NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


NTSB FINDS CHARLESTON COAST GUARD'S SUBSTANDARD PERFORMANCE CONTRIBUTED TO DEATHS OF PASSENGERS ON SUNKEN VESSEL

October 5, 1999

Washington DC - The National Transportation Safety Board has determined that the U.S. Coast Guard Group Charleston's substandard performance in initiating a search and rescue response contributed to the loss of life in the sinking of the recreational sailing vessel Morning Dew. The Board also noted the need for improvement in the training of Coast Guard watchstanders and Coast Guard communications equipment.

The report adopted today is the result of the Safety Board's investigation into circumstances surrounding the December 29, 1997 sinking of the Morning Dew and subsequent search and rescue efforts. Although the Safety Board's investigation focused on the search and rescue efforts, the report also cited the failure of the Morning Dew's operator to adequately assess, prepare for and respond to the known risks of the open ocean journey as probable cause for the sinking of the vessel.

Through its investigation of a missed "mayday call" from the Morning Dew, the Board determined that training of Coast Guard communication watchstanders was insufficient and that there was a lack of instruction in the analytical and decision- making skills needed by the watchstanders when making critical judgment calls in matters of public safety. The report also noted the need for a program of periodic operational readiness inspections of Coast Guard communications centers in order to maintain high performance levels.

In a further finding, the Board indicated that the Coast Guard's ability to effectively respond to distress calls, and to identify hoax calls would be improved by installing currently available off the shelf direction-finding (DF) equipment that would provide position fixes on incoming calls as well as the capability to easily record, retrieve and review DF data.

Based on its investigation the Safety Board issued the following recommendations; among them:

To the U.S. Coast Guard:

* For all your operations and communications center watchstanders, develop and implement a course or training program designed to develop or enhance those individuals' judgment and decision-making skills.

* Improve your telecommunications specialist qualification program, in concert with the telecommunications school and the guidance in the Group and Stations Communications Watchstander Qualification Guide, to provide for increasing levels of watchstanding responsibility under the direct supervision of experienced mentors and to allow for full telecommunications specialist certification only after candidate watchstanders have passed comprehensive proficiency tests that demonstrate their skills.

*Immediately institute procedures to provide improved management oversight of the performance of all your communications and operations centers, including instituting a program to periodically review the tapes of recorded radio transmissions and telephone calls.

*Institute a system of periodic operational readiness inspections for all your subordinate land-based search and rescue communications commands, groups, and units as a means of evaluating and improving the search and rescue communications effort at those activities.

*Immediately begin to equip all your search and rescue communications centers with currently available, commercial, off-the-shelf direction-finding systems that provide, at a minimum, the capability to establish a position fix and to record position data for later retrieval and analysis.

To the Coast Guard and the States:

* Within six months, revise statements and memoranda of understanding that define the relationship between the States and the Coast Guard to accurately reflect current responsibilities and jurisdictions of the State and the Coast Guard in such areas as boating casualty accident investigation and reporting, search and rescue, and related boating safety issues.

To the National Association of State Boating Law Administrators, to the U.S. Coast Guard Auxiliary, to the U.S. Power Squadron, and National Safe Boating Council:

* Use, in your recreational boating education programs, the circumstances and lessons learned from the accident involving the sailing vessel Morning Dew as a means of educating boaters about the relationship of good judgment and decision-making to boating safety.

The Board's final report may be accessed on the NTSB's website, www.ntsb.gov. Printed copies may be purchased from the National Technical Information Service (800) 553 - NTIS. Please specify report number MAR-99-01.

NTSB Office of Public Affairs: (202) 314-6100

 

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The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.