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Safety Recommendation Details

Safety Recommendation M-94-022
Details
Synopsis: ABOUT 1430 ON DECEMBER 5, 1993, THE 32-YEAR-OLD WOODEN-HULLED U.S. SMALL PASSSENGER VESSEL EL TORO II FOUNDERED IN ROUGH SEAS WHILE RETURNING TO ST. JEROME CREEK IN RIDGE, MARYLAND, FROM A FISHING EXCURSION IN THE CHESAPEAKE BAY. U.S. COAST GUARD AND U.S. NAVY RESCUE PERSONNEL RETRIEVED THE 20 PASSENGERS, 2 CREWMEMBERS, AND THE OWNER OF THE VESSEL FROM THE WATER. AS A RESULT OF THE SINKING, TWO PASSENGERS AND THE DECKHAND DIED FROM THE EFFECTS OF HYPOTHERMIA. THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE PROBABLE CAUSE OF THE EL TORO II SINKING WAS CATASTROPHIC FLOODING RESULTING FROM SEVERELY CORRODED HULL FASTENERS THAT HAD REMAINED UNDETECED AND UNCORRECTED BECAUSE OF THE LACK OF EFFECTIVE POLICIES AND PROCEDURES FOR INSPECTING, MAINTAINING, AND/OR SUPPLEMENTING THE STRUCTURAL INTEGRITY OF WOODEN-HULLED VESSELS. CONTRIBUTING TO THE LOSS OF LIVES WAS THE LACK OF SURVIVAL CRAFT CAPABLE OF PROVIDING OUT-OF-WATER FLOTATION FOR THE PASSENGERS AND CREW.
Recommendation: THE NTSB RECOMMENDS THAT THE U.S. COAST GUARD: RESEARCH AND DEVELOP, WITH THE ASSISTANCE OF THE WOODEN VESSEL INDUSTRY, NONDESTRUCTIVE INSPECTION TECHNIQUES FOR INSPECTING FASTENERS ON WOODEN VESSELS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Bays and Sounds, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MM007
Accident Reports:
Sinking of U.S. Small Passenger Vessel El Toro II
Report #: MAR-94-03
Accident Date: 12/5/1993
Issue Date: 9/14/1994
Date Closed: 12/10/1998
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 12/10/1998
Response: THE BOARD HAS REVIEWED THE USCG'S STUDY, IMPROVED INSPECTION OF WOODEN VESSEL FASTNERS. BECAUSE THE USCG HAS EVALUATED NEW METHODS OF TESTING HULL FASTENERS NON-DESTRUCTIVELY & HAS PUBLISHED ITS FINDINGS, M-94-22 HAS BEEN CLASSIFIED "CLOSED--ACCEDPTABLE 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 PLEASED THAT THE USCG IS EVALUATING NEW METHODS OF PERFORMING NONDESTRUCTIVE TESTING OF HULL FASTENERS, AS REQUESTED. THE BOARD WOULD APPRECIATE RECEIVING A COPY OF THE USCG R & D CENTER'S PROPOSED SCHEDULE FOR COMPLETION OF THIS PROJECT. PENDING FURTHER RESPONSE ON THE STATUS OF THESE EVALUATIONS, M-94-22 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: USCG
To: NTSB
Date: 6/26/1996
Response: RESEARCH & DEVELOP, WITH THE ASSISTANCE OF THE WOODEN VESSEL INDUSTRY, NONDESTRUCTIVE INSPECTION TECHNIQUES FOR INSPECTING FASTENERS ON WOODEN VESSELS.

From: NTSB
To: USCG
Date: 2/6/1996
Response: THROUGH STAFF DISCUSSIONS, THE BOARD HAS LEARNED THAT THE USCG IS PLANNING A FISCAL YEAR 1998 RESEARCH & DEVELOPMENT PROJECT THAT WILL INVESTIGATE NEW METHODS FOR NONDESTRUCTIVE INSPECTION OF WOODEN-VESSEL HULL FASTENERS, & THAT IT IS WORKING ALONG THESE SAME LINES WITH SEVERAL ACADEMIC INSTITUTIONS & SOME INDUSTRY GROUPS. THE BOARD WOULD APPRECIATE PERIODIC UPDATES ON THE STATUS OF THESE INITIATIVES. IN THE INTERIM M-94-22 WILL BE CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: USCG
To: NTSB
Date: 12/21/1995
Response: ST50 MARINE DIVISION STAFF TELEPHONE UPDATE WITH USCG STAFF (CDR BILL UBERTI & LT ERIC CHRISTENSEN ON THE T-BOAT PACKAGE & ON THE USCG PLANS WITH WOOD BOAT FASTENER NONDESTRUCTIVE INSPECTION TECHNIQUES.

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: 4/5/1995
Response: M-94-22 ASKED THE USCG TO RESEARCH & DEVELOP, WITH THE ASSISTANCE OF THE WOODEN VESSEL INDUSTRY, NONDESTRUCTIVE INSPECTION TECHNIQUES FOR INSPECTING FASTENERS ON WOODEN VESSELS THE BOARD IS PLEASED THAT THE UCSG IS INVESTIGATING NEW METHODS FOR NONDESTRUCTIVE INSPECTION OF WOODEN-VESSEL HULL FASTENERS AS REQUESTED, & M-94-22 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE." THE BOARD WOULD APPRECIATE PERIODIC UPDATES ON THE STATUS OF THESE INITIATIVES.

From: USCG
To: NTSB
Date: 1/4/1995
Response: I CONCUR WITH THIS RECOMMENDATION. THE USCG WILL INITIATE A RESEARCH & DEVELOPMENT PROJECT TO DETERMINE NONDESTRUCTIVE TESTING ALTERNATIVES TO THE PRACTICE OF PULLING FASTENERS. IN ADDITION, WE RECENTLY BECAME INVOLVED WITH A PROPOSAL FROM A VESSEL OPERATOR TO DETERMINE IF RADIOGRAPHY OF FASTENERS IN AN INSPECTED WOODEN HULLED VESSEL CAN ADEQUATELY DETERMINE THE CONDITION OF THE FASTENERS. THE PROPOSAL INVOLVES NONDESTRUCTIVE TESTING FOLLOWED UP WITH DESTRUCTIVE TESTING TO VALIDATE TEST INDICATIONS. THE INITIAL RESULTS ARE ENCOURAGING. WE WILL CONTINUE TO MONITOR THE RESULTS OF THIS PROPOSAL AS THEY BECOME A AVAILABLE, & ANY OTHER PROPOSALS SUBMITTED, TO DETERMINE EFFECTIVENESS & PRACTICALITY. THE USCG RECOGNIZES THAT SCIENTIFICALLY TESTED, PROVEN, & COST EFFECTIVE NONDESTRUCTIVE INSPECTION OPTIONS WILL CLEARLY BENEFIT THE INDUSTRY.