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Review of
The NTSB Marine Accident Report

Vessel "EL TORO II"

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.

Related Reading:

The ELTORO Tragedy 
Sinking of Party Fishing Vessel
An independent Review of USCG Investigation Report

EL TORO Addendum - Law Suit

Surveying Wood Hulls

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?

Eltoro II

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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David Pascoe - Biography

David Pascoe is a second generation marine surveyor in his family who began his surveying career at age 16 as an apprentice in 1965 as the era of wooden boats was drawing to a close.

Certified by the National Association of Marine Surveyors in 1972, he has conducted over 5,000 pre purchase surveys in addition to having conducted hundreds of boating accident investigations, including fires, sinkings, hull failures and machinery failure analysis.

Over forty years of knowledge and experience are brought to bear in following books. David Pascoe is the author of:

In addition to readers in the United States, boaters and boat industry professionals worldwide from nearly 80 countries have purchased David Pascoe's books, since introduction of his first book in 2001.

In 2012, David Pascoe has retired from marine surveying business at age 65.

On November 23rd, 2018, David Pascoe has passed away at age 71.

Biography - Long version


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