The EL TORO Tragedy
PART II : CG Analysis
by David Pascoe, Marine Surveyor
In this section I will offer my critique on the Coast Guard analysis and offer some sound reasons why government agencies, whether it's the NTSB or the Coast Guard should not be in a position of investigating accidents of craft which they certify. Upon studying the report, any highly experienced surveyor with a good knowledge of wooden vessels will quickly come to see it for what it is.
While the overall size of the report (34 pages) may appear impressive, considering the overall scope of the investigation, it is remarkably superficial and limited, particularly when it comes to investigating and assessing cause. Worse still is its obviously biased presentation bolstered by critical omissions of material facts.
The EL TORO was recovered the following day, refloated and hauled out at a local boat yard. Judging from the report, it had not broken up to any significant degree although, again, the report says almost nothing about its condition. The Coast Guard, insurance surveyors and other unidentified people from NTSB and Maryland Police were present to investigate. The Coast Guard review (I call it that because it's hardly a full report) of the survey comes to barely two full pages. It starts:
It is very interesting to note how this investigator makes judicious use of opinions of non-Coast Guard people present . . . "The consensus was . . ." when the writer wants to deflect attention from the failure of the CG inspections to note any problems, or rather should we say failure appreciate the importance of the evidence that was contained in their file notes, discussed in the next section. Here we have a hull that sprung three planks, had bad fasteners, sank and killed three people, but he's telling us that others thought it was in good condition. Yet, as the investigator, he does not say what he thinks.
The report goes on to say that six planks were then removed - apparently the three already sprung, and three others which are not clearly identified but are apparently two planks just fore and aft of the loose ones, and yet another on the opposite side of the keel. Remember that this is a bay bottom hull with the planking running transversely from keel to chine.
"Some necking?" Doesn't he consider it important enough to say how much? "Some necking" could be 10% or 90%, a factor that would tell volumes about the overall condition of the bottom.
The next paragraph:
Galvanic corrosion? To a steel nail imbedded in wood? Note here that fasteners do not corrode unless they get wet. The corrosion first takes place at the joint between plank and frame because this is where they first get wet. Once water gets at the nail, it will corrode all by itself: it doesn't require 32 years worth of galvanism.
If that's the case, then why does the coast Guard commonly approve these messy conditions? Why did this vessel have a messy electrical system after 32 years worth of Coast Guard inceptions, not one but literally dozens of inspections? Not one CG inspector ever found it worthy of mention? Here again, the report condemns the CG but the investigator does not find it worthy of comment.
Here the report does not mention that the insurance surveyor did his survey afloat. The surveyor's remarks, if he made them, are not qualified or put in proper context but used to support the Coast Guard's failure to find any problems. Moreover, the surveyors comments indicate that there were indications of trouble on the interior. But the writer wants us to believe that everyone agreed that it "was in remarkably good condition."
Remember that earlier the writer states that the planks were entirely free of deterioration, and yet now he's admitting that there was "angel hair' on the planks. Angel hair is a form of deterioration caused by constant wetting and drying of salt water within wood fibers. As the water dries, the salts crystallize, tearing the wood fibers apart. The report erroneously attributes this to stray current or 'galvanic" problems. This causes progressive deterioration because it increases the ability of the wood to absorb water and so it becomes progressive. The wood is no longer solid but shredded, yet we're to believe that it's in remarkably good condition.
Whether the writer is being deliberately obtuse or not, the point is conveyed that at least 50% of the fasteners were either wasted or in poor condition. He should have indicated the percentage of wastage to original size, not use such amateurish and relative terms such as "like new" or "minimal." Does the report offer exhibits of the nails as evidence? No, it does not. How about the planks? Again, no. Yet the report devotes a great deal of its space to convince of the CG inspectors experience and professionalism while the substance of the report denies that claim. Surely the writer knows that with all these injuries and deaths that there will be litigation. Yet he is willing to go out on a limb and provide a report that is amateurish at best, and decidedly self-serving. The most fitting conclusion we can draw here is that the writer has succumbed to the rampant disease of bureaucratic self-immolation to protect the Coast Guard hierarchy.
Here begins the Coast Guard's shifting of the blame. What he's saying is that since there is no written 'guidance' - and note the peculiar use of that word - that it's not the certifying authority's responsibility to KNOW when fasteners should be pulled and checked. In attempting to shirk responsibility, the writer is unwittingly exposing his agency's incompetence. Imagine if the NTSB made such comments in an official report on an air disaster! "We couldn't find any written guidance for over 50 years so we just kept approving it anyway." This same excuse appears yet again in the conclusions section of the report.
Moreover, you may have noted the subtle inclusion of "marine surveyors" along with "Coast Guard Inspectors" in that comment. They apparently didn't want to feel alone in their ignorance so they had to include the private sector as well.
Amazing! Here he's not saying that the broken tank saddle didn't exist 8 months ago in March, but rather that there's "no evidence" that this had "an adverse effect" on the intergrity of the hull.
Next, I'll go to item #6 of the conclusions section:
This statement is truly amazing. Here we have the aft end of the fuel tank support sitting not on a longitudinal plank, but a transverse plank. And the writer would have us believe that there more significant factors? And just what are those "other factors?" Well, he doesn't say. Corrosion in other planks? But he's talking about the plank that the saddle is resting on. What do other planks have to do with the failure of this one? How large was the tank? How much weight was resting on that plank? Again, the report is silent on critical evidence.
These statements in and of themselves destroy all credibility of this report. it's like justifying a flat tire by saying that it's only flat in one place.
This ends the narration of the investigation into the cause of the tragedy. The astute investigator will note that this report is as remarkable for what it does say as it doesn't say. This is followed by a list of 35 conclusions and 17 recommendations, most of which seem designed to deflect responsibility and disguise the Coast Guards own failures. (next)