On the January night the Patriot was lost with its crew of two, a riveting symbol of a generally ineffective response was the frustrated efforts of an operations unit controller at Coast Guard Sector Boston to gain access to the vessel monitoring system that could have located the boat.
This VMS is owned and used regularly by the National Oceanic and Atmospheric Administration in law enforcement of fishery regulations, and fishermen are aware of its capabilities in trained hands.
So the failure of the search-and-rescue personnel in Sector Boston to bring VMS to bear quickly on the mystery of the Patriot, which vanished before the captain, Matteo Russo, could mayday, added to the community's pain.
Facing that failure directly, Coast Guard officials, the admiral for the Atlantic and the search-and-rescue specialist who worked on the case, have pledged henceforth to take full advantage of VMS, a technology that came in as a law enforcement tool, but was always understood as a secondary search-and-rescue resource.
The lessons learned from the Patriot case study will be put to practice, they have pledged.
The last signal came from the Patriot's VMS system at 12:30 a.m. on Jan. 3. But, some time after, as concern began to gather for the safety of the fishing boat and its crew — Russo and his father-in-law John Orlando — the Coast Guard was unable to access the computer system that contained the final coordinates of the doomed boat.
The reports' chronologies don't indicate when the first effort to use VMS was made, but the process took at least 20 minutes, probably longer.
Even after the system was put to use, the decision to launch search and rescue was put off while inexperienced hands tried to penetrate what Vice Adm. R. J. Papp Jr.'s report called the "situational ambiguity" of the problem: What was the status of the Patriot, and where would the search focus?
The Coast Guard has taken a series of steps to prevent a recurrence of its imperfect use of VMS in search of the missing Patriot.
In an effort to make the Patriot a case study in the value of VMS as a search-and-rescue tool, from two separate reviews of the mishandling of the Patriot case have come a series of policies and actions:
Watchstanders in Boston will have their own passwords, and user accounts.
At a minimal of every six hours, the watchstanders will be required to log onto the system.
Watchstanders will undergo VMS training semi-annually.
The Boston District, which includes sectors for all of New England and New York, has created a VMS Web site "that consolidates all of the latest guidance on VMS, provides training tools and a use's guide for watchstanders," according to Lt. Erik Halverson, public affairs officer for the 1st District.
"I think the best way I can quantify it is (the Patriot) has put an emphasis on VMS," said Cmdr. Nathan Knapp, chief of response for the Boston Sector. "It's a priority and has our attention."
Knapp was on duty for the loss of the Patriot, and at the news conference at Station Gloucester that morning, was the face and voice of the service with the duty of announcing the Patriot's sinking, and Russo and Orlando's deaths.
The failure of the service to make efficient use of the VMS system was identified in two reviews of the efficacy of the response — the first undertaken Jan. 30 by Capt. Gail Kulisch, then commander of Sector Boston, the second initiated in May by Papp, who serves as commander of the Atlantic Area.
Papp said he decided to make public Kulisch's unfinished report "to ensure transparency in light of the extraordinary circumstances of this case and the prior public pronouncements about the case study."
Kulish, who was rotated out of Boston to Virginia last month, had updated the community and the Times more than once in the week after the sinking and deaths rocked Gloucester and the broader fishing nation.
Papp released his 9,000-word report and Kulisch's somewhat shorter, incomplete report last Friday.
In it, he explained that he decided on an independent review after learning how deeply involved the Boston district was in the somewhat fractured decision-making that preceded the delayed call to launch a full search-and-rescue operation for the Patriot — more than two hours after the first worried call from Josie Russo; she reported the remote radio-powered fire alarm on boat had gone off and further that she had lost cell-phone contact with her husband; that was uncommon, she explained.
She called Station Gloucester.
After Sector Boston was contacted, twice during the first hour after Josie Russo notified Station Gloucester of her concern about the Patriot, the operations unit controller, the duty point person for search and rescue, tried and failed to gain access to the database that aggregates "ping" signals from fishing boats at least once an hour.
According to Kulisch's report, "The operations unit controller (the point person for search and rescue decisions) made one attempt to log in to the VMS secure gateway and failed. He then referenced the national VMS connection instructions, provided by lst District, and tried a second time and failed to gain access again.
"He knew that three failed attempts could lock him out of the system until NOAA was able to reset it, so he did not attempt a third time."
Instead, she reported, he requested that lst District access VMS.
"It took 1st district eight minutes to successfully gain access to VMS and provide the last VMS position to Sector Boston," her report indicated.
The failure to make facile use of VMS was compounded by the inexperience of the watch team evaluating the data, as Kulisch and Papp's report makes clear. But Papp notes that search-and=rescue personnel were not required to be trained in the use of VMS at the time of the Patriot tragedy.
"At the time of the incident," Papp's final action memo reported, "knowledge of VMS operations or demonstration of proficiency in its use was not required by any (Coast Guard standard). The only performance standard requirement was for the commanding officer and the situation unit controller to have access to VMS ..."
"But," Papp wrote, "they were not required to demonstrate any proficiency in its use or knowledge of its capabilities and limitations."
Such ignorance, he indicated, should not be perpetuated under the policies on VMS written as a legacy to the Patriot's loss.
Richard Gaines can be reached at firstname.lastname@example.org