GloucesterTimes.com, Gloucester, MA

June 13, 2009

CG report shows broad failure in Patriot case

By Richard Gaines

The Coast Guard's delayed response to the initial notification of a fire alarm radio signal from the doomed fishing vessel Patriot reflected systemic failure by duty personnel at multiple levels, according to a final action memo issued by the Atlantic Area commander.

The 54-foot fishing vessel with its crew of two — Capt. Matteo Russo, 36, and his father-in-law John Orlando, 59 — sank about 15 miles from Gloucester, its home port, early on the Saturday morning of Jan. 3.

A separate investigation continues into the cause of the sinking. In all likelihood, the catastrophe occurred with lightning speed, so that, even if the multiple mistakes made by Station Gloucester, Sector Boston and the First District (also in Boston) that put off the search and rescue response had not occurred, the two lives still would have been lost, the report by Vice Adm. Robert J. Papp Jr. made clear.

He placed the actual sinking of the boat at between 1:17 a.m. and 1:30 a.m. — at least five minutes before the first notice to the Coast Guard of a possible boat in distress.

Both experienced fishermen apparently drowned quickly after entering the 42-degree water without survival suits that were believed to be on board the well equipped vessel. Russo and his wife Josie had acquired the boat the previous March, and put extensive renovation work into it.

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."

That problem was that "the vessel's fire alarm system, used for dockside monitoring, indicated it had been activated, but the vessel's multiple at-sea emergency distress signals had not provided any indication of emergency and distress."

Inexperienced personnel in key positions were slow to synthesize that information into an accurate appraisal of the situation, Papp noted.

Papp's report is a 9,000 word document that meticulously reviews nearly every moment of the Patriot's demise — from the first report to Station Gloucester at 1:35 a.m. by Josie Russo that the fire alarm had signaled.

The timeline tracks the events from that notice to show how the decision-making was drawn out, establishes a finding of facts and in the final section issues orders "to ensure that the inefficiencies and missteps that occurred during the case are not repeated."

Papp explained that he ordered an independent review and report on the incident in April once he learned how involved the 1st district command center in Boston was in the events that led to the search and rescue decision.

The administrative investigation was assigned to Capt. Patrick Brennan, chief of response for the 8th district (New Orleans).

Because of the interest in the case, Papp said he also decided to incorporate into Brennan's report the unfinished report that was underway in the 1st district.

Among the failures identified in report released Thursday night were:

Inexperienced officers at watchstand positions;

The inability of the make facile use of the VMS or vessel monitoring system;

Failure to follow proper procedures and checklists in working up data to determine if search and rescue was warranted;

Ineffective exercise of authority in the chain of command;

Ineffective telephone communications up and down the line;

General failure to engage higher level and more experienced decision-makers.

Papp noted that the Sector Boston command center the four officers on duty at the time of the incident had only 27 months of experience at their assignments, and that one officer accounted for 23 of those months, leaving three duty officers involved in the decision making about search and rescue for the Patriot with four months experience between them.

Sector Boston's command duty officers "are not qualified" as operations unit controllers, that is decision makers in search and rescue although they are "search and rescue school graduates," the admiral wrote.

"The actions and judgment exhibited by both the 1st district and Sector Boston command center call into question the qualification and staffing procedures at both the sector and district levels for the command center," Papp said.

"It is just this type of case, one that involved a great deal of ambiguity, which required experience to be brought to bear as soon as possible so that potential for distress could be identified early on," he wrote.

Compounding the inexperience was lack of training in VMS operations.

At the time, proficiency in the use of this technology was not required of Coast Guard search and rescue personnel. VMS long has been used for law enforcement and is under the control of the National Oceanic and Atmospheric Administration but the Coast Guard also has open access to VMS technology which is understood to be a supplementary resource in search and rescue.

Papp ordered a new protocol for VMS training; and beginning in February, each sector command sector is ordered to log into VMS every six hours "to build domain awareness."

Papp also noted that at three different times 1st district officials recommended launching search and rescue efforts, but did allowed the recommendations to be ignored.

The operations unit commander at Sector Boston "was overwhelmed by the number of phone calls in a relatively short period of time," Papp wrote, "and this more than likely contributed to his inability to fully process and understand the aggregate picture in this case."

In little more than three hours, the commander, who had little experience, had to field more than 40 calls.

"The sheer volume of calls handled exclusively by the operations unit commander indicates (he) had little time to effectively assess the facts presented before him," the admiral wrote.

Papp said he spoke to Josie Russo to "pass on my condolences for her family's loss, and to express my regret for the length of time this investigation has taken."

"I sent my team earlier (Thursday) to personally share the final report with them and answer any additional questions," Papp said in a prepared statement. "The Russo and Orlando families have my commitment that this review or our response will help us perform more effectively and decisively, even during uncertainty, and may one day, help to save someone's life."

Richard Gaines can be reached at rgaines@gloucestertimes.com

CG response 'failures'

Identified problems that contributed to Coast Guard's delayed search-and-rescue response to the F/V Patriot, according to Vice Admiral Robert J. Papp Jr.'s report.

Inexperienced officers in watchstand positions;

The inability to make facile use of VMS system;

Failure to follow effectively compile data to determine if search and rescue was warranted;

Ineffective exercise of authority in the chain of command.