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Safety Recommendation Details

Safety Recommendation M-94-023
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: CONSIDER REQUIRING THE REFASTENING OF WOODEN-HULLED PASSENGER VESSLS THAT ARE OVER 15 YEARS OLD AS A REMEDIAL ACTION UNTIL RELIABLE INSPECTION METHODS CAN BE DEVELOPED.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 2/6/1996
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 2/6/1996
Response: M-94-23 ASKED THE USCG TO CONSIDER REQUIRING THE REFASTENING OF WOODEN-HULLED PASSENGER VESSELS THAT ARE OVER 15 YEARS OLD AS A REMEDIAL ACTION UNTIL RELIABLE INSPECTION METHODS CAN BE DEVELOPED. THE USCG'S INCLUSION OF A FASTENING REMOVAL-INSPECTION SCHEDULE FOR EXISTING VESSELS & NEW VESSELS IN BOTH SALT & FRESH WATER SERVICE IN LIEU OF REQUIRING REFASTENING WOOD-HULLED VESSELS OVER 15 YEARS OLD, SATISFIES THE INTENT OF THIS RECOMMENDATION. ACCORDINGLY, M-94-23 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: USCG
To: NTSB
Date: 12/12/1995
Response: ON 12/1/95, THE USCG PUBLISHED NVIC-7-95, GUIDANCE ON INSPECTION, REPAIR & MAINTENANCE OF WOODEN HULLS, WHICH REVISED & UPDATED NVIC 1-63.

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: THE BOARD NOTES THAT THE USCG WILL INCLUDE GUIDANCE ON THE REFASTENING OF WOODEN-HULLED VESSELS IN CRITICAL AREAS ON A 5-YEAR BASIS IN THE REVISION TO NVIC 1-63. FURTHER, THROUGH STAFF CONTACT, THE BOARD UNDERSTANDS THAT THE UCSG IS EVALUATING INDUSTRY PROPOSALS ON FASTENER INSPECTION METHODS TO DETERMINE ACCURATE FASTENER CONDITIION. THE BOARD WOULD APPRECIATE PERIODIC UPDATES ON THE STATUS OF THESE DEVELOPMENT. PENDING PUBLICATION OF REVISED NVIC, M-94-23 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: USCG
To: NTSB
Date: 1/4/1995
Response: I CONCUR WITH THE INTENT OF THIS RECOMMENDATION. HOWEVER, FASTENERS ARE PERIODICALLY REPLACED ON MANY WOODEN HULLED SMALL PASSENGER VESSELS THROUGHOUT THEIR SERVICE LIFE. FASTENER WASTAGE CAUSED BY CORROSION CAN BE DETECTED BY PULLING FASTENERS IN CRITICAL AREAS OF THE VESSEL EVERY FIVE YEARS, & REFASTENING CAN ABE ACCOMPLISHED AS NECESSARY INSTEAD OF REQUIRING COMPLETE REFASTENING WHEN A VESSEL BECOMES 15 YEARS OLD. GUIDANCE REGARDING HULL FASTENING WILL BE INCLUDED IN THE REVISION TO NVIC 1-63. I ANTICIPATE NO FURTHER ACTION TO REQUIRE COMPLETE FASTENING OF VESSELS THAT ARE OVER 15 YEARS OLD, & I REQUEST THAT THIS RECOMMENDATION BE CLOSED.