Marine Accident Report MAR-06-01

124 Pages·2006·3.34 MB·English

National Transportation
Safety Board
PRSRT STD
Washington, D.C. 20594
Postage & Fees Paid
OFFICIAL BUSINESS
Penalty for Private Use, $300
NTSB
Permit No. G-200
Capsizing of U.S. Small Passenger Vessel Lady D
Northwest Harbor, Baltimore, Maryland
March 6, 2004
Marine Accident Report
NTSB/MAR-06/01
PB2006-916401
Notation 7679A
National National
Transportation Transportation
Safety Board Safety Board
Washington, D.C. Washington, D.C.

Marine Accident Report
Capsizing of U.S. Small Passenger Vessel Lady D
Northwest Harbor, Baltimore, Maryland
March 6, 2004
NTSB/MAR-06/01
PB2006-916401 National Transportation Safety Board
Notation 7679A 490 L’Enfant Plaza, S.W.
Adopted March 7, 2006 Washington, D.C. 20594
National Transportation Safety Board. 2006. Capsizing of U.S. Small Passenger Vessel Lady D,
Northwest Harbor, Baltimore, Maryland March 6, 2004. Marine Accident Report NTSB/MAR-06/01.
Washington, DC.
Abstract: On March 6, 2004, the small passenger vessel Lady D, a pontoon water taxi with 2
crewmembers and 23 passengers on board, was en route from Fort McHenry to Fells Point, Maryland,
when it encountered a rapidly developing storm with high winds. The pontoon vessel began to roll in the
waves and eventually continued over onto its starboard side and capsized. Responders were able to rescue
or recover all but 3 occupants of the Lady D and transport them to area hospitals within an hour of the
accident. The bodies of the remaining victims were recovered from the waterway on March 14 and 15. As
a result of this accident, 5 passengers died; 4 passengers suffered serious injuries; and 12 people sustained
minor injuries.
Major safety issues discussed in this report include passenger weight criteria for stability assessment;
pontoon vessel stability standards; and policies and procedures pertaining to weather operations.
As a result of its investigation of this accident, the Safety Board made safety recommendations to the U. S.
Coast Guard.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.
Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also
may be obtained from the Web site or by contacting:
National Transportation Safety Board
Records Management Division, CIO-40
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
[phone] or [phone]
Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2006-916401 from:
National Technical Information Service
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[phone] or [phone]

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
iii Marine Accident Report
Contents
Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Taxi Operations at Baltimore Harbor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Events On Board the Lady D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Escape and Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Crew Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Regulatory Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Master . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Mate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Regulatory Requirements for Small Passenger Vessels . . . . . . . . . . . . . . . . . . . . . . . . .10
The Lady D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Safety Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Stability Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Parent Organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Management Hierarchy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Other Seaport Taxi Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Operational Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Docking Agreements with City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Daily Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Passenger Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Weather Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
National Weather Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
National Weather Service Postaccident Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Digiwx System Sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Weatherbug Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Medical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Aspects of Survival in Cold Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
City of Baltimore Consolidated Communication Center . . . . . . . . . . . . . . . . . . . . . . .35
Response Assets for Marine Incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Response of Assets to Lady D Capsizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Contents iv Marine Accident Report
Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Safety Board’s Stability Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Vehicle Performance Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Postaccident Actions by the Coast Guard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Accidents Involving Pontoon Passenger Vessel Stability. . . . . . . . . . . . . . . . . . . . . . .47
Previously Issued Safety Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Status of Sister Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Accident Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Cause of the Capsizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Certification Error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Erroneous Sister Vessel Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Passenger Overloading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Influence of Weight and Wind on Intact Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Passenger Weight Criteria for Stability Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Pontoon Vessel Stability Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Policies and Procedures Pertaining to Weather Operations . . . . . . . . . . . . . . . . . . . . . . . . .63
NWS Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Seaport Taxi’s Weather Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
Adequacy of Propulsive Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
Survivability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
Construction and Arrangement of the Accident Vessel . . . . . . . . . . . . . . . . . . . . . . . . .67
Safety Briefing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Lifejacket Use in Enclosed Deckhouses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Response Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
Previously Issued Recommendation Classified in This Report . . . . . . . . . . . . . . . . . . . . . .76
Appendixes
A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77
B: Intact Stability Study of Lady D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
C: U.S. Coast Guard Policy Letter 04-10, Evaluation of Stability
and Subdivision Requirements for Small Passenger Vessels Inspected
Under 46 CFR Subchapter T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94
v Marine Accident Report
Abbreviations and Acronyms
ASOS Automated Surface Observing System
AWOS Automated Weather Observing System
BCFD Baltimore City Fire Department
BCPD Baltimore City Police Department
BWI Baltimore-Washington International Airport
CAMI Civil Aerospace Medical Institute
CESM Cold Exposure Survival Model
CFR Code of Federal Regulations
COI certificate of inspection
dBZ decibels of Z (where Z = energy reflected back to radar)
EMS emergency medical service
ICAO International Civil Aviation Organization
ISO International Organization for Standardization
LCM-8 mechanized landing craft
LWX Sterling weather radar station
MSC Marine Safety Center
MSO Marine Safety Office
NCEP National Centers for Environmental Prediction
NHS National Historic Seaport of Baltimore
nm nautical mile
NOAA National Oceanic and Atmospheric Administration
NPRM notice of proposed rulemaking
NVIC navigation and vessel inspection circular
NWR NOAA Weather Radio
NWS National Weather Service
OCMI Officer-in-Charge, Marine Inspection
PSST pontoon simplified stability test
SAR search and rescue
SST simplified stability test
TDWR terminal Doppler weather radar
UHF ultrahigh frequency
VHF very high frequency
Abbreviations and Acronyms vi Marine Accident Report
WFO weather forecast office
WSR-88D weather surveillance radar-88 Doppler
vii Marine Accident Report
Executive Summary
On March 6, 2004, the small passenger vessel Lady D, a pontoon water taxi with 2
crewmembers and 23 passengers on board, was en route from Fort McHenry to Fells
Point, Maryland, when it encountered a rapidly developing storm with high winds. The
pontoon vessel began to roll in the waves and eventually continued over onto its starboard
side and capsized. Personnel from the Naval Reserve Center Baltimore, a Navy training
installation adjacent to Fort McHenry, witnessed the capsizing, called 911 to report the
accident, and then launched a vessel to the scene to render assistance. Responders were
able to rescue or recover all but 3 occupants of the Lady D within an hour of the accident.
The bodies of the remaining victims were recovered from the waterway on March 14 and
15. As a result of this accident, 5 passengers died; 4 passengers suffered serious injuries;
and 12 people sustained minor injuries. Vessel damage was estimated at $35,000.
The Safety Board’s investigation of this accident identified major safety issues in
the following areas:
• Passenger weight criteria for stability assessment;
• Pontoon vessel stability standards; and
• Policies and procedures pertaining to weather operations.
The National Transportation Safety Board determines that the probable cause of
the capsizing of the pontoon-style small passenger vessel Lady D was its lack of intact
stability, which was insufficient to withstand the strong winds and waves that the boat
encountered. The lack of intact stability was caused by overloading, which resulted from a
combination of the following:
• The Lady D was erroneously granted sister status by the U.S. Coast Guard to a
pontoon vessel with different design characteristics;
• The Coast Guard certificated the Lady D to carry too many people as a result of
an inappropriate stability test on the vessel to which it was granted sister status;
and
• The Coast Guard’s regulatory stability test standards on which the Lady D’s
passenger allowance was based use an out-of-date average passenger weight.
As a result of this investigation, the Safety Board makes recommendations to the
U.S. Coast Guard.