NTSB reports on deadly USCG cutter collision with small boat

Written by Nick Blenkey
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The National Transportation Safety Board has issued its report on an August 8, 2022, incident in which the 154 foot long U.S. Coast Guard cutter Winslow Griesser (WPC-1116) collided with the 23-foot-long center-console boat Desakata about four miles off the northern coast of Puerto Rico. The cutter, with a crew of 21, was transiting westbound along the coast, and the boat was transiting northbound while trolling (fishing). Of the two Desakata crewmembers, one was seriously injured, and one was fatally injured. None of the Winslow Griesser crewmembers were injured. No pollution was reported. The Desakata, valued at $58,800, was a total loss.

As we reported earlier, the commander of the cutter was subsequently relieved of duties.

NTSB found that because neither vessel’s crew saw the other vessel in the developing crossing situation before the collision, neither had time to assess or apply the navigation rules to avoid the collision. The Winslow Griesser should have been visible to the Desakata operator before the collision, but the operator was not maintaining a proper lookout. Similarly, the Desakata should have been visible to the Winslow Griesser crewmembers before the collision, but the bridge watchstanders were not maintaining a proper lookout.

NTSB also found that the Winslow Griesser commanding officer and officer of the deck did not take sufficient measures to increase situational awareness when the cutter was transiting at high speed.

During the investigation, based on advice of their counsel, the Winslow Griesser commanding officer, officer of the deck, and quartermaster of the watch declined requests of NTSB investigators to be interviewed.


Something that emerges from the report is that the cutter was not equipped with a voyage data recorder (VDR), or its equivalent. Had it been fitted with a VDR, investigators would have been provided with additional critical factual information about the collision, which could help identify potential safety issues and result in safety improvements.

The full report goes into more detail on this issue:

“The NTSB has investigated several other casualties in which the lack of information that would have been provided by a VDR hampered the investigation and prevented better identification of potential safety issues. For example, in its report on the 2008 collision of the passenger ferry Block Island and Coast Guard cutter Morro Bay, the NTSB cited the reliance on limited information from crew and passenger interviews, electronic chart information, and security camera video (NTSB 2011). The NTSB’s investigation of the 2010 contact of the passenger ferry Andrew J. Barberi with the terminal structure at the St. George Terminal, Staten Island, New York, also was hampered by a lack of VDR information (NTSB 2012).

“Although investigators obtained CCTV video recordings from the bridge, the system could not capture, record, and safeguard important detailed data from vessel navigation and control systems. The NTSB’s report on the 2013 contact of the passenger ferry Seastreak Wall Street with Pier 11 in New York City stated that VDR data would have provided more complete evidence regarding several significant aspects of the casualty (NTSB 2014). For instance, a VDR could have recorded comprehensive engine, propeller, and steering orders and responses as well as audio recordings and main alarm activity. These data sets would have been central to determining the causes of the casualty.

“As a result of these investigations, the NTSB recommended that the Coast Guard require installation of VDRs that meet the IMO’s performance standard for VDRs on new ferry vessels subject to 46 CFR Subchapters H and K (M-14-3), require installation of VDRs that meet the IMO’s performance standard for simplified VDRs on existing ferry vessels subject to 46 CFR Subchapters H and K (M-14-4), and develop a U.S. VDR standard for ferry vessels subject to 46 CFR Subchapter T and require the installation of such equipment where technically feasible (M-14-5). All three of these recommendations are currently classified as Open—Unacceptable Response.”

The NTSB notes that the Coast Guard concluded that the overall benefits of VDRs do not justify the cost. The NTSB disagreed with the Coast Guard’s assessment that the cost outweighs the benefit of installing VDRs because passenger safety is the most important aspect of vessel operation

“While the NTSB’s previous recommendations about VDRs are specifically related to passenger vessels, this collision demonstrates a specific need for VDRs on Coast Guard vessels similar to the Winslow Griesser, a cutter,” says the full NTSB report. “Charged by Congress as the only independent investigator of Coast Guard casualties, the NTSB requires the availability of objective, time-stamped data such as that provided by a VDR to complete timely and thorough investigations that involve Coast Guard cutters. Accurate evidence from multiple sources leads to more-precise findings and targeted conclusions, which enable the NTSB to make more-specific safety recommendations, which, if implemented, have a greater impact on improving vessel safety. Therefore, the NTSB recommends that the U.S. Coast Guard install equipment on all U.S. Coast Guard cutters that records vessel parametric data and audio information that is equivalent to IMO voyage data recorder performance standards.”


NTSB also found that fitting small vessels with equipment—such as radar reflectors or automatic identification systems—when combined with proper visual lookout, would improve the opportunity for vessels with radar to detect them, therefore reducing the risk of a collision.

The full report on the cutter collision goes into more detail:

“Small wooden and fiberglass vessels are often difficult to detect by vessels equipped with radar, particularly if they disappear into the trough of each passing swell and the return is intermittent. Although a 1997 Coast Guard safety alert emphasized that small boat operators can use radar reflectors to significantly reduce the risk of collision, small fishing vessels such as the Desakata, which was constructed of fiberglass, were not required to have radar reflectors, and the Desakata was not outfitted with a radar reflector. The Coast Guard requires radar reflectors for federally documented fishing vessels (with nonmetallic hulls) operating beyond the Boundary Line, among others, but not for vessels such as Desakata. The NTSB has advocated the use of radar reflectors since 1969, when we recommended that the Coast Guard find ways to encourage the use of radar reflectors. Although radar reflectors are not required for small vessels such as the Desakata, the use of these devices enhances safety—reducing collision risk by ensuring that the vessel is more visible to radar.

“Similarly, the Desakata was not equipped with AIS, nor was it required. AIS Class B and, more recently, AIS B+ transponders have been developed to provide the safety and navigation benefits of AIS to smaller vessels at lower cost and with simpler installation than the more capable Class A type typically found on ocean-going and larger vessels. Had the Desakata been equipped with an AIS Class B or B+ transponder that was transmitting its location, its position would have been shown on AIS-equipped vessels up to several miles away. It is therefore more likely that the Winslow Griesser bridge watch may have been aware of the boat’s presence nearby in the minutes leading up to the collision if the Winslow Griesser bridge watch had been monitoring radar or AIS before the collision. Regardless, the NTSB encourages recreational and fishing vessels to use radar reflectors and AIS Class B or B+ to improve their detectability.”


Early detection of a vessel is one of the best ways to avoid collision, says the NTSB. However, fitting a radar reflector or AIS does not reduce the need to maintain a proper lookout and use all available resources in order to avoid collision.

​The NTSB determined that the probable cause of the cutter collision with the Desakata was the failure by both vessels’ crews to maintain a proper lookout. Contributing to the casualty was the Winslow Griesser commanding officer and officer of the deck not taking sufficient measures to increase situational awareness while transiting at a high speed.​

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