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Board Meeting - Marine Accident Report - Collision of U.S. Coast Guard Vessel CG 33118 and Sea Ray Recreational Vessel CF 2607 PZ, San Diego Bay, California, December 20, 2009 - Chairman's Opening and Closing Remarks
Deborah A. P. Hersman
National Transportation Safety Board (NTSB), Marine Accident Report - Collision of U.S. Coast Guard Vessel CG 33118 and Sea Ray Recreational Vessel CF 2607 PZ, San Diego Bay, California, December 20, 2009, Washington, DC

Good morning. Welcome to the Boardroom of the National Transportation Safety Board. I am Debbie Hersman, and it is my privilege to serve as Chairman of the National Transportation Safety Board. Joining me are my fellow Board members: Vice Chairman Chris Hart, Member Robert Sumwalt, Member Mark Rosekind, and Member Earl Weener. Today we meet in open session, as required by the Government in Sunshine Act, to consider two accident reports.

We begin with the accident report on the December 20, 2009, collision of a U.S. Coast Guard vessel with a recreational boat on San Diego Bay, California.

On behalf of my fellow Board members and the entire NTSB staff, I offer our deepest condolences to the family of the child who lost his life in this accident and to the four individuals who were seriously injured. We recognize that lives are forever changed in an accident, and we know that nothing can replace the loss of your loved one or repair the trauma of a life-changing injury. It is especially tragic when the life lost is that of a child, a young person with a full future ahead of him. This loss makes it even more imperative that we use these tragic circumstances as an opportunity to learn so that its outcome is never repeated.

Over the past several weeks, the Board Members have read the proposed report and individually met with NTSB staff. Today, however, is the first time that all of the Board Members are meeting together to discuss it.

Staff will make presentations on the major issues of the accident investigation. The presentations will be followed by questions from the Board Members. We will then consider the conclusions, probable cause, and safety recommendations. Because these are the Board's actual deliberations on the report, it may be revised as a result of actions taken during this meeting. Approximately 30 minutes after we conclude, an abstract of this report will be posted on the NTSB's website.

I'd like to recognize the groups who helped with our on-scene work and investigation; in particular, the cooperation and assistance of the San Diego Harbor Police, the U.S. Coast Guard, and the families on board the Sea Ray recreational boat.

Our role at the Board is investigatory — we find out what happened so that we can make recommendations to prevent similar tragedies from happening in the future. Our role is to follow the facts and allow those facts to inform our findings and recommendations. Our role is not to assign blame.

As you will hear from our team today, there are several clear findings.

Perhaps the most significant finding is that the Coast Guard patrol boat that struck the recreational boat was traveling too fast for the conditions. During San Diego's annual holiday Parade of Lights, the bay was packed with vessels of all shapes, sizes, and capabilities — and given the prevailing darkness, background lighting and high vessel density — the speed was excessive.

Rule 6 of the Inland Navigation Rules states: "Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropriate to the prevailing circumstances and conditions."

At the time of the collision, the patrol boat was not responding to an emergency, but to a call for assistance from a grounded sailboat. In reporting his situation, the sailboat operator had said that he and his passengers were not in distress and that he was going to wait for high tide to refloat his vessel. The non-emergency status was communicated to the Coast Guard patrol boat by the Joint Harbor Operations Center.

So why did the rescuers get so focused on getting to their destination that they took unnecessary risks to get there? Unfortunately, our investigators have seen unnecessary and unsafe actions too many times when the zeal to do good offsets sound decision making.

And, it isn't just in the marine world. Two months ago, we held a meeting on an accident where the rescuer, a state police helicopter pilot, also took unnecessary risks that resulted in loss of life.

In the case of the state police helicopter pilot, we found a weak organizational safety culture and structure. From this tragedy in San Diego Bay, we uncovered a similar failure, namely that the Coast Guard should do more to manage operational risks. They can work on team building and training and ensuring that those at the helm have the skills, maturity, and decision-making ability to safely guide the vessel. Today, we will hear about the evidence and facts collected over the past 18 months and discuss what happened on San Diego Bay on December 20, 2009. While it's difficult to make sense of this tragedy, we must take every opportunity to prevent it from happening again.

Dr. Mayer, will you please introduce the staff.