SUBJ: RELEASE OF CHIEF OF STAFFS FINAL DECISION LETTER ON THE 25
MARCH 2007 MSST ANCHORAGE CLASS A EJECTION MISHAP
1. THE RELEASE OF THE CHIEF OF STAFFS FINAL DECISION LETTER SIGNALS
THE COMPLETION OF A RIGOROUS SAFETY INVESTIGATION, MISHAP ANALYSIS,
AND HIGH LEVEL REVIEW OF THE CIRCUMSTANCES WHICH LED TO AND
CONTRIBUTED TO THE EJECTION AND SUBSEQUENT DEATH OF A COAST
GUARDSMAN ON 25 MARCH 2007. THE SOLE PURPOSE OF THE SAFETY
INVESTIGATION WAS TO FIND OUT WHY THE MISHAP OCCURRED SO SIMILAR
MISHAPS CAN BE PREVENTED IN THE FUTURE. THE FINAL DECISION LETTER
OUTLINES THE NUMEROUS CAUSAL AND CONTRIBUTING FACTORS THAT RESULTED
IN THIS MISHAP. IT ALSO TASKS VARIOUS COAST GUARD PROGRAMS WITH
REQUIRED ACTIONS TO IDENTIFY/AVOID SIMILAR HAZARDS AND THEIR
CONSEQUENCES IN THE FUTURE AND SUMMARIZES COMPLETED ACTIONS TO
DATE. ALL MEMBERS OF THE COAST GUARD ARE HIGHLY ENCOURAGED TO READ
THE ENTIRE FINAL DECISION LETTER AS POSTED ON THE FOLLOWING
WEBSITES:
 A. COAST GUARD MEMBERS WITH ACCESS TO A CG STANDARD WORKSTATION
SHOULD VIEW THE FINAL DECISION LETTERS POSTED ON CG CENTRAL AT:
(HTTP://CGCENTRAL.USCG.MIL).
 B. MBRS WITHOUT CGSW ACCESS CAN VIEW A COPY OF THE
SAME LETTER IN THE FOIA READING ROOM AT:
(HTTP://WWW.USCG.MIL/FOIA/READING-ROOM.ASP).
2. ALSO AVAILABLE IN THE FOIA READING ROOM IS THE FINAL ACTION
MEMORANDUM FROM THE ADMINISTRATIVE INVESTIGATION INTO THIS SAME
MISHAP. AN ADMINISTRATIVE INVESTIGATION IS CONDUCTED TO GATHER
AND ANALYZE FACTS IN ORDER TO GUIDE DECISION MAKING. AS SUCH, IT
IS EXPECTED THAT THERE WILL BE OVERLAP WITH THE SAFETY ANALYSIS
AND FINDINGS OF A MISHAP.
3. THERE WERE A TOTAL OF 10 CAUSAL AND 15 CONTRIBUTORY FACTORS
IDENTIFIED IN THE EJECTION MISHAP. WHILE THERE IS STILL ONGOING
WORK TO ADDRESS ALL OF THE CAUSAL FACTORS, THE FOLLOWING CHANGES
HAVE BEEN COMPLETED:
 A. REQUIRES BOAT FORCES COMMAND CADRE COURSE FOR ALL MEMBERS IN
RECEIPT OF ORDERS TO OR FILLING THEIR FIRST ASSIGNMENT AS
COMMANDING OFFICER, OFFICER-IN-CHARGE, EXECUTIVE OFFICER,
EXECUTIVE PETTY OFFICER, AND ENGINEERING PETTY OFFICER OF A
STATION, AIDS TO NAVIGATION TEAM, OR MARITIME SAFETY AND
SECURITY TEAM.
 B. DEPLOYED THE BOAT GUNNER RESTRAINT SYSTEM. REQUIRED ALL BOAT
CREW MANNING MOUNTED AUTOMATIC WEAPONS ON THE DEFENDER CLASS,
SPC-LE, AND TPSB TO BE TETHERED.
 C. DEPLOYED BALLISTIC HELMET AND BALLISTIC GOGGLES. REQUIRED THE
BALLISTIC HELMET AND BALLISTIC GOGGLES TO BE WORN BY THE BOAT
GUNNER(S) WHEN MANNING THE MOUNTED AUTOMATIC WEAPON.
 D. DEPLOYING BOAT CREW COMMUNICATIONS SYSTEM (BCCS). REQUIRED
THE BOAT GUNNERS AND COXSWAIN TO USE THE BCCS WHEN MANNING
THE MOUNTED AUTOMATIC WEAPON(S).
 E. ESTABLISHED TACTICAL BOAT CREW MEMBER COMPETENCY,
QUALIFICATION TASKS, AND CURRENCY REQUIREMENTS. TACTICAL BOAT
CREW MEMBER COMPETENCY INCLUDES BOAT GUNNER SKILL AND
KNOWLEDGE REQUIREMENTS.
 F. DEVELOPED A READINESS AND STANDARDIZATION PROGRAM, TO INCLUDE
READY FOR OPERATIONS AND READINESS AND STANDARDIZATION TEAMS,
FOR TACTICAL OPERATIONS AT DEPLOYABLE OPERATIONS GROUP (DOG)
DEPLOYABLE SPECIALIZED FORCES (DSF).
 G. DEVELOPED POLICY ON THE EMPLOYMENT OF TACTICAL MANEUVERING,
INCLUDING HIGH-SPEED MANEUVERING. ADDITIONALLY, DEVELOPED AND
INCLUDED A “CONTINUUM OF TACTICS” THAT PROVIDES A RANGE OF
RESPONSES FROM OFFICER PRESENCE THROUGH DEADLY FORCE.
ADDRESSED IMPLICATIONS AND MITIGATION OF RISK AND APPROPRIATE
RESPONSE TO THE THREAT ENVIRONMENT. ADDRESSED APPLICATION AND
LIMITS FOR TRAINING AS WELL AS APPROPRIATE TACTICS FOR NORMAL
OPERATIONS (OPERATIONS IN THE ABSENCE OF ARTICULATED
THREATS).
 H. DEVELOPED DOCTRINE FOR THE CERTIFICATION, INTEGRATION,
ACCEPTANCE, AND EMPLOYMENT OF DEPLOYABLE FORCES BY COMMANDS
EXERCISING TACTICAL CONTROL.
 I. CREATED AND PROMULGATED A STANDARD COMPREHENSIVE DEPLOYABLE
TEAM LEADER (DTL) PQS. CURRENTLY ALL DTLS MUST COMPLETE THIS
PQS AND BE CERTIFIED BY THEIR COMMAND PRIOR TO DEPLOYING IN
THIS CAPACITY. FORMAL BOARDS ARE REQUIRED. TACTICAL ACTION
OFFICERS (TAO) ARE REQUIRED TO COMPLETE THE PRE-DOG
ESTABLISHMENT PATROL COMMANDER SYLLABUS. WATERSIDE SECTION
CHIEFS FOLLOW TAO AND DTL PQS.
 J. DEVELOPED GUIDELINES FOR USE OF HIGHER LEVEL TACTICS FOR BOTH
OPERATIONS AND UNIT-LEVEL TRAINING. GUIDELINES ARE TAUGHT AT
TACTICAL COXSWAIN AND BOAT CREW MEMBER COURSES. NAVIGATION
STANDARDS GUIDELINES ARE AVAILABLE ON CG-731 (BOAT FORCES)
WEB SITE UNTIL THE BOAT OPERATIONS AND TRAINING MANUAL VOL
III, COMDTINST M16114.42 IS PROMULGATED.
 K. REVIEWED PWCS REQUIREMENTS TO IDENTIFY GAPS IN POLICY,
DOCTRINE, CAPABILITIES, TRAINING AND TACTICS, TECHNIQUES, AND
PROCEDURES. PROMULGATED UPDATES VIA MESSAGE, THE REVISED
DEFENDER CLASS BOAT OPERATORS HANDBOOK, AND CHANGE ONE TO
BOAT OPERATIONS AND TRAINING (BOAT) MANUAL VOL I AND WILL BE
INCORPORATED IN BOAT OPERATIONS AND TRAINING MANUAL VOL III,
COMDTINST M16114.42.
 L. REVIEWED ORGANIZATIONAL STRUCTURES FOR UNITS OPERATING BOATS
AND PROVIDED OVERSIGHT OF BOAT OPERATIONS TO ENSURE BOAT
FORCES KNOWLEDGE, SKILLS, AND ABILITIES EXIST IN KEY
LEADERSHIP POSITIONS, I.E. STAN PROGRAM AND OPENED UP COMMAND
CADRE COURSE TO ALL UNITS THAT OPERATE BOATS.
4. RADM MARK J. TEDESCO, DIRECTOR OF HEALTH, SAFETY, AND WORK-LIFE,
SENDS.
5. INTERNET RELEASE IS AUTHORIZED.