Testimony of
Jim Hall, Chairman
National Transportation Safety Board
before the
Committee on Transportation and Infrastructure
Subcommittee on Coast Guard and Maritime Transportation
House of Representatives
Regarding
Coast Guard Search and Rescue Communications
November 3, 1999

as presented | for the record


oral testimony as presented:

Good morning, Chairman Gilchrest and members of the Committee. It is a pleasure to represent the National Transportation Safety Board before you today regarding the subject of Coast Guard search and rescue (SAR) communications.

Before I begin, however, I'd like to thank the Coast Guard and in particular, Admiral Rick Larribee and the men and women of the Coast Guard's First District, for their endeavors in the SAR effort that concluded Monday and the on-going search and recovery for the victims of the crash of EgyptAir flight 990. We can all be proud of the dedication and professionalism of these individuals.

Mr. Chairman, it is noteworthy that the Morning Dew investigation did not identify the actual search by Coast Guard boat and helicopter crews as an issue in this accident. Once the SAR was initiated, it proceeded well. But, in order for a SAR to take place, Coast Guard communications and operations personnel must receive, acknowledge, and act upon a distress situation. In the case of the Morning Dew, this did not occur until after the Coast Guard SAR personnel were notified at 11:15 a.m. on December 29, 1997, some eight hours after the first mayday call from the vessel.

You have been given a packet of visual aids, including a chronology of events, that will help clarify my remarks.

The issues addressed in the Safety Board's report of the Morning Dew accident included: the need for upgrading Coast Guard SAR communications equipment; the adequacy of watchstander duty hours; the need for upgrading watchstander procedures for responding to an emergency; the need for additional training for communications watchstanders; management oversight of watchstander performance; and, the lack of investigation coordination.
 
 


Morning Dew
The owner of the Morning Dew was moving the vessel from South Carolina, to Florida, via the Intracoastal Waterway. However, on the afternoon of December 28, 1997, the vessel was seen proceeding outbound and toward the open ocean.

Salvaging Morning Dew
Just after 2:00 a.m., the Morning Dew struck the north side of the north rock jetty extending from the harbor at Charleston, tearing open the hull.

The paint markings and debris path documented by the South Carolina Department of Natural Resources show that the vessel was carried over the jetty, resulting in the vessel's coming to rest submerged in about 12 feet of water on the south side of the jetty.

At 2:17 a.m., a Coast Guard communications watchstander received a static-filled radio message.

The watchstander told the Board that the only words he heard were "U.S. Coast Guard." When the tape was replayed much later, the voice of an excited adolescent male was heard saying, "May ... mayday, U.S. Coast Guard come in." Although the watchstander tried to raise someone on the radio, he received no response.

About 6:20 a.m., the bosun of an inbound freighter heard cries for help coming from the water near buoy 22 as the ship entered Charleston Harbor. This was reported by telephone to the Coast Guard. When contacted, the Coast Guard duty officer decided to take no action.

A full Coast Guard search was not initiated until the bodies of two of the teenage victims were found just off shore about 11:00 a.m. The other teenager was found soon after, and the owner was not found until about three weeks later.

The Board found a number of deficiencies that we delineated in our written testimony, but I will focus my oral testimony on the equipment issues.

The Board's investigation of the Morning Dew accident sought to evaluate the adequacy of equipment resources available to the Coast Guard communication center watchstanders when they receive a call for assistance from a distressed mariner. Unfortunately, a number of significant deficiencies with the communication systems were found, such as:
 

  • Operation testing on the direction finding equipment at Group Charleston showed it had inaccuracies of up to 101 degrees and was not being used. It was designed to provide a line of bearing to, rather than the geographic location of, the transmitting radio, and could not record the bearing information for later review and correlation to recorded audio transmissions.
  • Some antennas and towers needed maintenance; however, there was no program to specifically inspect antenna towers. The Mount Pleasant antenna was located on a tower along with several other commercial antennas, causing interference at certain frequencies, and the quality of the telephone lines used to connect the group communications centers to the antenna high sites were less than optimum.
  • The recorder in use by the watchstander was difficult to operate when searching for specific recorded communications, and was not suitable for a quick replay of recorded messages.
DF Equipment Area
DF Equipment Monitor Screen
DF System 101o Indication Error

As part of the Board's investigation, Safety Board staff met with representatives of the Prince Rupert, British Columbia, Marine Communications and Traffic Services Station regarding their Coast Guard SAR communications.

The Prince Rupert radio station has been using a commercially available DF system in SAR operations since 1992. These off-the-shelf commercial DF systems are currently being manufactured by several companies in the United States and elsewhere.

We were advised that the Canadian DF system is easy to use, accurate, and capable of determining the geographic location of a transmitting radio through triangulation. Because this equipment is located on top of mountains, it is capable of receiving from sixty to eighty miles. It can also digitally record bearing information for later retrieval and analysis.

According to the Canadian Coast Guard, this DF system has reduced SAR response time by eliminating time-consuming searches for vessels in distress. As soon as the station receives a transmission, it also knows the vessel's location. The system can locate vessels in distress when incomplete calls are received. Because the equipment can also locate a hoax caller, it has reduced these nuisance calls, resulting in a reduction of unnecessary SAR missions and cost savings.

The Prince Rupert Marine Communications and Traffic Services station also has recording equipment to record all incoming and outgoing radio communications. The recording equipment consists of separate units for instant playback and for longer term archival recording. Unlike the equipment at Group Charleston at the time of the Morning Dew accident, it allows for quick replay of a message if there is any doubt about its content.

We are aware of the Coast Guard's national distress and response system modernization project, which has been in various stages of development for 20 years. Unfortunately, the initial operational capability is not scheduled until fiscal year 2003, with full operational capability in the 2005-2006 timeframe. In the interim, the Coast Guard intends to install new DF equipment at selected communication centers in areas having significant SAR activity, allocating $2 million in fiscal year 2000 for the procurement of the equipment.

It is our understanding that the interim DF equipment will be similar in capability to equipment now in place at communication centers, and will only provide a line of bearing to the transmitting vessel and will not have the ability to record the DF data. The Board believes that this equipment will not significantly improve the Coast Guard's ability to effectively respond to a distress call. The Coast Guard should immediately begin to equip all SAR communications centers with currently available, commercial, off-the-shelf DF systems that provide, at a minimum, the capability to establish a position fix and to record position data for later retrieval and analysis.

We recognize that over the last few years the Coast Guard has had its budget and personnel significantly reduced. However, it is the Coast Guard's responsibility to inform this Committee of the minimum resources required to ensure public safety.

That completes my statement and I will be happy to respond to whatever questions the Committee may have.

 


written testimony for the record:

Good morning Chairman Gilchrest and members of the Committee. It is a pleasure to represent the National Transportation Safety Board before you today regarding the subject of Coast Guard search and rescue (SAR) communications.

The Coast Guard's 1998 Annual Report states that "The Coast Guard seeks to save all mariners in imminent danger." And, they have a good record of achieving that goal. In 1998, the Coast Guard responded to approximately 38,700 distress calls and saved more than 4,000 lives. However, in December 1997, the distress call from the 34-foot recreational sailing vessel Morning Dew was not responded to, and the lives of the four individuals aboard were not saved. The Safety Board's investigation of that accident found serious deficiencies in the Coast Guard's communication system. My testimony will focus on those findings and our recommendations to correct the problems we found.

In addition to the accident involving the Morning Dew, the Safety Board has investigated five additional marine accidents involving Coast Guard communications since 1993.

August 4, 1993 - At 12:08 a.m., the operator of the sailing vessel Rite of Passage notified the Coast Guard that the vessel was disabled near the Isle of Palms, South Carolina, with engine problems and that he needed assistance. Believing that the operator was in no immediate danger, the watchstander classified the incident as a non-distress situation, issued a marine assistance request, and a local towing company advised that they would respond. At 1:00 a.m., the Coast Guard received a telephone call from the Isle of Palms Police Department reporting that an unidentified sailing vessel was aground and listing badly. The Coast Guard then dispatched a 41-foot utility boat to respond to what was thought to be a second vessel in distress. At 5:50 a.m., a local rescue squad recovered the operator's body from the surf. If the watchstander had asked the operator the questions on the SAR checklist, he would have learned that the operator was a 67-year-old man with a heart condition requiring medication, and may have increased the urgency of the situation and indicated a need for an immediate Coast Guard response.

August 21, 1994 - A disabled 18-foot Questar motorboat with the vessel's owner and one passenger on board capsized while being towed by the Coast Guard Auxiliary vessel Puppet near Juneau, Alaska, resulting in one fatality. Events surrounding this accident suggest that the SAR response was hampered by the undisciplined use of VHF-FM channel 16 by participants in a fishing derby. The Safety Board found that the Coast Guard made no attempt to minimize inappropriate use of channel 16 by the approximately 1,000 vessels participating in the fishing derby. The sheer volume of inappropriate radio traffic on a channel that was supposed to be reserved for calling out and distress severely compromised the Coast Guard's ability to receive and respond to distress calls. As a result of this accident, the Safety Board issued recommendations to the Coast Guard regarding radio reception capability, the use of Coast Guard Auxiliary resources, SAR policies, and post-accident toxicological testing of Coast Guard Auxiliary personnel.

April 14, 1995 - An 18-foot-long Thunderbird Cheyenne motorboat capsized in about 16 feet of water, in Oswego, New York, resulting in the deaths of all three occupants. Another boater saw the capsized vessel and reported the sighting and the location to someone at a local marina. The marina operator called Coast Guard Station Oswego and relayed the report. The watchstander at Station Oswego notified the duty officer of the call, but the duty officer decided that no immediate action should be taken. The boat was found the next day by a local law enforcement marine patrol boat after the boat was reported overdue.

June 13, 1998 - A distress call from the recreational boat Florida Air Specialist, which was in Apalachee Bay, Florida, for recreational fishing with three people on board, was logged by Coast Guard Auxiliary watchstanders as a hoax. The Coast Guard did not initiate a review of the recorded radio communications until after the only survivor of the accident reported that a distress call had been transmitted. Had no one survived the Florida Air accident, the Coast Guard may not have known that the distress call had been made. The investigation into this accident is on going.

January 18, 1999 - About noon, the Adriatic, with four people on board, completed clam harvesting operations and began the trip from the fishing grounds off the coast of Long Beach Island, New Jersey to Atlantic City, New Jersey. At about 2:58 p.m., the operator radioed a mayday to the Coast Guard. Watchstanders from three units converged onto the airwaves all within the first few seconds, overlapping one another. In addition, another Coast Guard unit made an unscheduled marine information broadcast at the same moment the call outs were initiated. All four people are missing from this vessel. The Board's investigation is on going.

Like these accidents, the Morning Dew tragedy involved Coast Guard communications. The Safety Board was first informed about this accident in April 1998, when several Members of Congress asked that we conduct an independent investigation into the circumstances surrounding the accident, and to review the Coast Guard's actions following the accident. I want to point out that under our current agreement with the Coast Guard, we were not initially informed about the accident because it did not meet the notification criteria.

As a result of the Congressional requests, we proceeded to conduct an extensive marine accident investigation. More than 35 witnesses were interviewed, and extensive factual information was gathered from the Coast Guard, the South Carolina Department of Natural Resources (SCDNR), the Charleston Pilots Association, the Charleston Coroner, and family members of the victims. We also contracted with the U.S. Naval Surface Warfare Center to survey the communications system serving Coast Guard Group Charleston, including two subordinate stations and six antenna high sites stretching from Myrtle Beach, South Carolina, to Savannah, Georgia. The Navy also transcribed more than 300 hours of radio and telephone communications recorded at the Charleston station. In addition, the Board held a public hearing in Charleston in February 1999. The final report was discussed at the October 5, 1999, Board meeting.

The Accident Investigation

The owner of the Morning Dew was moving the vessel from a marina near Myrtle Beach, South Carolina, to Jacksonville, Florida, via the Intracoastal Waterway (ICW), and had purchased the appropriate charts for that trip. The group on board, comprised of the owner, his two sons, ages 16 and 13, and his 14-year-old nephew, got underway a little after noon on December 27, 1997. On the afternoon of December 28, 1997, in Winya Bay, South Carolina, the Morning Dew was seen proceeding outbound in the main shipping channel, past the entrance to the ICW, and toward the open ocean.

In order for the Morning Dew to exit the bay and reach the open ocean, it had to continue in or near the shipping channel for about seven miles, during which time the boat would pass 12 or more channel markers before reaching the mouth of the bay. Once there, the vessel had to navigate past a 2.2-mile-long jetty before turning right to follow a southwesterly course, along the coast, toward Charleston, South Carolina, about 43 miles away.

From all available evidence, just after 2:00 a.m., the Morning Dew struck the north side of the north rock jetty extending from the harbor at Charleston. The paint markings and debris path documented by the SCDNR show that the vessel was carried over the jetty, probably by waves in combination with the rising tide, resulting in the vessel's coming to rest submerged in about 12 feet of water on the south side of the jetty.

At 2:17 a.m., a Coast Guard Group Charleston communications watchstander received a static-filled radio message -- the only words he heard were "U.S. Coast Guard." Although he tried to raise someone on the radio, he received no response. Despite having the capability to do so, the watchstander did not replay the recording of the message to determine the nature of the call, nor did he wake his duty officer. Much later, when the tape was finally replayed, the voice of an excited adolescent male was heard saying "May ... mayday, U.S. Coast Guard come in."

About 6:20 a.m., the boatswain of the inbound freighter Pearl Ace reported hearing cries for help coming from the water near buoy 22 as the ship entered Charleston Harbor. He immediately reported it by radio to the master on the bridge, and the pilot in turn contacted the pilot dispatcher and asked him to relay the information to the Coast Guard. The pilot also asked the operator of the pilot boat Palmetto State to search the area where the calls for help had been heard. The search by the Palmetto State was unsuccessful.

When the Coast Guard duty officer was contacted regarding the cries for help he decided to take no action, even though Coast Guard resources were available to initiate a search. He later told investigators that he thought the pilot boat could handle the situation.

A full Coast Guard search was not initiated until the bodies of two teenagers were discovered near the beach about 11:00 a.m. The other teenager was found soon after, and the owner was not found until about three weeks later.

Following the accident, the SCDNR initiated a death and boating safety investigation. Despite an SCDNR request to the Coast Guard regarding possible distress calls, the Coast Guard was not forthcoming with information because they were conducting an administrative investigation into the watchstander's actions. In fact, although Coast Guard officials were aware of the mayday call on the evening of December 29, 1997, no one outside the Coast Guard, including the SCDNR or the victims' families, was told about it for more than 2 1/2 months. That failure hampered the SCDNR's investigation. The information regarding the distress call was not released by the Coast Guard until Boating News filed a Freedom of Information Act request in February 1998.

Mr. Chairman, the results of the Board's investigation of the Morning Dew accident were distressing, particularly with regard to the following areas: the need to upgrade Coast Guard SAR communications equipment; the adequacy of watchstander duty time, and the need to upgrade watchstander procedures for responding to an emergency; the need for additional training for communications watchstanders; and the lack of investigation coordination.

SAR Communications

The Board's investigation of the Morning Dew accident sought to evaluate the equipment resources available to the Coast Guard communication center watchstanders when they receive a call for assistance from a distressed mariner. Specifically, we were interested in determining if the radio and recording equipment were adequate, and what means were available to the watchstander to locate a distressed boater when the boater did not or could not provide his location to the Coast Guard. The Board contracted with the Naval Surface Warfare Center, Carderock Division, in Philadelphia, Pennsylvania, to assist in this effort. Unfortunately, a number of significant deficiencies with the communication systems at the Charleston and Mobile group offices, the only two offices surveyed, were found, and suggested that similar problems may exist throughout the Coast Guard. Group Mobile was studied to provide another data point, and because of its connection with the Florida Air Specialist accident previously mentioned.

Operational testing on the direction finding (DF) equipment at group Charleston showed it was very inaccurate, had limited features, and thus was not being used. This DF system was designed to only provide a line of bearing to, rather than the geographic location of, the transmitting radio. In addition, it could not record the bearing information for later review and correlation to recorded audio transmissions.

The Navy's assessment of the communication system included an evaluation of the audio recording equipment used in the Coast Guard's communication centers. We found that the recorders in use at Charleston and Mobile were difficult to operate when searching for specific recorded communications. In addition, the recorders were not suitable for quickly replaying recently received messages.

Some antennas and towers needed maintenance, and there was no program to specifically inspect antenna towers. A continuous frequency swept voltage standing wave ratio measurement, which can be used to document antenna bandwidth and identify nulls, had not been performed on the antennas. The antenna at Mount Pleasant, which picked up the Morning Dew transmission, was found to be located on a tower along with several other commercial antennas, and tests found some interference from these other antennas at certain frequencies. The noise levels on the telephone lines connecting the Charleston Group Communications Center to the antenna high sites were not being routinely monitored, and the quality of the telephone lines used to connect the group communications centers to the antenna high sites were less than optimum.

As a result of their findings, the Naval Surface Warfare Center recommended the following improvements to optimize the efficiency of the communication system:

· Institute a programmed antenna maintenance program that would improve the early detection of faults;

· Institute a frequency management program to reduce the possibility of signal interference from other transmitters;

· Install a condition-based monitoring system that would provide continuous monitoring of remote equipment; and

· Upgrade the class of telephone service to reduce the possibility of signal degradation through the existing phone lines.

Safety Board staff visited the Marine Communications and Traffic Services Station in Prince Rupert, British Columbia, Canada for information about Canadian Coast Guard SAR communications. We learned that the Prince Rupert radio station has been successfully using a commercially available DF system in SAR operations since 1992. The Prince Rupert Station is one of three Canadian Marine Communications and Traffic Services stations that have radio DF equipment for use in SAR cases. These off-the-shelf commercial DF systems are reasonably priced and are currently being manufactured by several companies in the United States and elsewhere.

The officer-in-charge reported that the Canadian DF system is easy to use, accurate, and capable of determining the geographic location of a transmitting radio to a distance of sixty to eighty miles through triangulation. The system can also digitally record bearing information for later retrieval and analysis. According to the Canadian Coast Guard, the DF system has reduced SAR response time by eliminating time-consuming searches for vessels in distress. As soon as the station receives a transmission, it also knows the vessel's location. The system can locate vessels in distress when incomplete maydays are transmitted, and can provide navigation information to vessels lost in fog, and locate vessels with open microphones. Because the equipment can also identify and locate a hoax caller, it has reduced nuisance calls and unnecessary SAR missions, resulting in a cost savings.

The Prince Rupert Marine Communications and Traffic Services Station also has recording equipment to record all incoming and outgoing radio communications. The recording equipment consists of separate units for instant playback and for longer term archival recording. Unlike the equipment at Group Charleston, it allows for quick replay of a message if there is any doubt about its content.

The Safety Board is aware of the U.S. Coast Guard's national distress and response system modernization project, which has been in various stages of development for 20 years. Unfortunately, the initial operational capability is not scheduled until fiscal year 2003, and full operational capability will not be until the 2005-2006 timeframe. In the interim, the Coast Guard intends to install new DF equipment at selected communication centers in areas having significant SAR activity, and has allocated $2 million in fiscal year 2000 for the procurement of the equipment.

It is our understanding that the interim DF equipment will be similar to equipment now in place at communication centers, and will only provide a line of bearing to the transmitting vessel and will not likely have the ability to record the DF data. The Board believes that this equipment will not significantly improve the Coast Guard's SAR response capability.

Therefore, the Safety Board adopted a recommendation requesting that the Coast Guard immediately provide all SAR communications centers with the capability for watchstanders to easily and instantly replay the most recent recorded radio transmissions, and that they immediately begin to equip all SAR communications centers with currently available, commercial, off-the-shelf DF systems that provide, at a minimum, the capability to establish a position fix and to record position data for later retrieval and analysis.

Group Charleston's Personnel Duty Time, Equipment, and Procedures for Responding to an Emergency

The Board expressed concern that current Coast Guard duty policy does not provide redundancy for listening to communications. Such a procedure is typical during the night, for example, when the operations duty officer is sleeping.

At the time of the Morning Dew accident, a newly qualified and inexperienced communications watchstander was on duty, alone, for 6 to 8 hours, and it was during this time that he failed to detect the word "mayday" in the 2:17 a.m. transmission and consequently misidentified the call.

In addition, the Coast Guard is currently operating under an interim staffing policy, pending the results of an analysis of workload and staffing of all group and activity functions, that codifies practices in existence at the time of the Morning Dew's sinking. It permits communications watchstanders to work 12-hour shifts and sets a supervisory ratio of 1-to-5 for each watchstanding position.

In many communications centers, including Group Charleston, there is only one communications position; thus, the watchstander always stands a solo watch. This leaves watchstanders with no backup if they need to use the restroom; are unable to sustain attention or wakefulness; or benefit from a "second opinion" in the case of an unclear call, a unique situation, or concurrent SAR cases.

While the 12-hour watch duration may facilitate scheduling, the Board does not feel it adequately considers the watchstander's ability to perform. Work schedules must not only ensure that duty positions are covered at all times, they must ensure that continuous vigilance by watchstanders is possible and feasible. They must also take into account the need for oversight and supervision of novice watchstanders, so that sleep loss and fatigue do not degrade performance. Sleep loss has immense potential to exacerbate the problems of excessive shift length, monotony, and boredom. Coast Guard telecommunications specialists endure long hours of tedium, make routine radio broadcasts, perform routine administrative tasks, and listen to a drone of routine radio chatter. Without a mechanism for effectively monitoring their performance, a 12-hour watch can result in decreased alertness and diminished vigilance.

The Safety Board believes that the Coast Guard should develop permanent staffing policies that would require redundancy to monitor incoming radio traffic. This would provide oversight and supervision of relatively inexperienced watchstanders, have a backup in evaluating incoming radio calls, and generally provide redundancy in the overall listening and decision-making process. As a result, we adopted a recommendation that asks the Coast Guard to ensure that the workload and staffing analysis 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 SAR communications centers.

Communications Center Watchstander Training

The Board's investigation of the Morning Dew also examined the training received by the communications center watchstander on duty at the time of the accident. Since his entire experience as a communications watchstander at the time of the accident consisted of 6 months' duty at Group Charleston, we were particularly interested in whether his training adequately prepared him for the position.

Regular Coast Guard communications watchstanders attend a 10-week telecommunications school, during which they learn the operation of various communications equipment, radiotelephone protocols, and procedures for handling different types of communications, including distress messages. After completing the formal classroom training, they must complete the Group and Stations Communications Watchstander Qualification Guide and on-the-job training at their assigned communications center. The guide contains five divisions of qualification tasks comprising reading assignments and a number of tasks in each of the 22 divisions to be completed and practiced in sequence by the student, with the help of the instructor. Once candidate watchstanders complete the local on-the-job training, they are required to pass an oral examination by a qualifications review board before they are considered qualified to stand watch unsupervised.

The communications watchstander on duty at the time of the accident had completed on-the-job training on the qualification guide in 3 to 4 weeks, and spent only 20 to 30 minutes before his oral qualification review board. In order to complete his guide in 4 weeks, the candidate watchstander had to complete and master more than 4 to 6 tasks weekly, including completing the associated reading assignments.

The Safety Board believes that novice watchstanders should be provided with ample opportunity to practice what they were taught during their formal schooling and on-the-job training, and to demonstrate a suitable level of proficiency before they are deemed qualified to stand watch.

In addition, the current focus of the training for communications watchstanders is on the proper operation of hardware and the use of standardized responses to typical situations. However, communications watchstanders do not handle only typical situations. They also encounter atypical situations that require them to use analytical skills to make judgments and formulate decisions that may have life-and-death implications. For example, the watchstander in the Morning Dew accident failed to take into account such factors as the urgency in the voice of the caller, the time of night, and the prevailing weather when he concluded that the 2:17 a.m. call from the vessel did not require action. Similarly, in regard to the report of cries from the water, the operations duty officer at Group Charleston did not take into account the nature of the report, the credibility of those making the report, or the potential effectiveness of the pilot boat when he allowed that vessel to conduct an independent search even though Coast Guard resources were available.

The Safety Board adopted a safety recommendation to the Coast Guard that calls for implementation of a course or training program for all operations and communications center watchstanders designed to develop or enhance those individuals' judgment and decision-making skills.

Investigation Coordination

Because of questions raised in the months after the Morning Dew accident regarding investigation coordination, this issue was of interest to the Board. Throughout the initial response to the accident, the SCNDR, the coroner, and local agencies participated in an Incident Command System (ICS) that allowed them to effectively manage their personnel, resources, and communications.

The ICS allows different agencies with d operating procedures to work together in one system to accomplish a common goal. The ICS also reduces the duplication of effort and the burden that can be placed on people involved in an accident investigation who must obtain similar information from different parties. The fact that the Coast Guard did not participate in this system resulted in a lack of coordination between the Coast Guard and local agencies. For example:

· Both the coroner and the Coast Guard needed information from the families of the deceased. The Coast Guard needed to know how many people had been on the vessel, and the coroner needed to establish their identities and made death notifications. Had the Coast Guard participated in the ICS, Coast Guard representatives would have been aware of the coroner's procedures, and the process would have been much better coordinated.

· The SCDNR investigator-in-charge arrived on scene and was told that the Coast Guard had already requested that a commercial salvage operator send divers to identify the name on the sailboat. The SCDNR investigator-in-charge, wanting to preserve any evidence in case of a criminal investigation, had to tell the divers not to disturb any of the evidence. The preservation of evidence should have been discussed before divers were deployed.

· Although a Coast Guard representative was in telephonic contact with an SCDNR representative and police officials during different phases of the response, the absence of a Coast Guard representative at the command post where decisions were being made resulted in the Coast Guard representative's not being able to efficiently track the progress being made in the joint investigation or to answer any questions. In addition, he was not able to provide information known to the Coast Guard that may have facilitated the SCDNR investigation. For example, the investigator-in-charge learned from the newspaper about a witness who saw the Morning Dew and about the reports to the Coast Guard of a boatswain hearing cries from the water.

The problems in coordination that arose during this accident could have been avoided if the Coast Guard, the SCNDR, and local responders had used a system that allowed them to manage a joint SAR operation. Therefore, the Safety Board adopted a recommendation that asks the Coast Guard to 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.

When reviewing the initial accident investigation coordination, the Board was distressed to learn that the commanding officer of Group Charleston was unaware of a memorandum of understanding (MOU) between the Coast Guard and the State, even though it had been in place since 1984. The Federal Boat Safety Act of 1971 specified that cooperative agreements between the Coast Guard and each of the states within the district's area of responsibility be in place to foster cooperation between State and Federal governments in reducing deaths, injuries, and property damage from recreational boating accidents. These agreements usually cover such subject areas as law enforcement, public education and training, boating casualty reporting and investigative reports, SAR, aids to navigation, and use of the Coast Guard Auxiliary.

Although the agreement between the Coast Guard and the State of South Carolina had been reviewed in 1994, personnel changes have occurred in both the state agencies and the Coast Guard, and telephone numbers and points of contact may also have changed. Coast Guard Headquarters issued a message to all district commanders in February 1999 directing a review of all existing agreements or MOUs between the districts and other agencies within their areas of responsibility. The guidance, however, did not provide a timeframe for the completion of the reviews, nor did it provide for follow-up periodic review and updating, which is necessary to ensure that the agreements are kept current.

The Board Members have asked staff to draft safety recommendations to the Coast Guard and the Governors of the 50 states to review and revise, within 6 months and at least biannually thereafter, all boating safety agreements between the Coast Guard and the States to ensure that those agreements are coordinated between local Coast Guard authorities and the appropriate agencies within the States and accurately reflect current responsibilities and jurisdictions of each entity in such areas as boating casualty accident investigation and reporting, SAR, and related boating safety issues.

The Safety Board believes that if the commanding officer of Group Charleston had knowledge of the agreement and its provisions, the coordination between the Coast Guard and the SCDNR in the aftermath of the accident may have been significantly improved.

Mr. Chairman, it is noteworthy that the Morning Dew investigation did not identify the actual search by Coast Guard boat and helicopter crews as an issue in this accident. Once the SAR was initiated, it proceeded well. But, in order for an SAR to take place, Coast Guard communications and operations personnel must receive, acknowledge, and act upon a distress situation. In the case of the Morning Dew, this did not occur until after the Coast Guard was notified by the Sullivans Island Police Department that bodies were discovered near the beach 11:15 a.m. on December 29, 1997, some eight hours after the first mayday call from the vessel.

We recognize that over the last few years the Coast Guard has had its budget and personnel significantly reduced, and still maintained its high level of response to distress calls and lives saved. However, we believe the Coast Guard should reexamine its priorities and make the necessary investment in infrastructure and personnel that will help ensure the safety of Americans on our waterways. We believe rapid action in response to our safety recommendations by the Coast Guard will prevent the recurrence similar accidents.

Mr. Chairman that completes my statement and I will be happy to respond to whatever questions the Committee may have.

Speeches & Testimony