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SAFETY RECOMMENDATIONS: The purpose of safety recommendations is to identify corrective actions the Coast Guard, or other substantially involved federal agencies, should take to address known unsafe conditions, action, or other unwanted outcomes to prevent future casualties and improve safety of life at sea as required in 46 USC 6301.  An Investigating Officer or a Marine Board of Investigation considers making safety recommendations when their investigation indicates that laws, regulations, or the policies, tactics, techniques, and procedures that implement those laws, are inadequate or missing and that identified unsafe conditions, actions, or other unwanted outcomes may be mitigated through the amendment, repeal, or proposal of those laws, regulations, policies, etc.

In accordance with 46 CFR §4.07-10, safety recommendations are submitted to and subject to a process of review and endorsement by the cognizant Officers in Charge, Marine Inspection, and District Commanders.  For those recommendations that are addressed to the Commandant, once they are endorsed by the OCMI and District Commander, they are reviewed by the appropriate program office(s) at Commandant and a final response (i.e. final action) determined.

 

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Recommendation Category Stability/ Subdivision/Watertight Integrity
MISLE ID 11434
Recommendation

It was discovered during the casualty investigation, that the vessel was using an outdated stability letter that was invalid based on cargo system and software updates made to the vessels loading system.  A query was completed of another vessel within the company's fleet and it was also determined to have an invalid stability letter based on cargo system updates.  

Recommend District Nine provide guidance/work instruction/procedure to Sector OCMI's to examine the stability letters for US Laker Fleet within respective fleets of responsibility to ensure compliance with cargo loading system updates, and stability considerations.
OCMI Endorsement

Concur with recommendation. During the course of this investigation, it was discovered that multiple vessels within the fleet had outdated stability and cargo loading documents.  Some of this instances invalidated current stability documents.  Recommend that District Nine initiate a project to review and assess the accuracy, relevancy and validity of Great Lakes Deep Draft vessel stability documents.
District Endorsement

I concur with this recommendation and will be directing my staff to conduct a MISLE review of all relevant vessel stability documents for the Great Lakes deep draft fleet. As part of this review, my staff will review vessel stability documents to ensure that the information contained within is relevant and up to date. As part of Safety Recommendation 1 above, my staff will also incorporate an OCMI review of vessel stability information when evaluating a manning reduction request.

Finally, all OCMI’s shall be reminded that it is incumbent that vessel stability information can, and should be reviewed and validated by OCMI’s periodically, to include at Dry Dock, COI inspections and other opportunities to ensure that stability and loading information is relevant, accurate and up to date. The above actions constitute the final agency action for this safety recommendation.
Final Action

CGD-GL (dpi) staff conducted a comprehensive review of all deep draft stability letters, to ensure letters were in MISLE, up to date and accurate to the vessel.
Investigation ID 7621289
Incident Date 1/7/2023