I. Facts:
1. Per the Coast Guard Investigation report which involved the area of the River between mile markers 963.2-968: “On 21 June, , while the M/V Ri was moored aft to the CGB 18 fleet, two crewmen ( mate As and deck hand Jd) were washing down the decks when Jd fell into the water. The other crewman, As, attempted to reach Jd by tossing a lifering. The lifering fell approximately 15 ft. away from Jd, who attempted to reach it but was unable to do so. Search of the area by vessel crew and local authorities yielded negative results. On 2 July, Jd was found near NewMadrid, MO. Jd was certified as a death by drowning by the New Madrid coroner. No Autopsy was conducted…Investigation revealed that Jd and As were washing the (port aft exterior) bulkheads with Dawn dishwashing liquid in a bucket of water using deck brushes to scrub the deck and exterior bulkheads. The procedure was to rinse approximately 20 feet of the deck with fire hose from the engine room, then scrub the deck with the detergent, and rinse. This procedure was repeated down the length of the vessel. Part of Jd’s responsibility included washing the bulkheads at the same time. After passing the port engine room door, As placed the fire hose nozzle through the kevil and went aft around the stern of the tow boat to secure the fire pump. Prior to rounding the corner, As saw Jd standing by, having placed the deck brush into the 5 gallon bucket. After securing the pump, As opened the port side engine room door, and heard shouts from Jd. He (As) then saw Jd in the water, approximately 40 feet off the port side of the towboat, drifting aft. He (As) retrieved the lifering and threw it toward Jd, missing him by 10 feet. As watched as Jd made a futile attempt to reach the lifering. Mr. As then ran to the pilot house to notify the pilot of the man overboard, and went to launch the yawl. He (As) observed Jd’s hand go below the water as he (As) was making his way to the yawl…”
2. Per the Coast Guard report, investigation of the casualty revealed areas of concern:
A. “Lack of workvest or PFD. Jd was not wearing a workvest or personal flotation device while conducting a soapy water washdown of the Ri.”
B. “Misunderstanding of company policy. Safety rule #4 in Corp. Employees Manual states that “Life vests or work jackets must be worn at all times when the possibility of falling overboard exists.” It is clear by As’ (?) interview that this policy has been interpreted as not applying when a crewman is on the outside deck of the vessel, especially when moored. This belief is confirmed by the lead man, Mr. Ds. This same interpretation was passed earlier in the day at a safety meeting attended by deck crew.”
C. “Unfamiliarity of vessel, gear, and tripping hazards. The outside deck around the superstructure is about 3 ½-4 feet in width with several fittings, obstructions, and tripping hazards at various locations. In the suspected location of the casualty, as indicated by the location of the deck cleaning gear, the width of the deck is further reduced by the kevil, and a gooseneck vent protruding from the deck. Around the base of the kevil is a slightly raised (approximately ¼ inch) mount that extends approximately 6 inches further inboard. Walking on even these slight protrusions without extra care, especially during soapy washdowns could allow persons to lose balance.”
D. “Unsupported grab chains. The Lifelines on the M/V Ri consists of the chains extending from one stanchion located near the bow section, to a stanchion located near the stern, approximately 3.5 feet above deck level. At a spacing of every ten feet, an additional support chain extending from the overhead is attached. No support or attachments are connected from the deck. (See photographs attached to CG report.) While they provide something to grab while walking the deck, they are not designed to prevent persons from going overboard should they lean against them, either accidentally or by intention.”
E. “Smooth deck surface. The deck on the Ri is a smooth, weathered, glossy, painted surface without non-skid properties. Slipping hazard is very likely during soap and water washdowns. The addition of non-skid strips along the outside deck would reduce the possibility of slipping hazards.”
3. The Corporation Emploee Manual Revised 10/00 states under Company Safety Rules:
Responsibility, 1. “…The supervisor must review the Safety Rules with the employees and note the review in a Job Safety Analysis…4. All Corporation employees must follow company Safety Rules at all times.
Safety Rules “1. It is the policy of Corporation that we will operate safely and in full compliance with all safety regulations. All employees are to support this policy…4. Life vests or work jackets must be worn at all times when the possibility of falling overboard exists… Corporation employees must wear a life jacket…at any time when exposed to the water…”
4. Pay records indicate Jd worked eleven days for the company, including the day of his death. The New Employee Orientation Checklist for Mr. Jd indicates that he did not receive a deckhand manual. Rn, the captain of the vessel indicates that: “We take special attention to new employees.”
5. Rn was the captain of the Ri. In his deposition he states:
A. He has no knowledge of what a new deck hand goes through as far a safety orientation and training when they first hire on with the company.
B. He agrees that company policy did not require Jd to wear a PFD when the vessel was tied up.
C. The Coast Guard was not immediately notified of the man overboard.
D. When a man overboard happens the policy is to blow the ship’s whistle and turn on the (general) alarm, then everyone goes to their station. This was not done.
E. The general alarm (as well as the radios) is in the wheel house.
F. He did not know if there was non-skid protection on the deck.
G. He agrees that some of the vertical chains were not attached to the deck.
H. He is unaware of any written chain of command.
I. Jd’s wearing a PFD would not interfere with his washing down duties.
J. The ring buoys on either side of the pilot house have lines attached, the ones aft such as thrown to Jd by As do not.
6. Ds was the lead man on the Ri. In his deposition he stated:
A. That he did not know what was on the orientation video tape shown to new hands, but agrees that Jd was “green” and on his first trip.
B. Im Barge Lines requires wearing of a PFD when washing down and anytime a person steps out on the boat. This was mentioned at the safety meeting on June 21.
C. There was a retrieval line on the ring buoy thrown by As to Jd as well as all the ring buoys. As told him (Rs) that he (As) threw the ring buoy.Rs does not believe As used the retrieval line.
D. Man over board drills were conducted a few times per month. In the drills the procedure was to report a man overboard to the wheel house, the general alarm would be sounded along with making an announcement on channel 70-72 on the radio, and the yawl would be prepared for launching.
E. Wearing a safety vest (PFD) is not much of an impediment to doing a job.
7. Hn was the engineer on the Ri, working for approximately six years for the Corporation. In his deposition he stated:
A. Prior to the Jd incident he was unaware of a written policy regarding wearing PFD’s.
B. There was a fire hose stretched out on the deck and the deck was wet in the area of Jd’s going overboard.
8. In a statement taken on the date of Mr. Jd’s disappearance, Ds (lead man) stated that he didn’t know the corporation policy concerning wearing of lifevests when outside on the boat.
9. In a statement taken on the date of Jd’s disappearance, mate As stated that to the best of his knowledge this was the first time Jd had been involved in a washdown. Jd was wearing steel toed work shoes.
10. Wl was the trip pilot on the Ri. In his statement taken on the date of Mr. Jd’s disappearance he indicated that he and the engineer, Hn, were in the pilot house when the mate, (As) came running up to report man overboard. He then stated that both he and Bn followed As back down to see if they could see Jd. They then started putting the yawl in the water.
II. Opinions:
1. As indicated in the Coast Guard report, based on an on-scene investigation undertaken two hours and ten minutes after the incident (15:10-17:20 per ship’s log) the following conditions were present on the Ri prior to Jd’s entering the water:
A. Jd was unfamiliar with the vessel and inexperienced in river work in general. Also note that as shown in paragraph 5. above his new captain did not know what/how Jd had been trained, and that Jd did not have a deckhand’s manual.
B. Jd was not wearing a life vest while conducting a soapy water washdown.
C. The company policy requiring the wearing of life vests at all times when the possibility of falling over board exists, was not enforced.
D. The deck area where Jd was working was narrow and cluttered both with deck fittings and cleaning gear including the fire hose placed with its nozzle through the kevil.
E. The deck was a smooth, weathered, glossy, painted surface without non-skid properties.
F. The vertical support chains were not attached to the deck. Thereby greatly increasing the danger of falling, then slipping under them into the water.
2. Captain, pilot, and mate all relate that the company policy regarding wearing or not wearing PFD’s was frequently presented to the crew. The policy clearly says that: “Life vests or work jackets must be worn at all times when the possibility of falling overboard exists… Corporation employees must wear a life jacket…at any time when exposed to the water…” However, this was not the understanding of the crew on the Ri as they did not believe that PFD’s were required when the vessel was moored and someone was outside on the vessel’s deck. The conditions and situations outlined in paragraph 1. above all combine to present an obviously hazardous setting where a deck worker must positively be wearing a PFD. Additionally, lead man Ds states on the day of the incident, that he did not know the policy for PFD’s.
3. The high potential of falling under the safety chains, especially as their suspension from the overhead would allow them to swing outward when contacted or pushed from an inboard location, has been addressed. Additionally, photographs in the Coast Guard report also demonstrate the corresponding potential for a person’s backing into/over them at the lowest point in the chain’s catenaries. The worker in the Coast Guard photos has his knee at the approximate level of the chain behind him in the picture. Simply stepping or stumbling backwards would place Jd in jeopardy of tumbling head first and rearward over the unseen chain. Also, with Jd’s wearing steel toed boots, his ability to swim would be greatly impaired, should he enter the water.
4. Measurement of the rigid, doubled pipe railings on the upper decks of the Ri indicate their being continuously at the normal, waist height of three feet. Obviously this continued, non flexible height is an impossibility with the flexible chain on the main deck. The apparent danger of this condition to a supervisor observing a worker not wearing a PFD moving about the narrow, cluttered, slippery deck, with his (worker’s) back to the water, is inescapable, especially when that supervisor (As) has just conducted a safety meeting dealing with PFD usage.
5. As with the foregoing non application of PFD policy with an actual situation, two other glaring examples of the inability of the Ri supervisors to match safety requirements with an emergency are revealed in deposition testimony. First, no one rang the general alarm located in the Ri’s pilot house to alert the crew to the man overboard, which is required per the ship’s emergency drill plan. This failure resulted in time lost in waking crew members and launching/manning the yawl. Secondly, although there is deposition testimony indicating that man overboard drills are regularly conducted, this testimony also indicates conflict between whether the ring buoy thrown to Jd had a retrieval line attached. Not having a line attached is a serious deficiency since only one throw can be made where repeated throws are required, which is basic to practicing and throwing proficiency. Even more indicative of the low level of safety/emergency preparedness aboard the Ri, is the alarming gap between professed knowledge of what to do as gained by supposedly frequent, repeated drills, and what in reality was known and accomplished when an actual emergency situation occurred. Additionally, Emergency response services such as the Coast Guard are to be immediately notified of a man overboard event. Although two men were in the pilot house with the general alarm and radios, when notified that Jd had gone overboard, neither had the presence of mind to trigger the alarm, as required, or to immediately call the Coast Guard, as required.
III. Conclusions:
1. Based on the Coast Guard investigation and the gaps and lapses in basic seaman’s expected safety awareness and responsibility, as exhibited by the supervisors on the Ri, I find them directly responsible and culpable for this tragic and easily preventable death. These inexcusable lapses are particularly telling when the high level of safety awareness required by the Corporation’s policy is compared to the appalling deficiencies exhibited aboard the vessel.
