The delayed effort to unravel signals of the calamity that sank a Gloucester fishing boat in January was caused by analysis-paralysis in an inexperienced Coast Guard chain of command while two senior on-duty emergency response officers slept.
A congressional subcommittee reviewed these findings yesterday — and wanted to know why.
Without commenting directly about the flaws in the performance of the service in the sinking of the Patriot, which claimed the lives of two Gloucester fishermen, Rear Adm. 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 in the early morning hours of Jan. 3.
"The Patriot case will be imbedded in our training," the admiral told the committee.
Brice-O'Hara's prepared remarks and answers relied on generalizations, and contended that search and rescue training and performance had improved.
But Congressman and subcommittee Chairman Elijah Cummings, D-Maryland, countered that the Coast Guard's performance in the sinking of the Patriot suggested otherwise.
"This is not some hypothetical, this is real stuff," he said.
Brice-O'Hara conceded that "we have to instill within watchstanders a complete sense that any question, any need for assistance in standing their watch tautly and properly, should never be considered something embarrassing.
"They should have the understanding that they can call somebody else," she answered.
"By the time the first asset was launched from Air Station Cape Cod," the subcommittee briefing paper reported, the Sector Boston operations unit commander, whose job it is to coordinate search and rescue responses, "had participated in 20 phone calls over the previous two hours amounting to one phone call every six minutes," and confessed to suffering from information overload that hindered effective, acute thinking.
The Coast Guard's own investigation into the response faulted the senior command for failing to assert its authority and order search and rescue; instead, the higher command deferred down the line, which delayed the decision to go try to find the Patriot which went down only 14 miles from port.
The cause of the sinking remains undetermined and a Coast Guard investigation continues as does litigation by family of the lost fishermen, well-known and liked members of the Gloucester fishing community.
The steel-hulled, 54-foot Patriot was considered a model of modern technology.
The discovery of the bodies and the absence of a distress call, which helped flummox the search and rescue analysts in Boston, have been cited as evidence the boat went down quickly, without warning. It was found in about 100 feet of water on the sandy bottom of Middle Bank, with no apparent sign of collision.
The Coast Guard delayed launching search and rescue assets including a helicopter until 2 hours, 23 minutes, after the first call was made to Station Gloucester by Josie Russo, whose husband Matteo Russo was the captain of the Patriot, fishing overnight with her father John Orlando.
A fire alarm system was set off, sending a radio signal to the alarm company which contacted Josie Russo at her home.
The questioning yesterday was led by Cummings. The chairman of the Subcommittee on Coast Guard and Maritime Transportation, Cummings reminded Brice-O'Hara that the Coast Guard's own final investigation into the loss of the Patriot with its crew faulted the inexperience of the search and rescue watchstanders on duty the night of Jan. 3.
"The command duty officer was a lieutenant junior grade for whom the assignment to Sector Boston was the first assignment out of the (Coast Guard) Academy," Cummings noted. "The individual had attended SAR (search and rescue) school but had not received the SAR qualification."
Cummings also recalled for Brice-O'Hara that the situation unit controller and the communications unit controller together had "four months experience as qualified watchstanders."
Two other sector controllers were considered well-qualified for the duties.
Of the three senior officers on duty at the district level, only the most junior, the situation unit controller, was search and rescue qualified.
Cummings noted that these were not his findings, but those of Vice Adm. R. J. Papp Jr., commander of the Atlantic area, who issued an exhaustive analysis of the incident in June.
The subcommittee of the House Committee on Transportation and Infrastructure published its own background briefing paper for the hearing. In it, the panel spotlighted the finding that both the sector and district command duty officers "were asleep at the time of the incident," conditions that "may have played a role in the relatively inefficient processing and analysis of case information."
"By requiring the command duty officers to stand a 24-hour watch that includes sleep time," the subcommittee wrote, "potentially the most experienced watchstander won't be available when time critical decisions have to be made."
The subcommittee noted Papp's finding that watchstanders hesitated and delayed waking the command duty officers as the "ambiguity" of signs about the status of the Patriot piled on top of one another.
The subcommittee selected the Coast Guard's response to the sinking of the Patriot as one of two case studies for examination in the hearing yesterday.
The other case that was used to explore the state of the Coast Guard's art and science of search and rescue involved a botched response to a fatal high seas collision between a commercial boat and a fishing boat outside of San Francisco in 2007.
The Buono Madre was hit and sank by the Eva Danielsen, but the Coast Guard muffed the investigation and never launched search and rescue after reaching a series of faulty conclusions deduced from erroneous and misleading information relayed from the commercial boat.
Civil penalties against the Eva Danielsen's owner were dismissed "without penalty," Brice-O'Hara told the committee.
Cummings seemed incredulous.
"They falsified records, ran over a fishing boat and killed somebody ..." he repeated, and the case was dismissed?
"We know we have shortcomings in marine safety investigations," the admiral answered.
Richard Gaines can be reached at firstname.lastname@example.org