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DEPARTMENT OF TRANSPORTATION UNITED STATES COAST GUARD Mailing Address U.S. COAST GUARD (G-MMI/83) *** SEVENTH STREET SW WASHINGTON, D.C. ***** PHONE: 202-426-1455 Commandant's Action on The Marine Board of Investigation convened to investigate the circumstances surrounding the sinking of the SS EDMUND FITZGERALD in Lake Superior on 10 November 1975 with loss of life. The record of the Marine Board of Investigation convened to investigate the subject casualty has been reviewed; and the record, including the findings of fact, conclusions, and recommendations, is approved subject to the following comments. REMARKS 1. This casualty presented the Board unique investigative challenges which delayed the submission of the report. Since there were no survi- vors or witnesses to be questioned, the Board went to considerable lengths to examine wreckage located soon after the casualty. In the spring of 1976, an underwater examination of the wreckage, utilizing highly sophisticated remotely controlled TV and photographic equipment, positively identified the wreck of the SS EDMUND FITZGERALD. The equip- ment was used to develop a detailed survey and photographic record of the structural damage and position of the wreckage. The sketches of the wreckage in the Board's report, showing the inverted stern section, loose hatch covers, and bow section, were made from this video tape and photographic record. A further delay in the completion of the final report was due to the time needed to complete the sounding survey, conducted by Canadian authorities, of the water between Michipicoten Island and Caribou Island and adjacent waters. i --------------------------------------------------------------------------- 2. The Commandant concurs with the Board that the most probable cause of the sinking was the loss of buoyancy resulting from massive flooding of the cargo hold. This flooding most likely took place through ineffective hatch closures. As the boarding seas rolled over the spar deck, the flooding was probably concentrated forward. The vessel dove into a wall of water and never recovered, with the breaking up the ship occurring as it plunged or as the ship struck the bottom. The sinking was so rapid and unexpected that no one was able to success- fully abandon ship. With regard to opinions as to the causes of damage and the final sequence of events, an analysis has been made which demonstrates a possibility of capsizing and/or foundering. The analysis of various stages of flooding indicates that bending moment magnitudes and distribution would not support a conclusion of general structural failure as a primary cause of the casualty. ACTION CONCERNING THE RECOMMENDATIONS 1. The following Board recommendations relate to load line regulations and watertight integrity and are addressed jointly. Recommendation 1: That Part 45 of Title 46 of the United States Code of Federal Regulations (Great Lakes Load Lines) be amended imme- diately to rescind the reduction in minimum freeboard brought about by the 1969, 1971, and 1973 changes to the Load Line Regulations. Recommendation 3: That the owners and operators of Great Lakes ore carrying vessels undertake a positive and continuing program of repair and maintenance to insure that all closures for openings above the free- board deck are watertight, that is, capable of preventing the penetra- tion of water into the ship in any sea condition. This program should include frequent adjustment of hatch clamping devices and vent closures and prompt repair of all hatches, coamings, covers, and clamping devices found damaged or deteriorated. Recommendation 4: That Part 45 of Title 46 of the United States Code of Federal Regulations be amended to require closing and securing of hatches when underway in open waters and closing of vent caps when underway in a loaded condition. A visual inspection of the closure of hatch covers and vent caps should be conducted and logged by a licensed officer prior to sailing in a loaded condition. Recommendation 5: That the Coast Guard undertake a program to evaluate hatch closures presently used on Great Lakes ore carriers with a view toward requiring a more effective means of closure of such deck fittings. ii --------------------------------------------------------------------------- Action: Assignments of freeboard are based upon, among other things, a presumption of the ability to achieve the weathertight integrity necessary to prevent significant flooding. The mutually dependent areas of safety which are an integral part of all Load Line Regulations are: a. That the hull is strong enough for all anticipated seaways; b. That the ship is designed and operated with proper stability; c. That the hull is watertight to the freeboard deck; d. That the hull has sufficient reserve buoyancy for seaworthiness; e. That the topside area is properly fitted so as to be capable of being made weathertight for all anticipated seaways; and, f. That protection for the movement of the crew on the weather decks at sea is provided. None of these can be eliminated by additions to freeboard within practi- cal limits. Freeboard, or its increase, is not by itself an adequate substitute for properly designed, maintained and operated hatches, coam- ings, gaskets, and securing attachments. Such substitution unduly penalizes good design, maintenance, and operations. Since th fall sea- son of 1976, the Coast Guard has been conducting a Great Lakes Coast Guard ship-rider program to evaluate the overall effectiveness of the combination of freeboard, hatch closure, and ventilator closure effectiveness during the intermediate (Oct 1-31) and Winter (November 1 - March 31) freeboard seasons. This program has confirmed the evidence found by the Board of Investigation indicating that it is not a singular occurrence that the hatch covers on the EDMUND FITZGERALD may not have been properly secured. Several ships have been found to suffer in vary- ing degrees from a lack of weathertight integrity due to the inability to make hatch covers weathertight and due to the inattention to venti- lator covers prior to a winter season voyage. Accordingly, the Commandant is initiating action to: a. Continue the ship-rider program in 1977 and in succeeding years as necessary in order to prevent sailing or severely restrict the voyage weather limits of any ship found to lack sufficient weathertight integ- rity. Extra seasonal freeboard requirements may also be assigned to supplement weather limitations by the Commander, Ninth Coast Guard District to vessels on an individual basis. iii --------------------------------------------------------------------------- b. Bring to the attention of the owners and operators the fact that weathertight closures which are not effective when battened down void both the LOAD LINE CERTIFICATE and the CERTIFICATE of INSPECTION. c. Firmly bring to the attention of ships' masters their opera- tional responsibilities for weathertight integrity before and during weather conditions as outlined in operational regulations in 46 CFR 97. d. Direct the Merchant Marine Technical Division at Coast Guard Headquarters, in cooperation with Commander, Ninth Coast Guard District, to immediately undertake a critical evaluation of the effectiveness of those hatch closures presently in use on Great Lakes bulk carriers utilizing information from the shipboard Coast Guard inspections. If this evaluation shows the present designs to be either not effective or requiring such maintenance as to be difficult to assure weathertight integrity, regulatory notice will be published stating their design or maintenance shortcomings and including a requirement that ships modify or change hatch covers to correct the deficiencies. e. Direct the Merchant Marine Techincal Division to reassess the existing INTERMEDIATE and WINTER Season freeboard corrections utilizing wave analysis information on Great Lakes wave spectra to be gathered during an ongoing research program (1977-1979). 2. The following recommendation concerns vessel subdivision and is relevant to the preceding Action. Recommendation 2: That any subsequent amendments to the Great Lakes Load Line Regulations, as they apply to ore carriers such as FITZGERALD, reflect full consideration of the necessity for a means of detecting and removing flooding water from the cargo hold and for watertight sub- division of the cargo hold spaces. Such an appraisal should take due cognizance of: a. The severe weather and sea conditions encountered by these vessels and the resulting high degree of deck wetness; and, b. The inherent difficulty in meeting and maintaining a weathertight standard with the system of hatches, coamings, covers, gaskets, and clamps used on FITZGERALD and many other Great Lakes vessels. Action: The Commandant intends to develop a federal regulation establishing a minimum level of subdivision for inspected Great Lakes cargo ships for two reasons directly related to this casualty. First, the sudden catastrophic foundering of the vessel apparently allowed no time for radio messages nor for individual survival. Second, the SS EDMUND FITZGERALD survived for several hours after indicating by radio message that some damage had occurred and the ship was about one hour from a safe harbor when it sank. iv --------------------------------------------------------------------------- It is possible that even a minimum degree of watertight subdivision within the cargo hold could have effected a great change on the ulti- mate fate of both the ship and her crew. It is possible that the flooding, which is presumed to have occurred through ineffective hatch covers, might have occurred through only 1 or 2 hatches, but the subse- quent flooding was able to penetrate the entire cargo hold. Sub- division bulkheads in the cargo space would have limited this flooding, possibly enought to allow the ship to make it to safe harbor. If they had realized the extent of damage, the provision of subdivision calcu- lations and damage control instructions might have at the least allowed the crew more time to escape prior to the sinking. An additional concern is raised by the report of minor side damage incidents. Bulk carriers are now being built which do not have the crew passage, ballast tank combination at the sides which provided some protection in cases of minor penetration. The arrangements on these new vessels are such that a penetration of the hull near the waterline might cause flooding over 90% of the ship's length. An incident could occur such that little chance of preventing sinking of the vessel would exist and the crew might have a very short time to escape. Subdivision standards will be directed toward this type of casualty. As the bene- fits of subdivision apply also to oceangoing cargo ships, international discussions toward an increase of subdivision safety for all cargo ships will be further pursued. 3. The following recommendations concern lifesaving equipment and crew training and are addressed jointly. Recommendation 6: That the owners and operators of Great Lakes vessels, in cooperation with the maritime unions and training schools, undertake a program to improve the level of crew training in the use of lifesaving equipment installed on board the vessels and in other emer- gency procedures. This program should specifically include training in the use of inflatable life rafts and afford crews of vessels the oppor- tunity to see a raft inflated. Recommendation 7: That Part 97 of Title 46 of the United States Code of Federal Regulations be amended to require crew training in launching, inflation and operation of inflatable life rafts. Recommendation 8: That the Coast Guard institute a continuing program of inspections and drills for Great Lakes vessels prior to each severe weather season. The severe weather season should correspond to the Winter Load Line season, i.e., 1 November through 31 March. Under this program, just before the severe weather season began, there would be an inspection to verify that the crew had been trained in the use of the lifesaving equipment and drills would be conducted with the crew v --------------------------------------------------------------------------- then on board the vessel. There would be a physical inspection of the spar deck and all critical structural and non-structural members ex- posed to damage from cargo loading and off-loading equipment including, but not limited to, hatch coamings, hatch covers, vent covers, tank tops, side slopes, hatch-end girders, arches, spar deck stringers, and spar deck plating. Additionally, all emergency drills would be wit- nessed, and alarms, watertight closures, navigation equipment, and re- quired logs would be inspected. Recommendation 10: That the Coast Guard complete, as soon as pos- sible, the studies currently underway, which concern primary lifesaving equipment, its launching, and disembarkation from stricken vessels. And, that the measure be implemented promptly to improve the entire abandon ship system, including equipping and training personnel, auto- matic launching of equipment, and alerting rescue forces. Recommendation 13: That the Coast Guard promulgate regulations which require vessels operating on the Great Lakes during the severe weather season to have, for each person on board, a suit designed to protect the wearer from exposure and hypothermia. Recommendation 15: That the Coast Guard foster and support programs dedicated to increasing awareness, on the part of all concerned with vessel operations, inspection, and maintenance, of the hazards faced by vessels in Great Lakes service, particularly during the severe weather season. The program should make maximum use of company safety pro- grams, safety bulletins, publications, and trade journals. Action: The intent of these recommendations is concurred with and the need for improved and periodic meaningful training in the use of lifesaving equipment and a vessel readiness inspection program prior to severe weather sailing is supported. The following action has been taken or will be taken relative to these recommendations. a. In October, 1976, the Coast Guard instituted a con- tinuing program of inspections and drills for Great Lakes vessels prior to the severe weather season. The scope of the program includes the specific items listed in Recommendation 8 and the inspections are con- ducted while the vessels are underway and under actual operational conditions. The requirements for conducting emergency drills and crew training are contained in 46 CFR Parts 97.15-35 and 97.13-20. Emergency fire and boat drills are required at least once every week and the master is responsible to assure that they are conducted. Assuring adequate drills are conducted is not unique to Great Lakes vessels, therefore the operations sections of 46 CFR, Parts 35, 78, 167, 168, and 185 will be amended to incorporate crew training in the launching, inflation, and vi --------------------------------------------------------------------------- operation of inflatable life rafts. The Coast Guard recognizes this lack of training is of international magnitude and is working within IMCO in the preliminary stages of such a program. b. Owners, operators, labor organizations, and training schools will be encouraged to develop a training program of the type indicated in Recommendation 6. To support this effort, the Merchant Vessel Personnel Division will work with the Maritime Administration to develop such training programs. The Coast Guard will set qualifi- cation standards requiring all licensed officers and able seamen be trained in the operation of inflatable life rafts as well as other lifesaving equipment. Input from the owners and operators of Great Lakes vessels, along with their crews' labor organizations and training schools, will be solicited. c. The Coast Guard is expanding its public awareness program to provide useful information to seamen and aid operators and unions in the conduct of their training programs. In September, 1975, a pamphlet on hypothermia, CG-473, was published and distributed on the Great Lakes and other areas where cold weather survival could be a problem. A proposal has been submitted within the Coast Guard to the Office of Research and Development to develop a means by which the public, specifically those on board commercial vessels, will be made aware of various safety factors, regulations, and safe operating pro- cedures that apply to their particular commercial operation. For example, pamphlets may be developed and distributed (i.e., via labor unions, commercial fisherman organizations, vessel documentation of- ficers, professional and business organizations) for each class of com- mercial operation. Great Lakes vessels would be an appropriate area for such a public awareness program. A summary of the Board's report and an article, directed at increasing the mariner's awareness of the hazars of the Great Lakes, will be prepared for publication in the Proceedings of the Marine Safety Council. Concerning Recommendations 10 and 13, a Notice of Proposed Rulemaking based on an Advance Notice of Proposed Rulemaking, published 7 June 1976 in the Federal Register, is being prepared for Great Lakes cargo, tank, and passenger vessels which will propose that: a. All lifeboats on vessels be totally enclosed to provide protection from exposure and to lessen the danger of swamping and subsequent capsizing. b. All lifeboats be diesel engine driven with the ability to start the engine in temperatures as low as -22°F. c. Sufficient lifeboats be provided to accommodate 100% of the persons on board the ship with additional lifeboats and life vii --------------------------------------------------------------------------- rafts provided and located so as to provide accommodation for an addi- tional 100% in the event that a casualty renders the other lifeboats unusable. d. All survival craft be provided with launching devices which will be launched from their stowed positions with all persons onboard, elminating the need for lengthy pre-launch preparation, a deck crew to stay aboard to control the launch, and in the case of life rafts, the need to enter the water before boarding. e. Automatic float-free launching be required for life rafts. f. An exposure suit be required for each person on board that will protect the wearer from exposure and hypothermia. One lifeboat manufacturer is developing a float-free launching system for lifeboats which are also launched conventionally. This will be given further consideration as a requirement upon completion of a prototype system and an evaluation of its feasibility. The remainder of the Board's recommendations are addressed individually. 4. Recommendation 9: That the Coast Guard take positive steps to insure that the Masters of Great Lakes vessels are provided with infor- mation, as is required by the regulations, concerning loading and ballasting of Great Lakes vessels, and that the information provided include not only normal loaded and ballasted conditions, but also de- tails on the sequences of loading, unloading, ballasting, deballasting, and intermediate stages thereof, as well as information on the effect upon the vessel of accidental flooding from damage of other sources. Action: The Coast Guard will develop performance criteria for loading manuals which will cover all the items in this recommendation except flooding conditions. Flooding conditions will be addressed in conjunction with the casualty control efforts discussed in the action on Recommendation 2. 5. Recommendation 11: That the Coast Guard schedule maintenance status for buoy tenders and icebreakers located in the Great Lakes so as to maximize surface search and rescue capability during the severe weather season, consistent with their primary missions. Action: Commander, Ninth Coast Guard District has implemented this recommendation by issuing a District Directive on 9 September 1976. This Directive contains the requirements and guidelines for scheduling maintenance and underway periods of Coast Guard vessels on the Great Lakes. 6. Recommendation 12: That Subpart 94.60 of Title 46 of the United States Code of Federal Regulations, which requires emergency position indicating radio beacons (EPIRB), be amended to include requirements for such beacons on vessels operating on the Great Lakes during the severe weather season. viii --------------------------------------------------------------------------- Action: Action is being taken to permit the operation of EPIRB's in the VHF-FM marine band. There is at present virtually complete shore station coverage on the Great Lakes on this band and constant monitoring of Channel 16 by stations in both the United States and Canada. A prototype EPIRB for testing is now being developed by the Transportation Systems Center. When the VHF-FM EPIRB's become avail- able, regulations will be proposed requiring that they be installed on board inspected Great Lakes vessels during all seasons. 7. Recommendation 14: That navigation charts, showing the area imme- diately north of Caribou Island, be modified to show the extent of the shoals north of the island and that this modification be given the widest possible dissemination, including Notices to Mariners. Action: A copy of the completed marine casualty report will be forwarded to the U.S. Department of Commerce, National Oceanic and Atmospheric Administration, with a request that they coordinate the correction of the applicable charts with their counterparts in the Canadian Government. [signature) O. W. Siler O. W. Siler Admiral, U.S. Coast Guard Commandant ix ===========================================================================