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707.300.110429.USCGPathfndrFAMrpt.

pdf
Received 5/5/2011

u.s. Department o~ Commander


Seventeenth Coast Guard District
PO Box 25517
Juneau, Alaska 99802-5517
Homeland Security
Staff Symbol: (d)
Phone: (907) 463-2025
United States Fax (907) 463-2037
Coast Guard Email: Christopher.C.Colvin@uscg.mil

5800

From: CH LV DM
CGD SEVENTEEN (d)

To: D. P. VERFAILLIE, CDR


CG MSU VALDEZ
Thru: CG SECTOR ANCHORAGE (s)

Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD


ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF
THE TUG PATHFINDER ON 23 DEC 09

Ref: (a) Administrative Investigations Manual, COMDTINST M5830.lA


(b) Memorandum, Administrative Investigation into Coast Guard actions and response
activities concerning the grounding of the tug PATHFINDER on 23 DEC 09 dated
22 JAN 10
(c) USCG Regulations, COMDTINST M5000.3 (series)
(d) Vessel Traffic Services National Standard Operating Procedures Manual (VTS
NSOP), COMDTINST M16630.3
(e) VTS Prince William Sound Standard Operating Procedures, MSUVALDEZINST
16630A
(f) Prince William Sound - Vessel Escort and Response Plan (VERP) - Published
January 2007
(g) U.S. Coast Guard Vessel Traffic Service Prince William Sound - User's Manual
(Eighth Edition - September 2008)

1. Having considered reference (a) and other applicable references, appropriate actions are
hereby ordered, and this administrative investigation is closed. A summary of the pertinent facts
and my opinions based on those facts are herein provided. All times provided are in Alaska
Standard Time. Progress with respect to the ordered actions shall be reported on a monthly basis
to CGD SEVENTEEN (dcs) until all ordered actions have been implemented.

2. This investigation was directed for the purpose of ascertaining the facts and circumstances
associated with the mishap and to provide recommendations for the implementation of improved
procedures which, ultimately, reduce the risk of similar incidents occurring in the future. The
actions of the master and crew of the Tug PATHFINDER ("PATHFINDER") have been
investigated under a separate Coast Guard Marine Casualty Investigation. This informal
administrative investigation was not intended to determine the cause of the PATHFINDER
grounding. This investigation must be viewed in conjunction with the Marine Casualty
Investigation to fully understand the cause of this casualty.

3. Factual Summary.

a. On 23 December 2009, the Ship Escort/Response Vessel System (SERVS) directed the
PATHFINDER to serve as an Ice Scout Vessel (ISV) to conduct ice scouting operations and
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011

Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

provide an ice report in accordance with the Vessel Escort and Response Plan (VERP).

b. Ice reports are required pursuant to the VERP to provide periodic situational updates
regarding the presence of icebergs which can create navigational hazards in the vicinity of
Bligh Reef. Icebergs are produced throughout the year due to calving of the nearby
Columbia Glacier, some of which occasionally drift into the nearby Traffic Separation
Scheme (TSS).

c. The VERP is designed as a port specific guide to further aid and enhance the safety of
tanker navigation and the protection of the marine environment within the waters of the
Prince William Sound. The Prince William Sound Regional Citizens Advisory Council
(PWSRCAC), the SERVS, and the Coast Guard Captain of the Port Valdez are all signatories
to the VERP.

d. The VERP requires an "ice scout" to visually check for ice in the vicinity of Bligh Reef
no longer than six hours prior to a tanker transiting Prince William Sound. An ice report was
required due to the scheduled departure of the tanker KODIAK which was scheduled to
depart outbound from the Port of Valdez later that evening. Although the PATHFINDER
was designated as an ISV for 23 December 2009, an ice scout is not specifically required to
be a tug. Virtually any vessel or even an aircraft can serve as an ice scout. The primary
objective is to visually identify any floating ice that may endanger a tanker transit through
the TSS.

e. An ISV is defined as "any suitably sized vessel equipped with an operational radar and
searchlight." Due to size and power limitations, the PATHFINDER does not provide tanker
escort services and was regularly chosen by SERVS to perfolm ice scouting duties.

f. At approximately 1402, the PATHFINDER checked into the Prince William Sound
Vessel Traffic Service Area (PWS VTSA) and indicated they were enroute to Bligh Reef to
provide the ice report. As a Vessel Movement Reporting System (VMRS) user, the
PATHFINDER was required to check-in with the Vessel Traffic Service (VTS) to provide an
initial sail plan, report any deviations from the initial sail plan, or check-out of the VMRS
when transit or operations were complete.

g. The PATHFINDER was not required to check-in at any of the designated VTS RepOlting
Points in the PWS VTSA because the Ports and Waterways Safety System (PAWSS) at
Vessel Traffic Center (VTC) Prince William Sound received Automatic Identification
System (AIS) information from the PATHFINDER. VTS Prince William Sound was also
able to track vessels operating in the PWS VTSA, including the PATHFINDER, based on
information provided from the USCG radar site on Reef Island.

h. The PATHFINDER did not encounter any opposing or overtaking traffic during its
outbound transit.

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Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

i. At approximately 1649, the PATHFINDER provided an ice report reporting no ice in the
area while abeam Bligh Reef, in the outbound traffic lane.

j. At 1650, the PATHFINDER reported on-scene weather in the vicinity of Bligh Reef as
follows: four-foot swells from the south, southeast winds at 15 knots and visibility of
approximately four nautical miles. At this time, the PATHFINDER also stated that they
would remain in the vicinity of Bligh Reef until 1800 in order to provide an 1800 ice report.
This was in anticipation of an outbound transit by the Tanker KODIAK from the Port of
Valdez later that evening.

k. Earlier in the day, at 0520, Cape Hinchinbrook Entrance was closed to all outbound laden
tanker vessels due to weather. The 1800 ice report would extend the window of opportunity
for the Tanker KODIAK to depart Valdez to midnight if the Cape Hinchenbrook entrance
was opened later in the day.

l. At approximately 1654, the PATHFINDER began to cross the TSS toward the inbound
lane.

m. At 1657 relieved of the VTC Watch Supervisor


(VTCWS) duties. In addition to normal watchstanding responsibilities, the VTCWS in
Valdez is responsible for performing a variety of routine maintenance and unit security duties
while on watch. These duties include security rounds, colors, unlocking access doors, and
removing snow from the front-door sidewalk in extreme snow-fall situations. VTC
watchstanders are permitted regular breaks (at least 15 minutes every 3 hours)

n. The VTS Prince William Sound Internal Standard Operating Procedures (ISOP) provides
for minimum manning requirements that ensure 24-hour coverage of the VTS. Section
4.B.I.a provides that "[alt least one of the two personnel assigned to the watch must be in the
VTC at all times" and that "during inbound and outbound tanker transits of the Valdez
Narrows, when hazardous circumstances exist or are anticipated anywhere within the PWS
VTSA both rwatchstanders I shall be present to monitor the transit." Both the VTS National
Standard Operating Procedures (NSOP) and ISOP also provide for mandatory minimum rest
periods of at least 15 minutes for every 3-hour period for all watchstanders.

o. At approximately 1724, the PATHFINDER crossed and departed the TSS and continued
ice scout duties in vicinity of Bligh Reef. ISV's typically travel at various courses and
speeds and close to reefs and shoal water when transiting outside the TSS. Since ISV's
routinely operate in close proximity to Bligh Reef, neither watchstander detected any
anomalous activity associated with the PATHFINDER's operations.

p. At 1725, relieved LT of the VTC Specialist


(VTCS) duties. LT duties include her primary responsibility as VTS Chief,
and she remained on scene at the VTC following her relief.

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707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011

Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

q. At approximately 1800, the PATHFINDER provided an ice report reporting "no visible
ice" to the VTS.

r. At approximately 1802, the PATHFINDER, while on a south-southeast heading at an


approximate speed of 3.5 knots, reported to the VTS that they had been released of ice
scouting duties by SERVS and were headed back to Valdez. . the duty VTCS,
acknowledged receipt of the PATHFINDER's radio communication.

s. At approximately 1803, the PATHFINDER turned on a northerly heading and increased


speed to approximately 11-13 knots. At this time, the PATHFINDER was approximately 1
Y2 miles due south of Bligh Reef.

t. Since the PATHFINDER's activity was consistent with both watchstanders experience
with respect to ISV operations, neither watchstander magnified the location of the
PATHFINDER on their radar screen. Both watchstanders maintained the radar scale at a
smaller scale setting in order to provide maximum visual coverage of the PWS VTSA and
the entire Vessel Traffic Lanes. At this scale setting, the PATHFINDER's location could not
be differentiated from Bligh Reef.

u. At 1814, the PATHFINDER reported to VTS via channel 13 that the vessel was aground
on Bligh Reef. The location of the PATHFINDER was within the PWS VTSA but was
operating well outside of the TSS.

v. Both VTS watchstanders stated that at the time of the grounding, they were both actively
watching their consoles and focused on monitoring the entire TSS. Immediately following
the PATHFINDER's report of grounding, the VTS watchstanders replied via radio to the
PATHFINDER and followed standard procedures as they had been trained. They used the
Quick Response Cards (QRC) for both search and rescue (SAR) and marine pollution and
conducted notifications up the chain of command.

w. At the time of the grounding, the weather and tidal information was as follows:

I) Tides: were estimated to be +8.74 foot tide ebbing to a low tide of +2.48 foot at
approximately 2330.

2) Currents in the vicinity of Bligh Reef were estimated to be weak and variable.

3) Weather: The NOAA West Orca Bay weather buoy, located 15 NM south of Bligh
Reef, recorded 7-8 foot seas with east-southeast winds at 23 knots.

x. At 1826, VTCWS delivered notice of the grounding to , Executive


Officer (XO), Marine Safety Unit (MSU) Valdez, who at the time was also serving as the
Acting Commanding Officer (CO) of MSU Valdez since CDR Darryl Verfaillie, CO, was on
leave.

4
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011

Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

y. At 1827, notified CDR Verfaillie of the situation. CDR Verfaillie


immediately checked off of leave and resumed command. At approximately 1900, CDR
Verfaillie arrived at VTS Prince William Sound.

z. Shortly after the report of the grounding, the CGC LONG ISLAND was dispatched from
Valdez to provide on-scene information regarding the PATHFINDER's status.

aa. The USCG Sector Anchorage Command Center (CC) was monitoring marine radio
frequencies and began to communicate with the PATHFINDER to assess the need for
potential SAR assistance.

bb. At 1845, the PATHFINDER notified the CC that the tug was no longer aground and was
heading to the northeast where it anchored just northeast of Bligh Reef.

cc. CDR Verfaillie suspected the damage to the PATHFINDER may not be in excess of
$100,000 and was uncertain on the amount of fuel discharged; consequently, post-accident
drug testing for the VTS watchstanders was considered but not conducted shOitly after the
grounding. In accordance with the NSOP, Commandant (CG-1312) was notified on 28
December 2009 that a required post-accident test for illegal drug use was not conducted
within four hours of the accident. Drug testing of the watchstanders was conducted at 1000
on 28 December 2009 following direction by District Seventeen. Drug test results were
negative for all personnel tested.

dd. The Processed Ice Radar Picture (PIRP), designed to feed into the VTS system and
provide watchstanders with current information on the amount of ice in the TSS, was
installed in the VTS in February 2009. However, on 23 December 2009, the PIRP was not
available to the VTS because the ice processor had not been upgraded to be compatible with
the Terma radar upgrade completed in 2 October 2009. VTS watchstanders considered the
PIRP to be a good situational awareness tool for the VTC; however, use of the PIRP did not
circumvent the VERP requirement for on-scene ice reports delivered by vessel or aircraft.

ee. Although physically located in the VTC, the PIRP is neither owned nor maintained by the
Coast Guard. Under standard Coast Guard policy, Coast Guard technicians are not
authorized to repair or upgrade non-standard, non-Coast Guard property. However,
anticipating the potential need, the Coast Guard specifically left a port open on the Terma
radar for a technician to access and upgrade the system and notified the PWSRCAC and
SERVS in July 2009 that the system was inoperable absent an upgrade.

ff. The VTS program was established by the Ports and Waterways Safety Act, 33 U.S.c.
1221 et seq, to employ navigation safety systems and practices to reduce risk and to facilitate
maritime commerce in U.S. ports and waterways. The primary function of a VTS is to
facilitate good order and predictability on a waterway by providing a variety of services to
mariners operating in and around the ports where VTS systems have been implemented.

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Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

These services include: providing infonnation to mariners such as positions, intentions, and
destinations of other vessels operating within a VTSA; traffic organization information
which includes providing advance planning of movements, mandatory position reporting, or
speed restrictions through certain areas; and, upon request, providing navigation assistance to
vessels which includes positions relative to waypoints, ATON, and navigational infonnation
such as course or speed made good.

gg. VTS watchstanders are required to provide traffic advisories to vessels equipped with
operational Automatic Identification Systems (AIS), including the PATHFINDER, that elect
to make automated reports. A vessel traffic advisory includes infonnation regarding "all
traffic a vessel may encounter both visually and by radar while transiting the VTSA." VTS
watchstanders are instructed to "anticipate changing conditions to include weather, vessel
speeds, locations, operations, and the embarking/disembarking of pilots at the pilot station.
Traffic advisories shall be passed to enhance safety and vessel navigation. They shall be
passed when applicable and between reporting points, if needed." On 23 December 2009, no
traffic advisory was provided to the PATHFINDER because there was no other traffic
operating in the PWS VTSA throughout the PATHFINDER's transit.

hh. Unless requesting navigational assistance from the VTS or operating in the shipping lanes
and endangering TSS traffic, tug boats, fishing boats, charter boats and other smaller craft do
not normally receive traffic advisories from the VTS and are responsible for their own safe
navigation throughout Prince William Sound. The PATHFINDER did not request
navigational assistance at any time during their operations leading up to the grounding.

ii. All VTS Prince William Sound da and night watchstanders on 23 December were fully
qualified. The personnel on watch. and accounted for a total of 21
years total combined years of VTS experience and both had previously attended the National
VTS Operator Course at the Maritime Institute of Technology and Graduate Studies
(MITAGS).

jj. Previous meetings were held prior to the 2009 Ice Season with port partners (MSU
Valdez, SERVS and the PWSRCAC) to discuss ice routing procedures. Based on these
meetings and stakeholder input, the VTS made minor revisions to the Ice Routing Section of
the ISOP manual. At that time, neither the VERP nor the ISOP specifically identified the
operational duties and responsibilities, including area of operation, for an ISV.

kk. All Aids to Navigation (ATON) throughout the PWS VTSA were fully operational and
watching properly at the time of the grounding.

4. Opinions.

a. As a learning organization, the Coast Guard always seeks ways to improve performance.
This investigation was intended to assess whether improvements could be made to the vessel
traffic service provided to Prince William Sound. This investigation was not initiated under

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Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

any presumption that any action or inaction by the VTS watchstanders contributed in any
way to the grounding of the PATHFINDER.

b. In reviewing the watch routine and practices of the personnel on watch and comparing
this to the ISOP, the NSOP, and the Code of Federal Regulations, the actions of the VTS
watchstanders were fully in compliance with those policies, rules and regulations. I have
determined that the actions of the VTS watchstanders did not contribute, either directly or
indirectly, to the PATHFINDER grounding on Bligh Reef. With respect to other potential
causal factors, specifically the actions of the PATHFINDER's master and crew which may
have contributed to the grounding, the Coast Guard conducted a separate Marine Casualty
Investigation which specifically addressed these separate factors.

c. Pursuant to 33 CFR § 161.11 (VTS Measures), "conditions of vessel congestion,


restricted visibility, adverse weather, or other hazardous circumstances, a VTS may control,
supervise, or otherwise manage traffic, by specifying times of entry, movement, or depat1ure
to, from, or within a VTSA." The most recent weather report provided by the
PATHFINDER (85 minutes prior to grounding) indicated weather conditions of four-foot
swells, a southeast "breeze" of 15 knots, and visibility of about four nautical miles.
Recognizing that PATHFINDER's operations were observed to be consistent with typical
ISV operations and the absence of any additional reports indicating a change of weather
conditions, VTS watchstanders did not suspect that the PATHFINDER was in danger of
creating a hazardous situation, posing a danger to other vessels, or engaging in any activity
which would require the watchstanders to initiate any of the affirmative control measures
provided under 33 CFR § 161.11. Given the non-standard nature of the operations of ISV's,
it is not reasonable to expect that VTS watchstanders would or should have performed in a
maimer any different than what occurred leading up to the PATHFINDER grounding. The
unique facts surrounding this incident do not indicate a need to modify VTS Prince William
Sound procedures for monitoring the much higher risk tanker traffic transits into and out of
the Port of Valdez operating inside the TSS.

d. Further, 33 CFR § 161.10 (Services) provides that "a VTS may issue advisories or
respond to vessel requests for information, on... hazardous conditions or circumstances"
within the VTSA. The above referenced federal regulations are consistent with the Coast
Guard position that, absent a specific request from the vessel, these measures and services are
discretionary in function and are issued based on the judgment of the VTS watchstander. In
reviewing the radio transmissions from 23 December, such a request was never made by the
PATHFINDER. Based on the experience of the watchstanders in observing vessels
operating in the vicinity of Bligh Reef, there was no reason to transmit an unsolicited
advisory.

e. Since both watchstanders were at their assigned stations at the time of the grounding, the
requirement for a VTCWS to perform minor housekeeping or security tasks while on watch
was not a contributing factor to the PATHFINDER grounding. The requirement for the

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707.300.110429.USCGPathfndrFAMrpt.pdf
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Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

VTCWS to perform these infrequent tasks is not considered an impediment to the


watchstanders ability to monitor the safe transit of vessels throughout the PWS VTSA.

f. The inoperative PIRP was not a factor to the grounding of the PATHFINDER since the
visual ice report was required in accordance with the VERP. When it was operational, the
PIRP feed into the VTS was considered beneficial to help determine the amount of ice in the
TSS, but was never used as a substitute to the visual ice report to initiate closure of the traffic
lanes. The Coast Guard made proper notifications and outreach with respect to notifying
PWSRCAC and SERVS regarding the Terma radar upgrade of 2009 on Reef Island and the
impact it would have on the PIRP operability.

g. VTS Prince William Sound is a critical component for ensuring the safe movement of
vessel traffic in the TSS and through the PWS VTSA. As indicated above, current
authorities satisfactorily ensure the safe movement of crude oil tanker traffic inside the TSS
and through Prince William Sound. Although PATHFINDER ultimately grounded on a
known navigational hazard, it appeared to VTC watchstanders to be operating in conformity
with typical ISV operations. This incident does not serve as an indication that the VTS was
not working properly. In this instance the entire VTS system, both human and equipment,
operated in conformity with applicable requirements and regulations and was not a
contributing factor to this mishap.

h. The purpose of the VTS is to help mariners safely navigate through a VTSA where there
is typically a high volume of vessel traffic. It is not intended, nor should it be expected that
the presence of a VTS in a port should relieve professional mariners from the responsibility
to adhere to prudent and vigilant navigation practices. In the maritime industry, it has always
been customary to bestow full responsibility for the safe navigation and operation of a vessel
to the captain. This basic principle is also supported under federal law, which provides under
33 C.F.R § 161.1 that "the master is responsible for the safe navigation of the vessel." The
captain of a vessel is ultimately responsible for the safe navigation of their vessel. VTS
Prince William Sound has adequate authorities to ensure the safe, non-obstructed transit of
crude oil tankers inside the traffic separation scheme and through Prince William Sound.

i. The PATHFINDER ran aground while conducting normal duties operating outside the
TSS. While the PATHFINDER was associated with SERVS, this situation could have just as
easily involved a fishing boat, chm1er boat, recreational vessel or another vessel not
associated with SERVS.

5. Additional Comments

a. Although not specifically addressed in the investigation, there was speculation among
some Prince William Sound stakeholders that the Coast Guard either had or should be given
authority to actively direct all vessels all the time inside the PWS VTSA (the expansive area
of Prince Williams Sound as differentiated from the more narrowly defined TSS) in order to
prevent all marine casualties. The proposition was offered that the Coast Guard should adopt

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Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

a vessel traffic control scheme similar in operation to the air traffic control scheme
administered by the Federal Aviation Administration (FAA). I do not agree with this
suggested modification of the VTS function for several reasons, including the following:

1) As discussed above, the authorities provided to the Coast Guard for the operation of
VTS do not mirror authorities those authorities employed by the FAA in regulating
movement in restricted airspace; the former relying on the captain of a vessel to safely
navigate their vessel as compared to the specific courses, speeds, and altitudes provided
to aircraft by the latter. Should the Coast Guard be given additional authority and the
requirement to actively track and direct all vessels and ensure they navigate safely inside
a VTSA, the Coast Guard would need significant additional resources.

2) There are significant differences between air traffic and vessel traffic control systems.
Unlike controlled airspace for aircraft, vessel traffic systems rarely, if ever, provide
actual courses and speeds to steer. They provide navigational assistance only when
requested. Due to the high degree of responsibility given to masters of vessels; vessel
traffic systems, with limited exceptions, are generally advisory in nature. Unlike aircraft,
vessels can be stopped or even anchored.

b. Since full radar coverage of Prince William Sound was completed post-EXXON
VALDEZ, VTS Prince William Sound has helped facilitate the safe movement of 9.4 billion
barrels of oil.

6. Actions. The following actions are ordered for CG MSU Valdez:

a. Conduct an Internal Review Board (IRB) at VTS Prince William Sound in compliance
with the NSOP.

b. Review VTS Watchstanders assigned duties to ensure they do not have the potential to
interfere with watchstander duties or could be better accomplished by another crewmember
of the unit.

c. Work with local stakeholders in developing an SOP for the PIRP, if it becomes
operational.

d. Review the duties of an ISV with Prince William Sound stakeholders to determine
whether ISV duties should be more specified or whether it is better to leave the duties of an
ISV as flexible as possible similar to current operations.

e. Review the VERP with Prince Williams Sound stakeholders to determine whether the
VERP needs to be amended.

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Subj: FINAL ACTION ON ADMINISTRATIVE 5800


INVESTIGATION INTO COAST GUARD ACTIONS AND
RESPONSE ACTIVITIES CONCERNING THE GROUNDING
OF THE PATHFINDER ON 23 DEC 09

f. Conduct training and take action to ensure drug testing of watchstanders is properly
completed in a timely manner in accordance with U.S. Coast Guard policy as appropriate for
any future marine casualty.

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United States Coast Guard

Report of Investigation into the


Circumstances Surrounding the Incident
Involving
M/V PATHFINDER grounding

On 12/23/2009

MISLE Activity Number: 3655472


Originating Unit: Marine Safety Unit Valdez
MISLE Activity Owner: Commandant (CG-5453)
MISLE Activity Controller: Commandant (CG-5453)
MISLE Case Number: 485689
707.300.110429.USCGPathfndrFAMrpt.pdf
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Report of Investigation

I. INCIDENT BRIEF

On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway
in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef.
The vessel re-floated itself without assistance and transited under its own power to Busby Island
where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel
and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact
amount discharged could not be determined.

A Marine Casualty Investigator from MSU Valdez was deployed to the scene.

The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully
towed back to Valdez where the removal of the remaining fuel commenced.

Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA
where it will undergo permanent repairs.

The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost
during the incident was 6,410 gallons of diesel fuel.

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Report of Investigation

II. EXECUTIVE SUMMARY

Incident Summary

On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway
in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef.
The vessel re-floated itself without assistance and transited under its own power to Busby Island
where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel
and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact
amount discharged could not be determined.

A Marine Casualty Investigator from MSU Valdez was deployed to the scene.

The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully
towed back to Valdez where the removal of the remaining fuel commenced.

Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA
where it will undergo permanent repairs.

The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost
during the incident was 6,410 gallons of diesel fuel.

Incident Involved: Marine Casualty, Reportable


Discharge of Oil
USCG Credentialed Mariner, Misconduct
USCG Credentialed Mariner, Negligence
Civil Offense(s)

This incident resulted in a discharge or substantial threat of discharge of oil. This report does not
limit the discretion of the Director, NPFC, to determine facts, rights and liabilities with respect to
any claims, submitted to or by the NPFC, for removal costs and damages under the Oil Pollution
Act of 1990.
(b)(6) & (b)(7)(c)
Level of Investigation:
IMO Classification: Routine
USCG Classification: Major Marine Casualty
Was this a Serious Marine Incident? Yes
Was a Marine Board Convened by Commandant? No

Personnel Casualty Summary

Total Missing = 0
Total Dead = 0
Total Injured = 0
Total at Risk, Not Injured = 0
Total People at Risk = 6
Other Personnel (Not at Risk) = 0

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Report of Investigation

Vessel(s) Status Summary

Actual Total Loss(es) = 0


Total Constructive Loss, Salvaged = 0
Total Constructive Loss, Unsalvaged = 0
Damaged = 1
Undamaged = 0

Property Damage Summary/Total Damage

Vessel(s) = $500000*
Cargo = $
Facility(s) = $
Other = $

* Includes estimates

Waterway Mobility Summary

Vessel Delays (including speed restrictions): None

4
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

III. ACTIONS IN RESPONSE TO THIS REPORT

Actions on Recommendations

Safety Recommendation #7135: Crowley Marine Services Policy Review

During the course of the investigation into the grounding of the PATHFINDER,
numerous company policies and procedures pertaining to the vessel's mission, crew
performance and training were reviewed. Crowley Marine Services published numerous
policies regarding all aspects of marine operations. However, events leading up to the
grounding, including subsequent crew interviews, revealed that the PATHFINDER's
bridge team had largely chosen to disregard policy and procedure regarding proper watch
reliefs, charting, and the maintenance of vigilance on the bridge.

It is recommended that Crowley Marine Services develop a system that ensures company
policies and procedures are being followed in the field. This should include, but is not
limited to, a thorough review of vessel logs that are turned in to the company to certify
that they are being completed in accordance with company policy, focusing on watch
reliefs and fix intervals.

It is further recommended that the company deploy a team of personnel to conduct an


operational review of vessel missions at least bi-annually. This would enable the
company to evaluate the effectiveness of its policies and procedures.

Adopting these recommendations would provide Crowley Marine Services a system that
evaluates the level of adherence to company policy, potentially increasing employee
support.

Date Created: 01/20/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:16:11 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:09
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. Adherance to company policy and accountability
for such actions may have prevented the incident.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:00
>STATUS: Forward--->Forward

5
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
>NEW OWNER: COMDT 545
Concur. Crowley management is responsible for the corporate culture where
complacency is discouraged and robust bridge resource practices are encouraged. See
attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22,
2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:15
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:15:

The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

-----------------
>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:16:

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010


Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7138: Chemical Testing Review

6
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Following the grounding of the PATHFINDER, chemical testing was completed onboard
the vessel by the Master and Chief Mate. Crowley Marine Services maintains an adequate
program and ensures their personnel are trained by a third party in specimen collection
procedures following a Serious Marine Incident.

However, several mistakes were made on the chain of custody form as well as during the
collection process. Fortunately, the mistakes were not so egregious as to prevent them
from being useable. However, it is imperative that post-casualty drug testing be
completed in accordance with applicable regulations.

It is recommended that Crowley Marine Services review its policies regarding chemical
testing following a Serious Marine Incident, specifically, who is authorized to test,
documentation, and chain of custody. Crowley Marine Services should make the
necessary changes to prevent future oversight of the requirements.

It is also recommended that Crowley Marine Services review its determination policy on
when it is appropriate to send a third party collector to the site of an incident.

A letter from the District Seventeen Drug and Alcohol Program Inspector has been
submitted to Crowley Marine Services addressing this recommendation.

Date Created: 01/20/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:16:51 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:14
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. Following proper procedures may have alleviated
any fatal flaws.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:03
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, District Seventeen DAPI letter to Crowley Marine
Services dtd 26Jan10.

-----------------

7
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:16
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:16:

We note this recommendation was forwarded to Crowley Marine Services on January 26,
2010 by U.S. Coast Guard Seventeenth District.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010


Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7139: Computer Useage

It is recommended that Crowley Marine Services provide additional guidance on the use
of computers, electronic media, cell phones, etc., while standing the navigational watch.
Company policy states in general terms that the computer should only be used for
company business.

Recommend company policy be expanded upon to include times for use that are
appropriate (outside of a bridge watch), and the content that is allowable, specifically,
prohibited use of computer games on the bridge.

Date Created: 01/20/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:17:31 PM
Priority: Normal

8
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:19
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. The Master may not have been distracted from his
navigational responsiblities had he adhered to company policy regarding use of the
computer on the bridge. Additionally, revising company policy to provide specific
examples of inappropriate computer use would provide more clarity to vessel crews.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:07
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010. The use of computers, cell phones and other handheld devices is
expanding into nearly every facet of daily life. Recently, social media devices and
computers took center stage in horrific accidents (commuter train wreck in California
caused when the train conductor missed a signal while texting ) or frightening near
misses ( the northwest pilots who overflew their destination because they were trying to
decipher their work schedule on their laptops).

Games, music, phone calls to far away family are a strong temptation and could easily
distract a ship's officer from maintaining a proper lookout. Like aviation and rail
transportation, the marine transportation system is equally vulnerable to accidents with
significant loss of human life.

Recommend CG545 promulgate a Safety Alert cautioning the maritime community about
the distracting affects of using such devices on the bridge of vessels.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:17
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:17:

9
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez. Regarding District's additional
recommendation to issue a safety alert, Commandant issued a marine safety advisory on
distracted operations on October 29, 2010, in response to an earlier National
Transportation Safety Board (NTSB) recommendation.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010


Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7140: Training Evaluation

During the course of the investigation, it was discovered that the Second Mate was
involved in two marine casualties within the last year, which may have indicated a
problem with his ability to make sound decisions during critical situations.

While interviewing the Master and Chief Mate, both individuals discussed incidents
where the Second Mate mistakenly wrapped a line in the screw of a line boat after
making an improper judgment call during a training evolution, and again when the
Second Mate failed to respond to a steering pump alarm and failure on the
PATHFINDER.

The Chief Mate and the Master failed to counsel the Second Mate on the proper actions
he should have taken in the given situations, nor did they relay their concerns to the
company. The Second Mate was never given any remedial training on bridge
management and therefore was not aware of his shortcomings.

It is recommended that Crowley Marine Services develop a system that requires progress
reports of new personnel and trainees be submitted to the company. This would enable
the company to identify shortcomings and devise remedial action plans.

Date Created: 01/20/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:18:28 PM
Priority: Normal

Endorsement(s):

10
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:26
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. Immediate counselling to discuss shortcoming and
remedial actions would provide timely feedback to the individuals involved in casualties.
Addtionally, tracking a member's performance and periodic counselling by the supervisor
would help identify any trends of performance issues.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:09
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:17
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:18:

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010


Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:

11
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Action Commentary:

Safety Recommendation #7141: Night Vision Maintenance

At the time of the grounding, the Master was using the computer located on the bridge,
which may have affected the Second Mate's or Master's night vision.

It is recommended that Crowley Marine Services provide screens for computer monitors
or laptops located on the bridge to darken white light being emitted from the computer
while in use. Although neither the Second Mate nor the Master identified the computer
screen as a latent unsafe condition, the maintenance of night vision in a bridge
environment cannot be overstated.

Date Created: 01/20/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:19:21 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:30
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. Use of adequate tools would improve night vision
on the bridge.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:10
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:18
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

12
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Concur- Alternate Acceptable Action
>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:19:

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010


Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7143: Navigational Chart Plotting Standardization

It is recommended that Crowley Marine Services establish policy for taking navigational
fixes, to include chart markings and proper fix identification (i.e. dead reckoning, global
positioning system, estimated position, etc.).

At the time of the grounding, there were several marks on the PATHFINDER's chart that
were all dissimilar. When questioned about the markings on the chart, the Second Mate
stated that each conning officer had his own symbol for a fix, and pointed out his fix
signature.

The current method of charting or plotting a fix is not standardized and can provide
confusion as to who took the fix, when the fix was taken, or what means was used to
acquire the fix.

Date Created: 01/20/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:19:59 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:31
>STATUS: --->Forward
>NEW OWNER: D17 dp

13
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Concur with safety recommendation. Use of standardized chart symbology is good
marine practice.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:11
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:19
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:19:

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010


Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7190: Increased Navigational Fix Frequency

Current Crowley Marine Services policy states that the vessel's position will be charted
“every two hours at a minimum”. Any increase in the fix interval is left up to the
mariner.

14
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
It is recommended that Crowley Marine Services establish a minimum fix interval while
vessels transit near shoal waters, known hazards, or in decreased visibility environments.

Although in this incident the Master and Second Mate failed to comply with company
policy on numerous occasions, a policy mandating an increase in fix intervals when
operating in or near known hazards, shoal waters or in decreased visibility can positively
impact the safe navigation of Crowley Marine Services' vessels.

Date Created: 02/25/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:20:41 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:37
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. Increasing the fix intervals while transiting in
hazardous situations would provide the mariner with better awarenss of the vessel's
location in relation to such hazards.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:13
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:20
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:20:

15
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 02/25/2010 Actual Start Date: 02/25/2010


Proposed Completion Date: 02/25/2010 Actual Completion Date: 02/25/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7191: Equipment Failure Tracking

It is recommended that Crowley Marine Services review their equipment repair


procedures to ensure prioritization of essential navigational equipment. The Electronic
Bearing Line (EBL) on the starboard radar had not been operational since October 2009,
despite a repair order that had been filed with the maintenance department. According to
statements from the crew of the PATHFINDER, this was the second time that this piece
of equipment was inoperable.

The company's current repair process fails to identify equipment needing immediate
repairs, such as an EBL on a radar system. It also fails to recognize essential equipment
that has a history of defects. Without changes to the way Crowley Marine Services
prioritizes vessel equipment failures and repair times, these failures may directly impact
the safe navigation of their vessels.

Date Created: 02/25/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:21:19 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:39
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. Maintenance tracking and prioritization are
essential to identifying critical equipment failures and repairing such in a timely fashion.

-----------------

16
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:14
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:21
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:21:

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

D. S. Fish
By direction

Required Actions:

Proposed Start Date: 02/25/2010 Actual Start Date: 02/25/2010


Proposed Completion Date: 02/25/2010 Actual Completion Date: 02/25/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Recommendation #7194: Refloat Policy

It is recommended that Crowley Marine Services develop a system that requires its
Masters to complete a risk assessment prior to refloating a vessel after it has grounded. It
is also recommended, when the situation permits, that the Master contacts the company
and Coast Guard to discuss threats and option for refloating the vessel. Immediately
following the grounding of the PATHFINDER, the Master deemed it appropriate to
refloat the vessel. There was no discussion or request for guidance between the Master,

17
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Crowley Marine Services or the Coast Guard about whether or not the vessel should be
refloated and the manner in which the refloat should be completed.

Date Created: 03/03/2010


Current Owner Unit: Commandant (CG-545)
Date Last Modified: 03/31/2011 1:22:03 PM
Priority: Normal

Endorsement(s):

>USER: (b)(6) & (b)(7)(c) MSU Valdez


>TIME: 03/04/2010 11:48
>STATUS: --->Forward
>NEW OWNER: D17 dp
Concur with safety recommendation. A thorough assessment of a grounding situation
should be conducted prior to moving any grounded vessel. Fortunately the breaches to
the hull were such that refloating the vessel did not negatively impact it's stability.
However, refloating the vessel may have caused additional damage to the hull's integrity.

-----------------
>USER: (b)(6) & (b)(7)(c) D17 dp
>TIME: 04/07/2010 15:14
>STATUS: Forward--->Forward
>NEW OWNER: COMDT 545
Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services
dtd March 22, 2010.

-----------------
>USER: (b)(6) & (b)(7)(c) COMDT 545
>TIME: 03/31/2011 13:21
>STATUS: Forward--->Final Agency Action
>NEW OWNER: COMDT 545
The final agency action has been determined and approved by CAPT D. S. Fish by
direction of the Commandant.

Final Agency Action:

Concur- Alternate Acceptable Action


>(b)(6) & (b)(7)(c) COMDT 545
>03/31/2011 13:22:

We note this recommendation was forwarded to Crowley Marine Services on March 22,
2010 by U.S. Coast Guard Marine Safety Unit Valdez.

18
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
D. S. Fish
By direction

Required Actions:

Proposed Start Date: 03/03/2010 Actual Start Date: 03/03/2010


Proposed Completion Date: 03/03/2010 Actual Completion Date: 03/03/2010

Estimated Effort to Complete: 0 Staff Days


Action Status:
Action Commentary:

Safety Alerts

19
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Received 5/5/2011
Report of Investigation

IV. FINDINGS OF FACT

Subjects of the Investigation

Vessels. The following vessels were subjects of this investigation. Particulars for each vessel
follow.

Vessel Name: PATHFINDER


Flag: UNITED STATES
Vessel Identification Number: 524616
Call Sign: WBN8467
Status: Damaged
Role: Involved in a Marine Casualty
Vessel Class, Type, Sub-Type:
Gross Tonnage(GRT):
Net Tonnage(NRT):
Deadweight Tons:
Length: 136.2
Home/Hailing Port:
Keel Laid Date:
Delivery Date:
Place of Construction: AMELIA, MH, UNITED STATES
Builder Name: MCDERMOTT SHIPYARD
Propulsion: Diesel Reduction
Horsepower: 7000
Master:
Classification Society: American Bureau of Shipping
Owner: CROWLEY MARINE SERVICES INC
1102 SW MASSACHUSETTS ST

SEATTLE,, WA, 98134


US
PUGET SOUND TUG & BARGE CO
14020 SE JOHNSON ROAD
SUITE 201
MILWAUKIE, OR, 97267
US
Operator:
Inspection Subchapter:
Most Recent Vessel Inspection Activity:

Facilities. The following facilities were subjects of this investigation. Particulars for each
facility follow.

20
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Parties and Organizations. The following people and organizations were subjects of this
investigation.

(b)(6) & (b)(7)(c)


Status: Not at Risk
Role: Subject of Investigation
Gender: M
(b)(6) & (

Age:
(b)(6) & (b)(7)(c)
SSN:
(b)(6) & (b)(7)(c)
Birth Date:
Email Address:
Phone Number():
Address(Home/Primary Residence): (b)(6) & (b)(7)(c) .
(b)(6) & (b)(7)(c)
US
Comments:

(b)(6) & (b)(7)(c)


Status: Not at Risk
Role: Medical Review Officer
Gender: M
Age:
SSN:
Birth Date:
Email Address:
Phone Number(Daytime Phone): 215-637-6800
Address(Primary): University Services MRO
10551 Decatur Rd
Suite 200
Philadelphia, PA 19154
US
Comments:

(b)(6) & (b)(7)(c)


Status: Not at Risk
Role: Witness
Gender: M
(b)(6) & (

Age:
(b)(6) & (b)(7)(c)
SSN:
(b)(6) & (b)(7)(c)
Birth Date:
Email Address:
Phone Number():
Address(Home/Primary Residence): (b)(6) & (b)(7)(c)
(b)(6) & (b)(7)(c)
US
Comments:

(b)(6) & (b)(7)(c)

21
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Received 5/5/2011
Report of Investigation
Status: Not at Risk
Role: Witness
Gender: M
(b)(6) & (

Age:
(b)(6) & (b)(7)(c)
SSN:
(b)(6) & (b)(7)(c)
Birth Date:
Email Address:
Phone Number():
Address(Home/Primary Residence): (b)(6) & (b)(7)(c)
(b)(6) & (b)(7)(c)
US
Comments:

MONSEN, RONALD EUGENE


Status: Not at Risk
Role: Subject of Investigation
Gender: M
Age:
SSN:
Birth Date:
Email Address:
Phone Number():
Address(Home/Primary Residence):

US
Comments:

Status: Not at Risk


Role: Subject of Investigation
Gender: M
Age:
SSN:
Birth Date:
Email Address:
Phone Number():
Address(Home/Primary Residence):

UNITED STATES US
Comments:

Status: Not at Risk


Role: Witness
Gender: M
Age:
SSN:
Birth Date:

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Email Address:
Phone Number():
Address(Home/Primary Residence):

US
Comments:

COAST GUARD VALDEZ VTC


Status: Not at Risk
Role: Witness
Email Address:
Phone Number():
Address():
Comments:

CROWLEY MARINE SERVICES INC


Status: Not at Risk
Role: Subject of Investigation
Email Address:
Phone Number(Work): (206) 332-8037
Address(Primary): 1102 SW MASSACHUSETTS ST

SEATTLE,, WA 98134
US
Comments:

Drug and Alcohol Testing. The following people have been determined by the Coast
Guard, Law Enforcement Personnel, and/or the Marine Employer to have been directly
involved in a Serious Marine Incident as defined in 46 CFR 4.03-2:

Subject of Investigation
MONSEN, RONALD EUGENE; Subject of Investigation
(b)(6) & (b)(7)(c) Subject of Investigation
Witness
(b)(6) & (b)(7)(c) Witness
(b)(6) & (b)(7)(c) Witness

Response Resources. The following incident response resources were subjects of this
investigation.

Resource Name: HC130H - 1700


Resource ID: 1700
Kind: Aircraft (Fixed Wing)
Sub-Kind:
Type:

Resource Name: MH60J - 6007


Resource ID: 6007

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Kind: Aircraft (Helicopter)
Sub-Kind:
Type:

Resource Name: WPB - 1342


Resource ID: 1342
Kind: Vessels
Sub-Kind:
Type:

Other Subjects. The following were subjects of this investigation.

Waterway Segment(s). The following waterway segment(s) were subjects of this investigation.

PRINCE WILLIAM SOUND


Role: Location
Local Name:
Description: TATITLEK, AK

VALDEZ HARBOR
Role: Location
Local Name:
Description: VALDEZ HARBOR, AK

Incident Information

Location(s).

Description Latitude Longitude


Bligh Reef, Prince William Sound, Alaska 61 06.5 N 148 03.5 W
PRINCE WILLIAM SOUND 60 51.8664 N 146 40.902 W

Sequence of Events.

10/05/2009 12:00:00 to 12/23/2009 18:15:00 (Estimated): Electronic Bearing Line on the


starboard radar was not operational at the time of the incident. There was a work order submitted
to the company on October 5th, 2009.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Vessel Material/Equipment Condition
Subject Type: Navigation
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:

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Report of Investigation
Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Material/Equipment Condition
System: Navigation
Sub-System: Electronic Positioning
Component: Radio Direction Finding Device
Details: EBL was not operating properly on starboard radar.
Cite:

12/20/2009 18:15:00 to 12/23/2009 18:15:00 (Estimated): Attached evidence is 96 hour work


rest history for subject.

Condition Class: Person


Condition Type: 96-Hour Work/Rest History
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/20/2009 18:15:00 to 12/23/2009 18:15:00 (Estimated): Attached evidence is the 96 work/rest


history for the subject. The subject was unable to give a full work/rest history due to the fact that
he did not have the vessel's logs.

Condition Class: Person


Condition Type: 96-Hour Work/Rest History
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 0:00:00 to 12/23/2009 0:00:00 (Known): The VTS National Standard Operating
Procedures Manual states that the VTS may provide navigation assistance service to vessels who
request it. It goes on to state that navigation assistance service may include specific warnings to
individual vessels.

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Condition Class: Policy, Procedures, or Regulations
Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
COAST GUARD Party Not at Risk Witness
VALDEZ VTC
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate


Law/Regulation: No
Name: VTS NSOP COMDINST M16630.3
Effective Date: 08/18/2009
ISM Policy: No
ISO 9001 Policy: No
Issued By: Commandant, USCG
Policy Nature: General management
Reason Inadequate: Instruction clearly articulates the role of the VTS watchstander
as an additional navigational tool that a mariner may use. It does not replace mandatory
safe practices on the part of the mariner.

Latent Unsafe Condition: No

12/23/2009 0:00:00 to 12/23/2009 0:00:00 (Estimated): Alaska Chadux is the Oil Spill Response
Organization for the PATHFINDER.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Non-Vessel Material/Equipment Condition

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Subject Type: Pollution Prevention/Response
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: None

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Crowley Marine Services does not have
established ice scouting areas, or transit areas for its assigned Ice Scout vessels. Policy only
exists regarding instruction on what to look for and how to work with tank vessels proceeding in
and out of the port.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
CROWLEY MARINE Party Not at Risk Subject of
SERVICES INC Investigation
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence: There is no policy for vessel routing or transit areas for ice
scouting missions.
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

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Latent Unsafe Condition: No

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Capt. Monsen admittedly suffered from
constant stress caused by his wife being disabled/handicapped at home in Anchorage.

Condition Class: Person


Condition Type: Personnel Condition
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Personnel Condition
Human Factors:
Human Factor:
Factor Type: Psychosocial Factors
Factor Sub-Type: Family
Description: Captain's wife is disabled and at home by herself in
Anchorage.
Latent Unsafe Condition: No

Merchant Mariner: Yes


Personnel Credentials:
Credential Number: 1121418
Issue Date: 04/28/2006
Expiration Date: 04/28/2011
Issuing Authority: United States
Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE
THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC
TONNAGE) UPON COASTAL WATERS; ALSO RADAR OBSERVER (UNLIMITED)
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 33 Years Months
Positions Held:
Position Time in Position
Master 15 Years, 0 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): The Master had 33 years in the
industry, had worked on the PATHFINDER for more than 10 years and was planning on retiring
within the next 8 months.

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Condition Class: Person


Condition Type: Personnel Condition
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Personnel Condition
Human Factors:
Human Factor: Overall experience
Factor Type: Psychological Factors
Factor Sub-Type: Experience and Recency
Description: The Master had become complacent when it came to
following company policies. He had worked with the company for a number of years and had
transited through the area frequently.
Latent Unsafe Condition: No

Merchant Mariner: Yes


Personnel Credentials:
Credential Number:
Issue Date: 04/28/2006
Expiration Date: 04/28/2011
Issuing Authority: United States
Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE
THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC
TONNAGE) UPON COASTAL WATERS; ALSO RADAR OBSERVER (UNLIMITED)
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 33 Years Months
Positions Held:
Position Time in Position
Master 15 Years, 0 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to Crowley Marine Services'


policy, the Master was required to keep an accurate deck log, ensure that a proper lookout was
maintained, ensure vigilance was maintained on the bridge, ensure that the voyage plan is laid
out and checked in advance, and on transfer of watch plot the vessel's position, intended track,
course and speed, obtaining confirmation of the same.

Condition Class: Policy, Procedures, or Regulations

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Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: Yes

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to Crowley Marine Services'


policy regarding watchstanding and change of watch, the watch shall not be relieved until both
the off-going and on-coming watch personnel are satisfied in the exchange and understanding of
pertinent watch standing information, such as, but not limited to: orders, position, course, speed,
navigational hazards, traffic, and prevailing conditions.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:

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Report of Investigation
Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Policy/Regs/Procedures Condition


ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: Yes

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Crowley Marine Services' Directive


VDZ 09-008 states that any time a watch change occurs, log entries are to be signed by both the
off-going and oncoming watchstanders and, when underway, include an entry of the vessel's
position. Anyone must be able to accurately reconstruct the voyage if necessary.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
CROWLEY MARINE Party Not at Risk Subject of
SERVICES INC Investigation
Details Filed: Policy/Regs/Procedures Condition

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ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: Yes

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Regarding General Navigation and


Navigation Safety, Crowley Marine Services' policy states: "The watch will not allow himself to
be distracted when accurate and timely navigation is critical."

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

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Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: Yes

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to the Master and Chief
Mate, an electronic charting system called Nobletech was removed from the PATHFINDER
after it failed, never to be replaced. The Master felt that this equipment was very useful as a
navigational tool.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Vessel Material/Equipment Condition
Subject Type: Navigation
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Material/Equipment Condition
System: Navigation
Sub-System: Piloting/Steering
Component: Marine Charts
Details: Electronic charting system called NOBLETECH removed
from vessel. According to company, system was to be used primarily for tanker assist tugs.
Cite:

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Over the past year the Second Mate had
been involved in two separate incidents that should have led to concern in his judgment and
abilities but failed to be addressed by the company. See MISLE Activity Numbers 3674494 and
3674499 for incident details.

Condition Class: Person


Condition Type: Personnel Condition
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

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Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: Personnel Condition
Human Factors:
Human Factor:
Factor Type: Psychological Factors
Factor Sub-Type: Information Processing
Description: The Chief Mate voiced concern over the ability of the
Second Mate during his interview, and was witness to the Second Mate wrapping a line in the
lineboat's propeller. The Chief Mate failed to inform Crowley Marine Services of this concern.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number: 000017988
Issue Date: 07/23/2009
Expiration Date: 03/23/2014
Issuing Authority: United States
Ratings/Endorsements: MASTER OF TOWING VESSELS UPON
OCEANS; MASTER OF STEAM OR MOTOR VESSEL OF NOT MORE THAN 1600 GROSS
REGISTERED TONS (DOMESTIC VOYAGE), 3000 GROSS TONS (ITC TONNAGE) UPON
OCEANS.
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: Years Months
Positions Held:
Position Time in Position

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):


MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Personnel Condition
Human Factors:
Human Factor:
Factor Type: Psychological Factors
Factor Sub-Type: Perceptions
Description: While the Second Mate was standing a bridge watch
a steering pump failure occurred. The Second Mate failed to act accordingly resulting in the
master having to take over.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number: 1121418
Issue Date: 04/28/2006
Expiration Date: 04/28/2011
Issuing Authority: United States

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Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE
THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC
TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED)
EXPIRES APRIL 2011.
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 33 Years Months
Positions Held:
Position Time in Position
Master 15 Years, 0 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):


(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Personnel Condition


Human Factors:
Human Factor:
Factor Type: Psychological Factors
Factor Sub-Type: Information Processing
Description: The Second Mate was involved in two separate
incidents within the last year that should have brought into question his ability to make sound
decisions when on the bridge by himself or when faced with a difficult situation.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number:
Issue Date: 08/05/2009
Expiration Date: 10/08/2013
Issuing Authority: United States
Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSEL
OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED)
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 1 Years 6 Months
Positions Held:
Position Time in Position
Trainee 0 Years, 6 Months, 0 Days
Second Mate 0 Years, 6 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

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12/23/2009 13:45:00 to 12/24/2009 1:00:00 (Estimated): PATHFINDER U/W from SERVS
mooring Buoy 1 for Ice Scouting tasking

Action Type: Bridge Operations - Shiphandling


Action Class: Maneuver vessel in accordance with conning orders
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 14:02:00 to 12/23/2009 14:05:00 (Estimated): PATHFINDER calls VTC on VHF to


inform of being underway from SERVS buoy #1 for ice report.

Action Type: Bridge Operations - Bridge Communications


Action Class: Establish and maintain VHF radio communications with other vessels
and appropriate shore authorities
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: Communications Details
Communications Description: Vessel informs traffic that they are underway
Communications Type: Ship to Shore
Sent or Received: Sent
Means of Communication: Verbal
Communication Acknowledged: Yes
Communication Protocols: Transmitted via Channel 13
Communications Effectiveness: Communication Effective
Effectiveness Description:
Interference Difficulties:
Interference Description:

12/23/2009 16:49:00 to 12/23/2009 16:55:00 (Estimated): PATHFINDER reports to VTC via


VHF that they are off of Bligh Reef and have "no ice."

Action Type: Bridge Operations - Bridge Communications


Action Class: Establish and maintain VHF radio communications with other vessels
and appropriate shore authorities
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

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Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: Communications Details
Communications Description: Ice reports passed to VTC
Communications Type: Ship to Shore
Sent or Received: Sent
Means of Communication: Verbal
Communication Acknowledged: Yes
Communication Protocols: Transmitted via Channel 13
Communications Effectiveness: Communication Effective
Effectiveness Description:
Interference Difficulties:
Interference Description:

12/23/2009 16:50:36 to 12/23/2009 16:55:00 (Estimated): PATHFINDER receives word from


SERVS duty officer that they are to remain in the vicinity of Bligh Reef and provide another ice
report at 1800.

Action Type: Bridge Operations - Bridge Communications


Action Class: Establish and maintain VHF radio communications with other vessels
and appropriate shore authorities
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: Communications Details
Communications Description: SERVS base informed vessel that they would need to remain
on scene until 1800.
Communications Type: Ship to Shore
Sent or Received: Received
Means of Communication: Verbal
Communication Acknowledged: Yes
Communication Protocols:
Communications Effectiveness: Communication Effective
Effectiveness Description:
Interference Difficulties:
Interference Description:

12/23/2009 16:59:30 to 12/23/2009 17:05:00 (Estimated): It is Crowley Marine Services' policy


that all reliefs will be logged, and that prior to relief the oncoming watch (Conn) will have
ascertained the location or current position of the vessel.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition

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Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data
Does the ISM Code apply to the Vessel: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Vessel: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Vessel: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate


Law/Regulation: No
Name: Vessel Operations: Voyage Management
Effective Date: 02/10/2009
ISM Policy: No
ISO 9001 Policy: No
Issued By: Crowley Maritime Corporation
Policy Nature: Division of tasks and responsibilities
Reason Inadequate: Policy clearly outlines the responsibilities of watchstanders in
regards to watch relief.

Latent Unsafe Condition: Yes

12/23/2009 17:00:00 to 12/23/2009 17:22:00 (Estimated): In order to skip waypoints in the GPS,
the Master, Chief Mate and Second Mate admittedly had to go into the GPS operator's manual
for directions. The GPS is described as being difficult to use with this function.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Vessel Material/Equipment Condition
Subject Type: Navigation
Location: Known; US Waters

38
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Material/Equipment Condition
System: Navigation
Sub-System: Electronic Positioning
Component: GPS/DGPS Receiver
Details: The feature which allows the operator to "skip" waypoints
requires a review of the operator's manual.
Cite:

12/23/2009 17:00:00 to 12/23/2009 17:30:00 (Estimated): Master came up to the bridge and
relieved the Chief Mate for dinner, assuming the Conn. Master admittedly did not take a fix,
check the radars, or log a relief.

Action Type: Bridge Operations - Changing Watch


Action Class: Ensure that watch is relieved
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: None
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 17:14:00 to 12/23/2009 18:30:00 (Estimated): The vessel was in auto pilot.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Maneuverability Condition
Subject Type: Vessel Maneuverability
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Maneuverability Details
Handling Characteristics

39
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Report of Investigation
Angle of Turn: Degrees
Rudder Angle: Degrees
Advance: Meters
Transfer: Meters

Length Between Perpendiculars:


Tactical Diameter:
Maneuverability Rating:

Control Configuration
Critical System Alarm
Vessel Control Status
Location of Navigation Controls:

Location of Officer with the Conn:

Diving (Ballast)
Vertical Maneuvering Capabilities:

Ballast Control Power Adequacy Evaluation:

Hydrodynamics
Bank Cushion: No
Bank Suction: No
Current Effect: No
Squat: No
Other Effects: No

Pilots/Tugs
Pilot Aboard: No

AIS Onboard/Operating: No

Escort Tugs Required: No


Present: No

Assist Tugs Present: No


Navigation
Type of Navigation Equipment: Auto pilot
Required/Additional: Additional Equipment
Operational/Malfunctioning: Operational
Location:
Approved Equipment: No
Unapproved Items Used: No
Equipment Tested: No
Equipment Serviced: No

Required Equipment Missing: No


Equipment Used Properly: Yes

Applicable Charts On Board: Yes


Chart Number:
Mapping Agency:
Used No
Corrected No
Errors No

40
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
12/23/2009 17:15:00 to 12/23/2009 18:01:00 (Estimated): Master brought the throttles back to
one throttle ahead slow, making four to five knots, steering a 140 course, abeam Bligh Reef.

Action Type: Bridge Operations - Shiphandling


Action Class: Maneuver vessel in accordance with conning orders
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 17:20:00 to 12/23/2009 18:30:00 (Estimated): Second Mate arrives on the Bridge
after eating dinner.

Action Type: Bridge Operations - Changing Watch


Action Class: Ensure that watch is relieved
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/23/2009 17:21:59 to 12/23/2009 17:45:00 (Estimated): There was no relief or watch change
brief conducted, no fix taken and no log entry made to indicate the Second Mate relieved the
Conn.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Procedure
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data

41
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Received 5/5/2011
Report of Investigation
Does the ISM Code apply to the Vessel: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Vessel: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Vessel: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: Yes

12/23/2009 17:22:00 to 12/23/2009 17:25:00 (Estimated): Second Mate laid down a fix on the
chart at 1722 that he describes as "for his information only".

Action Type: Bridge Operations - Grounding Avoidance and Navigation


Action Class: Determine vessel position by use of available systems
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Detail Description


The Second Mate was on the bridge to relieve the watch from the Captain so the Captain could lay
below. The Second Mate laid down a fix but claims it was for his information purposes only.
Crowley Marine Services' policy requires that the positioning of the vessel is ascertained prior to
relief. Proper reliefs per company policy were not conducted.

12/23/2009 17:22:30 to 12/23/2009 18:15:00 (Estimated): Second Mate reports that at the time
he arrived on the bridge and checked the GPS for his fix, the route was on inbound with the next
waypoint being Rocky Point. The "dogleg" and Bligh Reef waypoints had been manually
"skipped".

Condition Class: Person


Condition Type: Personnel Condition

42
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Report of Investigation
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Personnel Condition


Human Factors:
Human Factor:
Factor Type: Psychological Factors
Factor Sub-Type: Knowledge
Description: The Second Mate noticed that the GPS had been
switched to inbound.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number:
Issue Date: 08/05/2009
Expiration Date: 10/08/2013
Issuing Authority: United States
Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSELS
OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED)
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 1 Years 6 Months
Positions Held:
Position Time in Position
Trainee 0 Years, 6 Months, 0 Days
Second Mate 0 Years, 6 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

12/23/2009 17:30:00 to 12/23/2009 17:44:00 (Estimated): Master laid below for dinner, leaving
the Second Mate on the Bridge.

Action Type: Bridge Operations - Changing Watch


Action Class: Ensure that watch is relieved
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:

43
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Report of Investigation
Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Detail Description
Master departed the bridge without ensuring the Second Mate knew the position of the vessel,
discussing the course and speed of the vessel or ensuring a log entry was made. All are violations
of company policy.

12/23/2009 17:44:00 to 12/23/2009 18:15:00 (Estimated): Master returns to the bridge from
dinner.

Action Type: Bridge Operations - Changing Watch


Action Class: Ensure that watch is relieved
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 17:45:00 to 12/23/2009 17:50:00 (Estimated): The Chief Mate reports having
"poked" his head back on the bridge before going to bed and observed the Master working on the
GPS.

Action Type: Bridge Operations - Bridge Communications


Action Class: Communicate and coordinate effectively among the vessel’s crew
(Bridge, Engine, and Deck)
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: None

12/23/2009 17:47:00 to 12/23/2009 18:00:00 (Estimated): Master was reportedly on the bridge
computer shortly after leaving the GPS, and admittedly, checked weather, looked at company
email and resumed playing hearts/solitaire.

Action Type: Bridge Operations - Bridge Communications


Action Class: Communicate and coordinate effectively among the vessel’s crew
(Bridge, Engine, and Deck)
Location: Known; US Waters

44
707.300.110429.USCGPathfndrFAMrpt.pdf
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Report of Investigation
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/23/2009 17:47:10 to 12/23/2009 18:00:00 (Estimated): The computer on the bridge is located
on the port after shelf requiring its operator to be facing aft.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Non-Vessel Material/Equipment Condition
Subject Type: Communications
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: None

12/23/2009 17:47:20 to 12/23/2009 18:15:00 (Estimated): The computer screen on the bridge
was not protected from emitting high glare or white light into a visually sensitive area.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Vessel Material/Equipment Condition
Subject Type: Communications
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Material/Equipment Condition
System: Operations/Management
Sub-System: Vessel Safety Management
Component: Company Verification/Review/Evaluation
Details: Computer screen was not protected.
Cite:

12/23/2009 17:50:00 to 12/23/2009 18:14:00 (Estimated): On scene weather

45
707.300.110429.USCGPathfndrFAMrpt.pdf
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Report of Investigation
Condition Class: Marine Environment
Condition Type: Marine Environment
Subject Type:
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
PRINCE WILLIAM Waterway Location
SOUND
Details Filed: Marine Environment Details
Weather Conditions:
Weather Forecast Actual Weather
Conditions
Wind Speed: 25 Knots
Wind Direction: 130
Wind Gusts: 30 Knots
Ceiling: Feet
Sky Conditions: Sky obscured
Air Temperature: 39° F
Weather/Precipitation: Rain
Visibility/Precipitation:
Visibility: 0.5 nm
Precipitation (24 hr period):
Sea Level Pressure: 29.63 Millibars

Weather a Forecast Obtained:


Date/Time Obtained:
Source of Forecast:
How were Conditions Predicted:
Weather Forecast Error: No

Water Conditions:
Water Forecast Actual Water Conditions
Water Temperature: °F
Water Depth/River Stage: (Feet above MLLW)
Tide:
Tidal Current Speed: Knots
Tidal Current Direction:
River Current Speed: Knots
River Current Direction:
Ice Coverage: %
Character of Ice:
Wave Height: feet
Wave Direction:
Wave Period: seconds
Swell Height: feet
Swell Direction:
Swell Period: seconds
Warnings in Effect:

Was a Water Forecast Obtained:


Date/Time Obtained:
Source of Forecast:

46
707.300.110429.USCGPathfndrFAMrpt.pdf
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Report of Investigation
Water Forecast Error:
Latent Unsafe Condition: No

12/23/2009 17:50:30 to 12/23/2009 17:52:00 (Estimated): Second Mate reports seeing the Bligh
Reef racon on radar off the vessel's port side, while on a course of 140.

Action Type: Bridge Operations - Visual Monitoring and Lookout


Action Class: Maintain lookout to detect objects, traffic, or navigational aids and
assess visibility
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/23/2009 17:55:00 to 12/23/2009 18:00:00 (Estimated): Master believed he was in the


"dogleg" portion of the track which would have allowed the vessel to transit clear of Bligh Reef.
The "dogleg" portion of the track is northwest of Bligh Reef.

Condition Class: Person


Condition Type: Personnel Condition
Subject Type: Person
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Personnel Condition
Human Factors:
Human Factor: Other attention information
Factor Type: Psychological Factors
Factor Sub-Type: Attention
Description: Master believed he was in a position other than where
the vessel was actually positioned because he had not ascertained the vessels' position prior to
changing course and speed.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number: 1121418
Issue Date: 04/18/2006
Expiration Date: 04/28/2011
Issuing Authority: United States

47
707.300.110429.USCGPathfndrFAMrpt.pdf
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Report of Investigation
Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE
THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC
TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED)
EXPIRES APRIL 2011
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 33 Years Months
Positions Held:
Position Time in Position
Master 15 Years, 0 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

12/23/2009 18:00:00 to 12/23/2009 18:00:30 (Known): Second Mate communicated ice report to
SERVS base and received "release from ice scout" orders from SERVS base and was to return
to Valdez.

Action Type: Bridge Operations - Bridge Communications


Action Class: Establish and maintain VHF radio communications with other vessels
and appropriate shore authorities
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Communications Details


Communications Description: Telephone call to SERVS base
Communications Type: Ship to Shore
Sent or Received: Sent
Means of Communication: Verbal
Communication Acknowledged: Yes
Communication Protocols:
Communications Effectiveness: Communication Effective
Effectiveness Description:
Interference Difficulties:
Interference Description:

12/23/2009 18:01:00 to 12/23/2009 18:02:00 (Estimated): Second Mate made radio call to VTC
to inform of the release from ice scout and that they would be returning to Valdez.

Action Type: Bridge Operations - Bridge Communications


Action Class: Establish and maintain VHF radio communications with other vessels
and appropriate shore authorities

48
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Report of Investigation
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Communications Details


Communications Description: VHF radio call to VTC
Communications Type: Ship to Shore
Sent or Received: Sent
Means of Communication: Communications Equipment
Frequency/Channel Channel 13
Power Setting:
Communication Acknowledged: Yes
Communication Protocols:
Communications Effectiveness: Communication Effective
Effectiveness Description:
Interference Difficulties:
Interference Description:

12/23/2009 18:01:12 to 12/23/2009 18:01:45 (Estimated): Second Mate returns to the "operating
station/chair" after calling and receiving release from ice scouting.

Action Type: Bridge Operations - Shiphandling


Action Class: Maneuver vessel in accordance with conning orders
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/23/2009 18:01:13 to 12/23/2009 18:10:00 (Estimated): Master reached over the Second Mate
and altered speed to all ahead full, and altered course to approximately 025 after getting the word
that the PATHFINDER was cleared to transit back to Valdez.

Action Type: Bridge Operations - Shiphandling


Action Class: Maneuver vessel in accordance with conning orders
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:

49
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Report of Investigation
Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 18:01:14 to 12/23/2009 18:15:00 (Estimated): Master did not know the actual
position of the vessel prior to changing course.

Condition Class: Person


Condition Type: Personnel Condition
Subject Type: Person
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Personnel Condition
Human Factors:
Human Factor:
Factor Type: Psychological Factors
Factor Sub-Type: Knowledge
Description: Master believed the vessel was in another position.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number:
Issue Date: 04/28/2006
Expiration Date: 04/28/2011
Issuing Authority: United States
Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE
THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC
TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED)
EXPIRES APRIL 2011.
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 33 Years Months
Positions Held:
Position Time in Position
Master 15 Years, 0 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

50
707.300.110429.USCGPathfndrFAMrpt.pdf
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Report of Investigation
12/23/2009 18:01:15 to 12/23/2009 18:07:00 (Estimated): Second Mate turned to the chart table
to log position and weather.

Action Type: Bridge Operations - Grounding Avoidance and Navigation


Action Class: Check and update navigation charts and publications
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Detail Description


The Second mate felt uncomfortable with the Master reaching across his lap to increase the
vessel's speed. The Second Mate decided to leave the conning chair and begin to complete his
required log book entries. The 1800 log book entry included the vessel's position, on-scene
weather and the statement that the vessel was released from ice scout.

12/23/2009 18:01:20 to 12/23/2009 18:01:30 (Estimated): Master made the comment to the
Second mate, after changing course and speed to "take us home".

Action Type: Bridge Operations - Bridge Communications


Action Class: Communicate and coordinate effectively among the vessel’s crew
(Bridge, Engine, and Deck)
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: Communications Details
Communications Description: Verbal communication between the Second Mate and the
Master.
Communications Type: Internal
Sent or Received: Sent
Means of Communication: Verbal
Communication Acknowledged: No
Communication Protocols: No log entries were made confirming who had the watch.
Communications Effectiveness: Problems Interpreting Communication
Effectiveness Description: The Second Mate never admits to hearing this from the
Master.
Interference Difficulties:
Interference Description:

12/23/2009 18:01:21 to 12/23/2009 18:06:00 (Estimated): Second Mate believed that the
Master's actions in changing the course and speed to return home indicated the Master had the

51
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Report of Investigation
Conn. The Second Mate stated he asked the Master if he had the Conn, with the Master
indicating he did because he was still on the bridge.

Condition Class: Person


Condition Type: Personnel Condition
Subject Type: Person
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Personnel Condition


Human Factors:
Human Factor:
Factor Type: Psychological Factors
Factor Sub-Type: Information Processing
Description: Second Mate believed the Master had the Conn of the
vessel. The Second Mate reportedly questioned the Master, and the Master replied that he did.
Latent Unsafe Condition: Yes

Merchant Mariner: Yes


Personnel Credentials:
Credential Number:
Issue Date: 08/05/2009
Expiration Date: 10/08/2013
Issuing Authority: United States
Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSELS
OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED).
Upgrade Date:

Personnel Training:
Personnel Experience:
Total Time in Industry: 1 Years 6 Months
Positions Held:
Position Time in Position
Trainee 0 Years, 6 Months, 0 Days
Second Mate 0 Years, 6 Months, 0 Days

Experience in Current Type of Position:

Other Experience (Shipboard):

Other Experience (Shoreside):

12/23/2009 18:01:45 to 12/23/2009 18:15:00 (Estimated): Master returned to the computer after
altering course and speed.

Action Type: Bridge Operations - Bridge Communications

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Report of Investigation
Action Class: Communicate and coordinate effectively among the vessel’s crew
(Bridge, Engine, and Deck)
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 18:07:00 to 12/23/2009 18:10:00 (Estimated): Second Mate returned to the starboard
radar and attempted to locate the Bligh Reef racon using the 3-6 mile scales. After several
attempts, the Second Mate was unable to locate the racon on the radar and began scanning for the
Bligh Reef Light through the starboard side windows of the bridge, never looking ahead.

Action Type: Bridge Operations - Grounding Avoidance and Navigation


Action Class: Determine vessel position by use of available systems
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/23/2009 18:08:00 to 12/23/2009 18:15:00 (Estimated): The Second Mate was required by
Crowley Policy to notify the Master when he was unsure of the vessel's position. He failed to do
this when he was unable to locate the Bligh Reef Light.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Policy
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Policy/Regs/Procedures Condition


ISM Code Data

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Report of Investigation
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: Yes

12/23/2009 18:10:00 to 12/23/2009 18:15:00 (Estimated): Second Mate returned to the chart
table to lay down a fix after not being able to locate Bligh Reef on radar or visually out of the
starboard side windows. Second Mate noticed that the speed at this time was 13.2 kts.

Action Type: Bridge Operations - Grounding Avoidance and Navigation


Action Class: Determine vessel position by use of available systems
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: None

12/23/2009 18:12:00 to 12/23/2009 18:45:00 (Estimated): PATHFINDER grounded on Bligh


Reef. The vessel was outside of the traffic separation scheme and returning from ice scouting
operations.

Event Type: Grounding


Event Class: Outside marked channel
Event Subclass: Full Control
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska

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Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Grounding Details
Type of Grounding: Hard
Type of Bottom: Rock
Depth of Water:
Charted: 16 Feet
Actual: Feet
Recorded: Feet
Part of Vessel Aground: Centerline Midships
Vessel Course: 25 True
Vessel Speed: 13.2 Knots
Steering Functional: Fully
Propulsion Functional: Fully
Hazard to Navigation: No
ATON Survey Required: Yes
Fuel On Board: diesel
Cargo On Board:
Cargo Name Quantity

Additional Information:

12/23/2009 18:13:00 to 12/23/2009 18:15:00 (Estimated): Master called Valdez Traffic to report
that the PATHFINDER had run aground on Bligh Reef.

Action Type: Other Actions - Reporting/Notifications


Action Class: Report/Notification of Casualty or Incident
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 18:15:00 to 12/27/2009 18:15:00 (Estimated): ACOE CODE 4816 includes Bligh
Reef where the incident occurred

Condition Class: Marine Environment


Condition Type: Waterway Condition
Subject Type:
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

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Subject(s) and Details:
Name Type Status Role
VALDEZ HARBOR Waterway Location
Details Filed: Environmental Damage Details
Details Filed: Waterway Condition
Waterway Characteristics

Waterway Description:
Approach Constriction: Open
Waterway Constriction: Open
Constriction Description:
Narrow Channel: No
Anchorage: No
Fleeting Area: No
Visibility Obstructions: No
Shoreline Congestion: No
Channel Crossing: No
Bridges: No
Number of Turns:
Blind Turns: No
Ferry Crossings: No
Junctions: No

Aids to Navigation (ATON)


Was ATON involved in any way: No
Latent Unsafe Condition: No

12/23/2009 18:20:00 to 01/20/2010 18:45:00 (Estimated): Failure of the forward side of


approximately frame 8 of the hull structure and keel both port and starboard to approximately
frame 42 in way of the #3 centerline fuel/oil tank. The damage to the hull was primarily centered
near the keel with opening from 2" to approximately 18" along the keel structure. There is
further damage in way of the props and rudders.

Event Type: Material Failure (Vessels)


Event Class: Construction/Loadline
Event Subclass:
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Material/Equipment Failure
System: Construction/Loadline
Sub-System: Hull
Component: Keel Plate
Failure: Yes
Category: Non-Catastrophic Failure Requiring Repair/Replacement
Details: Failure of the keel and associated plating from approximately
frame 8 to frame 42, sustained from grounding and removal from Bligh Reef.
Cite:

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Equipment Approval Information


Q-Number:
Manufacturer:
Serial No:
Year Built:
Description:

12/23/2009 18:20:01 to 01/05/2010 13:00:00 (Estimated): Vessel schematics from a sister ship to
the PATHFINDER was used in determining the potential amount spilled. It was later
determined that the tank sizes were not the same and there was no record of the actual tank size
on the PATHFINDER.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Cargo Condition
Subject Type: Bunker/Fuel/Lube
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: None

12/23/2009 18:21:00 to 12/28/2009 23:59:08 (Known): PATHFINDER discharged


approximately 6410 gallons of diesel into Prince William Sound. The initial spill was caused
when the vessel struck Bligh Reef. A secondary spill occurred when the vessel was being
lightered on 25-Dec-09.

Event Type: Damage to the Environment


Event Class: Oil Discharge
Event Subclass:
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: Discharge Details
Substance Name: Oil: Diesel
Potential Volume/Amount: 36000 Gallon (known)
Potential Only: No

Discharge/Released Amount: 6000 Gallon (estimated)


Situation: Point-source discharge over a period of time
Impacted Medium and Amount:

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Water 6000 (estimated)
Circumstances/Means Halted: The upward pressure of the water inside the breached
fuel tank kept the diesel fuel from completely discharging.

Not Discharged/Released Amount: 30000 Gallon (estimated)


Method Contained/Accounted For:

Substance Name: Oil: Diesel


Potential Volume/Amount: 36000 Gallon (estimated)
Potential Only: No

Discharge/Released Amount: 410 Gallon (estimated)


Situation: Point-source one-time discharge
Impacted Medium and Amount:
Water 410 (estimated)
Circumstances/Means Halted: During lightering operations, the back pressure in the
tank was disrupted causing diesel to discharge from the tank. Lightering operations were
immediately halted.

Not Discharged/Released Amount: 35590 Gallon (estimated)


Method Contained/Accounted For:

12/23/2009 18:25:00 to 12/23/2009 18:45:00 (Estimated): Master made a decision to navigate off
of the reef and find a safe anchorage area. The vessel was free of the reef at approximately 1845.

Action Type: Bridge Operations - Shiphandling


Action Class: Maneuver in accordance with sea/river/weather conditions
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
MONSEN, RONALD Party Not at Risk Subject of
EUGENE Investigation
Details Filed: None

12/23/2009 21:00:00 to 12/23/2009 21:40:00 (Known): Chemical testing/Post Casualty

Action Type: Other Actions - Drug and Alcohol Use and Testing
Action Class: Take Alcohol Test - Post-casualty
Location: Known; US Waters
Description: Bligh Reef, Prince William Sound, Alaska
Latitude: 61 06.5 N Longitude: 148 03.5 W

Subject(s) and Details:


Name Type Status Role
Party Not at Risk Subject of
Investigation
Details Filed: Drug and Alcohol Test Details
Sample Collection

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Reason for Sample: Post-casualty
Date/Time Directed: 12/23/2009 9:00:00 PM
Means of Direction:
Directed By:
Organization: Marine Employer
Description: Crowley Marine
Directed to get DOT Test: Yes
Chemical Test Sample Provided: Yes
Chemical Test Type: Alcohol
Sample Type: Breath
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Chemical Test Type: Dangerous Drugs
Sample Type: Urine
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: No
Field Sobriety Test
Field Sobriety Test Performed: No
Alcohol Analysis
Method of Analysis: Breath Test
Instrument Used: Lifeloc Technologies
Date/Time Results Obtained: 12/23/2009 9:00:00 PM
Results:
Agency Conducting Analysis: Crowley Marine
Description of Analysis:
Irregularities in Analysis: No
Drug Analysis
Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED,
Norristown, PA 19403
DOT Protocols Used: Yes
Test Results:
Medical Review Officer: (b)(6) & (b)(7)(c)
MRO Conclusions:
Sample Transferred and Chain
of Custody Complete: Yes
Drug Re-Analysis
Party Not at Risk Subject of
Investigation
Details Filed: Drug and Alcohol Test Details
Sample Collection
Reason for Sample: Post-casualty
Date/Time Directed: 12/23/2009 9:00:00 PM
Means of Direction: Marine Employer

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Directed By:
Organization: Marine Employer
Description: Crowley Marine
Directed to get DOT Test: Yes
Chemical Test Sample Provided: Yes
Chemical Test Type: Alcohol
Sample Type: Breath
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Chemical Test Type: Dangerous Drugs
Sample Type: Urine
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Field Sobriety Test
Field Sobriety Test Performed: No
Alcohol Analysis
Method of Analysis: Breath Test
Instrument Used: Lifeloc Technologies
Date/Time Results Obtained: 12/23/2009 9:00:00 PM
Results:
Agency Conducting Analysis: Crowley Marine
Description of Analysis:
Irregularities in Analysis: No
Drug Analysis
Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED,
Norristown, PA 19403
DOT Protocols Used: Yes
Test Results:
Medical Review Officer: (b)(6) & (b)(7)(c)
MRO Conclusions:
Sample Transferred and Chain
of Custody Complete: Yes
Drug Re-Analysis
(b)(6) & (b)(7)(c) Party Not at Risk Subject of
Investigation

Details Filed: Drug and Alcohol Test Details


Sample Collection
Reason for Sample: Post-casualty
Date/Time Directed: 12/23/2009 9:00:00 PM
Means of Direction: Vessel Master
Directed By:
Organization: Marine Employer

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Description: Post Cas.
Directed to get DOT Test: Yes
Chemical Test Sample Provided: Yes
Chemical Test Type: Alcohol
Sample Type: Breath
Date/Time Sample Taken: 01/23/2010 9:30:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Chemical Test Type: Dangerous Drugs
Sample Type: Urine
Date/Time Sample Taken: 12/23/2009 9:40:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Field Sobriety Test
Field Sobriety Test Performed: No
Alcohol Analysis
Method of Analysis: Breath Test
Instrument Used: Lifeloc Technologies
Date/Time Results Obtained: 12/23/2009 9:30:00 PM
Results:
Agency Conducting Analysis: Crowley Marine
Description of Analysis:
Irregularities in Analysis: No
Drug Analysis
Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED,
Norristown, PA 19403
DOT Protocols Used: Yes
Test Results:
Medical Review Officer: (b)(6) & (b)(7)(c)
MRO Conclusions:
Sample Transferred and Chain
of Custody Complete: Yes
Drug Re-Analysis
Party Not at Risk Witness

Details Filed: Drug and Alcohol Test Details


Sample Collection
Reason for Sample: Post-casualty
Date/Time Directed: 12/23/2009 9:00:00 PM
Means of Direction:
Directed By:
Organization: Marine Employer
Description: Crowley Marine
Directed to get DOT Test: Yes
Chemical Test Sample Provided: Yes

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Chemical Test Type: Alcohol
Sample Type: Breath
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Chemical Test Type: Dangerous Drugs
Sample Type: Urine
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Field Sobriety Test
Field Sobriety Test Performed: No
Alcohol Analysis
Method of Analysis: Breath Test
Instrument Used: Lifeloc Technologies
Date/Time Results Obtained: 12/23/2009 9:00:00 PM
Results:
Agency Conducting Analysis: Crowley Marine
Description of Analysis:
Irregularities in Analysis: No
Drug Analysis
Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED,
Norristown, PA 19403
DOT Protocols Used: Yes
Test Results:
Medical Review Officer: (b)(6) & (b)(7)(c)
MRO Conclusions:
Sample Transferred and Chain
of Custody Complete: Yes
Drug Re-Analysis
(b)(6) & (b)(7)(c) Party Not at Risk Witness
Details Filed: Drug and Alcohol Test Details
Sample Collection
Reason for Sample: Post-casualty
Date/Time Directed: 12/23/2009 9:00:00 PM
Means of Direction: Master
Directed By:
Organization: Marine Employer
Description: Crowley Marine
Directed to get DOT Test: Yes
Chemical Test Sample Provided: Yes
Chemical Test Type: Alcohol
Sample Type: Breath
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel

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DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Chemical Test Type: Dangerous Drugs
Sample Type: Breath
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Field Sobriety Test
Field Sobriety Test Performed: No
Alcohol Analysis
Method of Analysis: Breath Test
Instrument Used: Lifeloc Technologies
Date/Time Results Obtained: 12/23/2009 9:00:00 PM
Results:
Agency Conducting Analysis: Crowley Marine
Description of Analysis:
Irregularities in Analysis: No
Drug Analysis
Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED,
Norristown, PA 19403
DOT Protocols Used: Yes
Test Results:
Medical Review Officer: (b)(6) & (b)(7)(c)
MRO Conclusions:
Sample Transferred and Chain
of Custody Complete: Yes
Drug Re-Analysis
(b)(6) & (b)(7)(c) Party Not at Risk Witness

Details Filed: Drug and Alcohol Test Details


Sample Collection
Reason for Sample: Post-casualty
Date/Time Directed: 12/23/2009 9:00:00 PM
Means of Direction: Vessel Master
Directed By:
Organization: Marine Employer
Description: Crowley Marine
Directed to get DOT Test: Yes
Chemical Test Sample Provided: Yes
Chemical Test Type: Alcohol
Sample Type: Breath
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine

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Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: No
Chemical Test Type: Dangerous Drugs
Sample Type: Urine
Date/Time Sample Taken: 12/23/2009 9:00:00 PM
Sampling Location: Aboard Vessel
DOT Protocols Used: Yes
Collection Agent Name:
Collection Agent's Organization: Crowley Marine
Donor Certified: Yes
Irregularities Noted: No
Transferred/Chain of
Custody Complete: Yes
Field Sobriety Test
Field Sobriety Test Performed: No
Alcohol Analysis
Method of Analysis: Breath Test
Instrument Used: Lifeloc Technologies
Date/Time Results Obtained: 12/23/2009 9:00:00 PM
Results: d
Agency Conducting Analysis: Crowley Marine
Description of Analysis:
Irregularities in Analysis: No
Drug Analysis
Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED,
Norristown, PA 19403
DOT Protocols Used: Yes
Test Results:
Medical Review Officer: (b)(6) & (b)(7)(c)
MRO Conclusions:
Sample Transferred and Chain
of Custody Complete: Yes
Drug Re-Analysis

12/23/2009 23:15:00 to 12/25/2009 0:00:00 (Estimated): Pollution response gear was deployed.

Condition Class: Vessel, Facility, Equipment, Gear, or Cargo


Condition Type: Non-Vessel Material/Equipment Condition
Subject Type: Pollution Prevention/Response
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
PATHFINDER Vessel Damaged Involved in a Marine
Casualty
Details Filed: None

01/05/2010 9:00:00 to 01/05/2010 11:00:00 (Estimated): The Coast Guard District Seventeen
Drug and Alcohol Program Inspector audited Crowley Marine Services at the request of MSU
Valdez. Several mistakes during the post casualty drug testing were identified and

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recommendations were given to the company to assist in ensuring this does not happen in the
future. See Correspondence # 133810.

Condition Class: Policy, Procedures, or Regulations


Condition Type: Policy, Regs, and Procedures Condition
Subject Type: Procedure
Location: Known; US Waters
Description: PRINCE WILLIAM SOUND
Latitude: 60 51.8664 N Longitude: 146 40.902 W

Subject(s) and Details:


Name Type Status Role
CROWLEY MARINE Party Not at Risk Subject of
SERVICES INC Investigation
Details Filed: Policy/Regs/Procedures Condition
ISM Code Data
Does the ISM Code apply to the Party: No
Safety Management System (SMS) implemented: No

ISO 9000 Data


Does ISO 9000 apply to the Party: No
Quality Management System (QMS) implemented: No

ISO 14000 Data


Does ISO 14000 apply to the Party: No
Environmental Management System (EMS) implemented: No

Policies/Procedures that Do Not Exist


Explanation of Nonexistence:
Major Nonconformity: No

Policies/Procedures that Are Not Aboard


Explanation why Not Aboard:
Major Nonconformity: No

Policies/Procedures/Law/Regulation that is Present but Inadequate


Law/Regulation: No
Name: Vessel Operations Manual
Effective Date:
ISM Policy: No
ISO 9001 Policy: No
Issued By: Crowley Marine
Policy Nature: Assignment of duties
Reason Inadequate: Although the Master and Chief Mate were trained in how to
conduct post casualty testing, they failed to complete it properly. The company does not
conduct refresher training for their collectors which led to improper collections.

Policies/Procedures/Law/Regulation that is Present and Adequate

Latent Unsafe Condition: No

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V. CAUSAL ANALYSIS

The Initiating Event of the Incident


Initiating Event:

Grounding (12/23/2009 6:12:00 PM)

Production Factors

Active Human Failures - Execution Errors - Attention Failures - Inattention errors


Description Error; The Master made a decision to make a course change and bring
the speed to all ahead full, which in itself was use of a good rule.
The fact that he didn't have enough information to determine the vessel's position
and failed to chart his intended course made this decision an unsafe act that
resulted in the grounding of the vessel.
Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Active Human Failures - Planning Errors - Mistakes - Rule-based Mistakes - Use of a bad
rule
Inadvisable Rule; The Master decided to skip the vessel's normal waypoints for
their inbound route. His assumption of where the vessel was located made him
believe that by skipping the waypoints the voyage home would be faster.
Bridge Operations - Bridge Communications: 12/23/2009 5:45:00 PM,
Bligh Reef, Prince William Sound, Alaska,
Active Human Failures - Planning Errors - Mistakes - Knowledge-based Mistakes -
Heuristic
"As If" Heuristics; The Master acted on what he perceived to be "good
information" on what the position of the vessel was. The only information that he
used in determining the vessel's location was experience and the course and speed
that they were on. A chart was never consulted or a fix taken to verify this
conclusion prior to changing course and speed.
Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Active Human Failures - Planning Errors - Violations - Routine adaptation
Routine Adaptation; The Master was at the computer playing "hearts" after
changing course. This was against company policy on several different levels.
First, there needs to be someone actively engaged in pilotage of the vessel or
maintaining a plot. Second, there needs to be a "lookout" at all times.
Bridge Operations - Bridge Communications: 12/23/2009 6:01:45 PM,
PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE
Active Human Failures - Planning Errors - Violations - Willful violation
Routine Adaptation; The Master took actions, changed course and speed, without
determining the position of the vessel. He failed to pass any information to the
Second Mate, who he claims "had the Conn."
Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE

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Routine Adaptation; Due to the bridge configuration, the conning officer is
supposed to act as the lookout. In this case, no conning officer was identified,
therefore no one was acting as a lookout.
Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009
6:01:15 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c)

Routine Adaptation; The Master admittedly did not ascertain the position of the
vessel when arriving on the bridge to relieve the Chief Mate for dinner.
The Master did not log his relief in the logbook.
Crowley Marine Services' policy requires both of these actions to take place prior
to relief.
Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh
Reef, Prince William Sound, Alaska,
Routine Adaptation; Master did not follow company policy to lay down a fix or
ascertain the position of the vessel prior to watch relief.
No watch reliefs were logged as required by company policy.
Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh
Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Routine Adaptation; The Second Mate arrived on the bridge and failed to follow
policy and ascertain the position of the vessel prior to watch relief.
The Second Mate failed to log an entry as to the change of watch.
The Second Mate failed to ascertain what role he would be playing in the
upcoming transit into the port of Valdez after being relieved from ice scouting
duties.
Bridge Operations - Changing Watch: 12/23/2009 5:20:00 PM, PRINCE
WILLIAM SOUND, (b)(6) & (b)(7)(c)
Routine Adaptation; The Second Mate failed to follow company policy when he
did not notify the Master that he was unable to ascertain the ship's position by
radar ranging the racon on Bligh Reef or find the reef visually out of the starboard
window.
Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009
6:07:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c)

Other Violation Error; The Master returned from dinner but no fix was taken and
there was no discussion of the vessel's intentions. The only discussion was about
the need to make a call for the 1800 position.
There was no relief logged to assign positions on the bridge (i.e. Conning
Officer).
Bridge Operations - Changing Watch: 12/23/2009 5:44:00 PM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; Master deliberately violated company policy and used the
vessel's computer to play hearts or other games, directly after changing course and
speed. The Master's actions left the vessel's position unknown, other than an
assumption made by the Master on the vessel's previous course.
Bridge Operations - Bridge Communications: 12/23/2009 6:01:45 PM,
PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; Second Mate failed to follow company policy and log relief,
leaving question as to who had the Conn.

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Second Mate failed to ascertain the position of the vessel when coming on watch.
Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009
6:10:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c)

Preconditions

LUCs in People - Limitations of the person - Psychological conditions


The Second Mate has a history of failing to act quickly in adverse situations.
Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,
(b)(6) & (b)(7)(c)
The Master was planning on retiring in 8 months and had done 33 years with the
company. This could indicate a lack of concern, focus, or affect his decision
making abilities.
Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,
MONSEN, RONALD EUGENE
LUCs in People - Limitations of the person - Psychosocial conditions
According to Captain Monsen, his wife is disabled and in poor health, causing
him continual stress and concern over her condition.
Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,
MONSEN, RONALD EUGENE
LUCs in People - Person Mismatches - Mismatches between the person and software,
guidance or procedures
As part of its management activities, a Vessel Traffic Service (VTS) uses its
communications resources to highlight particular information or recommend
particular actions to vessel operators, shoreside facilities and other organizations.
Recommendations usually are given to resolve miscommunication or otherwise
call attention to particular circumstances, hazards, or conflicts when there is doubt
that appropriate action is being taken.

The PATHFINDER frequently operates in the vicinity of Bligh Reef and did not
request navigation assistance from the Prince William Sound VTS. The VTS
watch stander did not believe that the PATHFINDER had entered into a
hazardous situation due to the fact that ice scout vessels commonly operate in
close proximity to known hazards, such as Bligh Reef which is well marked with
both a RACON and a light. Additional safeguards have been implemented to
address future such operations.
Policy, Procedures, or Regulations: 12/23/2009, PRINCE WILLIAM
SOUND, COAST GUARD VALDEZ VTC
LUCs in People - Person Mismatches - Mismatches between the person and the
equipment
Crowley reps described the GPS as easy to use. The crew considered it difficult
and cumbersome when attempting to skip waypoints.
Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 5:00:00 PM,
Bligh Reef, Prince William Sound, Alaska, PATHFINDER
LUCs in People - Person Mismatches - Mismatches between the person and another
person

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The Second Mate was intimidated by the master's presence on the bridge. The
senior/subordinate relationship between the Master and Second Mate led to
confusion as to who was conning the vessel.
Person: 12/23/2009 6:01:21 PM, Bligh Reef, Prince William Sound,
Alaska, (b)(6) & (b)(7)(c)
LUCs in Equipment - Improper condition (i.e., wear, etc.)
The EBL on the starboard radar was inoperable since October of 2009.
Vessel, Facility, Equipment, Gear, or Cargo: 10/05/2009 12:00:00 PM,
PRINCE WILLIAM SOUND, PATHFINDER
LUCs in Equipment - Mismatch between design use and production activity
The computer screen on the laptop computer on the bridge was not protected from
emitting white light on the bridge which can affect night vision.
Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 5:47:20 PM,
PRINCE WILLIAM SOUND, PATHFINDER

Workplace Factors

LUCs in Supervision - Inadequate guidance


The Second Mate was never given a course and speed to steer, or directed to
ascertain the position of the vessel prior to or immediately following the course
change by the Master. The only command given was "take us home". The Second
Mate assumed that the Master still had the Conn even though the Master had his
back to the window and was on the computer at the time of the grounding.
Person: 12/23/2009 6:01:21 PM, Bligh Reef, Prince William Sound,
Alaska, (b)(6) & (b)(7)(c)
LUCs in Operations - Operations not in accordance with rules and regulations
Both the Master and Second Mate failed to follow policy on keeping logs, watch
reliefs, and lookouts.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
LUCs in Known Problem Correction - Corrective actions deferred/ignored
The Master and Chief Mate failed to adequately address the known deficiencies of
the Second Mate (line in prop and steering failure).
Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,

Organization Factors

LUCs in Equipment/Facility Resources - Poor design


The GPS unit on the vessel was complex, requiring its users to refer to the manual
whenever they needed to adjust/change waypoints.
Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 5:00:00 PM,
Bligh Reef, Prince William Sound, Alaska, PATHFINDER
LUCs in Structure - Missing or inadequate accountability for actions
On two occasions, the company was made aware of deficiencies in the judgment
of the Second Mate, however these deficiencies were not addressed.
Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,

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LUCs in Policies - Inadequate or improper drug and alcohol policies
Company's drug and alcohol policy is inadequate. It fails to provide refresher
training for their crews to ensure proper drug and alcohol testing is completed.
Policy, Procedures, or Regulations: 01/05/2010 9:00:00 AM, PRINCE
WILLIAM SOUND, CROWLEY MARINE SERVICES INC
LUCs in Operational Culture - Inadequate or absent organizational justice
Although the company published numerous policies regarding watchstanding and
navigation, there is no procedure in place to ensure the vessel crews are following
that policy.
Policy, Procedures, or Regulations: 12/23/2009 4:59:30 PM, PRINCE
WILLIAM SOUND, PATHFINDER
LUCs in Government - Inadequate or absent policies
Company's ice scout policy is inadequate. It fails to address the inherent dangers
that could be encountered during an ice scout mission.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, CROWLEY MARINE SERVICES INC

Defense Factors

Defenses that were in place but failed due to inadequacy - Inadequate engineered
defenses
The electronic bearing line on the vessel's radar had been inoperable for a number
of months. The company's maintenance policy is inadequate.
Vessel, Facility, Equipment, Gear, or Cargo: 10/05/2009 12:00:00 PM,
PRINCE WILLIAM SOUND, PATHFINDER
Defenses that were in place but failed due to inadequacy - Inadequate briefings
Master made a comment to the Second Mate after changing course and speed to
"take us home." The Master did not give the Second Mate information on the
vessel's course, speed or anything other than telling the Second Mate to "take us
home". The Second Mate did not question the Master, he assumed the Master
"knew what he was doing".
Bridge Operations - Bridge Communications: 12/23/2009 6:01:20 PM,
PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE
No information was passed regarding vessel's intended course, speed, or
intentions, other than doing an 1800 ice report. More importantly, it was not
communicated as to who had the Conn of the vessel.
Bridge Operations - Changing Watch: 12/23/2009 5:20:00 PM, PRINCE
WILLIAM SOUND, (b)(6) & (b)(7)(c)
No information was passed as to who had the Conn, position of the vessel,
intended course and speed, and future plans. No log entry was completed.
Bridge Operations - Changing Watch: 12/23/2009 5:44:00 PM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Improper reliefs. No information was passed as to the vessel's position, fix and
intended course.
Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh
Reef, Prince William Sound, Alaska,
Defenses that were in place but failed due to inadequacy - Inadequate/incorrect
information about hazards

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Master made the decision to alter course and speed without ascertaining the
vessel's position, failing to follow company policies regarding course changes.
Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Defenses that could reasonably have been expected but were never put in place - Absence
of supervision
There is no company policy on appropriate computer use.
Bridge Operations - Bridge Communications: 12/23/2009 5:47:00 PM,
PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c)
Active Human Failures - Execution Errors - Attention Failures - Inattention Errors
Description Error; The Master believed that he was in a different location at the
time of the action. His action would have been correct if the vessel was actually in
the "dogleg", as he incorrectly assumed. The error is a result of the Master
assuming the vessel's position. If there would have been good communication and
company policy followed, a fix would have been laid down to ascertain the
position of the vessel and a course would have been plotted on the chart prior to
the course change.
Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Active Human Failures - Planning Errors - Violations - Willful violation
Routine Adaptation; Watch reliefs were not properly conducted and a fix of the
position of the vessel was not done. Reliefs were not logged.
Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh
Reef, Prince William Sound, Alaska,
Routine Adaptation; The Master failed to pass his intentions to the Second Mate.
The Second Mate never logged the relief or took a fix.
Bridge Operations - Changing Watch: 12/23/2009 5:30:00 PM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; The Second Mate never made the Master aware of his
concern for the positioning of the vessel or the fact that he could not "find" Bligh
Reef Light, visually or via radar. When unsure of the vessel's position, company
policy requires the watchstander to inform the Master.
Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009
6:07:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c)

Routine Adaptation; After changing course, a fix or the Master's intentions for the
transit were never passed to the Second Mate, other than "take us home".
Company policy requires the vessel's course, speed and intended track be passed
to the oncoming watchstander.
Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Routine Adaptation; The Second Mate "believed" the Master had the Conn after
the Master made a course change. Policy requires a watch relief be logged and
communicated, which it was not. Adherence to company policy would have
answered the question as to who had the Conn prior to the incident.
Person: 12/23/2009 6:01:21 PM, Bligh Reef, Prince William Sound,
Alaska, (b)(6) & (b)(7)(c)

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Routine Adaptation; Instead of assuming the vessel's position, the Master was
required to ascertain the position of the vessel prior to relief. Company policy
requires the vessel's position to be logged upon watch relief.
Person: 12/23/2009 5:55:00 PM, Bligh Reef, Prince William Sound,
Alaska, MONSEN, RONALD EUGENE
Routine Adaptation; Failure to follow company policy and the Rule of Good
Seamanship.
Person: 12/23/2009 6:01:14 PM, PRINCE WILLIAM SOUND,
MONSEN, RONALD EUGENE
Routine Adaptation; Log entries for relief or required fixes were not made after
the Chief Mate left the bridge.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, CROWLEY MARINE SERVICES INC
Routine Adaptation; Reliefs were not logged.
Policy, Procedures, or Regulations: 12/23/2009 4:59:30 PM, PRINCE
WILLIAM SOUND, PATHFINDER
Routine Adaptation; The Master was not notified when the Second Mate was
unsure of intentions for the voyage or positioning of the vessel.
Policy, Procedures, or Regulations: 12/23/2009 6:08:00 PM, PRINCE
WILLIAM SOUND, (b)(6) & (b)(7)(c)
Routine Adaptation; Watch reliefs were not conducted.
Policy, Procedures, or Regulations: 12/23/2009 5:21:59 PM, PRINCE
WILLIAM SOUND, PATHFINDER
Routine Adaptation; Reliefs were not conducted or logged.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, (b)(6) & (b)(7)(c)
Routine Adaptation; Reliefs were not logged and information regarding intentions
or the position of the vessel was never ascertained.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; Accurate logs per policy were not maintained.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; Company policy requires the full attention of the bridge crew
while navigating. The Master was playing hearts and the Second Mate was
looking at the chart, both with their backs to the forward bridge window, as the
vessel grounded.
Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; The Master was aware of company policy, but never
ascertained the position of the vessel the entire time he was on the bridge. He
admittedly didn't have an idea as to where they were prior to the course change.
The fact that he went to the computer to play video games after a course change
further aggravates the situation and amplifies the lack of attention on the bridge
between the Master and Second Mate.
Bridge Operations - Bridge Communications: 12/23/2009 6:01:45 PM,
PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE

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Routine Adaptation; The Master made the comment "take us home" to the Second
Mate and assumed that this was his relief of the Conn. If policy were followed
they both would have been comfortable with the vessel's position prior to relief,
and a log entry would have been made as to who had control, or the Conn.
Bridge Operations - Bridge Communications: 12/23/2009 6:01:20 PM,
PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; Reliefs were not conducted as required. Important
information was not passed and log entries were not made.
Bridge Operations - Changing Watch: 12/23/2009 5:44:00 PM, PRINCE
WILLIAM SOUND, MONSEN, RONALD EUGENE
Routine Adaptation; Reliefs were not conducted as required by policy. The
position of the vessel and intentions were left unknown. Log entries were not
made.
Bridge Operations - Changing Watch: 12/23/2009 5:20:00 PM, PRINCE
WILLIAM SOUND, (b)(6) & (b)(7)(c)

Failures of Defense Against Subsequent Events in the Incident

Subsequent Event #1:

Material Failure (Vessels) (12/23/2009 6:20:00 PM)

Defense Factors

Active Human Failures - Planning Errors - Mistakes - Knowledge-based Mistakes - Bias


Framing Bias; The master believed that if he stayed on the reef, the vessel would
not have been able to be refloated. The actions to remove the vessel caused
additional damage to the hull.
Bridge Operations - Shiphandling: 12/23/2009 6:25:00 PM, Bligh Reef,
Prince William Sound, Alaska, MONSEN, RONALD EUGENE
Active Equipment/Material Failures - Active failures of material
The vessel grounded on Bligh Reef causing substantial damage to C/L tanks 2 and
3, and several other areas.
Material Failure (Vessels): 12/23/2009 6:20:00 PM, Bligh Reef, Prince
William Sound, Alaska, PATHFINDER

Subsequent Event #2:

Damage to the Environment (12/23/2009 6:21:00 PM)

Defense Factors

Defenses that were in place but failed due to inadequacy - Inadequate supervision
The lack of on-scene leadership may have directly affected the amount of fuel
recovered. At the incident command post, there was confusion as to who the
responsible party was. The vessel was contracted by SERVS and therefore it was
believed that they should take part in the response.

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Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 11:15:00 PM,
PRINCE WILLIAM SOUND, PATHFINDER
Active Human Failures - Planning Errors - Mistakes - Rule-based Mistakes - Misuse of a
good rule
General Rule; The oil spill response personnel applied good marine practice and
stopped the pump when they heard unusual noises. The stopping and restarting of
the pump led to the release of additional fuel from the ruptured tank.
Damage to the Environment: 12/23/2009 6:21:00 PM, Bligh Reef, Prince
William Sound, Alaska, PATHFINDER
Active Equipment/Material Failures - Active failures of equipment
The vessel grounded removing most of the bottom plating of tanks 2 and 3
centerline.
Material Failure (Vessels): 12/23/2009 6:20:00 PM, Bligh Reef, Prince
William Sound, Alaska, PATHFINDER

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VI. REFERRAL FOR ENFORCEMENT ACTION

The following referrals for enforcement action have been made as a result of this investigation
and represent those instances where the Coast Guard has gathered evidence that indicates one or
more alleged violations or offenses may have occurred. Any determinations as to whether or not
one or more actual violations or offenses have occurred are documented in the appropriate Coast
Guard enforcement activities.

Referral #1: USCG v (b)(6) & (b)(7)(c)


Party: (b)(6) & (b)(7)(c)
Enforcement Action: Suspension and Revocation - Status: Open - In Progress

Alleged Violations
Cite Date/Time Event/Action/Condition Location Subject(s)
46CFR5.27 12/23/2009 Policy, Procedures, or PRINCE MONSEN,
7:00:00 Regulations WILLIAM RONALD
SOUND EUGENE;
(b)(6) & (b)(7)(c)

Evidence
3655472-01- Bridge Log; ; Date/Time Collected: 12/24/2009 3:30:00 PM
3655472-05- Master Statement; ; Date/Time Collected: 12/24/2009 3:41:00 PM
3655472-07- Bridge Log Page from the day of the Grounding; ; Date/Time Collected:
12/24/2009 3:44:00 PM
3655472-09- 2692 and form B; ; Date/Time Collected: 12/24/2009 3:47:00 PM
3655472-10- Chief Mate Statement; ; Date/Time Collected: 12/26/2009 3:49:00 PM
3655472-32- VOM Part D, Vessel Operations; ; Date/Time Collected: 01/04/2010
9:39:00 AM
3655472-31- VOM Part K, Port Transits; ; Date/Time Collected: 01/04/2010 10:05:00
AM
3655472-30- VOM Part G, General Navigation and Navigation Safety; ; Date/Time
Collected: 01/04/2010 10:08:00 AM
3655472-29- VOM Part C2, Supervisors/Mates; ; Date/Time Collected: 01/04/2010
10:22:00 AM
3655472-19- Crowley Directive VDZ-09-008; ; Date/Time Collected: 01/04/2010
11:27:00 AM
3655472-18- VOM Part Q, Voyage Routing; ; Date/Time Collected: 01/05/2010
11:29:00 AM
3655472-17- VOM Part R, Watchstanding and Change of Watch; ; Date/Time
Collected: 01/05/2010 11:31:00 AM
3655472-16- VOM Part C1, Master; ; Date/Time Collected: 01/05/2010 11:33:00 AM

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3655472-15- VOM, Part I, Notifying the Master; ; Date/Time Collected: 01/05/2010
11:35:00 AM
3655472 VR 1- Voice Recording of interview with Master; ; Date/Time Collected:
01/05/2010 11:38:00 AM

Referral #41: PATHFINDER Damage to the Envirnoment 23DEC09


Party: CROWLEY MARINE
Enforcement Action: Administrative Civil Penalty (Class I) - Status: Closed - Payment
Received

Alleged Violations
Cite Date/Time Event/Action/Condition Location Subject(s)
33USC§ 12/23/2009 Damage to the Bligh PATHFIN
1321(b)(3) 18:21:00 Environment Reef, DER
Prince
William
Sound,
Alaska

Evidence
3655472-37 ; Photographs of PATHFINDER spill; ; Date/Time Collected: 01/14/2010
8:20:00 AM
3655472-38 ; Pollution Investigator's Statement; ; Date/Time Collected: 01/14/2010
8:24:00 AM

Referral #35: USCG v RONALD MONSEN


Party: MONSEN, RONALD EUGENE
Enforcement Action: Suspension and Revocation - Status: Closed - Administrative
Action

Alleged Violations
Cite Date/Time Event/Action/Condition Location Subject(s)
46CFR5.27 12/23/2009 Policy, Procedures, or PRINCE MONSEN,
7:00:00 Regulations WILLIAM RONALD
SOUND EUGENE
46CFR5.29 12/23/2009 Grounding Bligh PATHFIN
18:12:00 Reef, DER
Prince
William
Sound,
Alaska

Evidence
3655472-01- Bridge Log; ; Date/Time Collected: 12/24/2009 3:30:00 PM
3655472-06- 2nd Mate Statement; ; Date/Time Collected: 12/24/2009 3:42:00 PM
3655472-07- Bridge Log Page from the day of the Grounding; ; Date/Time Collected:
12/24/2009 3:44:00 PM
3655472-09- 2692 and form B; ; Date/Time Collected: 12/24/2009 3:47:00 PM

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3655472-10- Chief Mate Statement; ; Date/Time Collected: 12/26/2009 3:49:00 PM
3655472-34- LPS Directive 009-001; ; Date/Time Collected: 01/04/2010 3:28:00 PM
3655472-36- Chief Eng. Statement; ; Date/Time Collected: 01/06/2010 3:30:00 PM
3655472-32- VOM Part D, Vessel Operations; ; Date/Time Collected: 01/04/2010
9:39:00 AM
3655472-31- VOM Part K, Port Transits; ; Date/Time Collected: 01/04/2010 10:05:00
AM
3655472-30- VOM Part G, General Navigation and Navigation Safety; ; Date/Time
Collected: 01/04/2010 10:08:00 AM
3655472-29- VOM Part C2, Supervisors/Mates; ; Date/Time Collected: 01/04/2010
10:22:00 AM
3655472-19- Crowley Directive VDZ-09-008; ; Date/Time Collected: 01/04/2010
11:27:00 AM
3655472-18- VOM Part Q, Voyage Routing; ; Date/Time Collected: 01/05/2010
11:29:00 AM
3655472-17- VOM Part R, Watchstanding and Change of Watch; ; Date/Time
Collected: 01/05/2010 11:31:00 AM
3655472-16- VOM Part C1, Master; ; Date/Time Collected: 01/05/2010 11:33:00 AM
3655472-15- VOM, Part I, Notifying the Master; ; Date/Time Collected: 01/05/2010
11:35:00 AM

Referral #34: USCG v CROWLEY MARINE SERVICES, INC.


Party: CROWLEY MARINE SERVICES INC
Enforcement Action: Administrative Civil Penalty (Class I) - Status: Closed - Agency
Action Complete

Alleged Violations
Cite Date/Time Event/Action/Condition Location Subject(s)
46CFR4.05-1 12/23/2009 Person PRINCE
7:00:00 WILLIAM
SOUND

MONSEN,
RONALD
EUGENE;
(b)(6) & (b)(7)(c)

Evidence
3655472-043- CG-2692 from ROGER G incident; ; Date/Time Collected:
01/28/2010 3:27:00 PM
3655472-044- Log from the ROGER G, line boat; ; Date/Time Collected:
01/28/2010 3:27:00 PM

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APPENDIX 1 - EVIDENCE

3655472 VR 1-
Voice Recording of interview with Master
Collection Information:
Date/Time: 01/05/2010 11:38:00 AM
Location: MSU Valdez conference room
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; MSU Valdez
Tracking:
Attachments:
- WS210005.WMA; Marine Safety Unit Valdez;
01/07/2010;

3655472 VR2-
Voice recording of the 2nd Mate Interview
Collection Information:
Date/Time: 01/05/2010 11:45:00 AM
Location: MSU Valdez conference room
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; MSU Valdez
Tracking:
Attachments:
- WS210006.WMA; Marine Safety Unit Valdez;
01/07/2010;

3655472-01-
Bridge Log
Collection Information:
Date/Time: 12/24/2009 3:30:00 PM
Location: Aboard Vessel
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-01- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-02-
Lightering Plan
Collection Information:
Date/Time: 12/25/2009 3:32:00 PM
Location: Crowley Marine
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-02- pdf; Marine Safety Unit Valdez; 02/18/2010;

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3655472-03-
Eninge Room Log
Collection Information:
Date/Time: 12/24/2009 3:37:00 PM
Location: Aboard Vessel Pathfinder
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Engine Room Log.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-04-
Sounding Sheet
Collection Information:
Date/Time: 12/25/2009 3:39:00 PM
Location: Aboard Vessel Pathfinder
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Sounding Record.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-040-
CG-2692 rcvd frm company
Collection Information:
Date/Time: 01/28/2010 10:21:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-040- pdf; Marine Safety Unit Valdez;
01/29/2010;

3655472-041-
Vessel Logs book
Collection Information:
Date/Time: 01/28/2010 10:21:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-041- pdf; Marine Safety Unit Valdez;
01/29/2010;

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3655472-042-
Engine room log dtd 07-16-2009
Collection Information:
Date/Time: 01/28/2010 10:21:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-042- pdf; Marine Safety Unit Valdez;
01/29/2010;

3655472-043-
CG-2692 from ROGER G incident
Collection Information:
Date/Time: 01/28/2010 3:27:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-043- pdf; Marine Safety Unit Valdez;
01/29/2010;

3655472-044-
Log from the ROGER G, line boat
Collection Information:
Date/Time: 01/28/2010 3:27:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-044- pdf; Marine Safety Unit Valdez;
01/29/2010;

3655472-047-
Vessel Traffic Center Valdez schematic
Collection Information:
Date/Time: 02/11/2010 9:11:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-047- pdf; Marine Safety Unit Valdez;
02/11/2010;

81
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

3655472-048-
E-VRP for the PATHFINDER
Collection Information:
Date/Time: 02/10/2010 1:00:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-048- pdf; Marine Safety Unit Valdez;
02/11/2010;

3655472-049-
IO statement
Collection Information:
Date/Time: 02/05/2010 10:00:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-049- pdf; Marine Safety Unit Valdez;
02/11/2010;

3655472-05-
Master Statement
Collection Information:
Date/Time: 12/24/2009 3:41:00 PM
Location: Aboard Vessel Pathfinder
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Master Statement.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-050-
Chapter 2 from the Vessel Traffic Services National Standard Operating Procedures
Manual (VTS NSOP) , Commandant Instruction Manual 16630.3
Collection Information:
Date/Time: 02/11/2010 11:04:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:

82
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- 3655472-050- pdf; Marine Safety Unit Valdez;
02/11/2010;

3655472-052-
Alcohol test results for entire crew
Collection Information:
Date/Time: 02/18/2010 3:44:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; CWO2, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-052- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-053-
Summary of interview with LT conducted by LCDR
Collection Information:
Date/Time: 01/24/2011 3:46:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; LCDR, USCG, D17
Tracking:
Attachments:
- VTC Statement.pdf; Marine Safety Unit Valdez;
01/31/2011;

3655472-054-
Summary of interviews conducted with Mr. conducted by LCDR
Collection Information:
Date/Time: 01/24/2011 3:46:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; LCDR, USCG, D17
Tracking:
Attachments:
- VTC Statement.pdf; Marine Safety Unit Valdez;
01/31/2011;

3655472-055-
Summary of interview with Mr. conducted by LCDR
Collection Information:
Date/Time: 01/24/2011 3:45:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; LCDR, USCG, D17
Tracking:
Attachments:

83
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- VTC Statement.pdf; Marine Safety Unit Valdez;
01/31/2011;

3655472-056-
Summary of interview with OSC conducted by LCDR
Collection Information:
Date/Time: 01/24/2011 3:26:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; LT, USCG, MSU Valdez
Witnessed By: USCG Witness; LCDR, USCG, D17
Tracking:
Attachments:
- VTC Statement.pdf; Marine Safety Unit Valdez;
01/31/2011;

3655472-06-
2nd Mate Statement
Collection Information:
Date/Time: 12/24/2009 3:42:00 PM
Location: Aboard Vessel Pathfinder
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 2nd Mate Statement.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-07-
Bridge Log Page from the day of the Grounding
Collection Information:
Date/Time: 12/24/2009 3:44:00 PM
Location: Aboard Vessel Pathfinder
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Bridge Log short.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-08-
Vessel Schematic
Collection Information:
Date/Time: 12/24/2009 3:46:00 PM
Location: Aboard Vessel Pathfinder
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:

84
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- Vessel schematic.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-09-
2692 and form B
Collection Information:
Date/Time: 12/24/2009 3:47:00 PM
Location: Aboard Vessel
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-09- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-10-
Chief Mate Statement
Collection Information:
Date/Time: 12/26/2009 3:49:00 PM
Location: Crowley Marine Services
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Chief Mate Statement.pdf; Marine Safety Unit Valdez;
12/27/2009;

3655472-11-
Approved Tow Plan
Collection Information:
Date/Time: 12/26/2009 10:10:00 AM
Location: Crowley Unified Command
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-11- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-12
Notice Of Federal Interest (NOFI) issued to CROWLEY
Collection Information:
Date/Time: 12/28/2009 2:22:00 PM
Location: VALDEZ
Collected By: USCG Gathered; PO , MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-12 .pdf; Marine Safety Unit Valdez; 02/18/2010;

85
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
3655472-13-
SERVS Duty Log
Collection Information:
Date/Time: 12/29/2009 7:24:00 AM
Location: Via Email
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-13- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-14-
PPT of various pics on PATHFINDER
Collection Information:
Date/Time: 12/23/2009 10:22:00 AM
Location: Aboard Vessel
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- PATHFINDER Grounding.pps; ; Marine Safety Unit Valdez;
12/31/2009;

3655472-15-
VOM, Part I, Notifying the Master
Collection Information:
Date/Time: 01/05/2010 11:35:00 AM
Location: Crowley Marine Services, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Voyage Mgmt-Notifying the Master.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-16-
VOM Part C1, Master
Collection Information:
Date/Time: 01/05/2010 11:33:00 AM
Location: Crowley Marine Services
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Master Masters Authority.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-17-

86
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
VOM Part R, Watchstanding and Change of Watch
Collection Information:
Date/Time: 01/05/2010 11:31:00 AM
Location: Crowley Marine Services
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Watchstanding and Change of Watch.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-18-
VOM Part Q, Voyage Routing
Collection Information:
Date/Time: 01/05/2010 11:29:00 AM
Location: Crowley Marine Services, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Voyage Routing.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-19-
Crowley Directive VDZ-09-008
Collection Information:
Date/Time: 01/04/2010 11:27:00 AM
Location: Crowley Marine Services, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Crowley Directive VDZ 09-008.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-20-
Urinalysis Results, (b)(6) & (b)(7)(c)
Collection Information:
Date/Time: 01/05/2010 11:26:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- (b)(6) & (b)(7)(c) Results.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-21-

87
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Urinalysis Results,
Collection Information:
Date/Time: 01/05/2010 11:23:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Results.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-22-
Urinalysis Results, (b)(6) & (b)(7)(c)
Collection Information:
Date/Time: 01/05/2010 11:20:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Results.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-23-
Urinalysis Results, (b)(6) & (b)(7)(c)
Collection Information:
Date/Time: 01/05/2010 11:19:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Results.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-24-
Urinalysis Results for Ronald Monsen
Collection Information:
Date/Time: 01/05/2010 11:17:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Monsen Results.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-25-

88
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Urinalysis Results for
Collection Information:
Date/Time: 01/05/2010 11:12:00 AM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Results.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-26-
Ice Scout Vessel Procedures SERVS
Collection Information:
Date/Time: 01/04/2010 10:58:00 AM
Location: Crowley Marine Services, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- SERVS Ice Scout Vessel Procedures S550108.pdf; Marine Safety Unit Valdez;
01/07/2010;
- SERVS Ice Scout Vessel Procedures PG 2.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-27-
SERVS shift briefing log
Collection Information:
Date/Time: 01/05/2010 10:51:00 AM
Location: Crowley Marine Services
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- SERVS Duty Log.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-28-
Ice Navigation Procedures
Collection Information:
Date/Time: 01/04/2010 10:28:00 AM
Location: Crowley Marine Services
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VERP Ice Navigation Procedures.pdf; Marine Safety Unit Valdez;
01/07/2010;

89
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

3655472-29-
VOM Part C2, Supervisors/Mates
Collection Information:
Date/Time: 01/04/2010 10:22:00 AM
Location: Crowley Marine Services, Valdez,
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Mate Responsibilities.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-30-
VOM Part G, General Navigation and Navigation Safety
Collection Information:
Date/Time: 01/04/2010 10:08:00 AM
Location: Crowley Marine Services, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Gen Nav and Nav Safety.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-31-
VOM Part K, Port Transits
Collection Information:
Date/Time: 01/04/2010 10:05:00 AM
Location: Crowley Marine Services, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Port Transits.pdf; Marine Safety Unit Valdez;
01/07/2010;

3655472-32-
VOM Part D, Vessel Operations
Collection Information:
Date/Time: 01/04/2010 9:39:00 AM
Location: Crowley Marine, Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- VOM Vessel Operations.pdf; Marine Safety Unit Valdez;
01/07/2010;

90
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

3655472-33-
(b)(6) & (b)(7)(c) 96 hr work/rest history
Collection Information:
Date/Time: 02/18/2010 3:05:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; CWO2, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 3655472-33- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-34-
LPS Directive 009-001
Collection Information:
Date/Time: 01/04/2010 3:28:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Crowley Directive LPS 009-001.pdf; Marine Safety Unit Valdez;
01/06/2010;

3655472-35-
Work Rest History
Collection Information:
Date/Time: 01/05/2010 3:27:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Work Rest.pdf; Marine Safety Unit Valdez;
01/06/2010;

3655472-36-
Chief Eng. Statement
Collection Information:
Date/Time: 01/06/2010 3:30:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Chief Eng Statement.pdf; Marine Safety Unit Valdez;
01/06/2010;

91
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- Chief Engineer Statement Pg 2.pdf; Marine Safety Unit Valdez;
01/06/2010;

3655472-37
Photographs of PATHFINDER spill
Collection Information:
Date/Time: 01/14/2010 8:20:00 AM
Location: MSU VALDEZ
Collected By: USCG Gathered; MST3 MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- DSCN0443.JPG; Marine Safety Unit Valdez; 01/14/2010;
- DSCN0441.JPG; Marine Safety Unit Valdez; 01/14/2010;
- IMG_1394.JPG; Marine Safety Unit Valdez; 01/14/2010;
- IMG_1396.JPG; Marine Safety Unit Valdez; 01/14/2010;
- 105.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 106.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 107.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 108.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 109.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 110.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 111.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 112.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;
- 113.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez;
02/02/2010;

3655472-38-
Pollution Investigator's Statement
Collection Information:
Date/Time: 01/14/2010 8:24:00 AM
Location: MSU VALDEZ
Collected By: USCG Gathered; MST3 MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- PI Statement.pdf; Marine Safety Unit Valdez; 03/29/2010;

3655472-39-
Starboard radar EBL work order

92
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
Collection Information:
Date/Time: 01/05/2010 10:07:00 AM
Location: Crowley Marine
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- Radar EBL WO.pdf; Marine Safety Unit Valdez;
01/15/2010;
- Starboard Radar WO 1.pdf; Marine Safety Unit Valdez;
01/15/2010;

3655472-45
Tank soundings from a third party source of before and after amounts of fuel on board
showing 6410 gallons missing.
Collection Information:
Date/Time: 02/02/2010 2:48:00 PM
Location: MSU VALDEZ
Collected By: USCG Gathered; MST3 MSU Valdez
Witnessed By: USCG Witness; MST2 MSU Valdez
Tracking:
Attachments:
- 3655472-45 .pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-46
VTC GIS displays of PATHFINDER's track at Bligh Reef
Collection Information:
Date/Time: 02/02/2010 3:13:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; MST3 MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 1630-1700.JPG; Marine Safety Unit Valdez; 02/02/2010;
- 1700-1730.JPG; Marine Safety Unit Valdez; 02/02/2010;
- 1730-1800.JPG; Marine Safety Unit Valdez; 02/02/2010;
- 1800-1812.JPG; Marine Safety Unit Valdez; 02/02/2010;
- 1812-1830.JPG; Marine Safety Unit Valdez; 02/02/2010;

3655472-51-
Capt. Ronald Monsen 96 hour work rest history
Collection Information:
Date/Time: 02/18/2010 3:24:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; CWO2, USCG, MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:

93
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- 3655472-51- pdf; Marine Safety Unit Valdez; 02/18/2010;

3655472-VTC Log-
VTC Log for 23 Dec 10
Collection Information:
Date/Time: 02/01/2010 3:27:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 23DEC09 VTC Log.doc; Marine Safety Unit Valdez;
02/01/2010;

3655472-VTC Voice-
Voice Log for VTC
Collection Information:
Date/Time: 02/01/2010 3:30:00 PM
Location: MSU Valdez
Collected By: USCG Gathered; MSU Valdez
Witnessed By: USCG Witness; ,
Tracking:
Attachments:
- 01 Track 1.wma; Marine Safety Unit Valdez;
02/01/2010;
- 02 Track 2.wma; Marine Safety Unit Valdez;
02/01/2010;
- 04 Track 4.wma; Marine Safety Unit Valdez;
02/01/2010;
- 03 Track 3.wma; Marine Safety Unit Valdez;
02/01/2010;
- 05 Track 5.wma; Marine Safety Unit Valdez;
02/01/2010;
- 06 Track 6.wma; Marine Safety Unit Valdez;
02/01/2010;
- 07 Track 7.wma; Marine Safety Unit Valdez;
02/01/2010;
- 08 Track 8.wma; Marine Safety Unit Valdez;
02/01/2010;
- 09 Track 9.wma; Marine Safety Unit Valdez;
02/01/2010;
- 10 Track 10.wma; Marine Safety Unit Valdez;
02/01/2010;
- 11 Track 11.wma; Marine Safety Unit Valdez;
02/01/2010;
- 12 Track 12.wma; Marine Safety Unit Valdez;
02/01/2010;

94
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- 13 Track 13.wma; Marine Safety Unit Valdez;
02/01/2010;
- 14 Track 14.wma; Marine Safety Unit Valdez;
02/01/2010;
- 15 Track 15.wma; Marine Safety Unit Valdez;
02/01/2010;
- 16 Track 16.wma; Marine Safety Unit Valdez;
02/01/2010;
- 17 Track 17.wma; Marine Safety Unit Valdez;
02/01/2010;
- 18 Track 18.wma; Marine Safety Unit Valdez;
02/01/2010;
- 19 Track 19.wma; Marine Safety Unit Valdez;
02/01/2010;
- 20 Track 20.wma; Marine Safety Unit Valdez;
02/01/2010;
- 21 Track 21.wma; Marine Safety Unit Valdez;
02/01/2010;
- 22 Track 22.wma; Marine Safety Unit Valdez;
02/01/2010;
- 23 Track 23.wma; Marine Safety Unit Valdez;
02/01/2010;
- 24 Track 24.wma; Marine Safety Unit Valdez;
02/01/2010;
- 25 Track 25.wma; Marine Safety Unit Valdez;
02/01/2010;
- 26 Track 26.wma; Marine Safety Unit Valdez;
02/01/2010;
- 27 Track 27.wma; Marine Safety Unit Valdez;
02/02/2010;
- 28 Track 28.wma; Marine Safety Unit Valdez;
02/02/2010;
- 29 Track 29.wma; Marine Safety Unit Valdez;
02/02/2010;
- 30 Track 30.wma; Marine Safety Unit Valdez;
02/02/2010;
- 31 Track 31.wma; Marine Safety Unit Valdez;
02/02/2010;
- 32 Track 32.wma; Marine Safety Unit Valdez;
02/02/2010;
- 33 Track 33.wma; Marine Safety Unit Valdez;
02/02/2010;
- 34 Track 34.wma; Marine Safety Unit Valdez;
02/02/2010;
- 35 Track 35.wma; Marine Safety Unit Valdez;
02/02/2010;
- 36 Track 36.wma; Marine Safety Unit Valdez;
02/02/2010;

95
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- 37 Track 37.wma; Marine Safety Unit Valdez;
02/02/2010;
- 38 Track 38.wma; Marine Safety Unit Valdez;
02/02/2010;
- 39 Track 39.wma; Marine Safety Unit Valdez;
02/02/2010;
- 40 Track 40.wma; Marine Safety Unit Valdez;
02/02/2010;
- 41 Track 41.wma; Marine Safety Unit Valdez;
02/02/2010;
- 42 Track 42.wma; Marine Safety Unit Valdez;
02/02/2010;
- 43 Track 43.wma; Marine Safety Unit Valdez;
02/02/2010;
- 44 Track 44.wma; Marine Safety Unit Valdez;
02/02/2010;
- 45 Track 45.wma; Marine Safety Unit Valdez;
02/02/2010;
- 46 Track 46.wma; Marine Safety Unit Valdez;
02/02/2010;
- 47 Track 47.wma; Marine Safety Unit Valdez;
02/02/2010;
- 48 Track 48.wma; Marine Safety Unit Valdez;
02/02/2010;
- 49 Track 49.wma; Marine Safety Unit Valdez;
02/02/2010;
- 50 Track 50.wma; Marine Safety Unit Valdez;
02/02/2010;
- 51 Track 51.wma; Marine Safety Unit Valdez;
02/02/2010;
- 52 Track 52.wma; Marine Safety Unit Valdez;
02/02/2010;
- 53 Track 53.wma; Marine Safety Unit Valdez;
02/02/2010;
- 54 Track 54.wma; Marine Safety Unit Valdez;
02/02/2010;
- 55 Track 55.wma; Marine Safety Unit Valdez;
02/02/2010;
- 56 Track 56.wma; Marine Safety Unit Valdez;
02/02/2010;
- 57 Track 57.wma; Marine Safety Unit Valdez;
02/02/2010;
- 59 Track 59.wma; Marine Safety Unit Valdez;
02/02/2010;
- 60 Track 60.wma; Marine Safety Unit Valdez;
02/02/2010;
- 61 Track 61.wma; Marine Safety Unit Valdez;
02/02/2010;

96
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- 62 Track 62.wma; Marine Safety Unit Valdez;
02/02/2010;
- 65 Track 65.wma; Marine Safety Unit Valdez;
02/02/2010;
- 66 Track 66.wma; Marine Safety Unit Valdez;
02/02/2010;
- 67 Track 67.wma; Marine Safety Unit Valdez;
02/02/2010;
- 68 Track 68.wma; Marine Safety Unit Valdez;
02/02/2010;
- 69 Track 69.wma; Marine Safety Unit Valdez;
02/02/2010;
- 70 Track 70.wma; Marine Safety Unit Valdez;
02/02/2010;
- 71 Track 71.wma; Marine Safety Unit Valdez;
02/02/2010;
- 72 Track 72.wma; Marine Safety Unit Valdez;
02/02/2010;
- 73 Track 73.wma; Marine Safety Unit Valdez;
02/02/2010;
- 74 Track 74.wma; Marine Safety Unit Valdez;
02/02/2010;
- 75 Track 75.wma; Marine Safety Unit Valdez;
02/02/2010;
- 76 Track 76.wma; Marine Safety Unit Valdez;
02/02/2010;
- 77 Track 77.wma; Marine Safety Unit Valdez;
02/02/2010;
- 78 Track 78.wma; Marine Safety Unit Valdez;
02/02/2010;
- 79 Track 79.wma; Marine Safety Unit Valdez;
02/02/2010;
- 80 Track 80.wma; Marine Safety Unit Valdez;
02/02/2010;
- 81 Track 81.wma; Marine Safety Unit Valdez;
02/02/2010;
- 82 Track 82.wma; Marine Safety Unit Valdez;
02/02/2010;
- 83 Track 83.wma; Marine Safety Unit Valdez;
02/02/2010;
- 84 Track 84.wma; Marine Safety Unit Valdez;
02/02/2010;
- 85 Track 85.wma; Marine Safety Unit Valdez;
02/02/2010;
- 86 Track 86.wma; Marine Safety Unit Valdez;
02/02/2010;
- 87 Track 87.wma; Marine Safety Unit Valdez;
02/02/2010;

97
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- 88 Track 88.wma; Marine Safety Unit Valdez;
02/02/2010;
- 58 Track 58.wma; Marine Safety Unit Valdez;
02/02/2010;
- 63 Track 63.wma; Marine Safety Unit Valdez;
02/02/2010;
- 64 Track 64.wma; Marine Safety Unit Valdez;
02/02/2010;

98
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation

APPENDIX 2 - CORRESPONDENCE

133802 - Letter of concern to Crowley from MSU Valdez


Source: USCG
Type: Outgoing
Sent: To Crowley Maritime, Valdez on 02/04/2010 9:46:00 AM
Attachments:
- Crowley Letter.pdf; Marine Safety Unit Valdez; 02/04/2010;

133803 - Letter of Prediciation to CGIS


Source: USCG
Type: Outgoing
Sent: To Sec Anchorage on 02/04/2010 9:48:00 AM
Attachments:
- Letter of Predication.pdf; Marine Safety Unit Valdez;
02/19/2010;

133810 - Drug and Alcohol Inspector Recommendations letter


Source: USCG
Type: Outgoing
Sent: To Crowley Marine, FL on 02/04/2010 10:19:00 AM
Attachments:
- DAPI letter.pdf; Marine Safety Unit Valdez; 02/04/2010;

134717 - Interested Party Letter from attorney representing (b)(6) & (b)(7)(c)
Source: 3rd Party
Type: Incoming
Received: At MSU Valdez on 01/08/2009 9:12:00 AM
Attachments:
- (b)(6) & (b)(7)(c) lawyer.pdf; Marine Safety Unit Valdez;
02/18/2010;

134790 - Monsen Lawyer Change


Source: USCG
Type: Incoming
Received: At MSU Valdez on 02/19/2010 12:53:00 PM
Attachments:
- Monsen Lawyer change.pdf; Marine Safety Unit Valdez;
02/19/2010;

136853 - Safety Recommendations Letter


Source: USCG
Type: Outgoing
Sent: To hand delivered to Crowley Marine on 03/23/2010
11:00:00 AM
Attachments:

99
707.300.110429.USCGPathfndrFAMrpt.pdf
Received 5/5/2011
Report of Investigation
- Safety Recommendations Letter.pdf; Marine Safety Unit Valdez;
03/23/2010;

100

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