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Safety Recommendation Details

Safety Recommendation M-90-011
Details
Synopsis: ABOUT 1530, ON SEPTEMBER 15, 1988, THE 46-FOOT-LONG PASSENGER VESSEL COUGAR BEGAN TO TAKE ON WATER WHILE RETURNING FROM A FISHING TRIP OFF THE OREGON COAST. ABOARD WERE NINE PERSONS CONSISTING OF THE MASTER, THE MATE (WHO ASSISTED THE MASTER AT THE HELM), THE DECKHAND, AND SIX PASSENGERS. AN INSPECTION OF THE ENGINE COMPARTMENT AND LAZARETTE REVEALED SUBSTANTIAL FLOODING. THE PASSENGERS AND THE CREW FOUGHT THE RISING WATER WITH BUCKETS AND PUMPS FOR 1.5 HOURS WITHOUT SUCCESS. ABOUT 1615, A DISTRESS MESSAGE WAS REPEATEDLY TRANSMITTED OVER THE VESSEL'S VHF-FM AND CITIZENBAND RADIOS UNTIL THE MASTER ABANDONED THE COUGAR. ABOUT 1650, THE PASSENGERS AND CREW ABANDONED THE VESSEL. THE PASSENGER HAD SUFFICEIENT TIME TO LAUNCH A BUOYANT APPARATUS BEFORE LEAVING THE VESSEL. AT 1700, THE COUGAR SANK QUICKLY BY THE STERN. PIECES OF WRECKAGE THAT BROKE FREE OF THE VESSEL WERE GATHERED BY THE SURVIVORS AND USED TO REMAIN AFLOAT IN THE 55 DEGREES WATER. DURING THE FOLLOWING 18 HOURS, THE MASTER, THE DECKHAND, AND TWO PASSENGERS SUCCUMBED TO HYPOTHERMIA AND DROWNED. AT APPROXIMATELY 1048, ON SEPTEMBER 16, 1988, SEARCH AND RESCUE AIR UNITS OF THE U.S. COAST GUARD LOCATED THE MATE AND FOUR SURVIVING PASSENGERS. ABOUT 1100, THE FIVE SURVIVORS WERE RESCUED AND TRANSPORTED TO A HOSPITAL ASHORE FOR TREATMENT FOR HYPOTHERMIA AND EXPOSURE.
Recommendation: THE NTSB RECOMMENDS THAT THE U.S. COAST GUARD: PROVIDE IN THE MARINE SAFETY MANUAL ADDITIONAL WRITTEN GUIDANCE TO ALL MARINE INSPECTORS EXPLAINING THE IMPORTANCE OF DETERMINING THAT FREEING PORTS ARE MAINTAINED TO ALLOW RAPID DRAINAGE OF WATER FROM THE EXPOSED DECKS IN ALL PROBALE CONDITIONS OF LIST AND TRIM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Pacific Ocean, PO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA88MM061
Accident Reports:
Sinking of the Passenger vessel Cougar
Report #: MAR-90-02
Accident Date: 9/15/1988
Issue Date: 2/22/1990
Date Closed: 7/25/2001
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: USCG
To: NTSB
Date: 7/31/2001
Response: Letter Mail Controlled 04/10/2001 6:26:50 PM MC# 2010309 The CG has not yet completed the modifications to the Marine Safety Manual discussed in our previous responses to recommendations M-89-16, M-90-11, M-91-34 and M-94-17.

From: NTSB
To: USCG
Date: 7/25/2001
Response: Safety Board staff received a copy of the revised Marine Safety Manual, Volume II, Section B, Chapter 1, item 5.g, where the recommended guidance is included. Accordingly, Safety Recommendation M-90-11 is classified "Closed--Acceptable Action."

From: NTSB
To: USCG
Date: 7/14/1998
Response: NTSB REQUESTED A FOLLOWUP.

From: NTSB
To: USCG
Date: 3/12/1997
Response: THE BOARD IS DISAPPOINTED THAT ALMOST 3 YEARS HAVE ELAPSED SINCE THE USCG PROMISED TO INCLUDE THE RECOMMENDED INFO IN THE MARINE SAFETY MANUAL (MSM). THROUGH STAFF DISCUSSION, THE BOARD HAS LEARNED THAT THE REQUESTED GUIDANCE WILL BE INCLUDED IN A FORTHCOMING CHANGE TO THE MSM. PENDING FURTHER RESPONSE FROM THE USCG ON THE STATUS OF THIS INITIATIVE, M-90-11 WILL REMAIN CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: USCG
To: NTSB
Date: 6/26/1996
Response: PROVIDE IN THE MARINE SAFETY MANUAL ADDITIONAL WRITTEN GUIDANCE TO ALL MARINE INSPECTORS EXPLAINING THE IMPORTANCE OF DETERMINING THAT FREEING PORTS ARE MAINTAINED TO ALLOW RAPID DRAINAGE OF WATER FROM THE EXPOSED DECKS IN ALL PROBABLE OF LIST & TRIM.

From: NTSB
To: USCG
Date: 11/24/1995
Response: (GREENSHEET) SINCE 1977, THE BOARD HAS ISSUED TO THE UCSG 55 BOARD RECOMMENDATIONS THAT WERE CLASSIFIED "OPEN--ACCEPTABLE ACTION" BECAUSE THE USCG RESPONDED THAT IT WOULD TAKE THESE RECOMMENDATIONS INTO CONSIDERATION WHEN THE REGULATIONS WERE REVISED. BASED ON A LACK OF TIMELY ACTION, THE BOARD HAS RECLASSIFIED THESE RECOMMENDATIONS "OPEN--UNACCEPTABLE RESPONSE."

From: NTSB
To: USCG
Date: 11/28/1994
Response: REMINDER TO USCG OF PENDING ACTION.

From: NTSB
To: USCG
Date: 11/15/1993
Response: RECOMMENDATION M-90-11 ASKED THE USCG TO PROVIDE IN THE MARINE SAFETY MANUAL ADDITIONAL WRITTEN GUIDANCE TO ALL MARINE INSPECTORS EXPLANING THE IMPORTANCE OF DETERMINING THAT FREEING PORTS AS MAINTAINED TO ALLOW RAPID DRAINAGE OF WATER FROM THE EXPOSED DECKS IN ALL PROBABLE CONDITIONS OF LIST AND TRIM. BECAUSE A CAUTIONARY NOTE CONCERNING IMPROPERLY OPERATING FREEING PORTS WILL BE INCLUDED IN THE NEXT REVISION OF THE MARINE SAFETY MANUAL AND BECAUSE THE USCG WILL HIGHLIGHT THIS POTENTIAL PROBLEM WHEN PROVIDING GUIDANCE TO INSPECTORS, RECOMMENDATION M-90-11 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE." THE BOARD WOULD APPRECIATE RECEIVING COPY OF THE MARINE SAFETY MANUAL WHEN IT HAS BEEN COMPLETED.

From: USCG
To: NTSB
Date: 8/19/1993
Response: WE CONCUR WITH THIS RECOMMENDATION. A CAUTIONARY NOTE CONCERNING IMPROPERLY OPERATING FREEING PORTS WILL BE INCLUDED IN THE NEXT REVISION OF THE MSM. WE WILL ALSO HIGHLIGHT THIS POTENTIAL PROBLEM WHEN WE PROVIDE GUIDANCE TO INSPECTORS EMPHASIZING THE NECESSITY OF VERIFYING THAT HATCHES ARE WATERTIGHT, AS DISCUSSED IN MY RESPONSE TO RECOMMENDATION M-90-10. WE WILL ADVISE THE BOARD WHEN THE MSM REVISION HAS BEEN COMPLETED.