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Safety Recommendation Details

Safety Recommendation M-05-013
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: Require that passengers and crew wear lifejackets while transiting the Tillamook Bay inlet when rough bar warnings are in effect.
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 2 1,2005 as a result of the Taki-Too0 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 Safety Board is pleased that Garibaldi Charters now requires passengers to wear personal floatation devices (PFD) when rough bar conditions exist; however, the Board asked that Garibaldi Charters require that both passengers and crews wear lifejackets. Accordingly, the Safety Board requests that Garibaldi Charters revise its operating procedure accordingly. Pending information that this requirement will apply to both passengers and crew, Safety Recommendation M-05-13 to Garibaldi Charters is classified "Open-Acceptable Response." Your letter noted several concerns and questions with our investigation report. First, you questioned why the Board did not "blame" the U.S. Army Corps of Engineers (USACE) for the accident. USACE's 2003 report expressed some concern for the navigability of the Tillamook Bar channel. However, the Safety Board's investigation determined that the most important factor on the day of the accident was that the vessel operators, all highly experienced mariners with extensive knowledge of the area, disregarded the hazardous bar crossing conditions. It was for this reason that the Safety Board concluded that the condition of the channel and the jetties at Tillamook Bar were not a factor in the June 2003 accident. Second, while some operators advised Safety Board investigators that they had a go/no-go policy "in their heads," the Safety Board believes that without a formal/written company policy, operators may feel the need to exceed the capability of the vessel or their own expertise due to peer, passenger, or other pressure and thus may unduly endanger the safety of their passengers. The Safety Board's opinion is that owners know best the skills of their masters; the size, power, configuration, and sea-keeping capability of their vessels; and the conditions under which their masters can safely navigate vessels across a hazardous bar. The Board also believes that the go/no go policy should consider unexpected wave action, waves coming from different directions, varying wave heights, and wave frequency, which can be expected when hazardous bar conditions exist. Third, you raised the important issue of PFD comfort for passengers. The Safety Board discussed this issue at a recreational boating safety symposium in August 2004. The Board understands from discussion with Coast Guard staff that the Coast Guard is reviewing the design and capabilities of various lifejacket designs that ultimately could replace the current Type 1 lifejacket. It is recognized that the current Type 1 lifejackets are somewhat bulky, but they are designed to turn a person face up even when he or she is unconscious; thus, these lifejackets provide the best available protection against drowning. Whatever new design lifejacket may be approved, it must retain the same lifesaving capabilities as those of the present Type 1 lifejacket. Please note that in Safety Recommendation M-05-13, the Safety Board is asking only that passengers and crew don their lifejackets when crossing the hazardous bar; comfort should not be the determining factor during the few minutes required to cross the bar. Finally, regarding your concern that the safety recommendations issued as a result of this accident focused solely on the Tillamook Bay bar, overlooking other locations that are equally hazardous, I assure you that that was not the case. The Safety Board reviewed conditions all along the northwest coast and recently completed an investigation into the September 19, 2005, sinking of the uninspected small passenger vessel, Sydney Mae II, at the entrance to Umpqua River, near Winchester Bay, Oregon. A copy of that report is enclosed for your information. The TAKI TOOO accident investigation and report focused on the conditions at Tillamook, and therefore specifically addressed Safety Recommendations M 05-12 and M-05-13 to owners and operators of charter vessels operating out of that port. Additional recommendations were issued, however, to the United States Coast Guard (M-05-09 through -11) and the National Marine Charter Association (M-05-14 and -15) that address the issues of written go/no go policies and lifejacket use for all West Coast inlets where rough bars exist. A copy of the full TAKI TOOO accident report, which includes these recommendations, is enclosed for your information.

From: Garibaldi Charters
To: NTSB
Date: 11/1/2005
Response: Letter Mail Controlled 11/7/2005 9:12:35 AM MC# 2050513 11-1-05: We wish that Captain Davis would have asked his passengers to don lifejackets after watching, the Norwester and the Oakland Pilot transit the bar a few more people might have survived the accident. We have used our lifejackets far more frequently since the accident, and also find more people willing to wear them. It would be very helpful to us if you would make a suggestion to the Coast Guard to start a review process of the new, much lighter weight and technologically advanced life jackets that are now on the market that would be more acceptable for our customers to wear. Presently, we can not even carry any type of lifejackets on board other than the bulky and uncomfortable Type I life vests. 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.