On March 6, 2004, the small passenger vessel Lady D, a pontoon water taxi with 2 crewmembers and 23 passengers on board, was en route from Fort McHenry to Fells Point, Maryland, when it encountered a rapidly developing storm with high winds. The pontoon vessel began to roll in the waves and eventually continued over onto its starboard side and capsized. Personnel from the Naval Reserve Center Baltimore, a Navy training installation adjacent to Fort McHenry, witnessed the capsizing, called 911 to report the accident, and then launched a vessel to the scene to render assistance. Responders were able to rescue or recover all but 3 occupants of the Lady D within an hour of the accident. The bodies of the remaining victims were recovered from the waterway on March 14 and 15. As a result of this accident, 5 passengers died; 4 passengers suffered serious injuries; and 12 people sustained minor injuries. Vessel damage was estimated at $35,000.
The Safety Board's investigation of this accident identified major safety issues in the following areas:
- Passenger weight criteria for stability assessment;
- Pontoon vessel stability standards; and
- Policies and procedures pertaining to weather operations.
The National Transportation Safety Board determines that the probable cause of the capsizing of the pontoon-style small passenger vessel Lady D was its lack of intact stability, which was insufficient to withstand the strong winds and waves that the boat encountered. The lack of intact stability was caused by overloading, which resulted from a combination of the following:
- The Lady D was erroneously granted sister status by the U.S. Coast Guard to a pontoon vessel with different design characteristics;
- The Coast Guard certificated the Lady D to carry too many people as a result of an inappropriate stability test on the vessel to which it was granted sister status; and
- The Coast Guard's regulatory stability test standards on which the Lady D's passenger allowance was based use an out-of-date average passenger weight.
As a result of this investigation, the Safety Board makes recommendations to the U.S. Coast Guard.
As a result of its investigation of the Lady D accident, the National Transportation Safety Board makes the following recommendations.
To the U.S. Coast Guard:
Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. (M-06-5)
Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. (M-06-6)
Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves. (M-06-7)
Until such time as you revise the passenger weight standard as requested in Safety Recommendation M-06-5 and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation M-06-7, develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations. (M-06-8)
Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel's certificate of inspection. (M-06-9)
Previously Issued Recommendation Classified in This Report
Revise your guidance to Officers in Charge, Marine Inspection, to determine the maximum occupant capacity of small passenger pontoon vessels either (1) by dividing the vessel's simplified stability proof test weight by the per-person weight allowance for an average adult stipulated in Federal Aviation Administration Advisory Circular 120-27D (174 pounds per person, assuming summer clothing and a 50-50 gender mix), or (2) by restricting (at the time of loading) the actual cumulative weight of passengers and crew to the vessel's simplified stability proof test weight.
Safety Recommendation M-04-4 (previously classified "Open-Acceptable Response") is classified "Closed-Superseded" by Safety Recommendation M-06-5 as discussed in the "Passenger Weight Criteria for Stability Assessments" section of this report.