Excessive speed and poor oversight probably caused the fatal crash involving a U.S. Coast Guard boat in San Diego Bay in 2009, the National Transportation Safety Board (NTSB) has ruled.
An 8-year-old boy was killed when a 33-foot Coast Guard boat slammed into the stern of a 24-foot Sea Ray during a holiday light parade. Four other occupants of the pleasure boat were seriously injured.
In July 2011, an NTSB investigative report said the Coast Guard boat had been traveling too fast and its crew failed to serve as sufficient lookouts because some of them were using personal cell phones. NTSB Chairman Deborah Hersman attributed the accident to the "coxswain's poor judgment and the Coast Guard's ineffective oversight of vessel operations."
The Coast Guard vessel was CG 33118, a special purpose craft-law enforcement, or SPC-LE. It was responding to a grounding when it slammed into and rode up over the stern of the pleasure boat. The NTSB said the Coast Guard crew was aware of the "heavy vessel density" in the parade area and the challenging visibility caused by numerous lights. The coxswain sailed too fast, the report said.
"The vessel grounding to which the CG 33118 responded was not an emergency and did not necessitate a high-speed response that reached 42 knots at one point," the NTSB wrote. "The CG 33118 was planing, that is, traveling at least 19 knots, at the time of the collision, considerably faster than a safe speed of 8 knots or lower under the prevailing conditions."
The collision killed 8-year-old Anthony DeWeese. The incident prompted the Coast Guard to take several steps that resulted in changes to its small-boat practices and suggestions for the operation of the nation's commercial fleet. Last year, the Coast Guard banned its vessel crews from using electronic devices while underway. Later, the Coast Guard urged commercial operators to develop similar policies restricting the use of such devices that pose a hazard.
Then-Commandant Adm. Thad Allen ordered a Coast Guard-wide review of small-boat operations, policy and training. Crews are now required to receive more navigation instruction. Each station underwent a review to determine if they have the most appropriate vessels for their missions.
"We owe it to the DeWeese family, the memory of Anthony and the public we serve to learn all we can from this tragic accident," spokesman Cmdr. Christopher O'Neil said in a statement on the Coast Guard Compass blog after the NTSB hearing.
CG 33118's coxswain, Petty Officer Paul Ramos, was court-martialed in the fatal crash case. In March 2011, he was found guilty of dereliction of duty and was sentenced to three months in the brig, plus a demotion. The Coast Guard said Ramos failed to perform a risk assessment for the voyage. Two other members of that crew were reprimanded for inattentiveness.
"Records indicate that the CG 33118 crewmembers used their cellular phones for voice calls and text messaging while underway, distracting them from effectively performing their duties as lookouts," the NTSB report said.
The NTSB said the crew simply needed to go more slowly while navigating amid the vessel congestion and confusing light conditions. The accident happened Dec. 20, 2009, at 1744, in darkness.
"The continuous illumination of the Sea Ray's all-around light, the effects of the background lights that limited the conspicuity of the all-around light, and the similar headings of the two vessels coupled with the dead-astern approach by the CG 33118 made it difficult for the crew to visually detect and perceive the Sea Ray," the report said. "However, traveling at a slow speed would have compensated for these visual difficulties."
The NTSB investigators found that the SPC-LEs "have obstructions to forward visibility from the helm and the forward port positions, which increase risks if not properly addressed." The report recommends that the Coast Guard develop procedures enabling crews to compensate for the obstructed view.
The NTSB also recommends that the Coast Guard examine its oversight of all small-boat operations and require each local station to establish specific procedures that account for changing conditions affecting safety.
"We will continue to collaborate with the NTSB to improve the safety of our operations," said Capt. David Fish, who heads the Coast Guard's Office of Investigation and Analysis.
