707.300.110429.USCGPathfndrFAMrpt.pdf Department ......On 23 December 2009, the Ship Escort/Response...

u.s. Departmento~Homeland Security

United StatesCoast Guard

CommanderSeventeenth Coast Guard District

PO Box 25517Juneau, Alaska 99802-5517Staff Symbol: (d)Phone: (907) 463-2025Fax (907) 463-2037Email: [email protected]

5800

From: CH LV DMCGD SEVENTEEN (d)

To: D. P. VERFAILLIE, CDRCG MSU VALDEZ

Thru: CG SECTOR ANCHORAGE (s)

Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARDACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OFTHE TUG PATHFINDER ON 23 DEC 09

Ref: (a) Administrative Investigations Manual, COMDTINST M5830.lA(b) Memorandum, Administrative Investigation into Coast Guard actions and response

activities concerning the grounding of the tug PATHFINDER on 23 DEC 09 dated22 JAN 10

(c) USCG Regulations, COMDTINST M5000.3 (series)(d) Vessel Traffic Services National Standard Operating Procedures Manual (VTS

NSOP), COMDTINST M16630.3(e) VTS Prince William Sound Standard Operating Procedures, MSUVALDEZINST

16630A(f) Prince William Sound - Vessel Escort and Response Plan (VERP) - Published

January 2007(g) U.S. Coast Guard Vessel Traffic Service Prince William Sound - User's Manual

(Eighth Edition - September 2008)

1. Having considered reference (a) and other applicable references, appropriate actions arehereby ordered, and this administrative investigation is closed. A summary of the pertinent factsand my opinions based on those facts are herein provided. All times provided are in AlaskaStandard Time. Progress with respect to the ordered actions shall be reported on a monthly basisto CGD SEVENTEEN (dcs) until all ordered actions have been implemented.

2. This investigation was directed for the purpose of ascertaining the facts and circumstancesassociated with the mishap and to provide recommendations for the implementation of improvedprocedures which, ultimately, reduce the risk of similar incidents occurring in the future. Theactions of the master and crew of the Tug PATHFINDER ("PATHFINDER") have beeninvestigated under a separate Coast Guard Marine Casualty Investigation. This informaladministrative investigation was not intended to determine the cause of the PATHFINDERgrounding. This investigation must be viewed in conjunction with the Marine CasualtyInvestigation to fully understand the cause of this casualty.

3. Factual Summary.

a. On 23 December 2009, the Ship Escort/Response Vessel System (SERVS) directed thePATHFINDER to serve as an Ice Scout Vessel (ISV) to conduct ice scouting operations and

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Subj: FINAL ACTION ON ADMINISTRATIVE 5800INVESTIGATION INTO COAST GUARD ACTIONS ANDRESPONSE ACTIVITIES CONCERNING THE GROUNDINGOF THE PATHFINDER ON 23 DEC 09

provide an ice report in accordance with the Vessel Escort and Response Plan (VERP).

b. Ice reports are required pursuant to the VERP to provide periodic situational updatesregarding the presence of icebergs which can create navigational hazards in the vicinity ofBligh Reef. Icebergs are produced throughout the year due to calving of the nearbyColumbia Glacier, some of which occasionally drift into the nearby Traffic SeparationScheme (TSS).

c. The VERP is designed as a port specific guide to further aid and enhance the safety oftanker navigation and the protection of the marine environment within the waters of thePrince William Sound. The Prince William Sound Regional Citizens Advisory Council(PWSRCAC), the SERVS, and the Coast Guard Captain of the Port Valdez are all signatoriesto the VERP.

d. The VERP requires an "ice scout" to visually check for ice in the vicinity of Bligh Reefno longer than six hours prior to a tanker transiting Prince William Sound. An ice report wasrequired due to the scheduled departure of the tanker KODIAK which was scheduled todepart outbound from the Port of Valdez later that evening. Although the PATHFINDERwas designated as an ISV for 23 December 2009, an ice scout is not specifically required tobe a tug. Virtually any vessel or even an aircraft can serve as an ice scout. The primaryobjective is to visually identify any floating ice that may endanger a tanker transit throughthe TSS.

e. An ISV is defined as "any suitably sized vessel equipped with an operational radar andsearchlight." Due to size and power limitations, the PATHFINDER does not provide tankerescort services and was regularly chosen by SERVS to perfolm ice scouting duties.

f. At approximately 1402, the PATHFINDER checked into the Prince William SoundVessel Traffic Service Area (PWS VTSA) and indicated they were enroute to Bligh Reef toprovide the ice report. As a Vessel Movement Reporting System (VMRS) user, thePATHFINDER was required to check-in with the Vessel Traffic Service (VTS) to provide aninitial sail plan, report any deviations from the initial sail plan, or check-out of the VMRSwhen transit or operations were complete.

g. The PATHFINDER was not required to check-in at any of the designated VTS RepOltingPoints in the PWS VTSA because the Ports and Waterways Safety System (PAWSS) atVessel Traffic Center (VTC) Prince William Sound received Automatic IdentificationSystem (AIS) information from the PATHFINDER. VTS Prince William Sound was alsoable to track vessels operating in the PWS VTSA, including the PATHFINDER, based oninformation provided from the USCG radar site on Reef Island.

h. The PATHFINDER did not encounter any opposing or overtaking traffic during itsoutbound transit.

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i. At approximately 1649, the PATHFINDER provided an ice report reporting no ice in thearea while abeam Bligh Reef, in the outbound traffic lane.

j. At 1650, the PATHFINDER reported on-scene weather in the vicinity of Bligh Reef asfollows: four-foot swells from the south, southeast winds at 15 knots and visibility ofapproximately four nautical miles. At this time, the PATHFINDER also stated that theywould remain in the vicinity of Bligh Reef until 1800 in order to provide an 1800 ice report.This was in anticipation of an outbound transit by the Tanker KODIAK from the Port ofValdez later that evening.

k. Earlier in the day, at 0520, Cape Hinchinbrook Entrance was closed to all outbound ladentanker vessels due to weather. The 1800 ice report would extend the window of opportunityfor the Tanker KODIAK to depart Valdez to midnight if the Cape Hinchenbrook entrancewas opened later in the day.

l. At approximately 1654, the PATHFINDER began to cross the TSS toward the inboundlane.

m. At 1657 relieved of the VTC Watch Supervisor(VTCWS) duties. In addition to normal watchstanding responsibilities, the VTCWS inValdez is responsible for performing a variety of routine maintenance and unit security dutieswhile on watch. These duties include security rounds, colors, unlocking access doors, andremoving snow from the front-door sidewalk in extreme snow-fall situations. VTCwatchstanders are permitted regular breaks (at least 15 minutes every 3 hours)

n. The VTS Prince William Sound Internal Standard Operating Procedures (ISOP) providesfor minimum manning requirements that ensure 24-hour coverage of the VTS. Section4.B.I.a provides that "[alt least one of the two personnel assigned to the watch must be in theVTC at all times" and that "during inbound and outbound tanker transits of the ValdezNarrows, when hazardous circumstances exist or are anticipated anywhere within the PWSVTSA both rwatchstanders I shall be present to monitor the transit." Both the VTS NationalStandard Operating Procedures (NSOP) and ISOP also provide for mandatory minimum restperiods of at least 15 minutes for every 3-hour period for all watchstanders.

o. At approximately 1724, the PATHFINDER crossed and departed the TSS and continuedice scout duties in vicinity of Bligh Reef. ISV's typically travel at various courses andspeeds and close to reefs and shoal water when transiting outside the TSS. Since ISV'sroutinely operate in close proximity to Bligh Reef, neither watchstander detected anyanomalous activity associated with the PATHFINDER's operations.

p. At 1725, relieved LT of the VTC Specialist(VTCS) duties. LT duties include her primary responsibility as VTS Chief,and she remained on scene at the VTC following her relief.

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q. At approximately 1800, the PATHFINDER provided an ice report reporting "no visibleice" to the VTS.

r. At approximately 1802, the PATHFINDER, while on a south-southeast heading at anapproximate speed of 3.5 knots, reported to the VTS that they had been released of icescouting duties by SERVS and were headed back to Valdez. . the duty VTCS,acknowledged receipt of the PATHFINDER's radio communication.

s. At approximately 1803, the PATHFINDER turned on a northerly heading and increasedspeed to approximately 11-13 knots. At this time, the PATHFINDER was approximately 1Y2 miles due south of Bligh Reef.

t. Since the PATHFINDER's activity was consistent with both watchstanders experiencewith respect to ISV operations, neither watchstander magnified the location of thePATHFINDER on their radar screen. Both watchstanders maintained the radar scale at asmaller scale setting in order to provide maximum visual coverage of the PWS VTSA andthe entire Vessel Traffic Lanes. At this scale setting, the PATHFINDER's location could notbe differentiated from Bligh Reef.

u. At 1814, the PATHFINDER reported to VTS via channel 13 that the vessel was agroundon Bligh Reef. The location of the PATHFINDER was within the PWS VTSA but wasoperating well outside of the TSS.

v. Both VTS watchstanders stated that at the time of the grounding, they were both activelywatching their consoles and focused on monitoring the entire TSS. Immediately followingthe PATHFINDER's report of grounding, the VTS watchstanders replied via radio to thePATHFINDER and followed standard procedures as they had been trained. They used theQuick Response Cards (QRC) for both search and rescue (SAR) and marine pollution andconducted notifications up the chain of command.

w. At the time of the grounding, the weather and tidal information was as follows:

I) Tides: were estimated to be +8.74 foot tide ebbing to a low tide of +2.48 foot atapproximately 2330.

2) Currents in the vicinity of Bligh Reef were estimated to be weak and variable.

3) Weather: The NOAA West Orca Bay weather buoy, located 15 NM south of BlighReef, recorded 7-8 foot seas with east-southeast winds at 23 knots.

x. At 1826, VTCWS delivered notice of the grounding to , ExecutiveOfficer (XO), Marine Safety Unit (MSU) Valdez, who at the time was also serving as theActing Commanding Officer (CO) of MSU Valdez since CDR Darryl Verfaillie, CO, was onleave.

4



y. At 1827, notified CDR Verfaillie of the situation. CDR Verfaillieimmediately checked off of leave and resumed command. At approximately 1900, CDRVerfaillie arrived at VTS Prince William Sound.

z. Shortly after the report of the grounding, the CGC LONG ISLAND was dispatched fromValdez to provide on-scene information regarding the PATHFINDER's status.

aa. The USCG Sector Anchorage Command Center (CC) was monitoring marine radiofrequencies and began to communicate with the PATHFINDER to assess the need forpotential SAR assistance.

bb. At 1845, the PATHFINDER notified the CC that the tug was no longer aground and washeading to the northeast where it anchored just northeast of Bligh Reef.

cc. CDR Verfaillie suspected the damage to the PATHFINDER may not be in excess of$100,000 and was uncertain on the amount of fuel discharged; consequently, post-accidentdrug testing for the VTS watchstanders was considered but not conducted shOitly after thegrounding. In accordance with the NSOP, Commandant (CG-1312) was notified on 28December 2009 that a required post-accident test for illegal drug use was not conductedwithin four hours of the accident. Drug testing of the watchstanders was conducted at 1000on 28 December 2009 following direction by District Seventeen. Drug test results werenegative for all personnel tested.

dd. The Processed Ice Radar Picture (PIRP), designed to feed into the VTS system andprovide watchstanders with current information on the amount of ice in the TSS, wasinstalled in the VTS in February 2009. However, on 23 December 2009, the PIRP was notavailable to the VTS because the ice processor had not been upgraded to be compatible withthe Terma radar upgrade completed in 2 October 2009. VTS watchstanders considered thePIRP to be a good situational awareness tool for the VTC; however, use of the PIRP did notcircumvent the VERP requirement for on-scene ice reports delivered by vessel or aircraft.

ee. Although physically located in the VTC, the PIRP is neither owned nor maintained by theCoast Guard. Under standard Coast Guard policy, Coast Guard technicians are notauthorized to repair or upgrade non-standard, non-Coast Guard property. However,anticipating the potential need, the Coast Guard specifically left a port open on the Termaradar for a technician to access and upgrade the system and notified the PWSRCAC andSERVS in July 2009 that the system was inoperable absent an upgrade.

ff. The VTS program was established by the Ports and Waterways Safety Act, 33 U.S.c.1221 et seq, to employ navigation safety systems and practices to reduce risk and to facilitatemaritime commerce in U.S. ports and waterways. The primary function of a VTS is tofacilitate good order and predictability on a waterway by providing a variety of services tomariners operating in and around the ports where VTS systems have been implemented.

5



These services include: providing infonnation to mariners such as positions, intentions, anddestinations of other vessels operating within a VTSA; traffic organization informationwhich includes providing advance planning of movements, mandatory position reporting, orspeed restrictions through certain areas; and, upon request, providing navigation assistance tovessels which includes positions relative to waypoints, ATON, and navigational infonnationsuch as course or speed made good.

gg. VTS watchstanders are required to provide traffic advisories to vessels equipped withoperational Automatic Identification Systems (AIS), including the PATHFINDER, that electto make automated reports. A vessel traffic advisory includes infonnation regarding "alltraffic a vessel may encounter both visually and by radar while transiting the VTSA." VTSwatchstanders are instructed to "anticipate changing conditions to include weather, vesselspeeds, locations, operations, and the embarking/disembarking of pilots at the pilot station.Traffic advisories shall be passed to enhance safety and vessel navigation. They shall bepassed when applicable and between reporting points, if needed." On 23 December 2009, notraffic advisory was provided to the PATHFINDER because there was no other trafficoperating in the PWS VTSA throughout the PATHFINDER's transit.

hh. Unless requesting navigational assistance from the VTS or operating in the shipping lanesand endangering TSS traffic, tug boats, fishing boats, charter boats and other smaller craft donot normally receive traffic advisories from the VTS and are responsible for their own safenavigation throughout Prince William Sound. The PATHFINDER did not requestnavigational assistance at any time during their operations leading up to the grounding.

ii. All VTS Prince William Sound da and night watchstanders on 23 December were fullyqualified. The personnel on watch. and accounted for a total of 21years total combined years of VTS experience and both had previously attended the NationalVTS Operator Course at the Maritime Institute of Technology and Graduate Studies(MITAGS).

jj. Previous meetings were held prior to the 2009 Ice Season with port partners (MSUValdez, SERVS and the PWSRCAC) to discuss ice routing procedures. Based on thesemeetings and stakeholder input, the VTS made minor revisions to the Ice Routing Section ofthe ISOP manual. At that time, neither the VERP nor the ISOP specifically identified theoperational duties and responsibilities, including area of operation, for an ISV.

kk. All Aids to Navigation (ATON) throughout the PWS VTSA were fully operational andwatching properly at the time of the grounding.

4. Opinions.

a. As a learning organization, the Coast Guard always seeks ways to improve performance.This investigation was intended to assess whether improvements could be made to the vesseltraffic service provided to Prince William Sound. This investigation was not initiated under

6



any presumption that any action or inaction by the VTS watchstanders contributed in anyway to the grounding of the PATHFINDER.

b. In reviewing the watch routine and practices of the personnel on watch and comparingthis to the ISOP, the NSOP, and the Code of Federal Regulations, the actions of the VTSwatchstanders were fully in compliance with those policies, rules and regulations. I havedetermined that the actions of the VTS watchstanders did not contribute, either directly orindirectly, to the PATHFINDER grounding on Bligh Reef. With respect to other potentialcausal factors, specifically the actions of the PATHFINDER's master and crew which mayhave contributed to the grounding, the Coast Guard conducted a separate Marine CasualtyInvestigation which specifically addressed these separate factors.

c. Pursuant to 33 CFR § 161.11 (VTS Measures), "conditions of vessel congestion,restricted visibility, adverse weather, or other hazardous circumstances, a VTS may control,supervise, or otherwise manage traffic, by specifying times of entry, movement, or depat1ureto, from, or within a VTSA." The most recent weather report provided by thePATHFINDER (85 minutes prior to grounding) indicated weather conditions of four-footswells, a southeast "breeze" of 15 knots, and visibility of about four nautical miles.Recognizing that PATHFINDER's operations were observed to be consistent with typicalISV operations and the absence of any additional reports indicating a change of weatherconditions, VTS watchstanders did not suspect that the PATHFINDER was in danger ofcreating a hazardous situation, posing a danger to other vessels, or engaging in any activitywhich would require the watchstanders to initiate any of the affirmative control measuresprovided under 33 CFR § 161.11. Given the non-standard nature of the operations of ISV's,it is not reasonable to expect that VTS watchstanders would or should have performed in amaimer any different than what occurred leading up to the PATHFINDER grounding. Theunique facts surrounding this incident do not indicate a need to modify VTS Prince WilliamSound procedures for monitoring the much higher risk tanker traffic transits into and out ofthe Port of Valdez operating inside the TSS.

d. Further, 33 CFR § 161.10 (Services) provides that "a VTS may issue advisories orrespond to vessel requests for information, on... hazardous conditions or circumstances"within the VTSA. The above referenced federal regulations are consistent with the CoastGuard position that, absent a specific request from the vessel, these measures and services arediscretionary in function and are issued based on the judgment of the VTS watchstander. Inreviewing the radio transmissions from 23 December, such a request was never made by thePATHFINDER. Based on the experience of the watchstanders in observing vesselsoperating in the vicinity of Bligh Reef, there was no reason to transmit an unsolicitedadvisory.

e. Since both watchstanders were at their assigned stations at the time of the grounding, therequirement for a VTCWS to perform minor housekeeping or security tasks while on watchwas not a contributing factor to the PATHFINDER grounding. The requirement for the

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VTCWS to perform these infrequent tasks is not considered an impediment to thewatchstanders ability to monitor the safe transit of vessels throughout the PWS VTSA.

f. The inoperative PIRP was not a factor to the grounding of the PATHFINDER since thevisual ice report was required in accordance with the VERP. When it was operational, thePIRP feed into the VTS was considered beneficial to help determine the amount of ice in theTSS, but was never used as a substitute to the visual ice report to initiate closure of the trafficlanes. The Coast Guard made proper notifications and outreach with respect to notifyingPWSRCAC and SERVS regarding the Terma radar upgrade of 2009 on Reef Island and theimpact it would have on the PIRP operability.

g. VTS Prince William Sound is a critical component for ensuring the safe movement ofvessel traffic in the TSS and through the PWS VTSA. As indicated above, currentauthorities satisfactorily ensure the safe movement of crude oil tanker traffic inside the TSSand through Prince William Sound. Although PATHFINDER ultimately grounded on aknown navigational hazard, it appeared to VTC watchstanders to be operating in conformitywith typical ISV operations. This incident does not serve as an indication that the VTS wasnot working properly. In this instance the entire VTS system, both human and equipment,operated in conformity with applicable requirements and regulations and was not acontributing factor to this mishap.

h. The purpose of the VTS is to help mariners safely navigate through a VTSA where thereis typically a high volume of vessel traffic. It is not intended, nor should it be expected thatthe presence of a VTS in a port should relieve professional mariners from the responsibilityto adhere to prudent and vigilant navigation practices. In the maritime industry, it has alwaysbeen customary to bestow full responsibility for the safe navigation and operation of a vesselto the captain. This basic principle is also supported under federal law, which provides under33 C.F.R § 161.1 that "the master is responsible for the safe navigation of the vessel." Thecaptain of a vessel is ultimately responsible for the safe navigation of their vessel. VTSPrince William Sound has adequate authorities to ensure the safe, non-obstructed transit ofcrude oil tankers inside the traffic separation scheme and through Prince William Sound.

i. The PATHFINDER ran aground while conducting normal duties operating outside theTSS. While the PATHFINDER was associated with SERVS, this situation could have just aseasily involved a fishing boat, chm1er boat, recreational vessel or another vessel notassociated with SERVS.

5. Additional Comments

a. Although not specifically addressed in the investigation, there was speculation amongsome Prince William Sound stakeholders that the Coast Guard either had or should be givenauthority to actively direct all vessels all the time inside the PWS VTSA (the expansive areaof Prince Williams Sound as differentiated from the more narrowly defined TSS) in order toprevent all marine casualties. The proposition was offered that the Coast Guard should adopt

8



a vessel traffic control scheme similar in operation to the air traffic control schemeadministered by the Federal Aviation Administration (FAA). I do not agree with thissuggested modification of the VTS function for several reasons, including the following:

1) As discussed above, the authorities provided to the Coast Guard for the operation ofVTS do not mirror authorities those authorities employed by the FAA in regulatingmovement in restricted airspace; the former relying on the captain of a vessel to safelynavigate their vessel as compared to the specific courses, speeds, and altitudes providedto aircraft by the latter. Should the Coast Guard be given additional authority and therequirement to actively track and direct all vessels and ensure they navigate safely insidea VTSA, the Coast Guard would need significant additional resources.

2) There are significant differences between air traffic and vessel traffic control systems.Unlike controlled airspace for aircraft, vessel traffic systems rarely, if ever, provideactual courses and speeds to steer. They provide navigational assistance only whenrequested. Due to the high degree of responsibility given to masters of vessels; vesseltraffic systems, with limited exceptions, are generally advisory in nature. Unlike aircraft,vessels can be stopped or even anchored.

b. Since full radar coverage of Prince William Sound was completed post-EXXONVALDEZ, VTS Prince William Sound has helped facilitate the safe movement of 9.4 billionbarrels of oil.

6. Actions. The following actions are ordered for CG MSU Valdez:

a. Conduct an Internal Review Board (IRB) at VTS Prince William Sound in compliancewith the NSOP.

b. Review VTS Watchstanders assigned duties to ensure they do not have the potential tointerfere with watchstander duties or could be better accomplished by another crewmemberof the unit.

c. Work with local stakeholders in developing an SOP for the PIRP, if it becomesoperational.

d. Review the duties of an ISV with Prince William Sound stakeholders to determinewhether ISV duties should be more specified or whether it is better to leave the duties of anISV as flexible as possible similar to current operations.

e. Review the VERP with Prince Williams Sound stakeholders to determine whether theVERP needs to be amended.

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f. Conduct training and take action to ensure drug testing of watchstanders is properlycompleted in a timely manner in accordance with U.S. Coast Guard policy as appropriate forany future marine casualty.

#

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United States Coast Guard

Report of Investigation into the Circumstances Surrounding the Incident

Involving M/V PATHFINDER grounding

On 12/23/2009

MISLE Activity Number: 3655472 Originating Unit: Marine Safety Unit Valdez

MISLE Activity Owner: Commandant (CG-5453) MISLE Activity Controller: Commandant (CG-5453)

MISLE Case Number: 485689


Report of Investigation

2

I. INCIDENT BRIEF

On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef. The vessel re-floated itself without assistance and transited under its own power to Busby Island where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact amount discharged could not be determined. A Marine Casualty Investigator from MSU Valdez was deployed to the scene. The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully towed back to Valdez where the removal of the remaining fuel commenced. Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA where it will undergo permanent repairs. The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost during the incident was 6,410 gallons of diesel fuel.



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II. EXECUTIVE SUMMARY

Incident Summary On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef. The vessel re-floated itself without assistance and transited under its own power to Busby Island where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact amount discharged could not be determined. A Marine Casualty Investigator from MSU Valdez was deployed to the scene. The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully towed back to Valdez where the removal of the remaining fuel commenced. Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA where it will undergo permanent repairs. The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost during the incident was 6,410 gallons of diesel fuel. Incident Involved: Marine Casualty, Reportable Discharge of Oil USCG Credentialed Mariner, Misconduct USCG Credentialed Mariner, Negligence Civil Offense(s) This incident resulted in a discharge or substantial threat of discharge of oil. This report does not limit the discretion of the Director, NPFC, to determine facts, rights and liabilities with respect to any claims, submitted to or by the NPFC, for removal costs and damages under the Oil Pollution Act of 1990. Level of Investigation: IMO Classification: Routine USCG Classification: Major Marine Casualty Was this a Serious Marine Incident? Yes Was a Marine Board Convened by Commandant? No Personnel Casualty Summary Total Missing = 0 Total Dead = 0 Total Injured = 0 Total at Risk, Not Injured = 0 Total People at Risk = 6 Other Personnel (Not at Risk) = 0

(b)(6) & (b)(7)(c)



4

Vessel(s) Status Summary Actual Total Loss(es) = 0 Total Constructive Loss, Salvaged = 0 Total Constructive Loss, Unsalvaged = 0 Damaged = 1 Undamaged = 0 Property Damage Summary/Total Damage Vessel(s) = $500000* Cargo = $ Facility(s) = $ Other = $ * Includes estimates Waterway Mobility Summary Vessel Delays (including speed restrictions): None



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III. ACTIONS IN RESPONSE TO THIS REPORT

Actions on Recommendations Safety Recommendation #7135: Crowley Marine Services Policy Review

During the course of the investigation into the grounding of the PATHFINDER, numerous company policies and procedures pertaining to the vessel's mission, crew performance and training were reviewed. Crowley Marine Services published numerous policies regarding all aspects of marine operations. However, events leading up to the grounding, including subsequent crew interviews, revealed that the PATHFINDER's bridge team had largely chosen to disregard policy and procedure regarding proper watch reliefs, charting, and the maintenance of vigilance on the bridge. It is recommended that Crowley Marine Services develop a system that ensures company policies and procedures are being followed in the field. This should include, but is not limited to, a thorough review of vessel logs that are turned in to the company to certify that they are being completed in accordance with company policy, focusing on watch reliefs and fix intervals. It is further recommended that the company deploy a team of personnel to conduct an operational review of vessel missions at least bi-annually. This would enable the company to evaluate the effectiveness of its policies and procedures. Adopting these recommendations would provide Crowley Marine Services a system that evaluates the level of adherence to company policy, potentially increasing employee support. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:16:11 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:09 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Adherance to company policy and accountability for such actions may have prevented the incident. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:00 >STATUS: Forward--->Forward

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



6

>NEW OWNER: COMDT 545 Concur. Crowley management is responsible for the corporate culture where complacency is discouraged and robust bridge resource practices are encouraged. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:15 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action > COMDT 545 >03/31/2011 13:15: The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. ----------------- > COMDT 545 >03/31/2011 13:16: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary:

Safety Recommendation #7138: Chemical Testing Review

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



7

Following the grounding of the PATHFINDER, chemical testing was completed onboard the vessel by the Master and Chief Mate. Crowley Marine Services maintains an adequate program and ensures their personnel are trained by a third party in specimen collection procedures following a Serious Marine Incident. However, several mistakes were made on the chain of custody form as well as during the collection process. Fortunately, the mistakes were not so egregious as to prevent them from being useable. However, it is imperative that post-casualty drug testing be completed in accordance with applicable regulations. It is recommended that Crowley Marine Services review its policies regarding chemical testing following a Serious Marine Incident, specifically, who is authorized to test, documentation, and chain of custody. Crowley Marine Services should make the necessary changes to prevent future oversight of the requirements. It is also recommended that Crowley Marine Services review its determination policy on when it is appropriate to send a third party collector to the site of an incident. A letter from the District Seventeen Drug and Alcohol Program Inspector has been submitted to Crowley Marine Services addressing this recommendation. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:16:51 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:14 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Following proper procedures may have alleviated any fatal flaws. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:03 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, District Seventeen DAPI letter to Crowley Marine Services dtd 26Jan10. -----------------

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



8

>USER: COMDT 545 >TIME: 03/31/2011 13:16 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.


Concur- Alternate Acceptable Action > COMDT 545 >03/31/2011 13:16: We note this recommendation was forwarded to Crowley Marine Services on January 26, 2010 by U.S. Coast Guard Seventeenth District. D. S. Fish By direction

Required Actions:


Safety Recommendation #7139: Computer Useage

It is recommended that Crowley Marine Services provide additional guidance on the use of computers, electronic media, cell phones, etc., while standing the navigational watch. Company policy states in general terms that the computer should only be used for company business. Recommend company policy be expanded upon to include times for use that are appropriate (outside of a bridge watch), and the content that is allowable, specifically, prohibited use of computer games on the bridge. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:17:31 PM Priority: Normal

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



9

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:19 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. The Master may not have been distracted from his navigational responsiblities had he adhered to company policy regarding use of the computer on the bridge. Additionally, revising company policy to provide specific examples of inappropriate computer use would provide more clarity to vessel crews. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:07 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. The use of computers, cell phones and other handheld devices is expanding into nearly every facet of daily life. Recently, social media devices and computers took center stage in horrific accidents (commuter train wreck in California caused when the train conductor missed a signal while texting ) or frightening near misses ( the northwest pilots who overflew their destination because they were trying to decipher their work schedule on their laptops). Games, music, phone calls to far away family are a strong temptation and could easily distract a ship's officer from maintaining a proper lookout. Like aviation and rail transportation, the marine transportation system is equally vulnerable to accidents with significant loss of human life. Recommend CG545 promulgate a Safety Alert cautioning the maritime community about the distracting affects of using such devices on the bridge of vessels. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:17 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.


Concur- Alternate Acceptable Action > COMDT 545 >03/31/2011 13:17:

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



10

We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. Regarding District's additional recommendation to issue a safety alert, Commandant issued a marine safety advisory on distracted operations on October 29, 2010, in response to an earlier National Transportation Safety Board (NTSB) recommendation. D. S. Fish By direction

Required Actions:


Safety Recommendation #7140: Training Evaluation

During the course of the investigation, it was discovered that the Second Mate was involved in two marine casualties within the last year, which may have indicated a problem with his ability to make sound decisions during critical situations. While interviewing the Master and Chief Mate, both individuals discussed incidents where the Second Mate mistakenly wrapped a line in the screw of a line boat after making an improper judgment call during a training evolution, and again when the Second Mate failed to respond to a steering pump alarm and failure on the PATHFINDER. The Chief Mate and the Master failed to counsel the Second Mate on the proper actions he should have taken in the given situations, nor did they relay their concerns to the company. The Second Mate was never given any remedial training on bridge management and therefore was not aware of his shortcomings. It is recommended that Crowley Marine Services develop a system that requires progress reports of new personnel and trainees be submitted to the company. This would enable the company to identify shortcomings and devise remedial action plans. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:18:28 PM Priority: Normal

Endorsement(s):



11

>USER: MSU Valdez >TIME: 03/04/2010 11:26 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Immediate counselling to discuss shortcoming and remedial actions would provide timely feedback to the individuals involved in casualties. Addtionally, tracking a member's performance and periodic counselling by the supervisor would help identify any trends of performance issues. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:09 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:17 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.


Concur- Alternate Acceptable Action > COMDT 545 >03/31/2011 13:18: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status:

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



12

Action Commentary: Safety Recommendation #7141: Night Vision Maintenance

At the time of the grounding, the Master was using the computer located on the bridge, which may have affected the Second Mate's or Master's night vision. It is recommended that Crowley Marine Services provide screens for computer monitors or laptops located on the bridge to darken white light being emitted from the computer while in use. Although neither the Second Mate nor the Master identified the computer screen as a latent unsafe condition, the maintenance of night vision in a bridge environment cannot be overstated. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:19:21 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:30 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Use of adequate tools would improve night vision on the bridge. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:10 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:18 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.


(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



13


Required Actions:


Safety Recommendation #7143: Navigational Chart Plotting Standardization

It is recommended that Crowley Marine Services establish policy for taking navigational fixes, to include chart markings and proper fix identification (i.e. dead reckoning, global positioning system, estimated position, etc.). At the time of the grounding, there were several marks on the PATHFINDER's chart that were all dissimilar. When questioned about the markings on the chart, the Second Mate stated that each conning officer had his own symbol for a fix, and pointed out his fix signature. The current method of charting or plotting a fix is not standardized and can provide confusion as to who took the fix, when the fix was taken, or what means was used to acquire the fix. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:19:59 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:31 >STATUS: --->Forward >NEW OWNER: D17 dp

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



14

Concur with safety recommendation. Use of standardized chart symbology is good marine practice. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:11 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:19 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.



Required Actions:


Safety Recommendation #7190: Increased Navigational Fix Frequency

Current Crowley Marine Services policy states that the vessel's position will be charted “every two hours at a minimum”. Any increase in the fix interval is left up to the mariner.

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



15

It is recommended that Crowley Marine Services establish a minimum fix interval while vessels transit near shoal waters, known hazards, or in decreased visibility environments. Although in this incident the Master and Second Mate failed to comply with company policy on numerous occasions, a policy mandating an increase in fix intervals when operating in or near known hazards, shoal waters or in decreased visibility can positively impact the safe navigation of Crowley Marine Services' vessels. Date Created: 02/25/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:20:41 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:37 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Increasing the fix intervals while transiting in hazardous situations would provide the mariner with better awarenss of the vessel's location in relation to such hazards. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:13 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:20 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.


Concur- Alternate Acceptable Action > COMDT 545 >03/31/2011 13:20:

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



16

We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions:


Safety Recommendation #7191: Equipment Failure Tracking

It is recommended that Crowley Marine Services review their equipment repair procedures to ensure prioritization of essential navigational equipment. The Electronic Bearing Line (EBL) on the starboard radar had not been operational since October 2009, despite a repair order that had been filed with the maintenance department. According to statements from the crew of the PATHFINDER, this was the second time that this piece of equipment was inoperable. The company's current repair process fails to identify equipment needing immediate repairs, such as an EBL on a radar system. It also fails to recognize essential equipment that has a history of defects. Without changes to the way Crowley Marine Services prioritizes vessel equipment failures and repair times, these failures may directly impact the safe navigation of their vessels. Date Created: 02/25/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:21:19 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:39 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Maintenance tracking and prioritization are essential to identifying critical equipment failures and repairing such in a timely fashion. -----------------

(b)(6) & (b)(7)(c)



17

>USER: D17 dp >TIME: 04/07/2010 15:14 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:21 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.



Required Actions:


Safety Recommendation #7194: Refloat Policy

It is recommended that Crowley Marine Services develop a system that requires its Masters to complete a risk assessment prior to refloating a vessel after it has grounded. It is also recommended, when the situation permits, that the Master contacts the company and Coast Guard to discuss threats and option for refloating the vessel. Immediately following the grounding of the PATHFINDER, the Master deemed it appropriate to refloat the vessel. There was no discussion or request for guidance between the Master,

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



18

Crowley Marine Services or the Coast Guard about whether or not the vessel should be refloated and the manner in which the refloat should be completed. Date Created: 03/03/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:22:03 PM Priority: Normal

Endorsement(s):

>USER: MSU Valdez >TIME: 03/04/2010 11:48 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. A thorough assessment of a grounding situation should be conducted prior to moving any grounded vessel. Fortunately the breaches to the hull were such that refloating the vessel did not negatively impact it's stability. However, refloating the vessel may have caused additional damage to the hull's integrity. ----------------- >USER: D17 dp >TIME: 04/07/2010 15:14 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: COMDT 545 >TIME: 03/31/2011 13:21 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.


Concur- Alternate Acceptable Action > COMDT 545 >03/31/2011 13:22: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez.

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



19

D. S. Fish By direction

Required Actions:


Safety Alerts



20

IV. FINDINGS OF FACT

Subjects of the Investigation

Vessels. The following vessels were subjects of this investigation. Particulars for each vessel follow.

Vessel Name: PATHFINDER Flag: UNITED STATES Vessel Identification Number: 524616 Call Sign: WBN8467 Status: Damaged Role: Involved in a Marine Casualty Vessel Class, Type, Sub-Type: Gross Tonnage(GRT): Net Tonnage(NRT): Deadweight Tons: Length: 136.2 Home/Hailing Port: Keel Laid Date: Delivery Date: Place of Construction: AMELIA, MH, UNITED STATES Builder Name: MCDERMOTT SHIPYARD Propulsion: Diesel Reduction Horsepower: 7000 Master: Classification Society: American Bureau of Shipping Owner: CROWLEY MARINE SERVICES INC

1102 SW MASSACHUSETTS ST SEATTLE,, WA, 98134 US PUGET SOUND TUG & BARGE CO 14020 SE JOHNSON ROAD SUITE 201 MILWAUKIE, OR, 97267 US

Operator: Inspection Subchapter: Most Recent Vessel Inspection Activity:

Facilities. The following facilities were subjects of this investigation. Particulars for each facility follow.



21

Parties and Organizations. The following people and organizations were subjects of this investigation.

Status: Not at Risk Role: Subject of Investigation Gender: M Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence): .

US

Comments:

Status: Not at Risk Role: Medical Review Officer Gender: M Age: SSN: Birth Date: Email Address: Phone Number(Daytime Phone): 215-637-6800 Address(Primary): University Services MRO

10551 Decatur Rd Suite 200 Philadelphia, PA 19154 US

Comments:

Status: Not at Risk Role: Witness Gender: M Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

US

Comments:

(b)(6) & (

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)



22

Status: Not at Risk Role: Witness Gender: M Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

US

Comments:

MONSEN, RONALD EUGENE Status: Not at Risk Role: Subject of Investigation Gender: M Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

US

Comments:

Status: Not at Risk Role: Subject of Investigation Gender: M Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

UNITED STATES US

Comments:

Status: Not at Risk Role: Witness Gender: M Age: SSN: Birth Date:

(b)(6) & (

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)(b)(6) & (b)(7)(c)



23

Email Address: Phone Number(): Address(Home/Primary Residence):

US

Comments:

COAST GUARD VALDEZ VTC Status: Not at Risk Role: Witness Email Address: Phone Number(): Address(): Comments:

CROWLEY MARINE SERVICES INC

Status: Not at Risk Role: Subject of Investigation Email Address: Phone Number(Work): (206) 332-8037 Address(Primary): 1102 SW MASSACHUSETTS ST

SEATTLE,, WA 98134 US

Comments:

Drug and Alcohol Testing. The following people have been determined by the Coast Guard, Law Enforcement Personnel, and/or the Marine Employer to have been directly involved in a Serious Marine Incident as defined in 46 CFR 4.03-2:

Subject of Investigation MONSEN, RONALD EUGENE; Subject of Investigation

Subject of Investigation Witness

Witness Witness

Response Resources. The following incident response resources were subjects of this investigation.

Resource Name: HC130H - 1700 Resource ID: 1700 Kind: Aircraft (Fixed Wing) Sub-Kind: Type:

Resource Name: MH60J - 6007 Resource ID: 6007

(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c)(b)(6) & (b)(7)(c)



24

Kind: Aircraft (Helicopter) Sub-Kind: Type:

Resource Name: WPB - 1342 Resource ID: 1342 Kind: Vessels Sub-Kind: Type:

Other Subjects. The following were subjects of this investigation. Waterway Segment(s). The following waterway segment(s) were subjects of this investigation. PRINCE WILLIAM SOUND Role: Location Local Name: Description: TATITLEK, AK VALDEZ HARBOR Role: Location Local Name: Description: VALDEZ HARBOR, AK

Incident Information Location(s). Description Latitude Longitude

Bligh Reef, Prince William Sound, Alaska 61 06.5 N 148 03.5 W PRINCE WILLIAM SOUND 60 51.8664 N 146 40.902 W

Sequence of Events. 10/05/2009 12:00:00 to 12/23/2009 18:15:00 (Estimated): Electronic Bearing Line on the starboard radar was not operational at the time of the incident. There was a work order submitted to the company on October 5th, 2009.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Vessel Material/Equipment Condition Subject Type: Navigation Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details:



25

Name Type Status Role PATHFINDER Vessel Damaged Involved in a Marine

Casualty Details Filed: Material/Equipment Condition

System: Navigation Sub-System: Electronic Positioning Component: Radio Direction Finding Device Details: EBL was not operating properly on starboard radar. Cite:

12/20/2009 18:15:00 to 12/23/2009 18:15:00 (Estimated): Attached evidence is 96 hour work rest history for subject.

Condition Class: Person Condition Type: 96-Hour Work/Rest History Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role

Party Not at Risk Subject of Investigation

Details Filed: None 12/20/2009 18:15:00 to 12/23/2009 18:15:00 (Estimated): Attached evidence is the 96 work/rest history for the subject. The subject was unable to give a full work/rest history due to the fact that he did not have the vessel's logs.

Condition Class: Person Condition Type: 96-Hour Work/Rest History Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role

MONSEN, RONALD EUGENE


Details Filed: None 12/23/2009 0:00:00 to 12/23/2009 0:00:00 (Known): The VTS National Standard Operating Procedures Manual states that the VTS may provide navigation assistance service to vessels who request it. It goes on to state that navigation assistance service may include specific warnings to individual vessels.

(b)(6) & (b)(7)(c)



26

Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role

COAST GUARD VALDEZ VTC

Party Not at Risk Witness

Details Filed: Policy/Regs/Procedures Condition ISM Code Data

Does the ISM Code apply to the Party: No Safety Management System (SMS) implemented: No

ISO 9000 Data

Does ISO 9000 apply to the Party: No Quality Management System (QMS) implemented: No

ISO 14000 Data

Does ISO 14000 apply to the Party: No Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist

Explanation of Nonexistence: Major Nonconformity: No

Policies/Procedures that Are Not Aboard

Explanation why Not Aboard: Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate

Law/Regulation: No Name: VTS NSOP COMDINST M16630.3 Effective Date: 08/18/2009 ISM Policy: No ISO 9001 Policy: No Issued By: Commandant, USCG Policy Nature: General management Reason Inadequate: Instruction clearly articulates the role of the VTS watchstander as an additional navigational tool that a mariner may use. It does not replace mandatory safe practices on the part of the mariner.

Latent Unsafe Condition: No

12/23/2009 0:00:00 to 12/23/2009 0:00:00 (Estimated): Alaska Chadux is the Oil Spill Response Organization for the PATHFINDER.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Non-Vessel Material/Equipment Condition



27

Subject Type: Pollution Prevention/Response Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role

PATHFINDER Vessel Damaged Involved in a Marine Casualty

Details Filed: None 12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Crowley Marine Services does not have established ice scouting areas, or transit areas for its assigned Ice Scout vessels. Policy only exists regarding instruction on what to look for and how to work with tank vessels proceeding in and out of the port.






ISO 9000 Data


ISO 14000 Data



Explanation of Nonexistence: There is no policy for vessel routing or transit areas for ice scouting missions. Major Nonconformity: No



Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate



28

Latent Unsafe Condition: No

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Capt. Monsen admittedly suffered from constant stress caused by his wife being disabled/handicapped at home in Anchorage.

Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role



Details Filed: Personnel Condition Human Factors: Human Factor: Factor Type: Psychosocial Factors Factor Sub-Type: Family Description: Captain's wife is disabled and at home by herself in Anchorage. Latent Unsafe Condition: No Merchant Mariner: Yes Personnel Credentials: Credential Number: 1121418 Issue Date: 04/28/2006 Expiration Date: 04/28/2011 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON COASTAL WATERS; ALSO RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: 33 Years Months Positions Held:

Position Time in Position Master 15 Years, 0 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): The Master had 33 years in the industry, had worked on the PATHFINDER for more than 10 years and was planning on retiring within the next 8 months.



29

Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role



Details Filed: Personnel Condition Human Factors: Human Factor: Overall experience Factor Type: Psychological Factors Factor Sub-Type: Experience and Recency Description: The Master had become complacent when it came to following company policies. He had worked with the company for a number of years and had transited through the area frequently. Latent Unsafe Condition: No Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 04/28/2006 Expiration Date: 04/28/2011 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON COASTAL WATERS; ALSO RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: 33 Years Months Positions Held:



12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to Crowley Marine Services' policy, the Master was required to keep an accurate deck log, ensure that a proper lookout was maintained, ensure vigilance was maintained on the bridge, ensure that the voyage plan is laid out and checked in advance, and on transfer of watch plot the vessel's position, intended track, course and speed, obtaining confirmation of the same.

Condition Class: Policy, Procedures, or Regulations



30

Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role





ISO 9000 Data


ISO 14000 Data






Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to Crowley Marine Services' policy regarding watchstanding and change of watch, the watch shall not be relieved until both the off-going and on-coming watch personnel are satisfied in the exchange and understanding of pertinent watch standing information, such as, but not limited to: orders, position, course, speed, navigational hazards, traffic, and prevailing conditions.

Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details:



31

Name Type Status Role MONSEN, RONALD EUGENE


Details Filed: None




ISO 9000 Data


ISO 14000 Data







12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Crowley Marine Services' Directive VDZ 09-008 states that any time a watch change occurs, log entries are to be signed by both the off-going and oncoming watchstanders and, when underway, include an entry of the vessel's position. Anyone must be able to accurately reconstruct the voyage if necessary.




Details Filed: Policy/Regs/Procedures Condition

(b)(6) & (b)(7)(c)



32

ISM Code Data Does the ISM Code apply to the Party: No Safety Management System (SMS) implemented: No

ISO 9000 Data


ISO 14000 Data







12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Regarding General Navigation and Navigation Safety, Crowley Marine Services' policy states: "The watch will not allow himself to be distracted when accurate and timely navigation is critical."






ISO 9000 Data


ISO 14000 Data




33






12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to the Master and Chief Mate, an electronic charting system called Nobletech was removed from the PATHFINDER after it failed, never to be replaced. The Master felt that this equipment was very useful as a navigational tool.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Vessel Material/Equipment Condition Subject Type: Navigation Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role


Details Filed: Material/Equipment Condition System: Navigation Sub-System: Piloting/Steering Component: Marine Charts Details: Electronic charting system called NOBLETECH removed from vessel. According to company, system was to be used primarily for tanker assist tugs. Cite:

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Over the past year the Second Mate had been involved in two separate incidents that should have led to concern in his judgment and abilities but failed to be addressed by the company. See MISLE Activity Numbers 3674494 and 3674499 for incident details.

Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W



34

Subject(s) and Details: Name Type Status Role


Details Filed: Personnel Condition Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Information Processing Description: The Chief Mate voiced concern over the ability of the Second Mate during his interview, and was witness to the Second Mate wrapping a line in the lineboat's propeller. The Chief Mate failed to inform Crowley Marine Services of this concern. Latent Unsafe Condition: Yes Merchant Mariner: Yes Personnel Credentials: Credential Number: 000017988 Issue Date: 07/23/2009 Expiration Date: 03/23/2014 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS UPON OCEANS; MASTER OF STEAM OR MOTOR VESSEL OF NOT MORE THAN 1600 GROSS REGISTERED TONS (DOMESTIC VOYAGE), 3000 GROSS TONS (ITC TONNAGE) UPON OCEANS. Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Years Months Positions Held:

Position Time in Position Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):



Details Filed: Personnel Condition Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Perceptions Description: While the Second Mate was standing a bridge watch a steering pump failure occurred. The Second Mate failed to act accordingly resulting in the master having to take over. Latent Unsafe Condition: Yes Merchant Mariner: Yes Personnel Credentials: Credential Number: 1121418 Issue Date: 04/28/2006 Expiration Date: 04/28/2011 Issuing Authority: United States



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Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED) EXPIRES APRIL 2011. Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: 33 Years Months Positions Held:




Details Filed: Personnel Condition Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Information Processing Description: The Second Mate was involved in two separate incidents within the last year that should have brought into question his ability to make sound decisions when on the bridge by himself or when faced with a difficult situation. Latent Unsafe Condition: Yes Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 08/05/2009 Expiration Date: 10/08/2013 Issuing Authority: United States Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSEL OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: 1 Years 6 Months Positions Held:

Position Time in Position Trainee 0 Years, 6 Months, 0 Days Second Mate 0 Years, 6 Months, 0 Days


(b)(6) & (b)(7)(c)



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12/23/2009 13:45:00 to 12/24/2009 1:00:00 (Estimated): PATHFINDER U/W from SERVS mooring Buoy 1 for Ice Scouting tasking

Action Type: Bridge Operations - Shiphandling Action Class: Maneuver vessel in accordance with conning orders Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name Type Status Role



Details Filed: None 12/23/2009 14:02:00 to 12/23/2009 14:05:00 (Estimated): PATHFINDER calls VTC on VHF to inform of being underway from SERVS buoy #1 for ice report.

Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role


Details Filed: Communications Details Communications Description: Vessel informs traffic that they are underway Communications Type: Ship to Shore Sent or Received: Sent Means of Communication: Verbal Communication Acknowledged: Yes Communication Protocols: Transmitted via Channel 13 Communications Effectiveness: Communication Effective Effectiveness Description: Interference Difficulties: Interference Description:

12/23/2009 16:49:00 to 12/23/2009 16:55:00 (Estimated): PATHFINDER reports to VTC via VHF that they are off of Bligh Reef and have "no ice."

Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W



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Subject(s) and Details: Name Type Status Role


Details Filed: Communications Details Communications Description: Ice reports passed to VTC Communications Type: Ship to Shore Sent or Received: Sent Means of Communication: Verbal Communication Acknowledged: Yes Communication Protocols: Transmitted via Channel 13 Communications Effectiveness: Communication Effective Effectiveness Description: Interference Difficulties: Interference Description:

12/23/2009 16:50:36 to 12/23/2009 16:55:00 (Estimated): PATHFINDER receives word from SERVS duty officer that they are to remain in the vicinity of Bligh Reef and provide another ice report at 1800.

Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role


Details Filed: Communications Details Communications Description: SERVS base informed vessel that they would need to remain on scene until 1800. Communications Type: Ship to Shore Sent or Received: Received Means of Communication: Verbal Communication Acknowledged: Yes Communication Protocols: Communications Effectiveness: Communication Effective Effectiveness Description: Interference Difficulties: Interference Description:

12/23/2009 16:59:30 to 12/23/2009 17:05:00 (Estimated): It is Crowley Marine Services' policy that all reliefs will be logged, and that prior to relief the oncoming watch (Conn) will have ascertained the location or current position of the vessel.

Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition



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Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name Type Status Role



Does the ISM Code apply to the Vessel: No Safety Management System (SMS) implemented: No

ISO 9000 Data

Does ISO 9000 apply to the Vessel: No Quality Management System (QMS) implemented: No

ISO 14000 Data

Does ISO 14000 apply to the Vessel: No Environmental Management System (EMS) implemented: No





Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequ

707.300.110429.USCGPathfndrFAMrpt.pdf Department ......On 23 December 2009, the Ship Escort/Response...

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Transcript of 707.300.110429.USCGPathfndrFAMrpt.pdf Department ......On 23 December 2009, the Ship Escort/Response...