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Safety Recommendation Details

Safety Recommendation M-96-018
Details
Synopsis: ON 8/21/94, A DISABLED 18-FOOT QUESTAR MOTOR BOAT WITH THE VESSEL'S OWNER & ONE PASSENGER ABOARD CAPSIZED WHILE BEING TOWED BY THE COAST GUARD AUXILIARY VESSEL PUPPET IMMEDIATELY SOUTH OF SHELTER ISLAND, LYNN CANAL, NEAR JUNEAU, ALASKA. THE QUESTAR'S OWNER, WHO WAS MILDLY DISABLED, WAS TRAPPED INSIDE THE VESSEL'S CABIN & WAS DROWNED. THE PASSENGER WAS NOT INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE USCG: PUBLICIZE THE CIRCUMSTANCE OF THIS ACCIDENT TO ALL USCG UNITS RESPONSIBLE FOR SEARCH & RESCUE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Bays and Sounds, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA95MM032
Accident Reports:
Capsizing of Questar Motorboat and Drowning of Operator South of Shelter Island
​​​
Report #: MAR-96-01-SUM
Accident Date: 8/21/1994
Issue Date: 12/6/1996
Date Closed: 5/31/2005
Addressee(s) and Addressee Status: USCG (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 5/31/2005
Response: The Safety Board is pleased that the March 2005, issue of the Coast Guard's Office of Search and Rescue newsletter addresses the recommendation as follows: The second item is an old National Transportation Safety Board investigation of a towing accident that occurred in 1994. As we reviewed the accident description recently, there are a number of lessons learned that have been incorporated in our standard policies and procedures. But they could stand reiteration as to what can happen if we don't remain vigilant and apply risk assessment at all levels of SAR operations. The NTSB description of the case and the issues it raised is attached as a .PDF file. We request that the district OSR staff readdress this newsletter to the Group/sector/station level as feasible. Because the Coast Guard has taken steps to publicize the circumstances of this accident to all Coast Guard units responsible for search and rescue, Safety Recommendation M-96-18 is classified "Closed--Acceptable Action."

From: USCG
To: NTSB
Date: 4/7/2005
Response: Letter Mail Controlled 4/12/2005 1:29:58 PM MC# 2050157 USCG G-MOA (267-1428) provided an email with a copy the March 2005, Issue 38 Office of Search and Rescue G-OPR Newsletter. The newsletter states "The second item is an old National Transportation Safety Board investigation of a towing accident that occurred in 1994. As we reviewed the accident description recently, there are a number of lessons learned that have been incorporated in our standard policies and procedures. But they could stand reiteration as to what can happen if we don't remain vigilant and apply risk assessment at all levels of SAR operations. The NTSB description of the case and the issues it raised is attached as a .PDF file. We request that the district OSR staff readdress this newsletter to the Group/sector/station level as feasible."

From: NTSB
To: USCG
Date: 2/4/2002
Response: The Safety Board is aware that, in August 1999, the Coast Guard posted the report of the Questar accident on the Coast Guard Auxiliary's Web site, thereby making it available to auxiliary personnel involved in search and rescue missions. In its April 3, 2001, letter, the Coast Guard stated its intent to publish a follow-up article on the circumstances and lessons learned from the 1994 Questar accident, either in the On Scene magazine when its publication resumes, or in some other suitable forum. Accordingly, pending publication of the article by the Coast Guard, Safety Recommendation M-96-18 remains classified "Open--Acceptable Response" However, this action is an effective means of satisfying recommendation M-96-19. Accordingly, Safety Recommendation M-96-19 is classified "Closed--Acceptable Action."

From: USCG
To: NTSB
Date: 4/3/2001
Response: Letter Mail Controlled 04/12/2001 5:14:03 PM MC# 2010311 A follow-up article similar to the one described by the Board in its September 11, 1997, letter will be published in our On Scene magazine when we restart publication. The current delay is due to staffing shortfalls and budget constraints, which has placed the publication on hold for the time being. However, if it appears that the publication of the On Scene magazine will be delayed longer than originally anticipated, we will consider drafting an article and distributing it separate from the magazine to Coast Guard units responsible for search and rescue. We will keep the Board informed of our actions on this recommendation.

From: NTSB
To: USCG
Date: 3/16/2001
Response: The Safety Board is continuing to review its safety recommendation files to identify recommendations for which there has been no correspondence for an extended period of time. Our review indicates that currently, 79 safety recommendations that have been issued to the Coast Guard are being held in an "Open" status; no information was provided in the Coast Guard’s July 31, 2000, letter regarding these recommendations. In some cases, action on these 78 recommendations has not been reported for some time; for recommendations issued in 2000, there has been no response at all to the original recommendation letter. Enclosed is a list of these safety recommendations.

From: NTSB
To: USCG
Date: 7/14/1998
Response: NTSB REQUESTED A FOLLOWUP.

From: NTSB
To: USCG
Date: 9/11/1997
Response: THE BOARD NOTES THAT A STORY ABOUT THIS ACCIDENT WAS PUBLISHED IN THE FALL 1996 ISSUE OF NAVIGATOR, SUMMARIZING THE THINGS THE OPERATOR OF THE RECREATIONAL BOAT DID INCORRECTLY. HOWEVER, WHEN ISSUING THIS RECOMMENDATION, THE BOARD INTENDED THAT THE USCG PUBLICIZE A BALANCED OVERVIEW OF THE ACCIDENT, INCLUDING A DISCUSSION OF PROBLEMS EXPERIENCED BY ALL PARTIES. THE BOARD THEREFORE, REQUESTS THAT THE USCG PROVIDE A FOLLOW-UP ARTICLE THAT DISCUSSES PROBLEMS EXPERIENCED BY ALL PARTIES. PENDING A FURTHER RESPONSE, M-96-18 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: USCG
To: NTSB
Date: 5/9/1997
Response: WE CONCUR WITH THIS REOMMENDATION. THE CIRCUMSTANCES & LESSONS LEARNED OF THIS ACCIDENT WERE PUBLISHED IN THE FALL 1996 ISSUE OF THE NAVIGATOR, WHICH IS THE OFFICIAL INFO & EDUCATIONAL TOOL FOR THE USCG AUXILIARY. WE RQUEST THAT THE STATUS OF THIS RECOMMENDATION BE CHANGED TO "CLOSED ACCEPTABLE ACTION."