Findings

Under the direction of the Coast Guard’s 13th District, a formal administrative investigation convened on 19 February 1997 in Forks, Washington. The investigation board consisted of CDR James Hasselbalch, LT Polly Bartz, and CWO2 Terry Smock. For more on this and the other investigations, see this exhibit.

By 19 March 1997, the board compiled a 23-page report with over 90 enclosures and findings of fact, opinions, and recommendations.

The initial report was forwarded to the Coast Guard’s 13th District Commander, RADM J. David Spade for further review. After commenting and adding changes, RADM Spade forwarded it to the Coast Guard Commandant, ADM Robert E. Kramek on 28 March 1997.

ADM Kramek reviewed the entire package with RADM Spade’s annotations and issued a final summary on 14 June 1997. This was the official, final word on the mishap.

Presented here are summaries of the most significant findings of fact, opinions, and recommendations, as well as each higher authority’s comments.

Some of the most compelling entries will be emphasized with red text.

On 21 April 1997, before the Commandant issued his final summary, Chief of Staff ADM James M. Loy issued an internal letter regarding the class “A” mishap and death of the three Coast Guardsmen. His causes, lessons learned, and actions are displayed at the bottom of this page.


Findings of Fact

22. 23.The GALE RUNNER transmitted three mayday calls. The first indicated that the vessel had been dismasted, was without propulsion, was taking on water, and was drifting towards shore; only the third included a position. Approximately 23 minutes elapsed between the first and third mayday calls and the final position was passed as a latitude and longitude, not a geographical reference.

30.Before getting CG 44363 underway, BM2 Bosley did not brief his crew. Their only knowledge of the case was what they had heard from the pipe accompanying the SAR alarm.

41. 42.No member of the boat crew was wearing helmets. Additionally, only SA Wingo and SN Miniken definitively wore their heavy weather belts. SA Wingo assumed that MK3 Schlimme wore his and was clipped in as well, but he was unsure if BM2 Bosley wore his belt.

43. When the CG 44363 was between entrance light #3 and Wash Rock, MK3 Schlimme exclaimed, “Let’s get the fuck out of here!” and BM2 Bosley replied, “Fuck that!” SA Wingo was not sure what each comment meant in the context of the vessel’s situation.

121. 122. 123. BM2 Bosley’s most recent 44′ MLB Coxswain certification was in October 1995. His currency maintenance records indicated that he had not been recertified (completed the required semiannual currency tasks) by the Officer in Charge (OIC) for the period beginning 1 January 1997. BM2 Bosley’s currency lapse was due to one missing nighttime area familiarization transit across the Quillayute River Bar in a 44′ MLB. His records showed that between 1 July 1996 and 10 February 1997, he completed two nighttime bar transits.

124. 125. MK3 Schlimme’s currency maintenance records indicated that he had not been recertified by the OIC as 44′ MLB Engineer for the period beginning 1 January 1997. Unlike BM2 Bosley, MK3 Schlimme had met all currency maintenance tasks.

127. 134.SA Wingo was not certified as a 44′ MLB Boat Crewmember. The station’s SOP stated that a 44′ MLB will have a minimum crew of four certified members (Coxswain, Engineer, two Boat Crewmembers), though the second Boat Crewmember could be waived on ideal condition cases.

129. 130. 131. The BM2 Training Petty Officer maintained a status board showing recertification progress for the unit’s members. The status board was erased and reset on 1 January 1997, but the BM2 thought that it had shown that all members completed all currency requirements by the end of the cycle on 31 December 1997. BMCM LaForge (Officer in Charge) and BM1 Placido (Executive Petty Officer) both thought all of the crew were currently certified.

132. 133.The unit’s SOP required that a Surfman be on board a 44′ MLB during rough bar crossings. District 13’s SOP did not define “rough bar conditions,” but did define “heavy weather.”

135. 136. 137. The District 13 SOP from April 1996 required the station to have a minimum of four certified and four break-in Surfmen. At the time of the mishap, the station had three only certified Surfmen and one trainee.

138. The station SOP required the Officer of the Day (OOD) to notify the Senior Duty Officer (SDO) and duty Surfmen of any significant changes in the weather.

140. 141. 142. 143. 144. 145. BM2 Bosley first certified as 44′ MLB Coxswain at Station Yaquina Bay, OR in September 1993 and reported to Station Quillayute River in June 1994. At Station Quillayute River, BM2 Bosley’s Coxswain and OOD certifications were rescinded by a previous Officer in Charge (OIC) in March 1995 for “… a lack of judgment and disregard for standard practices which places the crew at extreme risk.” In July 1995, BM2 Bosley received administrative documentation for failing to meet semiannual recertification requirements.  In September 1995, after his performance improved, he was allowed to begin recertifying.

146. BM2 Bosley was counseled in April 1996 for not informing the Senior Duty Officer (SDO) of changes at the unit, including the presence of breaking bar conditions.

147. 148. Both the current Officer in Charge (OIC) and Executive Petty Officer (XPO) felt that BM2 Bosley lacked the judgment to become a Surfman.  The XPO, BM1 Placido, said that Bosley was, “unwilling to follow policies and procedures,” but was also a hard-worker and someone who learned from mistakes without repeating them.

149.- 155. CG 44363 and its outfit were in sound mechanical and material condition on 12 February 1997.

156. CG 44363’s navigation light switch was found in the “off” position.

162. Stadium-like floodlights were installed on James Island to help with nighttime bar transits, but had been inoperative since October 1996.  The Officer in Charge stated that functioning floodlights may have helped BM2 Bosley make a better decision when evaluating the bar.

163. 164. 165. Station Quillayute River was billeted for 25 members, including four certified Surfmen and three Surfman trainees.  During the incident, the station only had three certified Surfmen, including the Officer in Charge (OIC) and Executive Petty Officer (XPO).  The XPO stood Surfman duty and the OIC was perpetually on standby as the second boat Surfman.

166. 167. 169. In the 12 months prior to the mishap, the station received 15 new members: 60% turnover of personnel.  Only two of the station’s 11 had been at the unit longer than one year.  Because of the turnover, unit training focused mainly on “providing basic, introductory skills to help new personnel get their boat crew qualifications.”

174. The autopsy reports for BM2 Bosley, MK3 Schlimme, and SN Miniken all stated that the cause of death was blunt force injuries to the head.

177. 178. “Coast Guard District 13’s staff contacted Coast Guard Personnel Center on several occasions regarding staffing additional Surfmen” at the station. Before the incident, the 13th District requested that Station Quillayute River personnel be given a better assignment preference upon transferring out from the unit. (added by RADM J. David Spade)

179. A 1991 Station Staffing Study found that, “the central problem… is that many of our personnel arriving at stations are unqualified to fill the billets to which they have been assigned… staffing standards are based on the assumption that assigned billets are filled with fully qualified personnel.”
(added by RADM J. David Spade)

181. 182. “BMCM LaForge did not order BM2 Bosley to cross the bar”; it was BM2 Bosley’s decision. (added by RADM J. David Spade)

183. Before this incident, Coast Guard policy (in the 44′ MLB Operator’s Handbook) existed requiring boat crews to wear protective gear, including helmets and safety belts before operating in surf. (added by ADM Robert E. Kramek)

Opinions

1. CG 44363 “operated properly and performed as designed throughout” the incident.

3. At 1740, BM2 Bosley saw the 1640 National Weather Service forecast update.  He had “ample opportunity to inform both the Senior Duty Officer… and BMCM LaForge.”  Had BM2 Bosley passed the forecast to either person, a Surfman would have been onboard the unit on 11 February.  

RADM J. David Spade concurred with the opinion and added that this communication failure was consistent with his previously documented behaviors.

4. BM2 Bosley did not have the GALE RUNNER’s position before getting underway, “but concluded from the limited information that was available to him that the sailboat was close to the Quillayute River bar.  This helps to explain the sense of urgency that BM2 Bosley felt about getting MLB 44363 underway.”

5. MK3 Schlimme’s comments before CG 44363 reached the bar were made to get BM2 Bosley to turn around and not try to cross the bar.

ADM Robert E. Kramek did not concur with this opinion because sufficient information did not exist to determine the exact meaning of the comments.

6. CG 44363’s navigation lights were not energized.  If these lights had been on, the Officer in Charge might have been able to see the motor lifeboat from shore and warned them of their proximity to James Island.

RADM J. David Spade did not concur with this opinion. Various accounts stated that navigation lights were observed at different times in the 44363’s journey.

7. 10. After crossing the bar and before the first rollover, CG 44363’s crew “was disoriented and lost situational awareness.” Once the crew became disoriented, the aids to navigation in the vicinity of the bar “were of no assistance to the crew.”

RADM J. David Spade concurred with the opinion and added that the 44363 struck a rock before its first rollover. He believed that BM2 Bosley “was not aware of CG-44363’s proximity to James Island when it impacted the rock.

8. “BM2 Bosley did not have enough rough weather bar crossings at night in a 44′ MLB to prepare him” for the conditions on 12 February. He should “not have attempted to cross the bar.”

9. The inoperative bar lights were “not a critical factor” in the mishap, though they would have helped the crew assess the condition of the bar.

11. “If a Surfman had been on MLB 44363 that morning, the casualty would not have occurred.”

RADM J. David Spade did not concur with this opinion. “While Surfmen have the advantage of greater training… and a Surfman did in fact cross the bar safely afterwards… Surfmen are not invincible.” RADM Spade was of the opinion that, “had a Surfman been at the wheel of CG-44363 that morning, the casualty probably would not have occurred.”

ADM Robert E. Kramek concurred, except for the last sentence. He modified it to read, “the casualty may not have occurred.”

12. There should have been two certified boat crew members on CG 44363 based on the conditions on 12 February.

15. “The proximate cause of this casualty was the coxswain’s failure to safely navigate MLB 44363, causing the boat to capsize and founder in the surf conditions near James Island.”

RADM J. David Spade concurred with the opinion and added that BM2 Bosley “failed to exercise proper judgment expected of a Coast Guard coxswain and OOD by:”

-Failing to monitor his own currency requirements. His missing currency item (one nighttime bar transit) was directly related to his operation on 12 February.

-Failing to notify his supervisors about the deteriorating weather.

-Failing to “properly brief, coordinate, and prepare his boat crew.”

-Failing to “require his crew to wear helmets.”

-Failing to “navigate safely.”

-Failing to correctly asses the bar and “exercising inappropriate judgment” in crossing the bar.

RADM Spade continued that, “BM2 Bosley’s conduct in this incident is consistent with his documented performance deficiencies in 1995 and early 1996… BM2 Bosley was no doubt motivated by the noblest of intentions– to save others in peril upon an unforgiving sea. Unfortunately, while rushing out with the best of intentions, he failed to recognize his own limitations regarding his qualifications and experience handling boats in these conditions. Therefore, I find that the proximate cause of this incident was BM2 Bosley’s failure to conform to the standard of care of a reasonably prudent Coast Guard Coxswain.”

16. “Due to the high turnover of personnel, the Station’s operational readiness was diminished in the area of advanced skills/techniques.”

RADM J. David Spade concurred, adding that the “excessive turnover rate… required the command to spend an inordinate amount of time training basic skills… The inability to concentrate on training of advanced skills contributed to this mishap.”

17. The station had not been sufficiently monitoring the required semiannual recertification process.

RADM J. David Spade concurred with this opinion and added that the command was responsible for ensuring that BM2 Bosley met all currency requirements. RADM Spade noted, “…we will never know whether additional night familiarization training sorties would have made a difference…” It was also up to BMCM LaForge to “constantly assess whether BM2 Bosley’s judgment, training and skills merited retention of Coxswain qualifications.” Considering the “many positive statements by fellow crew members about BM2 Bosley’s performance– I will not second guess BMCM LaForge’s decision to retain BM2 Bosley as a Coxswain.”

18. “Due to the severity of their head injuries, the wearing of safety helmets may not have prevented the deaths of BM2 Bosley, MK3 Schlimme, and SN Miniken.”

ADM Robert E. Kramek concurred that helmets should have been worn, but did not concur that helmets could not have prevented the deaths because there was an “absence of detail” in the report regarding use of helmets and safety belts.

19. BMCM LaForge effectively coordinated search efforts because he didn’t have to get underway on CG 44393 as second boat. “Several key decisions were made that morning by BMCM LaForge which increased the chances of survival for both the sailboat and the MLB 44363 crews. His experience and expertise contributed to the sucessful recovery of the S/V GALE RUNNER’s crew.”

20. If SA Wingo could have gotten into the 44363’s messdeck compartment, he could have accessed a portable radio, additional flares, and a battle lantern. “These items would have been helpful in rescuing SA Wingo in a more timely manner.”

Recommendations

1. “That all small boat crew members attend Team Coordination Training.”

RADM J. David Spade concurred with this recommendation and added that the training should have “systematic program support”.”

ADM Robert E. Kramek included this item as a corrective action in his June 1997 final summary and ordered a Coast Guard-wide safety standown to address it.

2. The Commandant should promulgate clear guidance on the wearing of helmets and safety belts.

RADM J. David Spade concurred with this recommendation and added that it had been accomplished via a change to the Rescue and Survival Systems Manual in March 1997.”

ADM Robert E. Kramek included this item as a corrective action in his June 1997 final summary and ordered a Coast Guard-wide safety standown to address it.

3. During cases, it is crucial that the station’s Officer in Charge (OIC) or Executive Petty Officer (XPO) remain back to provide command and control. There should always be enough Surfmen at a station so that the OIC or XPO can remain back to handle every case. The station’s Surfmen billets should be increased from four (including the OIC) to four in addition to the OIC.

RADM J. David Spade did not fully concur with this recommendation. He agreed with the findings of an April 1996 “Surfman Quality Action Team” recommending that Station Quillayute River have four Surfmen at a minimum, including the Officer in Charge.”

ADM Robert E. Kramek agreed with RADM Spade.

4. Motor lifeboat Coxswains who have demonstrated the requisite maturity and judgment to pursue the Surfman qualification should be given a follow-on tour at another motor lifeboat unit. If necessary, the sea time requirement to make E-7 should be waived.

ADM Robert E. Kramek included this item (waiving the 12 month sea duty requirement for E-6 Boatswains Mate/ Surfmen) as a corrective action in his June 1997 final summary and ordered a Coast Guard-wide safety standown to address it.

6. 7. The transfer of personnel at Station Quillayute River should be monitored closely to ensure that there are always a “sufficient number of qualified personnel to safely carry out mission responsibilities.” Because the station is in an undesirable location, personnel stationed there should be given a higher assignment priority upon transferring out.

8. The station should implement a better system for monitoring the recertification process.

9. “The decision to discontinue the bar lights should be reevaluated,” because the lights provide the station and public with an additional means to evaluate bar conditions.

ADM Robert E. Kramek included this item as a corrective action in his June 1997 final summary and ordered the lights be returned to “operational status.”

10. The dogging handle for the forward main deck hatch should be stowed above deck in the coxswain flat area instead of below deck.

ADM Robert E. Kramek included this item as a corrective action in his June 1997 final summary and ordered a Coast Guard-wide safety standown to address it.

11. No disciplinary action is recommended for any of the crew of Station Quillayute River.

12. 14. Various headquarters and assignment offices should work with the 13th District (CGD13) to “establish clear policy on the number of Surfmen required at CGD13 stations.” Headquarters should consider each unit’s unique environmental risks when determining staffing. (added by RADM J. David Spade)

ADM Robert E. Kramek included this item as a corrective action in his June 1997 final summary and ordered a Coast Guard-wide safety standown to address it.

13. Headquarters should reevaluate the boat crew helmet design. (added by RADM J. David Spade)

ADM Robert E. Kramek included this item as a corrective action in his June 1997 final summary and ordered a Coast Guard-wide safety standown to address it.

ADM Robert E. Kramek ordered that the Coast Guard define “rough bar conditions” as a corrective action in his June 1997 final summary.

Chief of Staff’s Causes

a. “There was a combined disregard of risk assessment by elements of the Search and Rescue Response system during mission planning, crew selection, and environmental evaluations.”

b. “The Coxswain lost situational awareness… after turning west, he drove the MLB too close to James Island.”

c. “The Coxswain exhibited poor judgment by not recognizing that the situation was beyond his capabilities and experience…

Chief of Staff’s Lessons Learned

a. “The importance of conducting proper risk assessment…” The station and group practiced risk management, but not in a timely or well-communicated way to the Coxswain. “The misaligned actions combined to permit a disregard for risk at the boat level. The Coxswain’s actions implied moralizing judgments. Moralizing judgments do not consider safety risks, and are best embodied in the statement, ‘You have to go out.’ Unchecked, the Coxswain pressed on beyond a point of no return.”

“Semper Paratus [always ready] is a two-edged sword… To be be able to perform a mission, you must get there safely and understand what the mission is.”

Many of the major boat mishaps in the 1990s were related to “poor risk management.” While Team Coordination and Risk Management training is being addressed servicewide, “training without safeguard and routine enforcement at all levels… can and most likely will continue to produce similar outcomes.”

c. “Survival skills, training, and equipment… work under even the most catastrophic circumstances.”

Chief of Staff’s Actions

a.1 Amend all relevant directives to require that safety belts and helmets be worn during hazardous conditions.

a.2 Define “heavy weather” in relevant Commandant instructions.

a.3 Update the Boat Crew Seamanship Manual with a requirement that crew briefings cover weather, mission, and equipment.

a.6 Review the Coast Guard processes for recording boat crew training and find ways to improve and standardize the process.

c.2 Each Coast Guard district shall administer Team Coordination Training to all small boat units under their control that have not had the training in the last year.

d.1. The 13th District shall evaluate whether or not to repair the floodlights at James Island.

f.1 Headquarters shall determine if Team Coordination Training is required for groups and stations on a recurring basis.

f.2 Identify gaps in the way the organization trains and manages Coxswains and Surfmen, and work to find solutions to them.