The Morning Dew Tragedy- Lessons Learned

[McSkagit Tim Jones]

I've thought of writing a quarterly article on boating safety here on the forum for the club. I requested and received permission to reprint the Morning Dew article from Bob Adriance, Seaworthy Magazine, A Boat/US publication.
The article ran in the April 2000 edition.

It should be noted that the Coast Guard has greatly improved it's radio communications systems, direction finding equipment, policies and training of it's watchstanders since this event. One of the few recreational boating accidents investigated by the National Transportation Safety Board (NTSB)

The Seaworthy article:
On March 17, 1998, a representative of the Coast Guard met with the wife of the owner of Morning Dew, a sailboat that had struck a jetty on the morning of December 29 in Charleston, South Carolina, with the loss of all aboard.

The wife not only lost her husband, but her two young sons and nephew as well. The group commander said he had come to play a tape recording of a distress call so that the family could help him determine whether it was related to the loss of Morning Dew. He warned that listening to the tape might be painful.

When the tape was played, the woman immediately recognized the voice of her younger son, whom she lost in the accident. She was shocked; the accident had occurred almost three months ago and this was the first she had heard of the distress call.

She wasn't the only one who was miffed. Local investigators, who had also been stymied by the scarcity of information on the accident, contacted South Carolina's Senator Hollings. Eventually, the National Transportation Safety Board (NTSB) was asked in to investigate the loss. The result was an extensive, almost two-year investigation that culminated in a 68-page report. It was one the most comprehensive investigations that has ever been conducted into a small boat accident. BoatU.S insured the Morning Dew.

The Loss of the Morning Dew
According to the National Transportation Safety Board report, the 49-year-old owner planned a trip to move his newly purchased 1978 34-foot sailboat, Morning Dew, from its berth at a marina at Little River, near Myrtle Beach, South Carolina, to Jacksonville, Florida. He was accompanied on the trip by his two sons, ages 16 and 13, and his 14-year-old nephew. The owner's brother had been planning to go on the trip and accompanied the group to the boat in Little River, but left at the last minute because their father had become ill.

The two brothers were still together on the morning of December 26 when they bought charts covering the Intracoastal Waterway (ICW) between Little River and Jacksonville. The skipper then penciled in the intended route, which, according to his brother, followed the ICW.
The skipper's brother said they returned to the boat and tried to start the diesel engine but the battery was dead and it took quite awhile to start the engine. The VHF and nav lights were checked and found to be working. The brother recalled that before he left, they had gotten a weather report.

The owner and the three boys got under way at about 1230 on December 27, then stopped for fuel at a nearby marina. They made about 20 miles that day and tied up at a marina in Georgetown, South Carolina. The owner called his sister-in-law that night from a motel, according to the report, and again stated his intention to stay in the ICW all of the way to Jacksonville.

On December 28, a salvage master who had seen Morning Dew earlier tied at the marina saw the boat again at 1430 near buoy 26 heading east in the shipping channel of Winyah Bay. This was past the point where the ICW turns south, and the salvage master said that the boat was heading toward the ocean. He reported seeing the boys on the bow dressed in windbreakers and an adult dressed in foul weather gear at the helm. Thinking that they may have missed the turn to the ICW, the salvage master said he tried to raise Morning Dew to warn that they were headed for the ocean. He said he also heard a sportfishing vessel trying unsuccessfully to raise Morning Dew.

After passing the point where the channel for the ICW turned south, it was necessary for Morning Dew to pass 12 channel markers, all indicated on the chart, before reaching the ocean. The weather at the time was sunny, but the forecast called for winds to increase that night to 15 to 20 knots from the east with rain developing toward morning.

At 0217 on the following morning, December 29, Coast Guard Group Charleston received a VHF radio call on channel 16. The watchstander was at the coffee machine in an adjoining room and thought he heard the words "Coast Guard" repeated twice. The watchstander responded twice, "Vessel calling the Coast Guard, this is Coast Guard Group Charleston, over." There was no answer and the watchstander did not feel that the call was anything other than a routine message, perhaps a radio check. He did not play back the message.

Four minutes later, another call was received that sounded like a brief burst of static. Although unintelligible, it seemed to have been transmitted by the same person. The watchstander again responded twice, but received no response. The watchstander did not log either call.

About 0620, the boatswain on an incoming automobile carrier, Pearl Ace, said he heard cries for help coming from the water near buoy 22 on the starboardónorthóside of the entrance to Charleston Harbor. He immediately alerted the bridge, which then informed the pilot who was in charge of bringing the ship into port. The pilot, the ship's captain, and the ship's chief officer went outside with a small searchlight but saw nothing. At about 0625 they notified the pilot boat Palmetto State, which was in front of the ship.

The pilot boat's dispatcher also notified the Coast Guard at 0628, but the watch duty officer decided not to send a boat, since the pilot boat was already at the jetty.

It was still dark, the wind was blowing 25 knots from the northeast, and it was raining. Palmetto took 10 minutes to reach the area where the voice had been reported. Using floodlights and stopping every 50' to go on deck and listen, the operator said he searched from buoy 22 to buoy 2. The operator contacted Pearl Ace and reported that he had not seen or heard anything.

The pilot requested that Palmetto remain in the area until morning light. Another search was conducted from buoy 2 to buoy 22 and then to buoy 130, which was near the entrance to the ICW. At 0648, the pilot boat dispatcher again notified the Coast Guard, which took no further action. Palmetto had been in the area for about 30 minutes.

Shortly before 1100, a couple walking along the beach on Sullivans Island spotted a body, dressed in boxer shorts and pullover shirt, floating in the surf. They described sea conditions as rough, with extremely strong winds. A short time later, a second body, also lightly dressed, was spotted in the water near Sullivans Island.

At 1115, the Coast Guard operations duty officer received a call from an Isle of Palms police officer to report the discovery of the bodies and to request a Coast Guard boat to search the area. The duty officer then told the group operations officer about the 0628 call from the harbor pilot dispatcher, he said, because he was concerned that the 0628 call and the 1115 call might be connected. It would be another five hours before the watchstander would mention the possibility that the 0217 call might also be related to the accident.

At 1144, the operator of the pilot boat Sis, which was escorting Pearl Ace back out to sea, called the Coast Guard duty officer to report a mast sticking out of the water between buoys 16 and 20 near the north jetty. At 1146, a Coast Guard helicopter took off and a few minutes later, a 41' utility boat was heading to the area. At 1246, the helicopter crew spotted a third body floating in the water. The fourth body, that of the owner, would not be found until January 23, when it was discovered by a passerby near the lighthouse on Sullivans Island.

Some Key Questions
Given his intention to follow the ICW to Jacksonville, is it possible that Morning Dew's skipper missed the turn at the ICW and inadvertently followed the shipping channel to the ocean? Realizing his mistake later, he may then have opted to proceed to Charleston in the open ocean rather than going back eight miles to the ICW. According to investigators, witnesses stated that southbound boaters following the ICW through Winyah Bay sometimes lose track of the ICW and inadvertently follow the main shipping channel toward the ocean.

The Safety Board concluded that a navigational error was unlikely. According to NTSB investigators, Morning Dew's skipper of was an experienced sailor, having sailed extensively in Florida and the Bahamas in the 1970s. He had owned several boats and had lived aboard a 33' sailboat in the late 1970s and early 1980s. He had taken Coast Guard-sponsored safety courses and read and studied nautical reference books.

The skipper knew how to read charts and follow a marked channel. The report concluded that the appearance of a buoy or other marker without the yellow ICW symbols would have indicated that the vessel had left the ICW. Even if the first marker had been missed, continuing in the shipping channel and entering the Atlantic Ocean would have required passing 16 buoys, any one of which, by referring to the chart, would have shown the vessel's actual location.

This article is too long to post in one piece...continued below...

[McSkagit Tim Jones]

Morining Due continued

If he hadn't missed the turn on the ICW, why would an experienced skipper, being fully aware of the dangers involved, make the decision to go to sea when his intention had been to follow the ICW? The Safety Board concluded that he might have been frustrated at his lack of progress. When the skipper called his sister-in-law on the evening of December 27, he remarked that they had only made 20 miles because of a late start (the dead battery). The following day, for unknown reasons, they again started late and did not begin the transit through Winyah Bay until noon or later.

The report outlines the dangers they faced in the ocean: There was only one adult aboard; the weather was marginal; the seaworthiness of the vessel was unknown; much of the trip would be at night; and the boat was not equipped to sail offshore. With regard to the equipment aboard, Morning Dew had only the standard Coast Guard-required equipment plus a compass, a strobe, and a VHF radio. There was no GPS, life raft, survival suits, cell phone, handheld VHF, or EPIRB. (The report did not mention whether binoculars were aboard.) In what seems like an understatement, the Safety Board concluded that "neither Morning Dew, its operator, nor its passengers were adequately prepared or equipped for a trip into the open ocean, and the voyage should not have been attempted."

Why did the Morning Dew hit the jetty? The ICW chart book that was aboard included a chart of the jetty, and the report notes that, by referring to the chart, it would have been possible for the Morning Dew to have sailed around the jetty and into the harbor. The accident occurred at low tide, which meant that the jetty would have been about 7' above the water. (Scrape marks on the rocks indicated that Morning Dew went up and over the jetty sometime later when the tide had risen.)

Seas were about 4', the wind was out of the northeast at 25 knots, which, if they were following a compass course to the entrance, would have tended to push them toward shore. There was no moon and it was either raining or about to start raining when the sailboat struck the jetty. The boat had been under power and damage to the prop indicated that it was still turning when it struck the rocks.

One clue to what went wrong was that, based on the lack of clothes that the teenagers were wearing, it is likely that the skipper was the only one on deck. Assuming that he woke up at 0900 the previous morning, the skipper would have been awake for 17 hours at the time of the accident, which, according to the report, would have meant that he was at the nadir of his biological rhythm. The wind, spray, constant pounding, vibration, and the stress of constantly steering with a quartering sea would all have added to his considerable fatigue. The report also notes that the clothing the skipper brought for the trip did not adequately insulate him against the cold and wet conditions he encountered. The Safety Board concluded that the skipper was "probably severely fatigued and hypothermic to such a degree that his judgment and ability to keep track of his position may have been severely impaired."

The report concluded: "The National Transportation Safety Board determines that the probable cause of the sinking of the recreational sailing vessel Morning Dew was the operator's failure to adequately assess, prepare for, and respond to the known risks of the journey into the open ocean that culminated in the vessel's allision [sic] with the jetty at the entrance to Charleston Harbor. Contributing to the loss of life in this accident was the substandard performance of the U.S. Coast Guard Group Charleston in initiating a search-and-rescue response to the accident."

The Coast Guard's Role
If some good is to come out of this devastating accident, it is that the Coast Guard's search-and-rescue capabilities were examined thoroughly by NTSB investigators, found to be lacking, and may now be significantly upgraded. Recommendations by the NTSB, if followed, would significantly improve the Coast Guard's ability to receive and respond quickly to emergency calls.
One of the key points made in the report is that the Coast Guard search-and-rescue mission is largely a function of the readiness of its operations and communications centers: "These centers are the primary links between mariners in distress and people who have the assets and skills to render assistance." If a message was sent by the crew of the Morning Dew, why didn't Coast Guard Group Charleston respond? According to the Safety Board, there were several reasons, involving both mistakes in judgment by Coast Guard personnel and by the Coast Guard's antiquated communications equipment.

Mistakes in Judgment.
Since the watchstander was at the coffee machine instead of by the radio, he did not hear the mayday clearly. What he understood to be "Coast Guard, Coast Guard" was actually an excited adolescent voice saying, "May . . ., mayday, U.S. Coast Guard come in."

Based on the Safety Board's replaying of the tape recording, if the watchstander had replayed the 0217 call, the report concludes that he would have "recognized immediately" that it was a distress call. According to investigators, the watchstander was not guided by any formal procedures that may have helped him deal with the situation. He had not been trained to use "all available means to aggressively follow up on uncertain callsóespecially those received under unusual circumstances [late at night when weather conditions were deteriorating]óin an attempt to determine their nature."

Given the nature of the work, the Safety Board concluded that staffing policy should require having two persons on watch at all times. The Safety Board also questioned the efficacy of requiring personnel to stand 12-hour watches. The Safety Board notes, "Sleep loss has immense potential to exacerbate the problems of excessive shift length, monotony, and boredom." Would standing eight-hour watches or four-hour watches improve watchstander vigilance and overall performance? The Safety Board recommended that the Coast Guard should study the problem.

Investigators listened to tapes that were recorded around the time of the Morning Dew accident and discovered a large number of personal telephone calls made by watchstanders, which, the investigators said, could conflict with the levels of attentiveness. The investigation also revealed that the Coast Guard has no program to periodically evaluate the proficiency of its subordinate districtsóa practice that is common with watchstanding in the military. Without the possibility of periodic inspections, the Safety Board concluded that the readiness of Coast Guard personnel can be expected to gradually decline. The Safety Board said that the Coast Guard should immediately institute procedures to provide improved management oversight of communications and operations center performance, including instituting a program to periodically review the tapes of recorded radio transmissions and telephone calls.

Equipment.
The Safety Board concluded that the tape recorder may have contributed to the Coast Guard's lack of response. Investigators found that the tape recorder being used by Coast Guard Group Charleston (and other stations) is difficult to operate when searching for a specific message. The report notes that the Canadian Coast Guard uses a model recorder that allows a watchstander to easily press a button to play back the most recent message. "The emphasis," the Safety Board says, "should be on 'easily' because the easier the task, the more likely it will be performed."

Had the 0217 message been replayed by the watchstander, at a minimum, the report notes he could have broadcast an urgent marine information broadcast that would have alerted other mariners of the distress call. It is also likely, the report says, that the watch duty officer would have responded much differently to the 0628 call from Pearl Ace, had he been aware of the 0217 call.

[McSkagit Tim Jones]

Morning Due part 3

What the Coast Guard watchstander wouldn't have been able to do was ascertain where the mayday call was coming from. According to the Safety Board's report, Coast Guard Group Charleston's direction finder (DF) has limited range and is "inaccurate, unreliable, and obsolete." Tests of the equipment found bearing errors of as much as 101°. (Charleston's DF can only give a line-of-sight bearing and cannot give a fix of the vessel's position.) Investigators found, not surprisingly, that watchstander records indicate that the Charleston's DF is usually turned off.

Furthermore, the DF in Charleston is located behind the watchstander's station and a bearing can only be taken while a signal is being broadcast. The Safety Board recommends locating all equipment that must be viewed during the handling of a call at an appropriate distance and angle for concurrent, effective viewing.

The Coast Guard spent more than 400,000 hours on search-and-rescue sorties in 1997, the year that the Morning Dew struck the jetty in Charleston. But even in cases where the Coast Guard was notified, records indicate that 287 lives were lost. The report concluded that if Coast Guard stations had more effective direction-finding capabilities, at least some of the 287 people who died after the Coast Guard had been notified might have been saved.

Prior to the loss of the Morning Dew, a National Distress and Response System Modernization Project was already in the initial planning stages. The complex new $300M system will include the ability to get a position fix on every incoming message. This new system will be a vast improvement over the one currently being used, and has been compared to the communications systems used by fire and police stations in the 1950s.

This new system isn't scheduled to be operational until 2005, however, and in the meantime there are many Coast Guard stations that lack any direction-finding capability. The Coast Guard has been looking for an interim system and seems to have settled on one that is similar to that currently being used in Charleston. Instead of upgrading to a system that doesn't work very well, the Safety Board recommends a commercial "off-the-shelf" DF system that gives a bona-fide position fix and will also record the vessel's position for later reference. The report noted that these DF systems are readily available and are being used successfully in many developed countries, including Canada.

Epilogue
A Coast Guard briefing is April 1999 notes, "Most recreational boaters would be alarmed to learn how fragile this weak link is in our search-and-rescue system. As matters now stand, there is a vast disparity between the communications capability that the public thinks we have and the communications system that we do have."

Until the new 2005 system in implemented, the Coast Guard seems almost desperate to upgrade its current communications system. The question is how. The interim, off-the-shelf direction finder proposed in the NTSB report has considerable deficiencies, according to a spokesman for the Coast Guard's Office of Search and Rescue. While it works well in remote locations, such as Prince Rupert, Canada, the Coast Guard does not feel it would be effective in most U.S. locations. The reason is that it will only give a position fix for the most powerful VHF signal, which in high-traffic areas is not likely to be coming from the boater in distress. The cost to implement the system would be $80,000.

The other interim DF system currently being considered by the Coast Guard, the Doppler DDF600, costs significantly less, about $30,000 plus installation, but will only give a bearing to the distressed vessel, not a position fix. A spokesman for the Coast Guard says the interim Doppler system won't solve all of the direction-finding problems, but it will be more effective than the off-the-shelf system recommended by NTSB. The decision on which interim DF equipment to install is being left up to the various Coast Guard Districts. The newer systems will be installed in front of the watchstanders.

Thanks to another modernization project, the Coast Guard at least has state-of-the-art-recording capability. The new system allows watchstanders to play back messages easily, has less bleed-through between channels, and will continue to record messages while an earlier recording is being played.
As for personnel, a report is due out later this spring that will propose solutions to communications system problems with understaffing and training. Personnel shortages have been plaguing the Coast Guard for many years and an interim policy by RADM James D. Hull still allows 12-hour watches. Although too late for the crew of Morning Dew, two more watchstanders have already been added in Charleston.

Lessons
In its summary, the NTSB recommended that BoatUS the Coast Guard Auxiliary, and other boating organizations "Use in your recreational boat programs, the circumstances and lessons learned from the accident involving the sailing vessel Morning Dew as a means of educating boaters about the relationship of good judgment and decision-making to boating safety."

The following are a few of the more important lessons from the loss of the Morning Dew:

Even boats going a few miles offshore need to carry adequate electronics and safety equipment.
Morning Dew should have carried a GPS (and maybe a handheld backup GPS), an EPIRB, strobe lights for each of the crew, safety harnesses, man overboard equipment, and detailed charts. There should also have been a backup means of communication, either a cell phone or a handheld VHF radio (or both), as well as at least a coastal life raft.

Pay attention to weather forecasts.
The NTSB report noted that even in daylight, the weather was not favorable for taking a boat offshore.

Don't go offshore without experienced crew.
Owner fatigue and hypothermia, according to the report, may have severely impaired the owner's judgment and his ability to keep track of his position. Since the boat lacked an autopilot, there should have been enough experienced crew aboard for at least two, two-person watches. Each of the watches should also have included someone with considerable offshore experience to act as the watch captain.

Carry suitable clothing.
Even in the summer, nighttime temperatures can be chilly offshore. In winter, heavy clothing and foul weather gear are essential. And the further north you venture, the more necessary it is to carry survival suits for the crew.
Know your boat. Not every boat is capable of cruising offshore. If you're not sure how suitable your boat is in the open ocean, don't go offshore.

File a float plan.
Give a copy to your spouse or friend or anyone you check in with periodically who can let the Coast Guard know when you're overdue.

[Mark_Denis]

Wow, thanks for posting this Tim. This is a great reminder to make sure we all have adequate safety gear when out on the water...and boat within our limits.

I've always been very conservative when going out into "bigger" water. My boating experience was mostly on a river growing up so going out into the Puget Sound is a whole different world to me (I usually try to keep close to shore). I can't imagine being out in the open ocean in bad weather!

[McSkagit Tim Jones]

Morning Dew Pictures

Bob Adriance sent me a couple pictures of this story. Chartlets and a picture of the boat. They are at the bottom of page one..

Tim