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UNCLAS //N05100//

SUBJ: FINAL ACTION MESSAGE ON STATION NIAGARA CG-214341 CAPSIZING

AND SUBSEQUENT FATALITIES ON 23 MARCH 2001

1. SYNOPSIS. ON 23 MARCH 2001 AT 1941 CG-214341, A NONSTANDARD

FOAM COLLAR BOAT (FCB) WAS UNDERWAY FROM COAST GUARD STATION

NIAGARA TO CONDUCT A LAW ENFORCEMENT MISSION IN THE NIAGARA RIVER

FOR THE PURPOSE OF INTERDICTING ILLEGAL MIGRANTS. A THREE-PERSON

BOAT CREW/ARMED LAW ENFORCEMENT TEAM AND ONE BREAK-IN CREW MEMBER

WERE ON BOARD THE VESSEL. IMMEDIATELY UPON DEPARTURE, THE COXSWAIN

OF THE BOAT DEVIATED FROM THE PATROL PLAN AND TOOK THE VESSEL NORTH

INTO LAKE ONTARIO TO FAMILIARIZE THE BREAK-IN CREW MEMBER WITH THIS

PORTION OF THE STATIONS AREA OF OPERATION. THE BOAT EXPERIENCED

STEEP, FOUR-FOOT WAVES FROM THE NORTH SHORTLY AFTER ENTERING LAKE

ONTARIO. ON SCENE WINDS WERE REPORTED FROM THE NORTHWEST AT 10

KNOTS, THE AIR TEMPERATURE WAS 37 DEGREES AND THE WATER TEMPERATURE

WAS 36 DEGREES. THE COXSWAIN SUCCESSFULLY NAVIGATED THE BOAT

APPROXIMATELY 1,000 TO 1,500 YARDS NORTH OF BUOY NO. 3 (ABOUT 3,000

TO 3,500 YARDS NORTH OF THE MOUTH OF THE NIAGARA RIVER) IN LAKE

ONTARIO, TURNED THE VESSEL AROUND AND PROCEEDED BACK SOUTH IN THE

DIRECTION OF THE NIAGARA RIVER. AT SOME TIME SHORTLY BEFORE 2000

AND ON THE RETURN TRIP SOUTH, APPROXIMATELY 50 YARDS NORTH OF BUOY

NO. 3, THE COXSWAIN OVERTOOK A WAVE, SURFED DOWN THE FRONT OF THAT

WAVE AND BURIED THE BOW OF CG-214341 IN THE BACKSIDE OF ANOTHER

WAVE. THE VESSEL THEN SLOWLY ROLLED OVER TO STARBOARD AND ALL FOUR

CREW MEMBERS SAFELY ABANDONED THE VESSEL WITHOUT INJURY. THE

VESSEL MISSED ITS FIRST COMMUNICATIONS CHECK AT 2001. RESCUE

EFFORTS WERE INITIALLY HAMPERED BY THE COXSWAINS DECISION TO

PROCEED NORTH INTO LAKE ONTARIO WITHOUT ADVISING CG STATION NIAGARA

OF HIS DEVIATION FROM HIS PREVIOUS FLOAT PLAN. THE WILSON, NY FIRE

DEPARTMENTS BOAT CREW RECOVERED ALL FOUR CREWMEN AT 0027 SATURDAY,

24 MARCH 2001. TWO OF THE CREWMEN WERE IN CARDIAC ARREST WHEN

RECOVERED AND SUBSEQUENTLY DIED DESPITE THE HEROIC AND PROFESSIONAL

EFFORTS OF LOCAL EMS PERSONNEL TO RE-WARM AND RESUSCITATE THEM.

THE OTHER TWO CREWMEN RECOVERED AND HAVE RETURNED TO DUTY.

2. CAUSAL FACTORS. THE MISHAP ANALYSIS BOARD AND TESTIMONY AT THE

COMMANDANTS BOAT SAFETY BOARD REVEALED VARIOUS PRIMARY CAUSES AND

CONTRIBUTING FACTORS TO THIS MISHAP.

A. PRIMARY CAUSES:

(1) THE COXSWAINS INABILITY TO SAFELY MANEUVER THE BOAT IN

THE EXISTING SEA CONDITIONS;

(2) THE COXSWAIN DEVIATING FROM THE INTENDED AREA OF

OPERATION WITHOUT NOTIFYING THE STATION OF THE CHANGE, THUS

HINDERING THE SAR RESPONSE AND DELAYING RESCUE; AND

(3) THE CREWS EXTENDED EXPOSURE TO THE COLD WATER. THIS WAS

A RESULT OF THEIR DECISION TO ATTEMPT TO REACH A NEARBY BUOY AND

CLIMB OUT OF THE WATER ON IT, INSTEAD OF USING THE OVERTURNED HULL

OF THE BOAT, WHICH WAS MOVING ERRATICALLY IN THE CHOPPY SEAS. THE

BUOY WAS UP-CURRENT. VIGOROUS SWIMMING ATTEMPTING TO REACH IT

CAUSED WATER INTRUSION INTO SOME OF THE DRY SUITS, AS DID THE

COXSWAINS USE OF A NECK RING DEVICE. TOGETHER, THESE FACTORS

ACCELERATED THE ONSET OF HYPOTHERMIA.

B. CONTRIBUTING FACTORS. WHILE NOT THE IMMEDIATE CAUSE OF THE

MISHAP AND FATALITIES, THE FOLLOWING FACTORS WERE IMPORTANT LINKS

IN THE CHAIN OF ERRORS THAT RESULTED IN THIS MISHAP.

(1) EQUIPMENT FAILURE/SHORTFALL:

(A) LACK OF AN EMERGENCY POSITION INDICATING RADIO BEACON

(EPIRB) FOR EITHER THE PERSONNEL OR THE BOAT, OR SOME OTHER METHOD

TO AUTOMATICALLY SIGNAL DISTRESS AND POSITION.

(B) INSUFFICIENT NUMBER OF PERSONAL ISSUE COLD WEATHER

UNDERGARMENTS (BOTH LAYER ONE (POLYPROPYLENE) AND LAYER TWO

(POLYESTER FLEECE)) FOR ALL BOAT CREW MEMBERS.

(C) LACK OF A COAST GUARD STANDARD OR PROCESS FOR

DETERMINING SUITABILITY OF NON-STANDARD BOATS FOR OPERATION IN

VARIOUS ENVIRONMENTAL CONDITIONS.

(D) FAILURE OF THE SOLE MK 79 SIGNALING KIT TO BE

MAINTAINED IN AN OPERABLE CONDITION.

(2) TRAINING FAILURE/SHORTFALL:

(A) LACK OF AN ADEQUATE AND EFFECTIVE FORMAL TRAINING

PROGRAM FOR NON-STANDARD BOAT OPERATIONS.

(B) LACK OF KNOWLEDGE, SKILL AND/OR MOTIVATION TO

PROPERLY DON AND VENT ANTI-EXPOSURE SUITS AND TO PROPERLY LAYER

UNDERGARMENTS.

(3) PERSONNEL ERROR/SHORTFALL:

(A) FAILURE TO REPLACE THE BATTERY IN THE CG-1 STROBE

DURING THE REGULAR INSPECTION IN RESPONSE TO THE NOTED DISCREPANCY.

(B) A GENERAL TENDENCY TO ACCEPT KNOWN NATIONAL DISTRESS

SYSTEM COVERAGE GAPS AS THE COST OF DOING BUSINESS.

(C) FAILURE TO ENSURE THAT SUFFICIENT SAR/PYRO VESTS

WERE ON BOARD PRIOR TO GETTING UNDERWAY.

(4) LEADERSHIP:

(A) FAILURE OF THREE OF THE FOUR CREWMEN TO WEAR SAR/PYRO

VESTS.

(B) CHAIN OF COMMANDS FAILURE TO ACHIEVE A COMMON

UNDERSTANDING OF THE LEVEL OF RISK FOR VARIOUS MISSIONS (ROUTINE

MISSIONS WERE ASSUMED TO BE LOW RISK MISSIONS), AND OF

REPORTING/AUTHORIZATION REQUIREMENTS FOR LAW ENFORCEMENT MISSIONS.

(C) COAST GUARD GROUP BUFFALOS LACK OF AWARENESS OF ON-

GOING STATION OPERATIONS.

(D) DEVELOPMENT OF AN QUOTE UNOFFICIAL STANDARD UNQUOTE

WITHIN THE BOAT COMMUNITY TO NOT WEAR SAR/PYRO VESTS FOR LAW

ENFORCEMENT AND AIDS TO NAVIGATION MISSIONS.

(E) FAILURE TO PROPERLY MANAGE THE MAINTENANCE AND

OPERATION OF A LARGE NON-STANDARD BOAT FLEET (CONFIGURATION,

MODIFICATION, TRAINING, ASSESSMENT, ETC.).

3. ADDITIONAL FINDINGS/LESSONS LEARNED.

A. ROUTINE DOES NOT EQUAL LOW RISK; OPERATIONAL RISK MANAGEMENT

(ORM) MUST CONSIDER THE WHOLE SYSTEM. DURING THE COURSE OF THE

INVESTIGATION, STATION NIAGARAS MISSION ON THE NIGHT OF 23 MARCH

2001 WAS CHARACTERIZED BY MULTIPLE SOURCES AS ROUTINE. THE

ASSERTION THAT IT WAS A ROUTINE MISSION WAS STATED AGAIN IN

RESPONSE TO THE MISHAP BOARDS DESCRIPTION OF THE MISSION AS HIGH

RISK. IT IS IMPORTANT TO UNDERSTAND THAT ROUTINE AND HIGH RISK ARE

NOT MUTUALLY EXCLUSIVE. IN THE CONTEXT OF CURRENT TOUR LENGTHS

(ACTUAL TOURS ARE OFTEN SHORTER THAN NOMINAL TOURS), RAPID

PROMOTIONS, JUNIOR WORK FORCE AND NEW BOAT DESIGNS, IT IS VERY

POSSIBLE THAT MANY OF OUR ROUTINE EVOLUTIONS THAT PRESENTED LOW

RISK FIVE YEARS AGO NOW POSE MODERATE TO HIGH RISK. HAD THE ENTIRE

CHAIN OF COMMAND FROM DISTRICT COMMANDER TO COXSWAIN STARTED WITH A

BLANK PAGE AND APPLIED ORM TO THIS PARTICULAR MISSIONS CHALLENGES

(NIGHTTIME, LAW ENFORCEMENT, COLD AIR AND WATER TEMPERATURES,

SHARED PPE) AND CONSIDERED THE EXISTING BOAT FORCE SYSTEM

(CAPSIZING STATISTICS, JUNIORITY, RESEARCH AND DEVELOPMENT CENTERS

RISK ANALYSIS), THE RIVER LAW ENFORCEMENT PATROL MAY HAVE BEEN

CANCELLED, DEFERRED UNTIL DAYLIGHT, OR AT LEAST UNDERTAKEN WITH

ADDITIONAL CARE. ORM MANDATES THAT THE WHOLE SYSTEM, NOT JUST THE

INDIVIDUAL MISSION PROFILE, BE CONSIDERED.

B. TURNOVER AND JUNIORITY THWART TEAM COORDINATION

TRAINING(TCT)/ORM SKILL RETENTION; COMMANDERS MUST CONSTANTLY

ASSESS CREWS. ORM/TCT MUST BE ACCOMPLISHED ON A CONTINUOUS BASIS.

THOUGH IT IS REQUIRED BI-ANNUAL TRAINING, A WAY TO MEASURE THIS

TRAININGS SUCCESS, OTHER THAN THE END OF THE YEAR MISHAP REPORTS,

WILL BE ESTABLISHED. A WEB-BASED MEASUREMENT TOOL FOR TCT/ORM,

RECENTLY DEVELOPED AND PROTOTYPED, WILL BE IMPLEMENTED SOON. UNITS

SHOULD USE THIS TOOL TO HELP ASSESS PROFICIENCY IN THE ABILITY TO

APPLY TCT/ORM ON THE JOB. ORM AND TCT ADVOCATE THE GAR/SPE MODELS

AS TWO OPTIONS FOR RISK ASSESSMENT. WHICHEVER TOOLS ARE CHOSEN,

THEY SHOULD BE USED AS DICTATED BY GROUP/STATION COMMANDING

OFFICERS OR OINC. STAN TEAMS SHOULD CONTINUE TO EVALUATE THIS

REQUIREMENT, AND A SIMILAR EVALUATION SHOULD BE PART OF READY FOR

OPERATIONS INSPECTIONS.

4. CORRECTIVE ACTIONS. THE ANALYSIS OF THIS MISHAP IDENTIFIED

SELECT ACTIONS THAT ARE DIRECTLY LINKED TO PRIMARY CAUSAL FACTORS

IN THIS MISHAP AND COULD SIGNIFICANTLY REDUCE THE POTENTIAL FOR

FUTURE LOSS.

A. COMMANDANT (G-OCS) SHALL:

(1) ADVANCE FUNDING EFFORTS THROUGH THE NORMAL BUDGET PROCESS

TO PROVIDE PERSONAL ISSUE ANTI-EXPOSURE SUITS AND UNDERGARMENTS TO

EACH BOAT CREW MEMBER AT APPROPRIATE UNITS.

(2) ENSURE THAT THE CREW BRIEF SECTION OF THE COMMUNICATIONS

AND WATCHSTANDER GUIDE IS UPDATED TO REFLECT THAT A FLOAT PLAN

SHOULD BE FILED WITH THE WATCHSTANDER BY BOAT CREWS, AND THAT IT

INCLUDES PROCEDURES TO FOLLOW IF THERE WILL BE A DEVIATION.

(3) MODIFY BOAT CREW QUALIFICATION GUIDE VOL. 1 CREW MEMBER,

COMDTINST M16114.10A TO REQUIRE CREWMAN TO ACTUALLY DON AND

MANIPULATE EVERY PIECE OF SURVIVAL GEAR THE UNIT IS REQUIRED TO

CARRY, IN THE CONDITIONS FOR WHICH THEY WERE DESIGNED.

(4) MODIFY BOAT CREW TRAINING MANUAL, COMDTINST M16114.9 TO

REQUIRE ALL BOAT CREW POSITIONS TO SHOW PROFICIENCY, ON AN ANNUAL

BASIS, IN SURVIVAL TECHNIQUES IF LOST OVERBOARD OR INVOLVED WITH A

CAPSIZING (I.E. ANNUAL WET DRILLS).

B. COMMANDANT (G-OPL) AND (G-OPN) SHALL WORK WITH G-OCS TO

IDENTIFY APPROPRIATE SURVIVAL EQUIPMENT, INCLUDING SIGNALING

EQUIPMENT, FOR CREW MEMBERS ON LAW ENFORCEMENT AND AIDS TO

NAVIGATION MISSIONS, AND ENSURE THAT MARITIME LAW ENFORCEMENT AND

AIDS TO NAVIGATION SCHOOLS RE-ENFORCE THE REQUIREMENTS TO WEAR THE

EQUIPMENT.

C. COMMANDANT (G-OCU) SHALL REVIEW THE ORDNANCE MANUAL FOR

APPROPRIATENESS AND AVAILABILITY OF THE MK-79 AS SURVIVAL

EQUIPMENT, AND SHALL APPRAISE THE USE OF COMMERCIAL PYRO THAT MEETS

FEDERAL STANDARDS. AS THIS REVIEW PROCEEDS, G-OCU SHALL

IMMEDIATELY IMPLEMENT CHANGES TO THE MK 79 PREVENTATIVE MAINTENANCE

SYSTEM TO INCLUDE A METHOD TO ASCERTAIN WHETHER THE MK 79 TUBE CAN

ACCEPT A FLARE CARTRIDGE.

D. THE COAST GUARD MUST CONTINUE EFFORTS TO SYSTEMATICALLY

STANDARDIZE AND IMPROVE NON-STANDARD BOAT OPERATIONS. LISTED BELOW

ARE ADDITIONAL ACTION ITEMS IDENTIFIED DURING THE MISHAP ANALYSIS

THAT COULD REDUCE THE POTENTIAL FOR SIMILAR MISHAPS FROM OCCURRING.

THE CHIEF OF STAFF HAS DIRECTED THAT DESIGNATED OFFICES TAKE THESE

FOR ACTION.

(1) COAST GUARD ATLANTIC AREA (AO) AND PACIFIC AREA (PO)

SHALL RE-EMPHASIZE THE DISTRICT COMMANDERS ROLE AND

RESPONSIBILITIES FOR MANAGING AND SUPPORTING ALL FACETS OF NON-

STANDARD BOAT OPERATIONS AND MAINTENANCE.

(2) COMMANDANT (G-O) SHALL ENSURE THAT MEMBERS PERFORMING

SMALL BOAT OPERATIONS ARE EITHER OUTFITTED WITH PERSONAL LOCATION

DEVICES (I.E. PERSONAL RADIO BEACONS, EPIRBS, OR SIGNAL BEACONS TO

AID IN THEIR LOCATION), OR THAT THEIR BOATS ARE EQUIPPED WITH A

FLOAT-FREE EPIRB SYSTEM.

(3) COMMANDANT (G-OCS) SHALL:

(A) DEVELOP A STAND-ALONE SURVIVAL AND SAFETY ANNEX FOR

THE RESCUE AND SURVIVAL SYSTEMS MANUAL.

(B) WORK WITH STAN TEAMS TO DEVELOP A STANDARD COLD

WEATHER SURVIVAL ASSESSMENT MODULE TO BE INCLUDED IN THE SAR

SYSTEMS PORTION OF THE ASSESSMENT.

(C) WORK WITH COMMANDANT (G-SCT) TO REVISE STANDARD LOST

COMMUNICATIONS DOCTRINE TO RECOGNIZE THE NEED FOR MORE CONSERVATIVE

DOCTRINE FOR HIGH-RISK OPERATIONS. REQUIREMENTS FOR NIGHT AND

INCLEMENT WEATHER SHOULD BE TIGHTENED.

(D) COORDINATE WITH COMMANDANT (G-OCA) AND COMMANDANT (G-

W) COUNTERPARTS TO DETERMINE A REALISTIC REPLACEMENT CYCLE FOR PPE.

NOTE: THE EXCEPTIONALLY HIGH TURN OVER RATES AT STATIONS, THE

CONSUMABLE NATURE AND HIGH COST OF GEAR WILL COMPOUND THE FISCAL

IMPACT OF THIS ISSUE.

(E) IMPLEMENT AN ADDITION TO THE RESCUE AND SURVIVAL

SYSTEMS MANUAL, COMDTINST M10470.10D THAT REQUIRES THE SPECIFIC

VISUAL AND PHYSICAL CHECKING OF THE MK-79 FLARE KITS ASSEMBLY AND

THREADS, CONTINGENT UPON COMMANDANT (G-OCU) REVIEW OF ORDNANCE

MANUAL FOR APPROPRIATENESS AND AVAILABILITY OF MK-79 AS COLD

WEATHER SURVIVAL EQUIPMENT.

(F) INVESTIGATE DEVELOPING STANDARD TETHER LINES WITH D-

RING CONFIGURATION FOR CARRYING IN EACH SUIT.

(G) REVIEW AND ADOPT THE NON-STANDARD BOAT OPERATORS

HANDBOOK, D13INST M16114, FOR INCLUSION INTO THE COMDTINST M16114

SERIES.

(H) REVIEW CURRENT COAST GUARD PUBLICATIONS AND

DIRECTIVES FOR ACCURACY AND CONSISTENCY WITH RESPECT TO COLD-WATER

SURVIVAL INFORMATION.

(I) INVESTIGATE THE FEASIBILITY OF EQUIPPING CREW

SURVIVAL VESTS WITH CHEMICAL LIGHT STICKS.

(J) ENSURE THAT EVALUATION AND MEASUREMENT OF TCT/ORM IS

A STANDARD PART OF STAN TEAM ASSESSMENTS AND READY-FOR-OPERATIONS

INSPECTIONS.

(4) COMMANDANT (G-OPR) SHALL WORK WITH THE NATIONAL SEARCH

AND RESCUE SCHOOL TO CONSIDER INCLUDING A CASE STUDY OF THE NIAGARA

MISHAP IN THE SENIOR SAR SUPERVISORS COURSE AND OTHER APPROPRIATE

COURSES AT TRACEN YORKTOWN.

(5) COMMANDANT (G-AND) SHALL IMPLEMENT THE NATIONAL DISTRESS

RESPONSE SYSTEM MODERNIZATION PROJECT (NDRSMP) TECHNOLOGIES AS

QUICKLY AS FEASIBLE, PARTICULARLY ASSET TRACKING COMPONENTS.

(6) COMMANDANT (G-WKS) HUMAN FACTORS DIVISION SHALL WORK WITH

COMMANDANT (G-WKH) TO MODIFY/SIMPLIFY THE DATA REPORTS FORMS A-E

FOR THE FLIGHT SURGEONS MISHAP ANALYSIS IN THE SAFETY AND

ENVIRONMENTAL HEALTH MANUAL.

(7) COMMANDANT (G-WKW) SHALL MODIFY STANDARD CRITICAL

INCIDENT STRESS RESPONSE PROTOCOLS TO IDENTIFY INDIVIDUALS WHO NEED

COUNSELING. THE INITIAL RESPONSE SHOULD QUERY FLAG OFFICERS TO

HELP DETERMINE WHICH MEMBERS OF SENIOR LEADERSHIP SHOULD BE OFFERED

COUNSELING.

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