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Safety Recommendation Details

Safety Recommendation M-94-026
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 OUT-OF-THE WATER SURVIVAL CRAFT FOR ALL PASSENGERS AND CREW BE PROVIDED ON BOARD SMALL PASSENGER VESSELS ON ALL ROUTES.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 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: THIS RECOMMENDATION WAS ON THE SAFETY BOARD'S MOST WANTED LIST. THE BOARD IS DISAPPOINTED THAT THE USCG HAS NOT ACTED ON THIS RECOMMENDATION. THE NEW REGULATIONS AT 46 CFR 117.200 & 180.200 ONLY REQUIRE 100% OF THE OUT-OF-WATER SURVIVAL CRAFT ON OCEAN OR COASTWISE (MORE THAN 50 MILES FROM SHORE) ROUTES WHEN THE WATER IS LESS THAN 59 DEGREES F. THE BOARD HOLDS FIRM IN ITS BELIEF, AS IT HAS STATED IN MANY ACCIDENT INVESTIGATION REPORTS INVOLVING LOSS OF LIFE, THAT THERE MUST BE 100 PERCENTOUT-THE-WATER SURVIVAL CRAFT FOR ALL PASSENGERS ON ALL ROUTES REGARDLESS OF THE TEMPERATURE. CONSEQUENTLY, M-94-26 HAS BEEN CLASSIFIED "CLOSED--UNACCEPTABLE ACTION." WE WILL CONTINUE TO HIGHLIGHT THIS ISSUE IN FUTURE INVESTIGATIONS WHERE APPROPRIATE.

From: USCG
To: NTSB
Date: 6/26/1996
Response: The Coast Guard does not believe that out of the water survival craft is justified for all vessels equipped with life floats and buoyant apparatus. Based upon a review of comments to the SNPRM and sinking casualties over the past 20 years, the survival craft requirements in 46 CFR 117 and 180 were reduced in most cases from those proposed in the SNPRM. In Part 117, the Coast Guard generally focused out of the water survival craft to vessels operating in cold water (< 59 degrees Fahrenheit) offshore. In Part 180, the Coast Guard focused out of the water survival craft to wooden vessels without watertight subdivision bulkheads and all vessels operating far offshore without watertight subdivision bulkheads. The Coast Guard considered other requirements within the rule, such as EPIRBs, fixed fire fighting and detection systems, bilge alarms, and optional subdivision standards in determining the proper type and number of survival craft carried on board a small passenger vessel. All of these features make up an entire vessel safety system designed to reduce the risk of a vessel loss and shorten emergency response time. Overall, the Coast Guard believes the requirements better align out of the water survival craft requirements to casualty data and the perceived increased risk due to the scope of a vessel's operation and number of passengers carried. The Coast Guard requests that the status of this recommendation be changed to Closed, Acceptable Alternate Action.

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: WHILE THE BOARD IS ENCOURAGED THAT THE USCG IS CONSIDERING INCREASING PRIMARY LIFESAVING AS PART OF ITS CURRENT REGULATORY PROJECT FOR SMALL PASSENGER VESSEL INSPECTION & CERTIFICATION, WE ARE DISAPPOINTED THAT THE USCG STILL DOES NOT SEE THE NEED FOR 100 PERCENT OUT-OF-THE-WATER PROTECTION FOR ALL VESSELS ON ALL ROUTES. THE BOARD REJECTS THE ARGUMENT THAT CASUALTY STATISTIC DO NOT JUSTIFY THE ADDED EXPENSE OF PROVIDING 100 PERCENT OUT-OF-THE-WATER SURVIVAL CRAFT FOR ALL VESSELS, NO MATTER THE ROUTE. PEOPLE HAVE DIED IN THE GULF OF MEXICO, SOUTHERN CALIFORNIA, & THE CARIBBEAN, AS WELL AS NORTHERN WATERS, WITHOUT-OUT-OF-THE-WATER FLOTATION, & SUCH DEATHS WILL CONTINUE TO OCCUR. THE BOARD URGES THE USCG TO REEVALUATE ITS POSITION & REQUIRE THE PROVISION OF OUT-OF-THE-WATER FLOTATION EQUIPMENT SUFFICIENT TO ACCOMMONDATE ALL PASSENGERS & CREWMEMBERS ON ALL PASSENGER VESSELS, REGARDLESS OF THE WATER TEMPERATURE ALONE THE ROUTE. M-94-26 HAS BEEN CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE," PENDING PUBLICATION OF THE FINAL RULES IN AUGUST 1995.

From: USCG
To: NTSB
Date: 1/4/1995
Response: I PARTIALLY CONCUR WITH THIS RECOMMENDATION. CASUALTY STATISTICS DO NOT SUGGEST THE NEED FOR OUT-OF-THE WATER SURVIVAL CRAFT ON VESSELS OPERATING ON ALL ROUTES. THE USCG IS CONSIDERING INCREASING PRIMARY LIFESAVING AS PART OF THE CURRENT REGULATORY PROJECT FOR SMALL PASSENGER VESSEL INSPECTION & CERTIFICATION. WE BELIEVE THAT FOCUSING ON THE SURVIVABILITY OF THE WOODEN HULL VESSEL THROUGH BETTER INSPECTION GUIDANCE, THE ADDITION OF HIGH LEVEL BILGE ALARMS IN THE MACHINERY SPACE, FIXED FIREFIGHTING SYSTEMS, & OPTIONAL SUBDIVISION REQUIREMENTS, PROPERLY COMPLIMENTS THE REQUIRED SURVIVAL CRAFT EQUIPMENT.

From: NTSB
To: USCG
Date:
Response: At the 1994 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations M-86-61, M-86-72, M-86-73, M-86-76, and M-94-26 on the MWL under the issue category “Small Passenger Vessel Safety.” This issue was removed from the MWL in 1998.