Passenger weight criteria for stability assessment;

Pontoon vessel stability standards; and

Policies and procedures pertaining to weather operations.

The Lady D was erroneously granted sister status by the U.S. Coast Guard to a pontoon vessel with different design characteristics;

The Coast Guard certificated the Lady D to carry too many people as a result of an inappropriate stability test on the vessel to which it was granted sister status; and

The Coast Guard’s regulatory stability test standards on which the Lady D’s passenger allowance was based use an out-of-date average passenger weight.

Passenger weight criteria for stability assessment;

Pontoon vessel stability standards; and

Policies and procedures pertaining to weather operations.

The Lady D was erroneously granted sister status by the U.S. Coast Guard to a pontoon vessel with different design characteristics;

The Coast Guard certificated the Lady D to carry too many people as a result of an inappropriate stability test on the vessel to which it was granted sister status; and

The Coast Guard’s regulatory stability test standards on which the Lady D’s passenger allowance was based use an out-of-date average passenger weight.

Passenger weight criteria for stability assessment;

Pontoon vessel stability standards; and

Policies and procedures pertaining to weather operations.

The Lady D was erroneously granted sister status by the U.S. Coast Guard to a pontoon vessel with different design characteristics;

The Coast Guard certificated the Lady D to carry too many people as a result of an inappropriate stability test on the vessel to which it was granted sister status; and

The Coast Guard’s regulatory stability test standards on which the Lady D’s passenger allowance was based use an inaccurate average passenger weight.

Sleep deprivation, alcohol, drugs, and physical impairments were not factors in this accident.

The mechanical condition of the Lady D’s propulsion and steering systems was not a factor in this accident.

The propulsive power of the Lady D was not a factor in this accident.

Examination of the Lady D’s hull showed no evidence of preaccident damage.

The load for which the pontoon vessel Lady D was certificated was based on a monohull simplified stability proof test on the Fells Point Princess, which was not appropriate for pontoon vessels.

As a result of inappropriate sister vessel status to the Fells Point Princess being granted to the Raven, the Lady D, and the Misty Harbor II, all four pontoon boats had serious deficiencies in stability as a result of the inappropriate stability test used to determine the number of persons allowed on all the vessels. Although it was the Lady D that was involved in this accident, the potential risk of a capsize event was substantially the same for all four vessels during their years of operation.

The combination of the use of an out-of-date average weight standard for occupants of small passenger vessels and the excessive number of persons permitted in the Lady D’s original certification resulted in the pontoon boat carrying a load that reduced its reserve buoyancy and compromised its stability characteristics, which made it more susceptible to capsizing on the day of the accident.

The Lady D capsized as a result of the combined effects of the excessive load carried and the wind and wave conditions experienced at the time of the accident.

Masters need a simple and ready means such as a mark on the hull to determine whether their vessels are overloaded and potentially unsafe.

Existing Coast Guard intact stability standards for pontoon passenger vessels (the pontoon simplified stability test in Subchapter T, “Small Passenger Vessels,” and/or the alternative criteria in Subchapter S, “Subdivision and Stability”) do not adequately account for the dynamic loading from wind and waves on a pontoon vessel operating on an unrestricted protected route.

A Coast Guard endorsement on a vessel’s certificate of inspection restricting a pontoon passenger vessel to limiting weather conditions would provide definitive operational guidance to a vessel’s operator.

Meteorological data displayed on the workstation monitors at the National Weather Service Baltimore-Washington forecast office showed that the strong gusty winds and thunderstorm conditions associated with the Lady D accident could have been identified by forecasters as early as 1501, providing opportunity for them to verify conditions and issue a special marine warning more than 20 minutes before the Lady D left the dock near Fort McHenry.

The agency-wide actions taken by the National Weather Service to correct its system deficiencies and performance errors are adequate to address the problems that occurred at the Baltimore-Washington weather forecast office.

The weather information available to Seaport Taxi at the time of the accident did not accurately reflect the impending storm conditions, which compromised efforts to adhere to safe operating procedures.

In the panic situation that ensued after the Lady D capsized, the vessel’s normal means of egress from the deckhouse, including the differently designed doors and the slider windows, posed evacuation problems for the vessel’s occupants.

The currently required safety briefing on emergency procedures that includes a discussion of lifejacket stowage/donning and egress capabilities enhances small passenger vessel safety.

Donning lifejackets in the Lady D’s enclosed deckhouse before the capsizing could have resulted in additional fatalities.

The rapid response effort by personnel from Naval Reserve Center Baltimore to the Lady D’s capsizing probably resulted in fewer lives being lost. Moreover, the actions of all other City and first responders, including the fire department, the police, the emergency medical technicians, and the U.S. Coast Guard, were timely and effective.

Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated.

Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method.

Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves.

Until such time as you revise the passenger weight standard as requested in Safety Recommendation [1] and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation [3], develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations.

Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection.

Passenger weight criteria for stability assessment;

Pontoon vessel stability standards; and

Policies and procedures pertaining to weather operations.

The Lady D was erroneously granted sister status by the U.S. Coast Guard to a pontoon vessel with different design characteristics;

The Coast Guard certificated the Lady D to carry too many people as a result of an inappropriate stability test on the vessel to which it was granted sister status; and

The Coast Guard’s regulatory stability test standards on which the Lady D’s passenger allowance was based use an inaccurate average passenger weight.

Sleep deprivation, alcohol, drugs, and physical impairments were not factors in this accident.

The mechanical condition of the Lady D’s propulsion and steering systems was not a factor in this accident.

The propulsive power of the Lady D was not a factor in this accident.

Examination of the Lady D’s hull showed no evidence of preaccident damage.

The load for which the pontoon vessel Lady D was certificated was based on a monohull simplified stability proof test on the Fells Point Princess, which was not appropriate for pontoon vessels.

As a result of inappropriate sister vessel status to the Fells Point Princess being granted to the Raven, the Lady D, and the Misty Harbor II, all four pontoon boats had serious deficiencies in stability as a result of the inappropriate stability test used to determine the number of persons allowed on all the vessels. Although it was the Lady D that was involved in this accident, the potential risk of a capsize event was substantially the same for all four vessels during their years of operation.

The combination of the use of an out-of-date average weight standard for occupants of small passenger vessels and the excessive number of persons permitted in the Lady D’s original certification resulted in the pontoon boat carrying a load that reduced its reserve buoyancy and compromised its stability characteristics, which made it more susceptible to capsizing on the day of the accident.

The Lady D capsized as a result of the combined effects of the excessive load carried and the wind and wave conditions experienced at the time of the accident.

Masters need a simple and ready means such as a mark on the hull to determine whether their vessels are overloaded and potentially unsafe.

Existing Coast Guard intact stability standards for pontoon passenger vessels (the pontoon simplified stability test in Subchapter T, “Small Passenger Vessels,” and/or the alternative criteria in Subchapter S, “Subdivision and Stability”) do not adequately account for the dynamic loading from wind and waves on a pontoon vessel operating on an unrestricted protected route.

A Coast Guard endorsement on a vessel’s certificate of inspection restricting a pontoon passenger vessel to limiting weather conditions would provide definitive operational guidance to a vessel’s operator.

Meteorological data displayed on the workstation monitors at the National Weather Service Baltimore-Washington forecast office showed that the strong gusty winds and thunderstorm conditions associated with the Lady D accident could have been identified by forecasters as early as 1501, providing opportunity for them to verify conditions and issue a special marine warning more than 20 minutes before the Lady D left the dock near Fort McHenry.

The agency-wide actions taken by the National Weather Service to correct its system deficiencies and performance errors are adequate to address the problems that occurred at the Baltimore-Washington weather forecast office.

The weather information available to Seaport Taxi at the time of the accident did not accurately reflect the impending storm conditions, which compromised efforts to adhere to safe operating procedures.

In the panic situation that ensued after the Lady D capsized, the vessel’s normal means of egress from the deckhouse, including the differently designed doors and the slider windows, posed evacuation problems for the vessel’s occupants.

The currently required safety briefing on emergency procedures that includes a discussion of lifejacket stowage/donning and egress capabilities enhances small passenger vessel safety.

Donning lifejackets in the Lady D’s enclosed deckhouse before the capsizing could have resulted in additional fatalities.

The rapid response effort by personnel from Naval Reserve Center Baltimore to the Lady D’s capsizing probably resulted in fewer lives being lost. Moreover, the actions of all other City and first responders, including the fire department, the police, the emergency medical technicians, and the U.S. Coast Guard, were timely and effective.

Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated.

Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method.

Revise the stability criteria for small passenger pontoon vessels for all passenger loading conditions to minimize the potential for capsizing in wind and waves.

Until such time as you revise the passenger weight standard as requested in Safety Recommendation [1] and the stability criteria used to evaluate small passenger pontoon vessel safety as requested in Safety Recommendation [3], develop interim pontoon passenger vessel stability guidance based on static and dynamic intact stability considerations.

Establish limiting environmental conditions such as weather in which pontoon vessels may safely operate, and list those limiting conditions on the vessel’s certificate of inspection.