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:
| "129. . . The consensus was that the hull was in remarkably good
condition except for three sprung planks on the port side immediately
forward of the forward engine room bulkhead. The inboard end of the
planks had dropped about four inches from their normal position,
leaving a gap in way of the keel of about two inches. With the
exception of a single nail, all nails connecting these planks to the
sister keelson had wasted totally through at the faying surface with
the keelson." |
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.
| "129. The four planks removed amidships showed extreme wastage of
fasteners in way of the keel, with only 1 of 17 fasteners present for
planks a, b, and c. The planks themselves were in excellent condition,
free of visible deterioration." (Remember this statement because it
will be contradicted later.) "Fasteners toward the chine were
progressively better with most chine nails like new. Fasteners in the
two planks removed forward and aft had some necking but were
substantially intact and apparently effective, even at the keel."
|
"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:
| "130. On December 13, 1993, marine electrical specialist Mr. ___
examined the electrical system, metals in the hull and fasteners. He
had the two bottom planks just forward of plank A and the one just aft
of plank C removed. He concluded that the electrical grounding issue .
. . had no substantial impact on the wasted fasteners. (Note: prior
inspections had raised an issue about the vessel's grounding system
that back in 1988 was changed from a positive to negative grounding
system.) "He attributed wastage of fasteners in planks A, 8 and C to
32 years of galvanic corrosion, aggravated by the use of a variety of
metals in the hull." |
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.
| "131. Mr. ___ noted the electrical system to be a mess. He stated
that this condition is quite common on such vessels." |
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.
| "132. Mr. [the insurance surveyor] visited the vessel on the
railway and stated that picking planks A,B, and C for fastener removal
to find wasted fasteners during a drydock examination would have been
a "crap shoot" since no external or internal evidence of a problem
existed. He state that he would have focused on the engine room, based
on his experience and internal indications on this vessel, such as
angel hair noted in his survey report." |
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.
| "133. Of approximately 100 fasteners in the six planks removed on
10 December 1993, about 30 were wasted to the point of being totally
ineffective, about 20 were wasted to be marginally effective, and
about 50 were like new or had minimal wastage." |
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.
| "135. The marine surveyors and Coast Guard inspectors testifying
on appropriate intervals for removal of fasteners, and refastening in
general, had widely varying opinions. None identified written guidance
or even alluded to written guidance." |
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.
| "136. The fuel tanks were supported with transverse saddles.
The aft saddle supports had failed, allowing the weight of the
tanks to be partially supported by a bottom transverse plank. The wear
on this plank indicated that this condition existed for some time.
There was no evidence in March 1993 that this circumstance had any
adverse affect on the integrity of the hull." [boldface added].
|
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:
| "6. The unintended support of the fuel tank aft transverse saddle
by a bottom plank may have placed forces on the garboard joint over
time, contributing to the entry of water and the abnormal corrosion
rate in the area. However, corrosion of the fasteners in other planks
and battens indicates that other factors were more significant." |
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)
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