NTSB results are out. (www.ntsb.gov/publictn/2011/MAR1101.pdf)

First, I read the New London Day article that the Coast Guard news and blog summary pointed to,

“According to the NTSB’s report, it found probable cause of the collision between the ferry Block Island and the Coast Guard cutter Morro Bay was caused by the failure of the bridge watch officers on both vessels to monitor their radars, sufficiently assess traffic, and compensate for limited visibility. Contributing to the accident was the failure of the bridge watch officers on both vessels to maintain a proper lookout and to sound appropriate fog signals….The Coast Guard promised to use fog signals and to post lookouts in such conditions in the future.”

It was really a very minor accident, but it could have been a lot worse. From the NTBS report:

“…The ferry was carrying a total of 305 people and the cutter had 21 crewmembers on board. As a result of the collision, two passengers on the Block Island sustained minor injuries and were treated and released that same afternoon. The Block Island sustained about $45,000 in damage and the Morro Bay about $15,000. “

In fog, with visibility estimated at 500 yards, Morro Bay was not sounding fog signals or keeping a proper lookout? Reading the newpaper account, my thought was, “what could they have been thinking?” but of course it was more complicated.

Morro Bay had just completed a yard period. The captain had relieved the previous day. This was his first voyage as CO. After getting underway the rudder indicator was found to be five degrees off, and the throttle was not functioning properly. But both of these were corrected quickly. They actually were sounding fog signals, but, as the they had on every previous voyage in the crew’s memory, they were using a loud hailer that it turned out did not produce the 130 dB required. The cutter’s radar overlay and the electronic chart were out of alignment with each other and the gyrocompass was giving erratic readings. Recognizing that the the gyro was misbehaving, the radar was switched to head up, so the radar was not as stable or as useful as it should have been, and the helmsman was steering by magnetic, which also distracted the OOD. Two EMs were on the bridge, trying to trouble shoot the gyro. The collision occurred at 1215, as crewmembers were going to, or returning from lunch. During the period preceding the collision there were always five to seven people in the pilot house. There were numerous small craft in the area. There had been a close call with a power boat approximately 30 feet long, that the radar reportedly failed to pick up, only five minutes earlier, prompting the OOD to recognize visibility had gone from about two miles down to about 500 yards. He attempted to contact the CO, who returned from lunch only moments before the collision.

The Block Island ferry certainly was not blameless. It was going 15 knots and not using its automatic fog signal, preferring to sound them manually, although the captain admitted he may have gone up to five minutes between signals and their part time lookout was inside the pilot house with the doors closed.

The vessels were in a crossing situation with the ferry on the Morro Bay’s starboard hand, the ferry heading South and Morro Bay generally West.

On the Morro Bay, “everyone was a lookout,” so no one was, and specifically no one was stationed outside the enclosed bridge where they might have had a better chance of hearing a fog signal, although at least windows on the bridge were open. No one was specifically charged with monitoring the radar which was set on the 1.5 mile scale. Closing speed would have been approximately 18 knots, meaning the ferry would have transited the 1.5 miles covered by the radar in approximately 5 minutes. Quoting the NTSB report,

“Because the Morro Bay’s radar range scale was set to 1.5 miles, it is understandable that the Block Island did not appear on the cutter’s radar until probably about 1208 or 1209, some 11–12 minutes after the ferry had already entered the open waters of Block Island Sound. It was only then that the outer limits of the cutter’s 1.5-mile radar range scale would have picked up the ferry. Nevertheless, even after the Block Island would have appeared on the cutter’s 1.5-mile radarscope about 1208 or 1209, no one on the Morro Bay noticed the ferry on the radar screen, and a close quarters situation was allowed to develop in spite of properly functioning radar equipment. About this time, numerous personnel changes had taken place on the cutter’s bridge with people coming and going, which could have been distracting. Shortly before the accident, between five and seven persons were on the bridge, which was not an expansive space. The crossing of the 30-foot-long powerboat about 500 yards in front of the Morro Bay at 1210, 5 minutes before the collision, could also explain why the ferry continued to go unnoticed for the next few minutes. The chief took steps to ensure that the distance between the vessels opened, which was appropriate. However, while the chief watched the powerboat clear the Morro Bay’s path ahead, valuable time was lost in detecting the Block Island on the radar. Additional detection time (1–3 minutes, possibly) was also lost while the chief monitored the helmsman to ensure that he followed the order to return to original course after yielding to the powerboat. The chief also tried to reach the commanding officer by telephone to inform him of the decreasing visibility. The phone call took some time because the commanding officer was not immediately located (he was returning to the bridge). It cannot be determined who among the many persons on the bridge was monitoring the radar, or whether the radar was being monitored at all, during this phone call. The NTSB therefore concludes that the bridge watch personnel on both vessels failed to use their radars effectively in the minutes leading up to the collision.”

The ferry detected the Morro Bay when it appeared on one of its two radars then set on a 0.75 mile scale. The ferry captain “...immediately reduced speed, stopped the engines, and sounded the fog signal. He then reversed his engines” but apparently did not change course. On the Morro Bay, about 20 seconds after the Captain had returned to the bridge, they heard a prolonged blast to starboard. Moving to the starboard wing they “...saw the Block Island emerging from the fog, about 50–100 yards away. The chief pulled back on the throttles and ordered the helmsman to put the wheel to full port rudder.”

—————————-

Reading the full report, made me a bit more sympathetic. Still, it’s a cautionary tale.

That the radar failed to pickup a 30 foot boat at 500 yards suggest that, despite a later finding it was working properly, this was not the case. Why wasn’t there some sort of minimal sea trial after the availability before starting for home, that would have picked up the problems with the rudder angle indicator, throttle, gyro, and possibly the radar? Shouldn’t district have insisted on it? But what about the manning? It was only a six hour trip. Too much to ask for an assigned lookout and someone on the radar? And why only use the 1.5 mile scale?

When things start getting difficult, it is alright to ask for help even before you really need it. That may have been happening when they heard the prolonged blast, but by then it was too late.

We were very lucky we did not have another Blackthorn or Cuyahoga or worse yet, a sunken ferry with 300 people in the water.