On
December 5, 1993 the party fishing vessel EL TORO II sprung three
planks and sank 5 miles south of Point Lookout on the Chesapeake
Bay. There were 23 passengers aboard and three died in the incident,
mainly due to exposure to the cold bay waters.
The EL TORO is a story of particular interest to
marine surveyors that reveals some hard-learned lessons. EL TORO
was a Coast Guard certified passenger carrying vessel that had just
undergone its drydock inspection on March 23, 1993, little more
than 8 months prior. In addition, an insurance survey was completed
just 5 days before the loss of the EL TORO. Both of these are factors
which will come into play, as we shall soon see, that provide some
very important lessons for surveyors.
This review is based solely upon the U.S.C.G. investigation
report dated 29 July, 1994 and subsequently published on the Internet.
The report runs 34 pages in length and will only be excerpted here,
not be reproduced in whole. It is available on the U.S.C.G web site
for anyone interested at http://www.uscg.mil/hq/gm/moa/boards/eltoroII.pdf
from http://www.uscg.mil/hq/gm/moa/sinkcas.htm. This review
is intended solely for the purpose of analysis of a tragedy and
how marine surveyors may learn from it and better perform their
services. This writer recognizes that he does not have all the facts,
and that any criticism herein is based solely on the published report.
This is not a complete investigation of the incident and should
not be interpreted as such.
The names of the participants have been changed
to protect their identities.
PART I, THE INCIDENT
The story begins when Bob Smith purchased a fleet
of 5 aging wooden party boats in 1989, among these the then 32 year
old "ELTORO". According to Coast Guard interviews, Smith
said that he relied heavily on a 1987 survey performed
for the previous owner (emphasis added), and the fact that the
vessels held current Certificates of Inspection. In other words,
Smith said that he was relying on the Coast Guard to ensure that
his vessels were safe. Smith had no independent surveys of the vessels
made on his own behalf. The purchase was made with no log books
or maintenance records being given the buyer, nor were any kept
following the purchase.
Vessel Particulars EL TORO is described
as a 58' party boat specifically designed for party fishing and
built in Norfolk, Virginia in 1961. Typical of her type for that
era and region, she has what is known as a "bay bottom,"
being transversely planked in 1.75" yellow pine on a longitudinal
framing system. She has a 16.5' beam, draws 4.7' and is powered
with a single 310 HP Detroit Diesel. Perhaps most significantly,
she was fastened with galvanized cut nails. She is of a type well
known to the region in which she operated.
Coast Guard Inspections The past history
involving the U.S.C.G. program for inspected vessels is interesting
from a number of points. The investigation report delves back in
Coast Guard inspection records an to April 1988 drydock report,
but not earlier. The following direct quotes from the report are
considered relevant:
"26. On 29 mar 1988 Lieutenant Blank completed
routine triennial inspection for certification of the vessel. He
noted in internal reports " minor leakage from stbd chine between
frames 3 & 3 in NR compartment. All satisfactory. No requirements
issued . . ."
"27. CW03 Blank completed drydock examination
. . . noted in internal reports that wood around the chine fasteners
showed signs of damage from electron flow . . recommended fastener
removal for specific evaluation at next drydock . . A special 'inspection
note' was entered into the CG nationwide computer MSIS to call the
chine fasteners to attention of future inspections. The note expired
on 29 March 1993.
"28. On April 4, 1989 LTCDR Blank conducted
the annual reinspection . . . however he noted 'some working of
the keel and water seepage in the mid-portion of fuel tank compartment
(stbd side of keel) I examined transverse keel bolts and drift pins
. . . appeared satisfactory. Recommended these bolts and pins be
monitored at next DD.' No requirements pertaining to hull structure
were issued."
"31 Each spring from 1989 to 1992 Mr. Bob
Smith has the vessel drydocked without Coast Guard examination.
33. On 8 March Mr. B Smith requested extension of the CG drydock
examination
"34. ON 11 April 1990 BMC Blank conducted
the annual inspection . . . vessel does qualify for D/D extension
until April 91.
"35. ON 5 December Bob Smith requested . .
and extension of D/D examination due date 'for a five year period",
noting the vessel has been operated and will be operating [between
certain points on the Chesapeake]. LCDR Blank replied in writing
that the extension request was granted . . . due date changed to
14 April, 1993.
"37. . . .[U.S.C.G.] local guidance policy
and propagated brackish water category are not addressed in 46 CFR
176.15-1(a) The policy makes no provision for the age of the
vessel." [Emphasis added]/
"40. On 27 April 1992 . . . annual reinspection
. . . noted excessive evidence of stray current or exhaust leakage
in the engine compartment (sic). This was 'angel hair', also informally
called stringy wood but formally called dry rot, and wood around
fasteners turning white from electron flow. No special attention
was given to the 1988 drydock examination notes about pulling fasteners,
but a discussion with LCDR Blank led to a note not recommending
drydock extension . . . [the] decision however was not reversed."
Events of the Tragedy On December 4, 1993,
the evening TV weather reports indicated predicted winds of 22 to
30 mph for the Chesapeake Bay. Bob Smith, who would pilot the vessel
on the following mornings voyage, admitted that he had seen these
reports. At 3:30 AM on the morning of the 5th, NOAA issued a small
craft warning with predicted winds of 20-25 knots and six foot seas.
At 0730 Smith's brother Carl listened to the VHF weather report
and heard the small craft warning. At that time seas were calm.
But it was known that a frontal system was approaching that would
soon change the current conditions.
Note: The report conveniently does not mention
wind direction, along with a great number of other relevant details
and evidence that any surveyor would consider an absolute necessity
in an investigation of such magnitude. One of the prominent features
of this report is it's selective use of evidence and major
omissions of evidence of critical importance. One can easily
anticipate that if ever called into evidence in a trial, the author
would not have an easy time of it before a skilled trial attorney.
At 0800 twenty passengers boarded the EL TORO II
to go fishing. The crew consisted of Bob Smith, his brother Carl,
and a 19 year old male deckhand. Bob Smith held an appropriate Coast
Guard issued operators license and the other two held no licenses.
The vessel cast off at 0815 for the fishing grounds
"almost due east of Smith Point, Virginia and about a half
a mile south of the Maryland/Virginia border where it arrived around
1015. This position is approximately in the center of the bay. The
fetch in any given direction is ten miles or more, but the report
doesn't mention this. At no time were any of the passengers given
any safety instructions or briefing. Remember that this is in December
when the water temperature is indicated as being 50 degrees. It
is also of interest that the vessel operators did not keep any kind
of log nor did they create a passenger manifest, meaning that they
did not even know the names of their passengers except for one.
At 0853 gale warnings were issued for Chesapeake
Bay, predicting 30-35 knot winds but Captain Smith did not monitor
VHF weather channels after departing. Smith later stated that he
did not consider the EL TORO to be a small craft anyway. Another
vessel in the area first noted deteriorating conditions around 1200.
This vessel was monitoring weather conditions via cellular phone
to a source 20 miles to the northwest. The use of a cellular phone
obviously indicates that this operator was expecting very bad weather
to approach suddenly and wanted to be prepared to head for home
in time. This vessel, upon receiving the bad weather report, attempted
to contact EL TORO by VHF but was unsuccessful.
Although the Coast Guard obviously has interviewed
the operator of this vessel, the report gives no details or names.
Why not?
At 1135 the Patuxent Naval Air Station reports
winds from the north at 20 gusting to 39. By 1220 it was raining
but Smith reports only a light breeze and "conditions were
not adverse." This despite the other vessel reporting at the
same time seas of 6-8' at Smith Point only ten miles due south.
Finally, at 1245 Smith decides to head for home. "While enroute,
wind speed and wave heights increased . . .To maximize passenger
comfort, he operated the vessel at approximately 4.5 knots, half-speed
. . . as the vessel rode over the confused wave pattern at the mouth
of the Potomac River. Wind and waves were predominantly from the
northwest."
Here we can see that the vessel is already in
trouble because it has to reduce speed to one-half, thereby at least
doubling the amount of time it will take to return to home port.
Why the captain does not seek closer refuge is never addressed
in the report. No mention of the tide is made as to how its ebb
or flow would affect sea conditions vis-a-vie the Potomac River.
At about 1345 Smith directed the mate to check
on passengers and the engine room bilges. Passengers saw him open
the engine room hatch and express no concern at what he saw. One
passenger . . . "saw into the space and noted liquids in the
bilges, four to five inches below the engine mounts." The mate
reported to Captain Smith that all was well. "By this time
seas had built to 5 to 7 feet but the vessel was taking only spray
over the bow." (Note: the report does not attribute direct
quotes to any of the persons interviewed. These quotes are of the
report language only.)
Yet the report goes on to say that at around 1355,
ten minutes later, Bob Smith personally went aft and checked the
condition of the engine room, only ten minutes after his mate. Obviously,
all is not well. But, by this time the engine had stopped and Smith
was greeted with an engine room full to the top of the engine with
water.
At this point, the vessel is clearly in trouble
and the Captain recognized it as such. A mayday was sent and the
passengers directed to don what turned out to be aging cork life
preservers. Carl Smith then organized the passengers into a bucket
brigade and an attempt was made to bail out the sinking craft. Interestingly,
the report says that the buckets were more effective than the bilge
pumps.
By 1406 it is reported that the main deck was awash.
By 1430 the decks were still awash but passengers were complaining
that nothing had been done so far to deploy what apparently is a
single house top mounted life raft. Carl Smith assured passengers
that the Coast Guard was coming soon, despite being advised of a
30 minute ETA. Even the passengers were smart enough to know that
10, 20, or 30 minutes in fifty degree water would mean death. Finally,
the passengers went up on the house top and launched the raft themselves.
The question here is, what conclusions will the Coast Guard, which
is the author of this information, draw about the behavior of the
Captain and crew?
The Coast Guard report identifies it as a buoyant
"apparatus," probably an appropriate name for one of those
wrapped cork beauties with a rope net bottom, which is what it was.
By 1446 all but three passengers and crew had abandoned ship into
the "buoyant apparatus" in 50 degree waters of the Chesapeake.
At this point the report is very vague about what happened next,
but the report does say that three persons were rescued from the
water, outside of the raft. One of these was the 19 year old mate
who later died of exposure. Yet the Captain and his brother managed
to get safely in the raft. The implication here is that the 19 year
old sacrificed his life that another passenger might have a place
in the life raft while the Captain and his brother save themselves.
Oddly, no mention of the mate's heroism is made. Why not? Perhaps
because he doesn't hold a CG license? Would that have helped? Of
course the report will make note of the heroic efforts of their
own people and the exposure that they suffered.
In the meantime, another three persons - all passengers
- remained on the house top (while the owner and his brother got
in the raft) which apparently remained above water and were rescued
by a life raft from a recently arrived Coast Guard vessel.
"All passengers and crew suffered from hypothermia,
being in the water from 20 to 80 minutes. Many were physically rigid
when rescued."
"At 1830, three Coast Guard personnel from
UTB41411 were taken to the hospital for hypothermia. None of the
three entered the water during the rescue."
Two passengers and the 19 year old crewman ultimately
died of exposure while hospitalized.
With this brief summary of events as extracted
from the Coast Guard report, we can already identify a number of
serious problems, but there are more to come. Not the least of these
is the extraordinarily lax attitudes of party boat owners toward
the condition of their vessels and the safety of their passengers.
Just from the language of the report we can discern questionable
behavior of the Captain. How can anyone discount that 5-7 foot seas
are a threat to an aging wooden vessel with passengers aboard? He
was in the vicinity of the mouth of the Potomac and knew of the
dangerous currents. He knew there was bad weather approaching, and
he could have sought nearby shelter in time and yet refused. Gale
warnings were ignored. Another vessel attempted to warn him by radio,
but apparently he wasn't monitoring his radio as the report says
he was.
Again, judging by the report, the captain had all available knowledge
and ability to avert the disaster, but did not. Yet the Captain
is completely absolved by the report. Why? Is the writer of the
report so arrogant or stupid that he is not aware that his own writings
condemn the Captain? This willful ignoring of the facts as contained
in their own report is repeated again and again.
Marine surveyors who perform surveys on these craft
are no strangers to such happenings and the terrible conditions
aboard these vessels. The tragedy of the EL TORO points up vividly
why we as surveyors ought to be paying closer attention and applying
more rigid standards to these vessels. As this tragedy so amply
demonstrates, surveyors should not ascribe any significance to the
fact that a vessel is U.S.C.G. certified.
In the next section we'll take a look at the actions
of one independent surveyor, the actions of the Coast Guard inspectors,
and finally the Coast Guard report itself. For if the failings of
the various parties involved doesn't convince us of the need for
extra caution, the manner in which the Coast Guard deals with it's
investigation will. Remember that Coast Guard report is, in itself,
a conflict of interest. Here we have the certifying authority of
the vessel investigating the loss of the vessel and the activities
of many others that were involved with it. Knowing this, can there
now be any doubt but that the Coast Guard will absolve itself? Read
on.
PART II
In this section I will offer my critique on the
Coast Guard analysis and offer some sound reasons why government
agencies, whether its the NTSB or the Coast Guard should not be
in a position of investigating accidents of craft which they certify.
Upon studying the report, any highly experienced surveyor with a
good knowledge of wooden vessels will quickly come to see it for
what it is.
While the overall size of the report (34 pages)
may appear impressive, considering the overall scope of the investigation,
it is remarkably superficial and limited, particularly when it comes
to investigating and assessing cause. Worse still is its obviously
biased presentation bolstered by critical omissions of material
facts.
The EL TORO was recovered the following day, refloated
and hauled out at a local boat yard. Judging from the report, it
had not broken up to any significant degree although, again, the
report says almost nothing about its condition. The Coast Guard,
insurance surveyors and other unidentified people from NTSB and
Maryland Police were present to investigate. The Coast Guard review
(I call it that because its hardly a full report) of the survey
comes to barely two full pages. It starts:
"129. . . The consensus was that the hull
was in remarkably good condition except for three sprung planks
on the port side immediately forward of the forward engine room
bulkhead. The inboard end of the planks had dropped about four inches
from their normal position, leaving a gap in way of the keel of
about two inches. With the exception of a single nail, all nails
connecting these planks to the sister keelson had wasted totally
through at the faying surface with the keelson."
It is very interesting to note how this investigator
makes judicious use of opinions of non-Coast Guard people present
. . . "The consensus was . . ." when the writer wants
to deflect attention from the failure of the CG inspections to note
any problems, or rather should we say failure appreciate the importance
of the evidence that was contained in their file notes, discussed
in the next section. Here we have a hull that sprung three
planks, had bad fasteners, sank and killed three people, but he's
telling us that others thought it was in good condition. Yet, as
the investigator, he does not say what he thinks.
The report goes on to say that six planks were
then removed - apparently the three already sprung, and three others
which are not clearly identified but are apparently two planks just
fore and aft of the loose ones, and yet another on the opposite
side of the keel. Remember that this is a bay bottom hull with the
planking running transversely from keel to chine.
The rust stains all over the hull of EL
TORO clearly indicates that there is a corrosion problem with the
fasteners. Since the steel nails were galvanzied, the rust stains
mean that the corrosion has penetrated through the galvanizing,
and that advanced rates of corrosion should be anticipated.
"129. The four planks removed amidships showed
extreme wastage of fasteners in way of the keel, with only 1 of
17 fasteners present for planks a, b, and c. The planks themselves
were in excellent condition, free of visible deterioration."
(Remember this statement because it will be contradicted later.)
"Fasteners toward the chine were progressively better with
most chine nails like new. Fasteners in the two planks removed forward
and aft had some necking but were substantially intact and apparently
effective, even at the keel." "Some necking?"
Doesn't he consider it important enough to say how much? "Some
necking" could be 10% or 90%, a factor that would tell volumes
about the overall condition of the bottom.
The next paragraph: "130. On December 13,
1993, marine electrical specialist Mr. ___ examined the electrical
system, metals in the hull and fasteners. He had the two bottom
planks just forward of plank A and the one just aft of plank C removed.
He concluded that the electrical grounding issue . . . had no substantial
impact on the wasted fasteners. (Note: prior inspections had raised
an issue about the vessel's grounding system that back in 1988 was
changed from a positive to negative grounding system.) "He
attributed wastage of fasteners in planks A, 8 and C to 32 years
of galvanic corrosion, aggravated by the use of a variety of metals
in the hull."
Galvanic corrosion? To a steel nail imbedded
in wood? Note here that fasteners do not corrode unless they
get wet. The corrosion first takes place at the joint between plank
and frame because this is where they first get wet. Once water gets
at the nail, it will corrode all by itself: it doesn't require 32
years worth of galvanism.
"131. Mr. ___ noted the electrical system
to be a mess. He stated that this condition is quite common on such
vessels."
If that's the case, then why does the coast
Guard commonly approve these messy conditions? Why did this vessel
have a messy electrical system after 32 years worth of Coast Guard
inceptions, not one but literally dozens of inspections? Not one
CG inspector ever found it worthy of mention? Here again, the report
condemns the CG but the investigator does not find it worthy of
comment.
"132. Mr. [the insurance surveyor] visited
the vessel on the railway and stated that picking planks A,B, and
C for fastener removal to find wasted fasteners during a drydock
examination would have been a "crap shoot" since no external
or internal evidence of a problem existed. He state that he would
have focused on the engine room, based on his experience and internal
indications on this vessel, such as angel hair noted in his
survey report."
Here the report does not mention that the insurance
surveyor did his survey afloat. The surveyor's remarks, if he made
them, are not qualified or put in proper context but used to support
the Coast Guard's failure to find any problems. Moreover,
the surveyors comments indicate that there were indications of trouble
on the interior. But the writer wants us to believe that everyone
agreed that it "was in remarkably good condition."
Remember that earlier the writer states that
the planks were entirely free of deterioration, and yet now he's
admitting that there was "angel hair' on the planks. Angel
hair is a form of deterioration caused by constant wetting and drying
of salt water within wood fibers. As the water dries, the salts
crystallize, tearing the wood fibers apart. The report erroneously
attributes this to stray current or 'galvanic" problems. This
causes progressive deterioration because it increases the ability
of the wood to absorb water and so it becomes progressive. The wood
is no longer solid but shredded, yet we're to believe that its in
remarkably good condition.
"133. Of approximately 100 fasteners
in the six planks removed on 10 December 1993, about 30 were wasted
to the point of being totally ineffective, about 20 were wasted
to be marginally effective, and about 50 were like new or had minimal
wastage."
Whether the writer is being deliberately obtuse
or not, the point is conveyed that at least 50% of the fasteners
were either wasted or in poor condition. He should have indicated
the percentage of wastage to original size, not use such amateurish
and relative terms such as "like new" or "minimal."
Does the report offer exhibits of the nails as evidence? No, it
does not. How about the planks? Again, no. Yet the report devotes
a great deal of its space to convince of the CG inspectors experience
and professionalism while the substance of the report denies that
claim. Surely the writer knows that with all these injuries and
deaths that there will be litigation. Yet he is willing to go out
on a limb and provide a report that is amateurish at best, and decidedly
self-serving. The most fitting conclusion we can draw here is that
the writer has succumbed to the rampant disease of bureaucratic
self-immolation to protect the Coast Guard hierarchy.
"135. The marine surveyors and Coast Guard
inspectors testifying on appropriate intervals for removal of fasteners,
and refastening in general, had widely varying opinions. None identified
written guidance or even alluded to written guidance."
Here begins the Coast Guard's shifting of the
blame. What he's saying is that since there is no written 'guidance'
- and note the peculiar use of that word - that it's not the certifying
authority's responsibility to KNOW when fasteners should
be pulled and checked. In attempting to shirk responsibility, the
writer is unwittingly exposing his agency's incompetence. Imagine
if the NTSB made such comments in an official report on an air disaster!
"We couldn't find any written guidance for over 50 years so
we just kept approving it anyway." This same excuse appears
yet again in the conclusions section of the report.
Moreover, you may have noted the subtle inclusion
of "marine surveyors" along with "Coast Guard Inspectors"
in that comment. They apparently didn't want to feel alone in their
ignorance so they had to include the private sector as well.
"136. The fuel tanks were supported with transverse
saddles. The aft saddle supports had failed, allowing
the weight of the tanks to be partially supported by a bottom transverse
plank. The wear on this plank indicated that this condition existed
for some time. There was no evidence in March 1993 that this circumstance
had any adverse affect on the integrity of the hull." [boldface
added].
Amazing! Here he's not saying that the broken tank
saddle didn't exist 8 months ago in March, but rather that there's
"no evidence" that this had "an adverse effect"
on the intergrity of the hull.
Next, I'll go to item #6 of the conclusions section:
"6. The unintended support of the fuel tank aft transverse
saddle by a bottom plank may have placed forces on the garboard
joint over time, contributing to the entry of water and the abnormal
corrosion rate in the area. However, corrosion of the fasteners
in other planks and battens indicates that other factors were more
significant."
This statement is truly amazing. Here we have
the aft end of the fuel tank support sitting not on a longitudinal
plank, but a transverse plank. And the writer would have us believe
that there more significant factors? And just what are those "other
factors?" Well, he doesn't say. Corrosion in other planks?
But he's talking about the plank that the saddle is resting on.
What do other planks have to do with the failure of this one? How
large was the tank? How much weight was resting on that plank? Again,
the report is silent on critical evidence.
These statements in and of themselves destroy
all credibility of this report. Its like justifying a flat tire
by saying that its only flat in one place.
This ends the narration of the investigation into
the cause of the tragedy. The astute investigator will note that
this report is as remarkable for what it does say as it doesn't
say. This is followed by a list of 35 conclusions and 17 recommendations,
most of which seem designed to deflect responsibility and disguise
the Coast Guards own failures.
PART 111, RECOMMENDATIONS
1. As near as we can tell from the report, six,
and possibly eight planks were removed, all in the area of the three
loose planks. From this, the investigator concludes that it was
a localized problem (conclusion #6). How does he know its localized
when he didn't check other areas?
2. No indication is given that any effort was made
to check any planks other than the immediate area of the failed
planks. Why not? The obvious answer is that the investigator already
had a foregone conclusion which he set out to prove.
3. A 32 year old wooden boat fastened with steel
fasteners would be a prime suspect to any experienced surveyor.
Yet this report would infer that the rest of the fasteners in the
vessel are all okay without any kind of general survey, and offers
no proof of the inference. It justifies not pulling any planks or
fasteners in other areas on the absurd argument that the nails are
too hard to pull. This on a wrecked hull on which the fasteners
could have cut out.
"134. Generally, all marine surveyors and
Coast Guard inspectors testifying on the feasibility of removing
nails for examination felt removal of a plank was more prudent than
individually removing nails, due to plank damage caused by removing
nails."
4. As any experienced surveyor knows, bay bottom
boats bear that name for good reason. Transverse framing is a shortcut
method of boat building, intended for vessels used in protected
waters because they are not nearly as strong as longitudinally planked
boats. Bay bottom boats are notable for their tendency for wracking
which, in turn, produces the tendency for leakage, which in turn
wreaks havoc on fasteners. Nothing about the method of construction
is mentioned in the report. That none of these considerations are
raised gives rise to either questioning of the investigator's competence,
or his intent.
5. Conclusion #4 explains away the faults found
in prior CG inspections that were never addressed: leaking at the
starboard chine forward, deterioration of wood around keel bolts,
plus "working/seepage" at the starboard side of the keel,
midlength in the fuel tank compartment. Couldn't be due to the broken
tank saddles could it? ". . . all indicate that the vessel
was not in optimal condition." Optimal condition? What does
that mean? "However, the circumstances were not severe enough
to result in the issuance of requirements or supervisory direction
for the actions beyond the special inspection notes recommended
by the inspectors." In other words, they made notes in the
file on these conditions but otherwise did nothing. One has to wonder
just how serious does it have to be to get their attention? This
explanation is entirely inadequate.
6. The report states that the fuel tank saddle
was broken loose from its frame fasteners and was resting on a plank.
It further states that a wear pattern existed to show that the condition
was long standing. For the reporter to state that this was a secondary
consideration is ludicrous. Nothing in the report suggests that
the entire weight of one end of the fuel tank was not resting on
the plank. One could only conclude that a fuel tank saddle resting
on a bottom plank would be a major contributing cause to that planks
coming loose. This statement is clearly meant to deflect attention
away from the fact that the inspectors did not find this condition
in any of the last inspections. Or worse, that they knew of it and
did nothing. Since the insurance survey has not been made public,
we do not know if the insurance surveyor found this problem. Now
consider the following statement:
"There was no evidence as of the drydock examination
in March 1993 that this circumstance had any affect on the integrity
of the hull."
As with so many other conclusions in this report,
this statement is inserted in the report with no substantiation
at all.
Conclusions of the Investigation
"1. The proximate cause of the casualty was
failure of the fasteners in the planks A,B, and C in way of the
keel. The relatively severe seaway provided the forces that worked
the planks loose, flooding all compartments . . . " Apparently
he means that the seas pulled the planks loose but that the fuel
tank sitting on a plank had nothing to do with it.
This conclusion is also notable for the fact that it does not state
what the cause of the fastener failure was. Why does the
investigator fail to state that the cause of the failure was corrosion?
Although conclusion #3 talks about a variety of metals, including
through hull fittings and ground plates, "contributed to the
galvanic corrosion." At this point we have to be wondering
how you build a boat without a variety of metals under water. Since
all wood boats have dissimilar metals underwater, why is this one
more adversely affected? No mention of the vessel's age is made,
nor how long steel fasteners are expected to last. Nor to the general
rule of thumb that even bronze fastened boats should be thoroughly
checked after 15 years, yet alone 32 years.
More importantly, it is widely known that bay bottom
hulls defy the principles of strong wooden boat construction, that
they are fraught with problems, which is why only a few builders
in the mid-Atlantic coastal region used the method.
Conclusions #4 & 5 are also noteworthy for
their self-serving statements. This one deals with the observations
made by the CG at the 1989 and 1989 CG hull inspections, as previously
mentioned, in which "working/seepage at the starboard side
of the keel midlength in the fuel tank compartment," "leakage
around the keel," and wood deterioration around the keel bolts
were observed yet no orders for repair were given. Isn't this precisely
the area where the planks popped loose?
Conclusion #5 is particularly interesting from
the standpoint that it draws the conclusion that the wastage of
fasteners at the 3 planks is a "local problem" and is
a conclusion without substantiation. "The location was subject
to abnormal corrosion rates due to being a low point where
bilge water would collect, to the variety of nearby dissimilar metals
and to the design of the vessel in the garboard area." Is having
a low point in the bilge "abnormal"? And then this interesting
statement: "The inline end of the bottom planks is conducive
to working that would allow the joint to become loose and the water
to enter the joint." This statement clearly indicates that
the investigator is aware of the wracking problems with bay bottom
boats. He knows that the bottom planks work, and yet would have
us believe that its strictly a "local" problem.
All by itself, the above paragraph contradicts
and invalidates the entire investigation report. If the inline
end of the bottom planks are conducive to working that would allow
water to enter the joints, then it follows that the nails are going
to get wet and corroded. No galvanism is necessary as salt water
does a wonderful job on steel, galvanized or not. Further, it had
been substantiated in this and prior inspections that there was
looseness, working and leaking of water from inside the vessel when
it was hauled. Apparently the effect of looseness and water exposure
to steel nails at that time "were not serious enough to result
in issuance of requirements . . ."
But these conditions are now serious enough to
be cited as the cause of corrosion of the fasteners that ultimately
sank the vessel and killed three innocent people. In just a few
years, a period of time when drydock inspection was postponed three
times, it went from not serious to complete failure. To accept these
statements at face value, one would have to believe that the CG
inspectors and the investigator had no knowledge of the corrosive
effects of sea water on galvanized nails. Yet the report reflects
that they do know.
Any objective investigator would have concluded
that the CG had failed in its prior inspections, what with their
files containing notes of these serious conditions, to issue a requirement
for mandatory fastener inspections, along with granting of delays
for drydock inspections. After all, they are not inspecting farm
equipment but certifying a public conveyance that is going to sea
in the dead of winter.
Conclusion #10 passes the buck by saying that there
is no "well-known published guidance in the marine industry"
on when fasteners should be inspected. This despite the fact that
they are the certifying authority and its their responsibility to
know, not blame it on the marine industry. But then the writer destroys
his own argument by saying, "Much of the available guidance
on fastener examination typically assumes indications of wastage
are present to suggest examination." This is utter nonsense:
the surveyor does not have to see external evidence of fastener
wastage to know that 32 year old steel nails are likely to be completely
wasted, yet alone moderately so. Of course, no references are ever
cited. Yet the most well known book around, Ian Nicholson's Surveying
Small Craft goes into great detail about inspecting fastenings,
including discussion about telltale evidence that suggests fastener
problems.
The Statement of Fact section of the report item
#6 notes that CG Vessel Inspection Circular (NVIC) No. 1-63 recommends
against the use of cut nails due to a lack of holding power in some
circumstances. ABYC Project H-7 recommends against the use of ferrous
fasteners, and if ferrous should be hot dipped galvanized. This
does not prevent the CG from concluding that there is "no published
guidance" and no fault of their own inspectors from following
their own recommendations. How much more guidance do they
want? When a privately published and voluntary standard suggests
that its a problem for pleasure craft, can't they take the
hint that it could be disastrous for a public conveyance that is
32 years old?
Conclusions 7 & 8 provide cover for the inspectors
who carried out the earlier inspections, explaining why they only
examined the "wind and water line interface, limiting his examination
of fasteners to that area." Obviously they didn't just examine
the waterline area because their "notes" indicate problems
at the chine and keel. The essence of this commentary is that it
is the experience of the inspectors that the water line area is
a more critical area to inspect. This is their explanation for not
inspecting the planks at the keel rabbet which this very report
later states is the most probable area to expect corroded fastenings.
Again, the report discredits itself. See Conclusion #5 above.
Conclusion 25 is equally incriminating. I'll reproduce
it here in whole:
"Although Coast Guard marine inspectors are
sensitive to the time, material and labor costs imposed on owners
of wood boats caused by the requiring the removal of fasteners,
there is no evidence that this sensitivity directly contributed
to this casualty. [Emphasis added] These costs can be considerable
for owners of small vessel, especially those which carry few passengers
and have low value. The impact . . . could drive them out of business
. . ."
How about the cost to the passengers and three
people who lost their lives? Is this a Freudian slip or what? Here
the writer is giving the boat operators a free pass. In other words,
because we have passenger vessel operators who are using old, dilapidated
wooden boats to run a public conveyance, the Coast Guard shouldn't
risk bankrupting them by ensuring that these vessels are safe. As
with airlines, if the nature of the business doesn't produce sufficient
revenues to produce safe vessels, then they shouldn't be in business.
As with the ValueJet disaster late last year, once again we've witnessed
a federal regulating agency give a shaky business operation a free
pass on safety. As a result, over 100 people died.
If ever there was a prime example of how not to
write an investigation report, this is it. These statements are
little more than an excuse for failure to perform, not an objective
evaluation. Of course keeping old boats maintained will bankrupt
the owners, just as old jet aircraft can bankrupt an airline. Why
aren't 707's used in passenger service anymore? That's not an acceptable
excuse for allowing defective conveyances to operate. Old vessels,
like old aircraft, need to be retired when their safety can no longer
be assured.
Finally, here is the coup de gras that we would
expect from any government agency investigation of its own handiwork:
"34. There is no evidence of negligence on the part of any
other government employee or person holding a license or document
issued by the Coast Guard." - emphasis added.
Of course not. We investigated ourselves and we
are clean! And so are the people we grant licenses to.
Lessons to be Learned: The Surveyor's Role
At the outset of the CG report considerable issue
was made about the insurance surveyor's role in the case. This surveyor
was a direct employee of the insurer and was performing the survey
for the insurer at no cost to the vessel owner. He had already surveyed
the other four vessels owned by Mr. Smith. He found them to be in
poor condition and they had already been placed on port risk by
the underwriter at the time he surveyed EL TORO. They were not placed
on port risk because the surveyor thought they were safe. At that
point, its easy to imagine what the owner's attitude toward the
surveyor was.
When he surveyed the EL TORO, Smith accompanied
the surveyor to the vessel then left. The surveyor's comments in
his report to the insurer was "This is one of the worst Coast
Guard inspected vessels that I have ever seen," a comment that
is mentioned in the CG report. Although we do not know the exact
nature of his findings, we do know that the surveyor did not report
them to the vessel owner as he had left the scene. (The CG reports
indicates that the surveyor stated that no one of 20 odd defects
would be sufficient to condemn the vessel. Yet the implication of
the statement, along with the surveyors comments, indicate the cumulative
findings were sufficient to condemn it.) Further, the surveyor states
that he had been told by Smith that the vessel was laid up for the
season, and therefore he did not expect it to be going to sea. Smith,
as well we can imagine, denies that, saying that he told him the
vessel was still operating and would be operating soon.
Here we have a situation in which the insurance
surveyor condemned five out of five of this operator's vessels.
The CG report makes no mention of any of these other vessels. The
interesting question here is whether the CG gave these other four
boats a free pass also?
Legal Responsibility for Notification of Serious
Defects
The Coast Guard raises the issue of why the surveyor
did not inform them, the CG, or the vessel owner of his findings.
Since he condemned the other four boats, and this was the worst
of them, we can presume that he intended to constrain this one to
port risk also. Again, this is a subtle passing of the buck to the
insurance surveyor, saying, in essence, if you had told someone,
this wouldn't have happened. Clearly, the writer of the report
knows that this will paint the surveyor into a very dark corner
indeed.
No doubt the surveyor felt satisfied that the vessel
was laid up (as were the other four despite the confinement to port
risk, since the rockfish season had already ended.) and therefore
he felt he had no need to make an immediate notification. On the
other hand, in these situations, there is often a question of whose
responsibility it is to make a notification, if any.
With a legal system as muddy as ours, the issue
of liabilities in a disaster scatters like birdshot. The surveyor
is going to find himself caught up in it no matter how sterling
his performance. The issue of notification has not, to my knowledge,
ever been clarified. Yet the circumstances in this case clearly
points to the answer. Whether required to or not, notification should
be given the owner in writing. Obviously, verbal notification would
be of little value because the owner was already unhappy with the
surveyor, and in the event of an accident, would only deny the verbal
notice anyway. Therefore, only notification by certified mail would
have sufficed. Chances are that even notification by regular mail
would be denied, and there would be no proof that the owner had
ever received it.
As to whether the surveyor had an obligation to
report adverse conditions to the Coast Guard, my opinion is no,
he did not. Nor should he be required to do so, despite the CG recommendation
in the report. If the CG undertakes to certify vessels, then it
is their responsibility to ensure their satisfactory condition.
And, as we know only too well, they fail in this job miserably as
is clearly demonstrated in their own report. If surveyors are required
to notify the CG, this raises all sorts of legal issues and questions
of procedure and responsibility that could never be satisfactorily
resolved.
Participating in Joint Investigations
When participating in any investigation, particularly
governmental investigations, the lesson here is to be careful what
you say. Anything you say can and will be used against you. In this
case, the CG has a clear conflict of interest. It was entirely predictable
that their investigation would be completely self-serving. The surveyor
would have been best off had he said nothing to them. Not only did
they seek to shift the blame to him, but should the surveyor be
implicated in the lawsuits that are likely to go on into the next
millennium, both his comments and the report will hurt his defense.
Bias is Always Obvious Another interesting
point has to do with the report itself. That the report discredits
itself of course was never obvious to the writer, even though its
obvious to any non-involved person who reads it. The principle here
to remember is that bias in report writing is always obvious to
others, but never the writer. The effort to conceal, misrepresent
or omit factual evidence is often unconscious; the fact is that
obtaining true objectivity is very difficult for anyone, and there
are very few persons who have the capability to be entirely objective.
In all investigations surveyors are hired by someone
with an interest. It is a natural inclination to try to assist those
who are paying our fees or salaries. At first reading, the inconsistencies,
omissions and outright contradictions are not obvious; they only
become so upon careful study. But it is important to remember that
in a serious casualty, all reports are subjected to extremely detailed
study. And if the Coast Guard is being sued in this instance, there
can be no doubt but that the plaintiff lawyers will have a field
day with this report. Its a plaintiff's lawyers dream because it
impeaches itself.
The lesson, of course, is that important investigation
reports should never be rushed. The best way to craft as objective
report as possible is to refine it over a period of time, say a
week or so. There's nothing like proofing a report from a perspective
of a time interval from the moment it was written until it is issued.
That gives us the time to think about it, digest it, and approach
it on another day when our thoughts may be a bit clearer, the faults
and inconsistencies more obvious.
Old Boats By now it should be abundantly
clear that old wooden vessels should be approached with the maxim,
guilty until proven innocent. No one has ever been able to
establish an average term of safe life expectancy for wooden vessels
because the quality of materials and construction designs vary so
much. It is widely known that economically built hulls, such as
most pleasure craft, become suspect within 15 years or less. Tens
of thousands of Chris-Crafts, Pacemakers, Egg Harbors, Allied and
others were built in the 1960's and nearly all of them are gone
now. Fastener problems frequently arose after only ten years, and
all surveyors know this. Why doesn't the Coast Guard?
For better built craft, we have the examples of
Trumphy, Wheeler, Consolidated, Elco and others that had safe useful
lives of 30 years or more. Any yet because some of those boats are
still around, no one should ever assume that they are safe because
they are not. Wood structures and metal fasteners have limited life
spans; the older they get, the more deteriorated and suspect they
become. To look at the outside or inside and say that 32 year old
fasteners are probably okay is irresponsible. This writer decided
a decade ago to decline to survey old wooden vessels because his
experience was that none of them were safe for open sea conditions
and he didn't want to find himself in the position that the insurance
surveyor mentioned in this report finds himself. Nor is he alone,
as most competent surveyors now decline to survey old wooden vessels.
The risk is just too great. Yet the Coast Guard has gone blindly
on its way certifying these disasters waiting to happen. And while
the CG report states that it knows of no other similar casualties
involving wooden vessels, the fact is that there have been dozens
in the last decade alone, especially involving uninspected passenger
carrying vessels.
It is impossible for a surveyor who knows his business
to believe that the hull of this vessel on prior drydockings revealed
no evidence of its poor condition. Indeed, there are several mentions
in the report about its remarkably "apparent" good condition.
This writer has yet to see a 30 year old wooden hull that did not
display clear evidence of structurally deteriorated conditions,
from open seams, worm damage, cupped planks, loose planks and evidence
of corrosion from rust or copper stains in way of fastener heads
and bungs. The evidence is always present and the prior CG
files and reports prove it.
The CG uses the excuse on one inspection that the
bottom was freshly painted. Yes, indeed, but every surveyor knows
that one cannot survey a freshly painted bottom effectively unless
prepared to pull a lot of fasteners. But it has long been de
rigeur for surveyors to pull fasteners on any wooden vessel
regardless of age. And while they suggest fault of the insurance
surveyor for not providing immediate notice, they do not fault themselves
for their own negligence in raising the red flag at this point.
Instead, they complete the inspection, knowing that they can't do
it effectively, and then give it a clean bill of health. An independent
surveyor would hang for this. But here we're dealing with the government.
The correct procedure at this point would have been to pull fasteners,
or reschedule 90 days hence when the bottom paint would no longer
be fresh and the corrosion patterns would reappear through the now-aging
paint. It is impossible to believe that a 32 year old vessel with
steel fasteners does not show evidence of corrosion at frame intersects
or at bung heads.
Old Boats in General All material things
in this universe deteriorate, so at greater and some at lesser rates,
but deteriorate they do. When it comes to boats and ships, which
float in an extremely corrosive substance, age itself is a dangerous
factor that should never be treated lightly. Whether its wood, fiberglass
or aluminum all structures deteriorate and weaken over time, as
do systems and machinery. To use an old cliche, a book should never
be judged by its cover as boat should never be judged by its appearance.
To make assumptions when surveying based on appearances can ultimately
cost you dearly. The only proper attitude toward older vessels is
one of extreme caution. Inspect, verify and explain fully. That
means cover yourself with all necessary exculpatory statements and
written record.
These are the important lessons for surveyors in
the EL TORO tragedy:
1. Whenever any circumstance prevents the full
and effective performance of our function, we need to send a red
flag up the mast in clear and certain terms. Fortunately, we do
not certify, but we are responsible for making notification of any
evidence that adversely affects safety.
2. Never make the mistake of downplaying evidence
of defects such as saying, "It doesn't affect the structural
integrity," unless you absolutely certain of this and would
be prepared to defend that statement in court. Nearly every surveyor
is guilty of this, including myself, mainly due to the casualness
of the pleasure craft business. The case of the EL TORO reveals
how a casual comment can turn into a matter of life and death. It
is far better not to make a favorable summary judgment than to render
a casual opinion.
3. Surveyors are often pressed to render snap decisions
and fast reports. This is conducive to serious errors of judgment
and may happen frequently. We usually sense it by feeling uncomfortable
about it. We should never hesitate to review a situation that doesn't
sit right, and never hesitate to amend a faulty decision, particularly
one that could have dire consequences.
4. Notify vessel owners of dangerous defects both
verbally and in writing, and do it promptly. Don't wait for the
insurance company to do it. If something bad happens, the surveyor
is going to be on the hook.
5. When tragedy strikes, blame scatters like buckshot.
Suggestions for the Coast Guard Either get
serious about small vessel inspections or get out of the business.
Those of us who are familiar with the CG are aware that most of
their problems with the small vessel industry stems from a congress
harrassed by an industry lobby that pulls them in one direction,
and the need for competent regulation in another. But, as the FAA
has recently discovered with a rash of hideous airline crashes,
they can't have it both ways. Either the well-being of the industry
comes first, or safety does.
Competent regulation means that tough regulations
must be backed up with a philosophy that puts safety first. As this
case amply demonstrates, the Coast Guard has and does neither. By
no stretch of the imagination can regulation that permits old vessels
to go to sea with passengers with a single 32 year old bottomless
cork life raft and aging, deteriorating cork life jackets in the
dead of winter be called serious or tough. Three persons remained
on the vessel and three more were in the water. The implication
here is that not all 23 persons could fit in the life raft (for
they had plenty of time to get aboard) and yet the vessel is certified
for 49. What would have happened if EL TORO had her full capacity?
How many more would have died because the life raft would only hold
17?
Why don't regulations require life raft capacity
for all? I recently surveyed a vessel certified for 149 passengers
and it only had life raft capacity for no more than 50. Hasn't the
CG learned anything from the numerous passenger liner disasters
of the past where half the passengers died because there weren't
enough life boats? What in God's name does it take to get sensible
life saving equipment?
Despite the CG's absolution of itself, anyone who
takes the time to read that self-serving report will find many more
faults than I have mentioned here. Commercial fishing vessels operating
in cold waters are required to have immersion suits. Why are the
lives of commercial fishermen more worthy of this protection than
a vastly more ignorant general public?
Sure the CG has had long-standing problems of serious
budget cutbacks, reallocation of resources to such things as drug
and refugee interdictions, among many others. Yet if it is going
to continue to CERTIFY passenger carrying vessels, and not start
doing a better job of it, its inevitable that one day some old clunk
of vessel is going to take not just three persons, but 150 or 200
or 300 passengers to the bottom. And on that day the Secretaries
and Admirals are going to find themselves on C-SPAN facing angry
congressional committee members grandstanding for the folks back
home in yet another self-righteous effort to pass the buck. Only
this time, the Coast Guard brass will be the victims instead
of the buck-passers.
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