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Outer Continental Shelf National Center of Expertise (OCSNCOE)
Seacor Power Capsizing
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This incident involved the liftboat Seacor Power, which capsized approximately 7 nautical miles south of Port Fourchon, LA in the Gulf of Mexico, on April 13, 2021. The casualty claimed the lives of 13 individuals. The capsizing occurred when the vessel was caught in unpredicted and extreme weather conditions shortly after leaving port.
Our condolences go out to the families of the men who lost their lives during this incident.
The USCG formal investigation is complete, along with a Final Action Memo outlining the steps the Commandant will take in response to the casualty. The Final Action Memo is at the beginning of the report. The Recommendations tab above provides further details regarding the safety and administrative recommendations made in the report and the Commandant's action related to the same. The Coast Guard publicized the release of the Report of Investigation (ROI) via a Maritime Commons blog post, with a bookmarked copy of the ROI available here.
Use the tabs on this page (above) to view the following information related to the investigation, as well as additional information related to this casualty:
1) Introduction (this tab);
2) Executive Summary (as presented in the Report of Investigation;
3) National Transportation Safety Board (NTSB) Report;
4) Marine Board of Investigation Information;
5) U.S. Coast Guard Safety Alerts and related recommendations;
6) Safety and administrative recommendations from the Report of Investigation (with recommendation references hyperlinked or included for ready reference) and Commandant Actions;
7) Best practices recommended by the Marine Board of Investigation; and
8) Findings of Concern (published after the investigation was officially closed).
Executive Summary (from the Report of Investigation)
For more details see the full Report of Investigation.
On the morning of April 13, 2021, Liftboat SEACOR POWER was located at the Bollinger Dock in Port Fourchon, LA. The vessel was on charter to Talos and was in port conducting a crew change and loading equipment for a new job. The company emailed a weather forecast to the vessel that morning, and the forecast predicted calm weather for the day. The crew finished loading equipment, and the First Mate got the vessel underway just before 1230 (figure 1). There were 19 people aboard. The vessel reached the Belle Pass jetties (entrance to Port Fourchon) at 1410 and headed south at a speed of three knots. Seven other vessels also departed Port Fourchon between 1200 and 1500 that day.
The same morning, the National Weather Service (NWS) was tracking a line of severe weather, which moved over the New Orleans region around lunchtime. Around 1400, the line of severe weather developed into a wake low and began accelerating to the south. The NWS issued a Special Marine Warning at 1457, which warned mariners of severe thunderstorms and wind gusts of 34 knots or greater in the area where SEACOR POWER was operating. The crew did not receive the warning, and the weather that actually hit that afternoon was moving much faster and was far worse than predicted. The storm caught many experienced mariners off-guard.
At 1519, SEACOR POWER encountered a rain squall, and the winds strengthened significantly for a few minutes, and then went back down. Thirteen minutes later, SEACOR POWER encountered a second squall with white-out conditions and winds that exceeded 80 knots and gusted up to 99 knots. The Master and the First Mate attempted to lower SEACOR POWER’s legs to the seafloor in order to hold position until the storm passed, but the vessel heeled to starboard and quickly capsized. There was very little time to react, and only some of the people aboard managed to escape. The waves washed some individuals overboard, and a few people climbed onto the port side superstructure, which remained out of the water.
SEACOR POWER’s crew did not have time to send any distress signals. The Emergency Position Indicating Radio Beacon (EPIRB) automatically activated during the capsizing, but a company representative said the vessel was still in port. When the visibility cleared, almost an hour after the capsizing, the Master on a nearby liftboat saw the vessel and immediately made a distress call. The Coast Guard issued an Urgent Marine Information Broadcast and numerous Good Samaritan vessels in the area responded. A civilian helicopter, Coast Guard response boats, and Coast Guard helicopters and airplanes also joined the rescue efforts, but persistent high winds and seas prevented anyone from reaching the individuals remaining on SEACOR POWER. Six individuals who washed into the water, or entered the water, survived and were rescued that evening.
Between April 13th and April 19th, Coast Guard aircraft, cutters, and small boats searched a total of 9,290 square nautical miles. Two deceased individuals were found during these surface searches. Between April 15th and April 27th, divers hired by Seacor searched the submerged portions of the vessel. The dive teams found four deceased individuals. The remaining seven individuals from SEACOR POWER were never found and are presumed deceased.
The Coast Guard Investigation determined that the biggest factor that contributed to SEACOR POWER’s capsizing was the fact that the vessel was caught in unpredicted weather conditions that exceeded the vessel’s operating limits. The Investigation also identified a number of other causal factors that contributed to the casualty, along with a number of unsafe actions or conditions that did not contribute to the casualty.
NTSB Investigation into the Capsizing of Liftboat Seacor Power
National Transportation Safety Board (NTSB) Accident Reports "provide details about the accident, analysis of the factual data, conclusions and the probable cause of the accident, and the related safety recommendations". NTSB completed an investigation (Investigation No. DCA21MM024) and generated a report for the capsizing of the Liftboat Seacor Power. The report was adopted on October 18, 2022 with report number MIR-22/26.
NTSB's DCA21MM024 investigation page provides information about the casualty and links to the report, recommendations and docket information. Note that the docket information page contains evidence and reference material that was used during the investigation.
Abstract from the report: This report discusses the April 13, 2021, capsizing of the US-flagged liftboat SEACOR Power about 7 miles off the coast of Port Fourchon, Louisiana, in a severe thunderstorm with heavy rain, winds exceeding 80 knots, and 2- to 4-foot seas at the time of the capsizing. Search and rescue efforts were hampered by 30- to 40-knot winds and seas that quickly built to 10 to 12 feet and persisted throughout the evening and into the next day. Six personnel were rescued by the US Coast Guard and Good Samaritan vessels, and the bodies of six fatally injured personnel were recovered. Seven personnel were never found and are presumed dead. The vessel, valued at $25 million, was a total constructive loss. Safety issues identified in this report include gaps in forecasts and communications of weather events, the operation and stability of restricted-service liftboats in severe thunderstorms, the effectiveness of the initial response to the capsizing, and the difficulty in locating survivors in adverse weather and sea conditions. As part of its investigation, the National Transportation Safety Board makes three new recommendations and reiterates one recommendation to the United States Coast Guard. We also make one recommendation to the National Weather Service, one recommendation to the Federal Aviation Administration and the US Air Force, two recommendations to the Offshore Marine Service Association, and three recommendations to SEACOR Marine.
Marine Board of Investigation Information
The U.S. Coast Guard convened a Marine Board of Investigation (MBI) to investigate the Seacor Power capsizing. The MBI convening and authority is detailed in the Memorandum from the Deputy Commandant for Operations at the beginning of the MBI's Report of Investigation. All hearing and evidence information has been compiled on the Coast Guard's Seacor Power Marine Board of Investigation page at https://www.news.uscg.mil/News-by-Region/Headquarters/Seacor-Power/.
Safety Alerts and Advisories
Two Safety Alerts and a Safety Advisory were published by the Office of Investigations & Casualty Analysis (CG-INV) that were related to the Seacor Power capsizing investigation and findings as follows:
Safety Alert 07-21, Unexpected Heavy Weather Dangers: Weather will change, whether you are ready or not!;
Safety Advisory 01-22, Maritime Distress Communication Devices; and
Safety Alert 03-23, Ensure proper Configuration of Selective Calling (DSC)-Equipped Radios.
These are summarized below, and each is accessible through the links provided above.
USCG Safety Alert 07-21, Unexpected Heavy Weather Dangers: Weather will change, whether you are ready or not!
This section is only an excerpt of the recommendations from Safety Alert. See USCG Safety Alert 07-21 for additional discussion.
To prepare for heavy weather events or rapid changes in weather, the Coast Guard strongly recommends that all vessel owners, operators, mariners, and recreational boaters take the following actions:
USCG Safety Advisory 01-22, Maritime Distress Communication Devices
This section is only a summary of the recommendations from Safety Advisory. See USCG Safety Advisory 01-22 for additional discussion.
The Coast Guard strongly recommends that mariners fully understand the capabilities and limitations of devices when purchasing a distress communication device. It is imperative that mariners know how the devices work and who is notified when a distress signal is transmitted. Below is a list of the common devices, their capabilities, and potential considerations (see the Safety Advisory for a discussion of each).
The following devices NOTIFY the U.S. Coast Guard:
The following devices DO NOT NOTIFY the U.S. Coast Guard:
In addition, the following recommendations are made to all owners and operators of recreational or commercial vessels:
USCG Safety Alert 03-23, Ensure proper Configuration of Selective Calling (DSC)-Equipped Radios
This section is only an excerpt of the recommendations from Safety Alert. See USCG Safety Alert 03-23 for additional discussion.
The Coast Guard strongly recommends that vessel owners, operators, and crewmembers with DSC-equipped VHF radios:
Recommendations from the USCG Report of Investigation (ROI) and Commandant Actions
The following recommendations were made in the ROI. The review of the recommendations was also presented to the National Offshore Safety Advisory Committee as a task statement on March 1, 2023 (with a 1-year completion period). This investigation was closed as indicated in the Commandant Action Memo, IIA #7175076, dated 18May2023, and signed by the Deputy Commandant for Operations (CG-DCO).
The Commandant Actions are included at the beginning of the report and address each of the recommendations made by the Marine Board in the Report of Investigation. The Commandant actions are included below in italicized font for ready reference).
Please note that hyperlinks are provided throughout this page to U.S. Coast Guard offices, regulations and documents that are referenced in the recommendations and endorsements to aid in review and/or research.
Safety Recommendation 1: The Commandant should immediately revise Commandant Instruction 3140.2D and Commandant Instruction 3140.3D. The revisions should address the following issues:
Commandant Action: I concur with the intent of this recommendation. A Coast Guard working group will be established to review Commandant Instruction 3140.2D (Marine Weather Observation and Reporting) and Commandant Instruction 3140.3D (Coastal Weather Program) to determine the current applicability and gaps of these and other related references and will make any necessary changes based on this recommended action. The working group will also determine if any new references are needed.
Safety Recommendation 2: The Commandant should expedite their current study of liftboat stability, and then immediately use the results of that study to revise liftboat stability regulations. The Commandant should consider the following actions:
Commandant Action: I concur with this recommendation. The results of the Coast Guard's Research and Development Center (R&DC) stability study are scheduled to be completed in the Fall of 2023. The Coast Guard will use the results of the study to either validate or revise its liftboat stability regulations, with particular focus on the following:
The Coast Guard will also consider updating the wind speed versus height profile based on references identified in the MBI report. Additionally, technical literature will be reviewed to assess the basis on which wind calculation shape factors can be updated for cylindrical legs with racks. This response will be shared with R&DC for consideration regarding any additional areas of study.
Safety Recommendation 3: The Commandant should immediately require all liftboat owners and operators to reduce the current operating limits for each vessel, in order to provide a temporary additional safety margin while the actions in the previous recommendation are completed.
Commandant Action: I do not concur with this recommendation. An immediate reduction in current operating limits for all liftboats is not supported as the MBI determined that the vessel's capsizing occurred in conditions that well exceeded its maximum operating limits. However, the results of the investigation highlight the critical relationship between design criteria and operating limits. As a result, the Coast Guard will use the outcome of the liftboat stability study described in the response to Recommendation 2 and additional analysis to review and update liftboat operating limits, as appropriate.
Safety Recommendation 4: The Commandant should immediately establish a regulation or policy that prohibits offshore workers from riding aboard a liftboat while the vessel is underway, unless the vessel meets additional stability requirements to ensure a level of safety equivalent to a crewboat or offshore supply vessel.
Commandant Action: I do not concur with this recommendation. Design stability and operating limit criteria of any vessel should ensure the safe operation for the vessel's intended purpose. For liftboats, the intended purpose often includes the safe carriage and transit of offshore workers. As discussed in the response to Recommendation 2, further stability analysis of liftboats will be conducted, and the Coast Guard will continue to assess stability standards as they apply to design criteria and operating limits.
Safety Recommendation 5: The Commandant should consider a new regulation or policy requiring liftboat owners and operators to create a quick reference guide for each vessel. The quick reference guide would establish clear and simple operating information, and could include topics such as wave limits, wind limits, draft restrictions, trim conditions, and emergency procedures for sudden changes in weather or weather that exceeds the vessel’s operating limits.
Commandant Action: I concur with the intent of this recommendation. A Finding of Concern will be published recommending that owners and operators of liftboats review their operations manuals to ensure they are easily accessible and understood by the crew when making time-sensitive decisions. The Coast Guard will share this recommendation with the National Offshore Safety Advisory Committee for their consideration and direct them to develop standardized quick reference card templates for liftboats that can be used by the industry. NOSAC has been tasked to consider the SEACOR POWER National Transportation Safety Board (NTSB) report and any available public-facing reports, which will include this ROI once released, and propose recommendations. The Coast Guard will reevaluate this recommendation pending a response from NOSAC regarding any necessary regulatory or policy changes.
Safety Recommendation 6: The Commandant should issue one or more findings of concern to the National Weather Service recommending the following items:
Commandant Action: I concur with this recommendation. The Coast Guard, the National Oceanic and Atmospheric Administration (NOAA), and the NWS have a Memorandum of Agreement (MOA) which formally recognizes the USCG-NOAA/NWS Coordination Liaison Group (UNCLOG). UNCLOG is the principal vehicle through which the agencies coordinate on matters relating to marine weather information. A letter discussing the recommended items and a copy of the report of investigation and safety recommendations will be forwarded to the NWS and UNCLOG for their consideration.
Safety Recommendation 7: The Commandant should issue one or more findings of concern to all liftboat owners and operators stressing the importance of the following items:
Commandant Action: I concur with the recommendation. The Coast Guard will issue a Finding of Concern to liftboat owners and operators stressing the importance of crew familiarity with operating manual requirements with an emphasis on the points raised in this recommendation.
Safety Recommendation 8: The Commandant should issue one or more findings of concern to all commercial vessel owners and operators stressing the importance of the following items:
Commandant Action: I concur with this recommendation. The Coast Guard will issue a Finding of Concern to draw attention to the recommended points of emphasis. On October 21, 2021, the Coast Guard issued Safety Alert 07-21 Unexpected Heavy Weather Dangers: Weather Will Change, Whether You Are Ready Or Not!, which emphasized the importance of vessels having two independent methods of obtaining weather information.
Safety Recommendation 9: The Commandant should direct a concentrated inspection campaign designed to verify proper EPIRB registration on all types of vessels. The campaign could provide clear guidance and direction to marine inspectors (foreign and domestic), marine investigators, commercial fishing vessel examiners, cutter boarding teams, station boarding teams, Auxiliarists, and Public Affairs personnel in order to ensure all Coast Guard elements are participating in the campaign.
Commandant Action: I concur with this recommendation. The quality and accuracy of the information contained in the Coast Guard's EPIRB registration database is an issue that directly impacts response efforts in the event of marine distress and the Coast Guard has taken several actions to increase the number of accurately registered EPIRBs.
The Office of Boating Safety (CG-BSX) has initiated steps through existing initiatives to inform the recreational boating public on the requirement to register their EPIRBs and to keep the registration up to date. The most recent significant activity was update to the National Boating Education Standard, ANSI/NASBLA 100-2022: Basic Boating Knowledge - Core published on 1 June 2022. There is also a campaign that makes April 6th the 406 Beacon Day and encourages registration. The Coast Guard Auxiliary Vessel Safety Check program includes messaging on EPIRBs and Personal Locator Beacons (PLBs) to include registration. CG-BSX will continue to reinforce the message of registration with the recreational boating safety community.
The Office of Search and Rescue is working with NOAA and CG-BSX to develop a business card with a quick reference (QR) Code to be distributed through various Coast Guard interaction with the commercial vessel industry and vessel owners at boat shows, industry days, and other venues.
The Office of Commercial Vessel Compliance (CG-CVC) will continue to confirm EPIRB registration-as a part of regular commercial vessel inspections and exams.
Safety Recommendation 10: The Commandant should consider whether there is an opportunity to establish a requirement for vessel owners or operators to provide proof of valid EPIRB registration prior to renewing or obtaining a Certificate of Documentation.
Commandant Action: I concur with the intent of this recommendation. However, the Coast Guard believes that existing outreach campaigns described in the response to Safety Recommendation 9 are sufficient to verify EPIRB registration. The Coast Guard also recognizes that NOAA, the federal agency responsible for managing EPIRB registration, has active campaigns to promote and encourage proper registration. Information on registration is posted online at NOAA.gov and NAVCEN.uscg.gov to encourage use and registration of EPIRBs. Labeling and placarding on individual devices is also required to inform users of the regulatory requirement to maintain up to date registrations. The National Vessel Documentation Center reviews documentation such as evidence of nationality, vessel title, and mortgage among other requirements. Validation of EPIRB registration would require a significant regulatory and procedural overhaul to the Center's current systems. The Coast Guard will consider this recommendation in conjunction with future system upgrades.
Safety Recommendation 11: The Commandant should consider whether there is an opportunity to update the SARSAT system so that when the Coast Guard receives notice of an EPIRB activation, the registered user also receives a notice.
Commandant Action: I concur with the intent of this recommendation. Upon receipt of an alert by a Joint Rescue Coordination Center (JRCC), beacon owners are then contacted using the contact information provided on the alert message. The technical ramifications of an automatic owner notification must be assessed by the U.S. Search and Rescue Satellite Aided Tracking (SARSAT) Program. The Coast Guard Office of Search and Rescue (CG-SAR) will present this safety recommendation to the U.S. SARSAT Program Steering Group for consideration.
Safety Recommendation 12: The Commandant should consider publishing additional information regarding false EPIRB alerts, including information about the huge costs associated with these false alerts.
Commandant Action: I concur with this recommendation. This information is already available on the U.S. Coast Guard Navigation Center's (NAVCEN) website (https://www.navcen.uscg.gov/instructions-for-canceling-false-distress-alert) and the National Oceanic and Atmospheric Administration (NOAA) website (https://www.sarsat.noaa.gov/preventing-false-alerts/). Addressing false alerts is and will continue to be a U.S. Search And Rescue Satellite-aided Tracking (SARSAT) Program priority.
Safety Recommendation 13: The Commandant should consider creating a Memorandum of Understanding or Memorandum of Agreement with the Federal Communications Commission (FCC) so that the Coast Guard can enforce the FCC’s EPIRB registration requirements. Alternatively, the Commandant should issue clear guidance to all units explaining how to use the authority found in 14 USC 521 to enforce EPIRB registration.
Commandant Action: I concur with the intent of this recommendation. The Coast Guard meets with the FCC on a quarterly basis to discuss matters of mutual concern including potential EPIRB enforcement options and a MOA is not considered necessary. Under current procedures, for documented repeated violations of outdated or improper EPIRB registration, the Coast Guard can either initiate a violation case or make a referral to the FCC Enforcement Bureau for enforcement action. The Coast Guard will provide a copy of this investigation to the FCC and raise the issue of potential EPIRB registration enforcement strategies at the next quarterly meeting.
Safety Recommendation 14: The Commandant should take immediate action to improve phone communications at all District and Sector Command Centers.
Commandant Action: I concur with this recommendation. A project to upgrade the Coast Guard's phone infrastructure is underway. This project will align the Coast Guard's infrastructure with the Department of Defense's (DoD) voice over internet protocol VoIP). This upgrade will give the Coast Guard new capabilities including the ability to provide interoperability with other government agencies. This initiative was commenced in 2019 starting with 46 Coast Guard Command Centers. To date, 16 of the 46 command centers have completed the upgrades to their phone infrastructure. In 2023, contracting has been initiated with Defense Information System Agency (DISA) to upgrade 15 additional command centers. The remaining 15 are projected to be completed by 2024.
Safety Recommendation 15: The Commandant should consider whether there is an opportunity to establish equipment and processes to receive all types of distress alerts in one location, rather than different Coast Guard units.
Commandant Action: I do not concur with this recommendation. The Coast Guard follows Global Marine Distress and Safety System (GMDSS) alert procedures for the delivery of distress alerts to the responsible Rescue Coordination Center (RCC) as provided by international guidance (International Maritime Organization (IMO), International Civil Aviation Organization (ICAO), and the International Aeronautical and Maritime Search and Rescue (IAMSAR) Manual). Coast Guard RCCs are responsible for sharing relevant distress event information to the appropriate units when necessary.
Safety Recommendation 16: The Commandant should evaluate options that would allow District and Sector Command Centers to view EPIRB information, AIS information, and SAROPS information in one Common Operating Picture.
Commandant Action: I concur with this recommendation. A single, user-friendly interface that ingests, overlays, and displays EPIRB, AIS, and SAROPS in a unified Common Operating Picture (COP) should be available for Coast Guard watchstanders at every Sector, District, and Area Command Center. A single COP would enable Coast Guard watchstanders to assess potential distress situations quickly and efficiently, utilizing information from existing distress alert mechanisms and vessel reporting systems. Execution will likely require system modifications and upgrades to achieve full implementation of all desired functionality. As such, the Coast Guard will continue to support numerous initiatives to modernize and improve the COP available for Command Centers.
Safety Recommendation 17: The Commandant should consider whether there is a need to provide District and Sector Command Centers with additional means of tracking commercial vessel locations.
Commandant Action: I do not concur with this recommendation. The existing capabilities available to Coast Guard Command Centers for maintaining awareness of vessel movement through mandated and voluntary methods such as the Long-Range Identification and Tracking system and AIS are sufficient for tracking commercial vessels. Additionally, a new requirement could contribute to watchstander task saturation, which in tum would further degrade performance during high-consequence events.
Safety Recommendation 18: The Commandant should conduct a study to evaluate whether it would be beneficial to create one distress button that links to a variety of different shipboard systems, including, but not limited to, VHF DSC, MF/HF DSC, INMARSAT, and the vessel’s general alarm.
Commandant Action: I partially concur with this recommendation. A single "red" distress button is a requirement for "Passenger ships" to comply with the Safety of Life at Sea (SOLAS) Convention, Chapter IV, Regulation 6, paragraph . Conversely, the SEACOR POWER was a SOLAS Cargo Ship greater than 500 Gross Tonnage ITC1 and was not required to have a single distress button. The Coast Guard has the options of pursuing voluntary adoption or implementation of a new carriage requirement for non-SOLAS vessels. Coordination with the FCC on updating the Title 47 USC Part 80 rules may also be required. As a result, this Safety Recommendation will be forwarded to the Distress Signal Collaborative (DISCO) working group at Coast Guard Headquarters for review and any potential actions.
Safety Recommendation 19: The Commandant should create a campaign to educate vessel owners, operators and crew members on Digital Selective Calling (DSC) procedures and benefits.
Commandant Action: I concur with this recommendation. The Coast Guard will continue to educate vessel owners, operators, and crew members on the procedures and benefits of DSC.
The Office of Boating Safety (CG-BSX) recently updated the National Boating Education Standard, ANSI/NASBLA 100-2022: Basic Boating Knowledge - Core, published on June 1, 2022. This update ensures that boat operators receive education on DSC and comparisons with other communications methods. The Coast Guard Auxiliary Vessel Safety Check program also includes messaging for Auxiliarists conducting boating safety exams to educate boaters on DSC to include registration for a Maritime Mobile Service Identity. The Coast Guard published Marine Safety Advisory 01-22 on Maritime Distress Communication Devices on September 28, 2022, to educate users on all available communication devices, including DSC. In addition, the Coast Guard published Marine Safety Alert 3-23 on March 2, 2023, to educate vessel owners on how to ensure interconnectivity between DSC and Global Position System (GPS) equipment. The Safety Alert and Safety Advisory can be accessed at the following link: https://www.dco.uscg.mil/Our-Organization/Assistant-Commandant-for-Prevention-Policy-CG-5P/Inspections-Compliance-CG-5PC-/Office-of-Investigations-Casualty-Analysis/Safety-Alerts/
Safety Recommendation 20: The Commandant should conduct a study to assess the usefulness of SARTs, and then use those study results to evaluate whether SARTs should be removed from the domestic and international regulatory requirements. This study could include an assessment of various SART brands, the equipment and equipment settings necessary to receive SART signals, success stories associated with SART use, and costs associated with SART purchase, maintenance and replacement.
Commandant Action: I do not concur with this recommendation. The SART was tested by the manufacturer and the NTSB and was found to operate as designed. The underlying issue was knowing how the SART operates and understanding its limitations. The Coast Guard addressed both in Marine Safety Alert 12-22 and Safety Advisory 01-22, which can be accessed at the following link: https://www.dco.uscg.mil/Our-Organization/Assistant-Commandant-for-Prevention-Policy-CG-5P/Inspections-Compliance-CG-5PC-/Office-of-Investigations-Casualty-Analysis/Safety-Alerts/
Safety Recommendation 21: While awaiting the results of the SART study discussed in Recommendation 20 above, the Commandant should create an internal education campaign focused on training Coast Guard personnel to properly detect and identify SART signals.
Commandant Action: I concur with the intent of this recommendation. Although the Coast Guard does not intend to conduct a SART study, the existing SART training will be reviewed for appropriate information, delivery method, and target audience.
Safety Recommendation 22: The Commandant should consider a working group, research study, or other method of assessing the effectiveness and usefulness of NAVTEX, and then use those results to evaluate changes to the Coast Guard’s NAVTEX equipment and processes.
Commandant Action: I concur with intent of the recommendation. Navigational Telex (NAVTEX) disseminates maritime safety information and is a statutory requirement. NAVTEX is a legacy system that was installed in 1993 and has well exceeded its 20-year expected service life. The Coast Guard is evaluating the capability and potential courses of action to transition to the next generation Navigational Data (NAVDAT) system.
Safety Recommendation 23: The Commandant should re-evaluate the regulatory requirement that exempts vessels operating between 32 degrees N and 32 degrees S latitude from carrying immersion suits. While water temperatures in some of these areas may remain warm all year round, water temperatures in some areas of this region can drop to levels that quickly cause hypothermia, especially during winter and spring.
Commandant Action: I concur with the intent of the recommendation. The Coast Guard will reevaluate the statutory and regulatory requirements that exempt vessels operating between 32 degrees N and 32 degrees S latitude from carrying immersion suits. The Coast Guard will consider a legislative change proposal if appropriate and will update regulations accordingly.
Safety Recommendation 24: The Commandant should require all Coast Guard cutters and small boats to carry line throwing guns and train personnel in their use.
Commandant Action: I partially concur with this recommendation. All Coast Guard Cutters, with the exception of inland buoy tenders, currently have a line throwing weapon onboard as part of their weapon allowance. Depending on the class of Coast Guard Cutter, it will have a .30 caliber Shoulder Line Throwing Gun or MK87 Line Throwing Kit affixed to an M16 rifle, or both. Personnel train and fire the line throwing weapons quarterly to maintain qualifications and proficiency. Pre-commissioned cutters receive their Shoulder Line Throwing Gun after the cutter has been accepted by the Coast Guard and certified Ready for Operations.
The Coast Guard does not believe that the MBI's findings support the addition of line throwing guns to all small boats at this time.
Safety Recommendation 25: The Commandant should consider a study to assess the usefulness of drones or remote operated life rings for delivering rescue equipment to individuals who are out of reach of a Coast Guard asset.
Commandant Action: I partially concur with this recommendation. The Coast Guard agrees that the use of unmanned aircraft systems (UAS), commonly referred to as drones, to deliver rescue equipment to individuals out of reach of a Coast Guard asset should be studied. One example would be delivering a life ring to an individual caught in shoal water inaccessible from a rescue vessel. On March 31, 2023, the Coast Guard released the Unmanned Systems Strategic Plan. The Plan outlines Strategic Goals to integrate unmanned systems into the Coast Guard force structure to support missions such as search and rescue and will guide the Coast Guard as it examines the development of future capabilities. Unfortunately, in this casualty the extreme weather conditions, the severe wind and sea state, as well as the location of the individuals and the orientation of the partially submerged vessel, prevented recovery prior to the vessel capsizing. Currently, unmanned lifesaving systems do not have the capacity, modularity, dexterity, and potentially artificial intelligence necessary to affect such an extreme rescue.
Safety Recommendation 26: The Commandant should consider establishing a policy that creates clear steps and procedures for a Coast Guard Marine Inspector to review and approve liftboat operations manuals, and then procedures for providing feedback to the vessel owner/operation and any other entity involved in writing or reviewing the manual.
Commandant Action: I concur with this recommendation. The Coast Guard will develop guidance clarifying the Marine Inspector's role to review and/or approve the operating manual. The guidance will, at a minimum, address the proper level and frequency of review and approval for a liftboat operating manual.
Safety Recommendation 27: The Commandant should evaluate previous SAR cases to determine how many incidents involved underwater rescue, and use this information to evaluate whether there is a need for additional measures to prepare for underwater rescue situations.
Commandant Action: I concur with this recommendation. SAR Coordinators should place an emphasis on ensuring units are prepared to carry out SAR Mission Coordinator (SMC) responsibilities with respect to underwater rescues. CG-SAR should review SAR doctrine and policy related to past SAR events involving persons trapped in submerged or overturned vessels to ensure Coast Guard policy reflects this emphasis and make appropriate updates as needed.
Administrative Recommendation 1: The Commandant should release this Report of Investigation to the public immediately, and then generate the Coast Guard's Final Action Memorandum afterwards.
Commandant Action: I do not concur with this recommendation. The investigation has been closed in conjunction with issuance of the Coast Guard Final Action Memorandum.
Administrative Recommendation 2: The Commandant should request additional permanent Coast Guard billets to perform the work associated with a Marine Board of Investigation. Alternatively, the Commandant should identify funding and establish a clear process to provide backfills for some or all of the MBI members for at least one year following the convening order. The current practice of assigning members to serve on a MBI as a collateral duty, while they are still required to perform their regularly assigned job, causes extensive delays to all aspects of the investigation process.
Commandant Action: I concur with the intent of this recommendation. Over the last several decades, the complexity of marine casualty investigations and the frequency of MBIs has increased. These increases have placed a significant demand on resources, investigation team members and units as a collateral duty. The Office of Investigations and Casualty Analysis (CG-INV) will consider options for enhanced support to future MBIs and reducing the administrative burden currently placed on Board members.
Administrative Recommendation 3: The Commandant should create a working group with the NTSB representatives to see if there are any best practices or other options to minimize the duplication of government efforts while still allowing both agencies to conduct separate investigations.
Commandant Action: I concur with the intent of this recommendation. The CG-INV will engage with the NTSB's Office of Marine Safety to determine best practices and to evaluate the current Memorandum of Understanding for any appropriate updates that are needed to clarify agency roles.
Administrative Recommendation 4: The Commandant should close this investigation.
Commandant Action: I concur with this recommendation. This investigation is closed. [Commandant Action Letter IIA #7175076, dated 18May2023 and signed by CG-DCO]
1 Gross Tonnage ITC is defined in 46 CFR 69.9.
Best Practices from the USCG Report of Investigation (ROI)
The following best practices recommendations were made in the ROI.
Best Practice 1: All companies should establish a process to ensure that their employees update their next of kin information at least once a year.
Best Practice 2: It can sometimes be difficult to reach a mariner’s next of kin, so all companies should consider asking their employees to provide multiple contact numbers for that person(s).
Best Practice 3: The registration form for an Emergency Position Indicating Radio Beacon (EPIRB) includes multiple lines for phone numbers. An individual registering an EPIRB should consider adding several different phone numbers that could be used in the event their EPIRB is activated.
Best Practice 4: Personal, and non-required, use of PLBs should only be used by a mariner if they are willing to properly register and regularly update their device registration.
Best Practice 5: Vessel owners and operators should ensure that any required SART poles are always connected to, or stored in close proximity to, the SART.
Best Practice 6: Vessel owners and operators, classification societies, auditors, and Coast Guard Marine Inspectors should ensure that computer programs used to aid in stability calculations are validated on a regular basis, but no less than annually.
Best Practice 7: Vessel owners and operators should provide additional weather training to their Masters and licensed crew members. Training could include items such as options for checking weather underway, minimum intervals to check weather while underway, emergency procedures for unexpected weather changes, and providing voluntary weather reports to the National Weather Service.
Best Practice 8: Vessel owners and operators should review each vessel’s operations manual to ensure that the conditions described in the manual represent realistic operating conditions.
Best Practice 9: Companies that own or operate liftboats should review each vessel’s operating guidance and establish clear and simple directions for the Master and crew. The review should include, but not be limited to, stability calculation procedures, reading draft marks, operating restrictions, cargo securing processes, and emergency steps for unexpected weather.
Best Practice 10: Companies that employ individuals who serve as offshore workers should consider a requirement to have each individual pass basic swim training.
Best Practice 11: Vessel owners and operators should consider a requirement to have their crewmembers wear reflective coveralls (or other reflective clothing), and carry flashlights and knives (or another type of cutting device) while underway.
Best Practice 12: Coast Guard District and Sector Command Centers should ensure that all of their watchstanders are familiar with the list of outside companies that are available to assist with Search and Rescue activities, which is required by Section 1.5 of the SAR Addendum. They should also review their Quick Response Checklists to ensure they include appropriate steps to check with these outside companies.
Best Practice 13: Coast Guard District and Sector Command Centers should ensure that all of their watchstanders are familiar with types of vessels and common geographical references for their area of responsibility, including offshore block names and numbers assigned by the Bureau of Ocean Energy Management.
Best Practice 14: During the response to this incident, the Coast Guard Sector Commander provided his direct phone line to the representative for SEACOR POWER’s operator.
Best Practice 15: Coast Guard Areas, Districts and/or Sectors should identify a list of experienced individuals who can serve as a Subject Matter Expert and/or the Coast Guard’s single point of contact for Next of Kin notifications in a Mass Rescue Operation.
Best Practice 16: Coast Guard Areas, Districts and/or Sectors should consider establishing processes or procedures to create a continuous channel of communications (via Teams or another application) for Mass Rescue Operations or other cases involving response by numerous different Coast Guard units.
Findings of Concern
Three Findings of Concern (FOCs) were published by the Office of Investigations & Casualty Analysis (CG-INV) on June 26, 2023 in relation to the Seacor Power capsizing and closing of the Marine Board of Investigation into the casualty. FOCs issued for this casualty are as follows:
013-23, SEACOR POWER Casualty: Findings of Concern Regarding the National Weather Service;
014-23, SEACOR POWER Casualty: Findings of Concerns Regarding Liftboats; and
016-23, SEACOR POWER Casualty: Dispatcher Training, Draft Readings and Weather Forecasting for All Commercial Vessels.
The FOCs are summarized below, and each is accessible through the links provided above.
USCG Findings of Concern 013-23, SEACOR POWER Casualty: Findings of Concern Regarding the National Weather Service
This section is only an excerpt of the findings and recommendations to the National Weather Service (NWS). See USCG FOC 013-23 that also summarized the incident and contributing factors and analysis.
Coast Guard investigators have identified a number of measures that may mitigate the risks posed by the issues discussed above. The National Weather Service should consider the following voluntary actions:
USCG Findings of Concern 014-23, SEACOR POWER Casualty: Findings of Concerns Regarding Liftboats
This section is only an excerpt of the findings and recommendations to liftboat owners and operators. See USCG FOC 014-23 that also summarized the incident and contributing factors and analysis.
Coast Guard investigators identified a number of measures that may mitigate the risks posed by the issues discussed in FOC 014-23. All liftboat owners and operators should consider the following voluntary actions:
USCG Findings of Concern 015-23, SEACOR POWER Casualty: Dispatcher Training, Draft Readings and Weather Forecasting for All Commercial Vessels
This section is only an excerpt of the findings and recommendations to owners and operators of all commercial vessels. See USCG FOC 015-23 that also summarized the incident and contributing factors and analysis.
Coast Guard investigators have identified a number of measures that may mitigate the risks posed by the issues discussed in FOC 015-23. All commercial vessel owners and operators should consider the following voluntary actions: