1. Casualty Analysis LT Scott Wallen

2. Not on Agenda Fault Blame Root Cause Violations Civil Penalties
Suspension and Revocation

3. Vessel casualty example.
Agenda
Vessel casualty example.
Vessel details
Route
Crew
Hopefully many questions and discussion
This topic is a little out of the ordinary for what we would normally present at industry day.
I’m going to be presenting the details uncovered for a marine casualty investigation
Including vessel, personnel, and operational details as well as the results

4. Involved Vessel Profile
This is our only involved vessel. She is a 30 foot by 9 foot by 9 gross/net ton vessel being used for carriage of freight on protected inland waters.
The vessel is not subject to Coast Guard inspection. It did not carry passengers for hire, and since it is less than 15 gross tons it is not subject to inspection for carriage of freight/cargo.
She is arranged with a 15 foot flat deck forward of the house….presumably designed for carriage of various equipment and cargo.
The house is arranged with an operating station on the starboard side, and an adjacent navigation station on the port side.
*9 Gross Tons*

5. The vessel is subdivided into 3 below deck voids each equipped with a rule-mate 2000 GA/hour electric submersible bilge pump.
The bilge pumps are designed for automatic operation via float switch, and manual operation from the operating station.

6. The Operation 2 unlicensed operators (brothers).
Deliver 3 containers with 3x3x3 dimensions of liquid chemicals to offshore facility (7778 pounds)
Entire planned transit was through internal protected waters.
No adverse weather encountered
The crew on the vessel include two adult males (brothers) who owned/operated a oil/gas production support company. Their primary business was delivering equipment and various packaged/containerized cargo to inland water based drilling and production platforms.
The vessel was being operated on charter.
The day of the casualty the two individuals had an order to deliver 3 containers of liquid chemicals to a local production facility.
The shipment included 300 gallons of nasty chemical A, 300 gallons of nasty chemical B, and 250 gallons of nasty chemical C.
The containers were approximately 3’x3’x3’ dimension with some minor variation due to number of gallons.
The total weight of the material and the containers was 7778 pounds.

7. Lock system Pickup Deliver
At 11 AM on the day of the casualty the crew members launched the vessel at a local marina, and proceeded to a local shipyard where they were scheduled to pick up the containers.
Upon arrival they used a dockside crane to load the containers. They arranged the containers on deck with the two larger 300 gallon containers side by side along the centerline a few feet forward of the house. The third container was placed along the centerline approximately 1 foot forward of the larger containers.
At Noon they departed the shipyard to deliver the equipment.
They had delivered equipment to the customer several times in the past, and had a planned route highlighted in red. It required the vessel to transit one lock not a few miles from the shipyard.
The vessel arrived at the locks at approximately 1215 where they found a long line of vessels waiting to lock through.
Rather than wait for the locks they decided to take an alternate route highlighted in yellow. There is nothing particularly noteworthy about the alternate route.
No radio or cell phone calls were made to relay the alternate course to shoreside operators.
At approximately 1300 the onboard GPS system appeared to be malfunctioning so one crew member began troubleshooting the system.
At approximately 1310 the crew member who was still working on the GPS felt a slight bump that appear to originate from the port side of the vessel. They weren’t transiting fast, and the are was known for shoaling, so he wasn’t the slightest bit concerned. He didn’t even look up from the GPS to see what happened.
A few moment later the operator of the vessel noticed water coming onto the forward starboard deck.
The operator maneuvered hard to port.
The vessel capsized and rolled to a completely inverted position.

8. Vessel and 1 Survivor Found 36 hours later
One of the crew was able to open and escape from a window on the vessel
He surfaced and climbed on top of the now upside down vessel.
His brother never came out.

9. No bilge high level alarms
Vessel Condition
No bilge high level alarms
No shutoff/check valves for bilge discharge lines
Fuses for manual bilge switches at operating station panel had been removed
#1 and #3 void pumps auto switch inoperable
#2 pump operable via auto means
Post casualty inspection revealed the bilge pumping arrangements to be in completely unsatisfactory condition.
The auto switches in #1 and #3 voids did not work.
The fuses for manual operation had all been removed at the operating station.

10. Vessel Condition
As part of the investigation the Marine Safety Center conducted a stability analysis of the vessel.
In an unloaded condition the vessel easily met the righting energy requirements that would be applied to an inspected vessel of similar construction.
However, with loads in excess of 3700 pounds the vessel failed to meet all of the same criteria.
At the time of the casualty the vessel was carrying over 7700 pounds.
Basically, the righting energy was significantly limited throughout the voyage.

11. What Caused this Casualty?