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"Lessons Learned" is a series of drop-in articles prepared by the NTSB for use 
in publications of other organizations.  An index of articles is available at
http://www.ntsb.gov/events/journalist/lessons/lessons.htm
08/2005
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Lessons Learned from Accident Investigations

Better Safety Precautions Urged for Charter Fishing Vessels in Hazardous Weather


Marine safety advocates expressed frustration, anger, and disbelief when they issued the 
final accident report on the 2003 capsizing of a charter fishing vessel that cost 11 lives.

National Transportation Safety Board (NTSB) is so concerned about the issues raised in 
the accident investigation that they urge all marine charters to examine how they operate in 
hazardous water conditions, to pay attention to safety regulations, and to tighten up on their 
safety precautions.

"A shocking lack of safety awareness and an inexplicable lapse in common sense led to a 
tragedy that should not have happened," said Mark V. Rosenker, acting chairman of the NTSB.  
The simple and common sense task of putting on life jackets, which was ignored by the boat's 
crew, could have saved lives, he said.

The NTSB has issued its final report on the capsizing of the small charter fishing vessel 
Taki-Tooo, which occurred in 2003. The accident occurred shortly after the Taki-Tooo departed 
from Tillamook Bay in Oregon to the Pacific Ocean, claiming the lives of 11 of the 19 persons 
onboard, including the captain.  

The U.S. charter fishing vessel was en route from the marina at Garibaldi, Oregon, to the 
open seas for a day of fishing. A small craft advisory was in effect for the northern Oregon and 
southern Washington coasts, and personnel at the U.S. Coast Guard Station Tillamook Bay had 
activated the rough bar warning signs because of the hazardous conditions.

At the Tillamook Bay inlet, the Taki-Tooo operator waited for about 30 minutes in the 
channel for an opening in the ocean swells so that he could cross the bar. After the Taki-Tooo 
exited the inlet and turned northward around the north jetty, a wave struck and capsized the 
vessel. "Two flawed decisions, one to cross the bar in hazardous conditions and the other not to 
don life jackets led to this accident and the loss of life," Rosenker said.  "It is vital that the 
marine industry learns the lessons from this tragic accident and not repeat them," he added.

The NTSB also urged small passenger vessel owners and members of the National 
Marine Charter Association to develop and implement "go/no go" policies, based on risk-
management principles, regarding transiting bars and inlets. It also urged the Coast Guard and 
members of the National Marine Charter Association to require passengers of such vessels on the 
West Coast to wear lifejackets while transiting bars and inlets where rough bar warnings are in 
effect. The recommendations address operations conducted in Coast Guard-designated surf 
stations and regulated boating areas.  

NTSB investigators made numerous conclusions, including:
-- The absence of a "go/no-go" policy by the charter boat owners operating out of 
Tillamook Bay allowed the masters to exercise poor judgment in deciding to cross 
the bar, given the hazardous sea conditions.
-- If the master of the Taki-Tooo had required passengers and crew to wear life 
jackets, their chances of survival would have been better and the number of 
fatalities in this accident would probably have been lower.
-- The Coast Guard's failure to enforce regulations, which require that life jackets be 
worn during possibly hazardous conditions, contributed to the loss of life in the 
Taki-Tooo accident.
-- The other commercial vessel masters who crossed the Tillamook Bay bar on the 
morning of the accident should have required their passengers to wear life jackets 
during the transit. 

The Safety Board determined that the probable cause of the accident was the decision of 
the master to attempt to cross the bar despite the hazardous sea state that existed at the time. 
Contributing to the severity of the accident was the failure of the master to ensure that he and all 
aboard donned life jackets before crossing the bar. Also contributing to the severity of the 
accident was the failure of the U.S. Coast Guard to enforce its rules requiring vessel masters to 
have passengers wear life jackets before attempting a hazardous bar crossing.

-For a complete copy of the accident report, visit the NTSB's Web site at www.ntsb.gov.