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Safety Recommendation Details

Safety Recommendation M-90-015
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: REQUIRE THAT ALL LIFE PRESERVERS ABOARD INSPECTED SMALL PASSENGER VESSELS OPERATED A COASTWISE ROUTE (NOT MORE THAN 20 MILES FROM A HARBOR OF SAFE REGUGE) AND ALL FERRIER (REGARDLESS OF ROUTE) HAVE PERSONAL FLOTATION DEVICE LIGHTS ATTACHED.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 3/12/1997
Addressee(s) and Addressee Status: USCG (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 3/12/1997
Response: THE BOARD IS DISAPPOINTED THAT THE USCG HAS NOT IMPLEMENTED THIS RECOMMENDATION & DISAGREES WITH THE USCG'S POSITION THAT PERSONAL FLOTATION DEVICES DO NOT NEED LIGHTS. THE BOARD CONTENDS THAT PEOPLE IN THE WATER WILL NOT NECESSARILY BE WITH A SURVIVAL CRAFT EQUIPPED WITH LIGHTS. FURTHER, ALTHOUGH THE 406 EPIRB MARKS A SIGNIFICANT IMPROVEMENT TO MARINE SAFETY & WILL GREATLY ENHANCE FINDING DISTRESSED VESSELS, IT WILL NOT PINPOINTA PERSON IN THE WATER ON A DARK NIGHT OR DURING REDUCED VISIBILITY. PERSONS WHO ARE UNCONSCIOUS, CHILDREN, & THOSE WHO ARE UNABLE TO CALL FOR HELP ARE AN EVER GREATER DISADVANTAGE. IN THE PREAMBLE TO 46 CFR, SUBCHAPTER W, THE USCG STATES THAT A "PFD LIGHT ONLY COSTS $5.OO" THE BOARD BELIEVES THAT THIS COST IS INSIGNIFICANT FOR SOMETHING THAT MIGHT SPEED RECOVERY OF SOMEONE IN THE WATER AT NIGHT. FURTHER, THE BOARD NOTES THAT THE USCG REQUIRES PFD LIGHTS FOR PFDS, MUSTANG SUITS, & EXPOSURE SUITS WORN BY ITS OWN PERSONNEL. THESE LIGHTS OBVIOUSLY HAVE VALUE IF THE USCG REQUIRES THEM FOR THEIR OWN PERSONNEL. BECAUSE THE USCG WILL NOT IMPLEMENT THIS RECOMMENDATION, M-90-15 HAS BEEN CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

From: USCG
To: NTSB
Date: 6/26/1996
Response: REQUIRE THAT ALL LIFE PRESERVERS ABOARD INSPECTIED SMALL PASSENGER VESSELS OPERATING ON A COASTWISE ROUTE (NOTE MORE THAN 20 MILES FROM A HARBOR OF SAFE REFUGE) & ALL FERRIES (REGARDLESS OF ROUTE) HAVE PERSONAL FLOTATION DEVICE LIGHTS ATTACHED.

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: THE BOARD REQUESTS THAT IT REEVALUATE ITS POSITION. PENDING FURTHER RESPONSE, RECOMMENDATION M-90-15 WILL BE CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: USCG
To: NTSB
Date: 8/19/1993
Response: WE DO NOT CONCUR WITH THIS RECOMMENDATION. THROUGHT PAST RULEMAKING EFFORTS, THE USCG REQUIRED THAT EVERY PERSONAL FLOATATION DEVICE (PFD) BE EQUIPPED WITH A LIGHT IF CARRIED ABOARD A SMALL OR UNISPECTED PASSENGER VESSEL OPERATING ON AN OCEAN OR COASTWISE ROUTE BEYOND 20 MILES FROM A HARBER OF SAFE REFUGE. THUS, IN THE CASE OF THE COURGAR, THE PFD'S SHOULD HAVE BEEN EQUIPPED WITH LIGHTS. THE USCG STANDS BY IT EARLIER POSITION THAT THE LIGHTS ARE NOT JUSTIFIED FOR OTHER ROUTES. THEY ARE NOT INTENDED AS PRIMARY ALERTING OR LOCATING DEVICES. IN THE COURGAR CASUALTY, THE PRIMARY DIFFICULTY FACED IN THE USCG RESCUE EFFORT WAS THAT NEITHER THE LOCATION OF THE VESSEL NOR PERSONS IN THE WATER WAS KNOWN. THE NPRM FOR 46 CFR SUBCHAPTER T (CGD85-080) ADDRESS THIS SHORTCOMING BY PROPOSING REQUIREMENTS FOR EMERGENCY POSITION RADIO INDICATING BEACONS (EPIRBS) AND INFLATABLE PRIMARY LIFESAVING APPLIANCES. SATELLITE EPIRBS, AND INFLATABLE LIFERAFTS OR INFLATABLE BUOYANT APPARATUS THAT THESE VESSELS WOULD HAVE TO CARRY UNDER THE PROPOSED RULES, WOULD ALL BE EQUIPPED WITH LOCATING LIGHTS. ONCE THE EPIRBS AND SURVIVAL CRAFT HAVE BEEN LOCATED, SEARCH AND RESCUE FORCES SHOULD BE ABLE TO LOCATE PERSONS IN THE WATER BY THE RETROFLECTIVE MATERIAL WHICH IS ALREADY REQUIRED ON EACH PFD. WE ANTICIPATE NO FURTHER USCG ACTION, AND WE REQUEST THAT THIS RECOMMENDATION BE CLOSED.