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Safety Recommendation Details

Safety Recommendation M-94-024
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: REQUIRE THAT THE CRITICAL INSPECTION HISTORY, SUCH AS THE CONDITION OF FASTENERS AND HULL CONSTRUCTION MATERIALS, OF INSPECTED WOODEN-HULLED VESSELS BE MAINTAINED WHERE READILY AVAILABLE TO FIELD INSPECTORS.
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: 2/6/1996
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 2/6/1996
Response: M-94-24 AKSED THE USCG TO REQUIRE THAT THE CRITICAL INSPECTION HISTORY, SUCH AS THE CONDITION OF FASTENERS & HULL CONSTRUCTION MATERIALS, OF INSPECTED WOODEN-HULLED VESSELS BE MAINTAINED WHERE READILY AVAILABLE TO FIELD INSPECTORS. BECAUSE NVIC 7-95 EMPHASIZES THE NEED FOR KEEPING DETAIL FASTENER HISTORY RECORDS, M-94-24 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: USCG
To: NTSB
Date: 12/21/1995
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. ON PAGE 4-13, OF NVIC 7-95, UNDER PARAGRAPH K, INSPECTION OF FASTENINGS THE USCG GUIDANCE TO ITS INSPECTORS IS AS FOLLOWS: "IT IS EXTREMELY IMPORTANT THAT THE TYPE, MATERIAL, & LOCATION OF THE FASTENINGS REMOVED, ALONG WITH A DESCRIPTION OF THEIR CONDITION BE ACCURATELY DOCUMENTED. THIS INCLUDES AREAS OF THE VESSEL WHICH HAVE UNDERGONE REFASTENING AS WELL. USE OF A CAMERA IS INVALUABLE IN RECOARDING AREAS OF INTEREST DURING INSPECTIONS."

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-94-024 ASKED THE USCG TO REQUIRE THAT THE CRITICAL INSPECTION HISTORY, SUCH AS THE CONDITION OF FASTENERS & HULL CONSTRUCTION MATERIALS, OF INSPECTED WOODEN-HULLED VESSELS BE MAINTAINED WHERE READILY AVAILABLE TO FIELD INSPECTORS. BECAUSE THE USCG WILL EMPHSIZE THE NEED FOR KEEPING DETAILED FASTENER HISTORY RECORDS IN THE REVISION TO NVIC 1-63, M-94-24 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE," PENDING PUBLICATION OF THE REVISED CIRCULAR.

From: USCG
To: NTSB
Date: 1/4/1995
Response: I CONCUR WITH THIS RECOMMENDATION. THE NECESSITY FOR KEEPING DETAILED FASTENER HISTORY RECORDS WILL BE INCLUDED IN THE REVISION TO NVIC 1-63.