Charleston, South Carolina
December 29, 1997
NTSB Number: MAR-99/01
NTIS Number: PB99-916401
Adopted October 5, 1999
During the early morning hours of December 29, 1997, the 34-foot recreational sailing vessel Morning Dew struck the rock jetty on the north side of the shipping channel into the harbor of Charleston, South Carolina. The owner/operator of the vessel and his three passengers, all members of the same family, died as a result of the accident.
The National Transportation Safety Board determines that the probable cause of the sinking of the recreational sailing vessel Morning Dew was the operator's failure to adequately assess, prepare for, and respond to the known risks of the journey into the open ocean that culminated in the vessel's allision with the jetty at the entrance to Charleston Harbor. Contributing to the loss of life in this accident was the substandard performance of U.S. Coast Guard Group Charleston in initiating a search and rescue response to the accident.
The major safety issues identified in this investigation are the adequacy of the reasoning and decision-making of the operator; the fatigue and hypothermia suffered by the operator; the adequacy of the reasoning and decision-making of U.S. Coast Guard Group Charleston's watchstanders; the adequacy of Coast Guard Group Charleston's personnel, equipment, and procedures for responding to an emergency; and the role of the Coast Guard in providing factual information for safety investigations.
As a result of its investigation, the Safety Board makes safety recommendations to the U.S. Coast Guard, the Governors of the 50 States and the U.S. Territories, the National Association of State Boating Law Administrators, the U.S. Coast Guard Auxiliary, the U.S. Power Squadrons, the National Safe Boating Council, and the Boat Owners Association of the United States.
As a result of its investigation, the National Transportation Safety Board makes safety recommendations as follows:
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. (M-99-2)
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. (M-99-3)
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. (M-99-4)
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. (M-99-5)
Institute a permanent policy of promptly sharing pertinent search and rescue information with properly constituted local, State, and Federal investigative agencies so long as the release of such information does not compromise the ability of the Coast Guard to perform its search and rescue mission. (M-99-6)
Take the steps necessary to immediately begin to provide all Coast Guard search and rescue communications centers with the capability for watchstanders to easily and instantly replay the most recent recorded radio transmissions. (M-99-7)
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. (M-99-8)
Review the ergonomic adequacy of equipment layouts in all Coast Guard group communications centers and make changes as necessary to ensure that equipment critical to the proper performance of the watchstanders' duties is placed in the optimum ergonomic arrangement. (M-99-9)
Conduct a comprehensive review, similar to the one conducted by the Naval Surface Warfare Center, Carderock Division, at Group Charleston and group Mobile, of the communications infrastructure at all group communications centers and take immediate steps to correct any deficiencies found. (M-99-10)
Ensure that the workload and staffing analysis for which you have contracted with the Center for Naval Analysis fully incorporates existing human performance research on vigilance, attention, and fatigue in the determination of shift length, shift rotation, and staffing levels at all Coast Guard search and rescue communications centers. (M-99-11)
Implement a program whereby Coast Guard emergency response personnel participate in drills with local agencies within their area of responsibility in order to exercise their role in the incident command structure and gain experience in using the incident command system. (M-99-12)
Within 6 months, and at least biennially thereafter, review and revise, as necessary, all boating safety agreements between the Coast Guard and the States to ensure that those agreements (1) are coordinated between local Coast Guard authorities and the appropriate agencies within the States and (2) accurately reflect current responsibilities and jurisdictions in such areas as boating casualty accident investigation and reporting, search and rescue, and related boating safety issues. (M-99-13)
Disseminate the National Transportation Safety Board's report on the Morning Dew accident to all your group operations and communications center personnel as a way of informing them of the circumstances of the accident and the lessons to be learned from it. (M-99-14)
Establish procedures for toxicological testing for alcohol and drugs of Coast Guard personnel in group and unit operations and communications centers whose work performance may be linked to an accident. (M-99-15)
Review the navigation aids marking the route of the Intracoastal Waterway (ICW) at Winyah Bay and make any changes necessary to reduce the likelihood that southbound recreational boaters intending to follow the ICW will inadvertently depart that waterway and follow the main shipping channel toward the open ocean. (M-99-16)
To the Governors of the 50 States and the U.S. Territories:
Within 6 months, and at least biennially thereafter, work with the Coast Guard to review and revise, as necessary, all boating safety agreements between your State and the Coast Guard to ensure that those agreements accurately reflect current responsibilities and jurisdictions of each entity in such areas as boating casualty accident investigation and reporting, search and rescue, and related boating safety issues. (M-99-17)
To the National Association of State Boating Law Administrators: (M-99-18)
To the U.S. Coast Guard Auxiliary: (M-99-19)
To the U.S. Power Squadrons: (M-99-20)
To the National Safe Boating Council: (M-99-21)
to the Boat Owners Association of the United States: (M-99-22)
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.