recommendations

51 Marine Accident Report

Appendix A

Investigation 

The Safety Board learned of this accident from a news wire service report received

by the Safety Board Communications Center on January 12, 2002. A two-person team,

consisting of an investigator-in-charge and a survival factors specialist, arrived on scene

on Sunday, January 13, 2002. The team was later augmented by two additional

investigators, specializing in human performance. The investigative team documented the

damage to the Bayside Blaster and the Coast Guard patrol boat CG242513 and

interviewed the crews of both vessels, as well as the Bayside Blaster passengers, Boatrides

International and Coast Guard officials, and emergency responders. The on-scene

investigation was completed on January 20, 2002. 

The Safety Board investigated this public/nonpublic vessel accident under the

authority of the Independent Safety Board Act of 1974, according to Safety Board rules.

The designated parties to the investigation were the U.S. Coast Guard, Boatrides

International, Inc. (owner of the Bayside Blaster), and the Florida Fish & Wildlife

Conservation Commission.