NTSB says USCG patrol boat’s speed was “excessive”

The National Transportation Safety Board yesterday determined that the probable cause of a 2009 collision in San Diego Bay between a United States Coast Guard patrol boat and a recreational motorboat was due to the excessive speed of the Coast Guard boat in nighttime conditions in an area of high vessel density, and the Coast Guard’s ineffective oversight of its small boat operations nationally and at Coast Guard Station San Diego.

On December 20, 2009, at about 5:44 p.m. PST in San Diego Harbor, a 33-foot-long Special Purpose Craft-Law Enforcement (SPC-LE) Coast Guard vessel with five crewmembers aboard collided with a 24-foot-long Sea Ray recreational boat carrying 13 people. The collision occurred during an annual holiday boating event, the Parade of Lights. The Coast Guard boat, which was responding to a reported grounding (considered a non-emergency), struck the Sea Ray from behind. As a result, an 8-year-old boy was killed and four other people were seriously injured. None of the crewmembers in the Coast Guard boat were injured.

The Coast Guard boat, when it struck the Sea Ray, was being operated at planing speed, which was at least 19 knots and possibly as high as 42 knots.

“The Coast Guard is an organization that traditionally fills the role of rescuer,” said NTSB Chairman Deborah A.P. Hersman. “It is especially sad that a family night of celebration in the Bay ended in tragedy because of a coxswain’s poor judgment and the Coast Guard’s ineffective oversight of vessel operations.”

Visual conditions in San Diego Bay are particularly challenging at night when it becomes more difficult to distinguish small individual boat navigation lights from other lights in the area. However, the investigation showed that at least one crewmember saw the Sea Ray as they approached it from behind. Three of the five crewmembers on the Coast Guard boat, including the operator, refused to be interviewed by NTSB investigators.

Also causal to the accident was the Coast Guard’s lack of oversight of its small boat vessel operations. Coast Guard Station San Diego lacked an effective oversight system to monitor the operation of their vessels while on patrol. The presence of such a system could have prevented the accident. In addition, the Station’s officer of the day, who was on the Coast Guard boat at the time of the accident, did not advise the coxswain to slow down.

The NTSB recommended that the Coast Guard increase vigilance in checking the speed of its boats, establish policies that prohibit excessive speed, and develop a monitoring system to detect deviations from standard operating guidance and procedures. It also recommended that the Coast Guard implement procedures to ensure that crewmembers can compensate for obstructions potentially affecting forward visibility on their SPC-LE vessels.

A synopsis of the NTSB report, including the probable cause, conclusions, and safety recommendations is available.

The NTSB’s full report will be available on the website in several weeks.

http://www.ntsb.gov/investigations/2009/sandiego_ca.html

COAST GUARD STATEMENT

Officers from the Coast Guard’s office of investigations and casualty analysis attended a hearing of the National Transportation Safety Board yesterday as the NTSB outlined findings and recommendations related to recent accidents involving Coast Guard vessels, including the fatal collision with a recreational boat in San Diego, December 2009, killing 8-year-old Anthony DeWeese.

“We want to thank the NTSB for its thorough investigation and insight on this accident.  Many of the findings in the NTSB investigation confirm the Coast Guard’s own investigation and study of the accident,” said Capt. David Fish, chief of the office of investigations and casualty analysis.  “We will continue to learn all that we can from their insight and thorough investigation as well as our own.”

In October 2010 the Coast Guard completed the Boat Operations Safety Review, which examined root causes and underlying issues of boat accidents.  The Coast Guard has already, as a result of the BOSR, established policy on the use of personal electronic devices on boats, continued to standardize boats for increased safety across platforms, and increased navigation training requirements for boat crews.  The service is also ensuring boat stations have the most suitable boats to appropriately carry out local missions.

“With a reputation as the nation’s premier maritime safety agency; our role is to protect the public.  We will continue to collaborate with the NTSB to improve the safety of our operations,” said Fish. “Serious boat accidents in the Coast Guard are rare and we are committed to preventing even a single occurrence.”

In response to previous NTSB recommendations the Coast Guard established enhanced oversight procedures that direct unit commanders to continuously evaluate the readiness of their boats and crews.  Regional commanders were also directed to conduct annual “Ready for Operations” evaluations to determine unit compliance with Coast Guard policies and procedures.

July 13, 2011