R 012039Z FEB 13

ALCOAST 039/13
COMDTNOTE 5830
SUBJ: FINAL ACTION ON THE ADMINISTRATIVE INVESTIGATION INTO THE
COLLISION BETWEEN CG-33118 AND A RECREATIONAL VESSEL IN SAN DIEGO
HARBOR ON 20 DECEMBER 2009
A. COMDT COGARD WASHINGTON DC 191808Z MAR 12/ALCOAST 133/12
B. COMDT COGARD WASHINGTON DC 021732Z AUG 12/ALCOAST 356/12
1. The Final Action Memorandum (FAM) for the administrative
investigation into the collision between Coast Guard small boat
CG-33118 and a recreational vessel has been approved.  On the evening
of 20 December 2009, the CG-33118 collided with a 24-foot Sea Ray
carrying 13 persons in San Diego Harbor, California.  This collision
occurred during the San Diego Bay Parade of Lights marine event.
CG-33118 overran the Sea Rays stern, causing fatal injuries to an
eight-year-old boy, serious injuries to four, and minor injuries to
six others, all of whom were on board the Sea Ray.  No one on the
CG-33118 was injured.
2. This FAM is available in the Coast Guard FOIA reading room at:
http://www.uscg.mil/foia/foia(underscore)library.asp (cut and paste
to browser, add underscore, enter, then scroll to administrative
investigations).
3. The lessons learned from this mishap must be applied to all
operational missions executed by the Coast Guard.  All Commanding
Officers and Officers in Charge of operational units shall review
this FAM and employ its lessons learned to improve operational safety
and effectiveness across our mission lines.  Commanding Officers and
Officers in Charge of boat units shall personally review this FAM
with their boat crews within 30 days of the release of this message.
4. These findings reinforce the concepts raised in the FAM for the
CG-6017 mishap discussed in Shipmates 21, and the Commandants focus
on proficiency introduced in Shipmates 23.  This mishap further
reminds us that there is no substitute for sound leadership.  There
were lapses in oversight at many levels creating a climate that
failed to recognize departures from doctrine, policy and regulations.
An error chain developed that enabled the crew to assume unwarranted
risk, resulting in tragic consequences.  Following standard risk
management practices would likely have guided this crew to a
different result.  Proper mission planning would have ensured
designation of crew responsibilities, identification of hazards
present in the crowded harbor, and appropriate evaluation of mission
urgency.
5. The vast majority of Coast Guard operations are carried out safely
and effectively.  This mishap, although an anomaly, demonstrates that
we still have work to do.  The time for good leadership and mission
planning is before a mishap occurs.  Risk management must be part of
our culture for the safety and welfare of our crews and those we
serve.  Proper operational risk management techniques involve more
than a premission green-amber-red model.  Risk management must be
accomplished anytime tasking or conditions change.  I expect the
support of all Coast Guard men and women in learning the lessons from
this tragedy and making improvement in operational safety and
effectiveness.  We often operate in high risk situations, assessing
those risk factors and planning mitigation strategies are essential
to safe and effective operations.
6. VADM J. P. Currier, Vice Commandant, sends.
7. Internet release is authorized.