Sinking of Scandies Rose, Sutwik Island, AK, Dec, 31, 2019 – NTSB Board Meeting


NTSB Meeting: Jun 29, 2021, Sinking of Scandies Rose

The National Transportation Safety Board held a virtual public board meeting June 29 to determine the probable cause for the 2019 sinking of the fishing vessel Scandies Rose.

The Scandies Rose sank Dec. 31, 2019, 2.5 miles south of Sutwik Island, Alaska. The vessel had a crew of seven; two were rescued and five others missing after the accident were never found.

During the meeting the NTSB’s five-member board voted on the findings, probable cause and recommendations as well as any changes to the draft final report.

In keeping with established federal and local social distancing guidelines to prevent the spread of the coronavirus, while also ensuring the NTSB’s compliance with the Government in the Sunshine Act, the board meeting for this event was webcast to the public, with the board members and investigative staff meeting virtually.

Visit for more.

All audio is courtesy: National Transportation Safety Board.  The audio was cleaned up and meeting breaks removed.

If you want to see the visuals, you can watch the YouTube video posted on the NTSBgov channel.

The docket for the investigation is available at

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Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.
Sinking of Scandies Rose, Sutwik Island, AK, Dec, 31, 2019, NTSB Board Meeting
Thank you for joining and welcome to this virtual board meeting of the national transportation and safety board. I’m Robert Walt, and I’m honored to serve as the chairman of the NTSB and joining us today are my colleagues on the board as chairman Bruce Landsberg, and we’re Jennifer Hamadie number, Michael Graham and member Tom Chapman.
[00:00:22] Today, we made an open session as required by the government in the sunshine act to consider the capsizing and sinking of the commercial vessel commercial fishing vessel. Scandi is rose near island, Alaska on December the 31st, 2019 of the seven crew members of board to escape the vessel and were rescued by the coast guard.
[00:00:46] But tragically tragically, the five remaining crew members and including the vessels captain were never found on behalf of all of us at the NTSB. I’d like to offer our sincerest condolences to the family, family, and friends of all of those who were lost in this tragic accident. Our purpose in this investigation is to learn from it, to prevent it from happening again.
[00:01:13] So others don’t have to go through what you’re going through year after year. One of the deadliest ways to make a living in the U S is to be a commercial fish. More than 800 people have lost their lives aboard fishing vessels in the past two decades. And the safety of commercial fishing vessels is on our current list.
[00:01:37] Most wanted list of transportation, safety improvements alongside safety of passenger vessels, but unlike passenger vessels, however, fishing vessels such as the Scandi is rose carry only their crew who are assumed to know the risk. There are many seasoned Mariners who take on those risks to make their living as fishermen, but as tragedies like this one, there’s our teams system there.
[00:02:09] But as tragedies like this one we will discuss today, remind us that this deadly occupation does not have to be so deadly. And that the risks that fishermen except should only be mitigated commercial fishing vessels. Like the Scandi is rose encounter, rough weather routinely and commercial fishing is a year round business off the coast of Alaska.
[00:02:33] And the winter icing is an all too common hazard. In fact, the Scandi is rose carried onboard tools to break up ice that accumulated on its Jack and structures. This is not an unusual arrangement in the waters off of Alaska and the wetter. The question is not whether icing as POS. The question is how much icing can be tolerated while still maintaining a margin of safety around the vessel’s stability.
[00:02:59] Today, we will discuss what icing conditions prevail during what part of the voyage. And we’ll discuss what, if anything, the captain and the crew could have done differently to avoid the tragic outcome and tragically and critically we will discuss whether they had or could have had the information needed to make the right calls specifically how icing might affect vessel stability in various loading conditions.
[00:03:27] Now, each board member has done a study, the draft report, and each of us have met individually with the investigative staff, but today’s board meeting is the first time that we, as a deliberative body will have gathered to discuss the report today, the staff will lay out the pertinent facts and analysis found in the draft report and they will present the draft findings.
[00:03:48] So probable cause and recommendations to the board. And then we own the board will question the staff to ensure the report as we adopted today, truly provides the best opportunity to enhance it. The public docket for this investigation conduct contains more than 4,500 pages of additional relevant material.
[00:04:10] And it’s available on our website, The final report will also be available on our website in just a few weeks. Once any amendments voted upon today are incorporated in the report and the report is finalized at this time. I’d like for each of my colleagues on the board to introduce themselves as chairman Landsberg.
[00:04:32] Good morning chairman. Uh, I’m looking forward to, uh, our deliberation. So thank you for the offer. Thank you very much. Remember Hamadie good morning, Mr. Chairman and to my colleagues and thank you very much to the staff. Look forward to the discussion. Great. Thank you. Good morning. Number. How many member Graham?
[00:04:56] Good morning, Mr. Chairman, vice chairman, uh, fellow board members and investigative stack staff. I look forward to our deliberations today, right? I good to see you and member chap. Good morning, chairman, looking forward to the discussion today and congratulations to our team for an outstanding event. Thank you very much.
[00:05:18] I’ll. Now I asked the deputy managing director of, for investigations, Brian Curtis, to introduce the investigative staff and those who will be participating in this morning’s board meeting. Good morning, Mr. Curt. Good morning. And thank you, chairman some wall. I’d like to also thank everyone who helped make this virtual board meeting happened today.
[00:05:39] My only advice administrative announcement this morning is a reminder for the meeting participants to silence all electronic devices at this time. I’ll now introduce the staff for today’s meeting unless otherwise indicated staff is from the office. Okay. Marine safety Morgan. Chirael the director for the office of Marine safety, Bart Barnum investigator in charge.
[00:06:01] Paul Suffern meteorology group chairman from the office of aviation safety, Julie piano report writer, Scott Rainey safety record commendations from the office of safety recommendations and communications. Casey Blaine, deputy general counsel for the NTSB, Dolly and hatchet director for the office of safety recommendations and communications Barbara check deputy director for the office of research and engineering, Dana Schultz director for the office of aviation safety, Liam LaRue, chief of investigations, Rob Jones, deputy chief of investigations and Eric Stolsenberg chief of product development.
[00:06:45] Patients will begin with an investigation overview by the investigator insurance, Bart Barnum, Mr. Barnum.
[00:06:57] Thank you. Good morning, chairman Stonewall, vice chairman, Landsberg and board members. I’ll be providing an overview of the events that took place on December 31st and January 1st, 2019. I would like to acknowledge the staff noted here for their support during the investigation and the report development.
[00:07:19] I would like to also acknowledge the staff noted here, who produced this virtual board meeting. The coast guard parties to this investigation are listed here and we would like to thank them for their assistance on scene and throughout the investigation. The coast guard was the lead federal agency in this investigation.
[00:07:42] Following the accident, the coast guard convened a Marine board of investigation and TSP investigators coordinated with coast guard investigators to avoid duplicating efforts from February 22nd to March 5th, 2021, the coast guard conducted a formal hearing into the accident during the hearing coast guard and NTSB investigators, question 43 individuals, including surviving crew members, company management, coast guard, personnel, and commercial fishing industry stakeholders.
[00:08:20] The Scandi is rose was a steel fishing vessel built in 1978 and registered in Dutch Harbor, Alaska, the vessel fished in the Bering sea for king crag, Propelio crab and Pacific Cod. In the summer months, the vessel would store and transport the catch for the salmon fishery vessels in the Bering sea and Gulf of Alaska.
[00:08:45] The scan, these rows was subject to the regulations set forth in 46 code of federal regulations, part 28, which included equipment stability and other safety requirements. The vessel was required to participate in the coast guards, commercial fishing vessel dock side safety examination program, which primarily focused on saving equipment on board.
[00:09:11] The vessel, the vessel was owned by the scandals rose fishing company based in Bremerton, Washington, and was the company sole vessel. The captain of the vessel had 45 years of fishing experience with about 40 years as captain on various fishing vessels in the Gulf of Alaska and bearing seed as captain of the vessel, you made determinations on when and where to fish, the vessel layout consisted of the foam below the main deck, starting at the bow was a ballast.
[00:09:47] Followed by an anchor chain locker and then dry store room, next staff, or three crab tanks, flexible holds use to store the catch outboard and below of the crab tanks and not pictured here where the vessels fuel oil storage tanks. After these tanks for the vessels engine room, machinery space and steering gear room housing, the vessels, propulsion equipment, and other machinery associated with the operation of the vessel.
[00:10:20] Mid ships on the main deck was the fishing deck where the crew would stack the vessels crab pots while not being fished. Collectively the pots on deck were referred to as a pot stack. Further AFT was the deck house consisting of three levels. Two days before the accident, the captain and crew prepared the vessel for departure from Kodiak, Alaska to participate in the Bering sea pop Cod fishery, which was scheduled to open on January 1st.
[00:10:54] The crew worked late into the night loading and securing 195 combination pots on the vessel. The next day, the crew prepared the vessel for sea. They chained the pot stack secured hatches and tested builds level sensors. The captain who was the vessels certified safety drill instructor conducted drills with the crew, including discussions about the locations of life rafts, the vessels emergency position, indicating radio beacon, and how to make it Mayday.
[00:11:29] Call one crew member. Don demonstrated how to Dawn an emerging suit on December 30th at 8 35 in the evening. This Gainey’s rose departed Kodiak five hours prior the national weather service issued a Marine forecast that included a Gale warning and a heavy freezing spray warning for the vessels proposed route.
[00:11:55] The vessels plan route was Northwest through the Cooper Knopf straight than Southwest through the Shelikof Strait towards false pass on route to the Bering sea on Tuesday, December 31st at about two o’clock in the morning. This game, these rows exited Cooper Knopf straight and entered the Shelikof between the south side of the Alaskan peninsula and the west coast, the west coast of Kodiak island.
[00:12:24] The vessel steadied on a southwesterly course that followed the Kodiak coastline. The captain passed the watch to one of his crew members in the part of the bridge on December 31st from two o’clock to eight o’clock in the morning. The crew of the scanners rose rotated through our long bridge watches.
[00:12:43] At the end of each, watch the ongoing crew member completed a round of the engine room to ensure that vessel’s engines and auxiliary equipment were in good working order. The vessel had begun to encounter freezing spray and accumulate ice Deccan. One who stood watch from six o’clock to seven o’clock in the morning, told the NTSB that he had observed one inch of ice filling the mesh of the Ford starboard pots and accumulating on the exterior railings of the vessel that came to on watch from seven o’clock to eight o’clock in the morning, all the NTSB that the weather had picked up from the night before the wind and waves were acting on the starboard bow of the vessel.
[00:13:31] Both crew members noted that the amount of accumulated accumulated ice on the vessel at that time was not enough to warrant manual removal at eight o’clock in the morning when deck had to pass the bridge, watch the captain, the vessel had an even keel later that morning at 1118, the captain call the fishing vessel, Emma Tuli, which had departed Kodiak ahead of the scanners rose on route to Dutch Harbor.
[00:14:02] Before the two captains ended their 12 minute phone conversation, the captain of the scabies road. Said that his said that it was very cold. His vessel was experiencing light icing and the sea conditions report about two o’clock in the afternoon. After finishing his six hour bridge, watch the captain passed the watch to his crew for the next six hours.
[00:14:27] The crew rotated through their watches. The vessels heading remain steady on a southwesterly course. According to deckhand to the wind and weather started coming up a lot more and progressively got worse all day. You also told the NTSB that the vessel was bucking into the seas, making a lot of spray and the spray was making ice about seven 15 in the evening.
[00:14:54] The crew member on watch Deccan to called the captain to wake him for his watch. Shortly after the captain arrived on the bridge, the, to discuss the worsening weather, the accumulation of ice on the vessels, superstructure and crackpots, and the development of an approximately two degree starboard list.
[00:15:16] It considered reducing the vessel speed and altering course to limit the freezing spray causing icing on the vessel. And the crew member asked the captain, if he should wake the crew to break ice off the pots, ultimately the captain decided to maintain course and speed and not wake the entire crew.
[00:15:37] That can to told the NTSB that the captain said the weather was too rough to have the crew out on deck chopping ice, and that they would wait until the vessel was in protected waters after being relieved by the captain. And before leaving the bridge Deccan too took note of the accumulated ice on the vessels pot stack through the bridge window.
[00:16:01] He said that all pots were glazed over with ice, the starboard side pots, or more heavily coated with what he estimated to be about two inches of ice inside webbing of the starboard Potts was also coated with ice starting about eight o’clock that evening. The captain is scanned. These rows made a series of phone calls first to a friend who said that the captain had told her that his vessel was icing and had a list.
[00:16:33] She added that at the time of the call. The captain did not sound alarm at 8:37 PM. The skinnies rose was about five and a half miles due east of Ireland. Still maintaining a southwesterly course. The captain call a fellow captain on the commercial fishing vessel, Pacific sounder, according to the Pacific sounder captain, the captain of the scanners rose said that his vessel was icing really bad.
[00:17:04] And he was concerned about a 20 degree starboard list that had developed before ending their conversation. The skinnies rose captain also noted that the winds were blowing 60 to 70 knots from the west. The temperature was 12 degrees Fahrenheit, and it was too rough to send a crew out on deck to break ice.
[00:17:27] He was trying to seek shelter Southwest of island at 9:45 PM. Vessel position data shows that the Scandi, these rose was about two and a half miles south of salt lake island. The vessel had turned 50 degrees to starboard and held a northwesterly course in the direction of sunblock islands. Southern bay, shortly after the vessel had turned towards Southwick, the Pacific sounder captain called the scanners rose back.
[00:17:59] He said that the captains tone had changed from the previous conversation. You said that the captain of the scanners rose said that I don’t know how this is going to go. And that his vessels list had gotten a lot worse. The captain of the Pacific sounder said that he had never heard the level of stress in the voice of the scanner’s rose captain before just after the heading change to starboard, the two crew members who survived the accident report.
[00:18:31] That they were jolted from their beds by a sudden sustained vessel list to starboard the entire crew of the scam. These rows made it to the bridge and attempted to Dawn immersion suits. While the vessel listed, the two survivors managed to climb out the port side door and finish donning their immersion suits while leaning against the vessel superstructure, the captain was able to broadcast a Mayday call with the vessels position.
[00:19:01] And at 9:55 PM, the coast guard received the message. The two survivors attempted to help other crew out of the port bridge door, but were not successful. Ultimately, a wave swept them off the side of the vessel and into the water while floating in the water. They observed the scanners rose sink and did not see anyone else get off the vessel that can one and two found themselves separated in heavy winds and seas.
[00:19:35] Before deck came, one saw the light from an inflatable life raft that had automatically deployed from the scanners rose. As she sank, he was able to swim to the covered raft and climb a board. Once inside. He began yelling for his fellow crew member after several minutes, hearing his fellow crew member yelling deckhand too.
[00:19:59] Swam to the raft and climbed aboard. After receiving the Mayday call from the scanners rose the coast guard repeatedly made unsuccessful attempts to establish communications with the vessel. They also initiated search and rescue operations, launching a rescue helicopter from air station Kodiak. It took the crew of the rescue helicopter, roughly two and a half hours to complete the approximate 170 mile trip and arrive on scene.
[00:20:30] And what the flight commander testified to be the most challenging flight of his career. Upon arrival at the captain’s Mayday coordinates, the rescue helicopter crew began to search for the vessel and any survivors upon locating the life raft. They sent a rescue swimmer down to investigate and discovered that it was empty.
[00:20:52] They located the other life raft with the two crew members of board shortly after on January 1st, shortly after two o’clock in the morning poisoning operations of the two crew members again on board, the helicopter, the two survivors informed the coast guard. They had not seen any other crew members get off the vessel before it saying, after recovering the two crew members and rescue swimmer from the water, the rescue helicopter returned to base.
[00:21:24] After arriving the two crew met surviving crew members were transported to a waiting ambulance and driven to a local hospital for hypothermia treatment. The coast guard continued to search for the remaining crew of the scan. These rows throughout the day in total, the coast guard used three helicopters to see one 30 airplanes and in high endurance cutter the search of roughly 1400 square mile area near sunblock island shortly after 8:00 PM, 20 hours after receiving the Mayday call and after 16 hours of searching for any additional survivors on the scan, these rose, the coast guard, suspended search and rescue operations.
[00:22:10] Following the sinking of the scan, these rows, the owners of the vessel hired a Marine salver and a hydrographic survey company to find the vessel and document the wreck. The scan, these rows was located in about 160 feet of water, about 1100 feet from the Mayday position. The remote operated vehicle conducted video surveys of the scan, these rows and the debris field.
[00:22:39] Several of the vessels, external doors appeared to have been damaged by the impact of the sea floor. The remote operated vehicle was unable to video the starboard side of the vessel. Because of the vessels orientation on the sea floor footage of the vessels, bottom port side and stern did not show any whole breaches, an empty emergency position indicating radio beacon bracket was located, but ultimately the beacon was not found safety issues that were identified in the capsizing and sinking of the scan.
[00:23:16] These rows were the effect of extreme icing conditions, lack of accurate weather data for the accident area, the vessels inaccurate stability instructions and the need to update regulatory guidelines on calculating and communicating icing for stability. Instructions. Staff believes that the following were excluded factors in the accident.
[00:23:46] The captain’s pre-departure decision-making operational pressures, fatigue, drug, and alcohol use the vessels propulsion and steering systems and the vessels halt integrity. This concludes my presentation, the meteorology group chairman from the office of aviation safety. Mr. Paul Suffern will now discuss whether it related to finance.
[00:24:15] Good morning, chairman Sumwalt and members of the board. I will now discuss weather related issues associated with the sinking of the commercial fishing vessels. Candies froze Mariners interviewed throughout the course of this investigation, highlighted the weather conditions west to Kodiak island, near salt lake island and picnic bay as particularly hazardous, including some of the harshest weather conditions.
[00:24:38] The Mariners had experienced many said that the worst icing that ever seen was near Setlik island as the colder wind from Northwest flows across the area. This graphic highlights the locations of the weather observations nearest the accident site with weather observation sites located around a hundred miles away and greater south of the Alaska peninsula weather conditions reported at the observation sites highlighted in this graphic at the accident time match the Gale force conditions forecast.
[00:25:10] However, around the accident time, the accident captain reported measured winds of 60 to 70 knots with a helicopter rescue cue reporting, 30 foot seas near Setlik island with both wind and sea conditions, worse than 4k. The national weather service uses weather data from stations along the Alaska peninsula for forecasting and Mariners use the data to make real-time decisions.
[00:25:35] But as illustrated with the winds reported compared to the winds experienced by the scan, these rows data from these weather observation stations do not fully match the conditions in the city. Look, island and technique bay region observations sites that are more spread out and remote areas like Alaska can result in data that do not accurately represent the entire area and can lead to any accurate and less precise forecast and weather modeling.
[00:26:02] Therefore, Philly’s that due to the limited surface observation resources near settler island and the chicken sick bay region along the fishing vessel route from Kodiak to Dutch Harbor, the national weather service cannot accurately forecast the more extreme, localized wind and sea conditions for the area which can lead to vessels and conditions that are worse than expected.
[00:26:25] Staff has proposed a recommendation to address this issue. Currently as the weather conditions warrant the national weather service issues, either a freezing spray advisory or heavy freezing spray warning to alert Mariners to the potential for sea spray icing conditions with a heavy freezing spray warning issued.
[00:26:45] When I see accumulation rates exceed two centimeters per year, In contrast to the text information, the Nash, the weather service ocean prediction center, experimental icing forecast graphic website provides more categories and details on sea spray, icing levels above two centimeters per hour, giving Mariners in the barracks Gulf of Alaska and around seven island.
[00:27:10] More precise information on the higher rates of sea spray, icing accumulates. They may encounter none of the captains of the fishing vessels in the area interviewed at the Marine board of investigation. Public hearing were aware of the national weather service ocean prediction center, freezing spray website, and agree that the graphical freezing spray information would be a useful resource when operating in areas where freezing spray was prevalent.
[00:27:37] Currently the national weather service ocean prediction center freezing spray website remains experimental and therefore would not operate as robustly as an operational and national weather service website, nor is the national weather service ocean prediction center, freezing spray website advertise as an available resource for marijuana use.
[00:27:57] Therefore staff believes that the national weather service ocean prediction center site could provide Mariners with more detailed graphical information, not currently available elsewhere, which would help them make decisions based on more accurate weather information. Staff has proposed a recommendation to address this issue.
[00:28:17] This concludes my presentation. The investigator in charge, Bart Barnum will now discuss operational matters. Thank you. My second presentation this morning, we’ll discuss other elements of this accident. These elements include the following, the effects of extreme icing on vessels, stability, inaccurate stability instructions, and their consequences.
[00:28:43] The limitations of regulatory guidelines when calculating the effects of icing regulatory, stability, oversight, and training, and the lack of requirements for personal locator, beacons based on the ice accretion rate obtained from the NTSB weather model, the skinnies rose experienced progressively worse asymmetric icing during the voyage throughout the day on the 31st, the vessel moved through bands of light, moderate, and heavy icing based on the localized weather conditions reported by the captain and crew.
[00:29:22] The scan, these rows would have experienced ice accumulation greater than 1.6 inches per hour, which is categorized as extreme over the final two hours of the voyage. Therefore staff believes based on the voyage timeline and the estimated ice accumulation over that period. The scan, these rows likely accumulated between six and 15 inches of ice on surfaces exposed to wind and dicing during the accident voyage casing, the extreme, extreme icing conditions over the final two hours of the voyage.
[00:30:04] The captain determined that it was too dangerous to put his crew out on deck and remove the accumulated ice. Instead, the opted to seek shelter in the Lee of set with island, which was along his intended route, an area he was familiar with. And shortly after he assumed the watched the closest point of land, therefore staff believes that although the captain’s decision to proceed to salt lake island was reasonable, but at the time he was close enough to turn into the li the icing conditions have accelerated and reduce the vessel stability.
[00:30:43] The scanners rose was carrying a full stack of pots that reached about 20 feet above the main deck. The healing force to starboard created by the accumulation of ice that was forming ASAP asymmetrically on the starboard side of the pot stack focal boards and portions of the house was being counteracted by the wind and seas.
[00:31:09] Once the vessel altered course to starboard toward the Leigh of salt, what time. The wind and seas were no longer supporting the vessel shortly after the course change the vessels list to starboard increased and the vent and the vessel. Eventually capsized staff believes that they added weight from ice, accumulating asymmetrically on the vessel and the stack crackpots on deck raised the scan, these roses center of gravity, reducing its stability and contributing to the capsizing.
[00:31:46] The scan, these rows had stability instructions per coast guard regulations that had been completed by a qualified individual prior to departure the captain and crew loaded the vessel with 195 combination pots, which was below the 208 limit set on their stability instructions. They secured the pots and all other deck gear against shifting and ensured all doors and hatches were closed requirements specified in the stability instructions.
[00:32:21] In addition, the vessels fuel and crab tank levels were estimated to be in compliance with the stability instructions. Following the sinking, the coast guards Marine safety center conducted a forensic technical stability analysis of the scanners road. Which evaluated the stability instructions for the vessel.
[00:32:45] They noted differences when comparing tank capacities, mathematical errors omissions, as well as that. The 2019 stability assessment apparently neglected down flooding a key criteria when calculating vessel stability. Therefore staff believes that although the crew voted the scan, these rows per the stability instructions on board, the stability instructions were inaccurate.
[00:33:14] Therefore the vessel did not meet regulatory stability criteria and was more susceptible to capsizing because the festival did not meet regulatory criteria. The captain had little room for error in icing conditions that the vessel encountered on his voyage, the captain relied on and loaded his vessel in accordance with the stability instructions.
[00:33:43] Therefore staff believes because the stability instructions were inaccurate. The captain was unaware that his vessel did not meet the margin of safety intended to be provided by the stability instructions. The regulations governing stability for vessels that operate in waters, where there is a potential for icing, such as the scan, these rows factor in a minimum set amount of added weight.
[00:34:09] For accumulated ice and specify that ice accumulation should be applied symmetrically to exposed surfaces. The regulations do not specify specifically provide guidance on how to apply ice accumulation on crab pots, Naval architects from the coast guard and private industry agreed that per the regulations, they calculate the added weight of ice on a stack of crackpots by applying ice uniformally, to continue to the continuous, horizontal and vertical surfaces of the pot stack, like a shoe box of ice of the regulatory thickness placed over the stack.
[00:34:55] However, because crab pots are made of tubular frames in mesh. They do not act as continuous, horizontal or vertical surfaces and will accumulate ice not only on the vertical and horizontal frames, but on a bow on all external and internal mesh or webbing of the crab pots. Additionally, Mariners reported at freezing spray often results in ice asymmetrically, accumulating on the vessel and its pot stack.
[00:35:30] Therefore staff leaves that current regulatory guidelines on calculating the effects of icing on fishing vessels. Do not take into account how ice actually accumulates on and in crackpots and crowd pot stacks staff has proposed two recommendations to address this issue. Captains of commercial fishing vessels testified that they frequently consulted their vessels, stability instructions when operating, but when they are asked, if prior to the sinking of the Scandi is rose aware of the amount of accumulated ice, the regulations prescribed to be factored into their stability history directions, none new one.
[00:36:18] I learned that the regulations allotted for uniform icing of 1.3 inches on horizontal surfaces and 0.6, five of an inch on vertical surfaces. And only on the external surfaces of their pots, they’re all surprised on how little it was many even acknowledge that they would typically carry more ice than will then what was allotted for in regulations on the scanners rose the crew noted one inch of accumulated ice as early as six, the clock, the morning of the accident, but the captain likely not knowing the ice thickness used in his stability report did not voice concern when he relieved the watch at eight PacLock, nor later in the day, when the ice continued to build.
[00:37:08] And ultimately determined to delay sheltering or taking other mitigative actions. Therefore staff believes that a vessel captains are aware of the amount of icing that has factored into their stability instructions. They would be better prepared to make critical vessel safety decisions. When operating in areas of potential icing staff has proposed two recommendations in this area to address the issue.
[00:37:40] The regulations do not require that owners, masters or crew of commercial fishing vessels received formal stability training, and neither the majority owner, the captain nor the crew of the scanners rose had taken formal stability training Mirenas must rely on experience and what they have learned independently coast guard guidance indicates that operators should be provided training on stability schools and training facilities offer coast guard approved stability courses, specific to fishing vessels.
[00:38:20] The effects of icing being one of the topics covered several captains would voluntarily taken stability courses said that they took great value from them and suggested that they should be made mandatory for all captains. Therefore staff believes that the formal stability training would provide fishing vessel crews with a better understanding of the principles and regulatory basis of stability, including the effects of icing and staff proposes a reiteration of a currently open recommendation to address this issue as part of the post casualty investigation, investigations of both the fishing vessel destination, a similar vessel that sank and the Bering sea in 2007 and the scanners rose the coast guard Marine safety center conducted stability assessments and vessel stability instruction to review both vessels stability instructions had been created by qualified individuals, but were not subject to technical oversight or a view from a classification society or the coast guard.
[00:39:36] Ultimately the Marine safety center concluded that the stability instructions for both the destination and the scan, these rows fail to meet regulatory stability criteria. Therefore staff believes that an oversight program to review and audit stability instructions produced for uninspected commercial fishing vessels.
[00:40:03] Like the scanners road. That are not required to carry a load line certificate would identify and reduce potential errors in stability instructions, which in turn may reduce the chance that vessels are sample. That vessels are sailing without the intended margin of safety provided by applicable stability criteria.
[00:40:27] Staff has proposed a recommendation to address this issue. Personal locator beacons can provide search and rescue operations with an accurate, continuously updated location of every person carrying one. In the case of the scan, these rows, the failure of the emergency position indicating radio beacon to provide a position after crew members were forced to abandon the vessel into the water without means of communicating with search and rescue personnel and the inadvertent miscommunication of the correct search area from the on-scene rescue access staff believes that personal locator beacons would aid in search and rescue operations by providing continuously updated and correct coordinates of crew members, location and staff proposes a reiteration of a currently open recommendation to address this issue.
[00:41:33] Mr chairman, this completes staff’s presentations and we are prepared to answer any questions. Thank you very much for those, uh, very good presentations and, uh, most importantly, thank you for an excellent investigation. We’ll now turn to the board member questions and we’ll begin with vice chairman latch.
[00:41:54] Thank you. Uh, Mr. Chairman. Um, so I have a question for, uh, our meteorologist here. Um, is the, um, would you consider that the weather forecasting was accurate and the conditions that the Scandi rose encountered? Uh, the based on the forecast information and the information observed by the, uh, vessel captain, the wind and wave, uh, conditions were, uh, worse than that forecasts, how accurate are the, uh, are the freezing spray forecasts in this particular case?
[00:42:35] The forecast for was for heavy freezing spray, or greater than two centimeters per hour accumulation and staff believes that’s what the vessel was encountering, uh, on their Southwest word trip. So for a period of of time, um, could we perhaps bring up slide number 34? Um, I think that might clarify this a little.
[00:43:01] And while we’re working on that, if I remember correctly, it said, uh, that the vessel was, uh, uh, had about seven hours of moderate icing from about 10 o’clock until about 1700. And so that refers to the rate of accumulation. Do they have any way of measuring the cumulative effect? So if you stay in moderate long enough, you’re continuing to accumulate.
[00:43:31] And as, uh, uh, Mr. Barnum’s presentation has shown, uh, the stability instructions don’t account for anything, uh, anywhere near what the reality is. So do they account at all for if you’re in a moderate icing for a period of time, that it’s going to be the equivalent of a, uh, heavy icing, uh, for a shorter period.
[00:43:57] Is there any computation for that? Um, as far as computation and what’s available in the stability instructions, I’ll have to pass that off to, uh, investigator in charge, Mr. BARR Barnum. Yes. So the, um, as far as the forecast goes, not to my knowledge that there is a, uh, calculation, uh, that can be, um, used by the.
[00:44:22] Marriner to calculate the total icing that they will experience in that period that they’re going through that a band of IC. Um, I think it should be noted that icing will affect vessels differently depending on size, um, multitude of different factors, air temperature, uh, uh, ocean temperature, vessel heading.
[00:44:46] Um, so, um, for just to have a basic or a, uh, generic equation for adding up icy mint for a certain time period, I don’t think there is one available now. Um, it, it, yeah, it, I think this makes it pretty clear though, that we don’t at this juncture have a really full understanding of, of how this works. And as I said, we’re looking at the rate of accumulation versus the cumulative effect, uh, Mr.
[00:45:15] Suffering, um, does NWS have any way of very, um, uh, verifying their forecast? And I realized that we’re, we don’t have a lot of information up in that part of the world, but, uh, do Mariners submit the equivalent of pilot reports, um, when they’re, when they’re up there that actually get, not just talking to each other, but can get into the forecast offices.
[00:45:39] So currently the national weather service has a, uh, a program called the voluntary observing ship program or Voss. And, uh, there are certain ships, uh, that do provide observations, uh, based on that system, choose the national weather service forecast office. Uh, for example, the us coast guard cutter that came to the search area.
[00:46:03] It was one of the, uh, Voss ships. Um, so that is one of the programs that’s available for Mariners to submit observations. Well, it would seem to me that it it’s, it’s tough when you’re doing forecasting and looking at models. If you don’t have a way of verifying, whether it worked the way you thought it was going to, and to be able to, to modify them, um, it, it’s tough to, to get better forecast.
[00:46:28] So, uh, um, anyway, thank you very much. Thank you, Mr. Chairman, and I’ll wait for the next round.
[00:46:40] Sorry about that. I had some delays with one of my, uh, was the mic. Thanks very much, uh, to the staff and, uh, um, just a few questions on, uh, personal locator beacons, but first I’m wondering, uh, if you can describe the conditions, uh, that the two surviving crew members encountered. I know that they had remained on board for, uh, they stated as long as they could, uh, uh, yelling into the bridge for their fellow crew members to exit a wave, swept them off the side, they had their immersion suits on.
[00:47:25] But if you could talk about some of the conditions, uh, I, I believe for them that period of time that they were facing in the water. Yes. Ma’am um, conditions reported by both the surviving crew members. And then also the, um, arriving helicopter flight crew were about 30 foot waves, um, which was, you know, considerable wave Heights for that area.
[00:47:54] Uh, and then also, you know, um, four to six degree water, temperature Celsius, and, um, and then also there was, um, significant, um, wind velocity. Between 60 and 70 knots. And, um, how far, uh, how, how long was it until they were able to locate, uh, the rat, one of the rafts, the one they eventually boarded? Um, yes, ma’am the, um, the survivors indicated that, um, that came to before he was able to locate the first raft users in the water between 10 and 20 minutes, I believe.
[00:48:38] And, uh, their immersions suits are tested for how many degrees in I and water and for how long, um, regulate. Yes, ma’am the regulations require that, uh, vessels such as scanners, rows, carry immersion suits that are designed to keep the, the, where, um, their core body temperature from dropping two degrees, both that’s two degrees Celsius over a six hour period, um, in tutory water.
[00:49:15] So those that they had on board would have been rated for that two degrees in calm water. Yes ma’am. And this was definitely not calm water. Uh, and so the HELOC, they, they were rescued about four hours later, correct. From one, they were swept off the vessel. Okay. And can you talk about how difficult it is for search and rescue operations in these, in such a remote area?
[00:49:51] Yes, ma’am. So areas like Alaska, where it’s a large, um, area of potential large area, they need to cover, uh, it’s extremely difficult to try to strategically place assets, um, where they can be most effective where the fishing fleets are in this particular instance. Um, air station Kodiak is a major, um, base there where they launch assets out of with the weather conditions that were forecasted.
[00:50:21] Um, they have limitations on what type of aircraft can leave air station Kodiak. So strategically they move their C1, 30 airplanes to anchors Alaska. So they would be able to be, they would be able to take off and assist in any search and rescue that was needed because they would be grounded in that type of weather while in Kodiak.
[00:50:41] Um, so obviously to answer your question, ma’am, uh, weather in this area is a huge factor as well. Um, it can, can affect their communications significantly and also their ability to search. And there was heavy icing in that area. Yes. Ma’am. Um, have you guys seen, was experienced obviously on board, the scan, these rows, um, but also the flight crew of the rescue helicopter that arrived on scene, um, while they deployed their rescue swimmer, once they retrieved him from the water, uh, he was, he had to be diced because the isolate accumulated on his body and has space gear.
[00:51:22] Well, I, I have to say I have a lot of respect for, um, uh, the coast guard. I, uh, I had spent some time in April, 2019, uh, in Kodiak at air station Kodiak and in Anchorage, uh, for a number of days with the coast guard. And, um, they do a tremendous job. Uh, that’s very difficult and, um, uh, thank them for their work.
[00:51:52] I will have additional questions about this in the next round. Thanks so much.
[00:52:01] Thank you, Mr. Chairman. Uh, four, I began, uh, with question, I would just want to, um, add to what the chairman said a few minutes ago in his opening statement. That knowledge, why the NTSB has revitalized its focus on commercial fishing safety with its inclusion on the 20 21, 20 22 most wanted list in this capsizing coming to a public board.
[00:52:25] Commercial fishing is one of the most dangerous occupations in the United States. Every year, more than 40 lives are lost the center for disease control estimates, a fatality rate, 35 times that of all us workers for an industry that supports more than 700,000 jobs and contributes more than $50 billion to the economy.
[00:52:50] These workers deserve better. We must do more to protect those who have been risking their lives to feed all of us. Have a few questions for our meteorologist Mr. Suffern, the, uh, national weather service has two main categories of alerts for freezing spray, heavy freezing, spray warning, and freezing spray advisory.
[00:53:12] Mr Sufran, can you explain the difference between the two? So you’re, you’re a crack. There are two, uh, different levels. Um, the first being a freezing spray advisory where, um, freezing spray accumulation is predicted to be between zero and two centimeters per hour, and then heavy freezing spray warning is for two centimeters an hour and above ICQ.
[00:53:38] Right? So based on their weather conditions during the last two hours of the accident voyage, what was the estimated ice accumulation? So based on the observed conditions provided, uh, uh, relayed by the accident captain, uh, to his fellow captain, the 60 to 70 knots would equate to extreme freezing spray conditions, which would be four centimeters per hour and above.
[00:54:04] And the weather service doesn’t have a, a advisory for that or a warning for that. Is that correct? The heavy freezing spray advisory being two centimeters and above would include four centimeters and above it doesn’t have an extreme one. So can you please discuss why the estimated icing rate and the final two hours of the Boyage would be described as extreme icing based on the model that they use?
[00:54:29] The open-ended. So currently the national weather service for forecasting freezing spray uses, uh, scientific equations and guidelines, uh, produced by Overland, uh, in the late eighties and early nineties. And that basically takes into account, uh, air temperature, uh, water, temperature, um, wind speed, and, um, the freezing point of, uh, salt water.
[00:54:57] And, uh, through some math can calculate and estimate, um, light, moderate, heavy, and extreme, uh, freezing spray for those calculations. Great. So currently, how can a Mariner know whether he or she will encounter heavy freezing, spray, or extreme threes? When the national weather service issues, a, a heavy freezing spray warning that would include both heavy freezing, spray and extreme, uh, freezing spray conditions.
[00:55:28] In addition, the national weather service has an experimental ocean prediction center, uh, graphical website, which provides, uh, a lot more categories for freezing spray conditions above two centimeters per hour. Okay, so the, uh, the ocean prediction centers, uh, experimental icing website attempts to fix this problem and provide localized, freezing spray information.
[00:55:53] I take it, it provides a graphical representation of, uh, the, the freezing spray categories that could be experienced by Mariners throughout, uh, the Bering sea, uh, Gulf of Alaska. And, um, and that portion of, uh, of the United, it’s my understanding that this website’s not, uh, available to the Mariners at this time.
[00:56:16] And do we have a proposal in, uh, the, uh, draft recommend or do we have a draft recommendation to the national war weather service to make an operation? So currently the website is experimental and has been. So since 2014, what that pertains to is that while the website is available, um, anyone can, can get on the URL and click on that particular website and view the information, um, being experimental.
[00:56:50] If the website were to go down for some reason, uh, it would, um, take, uh, someone noticing or, or additional it resources to bring it back up while making that website operational, which staff has, has recommended to this report would provide a much more robust website as well as potentially, uh, leading to more, um, opportunities for individuals, including Mariners to, to view the information on the website and make it more accessible to Mariners.
[00:57:20] Okay. Thank you, Mr. . I see my time is up. Thank you, Mr. Chairman. Thank you. You’re welcome. And member Chapman. Thank you, Mr. Chairman, the circumstances of this accident are those tragic and they’re frightened. I joined and expressing condolences to the surviving crew and those who lost loved ones in this accident, the draft report notes, and my colleagues have highlighted that the NTSP is current most wanted list appropriately includes the issue area, improved passenger and fishing vessel safety fishing consistently tops the list, the most deadly occupations, and this accident underscores the reasons for our focus on commercial fishing and the context of the most wanted list.
[00:58:09] All of us, the NTSB Sharon interest in doing what we can to help improve that safety record. The scam. These rows was required to have stability instructions completed by what the relevant coast guard regulations refer to as a qualified individual. The term qualified individual is defined within the regulations.
[00:58:32] I understand those who fall into this category are most often practicing Naval architects. What qualifications must an individual meet or possess in order to practice as a Naval architect? And are those qualifications regulated on the state level or the federal level? Yes, sir. The regulations will define qual or due to find qualified individual.
[00:58:58] Like you said, uh, as someone that, uh, has formal training and experience, uh, completing. Naval architectural calculations in this particular accident, the Naval architect who completed the stability instructions was a licensed professional engineer in the state of Alaska. Okay. So those are state level qualifications that have to be met and there’s no, there’s, there’s no specific requirement at the federal level.
[00:59:29] Is that correct? That is correct. Other than what’s defining regulation, right. Okay. Okay. Have the draft report highlights that there was no requirement for the scan, these rows, stability and stability instructions to be reviewed. And we’ll discuss a recommendation, which I support by the way, which will be a offering to the coast guard that it developed an oversight program to review the stability instructions of commercial fishing festivals in the category of the scan, these rows under the existing regulatory structure, what would trigger a review of stability instructions for a larger commission?
[01:00:07] Uh, I’m sorry, for a larger commercial fishing Bestival vessel. I’m sorry. I understand that those larger vessels are subject to review. What would trigger that review? Well serve. I believe the class of vessel you’re referring to is potentially a, a fishing vessel, a modern one that maybe is required to carry a load line certificate.
[01:00:29] Um, load lines. Ficket load line is not only a physical mark on the vessel that denotes safe loading, but it also is a classification that, uh, structured around the structural design, construction and maintenance of the vessel, the additional oversight. So vessel of that class required to clear a little vine certificate.
[01:00:51] Um, there’s the building instructions are going to be reviewed by classification society. Most often the American bureau shipping shipping, um, that, that, that oversight is, is, is then done again, uh, the, by the coast guard who oversees the abs in a random, randomly audited, uh, method where they will periodically check, uh, spilling instructions for those vessels.
[01:01:18] Okay. Thank you. Okay. That’s helpful. So for larger, larger vessels is the process for developing those stability instructions, essentially the same. That is our stability instructions developed by a so-called qualified individual. And I understand that that they’re subject to further review, but the process for developing those instructions is essentially the same.
[01:01:41] Is that correct? That is correct. Thank you, Mr. Chairman, I may have some additional questions on this.
[01:01:50] Remember, Chapman, thank you very much.
[01:01:56] Numbers Chapman. I remember Graham, uh, some of the figures from NIOSH, which is a part of the centers for disease control. NIOSH is the national Institute for occupational safety and health. And the figures provided by their expert. One of their experts in the fishing industry, uh, Samantha Case, uh, pointed out that commercial fishing for, for the year 2019, which this, this tragedy, the occurred in 2019 with just just two hours to go before the new year.
[01:02:29] But commercial Vish, commercial fishing in 2019, wasn’t just one of the most deadly occupations in America. It was the most deadly occupation in America. Surpassing what is typically number one, and that is logging, uh, this boy in the rate of fatalities, the rate per 100,000 workers in the industry, uh, commercial fishing, uh, it fatality rate of 140 500 per 100,000 full-time employees compare that to.
[01:03:08] The average of all workers, which is 3.5 fatalities per 100,000. So it is, uh, uh, there’s a lot of need for improvement in this area. The NTSB charity, uh, hosted a two-day three-day forum on commercial fishing vessel safety in 2010, uh, and more needs to be done in this area. And that’s why it’s on the most wanted.
[01:03:32] Plus, um, as I did say during the most wanted list board meeting, uh, sir, Walter Scott said nearly 200 years ago, it’s not fish that you’re buying it’s men’s lives. And, uh, and I think that those figures that I just mentioned highlights, uh, that we are really, um, buying men’s lives when we go out and buy fish, because it is such a deadly industry.
[01:04:02] It is truly the deadliest catch. Um, so I do want to thank staff for a good investigator. Um, I think that, um, um, the coast guard Marine board, uh, did not complete, uh, did not get their, uh, Marine board, uh, completed until March of this year. So the accident happened on the last day of 2000, 19 six weeks later, we entered into a pandemic actually that was two months and 11 days later, we entered, entered into a pandemic that we are still officially an and then the coast guard did their Marine board.
[01:04:43] So we weren’t able to actually get a lot done on this until the Marine board completed. And so I want to point out that even though the accident was a year and a half ago, the bulk of staff’s investigative work, um, had to be done in the last three months. So thank you for your good work. A question for you, Mr.
[01:05:04] Barnum. And that is, is that was the captain’s decision to set sail under those conditions and the conditions of national weather service, Gale warning, and a heavy freezing spray advisory was the captain’s decision to set sail under those forecast conditions. Was that a reasonable decision?
[01:05:30] Yes, sir. The, uh, staff believes that it was, um, foul weather in that part of the world is commonplace. Um, it’s, uh, something they encounter almost on a daily basis. Um, What is no normal occurrence, normal, um, procedure when encountering, foul, whether it’s to seek shelter, there’s a variety of places along the, along the plant route there that the vessel could have potentially sought shelter.
[01:05:58] The captain was also, um, comfortable with his vessel. Uh, he loaded the vessel in accordance with his instill, uh, new stability instructions that he had on board. Uh, he’d been sailing that vessel for, um, a little over eight years as captain and Ben in similar situations, uh, with pots on deck and it come out.
[01:06:18] Um, unscaved um, in addition also there was other vessels leaving at the same time. He wasn’t the only one leaving. So ultimately staff believe that his decision to leave, uh, was acceptable. Right. I think that’s a very important finding right there that you’re proposing. So I just wanted to establish that.
[01:06:37] So, um, we’ll now proceed to the next round of questions, uh, chairman Landsberg. Uh, thank you, Mr. Chairman. I’d like to follow up on that line of questioning. Um, so if I understood you correctly, Mr. Barnum, you’re saying that the fishing crews typically launch, uh, in, in forecast conditions like this, is, is that a fair assumption?
[01:07:03] Yes, sir. It is. Um, okay. And if the conditions become worse than forecast, um, there were, there are safe zones that they can go to. Is that correct, sir, as, as described by, uh, fishermen that have frequent those areas, um, in interviews, they indicated that yes, there is various locations where a vessel of that size can seek shelter.
[01:07:31] Were there any safe zones along the route prior to, uh, set with island? So, um, and this, this seems to things got rather rapidly worse, uh, along the way. Um, what would the, would there have been another place where the captain could have diverted to a prior to trying to reach that way? I mean, you said that he was familiar with that, but I’m just wondering if there were other places in, are they marked on the chart or is this sort of, um, uh, just known by the locals that this is where you go?
[01:08:09] Uh, yes, sir. There was, uh, from what we are told, uh, places along the Southern side of the Alaskan peninsula between, uh, the west coast, Kodiak and Celadon, where he could have a soft shelter. Um, so had he even an hour or two prior. You could have sought shelter. Uh, am I correct in understanding that if the captain of the vessel had, um, reason where he, where he thought that they would need to seek shelter at that moment?
[01:08:46] Um, potentially there was some locations he could have sought shelter prior to stop what guests. And it seems like, uh, and it became very clear to me as we looked at this, that the wind was simultaneously helping while, uh, creating the ice on the starboard side, it was also helping to prop up the vessel.
[01:09:11] Do I understand that correctly? Yes, sir. That’s what staff believes as the vessel continued along its Southwest or the course, uh, the prevailing wind and waves were acting on the starboard side of the vessel, as you say, essentially propping up the vessel. So when he made the turn, obviously he lost the stabilizing effect of the wind and now the weight becomes predominant.
[01:09:40] Am I understanding that correctly? Yes, sir. That is correct. Okay. And so ultimately what we get to is that the, um, um, stability instructions don’t really take much of that into account. Am. Am I correct in understanding that? Or is that incorrect? Yes, sir. Partially. I mean, the stability instructions, the stability criteria, which there they are created from are designed to provide an adequate level of safety for vessels that are operated prudently.
[01:10:20] It does this through, um, including a safety margin that safety margin that’s calculated into them, um, takes into account certain aspects such as wind and roll water on deck in this case, I seem, um, so there is some level of safety margin built into them, but to the degree that the skinnies rose encountered it wouldn’t have been nearly that, that much.
[01:10:47] So the margins under these conditions are not sufficient. Well, sorry, I leave, um, you know, first that as we’ve recommended this report, this draft report that, uh, a study needs to be completed so we can, so the fine is this best study can be analyzed and then incorporated into regulations in the future.
[01:11:11] We needed to know how exactly these eyespots ice and how they will affect the vessel stability once that’s done. I think we can more accurately see if the regulations are inadequate. Understand. Thank you. Uh, thank you, Mr. Chairman. Uh, appreciate the opportunity.
[01:11:35] Thanks very much. Uh, okay, so we have a 30 foot. See, I just want to pick up from where I left off. We have 30 foot seas, 56 to 60, uh, a mile per hour wind gusts. And, um, can you tell me how far they drifted from the vessel where the vessels tank, the two surviving crew members? Uh, yes, ma’am. I, I know that information is contained on some of the information on the doc docket, but off the top of my head, I don’t know exactly how far they tripped him.
[01:12:10] That’s okay. I mean, but we do know that they were on, uh, the, the raft for four hours until they were rescued. So it must’ve been some, some distance at, at some point and the helicopter or at least the coast guard had some difficulty locating them because at some point the lights went off on the raft pretty early.
[01:12:34] They had found, I think, an hour in their emergency kit and there was a flashlight and I believe they waved down the helicopter with the flashlight. Correct. That is correct. Ma’am so, uh, when you have a situation like this, what could have helped, uh, locate the surviving crew members more quickly? Uh, yes.
[01:13:02] Ma’am. So obviously staff believes that, you know, the search ref rescue was obviously effective and that the rescue, these two survivors, um, there was, um, some question in that because the perp did not broadcast a receivable signal. And as mentioned earlier, there was some confusion with, uh, communication coordinates passed.
[01:13:26] An error staff believes that personal locator, beacons, if worn and if, uh, obtained or if had by the crew of the vessel would help a search and rescue operations more accurately pinpoint their location. And so the difference between an , which would have said, which would have, uh, uh, indicated the location of the vessel, uh, had it activated, uh, the difference there is personal locator, beacons, if provided to the crew would have been with each individual, correct.
[01:14:03] Uh, yes. Ma’am that the crew is trained to, um, if they need to abandon the vessel or if there’s a disaster like that, to take the paper with them. So, or it’s designed to flow free. So the port might necessarily not be with the, with the vessel. Okay. Yes, you correct. The POV’s are designed to be worn on the criminal.
[01:14:23] Great. And so have we, and maybe this might be where Mr. Rainey comes up and talks about previous recommendations on personal locator beacon, that beacons that we’ve issued. Certainly remember how many we issued a M 1745 out, um, out of the El farro accident, uh, recommending that personnel employed on bustles and coastal great lakes and oceans service, uh, be provided with personal locator beacon.
[01:14:54] Status of that is currently open, unacceptable a response. The coast guard responded in 2018 that, uh, they felt that at the time the technology did not provide the requisite location accuracy for the purpose. Uh, they are continuing to look into the technologies, working with, uh, ISO and in our TCM, we, we disagreed with that and thereby classified it open.
[01:15:23] And what did we, why did we disagree? We felt that, um, the, the accuracy on the PLB is, was sufficient to provide a useful tool for searching. It’s very hard to find a person in the water. Um, and, and as you point out in the, in these, um, you know, sea states and weather conditions that the, um, the satellite capability, the PLB, plus some local home homing capabilities that we felt that it would be a useful tool.
[01:15:51] So we, we didn’t agree with the coast guard position at the time, but we do know that they are looking into the technology. And then in Alfaro, three days after the sinking search crews spotted the remains of a crew member in an emergent immersion suit, it is unknown when the crew member perish, but if their immersion suit had a working personal locator, be again attached to it with a, could they have been located sooner.
[01:16:19] And we found in an, another investigate or at least in another investigation, uh, personal locator beacons may have aided search efforts in Trinity too in 2011. And that investigation, the crew had to abandon ship and the master was not able to grab the perv. The 10 crew members abandoned the vessel and were not found for three days and only six survived.
[01:16:42] If the lifesaving equipment had included a personal locator beacon, could the, uh, search team team maybe have, uh, found the crews sooner than three days? I think that’s certainly possible. We would. That was the lift boat accident. Yes. This is a recommendation included in our most wanted list, uh, of transportation safety, safety improvements.
[01:17:09] Thanks very much. Sorry. Thank you. And now thank you, Mr. Chairman. I was just looking here at the, uh, stability instructions and instructions to the master. And, uh, I’m amazed that nowhere on it, does it discuss how much ice can accumulate on the deck and on the pot stacks? I that’s just amazing as a, as a master, I would think that kind of information would be most important to you for the safety of the vessel.
[01:17:39] And I definitely support the proposed recommendation of including the icing amounts use to calculate the stability criteria. Um, I have some questions on the stability instructions. What is a load line certificate? Uh, yes, sir. So as I mentioned earlier, uh, load line of the vessel, it is a higher degree of oversight of the vessel and name in regards to its construction and its maintenance, uh, large, newer fishing vessels built after, um, July, 2013, uh, are required to have a load line certificate, basically ensuring that they meet those higher standards and they’re built to, uh, to, uh, uh, not only the standards, but also are, um, inspected periodically.
[01:18:30] They’re hauled out of the water periodically that they’re hollows. Okay. So if, if the Scandi is rose was built after, what is it? July of 2013, uh, this size, it would have required a load line certificate, correct. Okay. Would a load line certificate D is in your opinion, would have helped the Scandi is rose captain better understand his stability requirements and its limitations?
[01:18:59] I don’t necessarily think, I don’t necessarily think that it would be accurate. I do believe that his stability instructions would have, have had more oversight and therefore would have been, uh, potentially been accurate. And, um, and he wouldn’t have left court as he did here with inaccurate ones. Okay.
[01:19:19] Thank you for that. Um, I’m going to switch to a stability training. I know back in 2010, the NTSB held a fishing vessel safety forum and discuss the issue of training fishing vessel crews on vessel stability. Um, about a year later in 2011, it, um, that led to the NTSB issuing safety recommendation am 11 dash 24, addressing fishing vessels stability training to the coast guard.
[01:19:47] And I’ll read it here, require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and the use of vessel stability, infer mega information, regardless of plans for implementing the other training provisions of the 2010 coast guard authorization act.
[01:20:10] Uh, what is the status of this recommendation? Sir, please mammogram. The status is currently open, unacceptable. And as you mentioned, we, we have, uh, associated that with our current, most wanted list. Um, the coast guards last response was in, um, October of 2016, uh, letting us know that, uh, they are working with their federal advisory committee to develop a curriculum.
[01:20:40] Okay. So this, this recommendation has been out for 10 years and we haven’t heard anything in almost five years from an advisory committee. Yes. Okay. And, uh, and we’ve lost, or at least we’ve been investigated to a commercial major convention, commercial fishing vessel accidents since then. That’s correct?
[01:21:02] Yes, sir. Okay. Thank you for that. I’d like to see the coast guard act on this a little quicker, and I, I see we’re going to highlight that in our reiteration recommendation. So I thank you for that. And, uh, I yield back the rest of my time, Mr. Chairman. Thank you very much.
[01:21:25] Thank you, Mr. Chairman, a couple of questions about weather resources. Uh, obviously extreme weather conditions were a factor and I gather the accident site is known to be prone to difficult weather, including certainly. Yet the investigation revealed that the surface and the buoy station, I’m sorry, the surface and buoy stations nearest to the accident site where 95 and 125 miles away.
[01:21:51] Respectively, is it realistic to expect accurate Marine weather forecasting with such limited and widely dispersed surface observations based on the weather conditions that were experienced and the, um, the, the wind funneling through the terrain, uh, phenomenon typically, uh, discussed as Willy was in that area.
[01:22:15] Um, you’d have to have the surface observation resources to be able to be knowledgeable that, and, and, and the locations the observations are right now, they do not reflect, uh, the Willard walk conditions and the, and the conditions at the time of the accident while they were certainly on the extreme end.
[01:22:35] Not really unusual for that area. Is that correct? Um, based on the Mariner feedback, um, at a Marine board of investigation, they all described the weather conditions at the worst weather conditions that they experience were in the salt, WIC and Technica bay area. Do we know whether Noah or the national weather service have previously sought funding or whether they otherwise plan to increase surface, observation and resources in the area?
[01:23:06] Uh, as currently. And do we have a sense of what an optimal array or do you have an opinion about what an optimal array of observation resources might look like in that area? The observational resources to be able to capture the more extreme wind conditions, uh, especially on the higher end cases, such as this accident or other cases where you get a wind conditions that are, uh, basically hurricane force winds, uh, having the observation of resources to be able to not only let forecasters know those conditions are happening, but also, uh, highlight that to the mayor and our community would be a value.
[01:23:48] In addition, it would go into the weather computer model data, which would further make forecast, uh, conditions, more accurate, certainly need observation sites that are closer or more, more frequent than 95 and 125 miles away. It seems to me, um, there are few regions in the world where, uh, that are more dependent, uh, as you know, on Marine and aviation transportation than Alaska.
[01:24:20] In terms of Marine, it seems clear that weather observation resources are inadequate in the area. Encompassing the accident site. Are there similar gaps in resources necessary for aviation forecasts? Um, that particular, uh, line was not, um, um, discuss through this investigation. Oh, okay. I understand. Um, certainly I would, I would encourage Noah and, and NWS to take a look at that as well.
[01:24:50] It does appear that we’ve got some gaps here and that’s, uh, it’s, it’s an important area in terms of Marine and aviation. And, uh, it’s an area, obviously that’s subject to, uh, very difficult weather conditions. Mr. Chairman. I’m going to hold the remainder of my questions for the next round. Thank you. Thank you, member Chapman.
[01:25:10] I know that we’ve mentioned bits and pieces of the search and rescue effort. Um, but I think it’s worth noting a little bit more of it. Um, the coast guard is, uh, is an agency that some of us don’t think too much about until we see them rescuing people, plucking people off of roofs of homes during hurricanes and, uh, and extraordinary rescue efforts like this one.
[01:25:36] Um, the pilot, one of the pilots of the helicopter, uh, said it was the most challenging flight of his career to turbulence was so severe that it took both pilots, uh, to help keep the helicopter straight and level. There were severe turbulence. There was down drafts as a member Hamadie already pointed out.
[01:25:56] There were 30 foot seas. Helicopter was low on fuels. So they had to, uh, turn off the APU, uh, which turned off the heater inside the, uh, the helicopter once they were taking the, uh, the surviving two crew members back, uh, this was an incredible rescue. I think a lot of people don’t realize how remote parts of, uh, uh, Alaska can be.
[01:26:22] Can, can you, uh, elaborate, uh, Mr. Barnum, just a little bit more about the search and rescue efforts, those extraordinary efforts. Yes, yes, sir. I believe you put it extremely well there. Um, the, uh, when the coast guard was notified, uh, the search and rescue operation was gonna take place. They, uh, began to, uh, get preparations ready, um, because of the severe weather, uh, additional flight planning was required.
[01:26:52] Um, they needed to make sure that flying out there, they would be able to get back or get to another suitable location where they could take fuel and transport, any survivors. Um, but after doing that, they also had to, uh, throw in additional fuel on bullet the helicopter. Um, they traditionally don’t carry a full tank of fuel, uh, on board.
[01:27:12] So they, they had to fill, fill up on fuel. They also, after the helicopter left, they launched a C one 30 aircraft from Anchorage, Alaska that was acted as a overflight and was able to. Transfer communications from the helicopter, because it was low in flying at such low altitudes. Uh, any voice communication from the helicopter, wasn’t able to make it back to the base.
[01:27:37] So the, the overflight would, uh, would act as a communications platform. Yeah. Thank you very much. I want to switch now to stability because I think that’s certainly a central area of this, of this tragedy during the U S coast guard testing, uh, of where they sprayed, um, water, cold water on, uh, on grandpa during a test.
[01:28:06] Think they sprayed water on grandpa for like 72 hours. Uh, how much did the weight increase of that one pot? Yes, sir. I’m referring to the, uh, uh, preliminary kind of experiment on the polar star where they sprayed a crab pot with a freshwater for three-day period. The, um, the weight wasn’t accurately able to be determined because the load cell that they were using, uh, was maxed out and maxed out at 3000 pounds.
[01:28:38] Um, the gaining weight of the crab pot was roughly 1000 pounds. Yeah. So, so it, it more than tripled the. The regulatory requirements for stability calculations. Assume I think it’s a, I think it’s 1.3 inches of surface hard surface ice on the horror, horizontal surfaces and about points to six, five of an inch on the vertical set, um, surfaces.
[01:29:04] How realistic are those assumptions, sir, from what we experienced talking to captains and people familiar Naval architecture industry, uh, that deal with these types of vessels, aren’t often those, uh, assumptions. Weren’t very realistic. Yeah. And, uh, and in fact how much I did our investigative staff, uh, estimate was on the grandpa of Scandi is rose sure.
[01:29:38] Staff estimated to be between six and 15 inches of height between six and 15 inches. Um, yeah, so certainly I have more questions. We’re going to take a break before we take a break. I would like to encourage all participants to turn off their cameras and their microphones. And we’ll take a 10 minute break.
[01:30:00] We will reconvene at 1115, which is really about nine minutes from now. We are in recess.
[01:30:15] Okay. We’re back in session. And we will resume with questions from the board members as chairman Landsberg, Bruce, you may be muted. So I am, uh, if I could ask that we bring up a slide 39, please, but try to think we’ll, um, kind of illustrate all of the things that, uh, um, probably need to be covered here.
[01:30:41] And, and now I look at it, what, and I give all of my colleagues, uh, uh, accolades for, um, covering all of these points rather well, but you know, this illustrates, uh, this was, uh, a vessel that almost. Got into the same problem that the scan use roasted. Um, I think what we’ve seen is that even though we routinely operate in these environments, uh, we have rather badly underestimated, uh, the weather conditions, uh, that, and some of the requirements that we should have, um, we see that the national weather service doesn’t have the ability to accurately forecast or, or to model.
[01:31:26] And there are, uh, relatively easy fixes for that. What’s more observation points. We’ve seen that the stability instructions and regulations are not, uh, sufficient nor realistic. Uh, the chairman has pointed that out as have some of my other colleagues. Um, we’ve seen that, uh, personal locator beacons really are essential because a crew members can easily under these conditions be separated from the vessels.
[01:31:56] Uh and, uh, they, they do work rather well. I carry one, uh, when I, um, uh, sail or fly, I think, uh, the industry, uh, has operated under these environments and this sort of. Tribal wisdom, I guess that, um, you know, it’s going to be bad out there and y’all be careful. And after years of training, um, or I should say experience, not training, but experience, you kind of learn how to, how to deal with this.
[01:32:27] And in almost every case, we’ve overestimated our abilities to cope with some of the extreme conditions. And so I think if, uh, when we get to the recommendations, I’m really looking forward to hearing, uh, hearing that, because I think that can go a long way to stopping this from being the most deadly catch.
[01:32:48] So with that, Mr. Chairman, I have no further questions and thank you.
[01:32:58] Thank you. Uh, Mr. Barnum, can you, uh, talk about how much a personal locator beacon is roughly. Yes, ma’am, um, we’ve found that roughly $300 will buy a GPS equipped personal located. Okay, great. Uh, and I, I have a couple of questions. Well, at least one question that I always like to ask, uh, our director of safety recommendations and communications, Ms.
[01:33:28] Hatchet, um, about, uh, what happens after a board meeting with our recommendations. Once we adopt recommendations from my standpoint for board members and for the board in general, this is the first step in the process for, uh, bringing about change. So can you talk about, um, Ms. Hatchet, uh, what happens after the board meeting with our recommendations, certainly member hominy, uh, thank you for the question.
[01:34:01] Um, NTSB recommendations can prevent future accidents and save lives only if they’re acted upon. Otherwise. They’re just words on a piece of paper. So after the board meeting concludes our work continues and my office, the office of safety recommendations or SRC, as we like to call ourselves, we track and evaluate the responses to every NTSB recommendations that we issue to recipients.
[01:34:28] And we work with the board and the staff. To make sure that we keep the pressure on to close these recommendations, because it’s important for all the reasons that we’ve talked about here today. Um, we record the responses to the recommendations we issue. We track them. Um, of course we talked to Congress, um, we we’ll be speaking to them about the issues, um, and our recommendations, um, today.
[01:34:51] And we evaluate each response that we receive from our recipients to determine they’re not, you’re actually acting upon our recommendations. Um, as part of that, um, we manage the agency’s most wanted list. And I just want to pause there for a moment to explain why it’s important for us to elevate these issues.
[01:35:13] Um, as demonstrated by the scan, these rooms, this is an accident contract. Imagine that could have been prevented, proven fishing vessel safety is included on the most wines, that list to bring a tea attention to the safety issue. We most want action on, um, to amplify these issues and underscore our safety recommendations.
[01:35:33] I do want to point out that we are working with the office of Marine safety, who is planning for an October round table to make sure that our issues, our recommendations remain on the forefront and we keep pushing for the closure of those. So these are some of the things that the safety officer’s safety recommendation does to work with all of you to ensure that we cleat these issues on the forefront, uh, included in the dialogue of, uh, what we need to see happen so that we could prevent these accidents from occurring in the future.
[01:36:08] And I th I think, you know, I really appreciated what you said about the most wanted list, because if every once in awhile, I hear, why do you have a most wanted list? Uh, w you know, why bother with a list? And I think, you know, when, when we issue recommendations over and over again, to prevent tragedies, either to prevent the tragedy itself or prevent the loss of life, and I’m thinking, you know, personal locator, beacons right now, where we’ve issued recommendations in the past after Alfaro, um, we don’t have other, I mean, we do have dialogue ongoing with the coast guard, but this is one.
[01:36:50] Really great tool, the most wanted list. Keep that issue in the forefront to, to draw attention to the fact that we have issued this recommendation, these recommendations previously, and we need action to save lives. And this is a tool that allows that to happen, which is why we have a most wanted list. So I really appreciate, uh, you talking about that and I appreciate all the work of your staff and of course, uh, uh, our offices, our modal offices as well.
[01:37:23] So thanks very much. And that concludes my questions.
[01:37:28] Thank you. And, uh, uh, so we’ll now go to Michael Graham number grant. Uh, thank you, Mr. Chairman. I actually have no further questions member traveling. Thank you, Mr. Chairman, and I’ll be quick, uh, a quick clarifying question for Mr. Barnum. This is with respect to load lines certificates, and the requirement that, uh, the vehicle, um, uh, have one issued, uh, is that determined?
[01:37:59] Is that requirement determined by the size of the vessel, the date of manufacture, or is that a function of, of those of those considerations? Yes. Thank you, sir. For that clarification. Yes. It’s the function of the size vessel needs to be 79 feet or more, and the date of construction. Okay. All right. Thank you.
[01:38:18] Um, and a couple of questions, uh, uh, about personal locator, beacons, um, where as, as has been mentioned, we’re going to re reiterate a recommendation to the coast guard today, calling for our requirement that all, uh, personnel on certain commercial vessels be provided with a personal locator beacon. These appear to be relatively unintrusive devices.
[01:38:43] Um, I understand that they’re off the shelf. You mentioned previously the, the, the cost seemed they’re not inexpensive, but they’re relatively affordable. Is there any resistance on the part of crew to wearing PLTs?
[01:39:02] I believe that whenever there’s a new technology out like this, there’s, there’s both sides of the coin. Um, I think traditionally, when crews are required to wear this working on deck, they might see some issues with, with, uh, hitting, uh, as they’re loading, uh, some line that the crab pot or they’re doing some other function on deck, but ultimately from what we’ve heard from industry is that they’ve embraced them.
[01:39:28] And many people voluntarily have. So maybe a little bit of work to be done here in terms of educating, uh, the community of folks that are working on board these vessels, but, uh, generally easy to obtain affordable, relatively unobtrusive, and certainly the benefit, um, uh, outweighs, uh, any, any potential inconvenience in terms of wearing them.
[01:39:55] Uh, and a question I think this one really is, is for Mr. Chirael. Um, and this’ll be my last question, Mr. Chairman. Uh, my understanding is while we’re focusing today, of course, on the specifics of this tragedy, I understand that our office of Marine safety intends to develop a safety recommendation report, addressing broader issues associated with fishing vessel safety.
[01:40:19] Are you able to share additional details regarding the scope and objectives of that work? Uh, yes. Thank you. You remember Chapman? Uh, the officer Marine safety will be developing a safety recommendation report drawing from previous accidents. We’ve investigated, including the scan, these rows, the destination, and perhaps a half a dozen briefs we’ve done, uh, since 2012 each year.
[01:40:45] Uh, so there’s several dozen accents we’re looking at. Other report will include an analysis of accident. Data, many incidents that are investigated by the coast guard are below the threshold for the NTSB to investigate. So we’ll look at all fishing vessel incidents, not just, uh, majoring accidents, majoring, uh, casualties.
[01:41:06] So we’ll summarize the previous accident briefs. We’ll find a look for safety gaps and proposed safety recommendations to, uh, perhaps close some of those gaps and improve safety. Thank you very much forward to that. Congratulations to you and all of your team for an outstanding job on this investigation.
[01:41:26] Thank you, Mr. Chairman. That’s my last question and we’re Chapman. Thank you very much. That’s good. Barnum did, uh, did the 2019 stability assessment accurately model all of the decks on board, the closure on boards as candies rose, one sort of one point, uh, that was neglected on this, uh, 2019 spilling instructions was the worthy down flooding points of the vessel.
[01:41:54] Yeah. And did it properly model they poop deck and the fascial area of the boat. Based off the MSCs technical forensic analysis of the stability instructions. No, sir. It did not accurately model those two structures. Thank you. What are the, you mentioned mathematical errors in your opening presentation.
[01:42:16] What other error, errors or missions, uh, did, uh, did staff note in the 2019 stability assessment? So as previously met, previously mentioned, uh, the instruction neglected down flooding, which is a major criteria under Carmi vessel’s stability. Um, other more specific mathematical error errors. I can’t readily cite here, but are mentioned in the MSC report.
[01:42:45] Yeah. Thanks. Here’s the here’s the ironic thing is that after the destination, uh, Marine casualty, uh, the owners of Scandia rose, uh, decided to update their stability instructions and what they got was probably not what they paid for. Um, you know, they were trying to do the right things and, uh, there were errors and omissions in that report.
[01:43:14] And I think that’s a major point of this entire report. Um, Mr. Stolzenberg, you are a Naval architect. Uh, what does it take to be an, a Naval architect chairman. Typically it involves a, a four year program at a university, many folks go on to get a master’s some get doctorates. Um, and if you so choose, and a state has a professional licensing program, you can get a professional engineer’s license in the field as well in certain selected states, Washington state being thank you very much.
[01:43:51] It’s not just something that you can mail off for or apply for. And the internet is a very extensive, uh, qualification process. So, uh, um, and so anyway, we do know that there were errors and emissions in this one. And, uh, and as a result of that, the captain of this vessel was candies. Rose was not afforded the proper assessments that he needed to, uh, make determinations about the Seaworthiness of this vessel.
[01:44:21] Um, now overall, so we talked about the Arizona and emissions of the individual Marine, um, Marine architect, or I’m sorry, Naval architect, but let’s talk about the regulatory aspects of it. And I guess Mr. Barnum, this would be directed towards you. Um, do the current requirements for stability instructions, consider icing accumulation on pot stacks and the interior webbing.
[01:44:53] Yes, sir. Mr. Chairman, the current regulations do not allow account for icing on the interior webbing, but there is an allotment for the exterior surfaces of the pot stack, but it is assumed to be symmetrical icing and we’re learning. And we know that icing does not occur symmetrically. Is that correct?
[01:45:17] That is correct, sir. And so how can the, uh, regulatory requirements be changed to reflect, uh, icing, uh, cemetery and, uh, and for, um, icing and the interior, the webbing of the pots. How can that be changed, sir? As we mentioned in the draft report, we feel that a study needs to be conducted to accurately determine, uh, exactly how these pots ice and how they can be treated and referenced in regulation.
[01:45:48] Yeah. And that’s certainly a recommendation that staff will be proffering and that we will be voting on shortly. Thank you. And finally, one, one last question is, uh, should, so the way that pots are they, uh, the way that the icing is modeled currently is like you said, it’s a shoe box. Um, and so. And we’ve learned that it gets into interior webbing.
[01:46:15] So that messes up the modeling on the shoe box. Should pots be tart to allow for more symmetrical icing? Um, would that, would that, uh, do anything at all? Uh, Mr. Mr. Chairman, none. I know NTSB has had, uh, opinions on this in the past and in certain circumstances, um, individuals in the industry have indicated that harps will help prevent ice from accumulating inside the pots back.
[01:46:43] Um, obviously the ice still accumulates on the tarp on the outside. Um, but the majority of commercial fishing vessel captains that we spoke to on this topic indicated that often the tarp is a more a hindrance than it is, is good in their opinion. Uh, there’s dangers associated with removing the tarp when it’s time to fish on the tarps are traditionally ripped and ruined after they’re done.
[01:47:07] It’s a one-time use. So, um, ultimately there, isn’t an easy solution here, and there’s not a general consensus either on the use of tarps. Right. Thank you. And I guess, I guess ultimately what becomes of that would be what comes out of the study that we are recommending in any event. So, all right. Um, do any of my colleagues have any additional questions or comments before we move to the findings?
[01:47:34] Us seeing none at this time, uh, Mr. Curtis. If you would please read the proposed findings. Yes, sir. As a result of this investigation, staff proposes 13 findings, number one, none of the following were safety issues. The accident of voyage one, the captain’s pre-departure decision-making to operational pressures, three fatigue for drug and alcohol use by the vessels, propulsion and steering systems or six, the vessels hall integrity.
[01:48:16] Number two, based on the voyage timeline and the estimated ice accumulation over that period. The scan, these rows likely accumulated between six and 15 inches of ice on surfaces exposed to wind and icing during the accident voyage number three, although the captain’s decision to proceed to set WIC island was reasonable.
[01:48:38] By the time he was close enough to turn into the li the icing conditions had accelerated and reduced the vessels stability. And before the added weight from ice accumulating asymmetric asymmetrically on the vessel and the stacked crab pots on deck raised the scandium rose center of gravity, reduced stability and contributing to the capsule sizing number five, although the crew loaded the scanned, these rows per the stability instructions on board.
[01:49:11] The stability instructions were inaccurate. Therefore the vessel did not meet regulatory stability criteria and it was more susceptible to capsizing number six because the stability instructions were inaccurate. The captain was unaware that his decile did not meet the margin of safety intended to be provided by the stability regulation.
[01:49:34] Number seven, current regulatory guidelines on calculating the effects of icing on a fishing vessel. Stability do not take into account how ice actually accumulates on and in crab pots and crab pot stacks. Number eight, if vessel captains are aware of the amount of icing that is factored into their stability instructions, they would be better prepared to make critical vessel safety decisions.
[01:50:00] When operating in areas of potential icing number nine, formal stability training would provide fishing vessel crews with a better understanding of the principles and regulatory basis of stability, including the effect of icing number 10 and oversight program to review and audit stability instructions produced for uninspected commercial fishing vessels.
[01:50:25] Like the scan, these rows that are not required to carry a load bind certificate could identify and reduce potential errors in stability instructions. Which in turn may reduce the chance that vessels are sailing without the intended margin of safety provided by applicable stability criteria. Number 11, due to the limited surface observation resources near network island and the Chittick bay region along the fishing vessel route from Kodiak to Dutch Harbor, the national weather service cannot accurately forecast the most extreme localized wind and sea conditions.
[01:51:02] One of the area which can lead to vessels encountering conditions that are worse than expected. Number 12, the national weather service ocean prediction center site could provide Mariners with more detailed, graphical icing information, not currently available elsewhere, which would help them make decisions based on more accurate weather information.
[01:51:25] And number 13, personal locator beacons would aid in search and rescue operations by providing continuously updated and correct coordinates of crew members location, sir, Mr. Curtis, thank you very much for reading those recommendations at this time. We’ll have each of our board members, uh, we’ll do a roll call to make sure that all board members are ready to deliberate vice chairman Landsberg.
[01:51:52] I’m ready to deliberate. Uh, Mr. Chairman. Thank you. Thank you. Uh, look forward to the discussion. Thank you. Remember Graham. I am ready to deliberate Mr. Chairman. Thank you very much. And remember Chapman ready to go, Mr. Chairman, thank you very much. Um, so, uh, do we have a motion to adopt the findings as proposed?
[01:52:21] Okay. My chairman, uh, has moved. And is there a second? I’ll second, Mr. Chairman, Mr. I remember Chapman seconds. Is there any discussion, um, Mr. Chairman? Uh, I did note, I believe it was on finding 11, uh, the statement, uh, the national weather service can not accurately forecast and I believe the term is the more extreme, localized, and I believe it was red, most extreme, localized, a minor point, but, uh, just for, for the record.
[01:52:55] Yeah. Thank you very much. Um, and, uh, as it’s written, it does say, as you pointed out by chairman does, so the national weather service can not accurately forecast the more extreme, localized, wind and sea conditions for the area. So thank you. Uh, any, thank you. Any other comments or questions? Okay. It’s been moved and seconded to adopt the findings as proposed.
[01:53:23] There’s no further discussion. We’ll do a roll call vote, uh, um, vice chairman Landsberg. I vote. I share my votes on. Remember Hamadie I number? How many votes? Remember Graham? I am a gram votes number Chapman I number Chapman votes. The chairman votes on the findings have been adopted unanimously. And now Mr.
[01:53:50] Mr. Curtis, if you’ll please read the proposed probable cause staff proposes the following probable cause the national transportation safety board determines that the probable cause of the capsizing and sinking the commercial fishing vessel Scandi is rose was the inaccurate stability instructions or the vessel, which resulted in a low margin of stability to resist capsizing combined with a heavy asymmetric ice accumulation on the vessel due to localize, wind and sea conditions that were more extreme than forecasted during the accident voyage.
[01:54:30] Sure. Mr. Curtis, thank you very much. Is there a motion to adopt the probable cause as presented,
[01:54:39] um, member Homedy moves? And is there a second, second number or member Graham seconds? Uh, is there any discussion? Okay, thank you. It’s been moved and seconded to adopt the probable cause as presented. There appears to be no discussion. All in favor, we show them again and again with a roll call, vote. Vice chairman Landsberg, vice chairman, bow tie likes chairman votes on.
[01:55:08] Remember how, how many votes? I remember Graham, I regram votes. I remember chap by Amber Chapman votes. Aye. The chairman buttocks, not the probable cause has been adopted unanimously. Now, as far as the recommendations are concerned, I believe Mr. Curtis will read recommendations one through seven for our consideration to vote.
[01:55:35] And after we voted on those, then, uh, he will then read the recommendations that are being reiterated, uh, in the report, but will not require a vote. And that’s my understanding, Mr. Curtis, did I get that right? That is right, sir. Okay. If that’s the case and, uh, Mr. Curtis, if you’ll please read the proposed recommendations as a result of this investigation, staff proposes the following seven new safety recommendations for the us coast guard.
[01:56:09] Number one, conduct a study to evaluate the effects of icing, including asymmetrical accumulation on crab pots and crab pot stacks and disseminate findings of the study to industry by means such as a safety alert. Number two. Based on the findings of the study recommended and safety recommendation, one revised regulatory stability calculations for fishing vessels to account for the effects of icing, including asymmetrical accumulation on a crab pot or pot stack.
[01:56:46] Number three, revised title 46, coded better regulations. 28.530. To require that stability instructions include the icing amounts used to calculate stability criteria. Number four, develop an oversight program to review the stability instructions of commercial fishing vessels, which are not required to possess a load line certificate for accuracy and compliance with regulations.
[01:57:16] One recommendation to the north Pacific fishing vessel owners association. And we’re five notify your members, parent Bering, sea Aleutian islands, crabbers fishing vessel fleet closed paren of the specifics of this accident. The amount of ice assumed when developing stability instructions and the dangerous wising one recommendation to the national weather to sorry to the national oceanic and atmospheric administration.
[01:57:44] Number six, increase the surface observation resources necessary for improved local forecasts for the WIC island and CEG bay region in Alaska. And one to the national weather service, number seven, make your own prediction center, freezing spray website, operational and promote issues industry, sir. Thank you very much.
[01:58:11] Um, so there were the recommendations, the new recommendations proposed. Is there a motion to adopt the recommendations as presented? My chairman moves. Is there a second? Second? Okay. Um, member Chapman seconds. Is it seconds the motion? Is there any discussion regarding recommendations one through seven saying none it’s been moved in second and to adopt the recommendations as presented there appears to be no discussion for a vote vice chairman Landsberg.
[01:58:47] Let’s say you as chairman bow tie as chairman votes on. Remember Homedy number comedy votes. Remember Graham by gram votes are number chap. I number Chapman votes on the chairman votes on the recommendations have been approved unanimously, um, as presented. And so Mr. Curtis, if you’d please read for the record, the previously issued recommendations that are reiterated in this report.
[01:59:22] Staff proposes reiterating the following two safety recommendations, which are currently classified open, unacceptable response, both to the us coast guard. First, M 1124, which reads require all owners, masters and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use the vessel stability information, regardless of plans for implementing the other training provisions of the 2010 coast guard authorization act.
[02:00:00] Secondly, M 1745 require that all personnel employed on vessels and coastal great lakes and ocean service be provided for the personal locator beacon to enhance their chances of survival, sir. Yeah. Thank you very much. Uh, so those recommendations of course, have already been adopted by the board, uh, by, uh, a board they’ve already been adopted.
[02:00:24] So, um, Mr. Curtis was simply reading those to get them on record that that is a part of the report. Um, does anyone have any additional issues related to this report? Uh, that they wish to discuss saying none? Is there a motion to adopt the report? I, so move, remember Graham moves. Is there a second? Vice chairman Landsberg seconds.
[02:00:53] Uh, it’s been moved. Is there any, is there any discussion regarding the final report? Okay. It’s been moved in second, the motion to adopt the report. Um, we have a motion to spend a second to approve the report as presented. There appears to be no discussion for vote vice chairman, Landsberg, chairman, chairman votes.
[02:01:19] So I remember how many number of how many votes on number gram I then were Graham boats member Chaplin. I am Mr. Chairman, before you proceed to your closing statement or reminder to turn your camera? Uh, my camera. Yes, sir. You know, it’s funny because my camera shows on now and it shows, it showed let’s say when I tried to turn it off it, um, you know, I can’t, so just mark that up, chunk that up to technology.
[02:01:56] Um, now I turn it off and I can’t even turn it back on. So while Brian was reading something a little while ago, my camera would not turn off. So anyway, that’s just technology, but thank you for that. Um, so, um, in vice chairman, I think you, uh, I’m sorry. Remember, cam, when you just voted to approve the report.
[02:02:19] Uh, presented, I believe you did. Yes, sir. And the chairman votes. Aye. So the, the final report for this candies rose has been adopted unanimously. Um, do any of my colleagues on the board wish to file a concurring or dissenting statement? Okay. And for the record, uh, since no one can see me, uh, I do not wish to file a concurring or dissenting statement.
[02:02:48] So, um, anyway, Carl, can you turn my camera back on? I don’t think you can then it’s great out completely on, on my computer, but anyway, that’s technology for us. Um, so I’ll now move to the closing statement. And before we do that, I’ll welcome any participants to turn off their cameras and mikes, if they are so inclined.
[02:03:14] Um, in closing, I want to thank my colleagues on the board for their great preparation, uh, going into the board meeting, uh, all of earned kicked out, but maybe, uh, maybe I’m back anyway. Um, want to thank, uh, all of my colleagues for. Uh, good, uh, comments going into the board meeting when they, when they all met individually with staff?
[02:03:38] Uh, certainly appreciate the good questions. Um, asked by staff, uh, asked by the board members and the responses by staff. Uh, we always liked the investigative staff to the staff of the office, Marine safety and the office of aviation safety. Uh, of course the office of aviation safety provided the, uh, weather, uh, expertise and the resources.
[02:03:59] But as I’ve always said, nothing around here gets done by just one person or one department. It is an entire, uh, group effort. And this meeting is a great example. Um, it takes an entire organization to conduct a board meeting and I’m so sincere thanks to the investigative staff, but to the program staff and the support staff, um, to pull it all together.
[02:04:24] The Scandi is rose did not capsize and sank because of a crew member or the captain did not do their, their jobs or because the vessel had been poorly maintained, it sank because the captain only had partial access to the information that he needed to make the decision and the information that he did have wasn’t there.
[02:04:50] The vessel was loaded, according to the stability instructions that were not conservative enough. The captain set out to say without the margin of safety required by the regulations because of these errors and the stability instructions and the vessel met weather conditions that demanded scary safety margin.
[02:05:10] The recommendations we issued today, if acted upon, would result in more accurate stability instructions that realistically consider the effects of icing on crampons and cramped pot stacks. They would also increase the surface weather, observation resources necessary for improved weather forecast, and they would result in the ocean prediction centers, freezing spray website, becoming operational.
[02:05:36] The recommendations that we reiterated today would result in required vessels stability training for owners, masters, and chief engineers, as well as other training, they would also result in personal locator, but it confirmed every member of a vessel’s crew and prove passenger fishing vessel safety is on the NTSB is most wanted list of transportation safety.
[02:06:02] Okay. In part because commercial fishing is routinely, one of the most dangerous occupations in America. But it doesn’t need to be the TV series, the deadliest catch air to special segment about Sandy’s rose. And in it a fishermen asked, have I been pushing my luck for the past 40 years? Am I any different?
[02:06:29] I hope so. He said, but hope is not enough. The recommendations that the NTSB issued in reiterated today need not be acted upon to make tomorrow’s catches. They need to be acted upon to make tomorrow’s catches less deadly on a personal note. This will be the last board member. The board meeting that I will participate in as tomorrow is my last day at the NTSB.
[02:06:56] It has been such an honor and privilege to serve with this agency. I will miss the people very much. I will miss the agency. Thank you. We stand adjourned.


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