National 

Transportation

Safety Board

Washington, D.C.

National Transportation

Safety Board

Washington, D.C. 20594

OFFICIAL BUSINESS

Penalty for Private Use, $300

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Postage & Fees Paid

NTSB

Permit No. G-200

Marine Accident Report

Capsizing of U.S. Small Passenger Vessel 

Taki-Tooo, Tillamook Bay Inlet, Oregon 

June 14, 2003

NTSB/MAR-05/02

PB2005-916402 National Transportation Safety Board

Notation 7582B 490 L’Enfant Plaza, S.W.

Adopted June 28, 2005 Washington, D.C. 20594
National Transportation Safety Board. 2005. Capsizing of U.S. Small Passenger Vessel Taki-Tooo,

Tillamook Bay Inlet, Oregon, June 14, 2003. Marine Accident Report NTSB/MAR-05/02.

Washington, DC.

Abstract: This report discusses the June 14, 2003, accident in which the U.S. small passenger vessel TakiTooo capsized while attempting to cross the bar at Tillamook Bay, Oregon. A master, deckhand, and 17

passengers were on board the charter fishing vessel when it was struck broadside by a wave and

overturned. The master and 10 passengers died in the capsizing; the deckhand and 7 passengers sustained

minor injuries. The Taki-Tooo, with a replacement value of $180,000, was a total loss.

From its investigation of the accident, the Safety Board identified the following major safety issues:

decision to cross the bar, Tillamook Bay operations, and survivability. 

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

Marine Charter Association, and the owners and operators of charter fishing vessels operating out of

Tillamook Bay, Oregon.

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

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

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

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

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

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

purchase this publication, order report number PB2005-916402 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

Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

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

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Master . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Deckhand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

General Construction and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Lifesaving Apparatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Certification and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

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

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Bay Entrance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Tide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Water Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Tillamook Bar Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Company Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Medical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Toxicology Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Search and Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Cold Water Immersion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Coast Guard Safety Alert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Propeller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Chart Plotter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Coast Guard Surf Stations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Coast Guard Authority Regarding Unsafe Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Coast Guard Regulations on Wearing of Lifejackets . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Actions After Taki-Tooo Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Condition of Tillamook Bar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

National Marine Charter Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Contents iv Marine Accident Report

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Decision to Cross the Bar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Personal Factors Potentially Affecting the Taki-Tooo Master’s Decisions . . . . . . . . . 41

Decision of the Charter Operators to Leave Port . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Tillamook Bay Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Navigational Conditions at the Bar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Bar Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Survivability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

B: Accident Chronology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

C: Boating Safety Pamphlet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

D: Coast Guard–Approved Lifejackets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
v Marine Accident Report

Acronyms and Abbreviations

A-VIP Accredited Vessel Inspection Program 

CFR Code of Federal Regulations

COI certificate of inspection

COTP Captain of the Port

EMS emergency medical service

EPIRB emergency position indicating radio beacon

GPS Global Positioning System

ICAO International Civil Aviation Organization

IFR interim final rule

MLB motor lifeboat

NMCA National Marine Charter Association

NPRM notice of proposed rulemaking

NWG Natural Working Group

OHSU Oregon Health and Science University

PFD personal flotation device

SNPRM supplemental notice of proposed rulemaking

WAAS Wide Area Augmentation System
vi Marine Accident Report

Executive Summary

On June 14, 2003, the small passenger vessel Taki-Tooo, a U.S. charter fishing

vessel with 2 crewmen and 17 passengers on board, was en route from the marina at

Garibaldi, Oregon, to the Pacific Ocean for a day of fishing. A small craft advisory was in

effect for the northern Oregon and southern Washington coasts, and personnel at U.S.

Coast Guard Station Tillamook Bay had activated the rough bar warning signs based on

their assessments of existing hazardous conditions. At the Tillamook Bay inlet, the TakiTooo operator waited in the channel for an opening in the ocean swells so that he could

cross the bar. After the Taki-Tooo exited the inlet and turned northward around the north

jetty, a wave struck and capsized the vessel. As a result of this accident, the master and 10

passengers died; the deckhand and 7 passengers sustained minor injuries. The vessel,

which had a replacement value of $180,000, was declared a total loss. 

The Safety Board’s investigation of this accident identified the following major

safety issues:

• Decision to cross the bar

• Tillamook Bay operations

• Survivability 

The National Transportation Safety Board determines that the probable cause of

the capsizing of the Taki-Tooo was the decision of the master to attempt to cross Tillamook

Bay bar despite the hazardous sea state that existed at the time. Contributing to the

severity of the accident was the failure of the Taki-Tooo master to ensure that he, the

deckhand, and the passengers donned lifejackets before crossing the bar. Also contributing

to the severity of the accident was the failure of the U.S. Coast Guard to enforce the

regulatory requirement at 46 Code of Federal Regulations 185.508, which stipulates that

vessel masters shall require passengers to wear lifejackets when transiting a hazardous bar.

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

U.S. Coast Guard, the National Marine Charter Association, and the owners and operators

of charter fishing vessels operating out of Tillamook Bay, Oregon.
1 Marine Accident Report

Factual Information

Synopsis

About 0605 the morning of June 14, 2003,1 the U.S. charter fishing vessel TakiTooo departed the marina at Garibaldi, Oregon, with 17 passengers and 2 crewmembers on

board. The vessel proceeded to an area near the seaward entrance to Tillamook Bay, where

the master waited for an opening in the ocean swells to navigate the hazardous shoal area.2

About 0715, the Taki-Tooo left the inlet, turned to the north, and encountered a wave that

capsized the vessel. The master and 10 passengers died (two persons were missing and

were declared dead). The deckhand and seven passengers either washed or swam ashore

on a nearby beach and survived.

Accident Narrative

The day before the accident—Friday, June 13, 2003—the National Weather

Service in Portland, Oregon, had issued marine forecasts3

 containing a small craft

advisory4 for coastal areas of southern Washington and northern Oregon, which included

Tillamook Bay (see figure 1). 

For most of the day, the U.S. Coast Guard Station at Tillamook Bay (Station

Tillamook Bay) did not place any vessel restrictions on marine traffic into or out of the

bay. At 1645, the National Weather Service updated the area small craft advisory,

predicting heavy seas with wind waves of 4 feet and 10-foot swells. According to its

station log, Station Tillamook Bay immediately restricted vessel passage across Tillamook

bar, the sandy shoal at the mouth of Tillamook Bay, which is flanked by jetties on the

north and south (figure 2).

1 All times are Pacific daylight time, based on the 24-hour clock. A complete accident chronology is

found in appendix B.

2 On the West Coast, the open expanse of the Pacific Ocean permits the wind energy to build,

generating large swells, or waves created over a long distance. Wave conditions at the estuary at Tillamook

Bay are compounded by the wave action caused by the prevailing winds in the immediate area. Navigation

at the site is further complicated by the complex current characteristics at the bay inlet.

3 Marine forecasts for ocean-coastal zones. In the case of the coastal zone that included Tillamook,

coastal waters are 20 nautical miles from shore. Thus, the 11-foot swells predicted for coastal waters could

have improved or worsened by the time they reached the bar area and shore.

4 A small craft advisory is issued to alert vessel operators whenever sustained winds of 20 to 33 knots

inclusive, or seas of 7 feet or greater, are either ongoing or forecast to develop in the next 12 hours. The

National Weather Service has no official definition for the term “small craft.” However, the U.S. Coast

Guard considers any vessel less than or equal to 33 feet to be a small craft.
Factual Information 2 Marine Accident Report

Station Tillamook Bay broadcast the bar restriction via VHF-FM channels 16 and

22A5 and on citizens band channel 9. In addition, Coast Guard personnel raised a smallcraft advisory flag at the station and activated the yellow lights on the rough bar advisory

signs at both the station and the 68-foot-high Coast Guard observation tower on the north

side of the Tillamook Bay inlet, about 900 yards east of the north jetty tip. The restriction

Figure 1. Location of Tillamook Bay and accident area.

5 Channel 16 (156.8 MHz), which the Coast Guard monitors continuously, is the international calling

and distress frequency. Channel 22A (157.1 MHz) is the Coast Guard’s primary working channel, which it

uses to broadcast severe weather warnings, hazards to navigation, and other maritime safety warnings to

recreational and commercial mariners. 

Seattle 

WASHINGTON 

Pacific 

Ocean 

Tillamook 

Astoria 

Portland 

OREGON 

Garibaldi Tillamook 

Bay 

Cape 

Disappointment 

Manzanita

0 

0 

100 Miles 

100 Kilometers

Accident Site 

N 

Columbia River 

Columbia River 

OR 

WA 

ID 

MT 

WY 

NV 

CA UT 

CO 

AZ 

0

0 1 km 

1 mile 

Tillamook Bay Bay City 

Garibaldi 

Tillamook 

Miami 

Cove 

Pacific 

Ocean 

Rockaway Beach
Factual Information 3 Marine Accident Report

established by the Coast Guard station applied only to all recreational boats and

uninspected small passenger vessels; it did not apply to inspected charter or commercial

fishing vessels in the area.6

At 0330 the morning of the accident (Saturday, June 14), the National Weather

Service issued another small craft advisory for the northern Oregon and southern

Washington coasts, this time forecasting wind waves of 3 feet and northwest swells of 11

feet at 11-second intervals. 

At 0445, a Coast Guard seaman began duty in the observation tower to monitor

vessel traffic. He was equipped with a VHF radio, handheld binoculars, and tripodmounted “big-eye” binoculars with a 25 × 150 millimeter lens. At first light (0446), a 47-

foot motor lifeboat (MLB) left Station Tillamook Bay to assess conditions at the

Tillamook bar.7

 The MLB was manned by a crew of four, including a coxswain.8 Coast

Figure 2. Looking southeast from Pacific Ocean toward Tillamook 

Bay, with inlet between north jetty (left) and south jetty (right). The 

Tillamook bar, not shown, is west of the jetty tips. The Taki-Tooo

capsized outside the tip of the north jetty and washed up on the sandy 

beach on the left of the photo.

6 To restrict the waterway to all vessel traffic required that the Coast Guard authority for the zone, in

this case, the Captain of the Port in Portland, Oregon, order the closure. Additional information related to

Coast Guard procedures regarding bar closures appears in the “Waterways” section of this report.

7 The Coast Guard’s 47-foot MLBs are high-speed craft especially designed for use in severe weather

and rough seas. 

8 A coxswain is the authority in charge of a boat and its crew while under way. The coxswain in

question was a qualified MLB coxswain who had undergone special training to direct the 47-foot MLB. He

was training to be a surfman (a coxswain certified by the Coast Guard to perform rescues in surf and heavy,

breaking seas) but had not attained that qualification by the time of the accident. See “Coast Guard Surf

Stations” section for further information on surfmen. 

U.S. Army Corps of Engineers photo U.S. Army Corps of Engineers photo
Factual Information 4 Marine Accident Report

Guard logs indicate that, at 0512, the MLB coxswain notified Station Tillamook Bay that

he recommended continuing the bar restriction because of turbulent (sloughing and

plunging) seas at the ends of the jetties and 8- to 10-foot swells outside the jetties. The

staff duty officer and officer of the day concurred with the coxswain’s assessment and at

0514, the Coast Guard rebroadcast the previous day’s bar restriction. The MLB then

remained on patrol in the waterway to prevent any recreational boats or uninspected small

passenger vessels from attempting to transit the bar.

Shortly before 0530, the Taki-Tooo master left his home in Garibaldi, Oregon, for

Garibaldi harbor, where the vessel was moored (see figure 3).9 The Taki-Tooo was a

charter fishing vessel inspected by the Coast Guard under Title 46 Code of Federal

Regulations (CFR) parts 175-185 (subchapter T). The master had been scheduled by the

couple who owned Garibaldi Charters to take a fishing party of 17 into the Pacific Ocean

for 6 hours of bottom fishing10 that morning. 

The master had checked the weather forecast posted on computer websites the

evening of June 13. The following morning, he continued to monitor the weather and bar

conditions on his VHF radio at home. He also had a VHF radio in his truck that he

typically listened to while en route to the harbor.

The manager of the charter company office stated that the Taki-Tooo master

“bounced in the door that morning. . . . he was joking with people and laughing.” The

9 Except as noted otherwise, the actions of the Taki-Tooo master are based on his wife’s recollection as

told to Safety Board investigators. 

Figure 3. Approximate route of the Taki-Tooo from Garibaldi marina to accident site.

10 Dropping or casting a weighted, baited hook to the bottom of a body of water and waiting for a bite

from bottom fish such as ling cod, flounder, and rockfish.

Pacific 

Ocean 

South Jetty 

North Jetty 

Site of 

capsizing 

N 

Coast Guard 

lookout tower 

Coast Guard 

station 

Miami 

Cove 

Marina 

Barview 

Garibaldi 

Channel 

Tillamook Bay 
Factual Information 5 Marine Accident Report

deckhand of the Taki-Tooo, one of the survivors of the accident, told Safety Board

investigators that when the master arrived at the charter company office shortly after 0530,

she and he agreed that because of weather conditions at the bar, they would not set crab

pots11 as originally planned. 

At the Garibaldi marina, vessels were preparing to depart for a day’s fishing in the

ocean. The Taki-Tooo was a 32.5-foot-long vessel having a single 250-horsepower diesel

engine. The other commercial vessels that sailed early that morning and their

characteristics were as follows:

• Small passenger vessel Oakland Pilot (44.4-foot-long, 730-horsepower, twinengine charter fishing boat).

• Small passenger vessel Norwester (41.8-foot-long, 420-horsepower, twinengine charter fishing boat).

• Small passenger vessel D & D (32.4-foot-long, 230-horsepower, single-engine

charter fishing boat built by the same manufacturer as the Taki-Tooo and

having the same molded hull and virtually the same size).

• Uninspected commercial fishing vessel Amanda (23 feet long, single engine).

Two other small charter boats, the Bullfrog and the Kerri Lin, had scheduled

fishing trips for the day. However, the operator of the Bullfrog, a six-passenger

uninspected vessel that fell under the Coast Guard’s bar restriction, cancelled the fishing

trip. His two passengers then elected to go on other vessels, with one being assigned to the

Taki-Tooo and the other to the D & D. The owner of the Kerri Lin, a 29.4-foot-long small

passenger vessel having a single 330-horsepower engine, later told investigators that he

decided to cancel his day’s charter because he had a policy of not operating once the sea

swell reached “double digits,” meaning 10 feet.

At 0530, the Oakland Pilot left the Garibaldi marina and headed for Tillamook Bay

inlet. Shortly afterward, the Taki-Tooo master and deckhand went to their boat and boarded

the 17 passengers. According to the deckhand, the master gave a safety briefing informing the

passengers that lifejackets were stored inside the cabin in labeled bins under the table, and that

if anybody wanted to put one on, “it was up to them” and that passengers should “just ask us

if they needed help getting them on or anything.” The deckhand stated that the master also

told passengers that the vessel was equipped with a liferaft and a throw ring, and that the

cabin had an emergency flare kit and a first aid kit. She said that the master described his

personal rules against alcohol, drugs, throwing trash overboard, or being sick in the cabin, and

told the passengers that they were not going to take crab pots out because of the rough seas. 

The safety briefing did not include a demonstration of how to don a lifejacket.

According to Federal regulations at 46 CFR 186.506, as an alternative to a demonstration,

11 Crab pots are wire-mesh cages that contain bait, such as fishheads, to attract crabs. Crab-fishing

(“crabbing”) from a boat involves setting the pots in the water attached by a line to a buoy so they can be

pulled up later. Charter boats often set crab pots on the way out to the fishing grounds and retrieve them on

the return trip. 
Factual Information 6 Marine Accident Report

passengers can receive a card or pamphlet containing the required lifejacket information

before the vessel gets under way. The deckhand told Safety Board investigators that the

Taki-Tooo’s cabin had a placard showing how to don a lifejacket.

About 0600, the Taki-Tooo, the Norwester, the D&D, and the Amanda departed

the marina. The Taki-Tooo master assumed control of his vessel from the flying bridge12

and proceeded toward the entrance to the inlet. The deckhand described the master as

being happy and joking, “just like normal.” 

By 0645, the Taki-Tooo had arrived at the north jetty, along with the Norwester, the

D & D, the Amanda, and the Oakland Pilot, which had been there nearly an hour. At this

time, the tide was ebbing, which, according to a boating safety pamphlet for recreational

vessels jointly published by the Oregon State Marine Board and the Coast Guard, makes

the Tillamook Bay bar especially dangerous to cross.13 The pamphlet indicates that vessels

should cross the bar during “slack water,” that is, during the time at high or low tide when

no appreciable current is flowing in a body of water. On this morning, the low tide (minus

2.1 feet) was predicted at 0721. The slack water would occur at the same time.

Federal regulations at 46 CFR 185.508 stipulate “the master of a vessel shall

require passengers to don lifejackets when possible hazardous conditions exist, including,

but not limited to . . . when transiting hazardous bars and inlets.” (See “Coast Guard

Regulations on Wearing of Lifejackets” section for further information.) None of the

vessel operators preparing to cross the bar, including the master of the Taki-Tooo, directed

his passengers to don lifejackets. Several of the masters later told Safety Board

investigators that if the conditions were so dangerous that they needed to ask passengers to

wear lifejackets, they would not, or should not, take their vessels out.

Meanwhile, the MLB coxswain moved his boat up to the jetty tips to observe each

charter vessel go across the bar and then repositioned himself next to the tower so other

vessels could pass him. The tower watch prepared to maintain visual contact with the

vessels until he observed that they had safely crossed the bar and made it out to calmer

seas. Other witnesses to the crossings included the Amanda master, who later told

investigators that he decided not to attempt the crossing but to stay and watch the other

vessels, and one of the owners of Garibaldi Charters, whose son was operating the

Norwester and whose daughter was the deckhand on the Taki-Tooo. The Garibaldi

Charters co-owner had driven to the parking area near the Coast Guard observation tower,

where he had a “good view” of the vessels in the waterway. A little later, about 0700, the

Kerri Lin owner arrived at the north jetty to watch the vessels leave the inlet.

The Taki-Tooo, the D&D, the MLB, and the Amanda were on the north side of the

channel, near the jetty, and the Norwester and Oakland Pilot were “backing strongly” near

the jetty tips because of the outgoing channel current. The Garibaldi Charters co-owner

said the vessel operators appeared to be “milling around,” waiting for better conditions,

12 A permanent, raised steering cabin or platform on a vessel.

13 “Crossing the Tillamook Bay Bar” describes the dangers specific to the bar area, the north jetty, the

middle grounds, and the south jetty areas. A copy of the brochure appears in appendix C.
Factual Information 7 Marine Accident Report

and watching the pattern of the waves, which came in sets. He said that the large waves

were coming too close together for a boat to avoid going over at least one of them on the

way out of the inlet, and that the masters had to depart the jaws of the jetty when the seas

were not good to be “in the right position when it does get good.” The masters could not

proceed due west out of the channel because of breaking water on the shallow bar. Instead,

they had to proceed either southwest or northwest around one of the jetties to reach deep

water. On the day of the accident, all the boats took a north-northwest course.

The Norwester crossed the bar first, at 0650. The Norwester master told Safety

Board investigators that he waited 30 to 45 minutes before seeing a “window” that would

allow him through the surf (the area where waves break into foam as they approach the

shoreline). According to the seaman on watch at the Coast Guard observation tower, the

Norwester rode over one swell on its way across the bar and then “stood straight up” on a

second one. The coxswain on the MLB said he saw the stern of the Norwester “just go

way up in the air and come back down.” The tower watch maintained visual contact with

the Norwester until it cleared the surf. 

The Norwester master said that after clearing the bar, he contacted the other vessels

waiting at the inlet by VHF radiotelephone. The transmission was not taped or monitored

by the Coast Guard tower, but the Taki-Tooo deckhand told Safety Board investigators that

she heard the Norwester master say, “It wasn’t worth it to go out,” and that the vessels

should wait until conditions at the bar “settled down a little bit. . . .” The Norwester’s

message was corroborated by a passenger on the D & D who was standing near its master

and by the co-owner of Garibaldi Charters, who was monitoring radio traffic with a

handheld VHF radio. The charter company co-owner told investigators that he thought the

message was intended for the Taki-Tooo master. One of the Taki-Tooo passengers said he

also heard the Norwester master say over the radio that he had to avoid hitting a log. The

Norwester master told investigators that there were “logs all over the tips and stuff.”

In preparation for crossing the bar, the Oakland Pilot master directed his

passengers to sit down. Passengers told the Tillamook County sheriff that when the

Oakland Pilot “went over a huge swell and dropped 10 to 12 feet off the back end,” the

deckhand hit his head against the ceiling, was knocked unconscious, and bit his tongue,

causing it to bleed; a passenger hit his head and cracked a window; and another passenger

injured his hip. The Taki-Tooo deckhand told Safety Board investigators that after clearing

the bar, the Oakland Pilot master called back on the VHF radio and said that he had had to

dodge a log and that there were “a lot of logs floating out there.” 

The watch at the Coast Guard observation tower changed at 0700. In briefing his

replacement, the watchstander from the first shift advised that the surf was rough and that

he had “just missed some cowboy stuff pulled off by the Norwester and the Oakland Pilot.”

The D & D started over the bar next, shortly after 0700. From his vantage point on

the north jetty, the Kerri Lin owner observed that the D & D master did not hurry his

departure and had no trouble going past the bar. According to a D & D passenger, the

vessel went over two or three “good” waves, and the master turned north to maneuver

around a log at the end of the jetty. The D & D master said, however, that he did not recall
Factual Information 8 Marine Accident Report

seeing any logs. A passenger on the D & D told investigators that as soon as the D & D

crossed the bar, “a lot of people” donned lifejackets and left them on for the rest of the trip.

He said, “I would never cross the bar again without [a lifejacket].”

Meanwhile, the Taki-Tooo master was circling between the north jetty and the jetty

tips to assess the bar conditions and, according to the deckhand, waiting for a favorable

surf. The deckhand joined the Taki-Tooo master on the flying bridge shortly before they

departed the inlet. The deckhand told investigators that she “didn’t notice any” debris in

the water. She said that the vessel rode over one swell and that she yelled for everyone to

hold on. The waves got larger, she said, and the master said, “I didn’t want to get into

this.” The deckhand said that she believed the master put the engines in reverse or astern

power so the vessel “didn’t go flying off the other end” of the wave. She said that the boat

twisted to the north, and that the swell was coming from the west. The deckhand said that

the Taki-Tooo never lost power. 

The Coast Guard tower watch observed the Taki-Tooo depart the inlet and followed the

vessel’s track by looking through his “big-eye” binoculars. He told Safety Board investigators

that he had never seen a vessel pass as close to the tip of the north jetty as the Taki-Tooo did. He

said that the Taki-Tooo descended into a trough between the waves, and that a 15-foot wave

then hit the vessel on the port side and capsized it. The tower watch, the observers on the north

jetty, the surviving passengers, and the deckhand all agreed that the Taki-Tooo was parallel to

the wave that capsized it. The deckhand described the capsizing as follows:

When we were going over the first wave, it kind of got us tilted, when he backed up,

I saw the wave coming and I told everybody to hold on, I didn’t look back to see

where everybody was, I said, hold on. And I grabbed onto the boat and we went over

it and the, okay, I was telling somebody that that was probably about 9- or 10-foot

wave. But, right on the other side of it, right on the backside of it, I saw a huge one

building and it was really steep and it was coming straight at us. And somehow, I am

really not clear on how this happened, whether it was the captain that had turned the

boat or whether we were still turning from sliding down the back of the wave, but

somehow we got completely sideways to it. And my first impression was that he was

trying to turn the boat around to ride with it. But, we got completely sideways to the

wave and by the time it was real close, I could tell that we were going to go over. And

it was probably about 12 to 15 feet because I was looking up at it. And it just smashed

in the side of the boat and went over and, I knew it was going to go over, so it just

went straight over. I don’t know [whether] it landed on me or not. I heard it, and

somehow I touched the boat, so it may have pushed me down. 

During his postaccident interview, the Amanda master said that as he watched the

Taki-Tooo, it did not appear as if “the vessel was being pushed” by the wave but as if the

Taki-Tooo master “just backed off the throttle some, turned, and hit his throttle again to go

north, you know, to get off of the bar.” The Kerri Lin master told investigators that he saw

the Taki-Tooo go over a 10- to 12-foot wave and that he believed the master reduced

speed, which should have allowed the wave to roll under the vessel so it would not crash

down on the backside of the wave. The Kerri Lin master said the Taki-Tooo “backed down

and . . . kind of went sideways.” He thought the Taki-Tooo master gave more power to the

engines as the vessel rolled up and into the curl of a 12- to 15-foot wave that he described

as a “monster.”
Factual Information 9 Marine Accident Report

From interviews with the survivors, the Safety Board determined that just before

the capsizing, six of the passengers were sitting in the cabin, six were sitting on either side

of the engine cover in the middle of the deck, and five were sitting or standing at the stern

(table 1). The passengers at the stern were thrown into the water during the capsizing,

along with all but one of those sitting on the engine cover. That passenger stated that he

was washed into the water and then surfaced in the cabin but could not recall how he

wound up there. 

Table 1. Relation of occupants’ location on boat and use of lifejacket to survivability.

Location 

Age/ 

Gender Precapsize Postcapsize 

Use of 

Lifejacket Remarks 

Fatality Victims 

66/M Flying bridge Water No Master of vessel. Body recovered by Coast Guard 

lifeboat; taken to Station Tillamook Bay. 

66/M Cabin Cabin Yes Donned lifejacket. Unable to exit cabin. Body 

recovered from cabin when vessel washed up on 

beach. 

70/M Open deck Water No Body recovered. 

49/F Open deck Water No Body recovered. 

53/M Open deck Water No Body recovered. 

65/M Open deck Water No Body recovered. 

54/M Open deck Water No Body recovered. 

61/M Open deck Water No Body recovered. 

46/M Open deck Water No Body recovered. 

52/M Open deck Water No Body not recovered. 

43/M Open deck Water No Body not recovered. 

Survivors 

22/F Flying 

bridge 

Water No Deckhand on vessel. Removed boots and outer 

clothing gear; made it to shore. 

18/M Open deck Cabin Yes Held onto lifejacket as exited through window. Made 

way to shore. Aided out of surf by bystanders. 

28/M Open deck Water No Reached life float 5-6 times but unable to hold on. 

Washed to shore by wave action. 

52/M Cabin Cabin Yes While Taki-Tooo was upside down, pulled out 

lifejackets and passed them out. Removed lifejacket 

to exit through window; put lifejacket on over his 

head. Floated to shore. Aided out of water by 

bystanders 

23/M Cabin Cabin Yes Tied lifejacket around arm. Exited through window. 

Floated to shore. Aided out of surf by bystanders. 

34/M Cabin Cabin Yes Assisted in handing out lifejackets. Removed 

lifejacket to exit through window. Lost hold of 

lifejacket during exit. Swam to shore. 

48/M Cabin Cabin Yes Put lifejacket around neck, exited through window. 

Floated to shore hanging onto lifejacket. 

47/M Cabin Cabin Yes Exited through cabin door; made it to shore. 
Factual Information 10 Marine Accident Report

All but one of the surviving passengers were in the cabin, which they said came to

rest upside down and filled with about 4 feet of water. One passenger pulled lifejackets out

of the bins and handed them to the others. One survivor was able to exit through the cabin

door. Five men had to remove their lifejackets to exit through the cabin window. Of those,

four managed to hold onto their lifejackets as they exited into the water, which enabled

them to use their lifejackets to make it to shore. One took off his lifejacket to exit through

the window but was unable to hold on to it. He successfully swam to shore. One passenger

wearing a lifejacket remained in the cabin and was fatally injured. According to survivors,

as they were exiting the cabin, they repeatedly exhorted that passenger, their relative, to

leave the boat. They said that he just sat down, however, and emitted a moan.

The survivor who had been thrown into the ocean from the open deck told

investigators that he never had access to a lifejacket. He said that he had tried to reach the

Taki-Tooo’s liferaft [rigid buoyant apparatus] but was repeatedly knocked away from it.

The deckhand was thrown off the flying bridge and into the water without a lifejacket. She

took off her boots, pants, and jacket and made it to shore. She told investigators that she

was a good swimmer.

The Garibaldi Charters co-owner told investigators that from his vantage point on

the north jetty, he watched the Taki-Tooo pass the end of the jetty, going almost straight

north. Then he lost sight of the Taki-Tooo but could see a large wave rise about 4 feet

above the outline of the boat. The next thing he saw was the boat upside down. Then he

said that he “estimated [he saw] about 5 people in the raft,” which overturned, “and when

it came back up, no one was in it.” He radioed the Coast Guard on channel 16 and ran onto

the beach, looking for his daughter, who was the Taki-Tooo deckhand.

The Coast Guard coxswain said he had moved the MLB toward the bar, from

where he watched the Taki-Tooo depart the inlet and pass “really close to the north tip.” He

said he then lost view of the Taki-Tooo and waited for the tower watch to tell him what

happened to the vessel. Shortly after 0715, the Coast Guard tower notified the MLB that

the Taki-Tooo had capsized. The MLB coxswain said he waited about a minute before he

felt he could get safe passage across the bar. He described the seas as “really, really

choppy and big” and said that the MLB had to travel over a 14-foot-high swell. He said the

swells were breaking, and that the entire area around the bar was whitewater. The

coxswain told investigators that the Taki-Tooo was very close to the rocks and he felt that

any attempt to approach the capsized vessel would endanger the MLB. He estimated that

he was within 50 to 75 yards of the jetty tip, as opposed to his typical distance from the

jetty of 100 yards. He also told investigators that after clearing the inlet, he remembered

that he was not qualified to attempt a rescue in the surf.

At 0725, the Thirteenth Coast Guard District’s rescue coordination center in

Seattle, Washington, received a distress alert from an EPIRB (emergency position

indicating radio beacon) registered to the Taki-Tooo. At 0730, the rescue coordination

center received confirmation from Station Tillamook Bay that the vessel had capsized

with 19 persons in the water. 
Factual Information 11 Marine Accident Report

The Kerri Lin master told investigators that by the time he called 911 at 0732,

survivors were already coming ashore. Civilians who happened to be in the area provided

the initial aid to the survivors. Emergency response personnel arrived soon thereafter and

transported seven of the eight survivors by ambulance to Tillamook County General

Hospital in Tillamook, Oregon. The Taki-Tooo deckhand was brought to the hospital by

private automobile. 

The Coast Guard recovered the body of the Taki-Tooo’s master a half-hour after the

capsizing. (See “Survival Aspects” section for details of the search-and-rescue effort.)

Within 2 hours of the accident, the Coast Guard had retrieved two passengers from the

surf and the bodies of six other passengers had washed ashore. Two male passengers,

whose bodies were never recovered, were declared dead, bringing the fatality total to 11. 

Injuries

The injuries sustained in the Taki-Tooo accident, shown in table 2, 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.

Table 2. Injuries sustained in Taki-Tooo accident.

Damages

The Taki-Tooo had an estimated market value of $60,000 and a replacement value

of $180,000.14 The vessel was declared a total loss after the accident. Additional

information about the damage sustained by the Taki-Tooo appears in the “Wreckage”

section of this report.

Type of Injury Crew Passengers Total

Fatal 1 10 11

Serious 0 00

Minor 1 78

None 0 00

Total 2 17 19

Title 49 CFR section 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 thirddegree burns, or any burn affecting more than 5 percent of the body surface.

14 The values are based on a September 2002 survey performed by a marine surveyor. 
Factual Information 12 Marine Accident Report

Personnel Information

Master

The Taki-Tooo master, age 66, had over 26 years’ experience operating charter

fishing vessels, according to Coast Guard records. He was issued a license to operate

small passenger vessels, good for 5 years, by the Coast Guard in 1984. As qualifying

experience in his original application for his 1984 license, he indicated that he had worked

277 full (8-hour) days operating small passenger vessels on the Pacific Ocean in the

previous 3 years. His application also indicated that beginning in 1976, he had over 700

days of experience operating small passenger vessels on the Columbia River between the

Pacific Ocean and Bonneville Dam and on the Pacific Ocean from Tillamook Head,

Oregon, to Leadbetter Point, Washington. 

When his Coast Guard license was subject to renewal in 1989, as it was every 5

years, Federal regulations stipulated that support be submitted showing that the master had

1 year of experience in the previous 5 years on vessels of the appropriate tonnage or

horsepower.15 According to records submitted to the Coast Guard, from March 1984 until

his licensure as “Master . . . of Steam or Motor Vessels of Not More Than 50 Gross Tons”

in March 1999, all his experience was on the Taki-Tooo, departing from Tillamook Bay

and sailing in the Pacific Ocean. 

The master’s Coast Guard license file indicates that at the time he applied for his

current license in February 1999, he had operated the Taki-Tooo some 1,600 days. Three

other area vessel operators stated that the Taki-Tooo master had crossed the Tillamook bar

more than a thousand times and that he was regarded as a very capable vessel operator.

The Taki-Tooo master had lived in the Tillamook area for 15 years. He and his wife

owned Davis Fisheries, Inc., of which the Taki-Tooo and the D & D were assets. They

were the former owners of Garibaldi Charters, which they sold to the present owners in

2001. The terms of the charter company sale stipulated that the Taki-Tooo and the D & D

would be leased to and operated by Garibaldi Charters; however, the owner of the TakiTooo continued to operate it part time for Garibaldi Charters because he was highly

regarded by his former customers and they would frequently request that he serve as the

vessel operator when they booked a fishing voyage. 

The master and his wife had purchased a second home in Baja California and they

divided their time between the Tillamook area in the summer and Mexico in the winter.

They had returned from their winter home in Baja California a few weeks before the

accident, and the master had operated the Taki-Tooo about three times since his return to

become acquainted with new electronics equipment that had been installed on the boat. 

The master’s wife said that his sleep patterns had been consistent for several days

before the accident. She said that he and she went to bed at 2100, as was their custom, and

that the master rose at 0430 on the day of the accident, his usual time. She stated that he

15 Title 46 CFR 10.209 (c)(i). 
Factual Information 13 Marine Accident Report

had coffee, made a lunch to take with him, and listened to the weather report. She further

stated that he was pleased that he had been asked to operate the Taki-Tooo that day and

was looking forward to the trip.

The master had last undergone a physical examination to renew his license, as

required by 46 CFR 10.209, on February 17, 1999. The examination record (Coast Guard

form 719K, submitted by the master and signed by his evaluating physician) states that the

master was taking five prescription medications daily: 40 milligrams of Accupril®

[quinapril, used to treat high blood pressure], 25 milligrams of HCTZ

[hydrocholorothiazide, used to treat high blood pressure], 2 milligrams of Tenex®

[guanfacine, used to treat high blood pressure], 40 milligrams of Lipitor® [atorvastatin,

used to treat high cholesterol], and 20 milligrams of amitriptyline, to be taken nightly [an

antidepressant, trade name Elavil®]. The record indicates that the master had experienced

dizziness in 1996 and that he had been treated for prostate cancer in 1993. The 719K form

also indicates that the master’s field of vision, color vision, and hearing were normal.16

The examining physician found the master competent to carry out the duties to be

performed on board a U.S. merchant vessel. The master then forwarded the completed

719K form to the Coast Guard regional examination center in Portland, one of 17 such

centers that are responsible for overseeing and approving mariner licensing.17 According

to the Marine Safety Office in Portland, the Coast Guard regional examination center “had

nothing in the file regarding any follow-up action on any of [the master’s] physical

examinations.”

According to records of his primary care physician, the master had a history of

coronary heart disease, high blood pressure, insomnia, prostate cancer, kidney stones, and

high cholesterol. The physician’s records indicate that Elavil had been prescribed to treat

the master’s insomnia. 

Deckhand

The deckhand, age 22, was the charter owners’ daughter. She had worked as a

deckhand for 5 years. She began her career working with the master on the Taki-Tooo, then

worked with her brother, the master of the Norwester, for three summers before returning

to the Taki-Tooo in June 2003. The accident trip was her first with the Taki-Tooo master in

the 2003 season. 

The deckhand told investigators that she slept 7 1/2 or 8 hours the night before the

accident and that she kept regular hours. She said her usual schedule was to go to bed

about 2000 or 2100 and rise at 0430, except when she did not have a scheduled charter. 

16 The master wore glasses for reading.

17 See <www.uscg.mil/hq/g-m/marpers/recs.htm> (accessed April 15, 2005).
Factual Information 14 Marine Accident Report

Vessel Information

The Taki-Tooo was manufactured in 1977 in Tacoma, Washington, by Modutech

Marine. The principal characteristics of the Taki-Tooo are summarized below: 

Length: 32.5 feet

Beam: 12.33 feet

Depth: 5.3 feet

Gross tonnage: 14

Crew: 2 (master and 1 deckhand) 

Passenger capacity: 20

Propulsion: 250-horsepower John Deere model 6076AFM30 

turbocharged diesel engine

General Construction and Equipment

The Taki-Tooo was constructed of fiberglass-reinforced plastic. The decks, built on

wood frames, consisted of plywood covered with fiberglass. The vessel’s bronze propeller

had four blades, was 26 inches in diameter, and was “right-handed” (rotated clockwise).

The vessel’s electronic and communications equipment included a Furuno model

1833C/NT radar/chart plotter (type RDP-139, S/N 4312-1096), a magnetic compass, and a

VHF radio. The vessel was also equipped with a second VHF radio, a citizens band radio,

a single-sideband radio, a 24-mile-range radar, and an EPIRB. 

Lifesaving Apparatus

The Taki-Tooo was required by the Coast Guard to have lifesaving equipment on

board for 22 people. The equipment included the following:

Adult lifejackets 22

Child lifejackets 3

Life floats/rigid buoyant apparatus18 1

Ring buoys 1 (light and line attached)

The lifejackets were stowed under a table in the cabin. The deckhand told Safety

Board investigators that a placard on the wall described how to don the lifejackets. A

number of lifejackets floated free after the accident.

18 Flotation equipment with a line attached around the outside. Survivors in the water hold onto the line.

The apparatus is not designed to support survivors out of the water.
Factual Information 15 Marine Accident Report

Certification and Inspection

The Taki-Tooo was inspected and certificated by the Coast Guard as a small

passenger vessel under the regulations at 46 CFR parts 175-185. The Coast Guard

certificate of inspection (COI)19 issued on March 13, 2001, permitted the Taki-Tooo to

operate not more than 100 miles from land in the Pacific Ocean between Point St. George,

California, and Angeles Point, Washington. According to the COI, the total number of

persons allowed on the Taki-Tooo was 22, including 20 passengers and 2 crewmembers.

The boat was required to have both a licensed master and a deckhand. If the boat was

away from the dock or if passengers had access to it for more than 12 hours in one 24-hour

period, the COI required that an alternate crew be provided.

The Marine Safety Office in Portland was the local Coast Guard office in charge of

inspecting the Taki-Tooo. The Taki-Tooo was last drydocked for a complete hull

examination on November 29, 2001. The only deficiency noted by the Coast Guard

inspector was a leak entering the forward compartment from the kingpost (a short mast

that carries a cargo boom) on the main deck. The COI stated that the repair had to be

completed before the vessel could carry passengers again. The vessel’s next drydock

inspection was due in November 2003.

The Taki-Tooo underwent an annual inspection in March 2003. The inspector noted

eight deficiencies having to do with lines, masthead light, high-water bilge alarm, bilge

manifold labeling, fixed fire extinguisher system reinstallation, battery terminal guards, and

Rules of the Road book. Coast Guard records contain three reports of marine casualties20 for

the Taki-Tooo, in 1993, 1997, and 1999. The reports do not indicate the type of casualty.

The Coast Guard inspected the vessel after an onboard fire in March 2003.

Wreckage

On Sunday, June 15, 2003, the day after the accident, an investigative group

comprising a Safety Board investigator, a chief warrant officer from the Coast Guard, and

a deputy from the Tillamook County sheriff’s office conducted an on-site examination of

the wreckage of the Taki-Tooo, which had been pulled onto the beach 3 hours after the

accident (see figure 4). The flying bridge operating console was missing and never

recovered. The deck railings on the bow were loose from their mountings. 

19 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 in

which the boat operates. The COI, among other conditions, stipulates minimum firefighting, lifesaving, and

crew 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 vessel’s propulsion machinery, the number of passengers, the type and location of

lifesaving equipment, and the hazards peculiar to the route and service.

20 For any vessel (other than a public vessel) operating on the navigable waters of the United States, a

marine casualty refers to any accidental grounding or incident resulting in damage by or to the vessel, its

apparel, gear, or cargo, or injury or loss of life of any person. Marine casualties include collisions,

strandings, groundings, founderings, heavy weather damage, fires, explosions, failure of gear and

equipment, and any damage potentially affecting the seaworthiness of the vessel. See 46 CFR 4.03-1.
Factual Information 16 Marine Accident Report

In examining the vessel’s propulsion and steering components, investigators found

that the rudder and rudder post were solidly mounted and undamaged. The propeller shaft

was straight and unremarkable; however, the propeller’s four blades had minor nicks and

scratches consistent with normal operation, given the age of the propellers. Investigators

noted that the propeller blades were curled at the tips, so they had the propeller removed

and sent to the Safety Board’s materials laboratory in Washington, D.C., for detailed

examination and documentation of damage. The results are described below, in the “Tests

and Research” section.

The diesel engine was intact, with no signs of oil leaks or obvious signs of catastrophic failure. All fuel lines, fittings, and linkages were intact and attached. When manipulated at the lower helm station, the throttle and transmission control moved the throttle

linkage throughout its range. The lower helm station wheel turned freely in both directions. 

The Taki-Tooo was then moved to a site in Tillamook, where investigators continued their inspection on June 16. In checking the propulsion and steering mechanisms, they

found no evidence of preaccident mechanical malfunction. In addition, the engine and

transmission were solidly mounted, the two fuel tanks were secure, the bilge pumps were

connected and operable, the high-water bilge alarms were connected, and the electrical

fuses in the cabin were intact, though several were filled with water. Investigators had the

radar/chart plotter removed and sent to the Safety Board’s recorder laboratory in Washington, D.C. (See “Tests and Research” section for more information.)

Figure 4. Taki-Tooo on beach after capsizing.
Factual Information 17 Marine Accident Report

Waterway Information

General

The accident occurred at the entrance to Tillamook Bay, a large (6.2-mile-long, 2.1-

mile-wide), shallow (averaging 6.6 feet deep) estuary on the northern Oregon coast. Five

major rivers drain runoff from the west slopes of the Coast Range into the bay. At high tide,

Tillamook Bay covers about 8,400 acres; at low tide, about half the bottom is exposed as

sand and mud flats. The city of Tillamook (population 4,350) and the towns of Garibaldi

(population 935) and Bay City (population 1,150) are located on the bay (figure 1).

Bay Entrance

As noted earlier, the entrance to Tillamook Bay is protected by jetties on the north

and south (see figure 2). According to the U.S. Coast Pilot, the north jetty is 1,900 yards

long and extends 800 yards offshore, with the last 80 yards submerged.21 A lighted whistle

buoy sits in water over 100 feet deep about 1 mile west of the north jetty. The bar, a curved

shoal where the water is less than 30 feet deep, lies between the jetty tips and the whistle

buoy. Waves break over the bar on the ebbing tide, and the area is considered

unpredictable and hazardous. The Oregon State Marine Board cautions boaters trying to

cross the bar not to turn around if waves are breaking over it.22

Just outside the north jetty tip is the “north hole,” a section of deep water between

the shoal and another shallow area along the sandy beach that runs north of the bay.

According to the Station Tillamook Bay log, the Taki-Tooo “rolled in the north hole as it

exited the bar.” The Taki-Tooo ended up on the beach north of the north jetty. The waters

next to the beach are marked “changeable area”23 on the nautical chart for Tillamook Bay.24

The Tillamook Bay channel lies immediately south of the north jetty. The channel

runs 3 miles east to Garibaldi (Miami Cove) and is marked by a directional light, buoys,

and daybeacons. The U.S. Army Corps of Engineers maintains the entrance and inner

channels to a depth of 18 feet. The entrance channel has no specified width, while the

inner channel is 200 feet wide up to Miami Cove.25 There is a turning basin at Garibaldi. 

21 National Oceanic and Atmospheric Administration, National Ocean Service, U.S. Coast Pilot, vol. 7

(Pacific Coast: California, Oregon, Washington, and Hawaii), 2003, p. 299. According to field

measurements made by the U.S. Army Corps of Engineers in June 2003, the north jetty is only 1,772 yards

long and is receding more every year. See “Condition of Tillamook Bar” section for more information.

22 “If you decide to cross, proceed out—but do not attempt to turn around if the bar is breaking.”

Oregon State Marine Board website, “Tillamook Bay” <www.marinebd.osmb.state.or.us/

CoastalWaters/Tillamook.htm> (accessed May 28, 2004).

23 Meaning the shoreline and depths change frequently.

24 Tillamook Bay, chart 18558, Coast Survey, United States, Oregon–West Coast, 37th ed. (Washington,

DC: U.S. Department of Commerce, National Oceanic and Atmospheric Administration, National Ocean

Service, 2002).

25 <gisweb.co.tillamook.or.us/tcwrc/swcd/sect905b.htm>.
Factual Information 18 Marine Accident Report

According to the Oregon State Marine Board, the current runs out of the bay at 4 to

6 knots and is “very strong.”26 The strong current, together with the pinched shape of the

jetties, flushes sediment out the narrow entrance and helps maintain the channel at its 18-

foot depth. The channel was last dredged in 1976, before the south jetty was built.

According to a hydraulic engineer with the Corps of Engineers Portland District, “Since

completion of the Tillamook Bay south jetty in 1979, the entrance channel at Tillamook

Bay has been ‘self-maintaining’ due to tidal hydraulics.” 27

Although the Tillamook Bay channel does not require dredging, the Corps of

Engineers surveys the channel annually. The Corps was scheduled to survey the channel in

July 2003 but moved the survey to the third week of June 2003 to assist in the investigation of

the Taki-Tooo accident. As in other years, the Corps’s 2003 survey showed that the channel

had remained within its authorized depth.28 The Coast Pilot and the nautical chart for

Tillamook Bay caution mariners that “the entrance channel is subject to frequent changes.”

Tide 

According to navigation references, the mean tide at Barview (the east end of the

entrance channel to Tillamook Bay) is 3.9 feet; the higher high water level is 7.5 feet, the

mean high water level is 6.8 feet, the mean low water level is 1.1 feet, and the extreme low

water level is minus 3.0 feet. At 0721 on June 14, about 5 minutes after the accident, a low

tide of minus 2.1 feet was recorded at Barview. 

Water Temperature 

The average water temperature is 57o F for the period between June 1 and June 15

on the Oregon coast in the vicinity of Tillamook Bay.29 Three hours after the accident, the

water temperature at the site of the capsizing was 52o F, as measured from one of the two

Coast Guard MLBs. For the effect of water temperatures on the human body, see the

“Survival Aspects” section of this report.

Tillamook Bar Restrictions

As noted earlier, Station Tillamook Bay can restrict the bar only to recreational

and uninspected passenger vessels; the station does not have the authority to close the bar

to inspected passenger vessels. If hazardous conditions warrant closure of the bar, the

station works through its chain of command by first notifying the operations center at

Group Astoria, which, in turn, notifies the Captain of the Port (COTP) Portland, the

Coast Guard authority for the zone that includes Oregon. The COTP, acting under the

authority of the Ports and Waterways Safety Act,30 can close the bar to all vessel traffic.

26 Oregon State Marine Board, “Tillamook Bay.”

27 See “Other Information” section for more information on the condition of the Tillamook bar.

28 <www.nwp.usace.army.mil/issues/tillamook/cms/home.asp>.

29 National Oceanographic Data Center, Coastal Temperature Guide

<www.nodc.noaa.gov/dsdt/wtg12.html> (accessed June 2, 2004).

30 Title 33 U.S. Code 1221 et seq.
Factual Information 19 Marine Accident Report

The Coast Guard officer-in-charge at Station Tillamook Bay told Safety Board

investigators that in the 3 years he had been assigned at that location, the bar had never

been closed. A Coast Guard marine inspector at the Marine Safety Office in Portland,

who had records for the 5 years (1,825 days) before the accident, informed the Safety

Board that “at no time could we find that we had requested to restrict [Tillamook bar] to

commercial vessels.” He said that the logs indicated that Tillamook bar had been

restricted to recreation boats and uninspected small passenger vessels 1,422 times during

the previous 5 years; however, depending on the weather, bar restrictions can be enforced

and lifted several times a day. 

Company Operations

Garibaldi Charters advertises itself as a family-owned business that offers deep-sea

fishing, bottom fishing, diving, whalewatching, eco-tours, scenic excursions, occasional

weddings, and scattering of ashes. As noted earlier, Garibaldi Charters leased the TakiTooo and the D & D from the previous owner. The company also owned outright the

Norwester, the first vessel to depart the inlet on the day of the accident.

Garibaldi Charters’ operating season ran from March until October. According to

the owner of the charter company, the weather did not permit regular trips from October to

March. The D & D master told Safety Board investigators that the company never

pressured him to take his boat out, no matter what the weather.

The husband of the couple who owned Garibaldi Charters was the usual master of

the Taki-Tooo. However, the charter group that had reservations to fish on board the TakiTooo the day of the accident had requested the boat’s owner as the master. The charter

owner said that the group paid $70 each for the fishing trip. The master received about 30

percent of the gross from ticket sales. If a trip was canceled because of bad weather or sea

conditions, the ticket money was refunded and the master received no pay.

Meteorological Information

According to National Weather Service data, the wind in Garibaldi at the time of

the accident was about 10 knots from the southeast, with no precipitation. Surface

temperatures were about 56o F, and the sky was cloudy. 

The National Weather Service issued small craft advisories for hazardous seas on

the northern Oregon and southern Washington coasts at 1645 and 2130 on June 13 and at

0330 and 0930 on June 14. The forecast was for northwest swells of between 10 and 12

feet, with a large swell predicted to reach the coast during the day on Saturday. Actual

conditions at 0650 on June 14, according to the meteorologist-in-charge at the weather

forecast office in Portland, were comparable to the 0330 forecast. Winds were from the

south at 5 to 15 knots, and combined seas were 12 to 13 feet. 
Factual Information 20 Marine Accident Report

The forecast for Tillamook issued at 0430 on June 14 by the weather forecast

office in Portland called for mostly cloudy skies with a chance of showers early in the

morning. A west wind of 5 to 15 mph was predicted. 

Medical and Pathological Information

Medical Findings

The confirmed dead included one female and eight males, ranging in age from 46

to 70. The Tillamook County medical examiner recorded the cause of death in each case

as drowning by asphyxiation and hypothermia, based on clinical on-scene observation.

Autopsies were not performed on the fatally injured passengers.

An autopsy was performed on the master of the Taki-Tooo. As noted earlier, the

master had a history of coronary artery disease, high blood pressure, insomnia, prostate

cancer, kidney stones, and high cholesterol. The medical examiner’s report noted evidence

of previous conditions and indicated that none contributed to his death. The autopsy found

no evidence of recent heart attack, a recurrence of his prostate cancer, or evidence of

kidney stones. The autopsy report indicated a very small subdural hematoma (bleeding

into the brain) and an abrasion to the side of the head. There was no evidence of

underlying brain injury, and the hematoma was completely encapsulated. The medical

report concluded that the Taki-Tooo master died from drowning by asphyxiation with

hypothermia.

Tillamook County General Hospital treated all survivors for hypothermia. Of the

eight patients, seven were released the day of the accident; one passenger was kept in the

hospital overnight.

Toxicology Testing

The capsizing of the Taki-Tooo was classified as a “serious marine incident” under

Federal regulations.31 As a result, drug and alcohol testing of the master was mandatory.

The master’s body was sent to the Oregon Health and Science University (OHSU) medical

examiner in Portland, Oregon, for autopsy and toxicological analysis. The OHSU

laboratory performed a routine urinalysis for five illicit drugs,32 prescriptions, and overthe-counter medications and tested the master’s blood for alcohol. The analyses were

negative for the presence of alcohol or illicit drugs. 

The Safety Board obtained autopsy specimens and sent them for toxicological

examination to the Federal Aviation Administration’s Civil Aerospace Medical Institute in

Oklahoma City, Oklahoma. Tests for alcohol and illegal drugs were negative. The master’s

blood showed amounts of the prescription antidepressant amitriptyline (0.063

31 A serious marine incident is defined at 46 CFR 4.03-2 as one that results in death, injury beyond first

aid, damage to property in excess of $100,000, loss of an inspected vessel, or loss of a vessel of 100 gross

tons or more.

32 Marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP).
Factual Information 21 Marine Accident Report

milligrams/milliliter) and its metabolite nortriptyline (0.042 milligrams/milliliter). His

urinalysis also showed the presence of amitriptyline and nortriptyline. 

Survival Aspects

Emergency Response

At 0716, immediately after the accident, the Coast Guard MLB at the north jetty

notified Station Tillamook Bay that the Taki-Tooo had capsized. The MLB coxswain said

he could not attempt a rescue because the Taki-Tooo was too close to the jetty, in shallow

waters and breaking surf. In addition, the coxswain was not qualified to operate a rescue

craft in surf conditions (see “Other Information” section for details). 

As soon as it received news of the capsizing, Station Tillamook Bay sounded the

search-and-rescue alarm and at 0718, requested search-and-rescue helicopters from Air

Station Astoria, about 30 miles, or 26 minutes, from the accident scene. At 0720, Station

Tillamook Bay launched another 47-foot MLB to the accident scene, with a certified

surfman as coxswain.

At 0721, the Coast Guard station telephoned the Tillamook County Emergency

Communications District (911) and requested ambulances for the Coast Guard station and

the beach on the north side of the north jetty. The emergency communications operator

then paged the volunteer fire and rescue departments of the towns of Garibaldi, Bay City,

and Rockaway Beach (figure 1), as well as the emergency medical service (EMS) units for

Garibaldi, Manzanita, and Tillamook County. 

At 0725, the Coast Guard rescue coordination center in Seattle received an EPIRB

signal from the Taki-Tooo and 5 minutes later, received confirmation from Station

Tillamook Bay that the Taki-Tooo had capsized.

By 0726, the Garibaldi fire chief was en route to the accident scene. When the fire

chief and one rescue truck from the Garibaldi fire and rescue department arrived on the

beach 10 minutes later, the fire chief assumed command. Ambulances arrived from

Garibaldi, Manzanita, and Tillamook County between 0738 and 0814. Three patrol cars

from the Tillamook County sheriff’s office also arrived on scene during that time. The

Rockaway Beach fire department sent its fire chief and a water rescue team. Rockaway

fire and rescue brought a personal watercraft to the scene but could not deploy it because

of the rough seas. An official representative of the Garibaldi fire and rescue department

told Safety Board investigators that each dispatched unit had its own incident commander

and participated in the unified command system.33

33 The unified command system is a way of coordinating the response to an emergency. The incident

commanders of the various responding agencies work together to make consensus decisions but do not

surrender their individual jurisdictional responsibilities.
Factual Information 22 Marine Accident Report

Search and Rescue

At 0732, the second Coast Guard 47-foot MLB arrived at the accident scene and

relieved the first MLB, which stayed outside the surf zone. The crew of the second MLB

spotted a man floating face down inside the surf zone, not wearing a lifejacket. The

coxswain radioed Station Tillamook Bay that his crew had located a victim and was

maneuvering to pick him up. No additional victims were seen in the area. At 0745, the

second MLB recovered the unconscious victim (the master). The MLB crew performed

CPR on the victim while bringing him to Station Tillamook Bay, from where he was

transferred to Garibaldi EMS personnel. At the Coast Guard station, the officer-in-charge

came on board the second MLB, which then left on its second trip to the accident site. 

At 0745, while the MLB was recovering the victim, the Coast Guard HH-60J

Jayhawk rescue helicopter that had been launched from Air Station Astoria arrived at the

north jetty. The helicopter commander told Safety Board investigators that the Taki-Tooo

had already washed ashore and that the “surf was up pretty heavy” (figure 5). He said he

also saw empty lifejackets, a liferaft, clothing, logs, and other debris in the water. 

About 0800, a second helicopter was dispatched from Air Station Astoria. Shortly

after 0800, a rescue swimmer lowered from the first helicopter by cable recovered a victim,

not wearing a lifejacket, from the surf. The helicopter transferred the victim to EMS

personnel on the beach, then returned to the search. The second helicopter arrived about

0820 and began a parallel search of the water from the north jetty to about 1 1/2 miles north. 

About the same time, the second MLB joined the first MLB at the accident scene,

with the officer-in-charge on board. The officer-in-charge, a qualified surfman, told

investigators that he intended to jump from the second MLB into the first one so that both

MLBs would have a qualified surfman on board. However, he said, the two boats hit each

other when they drew alongside, so he jumped into the water and then climbed into the

Figure 5. Rescue personnel near Taki-Tooo in surf after capsizing.
Factual Information 23 Marine Accident Report

first MLB. He described that as the “safest way” for him to get from one MLB to the other

under the circumstances.

An hour later, at 0915, the first helicopter recovered another victim from the water

outside the surf line, about 200 yards from the tower. The victim was nonresponsive and

was not wearing a lifejacket. The helicopter took the victim to the beach and transferred

him to EMS personnel. The second helicopter continued to search the water for victims.

At 0923, Garibaldi fire and rescue confirmed that there were eight bodies on the

beach, including the two recovered from the water. By that time, six survivors had arrived

at Tillamook County General Hospital by ambulance and a seventh, the deckhand, had

arrived at the hospital by private automobile. At 0927, the Coast Guard cutter Steadfast,

based in Astoria, was diverted to help in the search.

About 1030, the first helicopter returned to Air Station Astoria and the first MLB

returned to Station Tillamook Bay. At 1105, Station Tillamook Bay was advised that only

17 of the 19 people on board the Taki-Tooo had been accounted for. The second helicopter

continued to search the water for the two missing victims but left the accident scene about

1600 without finding anyone. The Steadfast arrived on scene at 1700 and assumed onscene command. The second MLB continued to search until 2100, then returned to Station

Tillamook Bay. At 2115, the Steadfast completed its search and was released.

At first light on June 15, one of the 47-foot MLBs from Station Tillamook Bay and

an HH-60J Jayhawk helicopter from Air Station Astoria resumed the search for the

missing victims. Results were negative, and the Coast Guard suspended the search at 0857. 

According to the Coast Guard, the two 47-foot MLBs from Station Tillamook Bay

logged a total of 26 hours in the search-and-rescue effort. One of the HH-60J Jayhawk

helicopters from Air Station Astoria searched for 7 hours, the other, for 5.3 hours. An HH-65

Dolphin helicopter from the Coast Guard’s air facility at Newport, Oregon, was in the air

briefly. The Coast Guard cutter Steadfast logged nearly 13 hours in the search. 

Cold Water Immersion

According to a senior Coast Guard official, the U.S. Coast Guard Addendum to the

National Search and Rescue Supplement is being revised to address survivability in cold

air and cold water environments. Until recently, the primary danger from immersion in

cold water was considered to be death from hypothermia, a condition in which the body

loses heat to the water (which conducts heat away from the body 25 times faster than air of

the same temperature) and the core body temperature drops dangerously low. A 2003

study by Transport Canada34 found, however, that hypothermia is only the third of four

34 Transport Canada, Survival in Cold Waters: Staying Alive, report TP13822E (Ottawa, Ontario:

2003). The report, which was requested by the Marine Safety Directorate of Transport Canada, discusses

physiology of cold water immersion, research into protecting people from the dangers of sudden cold

water immersion, design of immersion suits and their relation to lifejackets, and various groups needing

protection. The report incorporates an earlier Transport Canada report on cold shock and swimming

failure.
Factual Information 24 Marine Accident Report

stages in cold water immersion at which death can occur, and that more than half the

deaths related to cold-water immersion occur during the “cold shock” and swimming

failure stages. 

The Coast Guard search-and-rescue addendum will incorporate the Cold Exposure

Survival Model developed by Canada’s Defense and Civil Institute for Environmental

Medicine. This model predicts “functional time” and survival time based on the cooling of

the body’s core as affected by the person’s physical characteristics and clothing and the

environmental conditions.35

The Canadian research, which builds on earlier surveys conducted in the United

Kingdom and other countries, found that the critical water temperature in incidents of cold

water immersion is 59o F (15o C). The Canadian study states, “Entry into water below 15o

C should be avoided.” The water temperature at the accident site 3 hours after the TakiTooo capsized measured 52o F. The various immersion stages that can cause death, as

described in the Canadian study, include the following.

Stage 1, initial immersion response or cold shock, occurs during the first 2 to 3

minutes of immersion. Unless victims are mentally prepared and physically protected

(with survival suits or lifejackets), they can drown immediately after entering cold water

because they cannot control their breathing. The shock of the cold water causes a large

gasp followed by hyperventilation (faster breathing) and a greatly increased heart rate and

blood pressure. The cardiac effects can cause death, particularly in older or less healthy

victims.

Stage 2, short-term immersion or swimming failure, occurs during the first 3 to 30

minutes after immersion. According to the Canadian study, “ability to swim in warm

water is no indication of how well a human can swim in cold water.” Two theories are

advanced to account for death at stage 2. The first is that death is caused by the respiratory

and cardiovascular responses begun during stage 1. The second is that cold water causes

breathing to stop, the heart rate to slow, or cardiac arrest.

In stage 3, long-term immersion or hypothermia, death can occur after 30 minutes

of immersion in cold water. Even with mild hypothermia, victims can drown after

becoming physically incapacitated or losing consciousness. The Coast Guard developed

survival curves to predict death from hypothermia at various water temperatures, and

boating safety organizations have published tables showing expected survival time in

water of different temperatures. The Canadian study cautions, however, that these curves

and tables are difficult to validate. 

35 Functional time is the predicted number of hours after initial exposure that a person’s body core

temperature decreases to the end of mild hypothermia at 34° C (93.2° F). At functional time, the person is

incapacitated by hypothermia and is at the limits of self-help. Survival time is the predicted number of hours

after immersion when the person’s core body temperature falls to the end of moderate hypothermia at 28° C

(82.4° F). A person with a core temperature of 28° C will lose consciousness. An immersed unconscious

person is unable to maintain an airway, which quickly results in drowning.
Factual Information 25 Marine Accident Report

Stage 4 is postrescue collapse, in which death occurs during rescue or hours

afterward. According to the Transport Canada report, a 1956 study found that 17 percent

of shipwrecked survivors rescued from water of 10o C (50o F) or below died within 24

hours.36

Coast Guard Safety Alert

On June 29, 2004, the Seventeenth Coast Guard District, based in Juneau, Alaska,

issued a safety alert entitled “Cold Water Immersion: It’s More Than Just Hypothermia” to

area mariners. The alert stated that a review of the boating fatalities in Alaska for the

previous 3 years had indicated that about 75 percent of the people who died probably

succumbed to cold shock and swimming failure rather than hypothermia. The alert

explained to mariners how their bodies would react when immersed in cold water and

what actions to take to increase their chances of survival. The alert stressed: “Wear a

lifejacket at all times when boating,” and offered the following rationale for doing so:

This [a lifejacket] keeps your head above water if you suddenly fall overboard or

capsize, and gives you those precious minutes you need to get back onboard. Even

if you have a lifejacket in your hands, you may not be able to put it on. If you

cannot self-rescue, it may give you some hypothermia protection and can extend

the time you can survive until someone else can rescue you. 

Tests and Research

Propeller

Technicians at the Safety Board’s materials laboratory examined the Taki-Tooo’s

propeller and found that the tip of each of the four blades curled forward, and that the

angle and area of the curl increased in the counterclockwise direction (looking forward).

The back of the blades did not show any scoring marks or scraping damage. Laboratory

personnel concluded that the curl damage was consistent with the propeller contacting the

soft bottom of the ocean floor while under power. 

One blade showed two dime-sized areas of local deformation in the aft direction.

The laboratory found no evidence of impact from hard material in the deformed areas. 

Chart Plotter

The Taki-Tooo’s Furuno model 1833C/NT radar/chart plotter (type RDP-139,

S/N 4312-1096) was delivered to the recorder laboratory at the Safety Board on April

30, 2003. The plotter is designed to display navigational data acquired from an

integrated onboard radar and an optional Global Positioning System/Wide Area

Augmentation System (GPS/WAAS) receiver.37 Recent position and track information is

36 Transport Canada, p. 16.

37 WAAS is a form of GPS that enhances position accuracy by correcting received navigation data

(http://users.erols.com/dlwilson/gpswaas.htm <accessed August 27, 2004>).
Factual Information 26 Marine Accident Report

stored in memory for as long as power is applied to the device. A battery is permanently

installed in the unit to maintain data integrity while the unit is disconnected from the

main power. 

The exterior of the device showed no evidence of structural damage, but the

interior was encrusted with salt. Metallic connections between the onboard battery and the

printed circuit card containing the semiconductor memory elements were found

completely corroded through. The onboard battery was found to be totally discharged. The

unit was sent to the manufacturer, Furuno USA, Inc., to assess the potential for data

recovery, but no data were found stored in the memory elements because of the loss of

electrical power. 

Other Information

Coast Guard Surf Stations

Station Tillamook Bay is a designated surf station, where the Coast Guard operates

rescue boats designed to pass through heavy, breaking waves. Surf stations are established

at Federally mandated navigable bars or entrances where surf greater than 8 feet occurs 10

percent or more of the time during a calendar year, averaged over at least 5 years,38 and

where the water is deep enough to operate surf boats. The Coast Guard has designated 20

surf stations, 5 on the East Coast and 15 on the West Coast (table 3).

The wave conditions that occur at the waterways monitored by West Coast surf

stations usually differ from the wave conditions at waterways overseen by the East Coast

surf stations. As noted earlier, waves are created by wind energy. Because of rotational

force effects, weather patterns, and other factors, the prevailing winds on the West Coast

are behind the waves, increasing their energy. The prevailing winds on the East Coast, in

contrast, blow against the waves, retarding their force. The Pacific Ocean is wider than the

Atlantic Ocean, which permits the wind energy to build, creating larger swells. Finally,

unlike the East Coast, the West Coast has a steep continental slope and narrow continental

shelf that allows the waves to enter shallow water closer to shore. As the waves encounter

a rapid change in water depth, their height becomes steeper and they break, spilling,

plunging, or surging in the shallows or on the beach.

The Coast Guard has identified that the sea state at coastal river bar entrances

overseen by several surf stations contributes to conditions that warrant the suspension of

traffic by recreational vessels and uninspected commercial boats. This is discussed further

in the following section. 

38 U.S. Coast Guard Boat Operations and Training (BOAT) Manual, vol. 1, chapter 4, “ Surf Stations”

(Commandant Instruction M16114.32A, January 18, 2005). 
Factual Information 27 Marine Accident Report

Table 3. Designated Coast Guard surf stations. 

The Coast Guard BOAT manual states that surf stations are required to be staffed

by a two-person command cadre (usually, a commanding officer or officer-in-charge and

an executive petty officer) and by from five to seven qualified surfmen. Surfmen are MLB

coxswains who are specially trained to perform rescues at sea in hazardous conditions

(surf and heavy, breaking seas). A surfman is required to be on board a responding MLB

when the surf exceeds 8 feet.

About 160 surfmen stand duty at the 20 designated surf stations and at the surfman

training center (the National Motor Lifeboat School at Cape Disappointment, Washington,

near the mouth of the Columbia River39). According to the Coast Guard, since 1999, only

about 50 percent of the surfman duty billets have been filled with qualified personnel. In

2003, the Coast Guard established a prospective surfman program to attract and train

Surf Station State

East Coast 

Merrimack River Massachusetts

Chatham Massachusetts

Barnegat Light New Jersey

Oregon Inlet North Carolina

Hatteras Inlet North Carolina

West Coast

Grays Harbor Washington

Cape Disappointment Washington

Quillayute River Washington

Tillamook Bay Oregon

Yaquina Bay Oregon

Depoe Bay Oregon

Umpqua River Oregon

Siuslaw River Oregon

Coos Bay Oregon

Chetco River Oregon

Humboldt Bay California

Noyo River California

Bodega Bay California

Golden Gate California

Morro Bay California

39 For further information, see National Motor Lifeboat School website <www.uscg.mil/hq/g-o/nmlbs/

Surfman/program.htm>.
Factual Information 28 Marine Accident Report

surfmen.40 A prospective surfman must be previously certified as a coxswain and must

meet the qualifications for MLB basic coxswain and heavy-weather coxswain41 before

undertaking surfman training. The training can take 2 years or more because most

practical tasks require surf conditions (surf in excess of 6 feet).42 

According to the Coast Guard’s BOAT manual, Station Tillamook Bay was required

to have five qualified surfmen. The Coast Guard Marine Safety Office in Portland informed

Safety Board investigators that at the time of the accident, Station Tillamook Bay had only

three qualified surfmen, due to the Coast Guard-wide personnel shortage noted above. 

Surf stations are also required to have at least two surf-capable boats. Station

Tillamook Bay had two 47-foot MLBs, the Coast Guard’s newest heavy-surf rescue vessels.43

The lifeboats are designed to operate in extreme conditions, including sustained winds of 50

knots, surf up to 20 feet, and 30-foot seas, and if overturned, can right themselves in 8

seconds. The 47-foot MLBs are equipped with two 450-horsepower engines and have an

operating speed of over 25 knots, a range of over 200 nautical miles, and an endurance time of

12 hours. The prototype of the 47-foot MLB was tested at Cape Disappointment.

Coast Guard Authority Regarding Unsafe Conditions

The Coast Guard has the authority under 33 CFR 177 to determine when unsafe

conditions exist on recreational boats or uninspected passenger vessels, or on a body of

water, and to require operators of those vessels to take immediate action to protect the

safety of those on board.44 The unsafe conditions defined in the rules include operating in

a designated “regulated boating area” when wave heights are above 4 feet, when the wave

height exceeds that determined by a formula related to the length and freeboard of the

boat,45 or when the surface current is 4 knots or greater in the regulated boating area. 

40 “Prospective Surfman Program,” Commandant Instruction 16114.35, July 31, 2003.

41 Coxswains who undergo advanced training in operating the 47-foot MLB in heavy weather, defined

by the Coast Guard as “sea, swell, and wind conditions combining to exceed 8 feet and/or winds exceeding

30 knots” (U.S. Coast Guard Boat Crew Seamanship Manual, Commandant Instruction M16114.5C,

September 13, 2003, appendix A).

42 Practical training is carried out at surf stations after trainees complete coursework at the National

Motor Lifeboat School. To be certified as a surfman, an MLB coxswain must satisfy the Coast Guard’s

personnel qualification standard. The performance criteria include transiting a bar or inlet inbound and

outbound through 8- to 15-foot surf, rescuing a person in the water in 8- to 15-foot surf, maintaining a

stationary position in 8- to 15-foot surf, and other tasks (U.S. Coast Guard BOAT Manual, vol. 2, part 6,

“Surfman Qualification”). The prospective surfman must also pass comprehensive written examinations.

43 Details about the 47-foot MLB are from the websites of the Thirteenth Coast Guard District

<www.uscg.mil/d13/ipa /factsheets/47.pdf> and the Seventh Coast Guard District <www.uscg.mil/d7/units/

grustpete/ stasandkey/page20. html>.

44 According to 33 CFR 177.05, the Coast Guard may direct operators to “correct the hazardous

condition immediately; proceed to a mooring, dock, or anchorage; or suspend further use of the boat until

the especially hazardous condition is corrected.”

45 The formula is given at 33 CFR 177.07(f)(2), as follows: L/10 + F = W, where L = overall length of a

boat measured in feet in a straight horizontal line along and parallel with the centerline between the

intersection of this line with the vertical planes of the stem and stern profiles excluding deckhouses and

equipment; F = the minimum freeboard when measured in feet from the lowest point along the upper strake

edge to the surface of the water; W = maximum wave height in feet to the nearest highest whole number.
Factual Information 29 Marine Accident Report

The Tillamook Bay bar is 1 of 16 river bar entrances in Oregon and Washington

defined as a regulated boating area (33 CFR 177.08[f]). All 10 Coast Guard surf stations

(see above) in those states are also regulated boating areas. Regulated areas without a

Coast Guard station near their entrances (Coquille River, Nehalem River, Netarts Bay,

Rogue River, and Siletz Bay in Oregon; Willapa Bay in Washington) are not normally

restricted.46

To protect small-boat operators, the Coast Guard has placed diamond-shaped

rough bar advisory signs at the bar entrances of 10 of the regulated boating areas. Two

rough bar advisory signs are found at the entrance to the Tillamook Bay channel, one at

the Coast Guard station and one on the observation tower (figure 6). The signs are painted

white, with an international orange border, and bear the words ROUGH BAR in black

capital letters. The signs have two flashing yellow lights that are activated when seas

exceed 4 feet in height and are considered hazardous for small boats.47

46 Standard Operating Procedures, Thirteenth Coast Guard District, Seattle, Washington, 2002.

Figure 6. Rough bar advisory sign on Coast Guard 

observation tower at Tillamook Bay.

47 U.S. Coast Pilot, vol. 7, 2003, p. 299. 
Factual Information 30 Marine Accident Report

Vessel movement at the Tillamook Bar is monitored by a Coast Guard seaman stationed in the observation tower on the north jetty. The tower is manned during daylight

from about one-half hour before sunrise and remains manned when the rough bar light is lit.

Coast Guard Regulations on Wearing of Lifejackets 

Current Rules. Federal regulations for the wearing of lifejackets on small

passenger vessels are found at 46 CFR 122.508 (subchapter K) and 185.508 (subchapter

T). These rules (part of the 1996 amendments to the Small Passenger Vessel Regulations)

make the vessel master responsible for determining when “possible hazardous conditions

exist” such that passengers should wear lifejackets:

(a) The master of a vessel shall require passengers to don life jackets

when possible hazardous conditions exist, including, but not limited to:

(1) When transiting hazardous bars and inlets;

(2) During severe weather;

(3) In event of flooding, fire, or other events that may possibly

call for evacuation; and

(4) When the vessel is being towed, except a non-self-propelled vessel under normal operation conditions.

(b) The master or crew shall assist each passenger in obtaining a life

jacket and donning it, as necessary.

Rulemaking History. The notice of proposed rulemaking (NPRM) for this

regulation was first published on January 30, 1989 (Federal Register, vol. 54, no. 18, p.

4412). The notice advised Congress and others that the Coast Guard was completely revising

the regulations governing the inspection and certification of small passenger vessels, parts

175 through 187 of 46 CFR. The original regulations had been developed in response to the

Small Passenger Vessel Act of 1956, passed by Congress as Public Law 84-519. 

In its 1989 NPRM, the Coast Guard cited a number of reasons for amending the

regulations, including statutory changes, increases in vessel size and capacity, and changes

in the scope of operation of small passenger vessels. The Coast Guard noted that “Public

Law 84-519 intended that the regulations promulgated thereunder provide a standard of

safety for weekend fishermen, sightseers, and possibly small ferries,” but that “the

environment in which small passenger vessels operate has changed dramatically.” For

example, many no longer operate out of one port, and some engage in international voyages. 

A further reason given for revising the small passenger vessel regulations was

vessel casualties. The NPRM cites 11 marine casualties reported to the Coast Guard

between 1973 and 1987, seven of which involved capsizings or sinkings:

• Comet, 1973: party fishing boat, foundered and sank off Rhode Island in 48o F

water; 12 drowned, 4 missing.

• Pearl C., 1976: charter fishing vessel, capsized while being towed across the

Columbia River bar off Astoria, Oregon; 1 drowned, 7 missing.
Factual Information 31 Marine Accident Report

• Dixie Lee II, 1977: charter fishing vessel, capsized during sudden, severe

thunderstorm; 12 died, 1 missing.

• Joan La Rie III, 1982: charter fishing vessel, swamped by large wave and sank

off New Jersey in 53o F water; 6 drowned, 2 missing.

• San Mateo, 1983: charter fishing vessel, capsized while crossing bar at Morro

Bay, California, all 32 persons on board thrown into water, all rescued; 3

serious injuries, operator later died of his injuries.

• Merry Jane, 1986: charter fishing vessel, broached and heeled sharply to

starboard approaching Bodega Bay, California, 19 of 51 aboard fell or were

thrown overboard; 9 drowned.

• Fish-n-Fool, 1987: charter fishing vessel, capsized off Baja California Norte,

Mexico, in 59o F water; 2 died, 8 missing.

The NPRM states that investigations of such casualties by the Safety Board and

the Coast Guard had led to recommendations that would help prevent casualties or

alleviate damages and injuries from future casualties, and that the Coast Guard considered

those recommendations in proposing changes to subchapter T.

A supplemental notice of proposed rulemaking (SNPRM) was published on

January 13, 1994 (Federal Register, vol. 59, no. 9, p. 2210). The rule in the SNPRM

contained the following two paragraphs:

(b) When evaluating the need to require the donning of lifejackets, the master shall

consider the size of the vessel and the location of the passengers on the vessel.

(c) Any passenger or crew member shall be permitted to voluntarily don a

lifejacket whenever he or she desires.

After receiving comments on the NPRM and the SNPRM, the Coast Guard

published the interim final rule for the subchapter T regulations on January 10, 1996

(Federal Register, vol. 61, no. 7, p. 1005). The interim final rule omits paragraphs (b) and (c)

from section 185.508. The Coast Guard described its rationale for the change as follows:48

The intent of this section was to raise the sensitivity of the master with regard to

donning of lifejackets, and raise the priority of donning lifejackets in certain

hazardous and deteriorating operating conditions. The comments received on this

section were focused on paragraph (c), which permitted passengers and crew to

don lifejackets whenever desired. The Coast Guard agrees with comments

received that required lifejackets are part of the vessel’s emergency gear, and

should not be compromised by allowing passengers to don them in other than

master directed circumstances. 

The final rule for 46 CFR subchapters K and T was published on

September 30, 1997.49 The final rule establishing the current regulations became effective

on October 30, 1997.

48 Federal Register, vol. 61, no. 7, p. 881.

49 Federal Register, vol. 62, no. 189, p. 51326.
Factual Information 32 Marine Accident Report

Previous Board Action—1983. The Safety Board made the following

recommendation to the Coast Guard in 1983 regarding the wearing of lifejackets by

passengers in hazardous conditions:

M-83-80

Amend 46 CFR part 185 to require that children carried on board small

passenger vessels wear life preservers while the vessel is departing

protected waters and until such time as the operator determines that it is

safe to remove them.

Safety Recommendation M-83-80 resulted from the Safety Board’s investigation of

the 1983 accident in which the small passenger vessel San Mateo capsized at the entrance

to Morro Bay, California, with 23 children and 7 adult chaperones on board.50 No one was

wearing a lifejacket, but all those aboard were rescued, with only three serious injuries

among the passengers. The operator of the vessel, however, later died of his injuries.

On February 23, 1984, the Coast Guard advised the Safety Board that it concurred

with the intent of the recommendation “to the extent that passengers should wear life

preservers when hazardous conditions exist or are expected to be encountered.” The Coast

Guard said that the operator of the San Mateo “should have required all passengers to put

on life preservers” in accordance with the regulations but that “the decision that

passengers aboard small passenger vessels wear life preservers should remain the

responsibility of the operator.” The Coast Guard further stated that in the San Mateo

accident, “the hazard was not the result of leaving protective waters, but crossing a

hazardous bar and standing into rough seas.” 

The Safety Board replied on July 5, 1984, that it regretted that the Coast Guard did

not concur with the recommendation and that “unless Federal regulations are revised to

‘require’ rather than to ‘recommend’ the wearing of life preservers during or in

anticipation of emergency situations, passengers of small passenger vessels will not be

afforded the full protection intended by the Federal regulations requiring that the

equipment be on board.” The Board placed Safety Recommendation M-83-80 in “Open—

Unacceptable Action” status and asked the Coast Guard to reconsider its opinion. 

On November 24, 1995, the Board classified the recommendation “Open—

Unacceptable Response” because of the Coast Guard’s lack of timely action. On

June 26, 1996, the Coast Guard requested that the Board reclassify the recommendation

because it had published final rules that provided requirements for passengers to don

lifejackets in possible emergency conditions. On March 12, 1997, citing the new

provisions of 46 CFR parts 122.508 and 185.508, the Safety Board classified Safety

Recommendation M-83-80 as “Closed—Acceptable Action.”

50 Capsizing of the Charter Passenger Vessel San Mateo, Morro Bay, California, February 16, 1983,

Marine Accident Report MAR-83/09 (Washington DC: National Transportation Safety Board, 1983).
Factual Information 33 Marine Accident Report

Previous Board Action—1986. The Safety Board made the following

recommendation to the Coast Guard in 1986 regarding the wearing of lifejackets by

passengers in hazardous conditions:

M-86-113

Require that life preservers be worn by passengers of small ocean and

coastwise passenger vessels up to 65 feet in length, while on open decks

during the time that these vessels are leaving or entering ports which are

susceptible to breaking waves similar to Bodega Bay, California.

Safety Recommendation M-86-113 resulted from the investigation of the 1986

accident in which the Merry Jane, a 65-foot-long charter passenger vessel, was overtaken

by large waves while returning to Bodega Bay, California, after a sportfishing trip.51 As

the first large wave passed under the Merry Jane’s port quarter, the vessel suddenly raised

and its bow swung to the left, forcing the vessel to become broadside to the waves. The

vessel heeled to starboard and nearly capsized. The sudden large heel caused two

passengers on the bow, one passenger on the flying bridge, and one crewmember near the

stern to be thrown overboard. A few seconds later, the same large wave broke over the

vessel’s port side, flooded the afterdeck, and washed 14 of the 48 passengers overboard.

After the vessel righted, it was struck again by another large wave, which again

heeled the vessel severely and also broke over the vessel. The operator succeeded in

turning the vessel to the left to head into the seas. Once headed into the seas, the Merry

Jane encountered one more large wave and one more passenger was thrown overboard. Of

the 19 persons thrown into the water, 10 persons were rescued and 9 persons died. The

Merry Jane sustained only minor damage.

On December 31, 1986, the Coast Guard responded that it concurred in part with

Safety Recommendation M-86-113. The Coast Guard stated that although “the operator of

a passenger vessel is responsible for the operational decisions affecting the safety of the

vessel and its passengers,” it would “aid and encourage operators to be more cautious.”

The Coast Guard further stated that it intended the local Officers in Charge, Marine

Inspection, to “designate hazardous inlets on which operators of small passenger vessels

will require to have passengers on open decks don life jackets prior to transiting.” 

On April 24, 1987, the Safety Board classified Safety Recommendation M-86-113

“Open—Acceptable Response,” pending further Coast Guard action. On November 24, 1995,

the Board reclassified the recommendation “Open—Unacceptable Response” because of

the Coast Guard’s lack of timely action. On March 12, 1997, after the Coast Guard

published its new regulations at 46 CFR 122.508 and 185.508, the Board classified Safety

Recommendation M-86-113 “Closed—Acceptable Action.” 

51 Near Capsizing of the Charter Passenger Vessel Merry Jane, Bodega Bay, California, February 8, 1986,

Marine Accident Report NTSB/MAR-86/11 (Washington, DC: National Transportation Safety Board, 1986).
Factual Information 34 Marine Accident Report

Masters’ and Passengers’ View on Wearing Lifejackets. As noted earlier,

several masters of the vessels who sailed on the day of the accident indicated that if

conditions were so dangerous that they would have to ask passengers to wear lifejackets,

they would not, or should not, take their vessels out. The Kerri Lin master stated, “If I

have to put lifejackets on people to go out, we don’t go.” The Norwester master told

investigators, “You are already in an emergency state if you are putting lifejackets on.”

When investigators asked the master whether passengers might be more willing to wear

lifejackets if they were lighter and not so cumbersome, possibly self-inflating, he said that

it would be up to individual passengers. But he also said that whether passengers are

willing to put on a lifejacket “is generally based on the comfortability of the lifejacket.”

(See appendix D for information about Coast Guard-approved lifejackets.)

The Oakland Pilot master said that requiring passengers to wear lifejackets would

frighten them. The D & D operator also told investigators that it frightens many people

when the master tells them to put on a lifejacket. But he said that if the Coast Guard had a

rule that people had to wear lifejackets when crossing the bar, then they would not

question it. “But for us to tell them they have to do it, it just scares the hell out of them.”

Actions After Taki-Tooo Accident 

Lifejacket Safety Alert. On June 17, 2003, the Coast Guard issued a safety alert

regarding the wearing of lifejackets. The alert reiterated the regulations at 46 CFR 185

requiring the master of a vessel to require passengers to don lifejackets when possible

hazardous conditions exist. The alert noted that wearing a lifejacket in such circumstances

is “similar to wearing seatbelts during aircraft take-offs and landings and periods of

turbulence.” The message went on to say, “The best time to don a life jacket is before it is

needed—before people are in the water.” The safety alert concluded as follows:

The Coast Guard has entrusted small passenger vessel masters to use their

judgment to determine when to require the passengers to wear life jackets. Should

Masters have questions concerning “hazardous conditions” and when life jackets

should be donned, they should contact their local Coast Guard Officer in Charge,

Marine Inspection for additional guidance. If there is doubt as to whether a

hazardous condition exists, passengers and crew should don life jackets.

Bar Closing. On September 11, 2004, the COTP Portland, citing adverse weather

conditions in the vicinity of Tillamook Bay, issued Order 2004-39 closing the bar to all vessel

traffic. The situation report indicates that after returning about 0830 from fishing in the ocean,

the D & D operator radioed Station Tillamook Bay of his intent to cross the bar. Station

personnel advised the D & D operator that the existing conditions included 18- to 20-foot

breakers on the north and south sides of the bar and 8- to 10-foot breakers inside the jetties and

recommended that he wait for conditions to change. Station Tillamook Bay then notified

Group Astoria of the existing conditions, and Astoria relayed the report to the COTP Portland.

At 1215, the order was issued to hold all commercial vessel traffic from crossing the entrance

to Tillamook Bay because of hazardous weather conditions. At 1353, after being advised that

the bar conditions had abated, the COTP Portland rescinded the order. Two MLBs

subsequently escorted the D & D across the bar at 1837, when tide conditions improved.
Factual Information 35 Marine Accident Report

Coast Guard Report on Small Passenger Vessel Safety. Fourteen months after

the Taki-Tooo capsized, Congress passed the Coast Guard and Maritime Transportation

Act of 2004, which included a provision requiring the Coast Guard to 

report to Congress regarding measures that should be taken to increase the

likelihood of survival of passengers on small passenger vessels who may be in the

water resulting from the capsizing of, sinking of, or other marine casualty

involving the small passenger vessel. The study shall include a review of the

adequacy of existing measures (1) to keep the passengers out of the water,

including inflatable life rafts and other out-of-the-water survival crafts; (2) to

protect individuals from hypothermia and cold shock in water having a

temperature of less than 68 degrees Fahrenheit; (3) for safe egress of passengers

wearing personal flotation devices; and (4) for the enforcement efforts and degree

of compliance regarding the 1996 amendments to the Small Passenger Vessel

Regulations (part 185 of title 46, Code of Federal Regulations) requiring the

master of a small passenger vessel to require passengers to wear personal flotation

devices when possible hazardous conditions exist . . . 52

Congress specifically directed the Coast Guard to describe enforcement of the

regulation requiring masters to have passengers don lifejackets in possibly hazardous

conditions, and to include in its report “the number of vessels and masters cited for

violations of those regulations for fiscal years 1998 through 2003.” Congress also required

the Coast Guard to provide recommendations for “improving compliance with, and

possible modifications to, those regulations.”

On March 31, 2005, the U.S. Department of Homeland Security delivered the

Coast Guard’s “Report on Small Passenger Vessel Safety” to the Senate Committee on

Commerce, Science and Transportation.53 In discussing the lifejacket regulation, the report

states, “At present, there have been no citations issued to vessels or masters for violations

of this regulation since it became effective, and the degree of compliance is unknown.”

The report describes enforcement or compliance monitoring as “problematical at best”:

Enforcement action would require either direct observation by the Coast Guard,

testimony or reporting by a passenger (who are [sic] unlikely to complain about

not wearing lifejackets) or crew member, or come about as a result of a casualty.

Further complicating enforcement, the regulation contains little metric guidance

to determine when a bar or inlet is sufficiently “hazardous,” or weather

sufficiently “severe,” to trigger the requirement for a given vessel and its

capabilities and the experience of its master. In the case of the TAKI TOOO, the

master was very familiar with the waters around the Tillamook Bar, and had 17

years of experience operating the vessel—and thus may not have perceived the

same degree of risk as a less experienced operator. As noted in the preamble to the

1996 IFR [interim final rule], the intent of the requirement was to raise the

sensitivity of the master, based on his/her discretion and judgment, with regard to

donning of lifejackets, and to raise the priority of donning lifejackets in certain

hazardous and deteriorating operating conditions. 

52 Section 624, Coast Guard and Maritime Transportation Act of 2004 (Public Law 108-293). The law

was passed on August 9, 2004, to authorize appropriations for the Coast Guard for fiscal year 2005. 

53 The Coast Guard transferred from the U.S. Department of Transportation to the Department of

Homeland Security in February 2003.
Factual Information 36 Marine Accident Report

In addition to the practical difficulties in enforcing the regulation, there have not

at present been any specific corresponding civil penalty provisions established in

connection with it (although in cases where a master shows poor discretion or

judgment that rises to the level of negligence, action could be taken against the

master’s license).

. . . The case of the TAKI TOOO remains under investigation; however since the

master is deceased and the vessel a total loss, it is unlikely that it will result in any

citations.

The last section of the report discusses, as required by Congress, improving

compliance with the regulations. In late 2004, the Coast Guard and the small passenger

industry began chartering a Natural Working Group (NWG) to develop “guidance as to

what conditions may warrant the mandatory donning of lifejackets on both inspected and

uninspected small passenger vessels.” The report states that “partnership with the industry

is believed to be preferable to a regulatory solution,” and quotes a statement by the

National Marine Charter Association (NMCA) opposing the mandatory use of lifejackets

on small passenger vessels:

Passengers on charter vessels have the distinct safety advantage of professional

guidance from trained, licensed, and experienced operators and crew. Operators of

passenger vessels are licensed by the U.S. Coast Guard and have the training and

experience to know when circumstances warrant passengers donning PFDs

[personal flotation devices, that is, lifejackets]. The safety briefings Captains give

to passengers before being underway show where PFDs are kept and how they

should be worn. A government intrusion on and regulation of this important

business-customer relationship is unwarranted and unneeded, and has not been

proven beneficial by any studies or empirical evidence.

The report concludes as follows:

The Coast Guard is hopeful that the work of the NWG will result in useful

guidance for masters of small passenger vessels to supplement their discretion and

judgment with regard to donning of lifejackets in hazardous and deteriorating

operating conditions, with a view to further improvement of the already excellent

safety record of the industry.

Condition of Tillamook Bar

Nearly all the charter fishing boat owners and operators at Tillamook Bay

interviewed by Safety Board investigators said that the condition of the Tillamook bar had

deteriorated in recent years.54 The masters described passage over the bar as more

dangerous than before because of increased shoaling, which has made the area “too

shallow” for safe passage. Several said that the destruction of the ends of the jetties has

exposed rocks at the end of the south jetty and that the erosion of the beach next to the

north jetty has caused a buildup of sand at the end of the north jetty, making both jetties

dangerous. One vessel master told investigators that charter boat operators had lost 20 to

54 Among those interviewed by Safety Board investigators were the masters of the four other boats that

left Garibaldi marina the morning the Taki-Tooo capsized and both owners of Garibaldi Charters. 
Factual Information 37 Marine Accident Report

30 days a year because of the deteriorated conditions. One of the Garibaldi Charters

owners said that the company’s boats could not go out 5 or 6 days a year because of the

weather and because “the bar is in bad condition.” 

The chief of operations for the Portland (Oregon) District of the Army Corps of

Engineers told Safety Board investigators that the Tillamook Bay jetties were constructed

to offset the accumulation of sand at the bar. She said that, despite local people’s

perception that the bar was getting worse, the Corps’s survey charts showed that

conditions had not changed much over the years. “The only change that I’ve seen from

looking back through the data over the past number of years is that the wave frequency,

wave heights and storm frequency had gotten worse,” she said. She explained that

maintenance dredging of the channel requires separate funding from maintenance of the

jetties and that the Corps has not requested funding for dredging because the jetties are

functioning as intended (that is, scouring the channel). The Corps’s public relations

manager said that he had received no “negative comments” about the state of the channel. 

The chief of operations told Safety Board investigators that the Corps had received

congressional funding to study the state of the Tillamook Bay jetties and to estimate the

cost of work to prevent the north jetty from breaching during a storm. In December 2003,

the Corps published a major maintenance report, an extensive study addressing the

deterioration of the north and south jetties and exploring repair alternatives and associated

costs.55 The study contains a design report and an environmental assessment and includes

data from field measurements of the jetties taken the week after the Taki-Tooo

accident.56

Deterioration of Jetties and Shoreline. According to the Corps’s study, both

jetties at the entrance to Tillamook Bay have been damaged by exposure to “more extreme

storm waves” in recent years: 

• The north jetty is now 384 feet shorter than its authorized length of 5,700 feet. The

jetty was completed in 1917 and has been extended or repaired six times since

then, the last time in 1991. The study predicts that, on the basis of past recession

rates (decreases in length), the north jetty will be 475 feet shorter by 2006.

• The south jetty is now 666 feet shorter than its authorized length of 8,025 feet.

The jetty was constructed in three stages between 1969 and 1971 and has never

been repaired. The south jetty is predicted to be 890 feet shorter by 2006.

• The shoreline along the north jetty has eroded. If wave action breaches the

jetty, it could destroy the Coast Guard watchtower as well as disrupt the

navigation channel.

Changes in Bar. The Tillamook bar (called the ebb tidal shoal in the report) has

changed as a result of jetty construction and the deterioration of the jetty tips. Before the

55 U.S. Army Corps of Engineers, Tillamook North and South Jetties, Garibaldi, Oregon, Major

Maintenance Report (Portland, Oregon: December 2003). The study was funded in 2002.

56 Week of June 23, 2003.
Factual Information 38 Marine Accident Report

south jetty was built, the shoal was evenly distributed both north and south. According to

the report, a 1984 survey found that the shoal had begun to hook away from the south side

of the entrance. By 2002, the hook had extended into the navigation channel. In addition,

increased shoaling along the south side of the channel had concentrated the ebb current on

the north side of the channel and deepened the north side. 

Navigation Concerns. The Corps’s study states that deterioration of the jetties

“has caused concern for navigability of the channel”:

Conditions through the south approach channel and inner channel between the jetty heads

are the major concerns to navigability. Wave conditions over the ebb tidal shoal, especially

during the ebb tide, have become very treacherous over the past 6 years, possibly caused

by receding jetty lengths, mainly the south jetty. The wave conditions over the ebb tidal

shoal are very dangerous. There is a channel located just west of the end of the south jetty

that boaters use to navigate the entrance. This situation is complicated by the presence of

remnant jetty stone that lies adjacent to this natural channel. This channel also forces

boaters to put their vessels in a precarious position, broadside to the waves. Non-local

boats that must use the entrance as a port of refuge are unaware of the particular dangers

of the ebb tidal shoal and the use of the natural channel used by local boaters. According

to the Coast Guard, non-locals do not navigate the entrance very well. 

The study concludes that not to repair the jetties “will eventually lead to an

increase in shoaling at the channel entrance. As more of the jetties deteriorate, waves will

move further into the navigation channel increasing boating hazards and further destabilizing the inner portion of the jetties.” The study does not discuss navigation

conditions faced by vessels proceeding outbound on a northwesterly heading, as on the

day of the Taki-Tooo capsizing, other than to note that breaking waves over submerged

rocks at the end of the north jetty are “problematic.”

Proposed Work. The study makes recommendations for partially restoring the

jetties and also recommends that “further analysis and project review be conducted to

establish the acceptable final length for both jetties that will provide an acceptable level of

navigation conditions at the Tillamook Navigation Project.” In July 2003, the Corps

received $500,000 to repair the erosion problems at the base of the north jetty. Congress

appropriated additional funding in fiscal year 2004 to build a revetment, or embankment,

on the north jetty. In September and October 2004, the Corps repaired the north jetty by

placing earth and rock at the base and by constructing a 300-foot-long revetment

perpendicular to the jetty along the shore. The revetment is intended to prevent further

erosion of the sandy beach near the base of the jetty and to protect the Coast Guard

watchtower. According to a Corps official, the revetment is a permanent repair and no

work to restore the jetties to their original length is anticipated.

National Marine Charter Association

The NMCA is a nonprofit organization, based in Washington, D.C., that serves the

interests of professional marine charter operators nationwide. The association was formed

in June 2003 as an offshoot of the National Association of Charterboat Operators. The 470

NMCA members offer for-hire services such as charter fishing, sailing charters, dive

charters, eco-tours, water taxis, and yacht charters. Members are kept informed about
Factual Information 39 Marine Accident Report

regulatory and legislative matters and other issues by means of a website, special alerts,

and a monthly Internet newsletter. The association also collects and disseminates

information about marine charter companies and publishes a national directory (available

at charternet.com).

Recently, the NMCA developed a voluntary program for marine charter vessels

called the Accredited Vessel Inspection Program (A-VIP). The program establishes

preferred industry operating practices, equipment standards, and safety measures for both

uninspected and inspected charter boats. A-VIP is described on the NMCA website as “the

marine charter industry’s first accreditation program.” A-VIP certification requires that

vessels carry additional equipment such as navigation-fixing devices, damage-control kits,

and alternative communication systems. Certified companies are required to have crews

trained in emergency procedures and to keep a log of emergency drills. Companies must

certify that their crews perform safety tasks before each trip, such as giving safety

orientations and counting passengers. Companies must provide proof of liability insurance

and crews must be enrolled in drug-testing programs that comply with Federal regulations.

Operators must certify that they participate in the Maritime Domain Awareness program

(Homeland Security). Operators must have a written plan for accommodating disabled

passengers, and must certify that their vessels are in compliance with applicable Coast

Guard requirements. The A-VIP application includes detailed guidelines for emergency

drills, such as rough weather at sea, and other certification requirements.
40 Marine Accident Report

Analysis

General

The analysis first identifies factors that can be eliminated as causal or contributory

to the accident. It then discusses the following safety issues identified in the accident

investigation:

• Decision to cross the bar

• Tillamook Bay operations 

• Survivability 

Exclusions

The Safety Board examined the Taki-Tooo, its engine, and related components, to

determine whether they showed deficiencies that might have been factors in this accident.

Investigators found no significant defect, scratch, marking, or other evidence of the

vessel’s striking an object or of the boat grounding. Witnesses, including the Taki-Tooo

deckhand, described hearing a reduction in engine power, potentially an indication of

propulsion failure. In checking the steering and propulsion mechanisms, however,

investigators found no evidence of preaccident mechanical malfunction. The engine and

transmission were solidly mounted. The engine was intact, with no signs of oil leaks or

signs of catastrophic failure. All fuel lines, fittings, and linkages were intact and attached.

When manipulated at the lower helm station, the throttle and transmission control moved

the throttle linkage throughout its range. Laboratory examination determined that the

condition of the propeller blades, which were curled at the tips, was consistent with a

propeller under power striking a soft ocean floor. The Safety Board, therefore, concludes

that the absence of defects and the evidence of propulsive power indicate that problems

with the engine, propeller, and associated boat components such as the throttle and the

rudder were not causal factors in this accident. 

Decision to Cross the Bar

The charter boat operators whose trips originate at Garibaldi marina make a series

of decisions in transiting the Tillamook Bay bar. They consider whether they should leave

port, based on the broadcast weather conditions. Once at the bay entrance, they consider

whether conditions present a go/no-go situation, that is, whether the sea state at the bar

permits or precludes an attempted transit to the ocean. Finally, they decide, based on the

prevailing seas and current conditions, how to maneuver their vessels so that they safely
Analysis 41 Marine Accident Report

reach the ocean. In the following discussion, the Safety Board examines personal factors

that could have affected the decisions made by the Taki-Tooo master as well as factors

affecting the decisions of all the charter boat operators who took vessels out on the day of

the accident. 

Personal Factors Potentially Affecting the Taki-Tooo Master’s Decisions

In analyzing the Taki-Tooo master’s actions, the Safety Board considered personal

factors that could have influenced his decision-making, including whether his physical

condition was affected by the use of alcohol or drugs (illegal and prescribed) or by a sleep

deficit. The Board also considered whether financial concerns might have been a factor. 

Autopsy findings showed that the cause of the master’s death was drowning by

asphyxiation with hypothermia and that he did not die as a result of previously noted

medical conditions. 

Toxicological samples from the master showed no evidence in his system of

alcohol or of the five classes of illegal drugs tested for under Coast Guard rules. The

toxicological analysis did show amounts of amitriptyline and its metabolite, consistent

with the master’s having used the prescribed sedative within 24 hours of the accident.57

Available records indicate the master had been taking 20 milligrams of amitriptyline

nightly to treat insomnia for at least 4 years, and he probably had been taking the sedative

longer. Toxicological studies with amitriptyline have shown that any adverse effect it

might have on psychomotor performance usually disappears with regular use of the drug.58

While the master may have experienced some subtle effects of the medication, how such

effects would have influenced his actions is unclear. 

The Safety Board considered whether the master was sleep deprived on the day of

the accident, which could have impaired his performance. His wife told Safety Board

investigators that for some time before the accident, the master had maintained a regular

routine in which he had obtained at least 7 1/2 hours of sleep each night, consistently at the

same times. Because the master reportedly received 7 1/2 hours of sleep the night before

the accident and a comparable amount of reported sleep each night for at least several

nights before the accident, and because he maintained a constant sleep/wake schedule, he

would not have sustained either an acute or a chronic sleep deficit or experienced a

disruption to his body clock or circadian rhythms. Thus, he was not considered to have

been sleep deprived at the time of the accident.

According to the owner of Garibaldi Charters, if the charter vessel masters elected

not to leave the marina to go fishing or returned to port after examining the bar conditions,

they would not receive their portion of the passengers’ fees for the fishing trip. The Safety

Board, therefore, considered whether the Taki-Tooo master’s decision to proceed with the

57 R. C. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 5th ed. (Foster City, California:

Chemical Toxicology Institute, 2000).

58 R. C. Baselt, Drug Effects on Psychomotor Performance (Foster City, California: Biomedical

Publications, 2001).
Analysis 42 Marine Accident Report

fishing trip might have been influenced by his concern about the possible loss of income.

The Safety Board examined the master’s financial records and dealings, including his

charter company sale, lease agreements, real estate dealings, and so forth, and found no

evidence that he might have been motivated by financial concerns.

Therefore, the Safety Board concludes that the following were not factors in the

performance of the Taki-Tooo master: sleep deprivation, alcohol, illegal or prescribed

drugs, and financial concerns. 

Decision of the Charter Operators to Leave Port

Since the day before the accident, the National Weather Service had issued small

craft advisories in its forecasts, which were broadcast over marine and weather radio

channels and posted on Internet sites. At 1645 on June 13, the National Weather Service

issued a small craft advisory predicting hazardous seas and 10-foot swells, whereupon the

Coast Guard staff at Station Tillamook Bay immediately broadcast a bar restriction via

VHF-FM channels 16 and 22A and on citizens band channel 9. The Coast Guard

watchstanders also raised a small-craft advisory flag at the station and activated the yellow

lights on the rough bar advisory signs. Safety Board investigators later observed the sign

and lights from the Tillamook channel and noted no obstructions that might have affected

the ability of mariners to observe these lights while transiting the channel and approaching

the bar.

At 0330 on June 14, the National Weather Service updated its forecast, issuing

another small craft advisory that predicted wind waves of 3 feet and northwest swells of

11 feet at 11-second intervals. Station Tillamook Bay then dispatched an MLB at first light

to assess conditions at the bar, and after being advised by the coxswain of the turbulent

seas at the ends of the jetties and the 8- to 10-foot swells outside the jetties, broadcast a

message that the bar restriction remained in effect. 

Thus, the National Weather Service made several broadcasts advising mariners of

weather and ocean sea conditions outside Tillamook Bay bar, and the Coast Guard warned

mariners in various ways (flag, lights, bar restriction announcements) of hazardous

conditions at the bar itself. The Safety Board, therefore, concludes that before the

accident, the National Weather Service and the Coast Guard effectively communicated

information about the weather conditions and the rough bar to mariners, including the

master of the Taki-Tooo. 

The wife of the Taki-Tooo master said that he had used his home computer to

check the weather forecast the night before the accident and had continued to monitor the

marine radio in his home for weather announcements the following morning. She further

stated that he usually continued to monitor the weather reports on a marine radio in his

truck while en route to the marina. 

At the marina, the actions of the master indicate that he was aware of the predicted

sea state. He and the deckhand discussed abandoning the plan to set out crab pots because

of the broadcast rough seas.
Analysis 43 Marine Accident Report

The decision of the Taki-Tooo master and the operators of the other four charter

vessels to leave port and proceed to the inlet area can be considered judicious. The

weather and bar conditions as described in broadcasts presented significant hazards to

vessel safety. The National Weather Service reports, however, were marine forecasts for

ocean-coastal zones. In the case of the coastal zone that included Tillamook, coastal

waters extended 20 nautical miles from shore. Thus, the 11-foot swells predicted for

coastal waters could have been greater or less by the time they reached the bar area and

shore. On the morning of the accident, all the charter vessel masters who transited the bar

before the Taki-Tooo later told investigators that once they were across, the swells they

encountered in the ocean were comparatively small. 

While the National Weather Service marine forecasts might not have accurately

reflected conditions at the bar, the Coast Guard restriction for recreational vessels was

based on an on-scene assessment conducted by an MLB crew 1 1/2 to 2 hours before any

of the five charter vessels left the marina. Because various factors affect the bar

conditions, notably the strong ebb tide and incoming seas and swells, the operating

environment at the bar can change quickly, dramatically affecting a vessel operator’s

ability to make a safe transit. On the day of the accident, the ebbing tide was predicted to

end about 0720, thereafter creating a slack water environment, which is the optimal time

to cross the bar. 

Based on their experience operating in the Tillamook Bay area, the masters of the

Taki-Tooo and the other charter vessels were no doubt aware that the sea conditions at the

bar could easily differ from the conditions described in the coastal marine forecasts. The

conditions at the bar are subject to change, as evidenced by the statements of Coast Guard

officials who indicated that, over the last 5 years, Station Tillamook Bay had imposed or

lifted the bar restriction more than once on a given day. The Taki-Tooo master, with more

than 15 years of experience in the area, would have known when the ebb tide was

predicted to end and might have believed that conditions could improve after he arrived at

the inlet. Therefore, the masters, including the master of the Taki-Tooo, were not

imprudent to sail from the marina and proceed to the inlet to assess conditions for

themselves. The Safety Board concludes that the decision of the Taki-Tooo master and the

other charter vessel masters to leave port and proceed to the bar area to make a first-hand

assessment of conditions was appropriate. 

While the decision to leave the dock to assess conditions at the bar might have

been prudent, it also probably subtly influenced the masters’ subsequent decisions to cross

the bar rather than return to the dock. By loading passengers on the vessel and taking them

almost as far as the bar, the masters’ decision-making ability to return to the dock without

crossing the bar was diminished. To return to the dock would have meant that each master

would have had to personally face and explain his decision to the passengers who had

prepared for the expedition and boarded the vessel and whose anticipation for the fishing

voyage no doubt had increased as they neared the bar. 

For the Taki-Tooo master, in particular, the knowledge that the passenger group

chartering his vessel had specifically requested that he serve as their master would most

likely have subtly affected his decision not only to leave port but also to subsequently
Analysis 44 Marine Accident Report

cross the bar. He would have been motivated not to disappoint those passengers who had

traveled some distance to engage in a fishing expedition under his command.

If, however, the charter operating companies had established go/no-go policies and

operating standards for crossing the bar, the masters would have been relieved from

making the decision to cross the bar. For example, the owner of the Kerri Lin, a charter

boat 3 feet shorter than the Taki-Tooo but with a larger engine, cancelled his fishing trip on

the day of the accident because he had a policy of not operating if the sea swell was 10 feet

or greater. If the vessel owner/operators or the masters had such operating parameters,

they either could have delegated the explanation for the decision to cancel the fishing trip

to the company office manager while the vessel was at the dock, or they could have

forewarned passengers when they boarded that, based on the forecast conditions, they

might not be able to cross the bar, thus somewhat lowering the anticipation of the

passengers. The need for charter operating companies to establish go/no-go policies and

operating standards is discussed later in this analysis.

When the Taki-Tooo and the other charter vessels arrived at Tillamook Bay bar, the

masters maneuvered their boats just inside the jetties and waited for conditions at the bar

to permit passage. On this day, however, the sea conditions at Tillamook Bay bar were

particularly hazardous. Waves and swells were 10 to 12 feet, on occasion even higher.

Witnesses on shore said that the large waves were coming too close together for a boat to

avoid going over at least one of them on the way out of the inlet. Moreover, the masters

could not position their boats to make the transit to good seas without putting their vessels

and their passengers at risk in the large waves.

Based on extensive research conducted in decision-making in dynamic

environments,59 the evidence suggests that each master would have made the decision to

cross based on such factors as his own personal experience and abilities and the

capabilities of the vessel he was operating, as well as such situationally specific factors as

the size and frequency of the waves and swells. In addition, each master would have had

his own personal reason for making a decision.

The master of the Norwester, the first vessel to cross, waited 30 to 45 minutes

before making the transit attempt. Coast Guardsmen on watch at the station and on the

MLB said that the charter boat rode over the first large swell; however, the large swell that

immediately followed stood the 41.8-foot-long Norwester “straight up,” almost on its

stern. Fortunately, no one on the Norwester was injured while the vessel crossed the bar.

Even though the transit appeared to be successful, in the Safety Board’s opinion, the

Norwester master should have recognized how quickly the large swells were coming and

should not have crossed the bar when he did.

After clearing the bar, the Norwester master radioed the other mariners, advising

them that “It wasn’t worth it to go out” and that they should wait until conditions at the bar

59 G. Klein, “Applied Decision Making,” in P.A. Hancock (ed.), Human Performance and Ergonomics

(San Diego, California: Academic Press, 1999).
Analysis 45 Marine Accident Report

“settled down a little bit. . . .” He also advised the other boat operators that he had avoided

a log, thus presenting information about additional hazards in the waterway. 

Despite the broadcast admonition from the Norwester master, the seemingly

successful transit of his vessel would have had the effect of making it more difficult for the

other masters at the inlet to turn back and return to the marina. Moreover, each successful

transit thereafter would have made it increasingly more difficult for those vessel masters

still waiting at the bar to cancel their voyages.

After the Norwester’s departure, the master of the Oakland Pilot waited only 5

minutes before attempting to cross the bar. In preparation for making the transit, the

Oakland Pilot master directed his passengers to sit down. Passengers later stated that the

44-foot-long Oakland Pilot rode over a “huge swell” and dropped 10 to 12 feet off the

back of the wave. The crossing attempt reportedly resulted in the deckhand and two

passengers sustaining minor injuries. Thus, the Oakland Pilot master’s attempt to mitigate

the risk to those on board of crossing the bar under the prevailing conditions was

unsuccessful. 

After clearing the bar, the Oakland Pilot master radioed the other vessel operators

that logs were floating in the area. The D & D started over the bar next, shortly after 0700.

According to a D & D passenger, the vessel went over two or three “good” waves, and the

master turned north to maneuver around a log at the end of the jetty. The Safety Board is

aware that fallen trees and logs frequently float in or along the waterways of the Pacific

Northwest and present a common hazard to navigation. Still, the decision of the D&D

master to attempt to transit a bar area made hazardous by both large waves and floating

logs was ill advised. 

The Taki-Tooo master continued to monitor the bar conditions, noting the

movements of other vessels and the success of their masters’ attempts to cross and

listening to the radio transmissions from the vessel masters. Given the small community of

charter fishing companies operating in the Tillamook Bay area and the level of interaction

among the owners and masters, the Taki-Tooo master most likely would have been fully

aware of the capabilities of each vessel waiting to cross the bar and the experience level of

each master. Certainly, he was familiar with the D & D, a single-engine, 32-foot vessel

like the Taki-Tooo but with a slightly less powerful engine. He owned and had operated the

D&D and therefore would have been fully aware of the D&D’s capabilities relative to

those of his own vessel. Possibly, the decision of the Taki-Tooo master to attempt to cross

the bar a few minutes later was influenced by the successful transit of the D & D. 

The master’s decision could also have been influenced by his extensive operating

experience in the Tillamook Bay area. Coast Guard documents support the statements of

other area vessel operators that the Taki-Tooo master had crossed the bar more than a

thousand times. In the 5 years before the accident, the Coast Guard had restricted the bar

over a thousand times. No doubt the Taki-Tooo master had previously crossed the bar in

conditions at least as rough as those encountered at the time of the accident. As a result,

his confidence in his ability to cross successfully, accrued over many years, may have led

him to minimize the hazards he faced. 
Analysis 46 Marine Accident Report

Thus, the decision of the Taki-Tooo master to cross the bar was probably

influenced by a host of factors, including the request of the passengers for his services, his

observations of sea conditions comparable to those he had seen before, his previous

experience making the bar transit with this vessel, and his observation of the crossings of

the other vessels before him. Notwithstanding the information that argued against making

the crossing, notably the weather forecasts, the bar restriction, and his own knowledge of

the potential hazards of making the effort, the master made the decision to cross the bar.

The tragic consequences of his attempt to transit the bar demonstrate the faultiness of his

decision-making.

The Safety Board concludes that the decision of the charter boat operators,

including the master of the Taki-Tooo, to transit Tillamook Bay bar in the hazardous sea

conditions that prevailed on the morning of the accident jeopardized the safety of all on

board. 

Safely crossing a bar depends on factors within a master’s control, such as his or

her skill and experience and the vessel’s size and power, as well as factors outside his or

her control, specifically, the severity of the sea state. The Coast Guard has designated

Station Tillamook Bay a surf station, meaning the surf exceeds 8 feet 10 percent or more

of the time during a calendar year, averaged over 5 years. Ocean swells, usually very

large, converge with waves generated by the prevailing winds in the immediate area.

Navigation at the site is further complicated by the complex characteristics of the tidal

currents. No master can be assured that the conditions encountered when crossing will be

the same conditions as those observed when the decision to cross is made. 

Witnesses reported that on the day of the accident, the Taki-Tooo traveled closer

than normal to the north jetty, recognized in published documents as an “extremely

dangerous” area. The deckhand said that she believed the master put the engines in reverse

or astern power while they passed over the first large wave so that the vessel “didn’t go

flying off the other end” of the wave. After the vessel rode over the first swell, a 9- or 10-

foot wave, the charter boat descended into a trough between building waves. The TakiTooo deckhand then heard the master say, “I didn’t want to get into this.” She said that she

was not sure whether the master had turned the charter boat or whether the boat was still

turning from sliding down the back of the wave, but somehow the Taki-Tooo twisted to the

north and a “steep,” 15-foot swell came from the west and capsized the charter boat.

Because the master died in the accident, the Safety Board was unable to discern

what the master meant by his remarks or why the vessel turned parallel to the waves.

Therefore, the Safety Board concludes that it cannot be determined whether the TakiTooo’s turn to a northerly heading, which placed the vessel broadside to the seas, was due

to a deliberate action by the master or to a loss of control by the master. 
Analysis 47 Marine Accident Report

Tillamook Bay Operations

Navigational Conditions at the Bar

Safety Board investigators interviewed charter fishing boat owners and operators

at Tillamook Bay and nearly all said that the condition of the Tillamook bar had

deteriorated in recent years. They claimed that increased shoaling of the “middle grounds”

had occurred, which had resulted in greater swell heights across the bar and jetties. An

Army Corps of Engineers study confirms that the conditions of the bar have deteriorated

over time. The Safety Board sought to determine whether the deterioration was a factor in

the accident. 

Although the Tillamook Bay channel does not require dredging, the Corps of

Engineers surveys the channel annually. Analysis of the Corps surveys shows that channel

conditions had not changed much over the years. Moreover, the Corps surveyed the

channel a week after the accident to assist in the investigation of the Taki-Tooo accident

and determined that the channel was within its authorized depth. 

According to the 2003 Corps of Engineers study, both jetties at the entrance to

Tillamook Bay have been damaged by exposure to “more extreme storm waves” in recent

years and are now several hundred feet shorter than their authorized length. The shoreline

along the north jetty has eroded. The Corps received funding from Congress to partially

restore the jetty area, and in September and October 2004, the Corps repaired the north

jetty by placing earth and rock at the base and by constructing a 300-foot-long

embankment perpendicular to the jetty along the shore. The embankment is intended to

prevent further erosion of the sandy beach near the base of the jetty and to protect the

Coast Guard watchtower from large waves. According to a Corps official, the

embankment is a permanent repair and no work to restore the jetties to their original

length is anticipated.

The Corps acknowledges in its report that the deterioration “has caused concern

for the navigability of the channel.” The Safety Board finds, however, that the condition of

the channel and the jetties by themselves were not factors in the accident. As noted above,

a postaccident survey showed that the channel was dredged to its allocated depth; thus it

posed no impediment to movement of the charter fishing vessels. The jetty tips, although

shorter today than when they were constructed, did not represent a danger. The greater

issue on the day of the accident is that the vessel operators, all highly experienced masters

with extensive knowledge of the area, disregarded the hazardous bar crossing conditions.

The Safety Board, therefore, concludes that the condition of the channel and the jetties at

the Tillamook Bay bar was not a factor in the accident. 

Bar Restrictions

To accomplish its missions, the Coast Guard has a hierarchical system of stations

and offices, each with its own level of authority and responsibility. To maintain safety in

navigable waters where hazardous conditions are present, it has established surf stations at

bars or inlets where surf greater than 8 feet occurs 10 percent of the time within a year,
Analysis 48 Marine Accident Report

averaged over 5 years. In the Pacific Northwest, all 10 surf stations, including Station

Tillamook Bay, oversee designated regulated boating areas, coastal areas where the bar

conditions are particularly treacherous. As the first level of Coast Guard oversight at the

bay, Station Tillamook Bay is authorized to restrict the operators of recreational boats and

uninspected small passenger vessels from crossing the bar. The station does not have the

authority to restrict commercial traffic, such as charter fishing boats. If conditions at the

bar are considered so hazardous that they endanger the passage of commercial vessels, the

person in charge at the station, sometimes a senior enlisted person, must go through his

command channels to the zone commander, the COTP Portland, who has the authority to

order the bar closed to all vessel traffic. 

On the day of this accident, Station Tillamook Bay restricted the bar to recreational

and uninspected small passenger vessels, but did not consider the conditions sufficiently

hazardous to recommend to its higher headquarters that the bar be closed to commercial

operators. As noted earlier, Station Tillamook Bay had restricted the bar to recreational

and uninspected small passenger vessels 1,422 times in the 5 years preceding the accident.

In that same period, however, COTP Portland had never closed the bar to commercial

vessels. Since the Taki-Tooo accident, the COTP Portland has closed Tillamook Bay bar to

commercial traffic once. 

The Safety Board concludes that a potentially unintended consequence of the

Coast Guard’s restricting Tillamook Bay bar only to recreational and uninspected vessels

was to afford the passengers on those vessels a higher level of safety than the passengers

on charter vessels. 

The Safety Board recognizes and agrees that the Coast Guard needs to have a

system of checks and balances when restricting commercial traffic and that the person at

the first level of Coast Guard oversight should not be authorized to shut down a waterway.

However, an improved means of safety oversight is needed to minimize the risk to people

on board such commercial small passenger vessels as charter boats when they are operated

in hazardous sea conditions.

Coast Guard regulations presently do not require owners/operators of small

passenger vessels to identify the conditions under which their charter boats should or

should not attempt bar crossings and to provide their masters with guidance containing

such operating criteria. The impact of this omission was reflected in the actions of the

charter vessel operators on the morning of the accident. The charter boat operators who

were experienced in crossing Tillamook Bay bar reached different decisions about

whether and when to attempt to transit the bar. Most attempted to cross; however, one

highly experienced master interviewed said that he elected not to go because the sea

conditions exceeded a personal safety standard that he had established for his operations.

Given the differences among mariners in skill level, knowledge of the bar, and personal

willingness to take risks, the absence of guidance to assist masters in making decisions

that put passengers at great risk is unacceptable. The Safety Board, therefore, concludes

that the absence of a go/no-go policy by the charter boat owners operating out of

Tillamook Bay allowed the masters to exercise poor judgment in deciding to cross the bar,

given the hazardous sea conditions. 
Analysis 49 Marine Accident Report

By comparison, Federal Aviation Regulations require operators of commercial air

transport, operating under 14 CFR part 121, to develop operating specifications that

strictly delineate the conditions under which their aircraft will be allowed to operate.

These go/no-go specifications, which are subject to Federal Aviation Administration

acceptance, apply to all aircraft in scheduled operations that have the capability to

transport 10 or more passengers.60 Unless the aircraft has certain navigation and flight

control equipment and the pilot has certain qualifications, passenger- and cargo-carrying

commercial air transport aircraft are forbidden from taking off or landing in clearly

defined conditions of restricted visibility or adverse wind.

In the Safety Board’s opinion, small passenger vessel owners know best the skills

of the masters they employ, the size, power, and configuration of the vessels they operate,

and the conditions under which masters can safely maneuver their vessels across a

hazardous bar. Owners are also familiar with other factors unique to each vessel, such as

hull shape, displacement, and propulsion system configuration, that can influence the

boat’s ability to safely traverse the bar. In developing vessel-specific operating standards

for their masters, the boat owners could be assisted by Coast Guard personnel, who have

the knowledge of local conditions, in evaluating whether the go/no-go policies developed

and implemented by the small passenger vessel owners are appropriate to attain a

sufficient level of safety during rough bar conditions. 

Therefore, the Safety Board believes that the Coast Guard should require that

owners of small passenger vessels operating within Coast Guard-designated surf stations

and regulated boating areas on the West Coast develop and implement written go/no-go

policies, based on risk-management principles, regarding transiting bars and inlets.

Recognizing that the rulemaking effort is a time-consuming process, it would be prudent

for small passenger operators to voluntarily develop this safety guidance. Therefore, the

Safety Board believes that the National Marine Charter Association should recommend

that its member small passenger vessel owners operating within Coast Guard-designated

surf stations and regulated boating areas on the West Coast develop and implement written

go/no-go policies, based on risk-management principles, regarding transiting bars and

inlets. Further, the owners of charter fishing vessels operating out of Tillamook Bay

should develop and implement written go/no-go policies, based on risk-management

principles, regarding transiting the Tillamook Bay bar. 

Survivability

No one on board the Taki-Tooo donned a lifejacket in preparation for transiting the

hazardous bar, as stipulated in Coast Guard regulations at 46 CFR 185.508. The results of

this failure to mitigate the risk associated with the crossing attempt are telling. Of the 19

people on board, 12 were not able to retrieve a lifejacket before the charter boat was

60 Title 14 CFR part 121, rules governing air transport operations, and 14 CFR part 91, general

operating rules.
Analysis 50 Marine Accident Report

swamped by a large wave. Of these, only two survived. In contrast, six of the seven people

who were able to retrieve lifejackets survived. 

Analysis shows that the events of the accident sequence occurred so quickly that

those on the deck of the Taki-Tooo had little or no time to take measures to protect

themselves. As the vessel departed the inlet and rode over the first swell, the deckhand

shouted for the passengers to hold on. The ensuing swells were larger, and within minutes,

the Taki-Tooo was in trouble. The passengers on the open deck would have had to try to

walk across the deck while the vessel was pitching and rolling to obtain lifejackets from

the cabin, where the jackets were stored. They, therefore, could not have easily retrieved a

lifejacket.

During the capsizing, the master and deckhand on the flying bridge and all but one

passenger on the open deck were thrown or washed into the sea. One passenger was

washed into the cabin, where he was able to obtain a lifejacket and subsequently escape

the overturned vessel. 

The cabin structure provided protection in two ways to the passengers within it.

First, the cabin protected the passengers inside from being washed into the sea. More

importantly, after the vessel overturned, the cabin had an air pocket until a window broke

and water entered the space. The air supply provided survivors sufficient time to pull

lifejackets from the storage bin and to prepare to exit the vessel. One survivor donned his

lifejacket and exited via the cabin door. Five survivors elected to exit through the cabin

windows; however, they could not get through the windows while wearing the lifejackets

as intended, so each individual improvised, either holding onto a jacket or placing it

around his arm or neck as he made his way out. One man was unable to hold onto his

lifejacket; however, he was able to swim to shore. The other four men, buoyed by their

lifejackets, floated to shore. One fatality victim was later found in the cabin wearing a

lifejacket. According to survivors, they repeatedly exhorted their relative, who had donned

a lifejacket, to leave the cabin. They said that he just sat down, however, and emitted a

moan. The Safety Board was unable to determine why this passenger, a 66-year-old man,

did not exit the cabin. 

The chaotic scenario of the capsizing and the severity of the sea state would have

made it especially difficult for those cast overboard without lifejackets to survive. The surf

was over 10 feet and contained floating debris such as logs and the overturned boat itself.

No autopsies were performed on anyone except the master, so the extent of injuries of the

fatally injured passengers is indeterminate. However, a healthy person with even a mild

head injury (with little or no visible marks on the body) could have become sufficiently

disoriented in the prevailing conditions to have died without the assistance of lifejackets.

Even without injury, a swimmer would have substantial difficulty remaining afloat in the

heavy surf without flotation assistance. It is also likely that the accident victims suffered

cold water immersion injuries in the seas, which were 52o F. Studies have shown that in

the first 2 to 3 minutes of being immersed in water that is less than 59o F, a person may

lose the ability to control breathing. If, as in the case of this capsizing, the accident victims

are in choppy water, the wave splash contributes to the loss of breath control. Thus, unless

cold water immersion victims are both mentally prepared and physically protected by
Analysis 51 Marine Accident Report

lifejackets or survival suits, they can drown immediately or suffer cardiac effects that, in

turn, can cause death, particularly in older or less healthy victims. Swimming failure may

occur between 3 and 30 minutes after cold water immersion, and death from hypothermia

may occur after 30 minutes. In the case of this accident, the vessel itself washed ashore

within 30 minutes of capsizing, and no vessel occupants were seen alive in the water by

that time. 

Lifejackets improve the survivability of accident victims in water a number of

ways: the design of the flotation device helps keep a victim’s head above water, which is

particularly crucial if the person is injured; the thermal qualities of the jacket provide

some insulation against the cold; and the buoyancy of the safety gear keeps the person

afloat, affording more time to reach safety or be rescued. Considering the multiple hazards

in the Taki-Tooo capsizing, the use of lifejackets by all people on the open deck would

have benefited them in all these ways. Therefore, the Safety Board concludes that if the

master of the Taki-Tooo had required passengers and crew to wear lifejackets, their

chances of survival would have been better and the number of fatalities in this accident

would probably have been less. 

In preparation for the fishing expedition, the master of the Taki-Tooo conducted a

safety briefing for his passengers, as required by Federal regulations, before the charter

boat left the marina. He discussed the donning of lifejackets, pointed out where they were

located, and told his passengers that they could don them if they wished. If they chose to

do so, he said that he or the deckhand would assist them. None elected to do so. During the

transit to the inlet area, the Taki-Tooo passed Station Tillamook Bay, where a small-craft

advisory flag was raised and a rough bar advisory sign was illuminated, and the Coast

Guard observation tower, where another rough bar advisory sign was illuminated. The

master then witnessed the much larger Norwester encounter problems with the sea swells

and received radio reports from other operators about the swells and waterway debris.

Thus, despite receiving several indications that bar conditions were hazardous, the TakiTooo master did not don a lifejacket or direct the deckhand and the passengers to don

lifejackets. 

Coast Guard regulations at 46 CFR 185.508 stipulate that the master should

require passengers to don lifejackets when possible [emphasis added] hazardous

conditions exist, such as when “transiting hazardous bars and inlets.” However, the

regulation permits the master to determine whether conditions are sufficiently hazardous

to require passengers to don lifejackets. In effect, the regulation puts masters in the

position of acknowledging that they are exposing their passengers to hazardous conditions

whenever they require them to don lifejackets, potentially increasing their perceived

exposure to liability if something untoward occurs.

The regulation followed a series of accidents in which the Safety Board

recommended to the Coast Guard that passengers on the open decks of vessels be required

to wear lifejackets when transiting areas of rough seas.61 In response, the Coast Guard

began the rulemaking process to change the applicable regulation. However, the Coast

61 Safety Recommendation M-86-113.
Analysis 52 Marine Accident Report

Guard ultimately issued a rule placing exclusive responsibility on the master for

passengers to don lifejackets. The Coast Guard stated that it agreed with comments made

during the rulemaking process that passengers should not be permitted to don lifejackets,

which are part of the emergency gear, unless so specified by the master. 

After the Taki-Tooo accident, Safety Board investigators interviewed mariners who

operated small passenger vessels across the Tillamook Bay bar, all of whom contended

that passengers should not be compelled to don lifejackets when crossing the bar. They

said that passengers found lifejackets to be uncomfortable and that requiring passengers to

wear lifejackets could frighten them. Of the vessel masters who crossed the bar on the

morning of the accident, none required passengers to don lifejackets. Further, none had

ever been cited by the Coast Guard for not adhering to the requirements of 46 CFR

185.508 and requiring their passengers to don lifejackets before crossing the bar.

Therefore, the Safety Board concludes that the Coast Guard’s failure to enforce

regulations at 46 CFR 185.508, which require that lifejackets be worn during possibly

hazardous conditions, contributed to the loss of life in the Taki-Tooo accident. 

After the Taki-Tooo capsized, Congress passed the Coast Guard and Maritime

Transportation Act of 2004, which specifically directed the Coast Guard to describe

enforcement of the regulation requiring masters to have passengers don lifejackets in

possibly hazardous conditions, and to include in its report “the number of vessels and

masters cited for violations of those regulations for fiscal years 1998 through 2003.”

Congress also required the Coast Guard to provide recommendations for “improving

compliance with, and possible modifications to, those regulations.”

On March 31, 2005, the U.S. Department of Homeland Security delivered the

Coast Guard’s “Report on Small Passenger Vessel Safety,” which indicated that no

citations had been issued to vessels or masters for violations of the lifejacket regulation

since it became effective, and that enforcement or compliance monitoring was

complicated by the fact that the regulation contained little metric guidance for determining

when a bar or inlet is sufficiently “hazardous,” or weather sufficiently “severe,” to trigger

the requirement for a given vessel after taking into consideration its capabilities and the

experience of its master. The report cited the “excellent safety record of the industry” and

stated that “partnership with the industry is believed to be preferable to a regulatory

solution” to the compliance issue. 

Charter boat operators should not be permitted to put themselves and their

passengers at risk in hazardous conditions, and in the Safety Board’s opinion, the

regulatory language clearly contemplated that passengers would have been required to

don lifejackets. By all reasonable standards, the Tillamook Bay bar conditions at the time

of the accident were hazardous and, therefore, all passengers crossing the bar who were on

open decks should have worn lifejackets. Therefore, the Safety Board concludes that the

commercial vessel masters who crossed the Tillamook bar on the morning of the accident

should have required passengers to wear lifejackets during the transit. 

Given that the Coast Guard has taken the position that it is too complicated for its

personnel to determine whether a bar or inlet is sufficiently hazardous to require those on
Analysis 53 Marine Accident Report

board small passenger vessels to wear lifejackets, a revision of existing regulations is

warranted. The Safety Board recognizes that a regulatory change affecting all bars and

inlets may not be warranted. The sea conditions at West Coast inlets are more severe than

the sea conditions at East Coast inlets. The fetch of the incoming swells and the effects of

the steep continental slope and the narrow continental shelf make the incoming seas at

West Coast bar greater in height and more unpredictable. The Safety Board, therefore,

believes that the Coast Guard should revise its regulations to require that small passenger

vessels operating in Coast Guard-designated surf stations and regulated boating areas on

the West Coast have all passengers and crew wear lifejackets while the vessels transit

inlets where rough bar warnings are in effect. 

Until such time as Federal regulations are revised, the Coast Guard should issue

guidance for mariners operating in Coast Guard-designated surf stations and regulated

boating areas on the West Coast to require passengers and crew on small passenger vessels

to wear lifejackets while transiting inlets where rough bar warnings are in effect. Further,

the owners and operators of small passenger vessels operating out of Tillamook Bay

should require passengers and crew to wear lifejackets while transiting the Tillamook Bay

bar when rough bar warnings are in effect. In addition, the Safety Board believes that the

National Marine Charter Association should recommend that its member small passenger

vessel owners who operate in Coast Guard-designated surf stations and regulated boating

areas on the West Coast require passengers and crew to wear lifejackets while transiting

inlets where rough bar warnings are in effect. 

Emergency Response 

At the time of the capsizing, a Coast Guard MLB was at the north jetty, monitoring

the bar conditions. Coast Guard personnel in the observation tower adjacent to the jetty

informed the MLB crew of the accident. However, the MLB on patrol did not assist in the

rescue because the safety of the Coast Guard personnel and the vessel would have been

jeopardized. 

Several factors argued against the MLB crew participating in the rescue. The TakiTooo was so close to the north jetty that the proximity of the jetty rocks and the rough

water would have made rescue exceedingly dangerous. Because Coast Guard

requirements compel crewmembers to regard their own safety when considering

attempting rescue efforts, and because of the extreme risk involved, the MLB crew’s

course of action was proper. Therefore, the Safety Board concludes that even if the Coast

Guard MLB had had a qualified surfman on board, the Taki-Tooo capsized in a treacherous

area with such heavy surf that any attempt at assistance by the MLB would have

endangered its crew.

Within 5 to 6 minutes of the capsizing, Station Tillamook Bay had requested that

Coast Guard rescue helicopters be dispatched to assist in the recovery efforts, launched a

second MLB to the scene, and notified local responders of the accident. 
Analysis 54 Marine Accident Report

The first individuals to reach the scene were civilians who had been on the beach

or nearby. They assisted survivors who had swum or been washed to shore. Within 10

minutes of receiving the first 911 call reporting the accident, emergency response

personnel arrived. They attended to the survivors and promptly transported them to the

local hospital. All but one passenger was subsequently treated and released. The passenger

who was admitted was treated for hypothermia and released the next evening.

About 0732, the second MLB, with a certified surfman as coxswain, arrived at the

accident site and recovered the first victim (the master). The second MLB returned to

Station Tillamook Bay, transferred the victim to rescue personnel, and returned to the

accident site with the officer-in-charge on board. As a certified surfman, the officer-incharge had routinely trained in 8- to 15-foot sea conditions and had “suited up” for this

mission; therefore, he was prepared and knew how to transfer to another vessel. He

jumped into the water, made his way over to the first MLB, and climbed aboard. Because

both MLBs now had qualified surfmen on board, both vessels were able to patrol the

heavy surf for accident victims.

The first Coast Guard helicopter arrived on scene at 0745 and eventually recovered

two bodies. A second helicopter arrived soon after and assisted in the search for victims.

By 0923, Garibaldi fire and rescue confirmed that eight bodies had either washed ashore,

been pulled from the surf, or been recovered from the ocean. At 0927, the Coast Guard

diverted the cutter Steadfast, based in Astoria, to help in the search. At 1105, Station

Tillamook Bay was advised that only 17 of the 19 people on board the Taki-Tooo had been

accounted for. The Coast Guard continued to search the area for the missing victims until

0857 on June 15, with negative results.

The Safety Board concludes that the timeliness of the Coast Guard’s search-andrescue efforts, the quick notification and rapid response of shoreside emergency

responders, and the assistance of nearby civilians resulted in an adequate response to the

emergency. 
55 Marine Accident Report

Conclusions

Findings

1. The absence of defects and the evidence of propulsive power indicate that problems

with the engine, propeller, and associated boat components such as the throttle and the

rudder were not causal factors in this accident.

2. The following were not factors in the performance of the Taki-Tooo master: sleep

deprivation, alcohol, illegal or prescribed drugs, and financial concerns. 

3. Before the accident, the National Weather Service and the Coast Guard effectively

communicated information about the weather conditions and the rough bar to

mariners, including the master of the Taki-Tooo.

4. The decision of the Taki-Tooo master and the other charter vessel masters to leave

port and proceed to the bar area to make a first-hand assessment of conditions was

appropriate.

5. The decision of the charter boat operators, including the master of the Taki-Tooo, to

transit Tillamook Bay bar in the hazardous sea conditions that prevailed on the

morning of the accident jeopardized the safety of all on board.

6. It cannot be determined whether the Taki-Tooo’s turn to a northerly heading, which

placed the vessel broadside to the seas, was due to a deliberate action by the master or

to a loss of control by the master.

7. The condition of the channel and the jetties at the Tillamook Bay bar was not a factor

in the accident.

8. A potentially unintended consequence of the Coast Guard’s restricting Tillamook Bay

bar only to recreational and uninspected passenger vessels was to afford the

passengers on those vessels a higher level of safety than the passengers on inspected

passenger vessels.

9. The absence of a go/no-go policy by the charter boat owners operating out of

Tillamook Bay allowed the masters to exercise poor judgment in deciding to cross the

bar, given the hazardous sea conditions.

10. If the master of the Taki-Tooo had required passengers and crew to wear lifejackets,

their chances of survival would have been better and the number of fatalities in this

accident would probably have been less.
Conclusions 56 Marine Accident Report

11. The Coast Guard’s failure to enforce regulations at 46 CFR 185.508, which require

that masters direct passengers to wear lifejackets during possibly hazardous

conditions, contributed to the loss of life in the Taki-Tooo accident.

12. The commercial vessel masters who crossed the Tillamook bar on the morning of the

accident should have required passengers to wear lifejackets during the transit.

13. Even if the Coast Guard motor lifeboat (MLB) had had a qualified surfman on board,

the Taki-Tooo capsized in a treacherous area with such heavy surf that any attempt at

assistance by the MLB would have endangered its crew. 

14. The timeliness of the Coast Guard’s search-and-rescue efforts, the quick notification

and rapid response of shoreside emergency responders, and the assistance of nearby

civilians resulted in an adequate response to the emergency.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the capsizing of the Taki-Tooo was the decision of the master to attempt to cross Tillamook

Bay bar despite the hazardous sea state that existed at the time. Contributing to the

severity of the accident was the failure of the Taki-Tooo master to ensure that he, the

deckhand, and the passengers donned lifejackets before crossing the bar. Also contributing

to the severity of the accident was the failure of the U.S. Coast Guard to enforce the

regulatory requirement at 46 Code of Federal Regulations 185.508, which stipulates that

vessel masters shall require passengers to wear lifejackets when transiting a hazardous bar.
57 Marine Accident Report

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the

following recommendations.

To the United States Coast Guard:

Require that owners of small passenger vessels operating within Coast Guarddesignated surf stations and regulated boating areas on the West Coast develop

and implement written go/no-go policies, based on risk-management principles,

regarding transiting bars and inlets. (M-05-09)

Revise your regulations to require that small passenger vessels operating in Coast

Guard-designated surf stations and regulated boating areas on the West Coast

have all passengers and crew wear lifejackets while the vessels transit inlets where

rough bar warnings are in effect. (M-05-10)

Until such time as your regulations are revised, issue guidance for mariners

operating in Coast Guard-designated surf stations and regulated boating areas on

the West Coast to require passengers and crew on small passenger vessels to wear

lifejackets while transiting inlets where rough bar warnings are in effect. (M-05-11)

To the Owners and Operators of Charter Fishing Vessels Operating Out of 

Tillamook Bay, Oregon:

Develop and implement written go/no-go policies, based on risk-management

principles, regarding transiting the Tillamook Bay bar. (M-05-12)

Require that passengers and crew wear lifejackets while transiting the Tillamook

Bay inlet when rough bar warnings are in effect. (M-05-13)

To the National Marine Charter Association:

Recommend that your member small passenger vessel owners operating within

Coast Guard-designated surf stations and regulated boating areas on the West

Coast develop and implement written go/no-go policies, based on riskmanagement principles, regarding transiting bars and inlets. (M-05-14)

Recommend that your member small passenger vessel owners who operate in

Coast Guard-designated surf stations and regulated boating areas on the West

Coast require passengers and crew to wear lifejackets while transiting inlets where

rough bar warnings are in effect. (M-05-15)
Recommendations 58 Marine Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

Adopted: June 28, 2005

MARK V. ROSENKER 

Acting Chairman

RICHARD F. HEALING

Member

ELLEN ENGLEMAN CONNERS

Member

DEBORAH A. P. HERSMAN

Member
59 Marine Accident Report

Appendix A

Investigation

The U.S. Coast Guard Command Center in Washington, D.C., notified the Safety

Board’s communication center of the Taki-Tooo accident about 1600 on June 14, 2003.

The Board elected to lead the investigation under the Safety Board–Coast Guard

memorandum of understanding and immediately dispatched a team of investigators to the

accident site. An investigator from the Board’s Northwest regional aviation office in

Seattle, Washington, arrived in Garibaldi, Oregon, about 1700 to control the accident

scene until the rest of the team arrived. The team from Board headquarters, consisting of

an investigator-in-charge and specialists in vessel operations, human performance, and an

aviation survival factors investigator, arrived in Garibaldi about 0830 on June 15. An

investigator from the Board’s Alaska regional aviation office in Anchorage was

dispatched to serve as group chairman for engineering. 

The team documented the damage to the Taki-Tooo and interviewed survivors,

witnesses, responders, and Coast Guard personnel. The Vice Chairman of the Safety

Board accompanied the investigative team to Oregon, and a Board Member joined them at

the scene. Also on scene were a specialist from the Board’s Office of Public Affairs and

two representatives from the Board’s Office of Transportation Disaster Assistance. The

on-scene investigation concluded on June 21, 2003.

The Safety Board investigated the 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 and the Oregon State Marine Board. The owner

of Garibaldi Charters declined to participate as a party in the investigation.
60 Marine Accident Report

Appendix B

Accident Chronology

June 13, 2003

1645 National Weather Service issues small craft advisory, predicting heavy seas

with wind waves of 4 feet and 10-foot swells.

1645 Coast Guard Station Tillamook Bay restricts Tillamook bar to recreational

boats and uninspected passenger vessels.

June 14, 2003

0330 National Weather Service issues small craft advisory.

0430 Taki-Tooo master wakes up, listens to weather report on home VHF radio.

0445 Seaman mans Coast Guard watchtower on north jetty.

0446 Coast Guard motor lifeboat (MLB) under way for first-light bar report.

0500 MLB on duty at Tillamook bar.

0512 MLB coxswain recommends keeping bar restricted to recreational vessels;

reports 6- to 8-foot sloughing and plunging seas at end of jetties [tips], 8- to

10-foot seas outside jetties, winds 14 knots, visibility 0.5 n mi.

0514 Coast Guard posts rough bar warnings at lower base and at watchtower;

hoists small craft advisory flag at base; transmits bar restriction on VHF

channels 16 and 22A, citizens band channel 09.

~0530 Taki-Tooo master leaves home for Garibaldi harbor, listens to weather

report on VHF car radio.

~0530 Taki-Tooo master arrives at Garibaldi Charters office.

0530 Passengers check in and begin boarding Taki-Tooo.

0530 Charter fishing boat Oakland Pilot (44.4 feet) departs Garibaldi marina.

0530 Owner of charter fishing boat Kerri Lin (29.4 feet) cancels day’s charter

because of sea conditions.

0545 Taki-Tooo master gives safety briefing (no one takes lifejackets).

0545 Oakland Pilot arrives next to Coast Guard tower.

0600 Charter fishing boats Norwester (41.8 feet long) and D & D (32.4 feet) and

uninspected fishing vessel Amanda (23 feet) leave marina for inlet.
Appendix B 61 Marine Accident Report

0600 Taki-Tooo departs marina with 2 crew members and 17 passengers.

0620 Garibaldi Charters owner arrives at north jetty to watch boats cross bar.

0645 Taki-Tooo arrives at north jetty, circles awaiting lull in waves.

0645 Norwester, D & D, and Amanda arrive at tower.

0650 Norwester goes over bar, master radios back “not worth it, wait a little.”

0650 Kerri Lin owner goes to north jetty to watch boats leave inlet.

0655 Oakland Pilot leaves inlet, turns northwest, slams down on swell; deckhand hits head on ceiling, one passenger breaks window, another passenger

injures hip.

0658 Oakland Pilot clears bar.

0700 Shift change at Coast Guard watchtower: seaman being relieved says, “The

bar is pretty rough; here is the bar report and you just missed some cowboy

stuff pulled off by the Norwester and the Oakland Pilot.”

~0700 D & D crosses bar.

~0705 Taki-Tooo starts across bar.

0715 Taki-Tooo reported by Coast Guard watchtower to have capsized in north

hole.

0716 Tower notifies MLB of capsizing.

0716+ MLB on way to accident scene.

0718 Coast Guard Station Tillamook Bay requests helicopter assistance from Air

Station Astoria.

0720 MLB tries to help, but Taki-Tooo too close to jetty.

0720 Second MLB launches from Coast Guard Station Tillamook Bay to accident scene.

0721 Coast Guard calls Tillamook County Emergency Communications District

(911).

0721 Ebb tide ends.

0725 Coast Guard rescue coordination center in Seattle receives EPIRB signal

from Taki-Tooo.

0726 911 operator notifies Garibaldi fire chief of accident.

0730 Rescue coordination center receives confirmation that Taki-Tooo has capsized with 19 people in water.
Appendix B 62 Marine Accident Report

0732 Second MLB arrives at accident scene and reports empty liferaft floating

free; locals on beach start arriving.

0737 Fire chief and rescue truck from Garibaldi fire and rescue arrive at north

jetty; fire chief takes command, reports five survivors on shore.

0740 Second MLB sees one person floating inside surf zone, radios Coast Guard

station that going to pick up victim.

0745 Second MLB recovers unconscious victim, begins cardiopulmonary

resuscitation.

0745 Coast Guard HH-60J Jayhawk helicopter arrives at north jetty from Astoria; aircraft commander reports Taki-Tooo already washed ashore.

0755 Second MLB arrives at Coast Guard station, transfers victim to Garibaldi

fire and rescue.

0800 Second Jayhawk helicopter launches from Air Station Astoria.

0802 Rescue swimmer from first Coast Guard helicopter recovers one victim

from surf; helicopter lands on beach and transfers victim to fire and rescue

unit.

0804 Officer-in-charge boards second MLB at Station Tillamook Bay and leaves

for accident site.

0810 Fire and rescue unit reports Taki-Tooo upright on beach with one victim in

cabin.

0821 Second MLB arrives back at accident scene, officer-in-charge swims to

first MLB.

0840 Second Jayhawk helicopter arrives at accident scene.

0848 Second MLB searches for victims outside surf line.

0908 First Jayhawk helicopter reports another victim in water off north jetty.

0910 Fire and rescue unit notifies Station Tillamook Bay that seven survivors are

at Tillamook Hospital.

0915 First Jayhawk helicopter rescues second victim from water 200 yards from

tower.

0923 First Jayhawk helicopter lands on beach and transfers victim to fire and

rescue unit.

0927 Rescue unit advises Station Tillamook Bay that 18 people are accounted

for.

0927 Coast Guard cutter Steadfast is diverted from Astoria to help in search.

0955 Both MLBs patrol surf line.
Appendix B 63 Marine Accident Report

1009 Deputies advise Coast Guard that they will pull Taki-Tooo onto beach to

look for survivors.

1015 Second MLB measures water temperature at 52o F.

1022 First Jayhawk helicopter leaves accident site, returns to Air Station Astoria.

1033 First MLB returns to station.

1105 Fire and rescue unit informs Station Tillamook Bay that only 17 people on

Taki-Tooo are accounted for.

1107 Station Tillamook Bay notifies second MLB that two people are still

missing.

1205-1213 Norwester and Oakland Pilot return safely across bar, with second MLB

standing by.

1228 First MLB returns to accident scene and resumes search for two missing

passengers.

1238 D & D returns safely across bar.

1254 Second MLB returns to station.

1340 First MLB returns to station.

1341 First MLB under way again, resumes search north of jetty for two missing

passengers.

1624 Second Jayhawk helicopter ends search and returns to Air Station Astoria.

1700 Coast Guard cutter Steadfast arrives on scene, assumes command.

1755 Second MLB relieves first MLB, continues searching beach and surf line.

1818 First MLB returns to station.

2100 Second MLB is released from search and returns to base; Coast Guard

watchtower is secured.

2115 Coast Guard cutter Steadfast completes search and is released.

June 15, 2003

0450 First MLB under way from Station Tillamook Bay to accident scene.

0521 Second MLB under way from Station Tillamook Bay to accident scene,

begins to patrol surf line north and south of north jetty.

0550 First MLB returns to base.

0557 Jayhawk helicopter launches from Air Station Astoria.
Appendix B 64 Marine Accident Report

0611 Jayhawk helicopter arrives on scene and begins hover-search of shoreline.

0730 Jayhawk helicopter completes search with negative results and returns to

base.

0735 Second MLB completes search with negative results and returns to base.

0857 Thirteenth Coast Guard District calls off search for two missing passengers.
65 Marine Accident Report

Appendix C

Boating Safety Pamphlet
Appendix C 66 Marine Accident Report

HAZARDS

Crossing the Bar

The bar is the area where the deep waters of the

Pacific Ocean meet with the shallower waters near themouth of a river.

Most accidents and deaths that occur on coastal bars

are from capsizing.

Improper loading and/or overloading are major

causes of capsizings. Improperly/overloaded boatshave less stability and less freeboard, which can allowseas to break into the vessel, causing the boat tobecome even less stable.

Boats are more likely to capsize when crossing the

bar from the ocean because the seas are on the sternand the boater may have less control over the vessel.

Boaters must make sure the bar is safe prior to

crossing. Check with other boaters or the Coast Guardto find out the condition of the bar.

If you are caught on a rough bar running in...

Make sure everybody aboard is wearing a personalflotation device.Keep the boat square before the seas.Keep the boat on the back of the swell. Ride theswell and stay clear of the following wave.

Avoid sudden weight shifts from passengers or gear

moving around in the boat. If possible, have passengers lie down as near the centerline of the boat aspossible.

Do not allow the waves to catch your boat on the

side (beam). This condition is called broaching, andcan easily result in capsizing.

Rough Bar Advisory Signs

Be aware of the location and status of rough bar

advisory signs. These signs are 6ft by 6ft white, diamond shaped daymarks, with the words “ROUGHBAR” in black letters. Two alternating amber lights onthe signs are activated when observed seas on the barexceed 4 feet in height and are considered dangerous.

DO NOT CROSS THE BAR WHEN THE

LIGHTS ARE FLASHIING!

Do not cross until you call Station Tillamook Bay

on Ch16 to see if the restriction applies to vesselsyour size.

If the lights are not flashing, there is no guarantee

that sea conditions are favorable.

Coastal bars may be closed to recreational boats

when conditions on the bar create a hazardouscondition. Failure to comply with the closure mayresult in voyage termination, and civil and/or criminal penalties. The regulations are enforced by CoastGuard boarding teams.

CROSSING THE

TILLAMOOK BAY BAR

For Additional Boating Safety Information www.uscgboating.org www.boatoregon.com

For Boating Class and Vessel Safety Check Information: www.uscgaux.org/~130/ www.usps.org

1-800-336-BOAT (2628) (class information only)

Boating Safety Tips✔ Check Weather, Tide, and Bar Conditions✔ File a Float Plan With Friends/Relatives✔ Don’t Overload Your Boat✔ Wear Your Life Jacket✔ Carry Flares and a VHF-FM Radio✔ Check Weather and Tides Before Departing

✔ Have Anchor with Adequate Line✔ Boat Sober

EMERGENCIES

VHF-FM Radio: Channel 16

 If in distress (threatened by grave and imminent danger):

 1. Make sure radio is on

 2. Select Channel 16 3. Press/Hold the transmit button 4. Speak slowly, and clearly say:

MAYDAY, MAYDAY, MAYDAY

 5. Give the following information

• Vessel Name and/or Description • Nature of Emergency

• Position and/or Location • Number of People Aboard

6. Release the Transmit Button

 7. Wait for 10 seconds – If no response, repeat “Mayday” call

 If not in immediate danger, follow the same steps as above,

except do not use the word “MAYDAY.”

Make Sure Everybody is Wearing a Life Jacket!

Telephone: 911

Tell the operator that you have a marine emergency. Be

 ready to provide the same information required in item number 5 of the mayday call.

Coast Guard Stations

Tillamook Bay

 (Garibaldi, OR

 503) 322-3531

Diver Down

Flag

Alpha Flag

Tides

Tides are the vertical rise and fall of the water and

tidal current is the horizontal flow of the water.

There are roughly two tides each day in the Pacific

Northwest.

Tidal movement toward the shore or upstream is

the flood current. Movement away from shore or

downstream is the ebb current. The period between

is known as slack water.

Tidal currents may gain tremendous velocity,

particularly when the ebb current is augmented byriver runoff.It is extremely dangerous to get caught onthe bar during a strong ebb current. Even ondays that are calm, a fast moving ebb can create barconditions that are too rough for small craft.Always know the stage of the tide!Avoid crossing the bar during an ebb tide.

It is best to cross the bar during slack water or on a

flood tide, when the seas are normally calmest.

Commercial and Recreational Divingin Tillamook Bay

Commercial and recreational diving is popular in

Tillamook Bay. Boaters and divers should exerciseextra caution to ensure their safetyon the water.

A rigid replica of the alpha flag

must be displayed on boatsengaged in diving operationswhenever these boats are restrictedin their ability to maneuver by thediving operation. The flag shouldbe at least one meter high and bevisible all around the horizon. The“diver’s flag,” a red flag with adiagonal white stripe, is arecognizable sign that a diver isoperating in the area, but its displayis not required by law.

Boaters who see either the alpha

flag or the divers flag should beaware that a diver is in the area andshould avoid that area or operatewith extreme caution. If you mustapproach an area where a diver isoperating, turn off motor if possibleor slow down to idle speed andproceed cautiously.

Likewise, people engaged in diving do not have

authority to block the channel or restrict navigation.Please dive responsibly.
Appendix C 67 Marine Accident Report A. Bar area. The entire area between the beach and the 20-foot curve is bar area and breaks on the ebbing tide. The water runs out from four to six knots on the average and is very strong. Boats proceeding out should stop in the channel east of the seaward end of the breakwater and carefully evaluate the bar. Between November and April all vessels should avoid the area around Bell Buoy 1. This is extremely hazardous. The bar area is consistently changing. B. North jetty. Approximately 100 yards of the seaward end of the north jetty is submerged. This, and all areas immediately adjacent to the jetty are extremely dangerous and should be avoided. About the last 150 yards of the outer tip of the North Jetty is curving towards the Tillamook Bay Channel. Do not proceed north or south until you are well clear of the submerged jetties (approximately 200 yards seaward of the jetty tips). C. Middle grounds. Shoaling makes this area unpredictable and hazardous; it should be avoided. D. South jetty. About 100 yards of the outer end of the south jetty is submerged. Extreme caution must be exercised when transiting the area. Junction Gong Buoy “S” has been established until the tip of the south jetty is repaired. Since this buoy sits adjacent to a shoal, surf conditions may be experienced in the immediate area surrounding the buoy and westward of it. Tillamook Bay Channel Tillamook Bay channel lies just south of the north jetty. Boaters are urged to navigate with extreme caution as this channel changes constantly. The Sector Light marks the correct location of the navigable channel only when between the jetties. The sector light should not be used to make an approach to the Tillamook Bay Bar since it runs directly over some hazard- ous areas west of the jetty tips. Most local mariners prefer to transit in and out of Tillamook Bay by following the “south hole” which is the deep water area that runs north and south, just west of the end of the submerged rocks on the south jetty. Rough Bar Warning sign A small boat rough bar warning sign is located just west of the Coast Guard boathouse. A second sign is mounted on the Coast Guard Tower, which is located on the North Jetty. If the yellow lights on these signs are flashing, a restriction has been placed on recreational boats crossing the bar. To see if this restriction affects your vessel, please contact Coast Guard Station Tillamook Bay on VHF-FM channel 16 or call (503) 322-3531. Bar Condition Reports Bar condition and weather reports for Tillamook Bay can be obtained by contacting Coast Guard Station Tillamook Bay on VHF-FM channel 16. KTIL (104.1 FM) reports are only given in the morning (once per day) and only in the summer time. With conditions changing frequently on the bar this morning radio report is only pertinent for the period the report is given. TILLAMOOK BAY BAR DANGER AREAS Soundings in feet In emergency . . . use these grid numbers to report your location.

➥
68 Marine Accident Report

Appendix D

Coast Guard–Approved Lifejackets

Only Type I lifejackets are approved for use on small passenger vessels.1 Type I

lifejackets are intended for offshore use, in open or coastal waters, and are designed for

extended survival in rough, open water. Type I lifejackets have 22 pounds of buoyancy

and will turn most unconscious wearers face up in the water.2

The Coast Guard has approved three varieties of Type I lifejackets for commercial

vessels. The first is the inherently buoyant lifejacket, made of material that is capable of

floating (kapok [requirements at 46 CFR 160.002], fibrous glass [requirements at 46 CFR

160.005], or plastic foam [requirements at 46 CFR 160.055]). These lifejackets are the

most effective type of life preserver in rough water, according to the Coast Guard.3

 The

lifejackets are reversible, come in sizes to fit children and adults, and are suitable for

nonswimmers. Disadvantages are that they are bulky, can be uncomfortable if worn over

long periods, and may not fit extremely large or extremely small passengers.

The second type of Coast Guard-approved Type I lifejacket is the inflatable

lifejacket. The lifejackets are approved only in the adult size. They are worn uninflated

and so can be worn continuously and in hot weather. When the lifejacket is submerged, a

carbon dioxide cartridge automatically inflates two separate chambers. Inflatable models

also have an oral backup system that requires the wearer to blow air into the device

through a tube. Disadvantages are that the lifejackets are available only in one universal

adult size (for adults over 80 pounds), are not suitable for nonswimmers, and do not

provide flotation without being inflated. They also need regular inspection and

maintenance, including rearming of the carbon dioxide cartridge.

The third variety of approved Type I lifejacket is the hybrid inflatable lifejacket.

The Coast Guard calls this type the “best for open, rough or remote water, where rescue

may be slow in coming.” The hybrid inflatable lifejacket is approved only in child and

youth sizes. It will turn most unconscious wearers face up in the water and is the only

inflatable lifejacket approved for weak swimmers, nonswimmers, and children. A hybrid

inflatable contains a small amount of built-in flotation material and an inflatable chamber.

The carbon dioxide cartridges need to be tested regularly and replaced if expended.

1 U.S. Coast Guard, Small Passenger Vessel Information Package, section C, “Life Saving Equipment

Requirements” <www.uscg.mil/d9/sault/mso/smallpassenger/tblifesaving.htm>.

2 Most adults need an extra 7 to 12 pounds of buoyancy to keep their heads above water

<www.boatwashington.org/lifejacket.htm> (accessed April 18, 2005).

3 “Lifesaving and Fire Safety Standards for Commercial Ships and Recreational Boats,” U.S. Coast

Guard <www.uscg.mil/hq/gm/mse4/pfseldata/htm> (accessed April 18, 2005).