The Office of Investigations and Casualty Analysis issued Findings of Concern 006-19, “Impacts of Modifications, Alterations, and Weight Creep on Stability,” after the fishing vessel Destination marine board of investigation concluded that unsafe stability conditions, combined with an open deck hatch and a fatigued crew, were the primary factors leading to the tragedy.
Coast Guard investigators identified the following voluntary actions for an owner / operator of similar vessels and operations to consider in order to reduce the likelihood of recurrence:
• Owners, operators, and masters should maintain an active awareness of vessel stability issues at all times, including the need for qualified individuals and naval architects to update stability instructions and booklets when structural changes are made to a vessel, other equipment or operational gear is changed, or their placement is altered. Furthermore, qualified individuals and naval architects should take the opportunity when stability instructions and booklets are updated to examine the vessel’s stability history to ensure previous stability calculations were sound and are suitable to continue to serve as a solid basis for any changes and updates.
• Owners, operators, and masters are encouraged to attend formalized stability training that should include stability principles regarding overloading, the effects of alterations and weight creep, icing, watertight integrity, deck drainage, and other issues particular to their type of vessel and fishery.
• Owners and operators are encouraged to take advantage of the flexibility of the stability instruction requirements for uninspected commercial fishing vessels in 46 CFR 28.530. These regulations, applicable to vessels 79 feet or over, intentionally provide maximum flexibility for owners and qualified individuals to determine how best to convey stability information to the masters or individuals in charge of their vessels. In doing so, they should take into consideration that operating personnel in the commercial fishing industry do not typically have specialized stability training.
• Owners, operators, masters, qualified individuals, technical superintendents and other personnel need to remain fully cognizant of “weight creep,” which is the result of modifications and alterations to the vessel that occur over its lifespan. Modifications and alterations may occur due to changing fisheries, fishing methods, variations in equipment and area of operation. These weight changes impact stability, and ultimately create the need for a qualified individual to revisit the stability instructions and associated calculations.
• One way to prevent “weight creep” is to develop a Modification and Alteration Log which can be maintained in various formats. The log can be as simple as a notebook or spreadsheet, or in the form of computer software. The vessel’s existing stability instructions and data should be first validated by a qualified individual or naval architect prior to creating a log to ensure future stability calculations start from an accurate baseline.
Coast Guard issues Findings of Concern to disseminate information related to unsafe conditions that investigators identified as causal factors in a casualty and could contribute to future incidents. Findings of Concern are intended to educate the public, state, or local agencies about the conditions discovered so they may address the findings with an appropriate voluntary action or so they can highlight existing applicable company policies or state/local regulations within their areas of influence. These findings of concern are provided for informational purpose only and do not relieve any domestic or international safety, operational, or material requirement.
The complete Destination Report on Investigation and Commandant’s Final Action Memo are available on the Coast Guard’s FOIA website.
Findings of Concern from other marine casualties available for download:
2/8/2019: Enhanced Passenger Safety Measures
2/8/2019: Crewmember Experience and Familiarity Requirements
2/8/2019: Emergency Notifications to the Coast Guard by VHS Radio
2/8/2019: Hazards of Low Visibility Diving
2/7/2019: Dredge Operation Manning Levels
6/18/2018: Improper Fixed Carbon Dioxide Servicing Procedures
7/16/2018: Effective Communications
This blog is not a replacement or substitute for the formal posting of regulations and updates or existing processes for receiving formal feedback of the same. Links provided on this blog will direct the reader to official source documents, such as the Federal Register, Homeport and the Code of Federal Regulations. These documents remain the official source for regulatory information published by the Coast Guard.