NOTE: This is a corrected version of this story. The initial version incorrectly reported that that the U.S. Coast Guard Report of Investigation showed alcohol in the blood of both crew members and drugs in the blood of John Orlando. That is not the case. In fact, the report showed no alcohol in the blood of either crewman and showed no drugs in the blood of John Orlando. As the story notes, portions of the report were redacted. We offer our apologies to the families of both men for our incorrect reporting.
The U.S. Coast Guard released findings Friday vindicating that the Gloucester fishing vessel Patriot likely capsized and sank from a chain reaction of mechanical failures, design flaws and possible human judgment error — all leading to the drowning deaths of Capt, Matteo Russo, 36, and his 59-year-old father-in-law, John Orlando.
The call for help from Josie Russo, Matteo's wife and Orlando's daughter, in the early-morning hours of Jan. 3, 2009, yielded a delayed and confused search and rescue effort.
But the cause report released Friday made clear that even the finest work would almost certainly not have saved her husband or her father, whose bodies were recovered from the icy water of Middle Bank, 14 miles from port.
In Gloucester's tight-knit fishing community, the tragedy has lingered in the stubborn fog of uncertainty surrounding the events leading to the failure of a boat and crew considered among the port's finest.
Autopsies by the state medical examiner showed the presence of a controlled substance in the blood of Russo, but indicated no presence of drugs or alcohol in the blood of Orlando, the Coast Guard report indicates. Further details were redacted from the report obtained by the Times.
The boat got underway at night and short one member of the standard crew, though the report noted that the Patriot had completed a number of trips with the crew of just two.
The more than 50-page report — on an 18-month investigation — discounted the only other official theory for the heretofore mysterious sinking — that the Patriot was sunk in an accident with a tug-barge train that was the only known traffic in the vicinity in the mid-night hours of Jan. 2 and 3, 2009.
Instead, the report found weaknesses in the design and functioning and possibly the operation of the 62-foot steel-hulled vessel that "most likely" led to the capsizing of the vessel which had been trawling the shallow sanding bottom.
Grace Burbidge, Josie Russo's sister, said the family would have no comment.
Aided by the Navy's underwater warfare experts, Coast Guard investigators used recordings from 19 acoustic buoys permanently placed on Middle Bank, a section of Stellwagen Bank Marine Sanctuary, to piece together a forensic final history for the Patriot. The buoys are primarily used to monitor the sound and movements of whales.
For all the work and forensic science, the final minutes of the Patriot and its crew remain somewhat unclear. Left with no signs of external impacts, the sinking and deaths were explained as most likely caused by a series of failures during the haulback of a trawl, an act that is repeated often in the course of groundfishing.
"The Patriot mostly likely capsized at 1:12 a.m. on Jan. 3, 2009, leading to rapid down flooding through her open fish hold and engine room hatches, and subsequently the vessel's sinking," according to the report signed by Coats Guard Rear Adm. Kevin S. Cook, director of prevention policy.
"Both crew members most likely entered the water between 1:12 a.m. and 1:15 a.m. and had drowned by 1:25 a.m. The cause of the capsize was possibly a stability failure created by a combination of factors and initiated by the lifting of the cod end of the net off the deck."
The report went on to say, "It is impossible to know the crew's final actions on board ... and how those decisions may have effected the casualty itself.
"However, getting underway late at night, getting underway shorthanded, and use of a controlled substance could have negatively affected the alertness of the crew and prevented them from reacting to an emergency situation," the report states.
The Coast Guard briefed the members of the Russo-Orlando family mid-afternoon Friday, and outlined the findings to the political leadership of the community at 5 p.m.
Coast Guard Capt. John Healey, commander of Sector Boston, also briefed the press at the Coast Guard campus in Boston's North End at 8 p.m. Healey succeeded Capt. Gail Kulisch, who was rotated out of Boston to Virginia last year during the final stages of the internal investigation into the rescue response for the Patriot, which produced a scathing report that built with small failings to a chilling indictment of lost focus on the service's historic mission — search and rescue.
The Coast Guard's investigation of the flawed search and rescue effort was released in June 2009. It found a "delayed response due to poor collection and analysis of information and decision-making regarding the vessel's status."
So many flawed reactions to the sketchy signs of catastrophic distress were discovered in the hierarchy between Station Gloucester and the First District that a vice admiral testifying before a congressional subcommittee almost a year ago said lessons learned from the Patriot "will be imbedded in our training."
The delayed effort to unravel signals of the calamity that sank the Patriot was caused by analysis-paralysis in an inexperienced Coast Guard chain of command, while two senior on-duty emergency response officers slept, as protocol authorized them to do.
Without commenting directly about the flaws in the performance of the service in the sinking of the Patriot, Sally Brice-O'Hara, a search and rescue expert, conceded training and orientation of duty officers needed improvement.
The only witness in a two-hour hearing, she also said more staffing would allow a shortening of the 24-hour shifts that found key decision-makers at the sector and district levels in Boston sleeping — as allowed — while, down the chain, inexperienced officers wrestled with information overload and indecision.
"Our review of this case showed that we were slow to launch search and rescue assets because of poor collection and analysis of information and decision-making regarding the Patriot's status," said Vice Adm. Robert J. Papp Jr.
Papp did not quantify the time lost; yet his report makes it clear that the decision to launch search and rescue assets should not have taken 2 hours, 23 minutes. The admiral also acknowledged that "situational ambiguity regarding the condition and location of the vessel made it particularly difficult to process the search and rescue case."
Richard Gaines can be reached at 978-283-7000 x3464, or at firstname.lastname@example.org.