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Safety Recommendation Details

Safety Recommendation M-05-012
Details
Synopsis: The recommendations address the need for your company to have written go/no-go policies for transiting Tillamook Bay bar and a requirement for the passengers and crew on your vessels to wear lifejackets while transiting Tillamook Bay inlet when rough bar warnings are in effect. The recommendations are derived from the Safety Board’s investigation of the capsizing of the small passenger vessel Taki-Tooo on June 14, 2003, and are consistent with the evidence we found and the analysis we performed. The Safety Board would appreciate a response from you within 90 days addressing actions you have taken or intend to take to implement the recommendations.
Recommendation: The National Transportation Safety Board, therefore, makes the following safety recommendations to the small passenger vessel companies offering charters out of Tillamook Bay: Develop and implement written go/no-go policies, based on risk-management principles, regarding transiting the Tillamook Bay bar.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Pacific Ocean, OR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA03MM035
Accident Reports:
Capsizing of U.S. Small Passenger Vessel Taki-Tooo
Report #: MAR-05-02
Accident Date: 6/14/2003
Issue Date: 7/21/2005
Date Closed: 7/1/2008
Addressee(s) and Addressee Status: Garibaldi Charters (Closed - Acceptable Action)
Kerri Lin Charters (Closed - Acceptable Action)
Siggi-G Charters (Closed - Unacceptable Action - No Response Received)
Troller and Linda Sue III Charters (Closed - Unacceptable Action - No Response Received)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Garibaldi Charters
Date: 7/1/2008
Response: On March 27, and on April 18, 2008, my staff spoke with you to address the concerns and questions raised in your letter regarding the intent of our recommendations and the meaning of the classification status. I hope that we have satisfactorily addressed these concerns and questions. On February 29, 2008, Safety Recommendations M-05-12 and -13 were classified Closed Unacceptable On March 27, and on April 18, 2008, my staff spoke with you to address the concerns and questions raised in your letter regarding the intent of our recommendations and the meaning of the classification status. I hope that we have satisfactorily addressed these concerns and questions. On February 29, 2008, Safety Recommendations M-05-12 and -13 were classified Closed Unacceptable Action to Garibaldi Charters. The Safety Board has since received by e-mail on April 22, 2008, and reviewed the document Garibaldi Charters Policy for Bar Crossing. This document is based on common risk management principles and provides sufficient guidance to the vessel captain, to assist the captain in determining whether it is safe to cross Tillimook Bar. Accordingly, Safety Recommendation M-05-12 is reclassified Closed Acceptable Action. Concerning Safety Recommendation M-05-13, Captain Buell confirmed that Garibaldi Charters’ policy is to require both passengers and crew on open decks to wear lifejackets while transiting the Tillamook Bay inlet whenever rough bar warnings are in effect. Accordingly, Safety Recommendation M-05-13 is reclassified Closed Acceptable Action.

From: Garibaldi Charters
To: NTSB
Date: 3/17/2008
Response: Letter Mail Controlled 3/25/2008 10:46:54 AM MC# 2080143: This letter addresses Safety Recommendations M-05- 12 and - 13 which you say were issued to Garibaldi Charters on July 21,2005 as a result of the Taki-Too accident on June 14,2003 outside of the Tillamook Bay ietties, Garibaldi, OR. Your letter indicates that our written go-no go policy which we have on file was unacceptable for you. This policy was considered appropriate with the USCG at the time we showed it to them, several months aAer the accident. We need to know exactly what you want us to include in the policy if you want us to change it. Also, I was told that you did not want us to put in the policy that it was required by the NTSB-is this what you wish to have us take out? You also indicated that you had no authority over our policy, so I assumed that you did not need or want a reply to the July 2 1,2005 letter. We think USCG would have told us if they did not like our policy. Finally, we would like to know what the consequences your “Closed- Unacceptable Action” for M-05-12 and -13 are for our company. We do not understand why M-05- 13 is also considered unacceptable when you say it was accepted, and we have dutifully followed this and all other aspects of our policy as written. We have thought about updating our policy as we now require children under 13 to wear life iackets while aboard our vessels even though this is not a Coast Guard requirement, and have made several other minor changes. Now-not three years from now-is a good time to tell us just what you want us to put into the revised policy.

From: NTSB
To: Garibaldi Charters
Date: 2/29/2008
Response: On June 22, 2006, based on information in your November 1, 2005, letter, Safety Recommendation M-05-12 was classified Open Unacceptable Response, and Safety Recommendation M-05-13 was classified Open Acceptable Response. To date, the Safety Board has received no further information from Garibaldi Charters regarding what, if anything, you have done to address these important safety issues. Because the Safety Board has been unable to confirm that your company has completed action on this issue, Safety Recommendations M-05-12 and -13 are classified Closed Unacceptable Action. Should the Board receive a timely response indicating action taken or planned to address these recommendations, we will consider reevaluating their classification.

From: NTSB
To: Garibaldi Charters
Date: 6/22/2006
Response: The draft go/no-go policy included in your letter of November 1, 2005, is not responsive to the Safety Board's recommendation. While the ultimate responsibility for the safety of a vessel and its passengers rests with the master, it is the obligation of the company to provide the best tools and guidance to assist the master. Risk-based approaches are useful and widely accepted as a means of evaluating safety decisions. They are not necessarily complicated, but they do provide an objective means of identifying and evaluating uncertainties and variables that affect safety. There is no indication that any sort of risk-based process was involved in developing your go/no-go policy. Your policy specifies wind and wave conditions that mirror those encountered by the Taki-Tooo when it capsized; therefore, the Safety Board questions how it will help prevent such an accident from occurring again. In addition, the policy does not take into account other important variables such as tides, vessel size and power, visibility, accuracy of estimates of wind and waves, consideration of U.S. Coast Guard warnings, or other factors that have a bearing on safety of vessel operations. Risk assessment is an effective means of determining the relative importance of such variables and for developing guidance to maintain safety under such adverse influences working in concert. While the Safety Board acknowledges your initiative to develop a written policy, the result appears arbitrary and incomplete, and in fact might mislead people into believing that adherence to the policy will ensure safety. Using principles of risk management could have avoided such an outcome. Because you have not provided any evidence that your written go/no-go policy was based on risk-management principles, Safety Recommendation M-05-12 is classified "Open-Unacceptable Response." The Safety Board awaits your revised go/no-go policy based on sound risk management principles. In making the needed changes, please delete the words as ordered or required by the NTSB; the Safety Board is not a regulatory agency and can only recommend safety improvements based on the results of our investigations.

From: Garibaldi Charters
To: NTSB
Date: 11/1/2005
Response: Letter Mail Controlled 11/7/2005 9:13:13 AM MC# 2050513 11-1-05: We have received your recommendations and have compiled-a Go/No-Go policy for Garibaldi Charters. While the recommendations were not unreasonable. we did not agree with your conclusions about the accident. It seems that you could not point a finger at any one person Without reprimanding all others involved including our office, the Captain, the other boats and the Coast Guard leaving out only the Corp of Engineers. I realize you would not want to lay any blame on mother government entity, but your "suggestion" that the Corp of Engineers look over the area again shows that you really are aware that one of the major contributing factors in the accident was the extremely poor condition of the jetties and the build up of sand just outside of the channel. men the jetties were built by the Corp of Engineers, they agreed to their upkeep and maintenance and in that they have failed. Also, you give Nature little credit for the formation of an unusual wave in an unusual place at just the wrong time. No amount of experience, could have told Captain Davis that a rogue wave was coming during his attempted crossing, nor could the Coast Guard watch tower have seen it coming. No Coast Guard personnel have as much knowledge and experience of the Tillamook Bar as the Captains of the Commercial and Charter Boats that transit the bar daily, year after year, and therefore should not be blamed for not telling them what to do. Also, to blame the other boats that had just made successful crossings for doing so is questionable and seems to have been done because you could not really explain what happened or who was to blame. You have never once mentioned that all Captains have their own personnel GO/No-GO policy as each one told you-just because it was not written down does not mean they did not have one. Jon Brown's was not written down either, yet you constantly refer to his "policy". I do agree that the office should have it's own written policy for liability reasons. Finally, I have a question about other ports and hazardous bars-notably the Columbia River bar which is rated as the worst bar on the West Coast. The rate of boat accidents and deaths is far higher than any other port-indeed a Charter Boat was grounded on the Columbia River Bar, and a Charter Boat out of Reedsport capsized, losing several passengers just in the last few months-no lifejackets required for either hazardous crossing. Why should your recommendations be for the Tillamook Bay Bar only? Other ports should have to follow these rules also, including the cruise ships that transit the Columbia Bar in hazardous seas.

From: NTSB
To: Siggi-G Charters
Date: 3/17/2008
Response: On July 25, 2006, the Safety Board requested information on the action taken or planned to implement these safety recommendations. To date, the Safety Board received no response from the «Company» regarding what, if anything, you have done to address these important safety issues. Because the Safety Board has been unable to confirm that your company has completed action on this issue, Safety Recommendations M-05-12 and -13 are classified Closed Unacceptable Action/No Response Received.

From: NTSB
To: Siggi-G Charters
Date: 7/26/2006
Response: The Safety Board has not yet received a response from the Siggi-G Charters regarding these recommendations and would appreciate an update on what, if anything, you have done to address these important safety issues. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of our recommendations. The Board would appreciate being informed of what action, if any, has been taken or planned to implement Safety Recommendations M-05-12 and -13.

From: NTSB
To: Kerri Lin Charters
Date: 6/5/2008
Response: On March 19, 2008, the U.S. Coast Guard, Sector Portland, Oregon, inspection office forwarded Kerri Lin Charters’ Tillamook Bar Crossing and PFD Condition Ratings policy. The Safety Board has reviewed the policy and is pleased that the go/no-go policy is based on risk-management principles that will assist the vessel operator in deciding whether or not to cross the bar when hazardous conditions exist. In addition, the policy provides clear instruction to the vessel operator to require passengers and crew to don lifejackets while transiting the Tillamook Bay inlet when rough bar warnings are in effect. Safety Recommendations M-05-12 and -13 were previously classified Closed Unacceptable Action No Response Received; however, given that you now have a policy that meets the intent of the recommendations, Safety Recommendations M-05-12 and -13 are reclassified Closed Acceptable Action.

From: Kerri Lin Charters
To: NTSB
Date: 3/19/2008
Response: Letter Mail Controlled 3/25/2008 9:30:56 AM MC# 2080137: E-mail rcvd. from USCG Sector Portland, OR, forwarding submission from Kerri Lin Charters that is responsive to these 2 recommendations.

From: NTSB
To: Kerri Lin Charters
Date: 3/17/2008
Response: On July 25, 2006, the Safety Board requested information on the action taken or planned to implement these safety recommendations. To date, the Safety Board received no response from the «Company» regarding what, if anything, you have done to address these important safety issues. Because the Safety Board has been unable to confirm that your company has completed action on this issue, Safety Recommendations M-05-12 and -13 are classified Closed Unacceptable Action/No Response Received.

From: NTSB
To: Kerri Lin Charters
Date: 7/26/2006
Response: The Safety Board has not yet received a response from the Kerri Lin Charters regarding these recommendations and would appreciate an update on what, if anything, you have done to address these important safety issues. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of our recommendations. The Board would appreciate being informed of what action, if any, has been taken or planned to implement Safety Recommendations M-05-12 and -13.

From: NTSB
To: Troller and Linda Sue III Charters
Date: 3/17/2008
Response: On July 25, 2006, the Safety Board requested information on the action taken or planned to implement these safety recommendations. To date, the Safety Board received no response from the «Company» regarding what, if anything, you have done to address these important safety issues. Because the Safety Board has been unable to confirm that your company has completed action on this issue, Safety Recommendations M-05-12 and -13 are classified Closed Unacceptable Action/No Response Received.

From: NTSB
To: Troller and Linda Sue III Charters
Date: 7/26/2006
Response: The Safety Board has not yet received a response from the Kerri Lin Charters regarding these recommendations and would appreciate an update on what, if anything, you have done to address these important safety issues. The Safety Board is vitally interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of our recommendations. The Board would appreciate being informed of what action, if any, has been taken or planned to implement Safety Recommendations M-05-12 and -13.