“Multiple Factors” Cause Sinking of Lady Mary, USCG Reports

 

The investigation revealed that the Lady Mary's sinking and the loss of the crew was not due to one single factor, but rather a combination of numerous unsafe preconditions and a few unsafe decisions.

 

As one example, a number of modifications were made to the vessel over the years and their cumulative effect subtly lowered existing safety margins. Also, a lack of training, lack of experience, language barriers, fatigue, vessel loading, drug use, insufficient watertight integrity, compromised vessel subdivision and weather all played a role. The unsafe decisions made on the morning of March 24, 2009, included the decisions to drift, to leave the lazarette hatch open and to leave two freeing ports blocked by solid covers.

 

The investigation also revealed the Lady Mary's sinking was a survivable event. The vessel was outfitted with a full complement of functioning life saving equipment and there was time for the captain or crew to broadcast a coherent Mayday, press one of the Digital Selective Calling alert buttons and/or launch a flare. Due to the lack of sufficient training, the captain and the crew were unprepared to deal with emergency situations and that negatively affected their ability to take actions to provide for their survival.

 

While there were defenses available to prevent unsafe conditions from developing onboard the Lady Mary, they either failed or were missing and thus were not able to alter the course of these catastrophic and tragic events. There were some defenses that could have been used onboard the vessel by the captain and crew, and some that could have been used by the vessel owner to improve the workplace before the vessel got underway. In addition, there were a number of regulatory defenses that also could have been used by outside organizations to help prevent unsafe preconditions from developing.

 

The investigation report in its entirety is available online at the Coast Guard's Homeport page.

 

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