Unabridged Tall Ship Bounty Sinking Conclusions

INVESTIGATION INTO THE CIRCUMSTANCES

SURROUNDING THE SINKING OF THE TALL SHIP BOUNTY

123 MILES OFF THE COAST OF CAPE HATTERAS, NORTH CAROLINA ON OCTOBER 29, 2012 WITH LOSS OF ONE LIFE AND

ANOTHER MISSING AND PRESUMED DEAD

Conclusions

1. In accordance with reference (d) the Initiating Event (or first unwanted outcome) for this casualty was flooding. BOUNTY began to flood uncontrollably the moment the rate of water ingress exceeded the rate the bilge pumps could dewater. It has been concluded that this occurred on October 27th, when Capt. went to engage the hydraulic bilge pumps, which were seen as “emergency pumps.”

2. The causal factors that led to this casualty are as follows:

a) Environment:
 There were four primary environmental causal factors.

1) The weather was clearly a factor from the beginning of the voyage. Although the
conditions related to Hurricane Sandy didn’t directly affect the vessel until Saturday, October 27th, the crew was stowing gear and preparing the vessel for heavy weather from the time they departed New London, CT. Once the conditions began to worsen, increasing seas accelerated the rate that BOUNTY was making water. The increasing winds blew out multiple sails and caused the spanker gaff to break.

2) The impact of the environmental conditions was also detrimental to the crew. The increasing sea state caused many of the crew members to become seasick. The
conditions also made it difficult to get adequate sleep, not only because of the rough seas, but because the crew sleeping quarters became saturated with water that leaked through the deck. As the voyage progressed and conditions worsened, moving about the vessel became increasingly difficult and 3 crew members were injured as a result of falls, including Capt. .

3) As the vessel foundered and the decision was made to abandon ship, the
environmental conditions impacted the crew’s ability to communicate with the US
Coast Guard, any other nearby vessels, as well as each other on deck. Environmental conditions also made preparations to abandon ship, including donning survival suits as well as lifejackets and climbing harnesses, extremely difficult.

4) Once the crew had abandoned ship, the heavy weather conditions made it exceedingly difficult to get into the inflatable life rafts. Crew members testified that entering the life raft took at least one hour once they reached the raft. Wind and seas caused one of the life rafts to flip during the rescue.
b) Personnel: There are eight primary causal factors that involve human error on the part of the company owner and vessel master.

1) The inability and failure of HMS BOUNTY Organization to provide effective
oversight and operating restrictions for their vessel and personnel. Both
and were responsible for and made critical decisions regarding
the maintenance and operation of BOUNTY. They were ill equipped to make such
decisions due to their lack of experience with vessel operations, especially with
respect to an aged wooden vessel. They each had full knowledge that Capt.
intended to take BOUNTY into close proximity to Hurricane Sandy, and
took no action to stop or question his decision making. This constitutes negligence.

2) The failure of HMS BOUNTY Organization and Capt. to effectively
evaluate and determine if prevailing and forecasted weather conditions were
favorable for sailing. This constitutes negligence.

3) The failure of HMS BOUNTY Organization and Capt. to appropriately
evaluate the vessels material condition and suitability for sailing in the forecasted
weather conditions (given what they both knew about the condition of the vessel’s
structure and the lack of testing to ensure all bilge systems were fully functional and up to the task of performing to designed parameters). This constitutes negligence.


4) Capt. was a mariner that had the respect of his crew, industry peers,
shipyard personnel and company management. From all reports he had tremendous
skill as the BOUNTY’s Master, and knew her better than anyone. That he chose to
embark on this voyage knowing of the vessel’s defects, the magnitude of the storm,
and the experience level of his short handed crew is unconscionable. It seemed that he had supreme confidence in himself and BOUNTY. It can only be surmised that this confidence kept him from recognizing the very real dangers his decisions
imposed on the ship and crew. CM approached him in New London to
discuss other options, but he did not want to take counsel. He was compelled largely by the Chief Mate to hold a meeting with the crew to address their concerns, and convince them he and the vessel were capable of the trip, and that leaving was a way to protect the vessel. The crew chose to stay because they trusted his experience, or they felt he would have gone anyway, and that would have left the ship even more shorthanded. Every tall ship captain interviewed for this investigation indicated disbelief over the actions of Capt. , and stated they never would have left port, or they would have sought a safe berth in sufficient time. Practically every vessel in the Atlantic chose to either tie up, or run from Hurricane Sandy. Capt. chose to steer towards Hurricane Sandy at a near constant bearing and decreasing range with no compelling reason to do so. His actions conflicted with all known maritime methodologies for storm avoidance. It can only be concluded that he was not trying to avoid it at all. He purposefully placed his crew and his vessel into extremely dangerous conditions. This constitutes negligence.

5) Capt. decided to notify the Coast Guard and HMS BOUNTY Organization
regarding their distress much too late. When asked by CM S to call the Coast
Guard, he refused stating that they would be better off working on the pumps. His
decision smacked of pride, and was illogical given the danger they were in. He
should have made calls for assistance on Saturday, October 27th at the first indication that the electric bilge pumps were not keeping up with the water ingress. This would have given them some opportunity to come up with an alternate plan or better their chances to receive assistance. This constitutes negligence.

6) was hired as the engineer for BOUNTY, even though an
engineer is not required due to its operation as a recreational vessel. That being said, he did not have sufficient experience with vessel systems to adequately perform his duties. He also was not given appropriate time or orientation to the vessel. Additionally, any effectiveness he would have provided was diminished by his injuries and extreme sea sickness, which began to be apparent on or about October 27th.

7) BOUNTY sailed from New London with less than a full complement of crew.
Surviving crew members testified that, from the point of departure, each crewmember
was doing several jobs at once. They had their normal duties, but were also busy
preparing the vessel for rough seas. When the seas started to get rough they were
forced to have two people on the helm, and have someone constantly stand by the
bilge pumps. As the voyage progressed the number of effective crew became less
and less due to injury, sea sickness and fatigue.

8) The crew that sailed with BOUNTY from New London had limited sailing
experience, and were not properly trained in several vital areas. The crew had not
done a fire or abandon ship drill in over two months, and Cook and Engineer
had never been involved in one. No one had training on how to use the
hydraulic bilge pumps or the gasoline powered trash pump. This is despite the fact
that they knew that they were sailing into a hurricane, and BOUNTY had a history of taking on water, more so in a heavy seaway.

c) Equipment:
There are seven primary causal factors that involve equipment.

1) The port generator and port main diesel engine shut down due to lack of fuel during the rough weather. This reduced the vessel’s speed, maneuverability, and ability to dewater the vessel.

2) There was no way to accurately gauge the port day tank level due to a broken sight glass. Failure to notice the broken sight glass by the crew during boat checks likely contributed to the port day tank running out of fuel, and therefore the loss of the port main engine and port generator. The crew also apparently failed to notice the trend when they logged the fuel level in the engine log book as per their Boat Checks.

3) The effectiveness of the electric bilge pumps was in question from the time the vessel left Boothbay, ME. Crew reported that they did not think the system was pumping water with the same efficiency and they were having trouble keeping the pumps primed. They were never able to determine why the pumps were not working correctly. The pumps were likely clogged with debris.

4) The portable hydraulic pump was initially inoperable due to insufficient maintenance. Once it was finally engaged, its effectiveness was limited because it was continually clogged with debris in the bilges.

5) The fixed hydraulic bilge pump was inoperable. No crew could provide any
information on when it was last operated or tested. The fixed pump was also not
optimally piped and configured to maximize the pumping capacity.

6) The portable gasoline powered trash pump was inoperable, but would have been of little value due to the insufficient capabilities of the pump, as well as the emission of dangerous fumes when operated inside the vessel.

7) The BOUNTY’s single side band radio and INMARSAT C phone were not
operational when the decision was made to request assistance. As they were not
tested prior to departure from Boothbay or New London it is not known how long
they were not functional.

d) Safety Standards:
There are four primary causal factors that involve safety standards.

1) The BOUNTY’s only written safety doctrine was the “HMS Bounty Crew Manual”.
There was no direction or input by the HMS BOUNTY Organization, which meant
that the creation, implementation and execution of safety management onboard the
vessel were left solely to Captain and his crew. With no oversight from
the owner or independent outside source, Captain instituted a safety
culture on the vessel with insufficient standards especially in the area of voyage
planning and emergency operations.

2) During this voyage, the BOUNTY was operating as a recreational vessel and thus was not subject to the 1) more stringent manning requirements for commercial vessels; 2) load line requirements, and; 3) immediate marine casualty reporting requirements of 46 CFR Part 4, which serves to make the Coast Guard aware of distress situations with vessels and provide assets to assist them.

3) The crew members adopted safety practices with the use of their lifesaving equipment that compromised the effectiveness of the gear. The addition of personal flotation jackets and climbing harnesses on top of survival suits did not increase the survival suits’ effectiveness. Instead the additional equipment became a hazard for catching in the rigging causing several crew members to be pulled under water and nearly drowned.

4) The vessel did not comply with the MSC issued stability letter. This had no bearing on the casualty as intact stability compliance was not a contributing factor.
The weight and moment changes that were performed after the 2009 incline test
invalidated the MSC issued stability letters of 2009 and 2011. However, the vessel was not subject to the requirements of these letters per the Code of Federal
Regulations. Overall, the alterations to the vessel, such as moving ballast to change trim, moving the tank and berthing spaces, removal of the top of the mizzen mast, did not likely change the vessel’s stability characteristics appreciably. These changes did not significantly contribute to the casualty.

e) The Hull:
There are two primary causal factors that involve the hull.

1) The age of the vessel’s main structural members, presence of rot, and use of materials not generally used or designed for the marine environment all likely contributed to the vessel taking on water in multiple locations leading to the progressive flooding, but the age of the vessel is the main contributor. Under normal operating conditions, both underway and at the pier, BOUNTY relied on her bilge pumps to maintain buoyancy due to the continuous ingress of water through the hull planking. In a heavy seaway the frequency and duration of bilge pump “run time” increased, because the proportional increase in water ingress as a result of the hull working. All crew testified to this fact, and BOUNTY had a history of near misses related to flooding. BOUNTY taking on water was apparently an occurrence that was accepted as the norm for wooden vessels. While it is not unusual for wooden hull vessels to make more water in a seaway, a vessel relying primarily on bilge pumps to stay afloat is a sign of more serious defects within the hull structure.

2) Had the vessel been sufficiently watertight by design or retrofit, it may have survived. The historically accurate yet obsolete arrangement of a ‘tween deck with transverse bulkheads that are not watertight to the weather deck impacted the vessel’s inherent survivability, especially once flooding was uncontrolled. Had the vessel met the watertight integrity standards detailed by ABS Load Line Surveys, the ingress of water may have been at a rate where the installed dewatering systems may have been adequate for the weather and sea conditions leading up to the casualty.

3. The causal factors that existed or occurred during the rescue efforts and abandoning ship are as follows:
a) Abandoning Ship: The leading cause that contributed to the loss of Capt. at
sea and the death of Deckhand Christian was Capt. decision to order the
crew to abandon ship much too late. However, under the unique circumstances of the approaching storm center, even if the order had been given earlier, there is no guarantee that assistance would have arrived or either of them would have survived. It was fortunate that Capt. e recognized that the water reaching the tween deck was a critical moment, and he ordered the crew to evacuate to the weatherdeck. However, testimony from CM indicates that Capt. believed that the vessel was going to simply fill up and settle down into the water, and that the Capt. believed the vessel was incapable of sinking. CM tried to impress upon Capt. moments before the capsizing that they needed to abandon ship, but Capt. e
refused until it was much too late. He failed to recognize the vessel’s rolling in the heavy seas was producing a powerful free surface effect on the tween decks that, when combined with the vessel’s low freeboard, expedited the vessel heeling over. When the vessel laid over, the crew was forced into the water in a disorganized fashion, rather than abandoning ship as part of a planned and coordinated evolution. The violent rolling continued and caused the masts and rigging to slam up and down injuring several of the crew. Any chance of an organized departure was lost, and it was every person for themselves. There was no opportunity to make sure that injured crew members were assisted, and the fatigued state of the crew hampered their ability to enter the life rafts. It is recognized that abandoning ship into the liferafts presents a challenge even in the
best of sea conditions, much less in the existing weather conditions, which proved to be extremely difficult. The fact that the crew had not drilled in months (some never) no doubt complicated matters greatly.
Captain actions/and or inactions in this regard constitutes negligence.

4. There is substantial evidence that HMS BOUNTY Organization LLC. and Capt.
, Master of the BOUNTY, and the holder of an MMC, through their actions or
inactions, committed acts of negligence that contributed to the cause of this casualty and the death of one person, as well as Capt. own presumed death.

5. There is no evidence that the use of dangerous drugs or alcohol contributed to this casualty, because drug testing was not conducted.

6. With the above exceptions, the investigation did not identify any inconsistencies with regards to the vessel’s compliance with the regulations for recreational vessels contained in 33 CFR Parts 175 and 183.

7. There is substantial evidence that work/rest related issues contributed to this casualty. The crew was suffering from fatigue which was born out of lack of sleep, being sea sick, and from the physical exertion of fighting to save the vessel while in extreme weather conditions for over 24 hours.

8. There is no evidence that any act of misconduct, incompetence, negligence, lack of professionalism, and/or willful violation of law committed by any officer, employee, or member of the Coast Guard contributed to this casualty.

Recommendations
Safety:
If HMS BOUNTY Organization representatives or Capt. had exercised the proper
responsibility, judgment and prudence expected of a professional maritime company or a merchant mariner this casualty would have been prevented. HMS BOUNTY Organization only operated one vessel, and it is not known if they plan ever to operate a vessel again. It can be argued that the simple lessons to be learned from this investigation is that Masters in command of a vessel and crew must have a profound respect for the sea and the forces of nature, and the
value of a vessel pales in comparison to that of a human life. However, this casualty did provide insight to policy gaps and areas where safety recommendations would be useful as lessons learned. Recommendations to HMS BOUNTY Organization are done so in the hopes that the Tall Ships America fleet or similar entities will heed them.

1. It is recommended that the Commandant of the Coast Guard review the policy for attraction vessels and evaluate their regulatory status when traveling from port to port, and determine whether the classification of any of these vessels as recreational is appropriate. This policy should be updated accordingly.

2. It is recommended that the Commandant of the Coast Guard review the Officers Competency Certificates Convention, 1936 and the manning regulations in 46 CFR Part 15, Subpart G to determine if the term “uninspected vessel” is intended to exclude recreational vessels from the requirement for licensed mates and engineers for documented, self propelled sea going vessels over 200 gross tons.

3. It is recommended that the Commandant of the Coast Guard establish policy or provide guidance to the Officer in Charge, Marine Inspections (OCMI) on the protocol, scope, limits and or responsibilities/liabilities of conducting inspection type activities (plan review/approvals, construction/repair oversight, system installation & testing, etc.) on uninspected or recreational vessels.

4. It is recommended that the Commandant of the Coast Guard review Navigation and Inspection Circular (NVIC) 2-00, Marine Events of National Significance (MENS), and revisit the determination to allow attraction vessels or other uninspected and recreational vessels to carry passengers for hire underway via a special permit under the cognizance of a MENS event.

5. It is recommended that the Commandant of the Coast Guard revise Navigation and Inspection Circular (NVIC) 7-94, Guidance on the Passenger Vessel Safety Act of 1993, and address the use of volunteers on attraction and sail training vessels while underway.

6. It is recommended that HMS BOUNTY Organization establish organizational policy that defines how the organization manages risk, establishes effective communication throughout the organization, establishes a process for identifying and correcting defects, sets clear safety and environmental standards, and implements a continual improvement process.

7. It is recommended that HMS BOUNTY Organization establish a policy that dictates vessel operational parameters based on weather, sea state or destination and it requires consensus between qualified persons afloat and ashore. “Go/no go” decisions should be based on consideration of vital system functionality (such as bilge systems), crew strength and fatigue.

8. It is recommended that HMS BOUNTY Organization establish organizational policy and requirements for the hiring of a professional engineer, and provide him/her clear task direction on expected duties and performance.

9. It is recommended that the Commandant of the Coast Guard provide a copy of this report to the following entities:
a. Area, District, and Sector Commanders;
b. Estates of the deceased;
c. Parties in interest;
d. Tall Ships America;
e. The National Transportation Safety Board;
f. All Federal and State Maritime Academies;
g. Institutes where approved Basic Safety Training is offered.

Enforcement:
1. There is no recommended enforcement action at this time.
Other:

1. The men and women from U.S. Coast Guard Sector North Carolina, Air Station Elizabeth
City, USCGC ELM, and the Fifth District should be commended for their efforts during the BOUNTY Search and Rescue efforts from October 29 – November 1, 2012. Their actions went above and beyond the call of duty.

2. The Investigations National Center of Expertise (INCOE) was established in 2009 as a result of the Commandant of the Coast Guard’s Marine Safety Performance Plan. The INCOE’s mission is to support the execution of the Coast Guard’s Investigation Program. Their support was integral into the success of this investigation.

3. is commended for coming forward regarding the condition of BOUNTY’s
hull. Multiple interviews were conducted with the BOUNTY Organization, the crew and ship yard personnel, and no one acknowledged the decay until he did.

4. This casualty investigation should be closed.