USCG Mishap Investigations

three investigations

Administrative

CLICK to view the Administrative Investigation. U.S. Coast Guard record

After the accident, the administrative investigation received the most attention. The administrative investigation identified if there was culpability and blame for the military personnel by looking most closely at facts of the incident and individuals’ behavior. In June 1997, the Coast Guard Commandant made this investigation public. (1)(2)(3)

For a comprehensive list of this board’s findings, and later reviews by senior officers, see this page. (3)

safety

Aviation mishaps originally demonstrated the need for a separate, “parallel investigation.” Not surprisingly, parties to an administrative investigation were not always forthcoming with the boards in order to protect themselves or others from prosecution. Because of this, vital safety lessons could be missed. A safety investigation is designed to be a parallel investigation that runs alongside an administrative investigation. It does not have “parties,” is confidential, and is much more far-reaching than an administrative one. (1)(2)

Safety investigations examine many issues, including systemic, organizational issues that may have contributed to the accident. In contrast to the administrative investigation’s focus, it is able to look at all aspects of the mishap. While the findings of the administrative investigation take precedence, the findings of the safety investigation can be very enlightening if they point to any root causes of the mishap. (1)(2)

All parts of the safety investigation were made classified to encourage contributors to be completely forthright, and it would not have been compared to other investigations until completion. This investigation was led by CAPT Carmond Fitzgerald, Commander, Group Detroit, Michigan, and its results were kept within the Coast Guard and could be used to drive internal changes. (1)(2)

COMMANDANT’S VESSEL SAFETY BOARD

The Commandant’s Vessel Safety Board was a third, parallel, and classified investigation aimed to find out what occurred, what the causative factors were, and what changes should be made in the future. It was compiled by a board of officers from around the Coast Guard and was ultimately reviewed by Station Quillayute River’s Officer in Charge and the commands at Group Port Angeles and the 13th District. (1)(2)

investigation Process

The administrative investigation lasted 34 days and included phone and in-person interviews, as well as data and evidence collection. Investigators pushed for a rapid inquiry because it ensured that each person’s story was preserved as much as possible, before time skewed the details or stories changed. Investigators were particularly sensitive to the natural way that two peoples’ memories can combine when they come together and discuss their separate experiences. (1)(2)(3)

Investigators had the challenging job of interpreting numerous personal accounts, forensic evidence, and service documentation. Given the limitations of human memory during chaotic events, it is impressive that a single cohesive narrative could be compiled. Still, students of the CG 44363 mishap will notice some discrepancies and contradictions. (1)(2)(3)

One example comes from the administrative report. District 13’s RADM J. David Spade refuted the administrative investigation’s opinion that CG 44363’s navigation lights were not energized, citing SA Wingo’s comments that he used the “stern light” to track his progress in the cove while adrift after the third rollover. Yet earlier, the administrative investigation found that the mast was gone after the second rollover. Though configurations have changed over the years, the stern navigation light was located on the mast in 1997. (1)(2)(3)(4)(5)

(left) 1997 stern and towing lights on the mast (right) stern deck light. U.S. Coast Guard photos

This contributed to the administrative board’s conclusion that the navigation lights were not energized. When SA Wingo testified about using the stern light in the cove, the board interpreted his comments to mean that he used the stern deck light. Based on how the switches were found at the site of the CG 44363’s wreckage, this conclusion made factual sense. (1)(2)(3)(4)(5)

Note navigation light switch in the “off” position. U.S. Coast Guard photo

33 minutes aboard cg44363

The image below depicts the approximate path and orientation of CG 44363 after leaving the protection of the Quillayute River. CG 44363 had been underway for approximately 14 minutes at the time of the first rollover. When SA Wingo looked at his watch after the third rollover, CG 44363 had been underway for 33 minutes. It soon came to rest at the back of the cove on James Island. (1)(2)(3)(4)

Approximate path of CG 44363 and location of rollovers. U.S. Coast Guard photo

14 February 1997 James Island Photos

U.S. Coast Guard photos/ PA3 Della Price

References

(1) Noble, Dennis L. The Rescue of the Gale Runner. University Press of Florida, 2002.

(2) Interviews with active duty and retired members, grades E-5 to O-6: Surfmen, investigation members, Officers-in-Charge, and Commanding Officers

(3) CDR Hasselbalch, James M. Investigation into the Capsizing and Subsequent Loss of MLB 44363 and the Death of Three Coast Guard Members That Occurred at Coast Guard Station Quillayute River on 12 FEB 1997. March, 1997 (including reviews by RADM J. David Spade and ADM Robert E. Kramek).

(4) Team Coordination Training Exercises & Case Studies. ser. G65302, 1998.

(5) 44′ Motor Lifeboat Operator’s Manual. ser. CIM16114.3C, U.S. Coast Guard, 1999.

cover: U.S. Coast Guard photo