Many individuals connected to the events of 12 February believed the Coast Guard’s published investigation could have included more perspectives. Being an administrative investigation, its purpose was to look at causes and culpability, but this focus did not fully address some of the equally valid perspectives held by others close to the situation. This page is devoted to many lenses: the questions, concerns, and observations that contributors thought needed to be included in the Coast Guard’s analysis. Many of them are still relevant today.
“The MK3 did an incredible thing.”
“This case should have never happened [had the Group told the GALE RUNNER to wait in deep water instead of immediately crossing the bar]. There’s a huge lesson to be learned from [the audio]; the Coast Guard didn’t make it part of the report… The Group didn’t understand [river] bars… The Coast Guard report never addressed that. They threw Bosley under the bus.”
“There were systemic problems in the service that inevitably led to the tragedy.”
“It would be dishonest not to admit that some of the problems at the stations are exacerbated by the people at the units. Stations have a tradition of poorly documenting their actions, which is unquestionably caused by too few people and too little time.”
“You have to remember; all of this happened before BOAT I.” (BOAT I is the Coast Guard “Boat Operations And Training Manual, Volume I,” which covers standard policies and procedures for the operation of small boat stations and their boats.)
“Senior leadership did not understand what was going on below the Group level.”
“We’ve come full circle [since 1997], and I bet something will happen.”
“The incident was significant enough, we all had to take a step back.”
“The way in which the service views its small-boat stations [is] illustrated by an old saying, ‘small boats, small problems.’ …The personnel policies of the U.S. Coast Guard and the way in which the small-boat rescue stations have traditionally been viewed and treated within the service have as much, if not more, to do with what happened than Bosley’s presumably faulty decisions.”
“The Coast Guard opened the curtain and put those actors up there [to set the stage for the 44363 disaster].”
“Knowing full well the policy that was in the unit’s standing orders and the District SOP, Bosley failed to make the required notification to the unit’s SDO that the bar conditions had drastically changed. The second boat crew with the duty Surfman should have been recalled and on board much earlier in the evening. PO Bosley made a decision to disregard several standing orders.
Once the unit was notified of the GALE RUNNER’s situation he should have awaited the arrival of the second boat crew but instead, with judgement incapacitated through emotion and ego, launched into conditions far beyond his skills and ability. And last, he failed to follow CG policy by ensuring everyone on board was prepared for heavy weather, belted in and in the proper [personal protective equipment]. Each and every mistake was a total disregard for CG policy that he had had hammered into him as part of his Coxswain and OOD qualifications.”
Station turnover should be about 25% based on standard four-year tours, but the average projected turnover for grades E-4 and above at 13th District surf stations stands at 39% (1)(2). At the district’s largest surf station, turnover in terms of newly reporting members was 62% from June 2017 to June 2018 (1). When the investigation looked at Station Quillayute River in 1997, they found that new-report turnover was 60%. Because of the high turnover, they found that training had to focus on providing basic, introductory skills to the new members.
(1) U.S. Coast Guard statistics, 2019
(2) Non-rated turnover makes these figures significantly higher.
“The central problem identified in this study is that many of our personnel arriving at stations are unqualified to fill the billets to which they have been assigned.”
“The Coast Guard is very reactive and then loses those lessons over time.”
“As far back as 1961 with the TRIUMPH-MERMAID disaster at Cape Disappointment, one analyst observed that crew inexperience was a contributing factor to the loss of life that occurred. History has repeated itself in the lifeboat community.”
“Can the Coast Guard still support the small-boat stations in the way they should be supported? The response to this question is a firm yes.“
“The Station’s communications watchstander called the Group after hearing the first transmissions about there being no restrictions. On his own initiative, he notified the Group that the present conditions would warrant a restriction and that the GALE RUNNER should be aware of this. This is a fine example of empowered junior members displaying the unprecedented maturity that is common among Coast Guard enlisted members.”
“To say that [Petty Officer Bosley] was ‘thrown under the bus’ is deflecting the real issue. The systemic problems within the chain of command did not make those decisions for him, and he was well trained in the proper procedures and policy to have made the correct decision. Bosley made a series of decisions that set events, following events into motion. He was trained better and knew better.
The systemic failures of the CG that placed him there are secondary. Together they became a perfect storm of failure. There are failures at every level… but bottom line, the checks and balances are adherence to policy, and if he had followed policy this would have ended very differently.”
“Looking back, we never trained for going across [a breaking bar at night] without bar lights. We depended on those bar lights in a way we shouldn’t have…
If I were still in [and training units], I would look at each surf station and take away or change the tools they depend on, and see how they respond to that… Take away [a reference] someone has always relied on. Then what?”
“We’re in a position where [personnel at stations] are spending more time on toilets than on shining brass. [Operations Specialists] at Sectors have 500 things going on, and then they get a call from a boat coming in across the bar… All these distractions take us away from what really matters.”
“We’ve flipped; now we’re risk-averse… We’re in the process of re-learning and we’re back where we started.”
“It was an eye-opener… Experience brings a better appreciation of danger, which can cause us to fear and respect the situation… The fleet hadn’t seen [an accident like Quillayute River] in years. It just made our jaws drop- we realized how serious it was.”
“There’s always a culture you have to operate in. It has to be a culture of safety, professionalism, communications, and respect… The essence of professionalism is to work around [rank and organizational perceptions] so people don’t get hurt.”