Previously
I posted on this site The EL TORO II Tragedy:
An Independent Review of the Coast Guard Investigation Report
in which I roundly criticised this investigation report as
being self-serving and selectively misinterpretive of the facts
contained within their own report.
The National Transportation Safety Board completed
a parallel investigation along with the Coast Guard on September
7, 1997, a copy of which I have recently obtained. As with the CG
report, I was impressed that the NTSB also seems to go out of its
way to absolve everyone but the insurance surveyor. As with the
CG report, this one also discusses the insurance surveyor's role
and leaves the reader hanging whether the insurance surveyor should
have informed the vessel owner of his findings. Yet this report
also finds that neither the vessel owner nor the CG made any mistakes.
Since the vessel captain, owner and the CG are
the regulated and regulator, its hard not to wonder why they were
absolved, and yet the insurance surveyor is left hanging. Why didn't
they conclude that he had no fault either? Have they just made him
a convenient target because none of his actions would reflect back
on them?
The EL TORO II hauled after salvaging.
Notice the rust stains even on the hull sides from corroded steel
fasteners.
Investigating the Investigators The NTSB
and the FAA have recently come under a great deal of criticism from
both the public, citizen's lobbys and congress over regulatory problems
involving in recent airline disasters. The Inspector General of
the FAA, Mary Schiavo, became a whistle blower over alleged corruption
and malpractice within these agencies and ultimately resigned after
being subjected to public ridicule by the brass. But not before
revealing the very cozy relationship between the regulators and
regulated. Good work, Mary. We are all in your debt and can feel
a little safer when we fly.
Readers of Government investigation reports will
quickly recognise the typical methodology and means of dealing with
conclusions. They investigated, they found serious problems, but
were loathe to state that anyone was at fault, least of all another
government agency or anyone holding a government license. You will
find exactly the same methodology in the I.G. investigation of the
FBI labs scandal. Most of the criticism was leveled at whistle blower
Fred Whitehurst. But never mind. The astute observer can easily
read between the lines. Reading between the lines is not even necessary
because, as one would rightly expect of the NTSB, they have done
a considerably better job with their report, if not the conclusions,
particularly as to background investigations involving casualties
of other wood vessels.
Both the CG and NTSB generally outline the mistakes
that, had they been avoided, would have prevented the tragedy. These
are mistakes that apparently materialize out of thin air. The NTSB
is a bit more forthcoming about them, yet draws the same conclusions
that there is no one at fault - except possibly the surveyor, whom
they leave dangling. Essentially both reports draw the same conclusions
- to blame the rules or lack of "adequate guidance". After
all, these things are not persons and don't have names and can't
fight back.
To make matters worse, the NTSB report makes clear
that this accident occurred despite clear warnings about aging wood
hulls that were issued to all Marine Safety Offices back in 1991,
and also in individual investigation reports issued by the CG. Thus,
the claim of inadequate guidance is sheer nonsense. Warnings were
issued and they were ignored.
What has to rock those of us in private industry
back on our heels is the incredible double standard that government
agencies apply to themselves as compared to private persons. The
laws of the individual states and the Federal Government holds all
of us who provide products and services to the public to a very
high standard of performance and liability. The law charges us,
not only for the avoidance of mistakes and negligence, but also
for maintaining an awareness of, and applying the highest possible
standard of safety where the public is concerned.
Yet that same level of care is rarely, if ever,
applied by the federal agencies who are charged with maintaining
that level of safety. While one might be somewhat sympathetic to
the idea that government agencies probably wish to avoid injecting
themselves, by means of their investigation reports, into what they
obviously know will end up as civil litigation, we in private industry
have to deal with these issues on a daily basis and take those risks.
All with resources that are minuscule compared to those of the federal
government.
Already I have received quite a bit of negative
feedback from surveyors who have working relationships with the
Coast Guard. They are not happy about my criticism at all. Apparently
they miss the point that there are three people dead and many injured
in a tragedy that could easily have been prevented. Marine surveyors
are often faced with the same hard choices that the CG was here.
Namely to mandate costly repairs and raise the ire of the vessel
owner, or be faced with the consequences of a tragedy such as EL
TORO II.
For myself, that choice has always been clear.
I am a student of disasters and how to prevent them. That's the
service I provide, and I don't want to find myself on the wrong
end of multi-million dollar law suit as inevitably follows accidents
like this. The only good news is that that eventuality is completely
avoidable.
As the case of FBI forensic scientist Frederick
Whitehurst and shoddy practices at the FBI labs has shown, whistle
blowers are never popular and, indeed, are usually scored and ridiculed.
Usually their careers are deliberately ruined by those who attempt
to preserve the status quo for their own selfish purposes. We make
our beds and we must sleep on them, if we can.
My purpose in revealing the EL TORO II incident
is to show that doing the right thing is usually easier than doing
otherwise. Just as building a good boat is not much more difficult
than building a bad one. Nearly the same amount of effort is involved.
All that is required is better knowledge. The main difference is
that everyone can sleep a little easier at night. When we do the
right thing, our souls are at rest.
NTSB Report Summary In this reviewer's opinion,
the NTSB report is even more contradictory and self-impeaching than
the CG report. This report generally avoids looking into the past
CG surveys and records of the vessel in any detail. Although they
are briefly mentioned, the report does go into very considerable
detail about past accidents involving wooden vessels. Whereas the
CG report stated that there very few prior disasters involving wooden
vessels, the NTSB report indicated numerous accidents involving
wooden vessels, as many as 134, thoroughly destroying the CG claim
that they had little past knowledge to go on.
This included a 1991 CG study of accidents that
involved passenger abandonment of the vessel. Incredibly, this report
is cited as stating that 15 out of 16 vessels were wood hull vessels.
But the CG tried to wiggle out of knowledge of this huge base of
information by saying that there were few cases of "inspected"
vessels, as if that made a great difference.
As if that were not enough, the NTSB report goes
on to cite it's own records of wooden boat casualties, which appears
as follows:
The Safety Board investigated the May 19, 1973
sinking of the charter fishing vessel COMET and determined that
the sinking was probably caused by major, undetected flooding due
to the ingress of water through deteriorated hull planking. Since
the COMET sinking, the Safety Board has investigated other accidents
that involved small passenger vessels and has found that older wooden
vessels, including small passenger vessels, have unique safety problems
inherent in their hull construction materials. [emphasis
added] The 1985 through 1991 accident statistics obtained from
the Coast Guard show that a disproportionate higher number of
wooden passenger vessels have accidents compared with passenger
vessels constructed with other materials. The fleet of CG-inspected
small passenger vessels is constructed primarily of wood, steel,
aluminum and fiberglass (24,23,26 and 25 percent, respectively).
The statistics show as many as 41 percent of accidents that entailed
vessel flooding and foundering involved wooden-hulled vessels: however,
a lower number of these accidents involved vessels constructed of
steel, aluminum, and fiberglass (19, 11, and 15 percent, respectively).
As a result of the March, 1985 sinking of . . .
CAPTAIN CRUNCH, a 29 year old, 65 foot-long wooden-hulled vessel
. . . CG issued notice to all CG districts in March, 1985 . . .
the notice emphasized the need for thorough inspection of wooden-hulled
small passenger vessels over 15 years old and stated, 'the hull
integrity of older wooden T-boats is an area of particular concern.'
The 1991 CG study is summarized by the NTSB report
as follows:
The high proportion of wooden vessels indicates
the significantly higher susceptibility of wooden vessels to develop
safety problems, including undected hull deterioration. At least
four of these wooden-hulled vessels (COMET, ZEPHYR II, SUNRISE II,
and ALMA III) sank after flooding that occurred when hull planking
had sprung or become detached from the hulls because of its
poor condition and age. Fourteen of the 16 accidents involved
small passenger vessels like the EL TORO II that were engaged in
charter fishing or head boat service.
The study further concluded:
The vessels involved in accidents had an average
age of 26 years. Sixteen years is the average age of the entire
small passenger vessel fleet. Older wood vessels are susceptible
to undetectable deterioration of the hull.
Vessels over 20 years old are more susceptible
to flooding and foundering than newer vessels, and a large percent
of vessels in this age group are wood.
Finally, how much more damning can it get than
this next quote from the 1991 CG study:
[O]f the vessel casualites reported between 1981
and 1993, 134 involved wooden vessels, and the primary cause of
casualty was "failed materials, structural." These structureal
material failures resulted in either flooding or foundering (sinking)
of all 134 vessels . . . of the 134, 6 are Coast Guard inspected
passenger vessels, the remaining are mainly various types of uninspected
fishing vessels.
From the NTSB report:
The [CG] inspects more than 5, 000 small passenger
vessels each year, of which about 1400 are wood hulled and at least
1,000 are over 15 years old.
Apparently the NTSB and Coast Guard must believe
that no one will bother to read their reports, for how can they
come to the conclusion that the CG doesn't have enough "guidance"
when the NTSB has just demonstrated that the CG is undoubltly the
leading expert on the subject and has condemned them with their
own knowledge. The CG investigation report statement that it has
little evidence of prior accidents and knowledge of the problem
flies in the face of their own reports.
The fact is that, next to a man's feet and the
horse, wooden vessels are one of the world's oldest means of conveyance,
going back thousands of years. Just about everything that can be
known about them is known. One can only conclude that the CG has
turned a blind eye on a public safety problem that is thoroughly
documented in their own work.
Compared to a marine surveyor, who in the heyday
of wooden vessels, would have the capability to survey no more than
perhaps 50 wood pasenger vessels in a year, the CG is inspecting
over 1400 annually. And in the process it has to be accumulating
an enormous volume of critical data, all of which it has apparently
chosen to ignore. Moreover, the prior inspections of EL TORO II
do not appear to have been affected by a high rate of turnover with
inspectors, for the CG report takes pains to indicate that their
inspectors had 6-8 years of experience.
Responsibility For Vessel Safety One of
the most inviolable cannons of maritime law is that vessel owners
and others involved with vessels carrying crew and passengers are
charged with the highest level of responsibility. Utmost regard
is the phrase used. Yet by its own admission, the utmost regard
of the CG concerned the economic viability of the vessel owner.
They did not wish to submit the owner to the expense of pulling
planks or fasteners even though their own studies and records show
that older woooden vessels are at high risk. This from the CG report:
"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
. . ."
Unfortunately, far too often this is the cozy relationship
between the regulators and the regulated. The FAA had the same attitude
toward ValueJet. And yet over and over again the casualties occur
and the irresponsible actions of the regulating agency are swept
under the rug. None of this would be possible if the federal government
did not have the power to limit its own liability. But it does.
If these people were subject to the same liabilities that marine
surveyors are, you can bet they'd shape up fast.
The NTSB resorts to the same excuses as the CG,
although somewhat differently. In part, it passes the buck off onto
the Small Passenger Vessel Owner Association. Because the SPVOA
published certain guidelines, the NTSB found a convenient out by
saying that "[they] do not generally provide specific guidance
for maintaining the structural integrity of wooden hulls, especially
fasteners." And all the while we thought the Coast Guard was
the regulating agency.
Although it does fault the CG for not having adequate
inspection methodology, the CG is not criticized for making use
of the knowledge that they already posess, as contained in their
own reports - that age and fastener problems pose serious hazards
to wooden vessels.
Again, as with the CG, the NTSB absolves the vessel
owner in heading out to sea despite his prior knowledge of the issuance
of gale warnings. Because other vessels were also out, this provided
a convenient excuse: others were irresponsible too. Yet one does
not have to look very far to find cases of CG reports that criticised
private yacht owners from heading out in face of small craft warnings,
yet alone gale warnings. They level this criticism frequently. Why
is the passenger carrying public converyance EL TORO II subjected
to a different standard?
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