The EL TORO Tragedy:
Sinking of Party Fishing Vessel "EL TORO II
An Independent Review of the Coast Guard Investigation Report
by David Pascoe
On December 5, 1993 the party fishing vessel EL TORO II sprung three planks and sank 5 miles south of Point Lookout on the Chesapeake Bay. There were 23 passengers aboard and three died in the incident, mainly due to exposure to the cold bay waters.
The EL TORO is a story of particular interest to marine surveyors that reveals some hard-learned lessons. EL TORO was a Coast Guard certified passenger carrying vessel that had just undergone its drydock inspection on March 23, 1993, little more than 8 months prior. In addition, an insurance survey was completed just 5 days before the loss of the EL TORO. Both of these are factors which will come into play, as we shall soon see, that provide some very important lessons for surveyors.
This review is based solely upon the U.S.C.G. investigation report dated 29 July, 1994 and subsequently published on the Internet. The report runs 34 pages in length and will only be excerpted here, not be reproduced in whole. It is available on the U.S.C.G web site for anyone interested at http://www.uscg.mil/hq/cg5/cg545/docs/boards/eltoroII.pdf (link updated May-02-2015) from http://www.uscg.mil/hq/gm/moa/sinkcas.htm (updated link not found). This review is intended solely for the purpose of analysis of a tragedy and how marine surveyors may learn from it and better perform their services. This writer recognizes that he does not have all the facts, and that any criticism herein is based solely on the published report. This is not a complete investigation of the incident and should not be interpreted as such.
The names of the participants have been changed to protect their identities.
PART I, THE INCIDENT
The story begins when Bob Smith purchased a fleet of 5 aging wooden party boats in 1989, among these the then 32 year old "ELTORO". According to Coast Guard interviews, Smith said that he relied heavily on a 1987 survey performed for the previous owner (emphasis added), and the fact that the vessels held current Certificates of Inspection. In other words, Smith said that he was relying on the Coast Guard to ensure that his vessels were safe. Smith had no independent surveys of the vessels made on his own behalf. The purchase was made with no log books or maintenance records being given the buyer, nor were any kept following the purchase.
EL TORO is described as a 58' party boat specifically designed for party fishing and built in Norfolk, Virginia in 1961. Typical of her type for that era and region, she has what is known as a "bay bottom," being transversely planked in 1.75" yellow pine on a longitudinal framing system. She has a 16.5' beam, draws 4.7' and is powered with a single 310 HP Detroit Diesel. Perhaps most significantly, she was fastened with galvanized cut nails. She is of a type well known to the region in which she operated.
Coast Guard Inspections
The past history involving the U.S.C.G. program for inspected vessels is interesting from a number of points. The investigation report delves back in Coast Guard inspection records an to April 1988 drydock report, but not earlier. The following direct quotes from the report are considered relevant:
"26. On 29 mar 1988 Lieutenant Blank completed routine triennial inspection for certification of the vessel. He noted in internal reports " minor leakage from stbd chine between frames 3 & 3 in NR compartment. All satisfactory. No requirements issued . . ."
"27. CW03 Blank completed drydock examination . . . noted in internal reports that wood around the chine fasteners showed signs of damage from electron flow . . recommended fastener removal for specific evaluation at next drydock . . A special 'inspection note' was entered into the CG nationwide computer MSIS to call the chine fasteners to attention of future inspections. The note expired on 29 March 1993.
"28. On April 4, 1989 LTCDR Blank conducted the annual reinspection . . . however he noted 'some working of the keel and water seepage in the mid-portion of fuel tank compartment (stbd side of keel) I examined transverse keel bolts and drift pins . . . appeared satisfactory. Recommended these bolts and pins be monitored at next DD.' No requirements pertaining to hull structure were issued."
"31 Each spring from 1989 to 1992 Mr. Bob Smith has the vessel drydocked without Coast Guard examination. 33. On 8 March Mr. B Smith requested extension of the CG drydock examination
"34. ON 11 April 1990 BMC Blank conducted the annual inspection . . . vessel does qualify for D/D extension until April 91.
"35. ON 5 December Bob Smith requested . . and extension of D/D examination due date 'for a five year period", noting the vessel has been operated and will be operating [between certain points on the Chesapeake]. LCDR Blank replied in writing that the extension request was granted . . . due date changed to 14 April, 1993.
"37. . . .[U.S.C.G.] local guidance policy and propagated brackish water category are not addressed in 46 CFR 176.15-1(a) The policy makes no provision for the age of the vessel." [Emphasis added]/
"40. On 27 April 1992 . . . annual reinspection . . . noted excessive evidence of stray current or exhaust leakage in the engine compartment (sic). This was 'angel hair', also informally called stringy wood but formally called dry rot, and wood around fasteners turning white from electron flow. No special attention was given to the 1988 drydock examination notes about pulling fasteners, but a discussion with LCDR Blank led to a note not recommending drydock extension . . . [the] decision however was not reversed."
Events of the Tragedy
On December 4, 1993, the evening TV weather reports indicated predicted winds of 22 to 30 mph for the Chesapeake Bay. Bob Smith, who would pilot the vessel on the following mornings voyage, admitted that he had seen these reports. At 3:30 AM on the morning of the 5th, NOAA issued a small craft warning with predicted winds of 20-25 knots and six foot seas. At 0730 Smith's brother Carl listened to the VHF weather report and heard the small craft warning. At that time seas were calm. But it was known that a frontal system was approaching that would soon change the current conditions.
Note: The report conveniently does not mention wind direction, along with a great number of other relevant details and evidence that any surveyor would consider an absolute necessity in an investigation of such magnitude. One of the prominent features of this report is it's selective use of evidence and major omissions of evidence of critical importance. One can easily anticipate that if ever called into evidence in a trial, the author would not have an easy time of it before a skilled trial attorney.
At 0800 twenty passengers boarded the EL TORO II to go fishing. The crew consisted of Bob Smith, his brother Carl, and a 19 year old male deckhand. Bob Smith held an appropriate Coast Guard issued operators license and the other two held no licenses.
The vessel cast off at 0815 for the fishing grounds "almost due east of Smith Point, Virginia and about a half a mile south of the Maryland/Virginia border where it arrived around 1015. This position is approximately in the center of the bay. The fetch in any given direction is ten miles or more, but the report doesn't mention this. At no time were any of the passengers given any safety instructions or briefing. Remember that this is in December when the water temperature is indicated as being 50 degrees. It is also of interest that the vessel operators did not keep any kind of log nor did they create a passenger manifest, meaning that they did not even know the names of their passengers except for one.
At 0853 gale warnings were issued for Chesapeake Bay, predicting 30-35 knot winds but Captain Smith did not monitor VHF weather channels after departing. Smith later stated that he did not consider the EL TORO to be a small craft anyway. Another vessel in the area first noted deteriorating conditions around 1200. This vessel was monitoring weather conditions via cellular phone to a source 20 miles to the northwest. The use of a cellular phone obviously indicates that this operator was expecting very bad weather to approach suddenly and wanted to be prepared to head for home in time. This vessel, upon receiving the bad weather report, attempted to contact EL TORO by VHF but was unsuccessful.
Although the Coast Guard obviously has interviewed the operator of this vessel, the report gives no details or names. Why not?
At 1135 the Patuxent Naval Air Station reports winds from the north at 20 gusting to 39. By 1220 it was raining but Smith reports only a light breeze and "conditions were not adverse." This despite the other vessel reporting at the same time seas of 6-8' at Smith Point only ten miles due south. Finally, at 1245 Smith decides to head for home. "While enroute, wind speed and wave heights increased . . .To maximize passenger comfort, he operated the vessel at approximately 4.5 knots, half-speed . . . as the vessel rode over the confused wave pattern at the mouth of the Potomac River. Wind and waves were predominantly from the northwest."
Here we can see that the vessel is already in trouble because it has to reduce speed to one-half, thereby at least doubling the amount of time it will take to return to home port. Why the captain does not seek closer refuge is never addressed in the report. No mention of the tide is made as to how its ebb or flow would affect sea conditions vis-a-vie the Potomac River.
At about 1345 Smith directed the mate to check on passengers and the engine room bilges. Passengers saw him open the engine room hatch and express no concern at what he saw. One passenger . . . "saw into the space and noted liquids in the bilges, four to five inches below the engine mounts." The mate reported to Captain Smith that all was well. "By this time seas had built to 5 to 7 feet but the vessel was taking only spray over the bow." (Note: the report does not attribute direct quotes to any of the persons interviewed. These quotes are of the report language only.)
Yet the report goes on to say that at around 1355, ten minutes later, Bob Smith personally went aft and checked the condition of the engine room, only ten minutes after his mate. Obviously, all is not well. But, by this time the engine had stopped and Smith was greeted with an engine room full to the top of the engine with water.
At this point, the vessel is clearly in trouble and the Captain recognized it as such. A mayday was sent and the passengers directed to don what turned out to be aging cork life preservers. Carl Smith then organized the passengers into a bucket brigade and an attempt was made to bail out the sinking craft. Interestingly, the report says that the buckets were more effective than the bilge pumps.
By 1406 it is reported that the main deck was awash. By 1430 the decks were still awash but passengers were complaining that nothing had been done so far to deploy what apparently is a single house top mounted life raft. Carl Smith assured passengers that the Coast Guard was coming soon, despite being advised of a 30 minute ETA. Even the passengers were smart enough to know that 10, 20, or 30 minutes in fifty degree water would mean death. Finally, the passengers went up on the house top and launched the raft themselves. The question here is, what conclusions will the Coast Guard, which is the author of this information, draw about the behavior of the Captain and crew?
The Coast Guard report identifies it as a buoyant "apparatus," probably an appropriate name for one of those wrapped cork beauties with a rope net bottom, which is what it was. By 1446 all but three passengers and crew had abandoned ship into the "buoyant apparatus" in 50 degree waters of the Chesapeake. At this point the report is very vague about what happened next, but the report does say that three persons were rescued from the water, outside of the raft. One of these was the 19 year old mate who later died of exposure. Yet the Captain and his brother managed to get safely in the raft. The implication here is that the 19 year old sacrificed his life that another passenger might have a place in the life raft while the Captain and his brother save themselves. Oddly, no mention of the mate's heroism is made. Why not? Perhaps because he doesn't hold a CG license? Would that have helped? Of course the report will make note of the heroic efforts of their own people and the exposure that they suffered.
In the meantime, another three persons - all passengers - remained on the house top (while the owner and his brother got in the raft) which apparently remained above water and were rescued by a life raft from a recently arrived Coast Guard vessel.
"All passengers and crew suffered from hypothermia, being in the water from 20 to 80 minutes. Many were physically rigid when rescued."
"At 1830, three Coast Guard personnel from UTB41411 were taken to the hospital for hypothermia. None of the three entered the water during the rescue."
Two passengers and the 19 year old crewman ultimately died of exposure while hospitalized.
With this brief summary of events as extracted from the Coast Guard report, we can already identify a number of serious problems, but there are more to come. Not the least of these is the extraordinarily lax attitudes of party boat owners toward the condition of their vessels and the safety of their passengers. Just from the language of the report we can discern questionable behavior of the Captain. How can anyone discount that 5-7 foot seas are a threat to an aging wooden vessel with passengers aboard? He was in the vicinity of the mouth of the Potomac and knew of the dangerous currents. He knew there was bad weather approaching, and he could have sought nearby shelter in time and yet refused. Gale warnings were ignored. Another vessel attempted to warn him by radio, but apparently he wasn't monitoring his radio as the report says he was.
Again, judging by the report, the captain had all available knowledge and ability to avert the disaster, but did not. Yet the Captain is completely absolved by the report. Why? Is the writer of the report so arrogant or stupid that he is not aware that his own writings condemn the Captain? This willful ignoring of the facts as contained in their own report is repeated again and again.
Marine surveyors who perform surveys on these craft are no strangers to such happenings and the terrible conditions aboard these vessels. The tragedy of the EL TORO points up vividly why we as surveyors ought to be paying closer attention and applying more rigid standards to these vessels. As this tragedy so amply demonstrates, surveyors should not ascribe any significance to the fact that a vessel is U.S.C.G. certified.
In the next section we'll take a look at the actions of one independent surveyor, the actions of the Coast Guard inspectors, and finally the Coast Guard report itself. For if the failings of the various parties involved doesn't convince us of the need for extra caution, the manner in which the Coast Guard deals with it's investigation will. Remember that Coast Guard report is, in itself, a conflict of interest. Here we have the certifying authority of the vessel investigating the loss of the vessel and the activities of many others that were involved with it. Knowing this, can there now be any doubt but that the Coast Guard will absolve itself? Read on.
In this section I will offer my critique on the Coast Guard analysis and offer some sound reasons why government agencies, whether its the NTSB or the Coast Guard should not be in a position of investigating accidents of craft which they certify. Upon studying the report, any highly experienced surveyor with a good knowledge of wooden vessels will quickly come to see it for what it is.
While the overall size of the report (34 pages) may appear impressive, considering the overall scope of the investigation, it is remarkably superficial and limited, particularly when it comes to investigating and assessing cause. Worse still is its obviously biased presentation bolstered by critical omissions of material facts.
The EL TORO was recovered the following day, refloated and hauled out at a local boat yard. Judging from the report, it had not broken up to any significant degree although, again, the report says almost nothing about its condition. The Coast Guard, insurance surveyors and other unidentified people from NTSB and Maryland Police were present to investigate. The Coast Guard review (I call it that because its hardly a full report) of the survey comes to barely two full pages. It starts:
"129. . . The consensus was that the hull was in remarkably good condition except for three sprung planks on the port side immediately forward of the forward engine room bulkhead. The inboard end of the planks had dropped about four inches from their normal position, leaving a gap in way of the keel of about two inches. With the exception of a single nail, all nails connecting these planks to the sister keelson had wasted totally through at the faying surface with the keelson."
It is very interesting to note how this investigator makes judicious use of opinions of non-Coast Guard people present . . . "The consensus was . . ." when the writer wants to deflect attention from the failure of the CG inspections to note any problems, or rather should we say failure appreciate the importance of the evidence that was contained in their file notes, discussed in the next section. Here we have a hull that sprung three planks, had bad fasteners, sank and killed three people, but he's telling us that others thought it was in good condition. Yet, as the investigator, he does not say what he thinks.
The report goes on to say that six planks were then removed - apparently the three already sprung, and three others which are not clearly identified but are apparently two planks just fore and aft of the loose ones, and yet another on the opposite side of the keel. Remember that this is a bay bottom hull with the planking running transversely from keel to chine.
The rust stains all over the hull of EL TORO clearly indicates that there is a corrosion problem with the fasteners. Since the steel nails were galvanzied, the rust stains mean that the corrosion has penetrated through the galvanizing, and that advanced rates of corrosion should be anticipated.
"129. The four planks removed amidships showed extreme wastage of fasteners in way of the keel, with only 1 of 17 fasteners present for planks a, b, and c. The planks themselves were in excellent condition, free of visible deterioration." (Remember this statement because it will be contradicted later.) "Fasteners toward the chine were progressively better with most chine nails like new. Fasteners in the two planks removed forward and aft had some necking but were substantially intact and apparently effective, even at the keel." "Some necking?" Doesn't he consider it important enough to say how much? "Some necking" could be 10% or 90%, a factor that would tell volumes about the overall condition of the bottom.
The next paragraph: "130. On December 13, 1993, marine electrical specialist Mr. ___ examined the electrical system, metals in the hull and fasteners. He had the two bottom planks just forward of plank A and the one just aft of plank C removed. He concluded that the electrical grounding issue . . . had no substantial impact on the wasted fasteners. (Note: prior inspections had raised an issue about the vessel's grounding system that back in 1988 was changed from a positive to negative grounding system.) "He attributed wastage of fasteners in planks A, 8 and C to 32 years of galvanic corrosion, aggravated by the use of a variety of metals in the hull."
Galvanic corrosion? To a steel nail imbedded in wood? Note here that fasteners do not corrode unless they get wet. The corrosion first takes place at the joint between plank and frame because this is where they first get wet. Once water gets at the nail, it will corrode all by itself: it doesn't require 32 years worth of galvanism.
"131. Mr. ___ noted the electrical system to be a mess. He stated that this condition is quite common on such vessels."
If that's the case, then why does the coast Guard commonly approve these messy conditions? Why did this vessel have a messy electrical system after 32 years worth of Coast Guard inceptions, not one but literally dozens of inspections? Not one CG inspector ever found it worthy of mention? Here again, the report condemns the CG but the investigator does not find it worthy of comment.
"132. Mr. [the insurance surveyor] visited the vessel on the railway and stated that picking planks A,B, and C for fastener removal to find wasted fasteners during a drydock examination would have been a "crap shoot" since no external or internal evidence of a problem existed. He state that he would have focused on the engine room, based on his experience and internal indications on this vessel, such as angel hair noted in his survey report."
Here the report does not mention that the insurance surveyor did his survey afloat. The surveyor's remarks, if he made them, are not qualified or put in proper context but used to support the Coast Guard's failure to find any problems. Moreover, the surveyors comments indicate that there were indications of trouble on the interior. But the writer wants us to believe that everyone agreed that it "was in remarkably good condition."
Remember that earlier the writer states that the planks were entirely free of deterioration, and yet now he's admitting that there was "angel hair' on the planks. Angel hair is a form of deterioration caused by constant wetting and drying of salt water within wood fibers. As the water dries, the salts crystallize, tearing the wood fibers apart. The report erroneously attributes this to stray current or 'galvanic" problems. This causes progressive deterioration because it increases the ability of the wood to absorb water and so it becomes progressive. The wood is no longer solid but shredded, yet we're to believe that its in remarkably good condition.
"133. Of approximately 100 fasteners in the six planks removed on 10 December 1993, about 30 were wasted to the point of being totally ineffective, about 20 were wasted to be marginally effective, and about 50 were like new or had minimal wastage."
Whether the writer is being deliberately obtuse or not, the point is conveyed that at least 50% of the fasteners were either wasted or in poor condition. He should have indicated the percentage of wastage to original size, not use such amateurish and relative terms such as "like new" or "minimal." Does the report offer exhibits of the nails as evidence? No, it does not. How about the planks? Again, no. Yet the report devotes a great deal of its space to convince of the CG inspectors experience and professionalism while the substance of the report denies that claim. Surely the writer knows that with all these injuries and deaths that there will be litigation. Yet he is willing to go out on a limb and provide a report that is amateurish at best, and decidedly self-serving. The most fitting conclusion we can draw here is that the writer has succumbed to the rampant disease of bureaucratic self-immolation to protect the Coast Guard hierarchy.
"135. The marine surveyors and Coast Guard inspectors testifying on appropriate intervals for removal of fasteners, and refastening in general, had widely varying opinions. None identified written guidance or even alluded to written guidance."
Here begins the Coast Guard's shifting of the blame. What he's saying is that since there is no written 'guidance' - and note the peculiar use of that word - that it's not the certifying authority's responsibility to KNOW when fasteners should be pulled and checked. In attempting to shirk responsibility, the writer is unwittingly exposing his agency's incompetence. Imagine if the NTSB made such comments in an official report on an air disaster! "We couldn't find any written guidance for over 50 years so we just kept approving it anyway." This same excuse appears yet again in the conclusions section of the report.
Moreover, you may have noted the subtle inclusion of "marine surveyors" along with "Coast Guard Inspectors" in that comment. They apparently didn't want to feel alone in their ignorance so they had to include the private sector as well.
"136. The fuel tanks were supported with transverse saddles. The aft saddle supports had failed, allowing the weight of the tanks to be partially supported by a bottom transverse plank. The wear on this plank indicated that this condition existed for some time. There was no evidence in March 1993 that this circumstance had any adverse affect on the integrity of the hull." [boldface added].
Amazing! Here he's not saying that the broken tank saddle didn't exist 8 months ago in March, but rather that there's "no evidence" that this had "an adverse effect" on the intergrity of the hull.
Next, I'll go to item #6 of the conclusions section: "6. The unintended support of the fuel tank aft transverse saddle by a bottom plank may have placed forces on the garboard joint over time, contributing to the entry of water and the abnormal corrosion rate in the area. However, corrosion of the fasteners in other planks and battens indicates that other factors were more significant."
This statement is truly amazing. Here we have the aft end of the fuel tank support sitting not on a longitudinal plank, but a transverse plank. And the writer would have us believe that there more significant factors? And just what are those "other factors?" Well, he doesn't say. Corrosion in other planks? But he's talking about the plank that the saddle is resting on. What do other planks have to do with the failure of this one? How large was the tank? How much weight was resting on that plank? Again, the report is silent on critical evidence.
These statements in and of themselves destroy all credibility of this report. Its like justifying a flat tire by saying that its only flat in one place.
This ends the narration of the investigation into the cause of the tragedy. The astute investigator will note that this report is as remarkable for what it does say as it doesn't say. This is followed by a list of 35 conclusions and 17 recommendations, most of which seem designed to deflect responsibility and disguise the Coast Guards own failures.
PART 111, RECOMMENDATIONS
1. As near as we can tell from the report, six, and possibly eight planks were removed, all in the area of the three loose planks. From this, the investigator concludes that it was a localized problem (conclusion #6). How does he know its localized when he didn't check other areas?
2. No indication is given that any effort was made to check any planks other than the immediate area of the failed planks. Why not? The obvious answer is that the investigator already had a foregone conclusion which he set out to prove.
3. A 32 year old wooden boat fastened with steel fasteners would be a prime suspect to any experienced surveyor. Yet this report would infer that the rest of the fasteners in the vessel are all okay without any kind of general survey, and offers no proof of the inference. It justifies not pulling any planks or fasteners in other areas on the absurd argument that the nails are too hard to pull. This on a wrecked hull on which the fasteners could have cut out.
"134. Generally, all marine surveyors and Coast Guard inspectors testifying on the feasibility of removing nails for examination felt removal of a plank was more prudent than individually removing nails, due to plank damage caused by removing nails."
4. As any experienced surveyor knows, bay bottom boats bear that name for good reason. Transverse framing is a shortcut method of boat building, intended for vessels used in protected waters because they are not nearly as strong as longitudinally planked boats. Bay bottom boats are notable for their tendency for wracking which, in turn, produces the tendency for leakage, which in turn wreaks havoc on fasteners. Nothing about the method of construction is mentioned in the report. That none of these considerations are raised gives rise to either questioning of the investigator's competence, or his intent.
5. Conclusion #4 explains away the faults found in prior CG inspections that were never addressed: leaking at the starboard chine forward, deterioration of wood around keel bolts, plus "working/seepage" at the starboard side of the keel, midlength in the fuel tank compartment. Couldn't be due to the broken tank saddles could it? ". . . all indicate that the vessel was not in optimal condition." Optimal condition? What does that mean? "However, the circumstances were not severe enough to result in the issuance of requirements or supervisory direction for the actions beyond the special inspection notes recommended by the inspectors." In other words, they made notes in the file on these conditions but otherwise did nothing. One has to wonder just how serious does it have to be to get their attention? This explanation is entirely inadequate.
6. The report states that the fuel tank saddle was broken loose from its frame fasteners and was resting on a plank. It further states that a wear pattern existed to show that the condition was long standing. For the reporter to state that this was a secondary consideration is ludicrous. Nothing in the report suggests that the entire weight of one end of the fuel tank was not resting on the plank. One could only conclude that a fuel tank saddle resting on a bottom plank would be a major contributing cause to that planks coming loose. This statement is clearly meant to deflect attention away from the fact that the inspectors did not find this condition in any of the last inspections. Or worse, that they knew of it and did nothing. Since the insurance survey has not been made public, we do not know if the insurance surveyor found this problem. Now consider the following statement:
"There was no evidence as of the drydock examination in March 1993 that this circumstance had any affect on the integrity of the hull."
As with so many other conclusions in this report, this statement is inserted in the report with no substantiation at all.
Conclusions of the Investigation
"1. The proximate cause of the casualty was failure of the fasteners in the planks A,B, and C in way of the keel. The relatively severe seaway provided the forces that worked the planks loose, flooding all compartments . . . " Apparently he means that the seas pulled the planks loose but that the fuel tank sitting on a plank had nothing to do with it.
This conclusion is also notable for the fact that it does not state what the cause of the fastener failure was. Why does the investigator fail to state that the cause of the failure was corrosion? Although conclusion #3 talks about a variety of metals, including through hull fittings and ground plates, "contributed to the galvanic corrosion." At this point we have to be wondering how you build a boat without a variety of metals under water. Since all wood boats have dissimilar metals underwater, why is this one more adversely affected? No mention of the vessel's age is made, nor how long steel fasteners are expected to last. Nor to the general rule of thumb that even bronze fastened boats should be thoroughly checked after 15 years, yet alone 32 years.
More importantly, it is widely known that bay bottom hulls defy the principles of strong wooden boat construction, that they are fraught with problems, which is why only a few builders in the mid-Atlantic coastal region used the method.
Conclusions #4 & 5 are also noteworthy for their self-serving statements. This one deals with the observations made by the CG at the 1989 and 1989 CG hull inspections, as previously mentioned, in which "working/seepage at the starboard side of the keel midlength in the fuel tank compartment," "leakage around the keel," and wood deterioration around the keel bolts were observed yet no orders for repair were given. Isn't this precisely the area where the planks popped loose?
Conclusion #5 is particularly interesting from the standpoint that it draws the conclusion that the wastage of fasteners at the 3 planks is a "local problem" and is a conclusion without substantiation. "The location was subject to abnormal corrosion rates due to being a low point where bilge water would collect, to the variety of nearby dissimilar metals and to the design of the vessel in the garboard area." Is having a low point in the bilge "abnormal"? And then this interesting statement: "The inline end of the bottom planks is conducive to working that would allow the joint to become loose and the water to enter the joint." This statement clearly indicates that the investigator is aware of the wracking problems with bay bottom boats. He knows that the bottom planks work, and yet would have us believe that its strictly a "local" problem.
All by itself, the above paragraph contradicts and invalidates the entire investigation report. If the inline end of the bottom planks are conducive to working that would allow water to enter the joints, then it follows that the nails are going to get wet and corroded. No galvanism is necessary as salt water does a wonderful job on steel, galvanized or not. Further, it had been substantiated in this and prior inspections that there was looseness, working and leaking of water from inside the vessel when it was hauled. Apparently the effect of looseness and water exposure to steel nails at that time "were not serious enough to result in issuance of requirements . . ."
But these conditions are now serious enough to be cited as the cause of corrosion of the fasteners that ultimately sank the vessel and killed three innocent people. In just a few years, a period of time when drydock inspection was postponed three times, it went from not serious to complete failure. To accept these statements at face value, one would have to believe that the CG inspectors and the investigator had no knowledge of the corrosive effects of sea water on galvanized nails. Yet the report reflects that they do know.
Any objective investigator would have concluded that the CG had failed in its prior inspections, what with their files containing notes of these serious conditions, to issue a requirement for mandatory fastener inspections, along with granting of delays for drydock inspections. After all, they are not inspecting farm equipment but certifying a public conveyance that is going to sea in the dead of winter.
Conclusion #10 passes the buck by saying that there is no "well-known published guidance in the marine industry" on when fasteners should be inspected. This despite the fact that they are the certifying authority and its their responsibility to know, not blame it on the marine industry. But then the writer destroys his own argument by saying, "Much of the available guidance on fastener examination typically assumes indications of wastage are present to suggest examination." This is utter nonsense: the surveyor does not have to see external evidence of fastener wastage to know that 32 year old steel nails are likely to be completely wasted, yet alone moderately so. Of course, no references are ever cited. Yet the most well known book around, Ian Nicholson's Surveying Small Craft goes into great detail about inspecting fastenings, including discussion about telltale evidence that suggests fastener problems.
The Statement of Fact section of the report item #6 notes that CG Vessel Inspection Circular (NVIC) No. 1-63 recommends against the use of cut nails due to a lack of holding power in some circumstances. ABYC Project H-7 recommends against the use of ferrous fasteners, and if ferrous should be hot dipped galvanized. This does not prevent the CG from concluding that there is "no published guidance" and no fault of their own inspectors from following their own recommendations. How much more guidance do they want? When a privately published and voluntary standard suggests that its a problem for pleasure craft, can't they take the hint that it could be disastrous for a public conveyance that is 32 years old?
Conclusions 7 & 8 provide cover for the inspectors who carried out the earlier inspections, explaining why they only examined the "wind and water line interface, limiting his examination of fasteners to that area." Obviously they didn't just examine the waterline area because their "notes" indicate problems at the chine and keel. The essence of this commentary is that it is the experience of the inspectors that the water line area is a more critical area to inspect. This is their explanation for not inspecting the planks at the keel rabbet which this very report later states is the most probable area to expect corroded fastenings. Again, the report discredits itself. See Conclusion #5 above.
Conclusion 25 is equally incriminating. I'll reproduce it here in whole:
"Although Coast Guard marine inspectors are sensitive to the time, material and labor costs imposed on owners of wood boats caused by the requiring the removal of fasteners, there is no evidence that this sensitivity directly contributed to this casualty. [Emphasis added] These costs can be considerable for owners of small vessel, especially those which carry few passengers and have low value. The impact . . . could drive them out of business . . ."
How about the cost to the passengers and three people who lost their lives? Is this a Freudian slip or what? Here the writer is giving the boat operators a free pass. In other words, because we have passenger vessel operators who are using old, dilapidated wooden boats to run a public conveyance, the Coast Guard shouldn't risk bankrupting them by ensuring that these vessels are safe. As with airlines, if the nature of the business doesn't produce sufficient revenues to produce safe vessels, then they shouldn't be in business. As with the ValueJet disaster late last year, once again we've witnessed a federal regulating agency give a shaky business operation a free pass on safety. As a result, over 100 people died.
If ever there was a prime example of how not to write an investigation report, this is it. These statements are little more than an excuse for failure to perform, not an objective evaluation. Of course keeping old boats maintained will bankrupt the owners, just as old jet aircraft can bankrupt an airline. Why aren't 707's used in passenger service anymore? That's not an acceptable excuse for allowing defective conveyances to operate. Old vessels, like old aircraft, need to be retired when their safety can no longer be assured.
Finally, here is the coup de gras that we would expect from any government agency investigation of its own handiwork: "34. There is no evidence of negligence on the part of any other government employee or person holding a license or document issued by the Coast Guard." - emphasis added.
Of course not. We investigated ourselves and we are clean! And so are the people we grant licenses to.
Lessons to be Learned: The Surveyor's Role
At the outset of the CG report considerable issue was made about the insurance surveyor's role in the case. This surveyor was a direct employee of the insurer and was performing the survey for the insurer at no cost to the vessel owner. He had already surveyed the other four vessels owned by Mr. Smith. He found them to be in poor condition and they had already been placed on port risk by the underwriter at the time he surveyed EL TORO. They were not placed on port risk because the surveyor thought they were safe. At that point, its easy to imagine what the owner's attitude toward the surveyor was.
When he surveyed the EL TORO, Smith accompanied the surveyor to the vessel then left. The surveyor's comments in his report to the insurer was "This is one of the worst Coast Guard inspected vessels that I have ever seen," a comment that is mentioned in the CG report. Although we do not know the exact nature of his findings, we do know that the surveyor did not report them to the vessel owner as he had left the scene. (The CG reports indicates that the surveyor stated that no one of 20 odd defects would be sufficient to condemn the vessel. Yet the implication of the statement, along with the surveyors comments, indicate the cumulative findings were sufficient to condemn it.) Further, the surveyor states that he had been told by Smith that the vessel was laid up for the season, and therefore he did not expect it to be going to sea. Smith, as well we can imagine, denies that, saying that he told him the vessel was still operating and would be operating soon.
Here we have a situation in which the insurance surveyor condemned five out of five of this operator's vessels. The CG report makes no mention of any of these other vessels. The interesting question here is whether the CG gave these other four boats a free pass also?
Legal Responsibility for Notification of Serious Defects
The Coast Guard raises the issue of why the surveyor did not inform them, the CG, or the vessel owner of his findings. Since he condemned the other four boats, and this was the worst of them, we can presume that he intended to constrain this one to port risk also. Again, this is a subtle passing of the buck to the insurance surveyor, saying, in essence, if you had told someone, this wouldn't have happened. Clearly, the writer of the report knows that this will paint the surveyor into a very dark corner indeed.
No doubt the surveyor felt satisfied that the vessel was laid up (as were the other four despite the confinement to port risk, since the rockfish season had already ended.) and therefore he felt he had no need to make an immediate notification. On the other hand, in these situations, there is often a question of whose responsibility it is to make a notification, if any.
With a legal system as muddy as ours, the issue of liabilities in a disaster scatters like birdshot. The surveyor is going to find himself caught up in it no matter how sterling his performance. The issue of notification has not, to my knowledge, ever been clarified. Yet the circumstances in this case clearly points to the answer. Whether required to or not, notification should be given the owner in writing. Obviously, verbal notification would be of little value because the owner was already unhappy with the surveyor, and in the event of an accident, would only deny the verbal notice anyway. Therefore, only notification by certified mail would have sufficed. Chances are that even notification by regular mail would be denied, and there would be no proof that the owner had ever received it.
As to whether the surveyor had an obligation to report adverse conditions to the Coast Guard, my opinion is no, he did not. Nor should he be required to do so, despite the CG recommendation in the report. If the CG undertakes to certify vessels, then it is their responsibility to ensure their satisfactory condition. And, as we know only too well, they fail in this job miserably as is clearly demonstrated in their own report. If surveyors are required to notify the CG, this raises all sorts of legal issues and questions of procedure and responsibility that could never be satisfactorily resolved.
Participating in Joint Investigations
When participating in any investigation, particularly governmental investigations, the lesson here is to be careful what you say. Anything you say can and will be used against you. In this case, the CG has a clear conflict of interest. It was entirely predictable that their investigation would be completely self-serving. The surveyor would have been best off had he said nothing to them. Not only did they seek to shift the blame to him, but should the surveyor be implicated in the lawsuits that are likely to go on into the next millennium, both his comments and the report will hurt his defense.
Bias is Always Obvious
Another interesting point has to do with the report itself. That the report discredits itself of course was never obvious to the writer, even though its obvious to any non-involved person who reads it. The principle here to remember is that bias in report writing is always obvious to others, but never the writer. The effort to conceal, misrepresent or omit factual evidence is often unconscious; the fact is that obtaining true objectivity is very difficult for anyone, and there are very few persons who have the capability to be entirely objective.
In all investigations surveyors are hired by someone with an interest. It is a natural inclination to try to assist those who are paying our fees or salaries. At first reading, the inconsistencies, omissions and outright contradictions are not obvious; they only become so upon careful study. But it is important to remember that in a serious casualty, all reports are subjected to extremely detailed study. And if the Coast Guard is being sued in this instance, there can be no doubt but that the plaintiff lawyers will have a field day with this report. Its a plaintiff's lawyers dream because it impeaches itself.
The lesson, of course, is that important investigation reports should never be rushed. The best way to craft as objective report as possible is to refine it over a period of time, say a week or so. There's nothing like proofing a report from a perspective of a time interval from the moment it was written until it is issued. That gives us the time to think about it, digest it, and approach it on another day when our thoughts may be a bit clearer, the faults and inconsistencies more obvious.
By now it should be abundantly clear that old wooden vessels should be approached with the maxim, guilty until proven innocent. No one has ever been able to establish an average term of safe life expectancy for wooden vessels because the quality of materials and construction designs vary so much. It is widely known that economically built hulls, such as most pleasure craft, become suspect within 15 years or less. Tens of thousands of Chris-Crafts, Pacemakers, Egg Harbors, Allied and others were built in the 1960's and nearly all of them are gone now. Fastener problems frequently arose after only ten years, and all surveyors know this. Why doesn't the Coast Guard?
For better built craft, we have the examples of Trumphy, Wheeler, Consolidated, Elco and others that had safe useful lives of 30 years or more. Any yet because some of those boats are still around, no one should ever assume that they are safe because they are not. Wood structures and metal fasteners have limited life spans; the older they get, the more deteriorated and suspect they become. To look at the outside or inside and say that 32 year old fasteners are probably okay is irresponsible. This writer decided a decade ago to decline to survey old wooden vessels because his experience was that none of them were safe for open sea conditions and he didn't want to find himself in the position that the insurance surveyor mentioned in this report finds himself. Nor is he alone, as most competent surveyors now decline to survey old wooden vessels. The risk is just too great. Yet the Coast Guard has gone blindly on its way certifying these disasters waiting to happen. And while the CG report states that it knows of no other similar casualties involving wooden vessels, the fact is that there have been dozens in the last decade alone, especially involving uninspected passenger carrying vessels.
It is impossible for a surveyor who knows his business to believe that the hull of this vessel on prior drydockings revealed no evidence of its poor condition. Indeed, there are several mentions in the report about its remarkably "apparent" good condition. This writer has yet to see a 30 year old wooden hull that did not display clear evidence of structurally deteriorated conditions, from open seams, worm damage, cupped planks, loose planks and evidence of corrosion from rust or copper stains in way of fastener heads and bungs. The evidence is always present and the prior CG files and reports prove it.
The CG uses the excuse on one inspection that the bottom was freshly painted. Yes, indeed, but every surveyor knows that one cannot survey a freshly painted bottom effectively unless prepared to pull a lot of fasteners. But it has long been de rigeur for surveyors to pull fasteners on any wooden vessel regardless of age. And while they suggest fault of the insurance surveyor for not providing immediate notice, they do not fault themselves for their own negligence in raising the red flag at this point. Instead, they complete the inspection, knowing that they can't do it effectively, and then give it a clean bill of health. An independent surveyor would hang for this. But here we're dealing with the government. The correct procedure at this point would have been to pull fasteners, or reschedule 90 days hence when the bottom paint would no longer be fresh and the corrosion patterns would reappear through the now-aging paint. It is impossible to believe that a 32 year old vessel with steel fasteners does not show evidence of corrosion at frame intersects or at bung heads.
Old Boats in General
All material things in this universe deteriorate, so at greater and some at lesser rates, but deteriorate they do. When it comes to boats and ships, which float in an extremely corrosive substance, age itself is a dangerous factor that should never be treated lightly. Whether its wood, fiberglass or aluminum all structures deteriorate and weaken over time, as do systems and machinery. To use an old cliche, a book should never be judged by its cover as boat should never be judged by its appearance. To make assumptions when surveying based on appearances can ultimately cost you dearly. The only proper attitude toward older vessels is one of extreme caution. Inspect, verify and explain fully. That means cover yourself with all necessary exculpatory statements and written record.
These are the important lessons for surveyors in the EL TORO tragedy:
1. Whenever any circumstance prevents the full and effective performance of our function, we need to send a red flag up the mast in clear and certain terms. Fortunately, we do not certify, but we are responsible for making notification of any evidence that adversely affects safety.
2. Never make the mistake of downplaying evidence of defects such as saying, "It doesn't affect the structural integrity," unless you absolutely certain of this and would be prepared to defend that statement in court. Nearly every surveyor is guilty of this, including myself, mainly due to the casualness of the pleasure craft business. The case of the EL TORO reveals how a casual comment can turn into a matter of life and death. It is far better not to make a favorable summary judgment than to render a casual opinion.
3. Surveyors are often pressed to render snap decisions and fast reports. This is conducive to serious errors of judgment and may happen frequently. We usually sense it by feeling uncomfortable about it. We should never hesitate to review a situation that doesn't sit right, and never hesitate to amend a faulty decision, particularly one that could have dire consequences.
4. Notify vessel owners of dangerous defects both verbally and in writing, and do it promptly. Don't wait for the insurance company to do it. If something bad happens, the surveyor is going to be on the hook.
5. When tragedy strikes, blame scatters like buckshot.
Suggestions for the Coast Guard
Either get serious about small vessel inspections or get out of the business. Those of us who are familiar with the CG are aware that most of their problems with the small vessel industry stems from a congress harrassed by an industry lobby that pulls them in one direction, and the need for competent regulation in another. But, as the FAA has recently discovered with a rash of hideous airline crashes, they can't have it both ways. Either the well-being of the industry comes first, or safety does.
Competent regulation means that tough regulations must be backed up with a philosophy that puts safety first. As this case amply demonstrates, the Coast Guard has and does neither. By no stretch of the imagination can regulation that permits old vessels to go to sea with passengers with a single 32 year old bottomless cork life raft and aging, deteriorating cork life jackets in the dead of winter be called serious or tough. Three persons remained on the vessel and three more were in the water. The implication here is that not all 23 persons could fit in the life raft (for they had plenty of time to get aboard) and yet the vessel is certified for 49. What would have happened if EL TORO had her full capacity? How many more would have died because the life raft would only hold 17?
Why don't regulations require life raft capacity for all? I recently surveyed a vessel certified for 149 passengers and it only had life raft capacity for no more than 50. Hasn't the CG learned anything from the numerous passenger liner disasters of the past where half the passengers died because there weren't enough life boats? What in God's name does it take to get sensible life saving equipment?
Despite the CG's absolution of itself, anyone who takes the time to read that self-serving report will find many more faults than I have mentioned here. Commercial fishing vessels operating in cold waters are required to have immersion suits. Why are the lives of commercial fishermen more worthy of this protection than a vastly more ignorant general public?
Sure the CG has had long-standing problems of serious budget cutbacks, reallocation of resources to such things as drug and refugee interdictions, among many others. Yet if it is going to continue to CERTIFY passenger carrying vessels, and not start doing a better job of it, its inevitable that one day some old clunk of vessel is going to take not just three persons, but 150 or 200 or 300 passengers to the bottom. And on that day the Secretaries and Admirals are going to find themselves on C-SPAN facing angry congressional committee members grandstanding for the folks back home in yet another self-righteous effort to pass the buck. Only this time, the Coast Guard brass will be the victims instead of the buck-passers.
David Pascoe - Biography
Marine Survey Articles
At A Glance
- Moisture Meters on Boat Hulls
- Hi Tech Materials in Boat Building
- New Materials Again
- Avoiding the Blister Blues
- Hull Design Defects Part I
- Hull Design Defects Part II
- Surveying Storm Damaged Boats
- Surveying Boats with Grid Liners
- Surveyor's Guide to Insurance Surveys
- How to Survey A Wood Hull
- EL TORO Tragedy, The
- EL TORO Addendum
- EL TORO II: The NTSB Report
A Guide for Discriminating Buyers
Focuses exclusively cruiser class generally 30-55 feet
With discussions on the pros and cons of each type: Expresses, trawlers, motor yachts, multi purpose types, sportfishermen and sedan cruisers.
Selecting and Evaluating New and Used Boats
Dedicated for offshore outboard boats
A hard and realistic look at the marine market place and delves into issues of boat quality and durability that most other marine writers are unwilling to touch.
The Art of Pre-Purchase Survey The very first of its kind, this book provides the essentials that every novice needs to know, as well as a wealth of esoteric details.
Pleasure crafts investigations to court testimony The first and only book of its kind on the subject of investigating pleasure craft casualties and other issues.
Over 70 countries
- Chapter 1
- Basic Considerations
- Chapter 2
- Boat Types: Which is Right for You?
- Chapter 3
- Old Boats, New Boats and Quality
- Chapter 4
- Basic Hull Construction
- Chapter 5
- Evaluating Boat Hulls
- Chapter 6
- Performance and Sea Keeping
- Chapter 7
- Decks & Superstructure
- Chapter 8
- Stress Cracks,Finishes and Surface Defects
- Chapter 9
- Power Options
- Chapter 10
- The Engine Room
- Chapter 11
- Electrical & Plumbing Systems
- Chapter 12
- Design Details
- Chapter 13
- Steering, Controls, Systems & Equipment
- Chapter 14
- The Art of the Deal
- Chapter 15
- Boat Shopping
- Chapter 16
- The Survey & Post Survey
- Chapter 17
- Boat Builders by Company
- 512 pages
- Chapter 1
- What is
- Chapter 2
- Business Practices and Client Relations
- Chapter 3
- Sound vs. Seaworthiness
- Chapter 4
- Chapter 5
- Hull and Its Structure
- Chapter 6
- Surveying the Hull
- Chapter 7
- Using Moisture Meters
- Chapter 8
- Stress Cracks & Surface Irregularities
- Chapter 9
- Deck & Superstructure
- Chapter 10
- Chapter 11
- Drive Train
- Chapter 12
- Gas Engines
- Chapter 13
- Fuel Systems
- Chapter 14
- Exhaust Systems
- Chapter 15
- Electrical Systems
- Chapter 16
- Plumbing Systems
- Chapter 17
- Sea Trials
- Chapter 18
- Chapter 19
- 480 pages
- Chapter 1
- The Marine Investigator
- Chapter 2
- The Nature of Investigations
- Chapter 3
- The Nature of Evidence
- Chapter 4
- Marine Insurance and Issues of Law
- Chapter 5
- Bilge Pumps & Batteries
- Chapter 6
- Finding the Leak
- Chapter 7
- Sinking Due To Rain
- Chapter 8
- Fire Investigations
- Chapter 9
- Machinery Failure Analysis
- Chapter 10
- Fraud Investigations
- Chapter 11
- Interrogation Techniques
- Chapter 12
- Chapter 13
- Deposition & Court Testimony
- 544 pages