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The EL TORO Tragedy  

PART III : CG Conclusions of the Investigation

by David Pascoe, Marine Surveyor

1.As near as we can tell from the report, six, and possibly eight planks were removed, all in the area of the three loose planks. From this, the investigator concludes that it was a localized problem (conclusion #6). How does he know it's localized when he didn't check other areas? 

2. No indication is given that any effort was made to check any planks other than the immediate area of the failed planks. Why not? The obvious answer is that the investigator already had a foregone conclusion which he set out to prove. 

3. A 32 year old wooden boat fastened with steel fasteners would be a prime suspect to any experienced surveyor. Yet this report would infer that the rest of the fasteners in the vessel are all okay without any kind of general survey, and offers no proof of the inference. It justifies not pulling any planks or fasteners in other areas on the absurd argument that the nails are too hard to pull. This on a wrecked hull on which the fasteners could have cut out.

"134. Generally, all marine surveyors and Coast Guard inspectors testifying on the feasibility of removing nails for examination felt removal of a plank was more prudent than individually removing nails, due to plank damage caused by removing nails." 

4. As any experienced surveyor knows, bay bottom boats bear that name for good reason. Transverse framing is a shortcut method of boat building, intended for vessels used in protected waters because they are not nearly as strong as longitudinally planked boats. Bay bottom boats are notable for their tendency for wracking which, in turn, produces the tendency for leakage, which in turn wreaks havoc on fasteners. Nothing about the method of construction is mentioned in the report. That none of these considerations are raised gives rise to either questioning of the investigator's competence, or his intent. 

5. Conclusion #4 explains away the faults found in prior CG inspections that were never addressed: leaking at the starboard chine forward, deterioration of wood around keel bolts, plus "working/seepage" at the starboard side of the keel, midlength in the fuel tank compartment. Couldn't be due to the broken tank saddles could it? ". . . all indicate that the vessel was not in optimal condition." Optimal condition? What does that mean? "However, the circumstances were not severe enough to result in the issuance of requirements or supervisory direction for the actions beyond the special inspection notes recommended by the inspectors." In other words, they made notes in the file on these conditions but otherwise did nothing. One has to wonder just how serious does it have to be to get their attention? This explanation is entirely inadequate. 

6. The report states that the fuel tank saddle was broken loose from its frame fasteners and was resting on a plank. It further states that a wear pattern existed to show that the condition was long standing. For the reporter to state that this was a secondary consideration is ludicrous. Nothing in the report suggests that the entire weight of one end of the fuel tank was not resting on the plank. One could only conclude that a fuel tank saddle resting on a bottom plank would be a major contributing cause to that planks coming loose. This statement is clearly meant to deflect attention away from the fact that the inspectors did not find this condition in any of the last inspections. Or worse, that they knew of it and did nothing. Since the insurance survey has not been made public, we do not know if the insurance surveyor found this problem. Now consider the following statement: 

"There was no evidence as of the drydock examination in March 1993 that this circumstance had any affect on the integrity of the hull." 


As with so many other conclusions in this report, this statement is inserted in the report with no substantiation at all. 

Conclusions of the Investigation

"1. The proximate cause of the casualty was failure of the fasteners in the planks A,B, and C in way of the keel. The relatively severe seaway provided the forces that worked the planks loose, flooding all compartments . . . " 

  Apparently he means that the seas pulled the planks loose but that the fuel tank sitting on a plank had nothing to do with it. 

This conclusion is also notable for the fact that it does not state what the cause of the fastener failure was. Why does the investigator fail to state that the cause of the failure was corrosion? Although conclusion #3 talks about a variety of metals, including through hull fittings and ground plates, "contributed to the galvanic corrosion." At this point we have to be wondering how you build a boat without a variety of metals under water. Since all wood boats have dissimilar metals underwater, why is this one more adversely affected? No mention of the vessel's age is made, nor how long steel fasteners are expected to last. Nor to the general rule of thumb that even bronze fastened boats should be thoroughly checked after 15 years, yet alone 32 years.  

More importantly, it is widely known that bay bottom hulls defy the principles of strong wooden boat construction, that they are fraught with problems, which is why only a few builders in the mid-Atlantic coastal region used the method.  

Conclusions #4 & 5 are also noteworthy for their self-serving statements. This one deals with the observations made by the CG at the 1989 and 1989 CG hull inspections, as previously mentioned, in which "working/seepage at the starboard side of the keel midlength in the fuel tank compartment," "leakage around the keel," and wood deterioration around the keel bolts were observed yet no orders for repair were given. Isn't this precisely the area where the planks popped loose? 

Conclusion #5 is particularly interesting from the standpoint that it draws the conclusion that the wastage of fasteners at the 3 planks is a "local problem" and is a conclusion without substantiation. "The location was subject to abnormal corrosion rates due to being a low point where bilge water would collect, to the variety of nearby dissimilar metals and to the design of the vessel in the garboard area." Is having a low point in the bilge "abnormal"? And then this interesting statement: "The inline end of the bottom planks is conducive to working that would allow the joint to become loose and the water to enter the joint." This statement clearly indicates that the investigator is aware of the wracking problems with bay bottom boats. He knows that the bottom planks work, and yet would have us believe that it's strictly a "local" problem. 

All by itself, the above paragraph contradicts and invalidates the entire investigation report. If the inline end of the bottom planks are conducive to working that would allow water to enter the joints, then it follows that the nails are going to get wet and corroded. No galvanism is necessary as salt water does a wonderful job on steel, galvanized or not. Further, it had been substantiated in this and prior inspections that there was looseness, working and leaking of water from inside the vessel when it was hauled. Apparently the effect of looseness and water exposure to steel nails at that time "were not serious enough to result in issuance of requirements . . ." 

But these conditions are now serious enough to be cited as the cause of corrosion of the fasteners that ultimately sank the vessel and killed three innocent people. In just a few years, a period of time when drydock inspection was postponed three times, it went from not serious to complete failure. To accept these statements at face value, one would have to believe that the CG inspectors and the investigator had no knowledge of the corrosive effects of sea water on galvanized nails. Yet the report reflects that they do know. 

Any objective investigator would have concluded that the CG had failed in its prior inspections, what with their files containing notes of these serious conditions, to issue a requirement for mandatory fastener inspections, along with granting of delays for drydock inspections. After all, they are not inspecting farm equipment but certifying a public conveyance that is going to sea in the dead of winter. 

Conclusion #10 passes the buck by saying that there is no "well-known published guidance in the marine industry" on when fasteners should be inspected. This despite the fact that they are the certifying authority and it's their responsibility to know, not blame it on the marine industry. But then the writer destroys his own argument by saying, "Much of the available guidance on fastener examination typically assumes indications of wastage are present to suggest examination." This is utter nonsense: the surveyor does not have to see external evidence of fastener wastage to know that 32 year old steel nails are likely to be completely wasted, yet alone moderately so. Of course, no references are ever cited. Yet the most well known book around, Ian Nicholson's Surveying Small Craft goes into great detail about inspecting fastenings, including discussion about telltale evidence that suggests fastener problems. 

The Statement of Fact section of the report item #6 notes that CG Vessel Inspection Circular (NVIC) No. 1-63 recommends against the use of cut nails due to a lack of holding power in some circumstances. ABYC Project H-7 recommends against the use of ferrous fasteners, and if ferrous should be hot dipped galvanized. This does not prevent the CG from concluding that there is "no published guidance" and no fault of their own inspectors from following their own recommendations. How much more guidance do they want? When a privately published and voluntary standard suggests that it's a problem for pleasure craft, can't they take the hint that it could be disastrous for a public conveyance that is 32 years old?  

Conclusions 7 & 8 provide cover for the inspectors who carried out the earlier inspections, explaining why they only examined the "wind and water line interface, limiting his examination of fasteners to that area." Obviously they didn't just examine the waterline area because their "notes" indicate problems at the chine and keel. The essence of this commentary is that it is the experience of the inspectors that the water line area is a more critical area to inspect. This is their explanation for not inspecting the planks at the keel rabbet which this very report later states is the most probable area to expect corroded fastenings. Again, the report discredits itself. See Conclusion #5 above. 

Conclusion 25 is equally incriminating. I'll reproduce it here in whole: 

"Although Coast Guard marine inspectors are sensitive to the time, material and labor costs imposed on owners of wood boats caused by the requiring the removal of fasteners, there is no evidence that this sensitivity directly contributed to this casualty. [Emphasis added] These costs can be considerable for owners of small vessel, especially those which carry few passengers and have low value. The impact . . . could drive them out of business . . ." 


How about the cost to the passengers and three people who lost their lives? Is this a Freudian slip or what? Here the writer is giving the boat operators a free pass. In other words, because we have passenger vessel operators who are using old, dilapidated wooden boats to run a public conveyance, the Coast Guard shouldn't risk bankrupting them by ensuring that these vessels are safe. As with airlines, if the nature of the business doesn't produce sufficient revenues to produce safe vessels, then they shouldn't be in business. As with the ValueJet disaster late last year, once again we've witnessed a federal regulating agency give a shaky business operation a free pass on safety. As a result, over 100 people died. 

If ever there was a prime example of how not to write an investigation report, this is it. These statements are little more than an excuse for failure to perform, not an objective evaluation. Of course keeping old boats maintained will bankrupt the owners, just as old jet aircraft can bankrupt an airline. Why aren't 707's used in passenger service anymore? That's not an acceptable excuse for allowing defective conveyances to operate. Old vessels, like old aircraft, need to be retired when their safety can no longer be assured. 

Finally, here is the coup de gras that we would expect from any government agency investigation of its own handiwork: 

"34. There is no evidence of negligence on the part of any other government employee or person holding a license or document issued by the Coast Guard." - emphasis added. 


Of course not. We investigated ourselves and we are clean! And so are the people we grant licenses to. (next)

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About Author:
David H. Pascoe is a marine surveyor (retired) with 40 years' experience.

He is author and publisher of power boat books:

"Mid Size Power Boats"
"Surveying Fiberglass Power Boats" 2E
"Buyers' Guide to Outboard Boats"
"Marine Investigations"

Visit  yachtsurvey.com  for more than 160 online articles.

David Pascoe's biography

Page last updated May, 2015.
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