R 202136Z DEC 07 ZUI ASN-A00354000025 ZYB
FM COMDT COGARD WASHINGTON DC//CG-00//
TO ALCOAST
BT
UNCLAS //N01000//
ALCOAST 580/07
SUBJECT: COMMANDANT FINAL ACTION ON THE ADMINISTRATIVE
INVESTIGATION INTO MSST ANCHORAGE MISHAP OF 25 MARCH 2007
A. COMMANDANTS ALL HANDS EMAIL/MSG DTG 271814Z MAR 07
1.  LAST MARCH, WE LOST ONE OF OUR SHIPMATES ASSIGNED TO MSST
ANCHORAGE (91111) IN A TRAGIC ACCIDENT WHEN PS3 RONALD GILL, THE
GUNNER ABOARD A 25-FT DEFENDER CLASS BOAT CONDUCTING AN ESCORT OF A
WASHINGTON STATE FERRY, WAS EJECTED FROM THE BOW OF THE BOAT DURING
A HIGH SPEED TURN. DESPITE THE LIFE SAVING EFFORTS OF HIS SHIPMATES
AND EMERGENCY MEDICAL PERSONNEL, PETTY OFFICER GILL DID NOT SURVIVE
HIS INJURIES.
2.  EARLIER THIS WEEK, I TOOK FINAL ACTION ON THE ADMINISTRATIVE
INVESTIGATION INTO THIS INCIDENT. PETTY OFFICER GILLS FAMILY WAS
PERSONALLY BRIEFED ON THE RESULTS OF THIS INVESTIGATION WEDNESDAY
BY A COAST GUARD TEAM LED BY FIRST DISTRICT COMMANDER RADM TIM
SULLIVAN, IN KEEPING WITH THE WISHES OF THE FAMILY TO BE BRIEFED AS
SOON AS POSSIBLE. IN ADDITION, MEMBERS ASSIGNED TO MSST ANCHORAGE,
MSST SEATTLE, AND SECTOR SEATTLE WERE ALSO BRIEFED ON THE RESULTS
OF THIS INVESTIGATION.
3.  LIKE MOST ACCIDENTS, THIS MISHAP WAS CAUSED BY A COMBINATION OF
FACTORS, INCLUDING GAPS IN OPERATIONAL DOCTRINE, INADEQUATE
OVERSIGHT AND DIRECTION AT KEY LEVELS OF LEADERSHIP, A FAILURE TO
FOLLOW PROPER PROCEDURES, INEFFECTIVE COMMUNICATIONS, AND ERRORS IN
JUDGMENT. A COMPREHENSIVE LIST OF CORRECTIVE ACTIONS ORDERED,
INCLUDING THOSE THAT HAVE BEEN COMPLETED, ARE CONTAINED IN THE
FINAL ACTION MEMORANDUM (FAM). MOST NOTABLY, SINCE THIS INCIDENT
OCCURRED, A NEW RESTRAINT SYSTEM FOR THE GUNNER AND A BOAT CREW
COMMUNICATION SYSTEM HAVE BEEN APPROVED AND ARE BEING FIELDED CG
WIDE FOR THOSE UNITS THAT HAVE NOT ALREADY RECEIVED THEM.
4.  WE CAN ALL LEARN VALUABLE LESSONS IN LEADERSHIP, RISK
MANAGEMENT, AND TRAINING FROM THIS INCIDENT. COAST GUARD MEMBERS
WITH ACCESS TO A CGSW CAN READ THE FINAL ACTION MEMO ALONG WITH
SUPPORTING DOCUMENTS THAT ARE POSTED ON CG CENTRAL. ALL OTHERS CAN
VIEW A PUBLICLY ACCESSIBLE COPY OF THESE DOCUMENTS ON THE INTERNET
AT: HTTP://WWW.USCG.MIL/FOIA/READING_ROOM.ASP.
5.  AS WITH ANY ADMINISTRATIVE INVESTIGATION, SENIOR OPERATIONAL
COMMANDERS WILL REVIEW THIS FAM TO DETERMINE WHAT, IF ANY,
ADDITIONAL ACTION IS WARRANTED, INCLUDING AN ASSESSMENT OF THE
CULPABILITY AND ACCOUNTABILITY OF ANY PERSONS INVOLVED IN THIS
INCIDENT. IN ADDITION TO THIS ADMINISTRATIVE INVESTIGATION, A
SAFETY ANALYSIS OF THIS MISHAP IS BEING CONDUCTED AND ITS RESULTS
WILL BE DISSEMINATED VIA ALCOAST UPON ITS COMPLETION IN THE COMING
MONTHS.
6.  THIS TRAGIC ACCIDENT IS A STARK REMINDER THAT COAST GUARD MEN
AND WOMEN OPERATE IN HAZARDOUS ENVIRONMENTS EVERY DAY. IT IS THE
NATURE OF OUR DUTY, YET WE MUST ALWAYS REMAIN VIGILANT IN
IDENTIFYING AND MITIGATING UNNECESSARY RISK WHEREVER AND WHENEVER
WE FIND IT. WE HONOR PS3 GILL BY RE-DEDICATING OURSELVES TO THE
IMPORTANT WORK WE DO FOR THE AMERICAN PEOPLE. I ASK THAT YOU KEEP
PETTY OFFICER GILLS FAMILY, FRIENDS AND SHIPMATES IN YOUR THOUGHTS
AND PRAYERS, ESPECIALLY AS WE COME TOGETHER WITH OUR OWN FAMILY AND
FRIENDS THIS HOLIDAY SEASON.
7.  ADM THAD ALLEN, COMMANDANT, SENDS.
8.  INTERNET RELEASE AUTHORIZED.
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