Marine Accident Report: Collision between USCG boat and recreational vessel

[dougpine]

http://www.ntsb.gov/news/events/2011.../synopsis.html



Marine Accident Report: Collision between USCG boat and recreational vessel, San Diego, CA, December 20, 2009
This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.
EXECUTIVE SUMMARY
On Sunday, December 20, 2009, about 1744 Pacific standard time, the 33-foot-long Coast Guard vessel CG 33118, designated by the Coast Guard as a "special purpose craft - law enforcement" or SPC-LE,with five crewmembers on board,collided with a 24-foot-long Sea Ray recreational vessel with state registration number CF 2607 PZ, carrying 13 people, on San Diego Bay, California. The collision occurred during the city's annual holiday boat parade, the Parade of Lights. The Sea Ray was headed west near the main shipping channel to enable the occupants to watch the boat parade. The CG 33118, on patrol in the bay, was also headed west, its crew responding to a reported grounding. The CG 33118 struck and overran the Sea Ray's stern near the west end of Harbor Island. As a result of the collision, an 8-year-old boy on board the Sea Ray was fatally injured and four other people on board sustained serious injuries. No CG 33118 crewmembers were injured in the accident.
Following the collision, drug and alcohol testing was performed on CG 33118 crewmembers, and all results were negative. The Sea Ray operator voluntarily submitted to drug and alcohol testing, and the results of his tests were negative as well.
FINDINGS
Weather, illegal drugs and alcohol, and the mechanical condition of both vessels were not factors in this accident.
The vessel grounding to which the CG 33118 responded was not an emergency and did not necessitate a high-speed response that reached 42 knots at one point.
The CG 33118 was planing, that is, traveling at least 19 knots, at the time of the collision, considerably faster than a safe speed of 8 knots or lower under the prevailing conditions.
The CG 33118 coxswain and crew were aware of the heavy vessel density in the area.
The coxswain's operating the CG 33118 at any planing speed was unsafe for the prevailing conditions and circumstances of darkness, background lighting, and high vessel density in the parade area.
The continuous illumination of the Sea Ray's all-around light, the effects of the background lights that limited the conspicuity of the all-around light, and the similar headings of the two vessels coupled with the dead-astern approach by the CG 33118 made it difficult for the crew to visually detect and perceive the Sea Ray; however, traveling at a slow speed would have compensated for these visual difficulties.
Special purpose craft - law enforcement (SPC-LE) vessels have obstructions to forward visibility from the helm and the forward port positions, which increase risks if not properly addressed.
The Sea Ray operator was driving his vessel at a safe speed and manner for the prevailing conditions and circumstances.
The CG 33118's high speed and its astern path relative to the Sea Ray precluded the Sea Ray operator from taking effective action to avoid the collision.
Station San Diego oversight of small boat operations was ineffective in ensuring compliance with established policies for safe operations.
At the time of the accident, the absence of Station San Diego speed restrictions for routine patrols at night allowed coxswains too much latitude in selecting patrol boat speed.
The Coast Guard failed to effectively ensure that its automatic identification system policy was enforced in San Diego.
Systematic monitoring of all available operating data could assist Coast Guard small boat supervisors in objectively assessing how their vessels are operated, and periodic review of this information could enhance operational safety and oversight by aiding supervisors in detecting and correcting deviations from standard operating guidance and procedures.
Records indicate that the CG 33118 crewmembers used their personal cellular phones for voice calls and text messaging while under way, distracting them from effectively performing their duties as lookouts.
Actions of the emergency response personnel following the collision were timely and effective.
PROBABLE CAUSE
The National Transportation Safety Board determines the probable cause of the collision between the CG 33118 and the Sea Ray was the failure of the CG 33118 crew to see and avoid the Sea Ray because of the excessive speed at which the coxswain operated the CG 33118, given the prevailing darkness, background lighting, and high vessel density and the U.S. Coast Guard's lack of effective oversight of its small boat operations both nationally and at Coast Guard Station San Diego.
RECOMMENDATIONS
To the U.S. Coast Guard:
Develop and implement procedures for your special purpose craft – law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions.
Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances.
Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations.
Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies.
Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures.
Previously Issued Recommendations Resulting From This Accident:
Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. (M-10-2)
Issue a safety advisory to the maritime industry that (1) promotes awareness of the risk posed by the use of cellular telephones and other wireless devices while operating vessels and (2) encourages the voluntary development of operational policies to address the risk. (M-10-3)

[BMCSRetired]

http://www.ntsb.gov/news/events/2011.../synopsis.html

PROBABLE CAUSE
The National Transportation Safety Board determines the probable cause of the collision between the CG 33118 and the Sea Ray was the failure of the CG 33118 crew to see and avoid the Sea Ray because of the excessive speed at which the coxswain operated the CG 33118, given the prevailing darkness, background lighting, and high vessel density and the U.S. Coast Guard's lack of effective oversight of its small boat operations both nationally and at Coast Guard Station San Diego.

I agree with everything except that. The kid was the coxswain, the kid was going too fast for conditions, the kid was letting his crew use their cellphones, the kid effed up! Hold him responsible! If the NTSB did not think he could carry out the mission then nail his boss as an accessory before and after the fact, don't penalize all the other coxswains and Officers in Charge out there standing the watch because of this incident. Compare this one incident to all the other patrols in the last year and I think you'll see a pretty darn good record.

I usually agree with NTSB findings but I think they went a little too far on this far. Besides, their recommendations are just that, recommendations, they are not legally binding at all.

[Steamer]

I usually agree with NTSB findings but I think they went a little too far on this far. Besides, their recommendations are just that, recommendations, they are not legally binding at all.

Too bad they aren't legally binding, maybe that little boy would still be alive.

"Besides working excessive hours, the dwindling numbers of experienced SAR station personnel are continually burdened with the requirement to provide `on-the-job' training to an increasing number of inexperienced personnel. Boatswains Mates account for over 60 percent of the coxswains and boat crewmembers assigned to Coast Guard SAR stations. However, no entry-level training school currently exists for all active duty Boatswains Mates, even though 20 other Coast Guard enlisted job specialties do receive formal entry-level training ranging from 4 to 26 weeks in length.
Given these serious staffing and training shortfalls, it is not surprising to see an increase in the number of accidents involving Coast Guard rescue boats. Coast Guard data shows that, in fiscal year 2000, there were 130 rescue boat accidents, which represents a 225 percent increase over the 40 accidents that occurred during fiscal year 1998. The Coast Guard found that over half of these accidents were caused by navigational and operational errors or poor judgement ..."

"Coast Guard data shows that, during the past 3 years, over 50 Coast Guard members either fell overboard or were ejected from rigid-hull inflatable boats. As recently as March 2001, two Coast Guard members from Station Niagara lost their lives when their rigid-hull inflatable boat capsized and ejected its four-member crew into Lake Ontario. Despite their potential hazards, these non-standard rescue boats are not subject to formal readiness inspections. In addition, boat coxswains may not have adequate training on how to safely operate these boats. In July 2000, in response to a rise in accidents involving these boats, the Coast Guard conducted an internal study on non-standard rescue boat operations. To date, the Coast Guard has made little progress in implementing the majority of the study's recommendations."



http://www.uscg.mil/foia/docs/MSSTAnchCapsizeFDL.PDF

http://www.uscg.mil/FOIA/docs/MSSTAn...FINAL%20.pd f

[BMCSRetired]

I agree they should be legally binding but one branch of the government is not going to be beholden to another anytime soon. Jeezus, we can't even balance our own checkbook and now you want to spend money on training?

Once again, "...navigational errors and poor judgment." It is the operator once again not following proper procedure and doing, "what needs to be done". In most cases everything goes well, especially with older more experienced coxswains. It still boils down to the kid was qualified but not proficient can't handle the boat to its full capabilities. He should have run it accordingly and reported and shortcomings in training to his superior. Whether anyone likes it or not, the kid says he was ready for the responsibility, passed a board and was certified. If his bosses think he has the proper training and the NTSB does not, the NTSB recommendations are still that recommendations until the law is changed for someone gets embarassed.

1998-2000 was also when the USCG was starting to merge the BM and QM rates thereby saving MONEY on training and increasing the amount of knowledge required to advance in rank so there was/is alot of cross training. As a Quartermaster, I was a ship guy and knew I would reach the level of expertise on small boats that I had on the larger cutters which is the main reason I retired when I did. I fought the merger hard until 2001 when I was told this was the COMDT's pet project when he was a COMMANDER and no matter what arguments I had (loss of proficiency and knowledge, increased accidnts on cutters and boats, etc..) it was going to happen so I needed to STFU. Whereas before Boatswain mates (BM) could specialize in stations and other skills (Aids to Navigation, Law Enforcement...) with the disestablishement of the Quartermaster (QM) rating, junior BM's were now required to qualify as underway OOD's (OincW) now have to qualify not only on small boats AND larger cutters to advance. Notice I said qualify, not be proficient. If this kid had been proficient, who knows. To be a really good coxswain is a career commitment in most cases as is driving the larger cutters. By increasing the knowledge required you have jacks of all trades and masters of none just when boats and cutters are getting more technologically advanced and faster. Of course the training has not caught up yet, surprise, surprise. Training normally takes a back seat to operations which why you have accidents like this. Throw in the growth of the USCG after 9/11 and you can quickly see this problem has been growing for a long time. But again, it comes down to the guy behind the wheel doing the right thing and that is what the USCG will hide behind.

If a boat is non-standard, then it is up to the officer in charge to come up with proper operating parameters and training and his boss needs to be aware. If he does not do that or the training is not sufficient, he should hang too. Do you think ever happens? No it gets buried and the lowest level is blamed. For example, there was incident in New York with what became a standard boat eventually but was not at the time. Two boxes of ammunition were lost overboard due to what was officially described as a training accident. Baloney, they had two girls in the boat from another unit they were trying to impress and while showing off and not watching what they were doing, they lost the ammo. Is that improper training, no, once again it was poor judgement, showboating and not being held accountable but of course that was not listed as the cause and won't be.

I hope the dead child's parents use this report to force the USCG to make changes. That is normally the only way changes are made in the USCG, someone has to die or a lawsuit is lost before upper management listens to ideas of change. They get input about change all the time from the field, they form a "study" group or because they think they have bigger brains than the field, make a conscious decision that it is too expensive until a tragedy like Station Niagara or Station San Diego happens.

[BMCSRetired]

I just read my own post again. I am not going to defend them anymore.

They got themselves into this mess. It's depressing when you give an organization 22 years and they can't learn from their own mistakes.

[PMC]

Reminds me of watching the Los Angeles port police practicing their high-speed turns at 0600 hours - throwing up big wakes that would rock the small yachts tied up at the docks. And what was the maximum speed in the harbor? 5 knots. And are there places in the harbor that would not cause wake damage or issues? Of course - but they would have had to move a mile down the channel.