Internal investigation: Failures of Coast Guard leadership contributed to fatal boat collisionApr 29, 2013 01:36 PM
A fatal accident involving a U.S. Coast Guard law-enforcement boat in San Diego was the result of reckless operation and a string of command failures, an internal investigation concluded.
An 8-year-old boy was killed and 10 others were injured when the 33-foot Coast Guard boat struck the stern of a 24-foot Sea Ray pleasure boat during the San Diego Bay Parade of Lights on Dec. 20, 2009.
The coxswain of Special Purpose Craft-Law Enforcement vessel CG-33118 was sent to the brig and two other crewmembers were disciplined as a result of the accident. The Coast Guard said no pre-voyage plan was prepared, and no one performed lookout duties during the high-traffic nighttime event.
The results of the Coast Guard’s investigation were made public in a Final Action Memorandum issued in January 2013 by Vice Adm. J.P. Currier, the vice commandant. Currier found fault with the chain of supervisors beginning with the coxswain running all the way up to the sector command.
“Sound leadership could have averted this mishap,” he said. “Instead, there were leadership compromises at several levels.”
Witnesses and victims had alleged that the Coast Guard vessel, which was responding to a non-emergency report of a sailboat aground, was speeding unnecessarily. The investigation determined that the boat had been moving at 42 knots prior to the accident, but the Coast Guard was not able to confirm an exact speed at the moment of the collision. Instead, citing crew and witness accounts and engine data, the memo gave an estimated speed of 19 to 40 knots.
“The speed was excessive for safe operation of the vessel and did not allow time for effective action to be taken to avoid collision or to stop within a distance appropriate under the prevailing circumstances,” Currier wrote. “The speed may also have obstructed the ability of the coxswain and crew to observe the Sea Ray, whose stern light may have been the only part of the boat visible to CG-33118 prior to the collision.”
The accident could very well have been prevented if the Coast Guard crew had performed their required duties. A “pre-mission brief or risk assessment” is required to ensure safe operations under existing conditions, but wasn’t performed that night. For this failure, the coxswain was found guilty of dereliction of duty.
Investigators said he didn’t take into account the traffic density, the lighting and the effect of his vessel’s bow rise on his field of vision.
“The absence of an adequate pre-mission brief resulted in the crew’s failure to review charts and the intended track/patrol area; consider safe speed for the mission and/or conditions; consider hazards to navigation; consider the impact of anticipated traffic, and consider the operating environment including tides, currents and weather,” the memo said.
“On the night of the mishap, the operating conditions included confused vessel and background lighting and a crowded harbor,” it stated. “As a result, the coxswain had poor situational awareness of the operational hazards.”
The Coast Guard said the breakdown revealed an inadequate command environment within the small-boat operation at Station San Diego. The officer in charge (OIC) was removed for cause just nine days before the accident, and that was just the latest example of “an abnormally high level of turnover” in that job. Personnel reported that the unit didn’t always follow standard operational risk management (ORM) procedures.
“A lack of consistency in Station San Diego’s command cadre and marginal oversight by the OIC resulted in a weak command climate at the station,” Currier wrote. “The two previous permanent OICs had been relieved for cause, resulting in five different permanent or temporary OICs or COs in the nine-year period leading up to this mishap.”
The recent OIC allowed duty section members to go home early if the number of watchstanders exceeded a minimum level. CG-33118’s section leader took advantage of that policy regularly, becoming “detached” from the unit, Currier wrote.
“The section leader of A-1, of which the crew of CG-33118 was part, had functionally withdrawn from active oversight of the duty section,” the memo said. “This was likely tolerated by the OIC as a result of the inappropriate relationship between the two. More junior and less experienced members assumed leadership and management responsibilities for which they were not suitably prepared.”
The memo said the Sector San Diego commander and staff provided insufficient oversight of the station’s readiness and command climate.
Currier ordered all Coast Guard commanding officers of OICs of boat stations to review with coxswains and crews the failures that led to the fatal San Diego crash. They have been ordered to discuss the importance of situational awareness, lookout duty and safe speeds. The case is to be used in Coast Guard boat training curricula.
“ORM must be enculturated as an ongoing process, not just a mission prerequisite,” Currier said.
Currier called the incident “a tragic anomaly” that demonstrates the need for more discipline and teaching.
“OICs and COs must establish clear expectations, both in writing and through their actions and direct engagement. They must be active coaches and mentors; one of their essential tasks is the development of junior members — that was not the case in this unit.”