Marine Accident Report: Collision between USCG boat and recreational vessel, San Diego, CA, December 20, 2009

This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

On Sunday, December 20, 2009, about 1744 Pacific standard time, the 33-foot-long Coast Guard vessel CG 33118, designated by the Coast Guard as a "special purpose craft - law enforcement" or SPC-LE,with five crewmembers on board,collided with a 24-foot-long Sea Ray recreational vessel with state registration number CF 2607 PZ, carrying 13 people, on San Diego Bay, California. The collision occurred during the city's annual holiday boat parade, the Parade of Lights. The Sea Ray was headed west near the main shipping channel to enable the occupants to watch the boat parade. The CG 33118, on patrol in the bay, was also headed west, its crew responding to a reported grounding. The CG 33118 struck and overran the Sea Ray's stern near the west end of Harbor Island. As a result of the collision, an 8-year-old boy on board the Sea Ray was fatally injured and four other people on board sustained serious injuries. No CG 33118 crewmembers were injured in the accident.

Following the collision, drug and alcohol testing was performed on CG 33118 crewmembers, and all results were negative. The Sea Ray operator voluntarily submitted to drug and alcohol testing, and the results of his tests were negative as well.

FINDINGS

  1. Weather, illegal drugs and alcohol, and the mechanical condition of both vessels were not factors in this accident.
  2. The vessel grounding to which the CG 33118 responded was not an emergency and did not necessitate a high-speed response that reached 42 knots at one point.
  3. The CG 33118 was planing, that is, traveling at least 19 knots, at the time of the collision, considerably faster than a safe speed of 8 knots or lower under the prevailing conditions.
  4. The CG 33118 coxswain and crew were aware of the heavy vessel density in the area.
  5. The coxswain's operating the CG 33118 at any planing speed was unsafe for the prevailing conditions and circumstances of darkness, background lighting, and high vessel density in the parade area.
  6. The continuous illumination of the Sea Ray's all-around light, the effects of the background lights that limited the conspicuity of the all-around light, and the similar headings of the two vessels coupled with the dead-astern approach by the CG 33118 made it difficult for the crew to visually detect and perceive the Sea Ray; however, traveling at a slow speed would have compensated for these visual difficulties.
  7. Special purpose craft - law enforcement (SPC-LE) vessels have obstructions to forward visibility from the helm and the forward port positions, which increase risks if not properly addressed.
  8. The Sea Ray operator was driving his vessel at a safe speed and manner for the prevailing conditions and circumstances.
  9. The CG 33118's high speed and its astern path relative to the Sea Ray precluded the Sea Ray operator from taking effective action to avoid the collision.
  10. Station San Diego oversight of small boat operations was ineffective in ensuring compliance with established policies for safe operations.
  11. At the time of the accident, the absence of Station San Diego speed restrictions for routine patrols at night allowed coxswains too much latitude in selecting patrol boat speed.
  12. The Coast Guard failed to effectively ensure that its automatic identification system policy was enforced in San Diego.
  13. Systematic monitoring of all available operating data could assist Coast Guard small boat supervisors in objectively assessing how their vessels are operated, and periodic review of this information could enhance operational safety and oversight by aiding supervisors in detecting and correcting deviations from standard operating guidance and procedures.
  14. Records indicate that the CG 33118 crewmembers used their personal cellular phones for voice calls and text messaging while under way, distracting them from effectively performing their duties as lookouts.
  15. Actions of the emergency response personnel following the collision were timely and effective.

PROBABLE CAUSE

The National Transportation Safety Board determines the probable cause of the collision between the CG 33118 and the Sea Ray was the failure of the CG 33118 crew to see and avoid the Sea Ray because of the excessive speed at which the coxswain operated the CG 33118, given the prevailing darkness, background lighting, and high vessel density and the U.S. Coast Guard's lack of effective oversight of its small boat operations both nationally and at Coast Guard Station San Diego.

RECOMMENDATIONS

To the U.S. Coast Guard:

  1. Develop and implement procedures for your special purpose craft law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions.
  2. Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances.
  3. Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations.
  4. Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies.
  5. Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures.

Previously Issued Recommendations Resulting From This Accident:

Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. (M-10-2)

Issue a safety advisory to the maritime industry that (1) promotes awareness of the risk posed by the use of cellular telephones and other wireless devices while operating vessels and (2) encourages the voluntary development of operational policies to address the risk. (M-10-3)