Commander Seventeenth Coast Guard District

u.s. Department o~ Homeland Security Commander Seventeenth Coast Guard District United States Coast Guard PO Box 25517 Juneau, Alaska 99802-5517 Staff Symbol: (d) Phone: (907) 463-2025 Fax (907) 463-2037 Email: Christopher.C.Colvin@uscg.mil 5800 From: CH LV CGD SEVENTEEN (d) To: D. P. VERFAILLIE, CDR CG MSU VALDEZ CG SECTOR ANCHORAGE (s) Thru: DM Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE TUG PATHFINDER ON 23 DEC 09 Ref: (a) Administrative Investigations Manual, COMDTINST M5830.lA (b) Memorandum, Administrative Investigation into Coast Guard actions and response activities concerning the grounding of the tug PATHFINDER on 23 DEC 09 dated 22 JAN 10 (c) USCG Regulations, COMDTINST M5000.3 (series) (d) Vessel Traffic Services National Standard Operating Procedures Manual (VTS NSOP), COMDTINST M16630.3 (e) VTS Prince William Sound Standard Operating Procedures, MSUVALDEZINST 16630A (f) Prince William Sound - Vessel Escort and Response Plan (VERP) - Published January 2007 (g) U.S. Coast Guard Vessel Traffic Service Prince William Sound - User's Manual (Eighth Edition - September 2008) 1. Having considered reference (a) and other applicable references, appropriate actions are hereby ordered, and this administrative investigation is closed. A summary of the pertinent facts and my opinions based on those facts are herein provided. All times provided are in Alaska Standard Time. Progress with respect to the ordered actions shall be reported on a monthly basis to CGD SEVENTEEN (dcs) until all ordered actions have been implemented. 2. This investigation was directed for the purpose of ascertaining the facts and circumstances associated with the mishap and to provide recommendations for the implementation of improved procedures which, ultimately, reduce the risk of similar incidents occurring in the future. The actions of the master and crew of the Tug PATHFINDER ("PATHFINDER") have been investigated under a separate Coast Guard Marine Casualty Investigation. This informal administrative investigation was not intended to determine the cause of the PATHFINDER grounding. This investigation must be viewed in conjunction with the Marine Casualty Investigation to fully understand the cause of this casualty. 3. Factual Summary. a. On 23 December 2009, the Ship Escort/Response Vessel System (SERVS) directed the PATHFINDER to serve as an Ice Scout Vessel (ISV) to conduct ice scouting operations and

Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 5800 provide an ice report in accordance with the Vessel Escort and Response Plan (VERP). b. Ice reports are required pursuant to the VERP to provide periodic situational updates regarding the presence of icebergs which can create navigational hazards in the vicinity of Bligh Reef. Icebergs are produced throughout the year due to calving of the nearby Columbia Glacier, some of which occasionally drift into the nearby Traffic Separation Scheme (TSS). c. The VERP is designed as a port specific guide to further aid and enhance the safety of tanker navigation and the protection of the marine environment within the waters of the Prince William Sound. The Prince William Sound Regional Citizens Advisory Council (PWSRCAC), the SERVS, and the Coast Guard Captain of the Port Valdez are all signatories to the VERP. d. The VERP requires an "ice scout" to visually check for ice in the vicinity of Bligh Reef no longer than six hours prior to a tanker transiting Prince William Sound. An ice report was required due to the scheduled departure of the tanker KODIAK which was scheduled to depart outbound from the Port of Valdez later that evening. Although the PATHFINDER was designated as an ISV for 23 December 2009, an ice scout is not specifically required to be a tug. Virtually any vessel or even an aircraft can serve as an ice scout. The primary objective is to visually identify any floating ice that may endanger a tanker transit through the TSS. e. An ISV is defined as "any suitably sized vessel equipped with an operational radar and searchlight." Due to size and power limitations, the PATHFINDER does not provide tanker escort services and was regularly chosen by SERVS to perfolm ice scouting duties. f. At approximately 1402, the PATHFINDER checked into the Prince William Sound Vessel Traffic Service Area (PWS VTSA) and indicated they were enroute to Bligh Reef to provide the ice report. As a Vessel Movement Reporting System (VMRS) user, the PATHFINDER was required to check-in with the Vessel Traffic Service (VTS) to provide an initial sail plan, report any deviations from the initial sail plan, or check-out of the VMRS when transit or operations were complete. g. The PATHFINDER was not required to check-in at any of the designated VTS RepOlting Points in the PWS VTSA because the Ports and Waterways Safety System (PAWSS) at Vessel Traffic Center (VTC) Prince William Sound received Automatic Identification System (AIS) information from the PATHFINDER. VTS Prince William Sound was also able to track vessels operating in the PWS VTSA, including the PATHFINDER, based on information provided from the USCG radar site on Reef Island. h. The PATHFINDER did not encounter any opposing or overtaking traffic during its outbound transit. 2

Subj: FINAL ACTION ON ADMINISTRATIVE 5800 INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 i. At approximately 1649, the PATHFINDER provided an ice report reporting no ice in the area while abeam Bligh Reef, in the outbound traffic lane. j. At 1650, the PATHFINDER reported on-scene weather in the vicinity of Bligh Reef as follows: four-foot swells from the south, southeast winds at 15 knots and visibility of approximately four nautical miles. At this time, the PATHFINDER also stated that they would remain in the vicinity of Bligh Reef until 1800 in order to provide an 1800 ice report. This was in anticipation of an outbound transit by the Tanker KODIAK from the Port of Valdez later that evening. k. Earlier in the day, at 0520, Cape Hinchinbrook Entrance was closed to all outbound laden tanker vessels due to weather. The 1800 ice report would extend the window of opportunity for the Tanker KODIAK to depart Valdez to midnight if the Cape Hinchenbrook entrance was opened later in the day. l. At approximately 1654, the PATHFINDER began to cross the TSS toward the inbound lane. m. At 1657 relieved of the VTC Watch Supervisor (VTCWS) duties. In addition to normal watchstanding responsibilities, the VTCWS in Valdez is responsible for performing a variety of routine maintenance and unit security duties while on watch. These duties include security rounds, colors, unlocking access doors, and removing snow from the front-door sidewalk in extreme snow-fall situations. VTC watchstanders are permitted regular breaks (at least 15 minutes every 3 hours) n. The VTS Prince William Sound Internal Standard Operating Procedures (ISOP) provides for minimum manning requirements that ensure 24-hour coverage of the VTS. Section 4.B.I.a provides that "[alt least one of the two personnel assigned to the watch must be in the VTC at all times" and that "during inbound and outbound tanker transits of the Valdez Narrows, when hazardous circumstances exist or are anticipated anywhere within the PWS VTSA both rwatchstandersi shall be present to monitor the transit." Both the VTS National Standard Operating Procedures (NSOP) and ISOP also provide for mandatory minimum rest periods of at least 15 minutes for every 3-hour period for all watchstanders. o. At approximately 1724, the PATHFINDER crossed and departed the TSS and continued ice scout duties in vicinity of Bligh Reef. ISV's typically travel at various courses and speeds and close to reefs and shoal water when transiting outside the TSS. Since ISV's routinely operate in close proximity to Bligh Reef, neither watchstander detected any anomalous activity associated with the PATHFINDER's operations. p. At 1725, relieved LT ofthe VTC Specialist (VTCS) duties. LT duties include her primary responsibility as VTS Chief, and she remained on scene at the VTC following her relief. 3

Subj: FINAL ACTION ON ADMINISTRATIVE 5800 INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 q. At approximately 1800, the PATHFINDER provided an ice report reporting "no visible ice" to the VTS. r. At approximately 1802, the PATHFINDER, while on a south-southeast heading at an approximate speed of 3.5 knots, reported to the VTS that they had been released of ice scouting duties by SERVS and were headed back to Valdez.. the duty VTCS, acknowledged receipt of the PATHFINDER's radio communication. s. At approximately 1803, the PATHFINDER turned on a northerly heading and increased speed to approximately 11-13 knots. At this time, the PATHFINDER was approximately 1 Y2 miles due south of Bligh Reef. t. Since the PATHFINDER's activity was consistent with both watchstanders experience with respect to ISV operations, neither watchstander magnified the location of the PATHFINDER on their radar screen. Both watchstanders maintained the radar scale at a smaller scale setting in order to provide maximum visual coverage of the PWS VTSA and the entire Vessel Traffic Lanes. At this scale setting, the PATHFINDER's location could not be differentiated from Bligh Reef. u. At 1814, the PATHFINDER reported to VTS via channel 13 that the vessel was aground on Bligh Reef. The location of the PATHFINDER was within the PWS VTSA but was operating well outside of the TSS. v. Both VTS watchstanders stated that at the time of the grounding, they were both actively watching their consoles and focused on monitoring the entire TSS. Immediately following the PATHFINDER's report of grounding, the VTS watchstanders replied via radio to the PATHFINDER and followed standard procedures as they had been trained. They used the Quick Response Cards (QRC) for both search and rescue (SAR) and marine pollution and conducted notifications up the chain of command. w. At the time of the grounding, the weather and tidal information was as follows: I) Tides: were estimated to be +8.74 foot tide ebbing to a low tide of +2.48 foot at approximately 2330. 2) Currents in the vicinity of Bligh Reef were estimated to be weak and variable. 3) Weather: The NOAA West Orca Bay weather buoy, located 15 NM south of Bligh Reef, recorded 7-8 foot seas with east-southeast winds at 23 knots. x. At 1826, VTCWS delivered notice of the grounding to, Executive Officer (XO), Marine Safety Unit (MSU) Valdez, who at the time was also serving as the Acting Commanding Officer (CO) of MSU Valdez since CDR Darryl Verfaillie, CO, was on leave. 4

Subj: FINAL ACTION ON ADMINISTRATIVE 5800 INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 y. At 1827, notified CDR Verfaillie of the situation. CDR Verfaillie immediately checked off of leave and resumed command. At approximately 1900, CDR Verfaillie arrived at VTS Prince William Sound. z. Shortly after the report of the grounding, the CGC LONG ISLAND was dispatched from Valdez to provide on-scene information regarding the PATHFINDER's status. aa. The USCG Sector Anchorage Command Center (CC) was monitoring marine radio frequencies and began to communicate with the PATHFINDER to assess the need for potential SAR assistance. bb. At 1845, the PATHFINDER notified the CC that the tug was no longer aground and was heading to the northeast where it anchored just northeast of Bligh Reef. cc. CDR Verfaillie suspected the damage to the PATHFINDER may not be in excess of $100,000 and was uncertain on the amount of fuel discharged; consequently, post-accident drug testing for the VTS watchstanders was considered but not conducted shoitly after the grounding. In accordance with the NSOP, Commandant (CG-1312) was notified on 28 December 2009 that a required post-accident test for illegal drug use was not conducted within four hours of the accident. Drug testing of the watchstanders was conducted at 1000 on 28 December 2009 following direction by District Seventeen. Drug test results were negative for all personnel tested. dd. The Processed Ice Radar Picture (PIRP), designed to feed into the VTS system and provide watchstanders with current information on the amount of ice in the TSS, was installed in the VTS in February 2009. However, on 23 December 2009, the PIRP was not available to the VTS because the ice processor had not been upgraded to be compatible with the Terma radar upgrade completed in 2 October 2009. VTS watchstanders considered the PIRP to be a good situational awareness tool for the VTC; however, use of the PIRP did not circumvent the VERP requirement for on-scene ice reports delivered by vessel or aircraft. ee. Although physically located in the VTC, the PIRP is neither owned nor maintained by the Coast Guard. Under standard Coast Guard policy, Coast Guard technicians are not authorized to repair or upgrade non-standard, non-coast Guard property. However, anticipating the potential need, the Coast Guard specifically left a port open on the Terma radar for a technician to access and upgrade the system and notified the PWSRCAC and SERVS in July 2009 that the system was inoperable absent an upgrade. ff. The VTS program was established by the Ports and Waterways Safety Act, 33 U.S.c. 1221 et seq, to employ navigation safety systems and practices to reduce risk and to facilitate maritime commerce in U.S. ports and waterways. The primary function of a VTS is to facilitate good order and predictability on a waterway by providing a variety of services to mariners operating in and around the ports where VTS systems have been implemented. 5

Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 5800 These services include: providing infonnation to mariners such as positions, intentions, and destinations of other vessels operating within a VTSA; traffic organization information which includes providing advance planning of movements, mandatory position reporting, or speed restrictions through certain areas; and, upon request, providing navigation assistance to vessels which includes positions relative to waypoints, ATON, and navigational infonnation such as course or speed made good. gg. VTS watchstanders are required to provide traffic advisories to vessels equipped with operational Automatic Identification Systems (AIS), including the PATHFINDER, that elect to make automated reports. A vessel traffic advisory includes infonnation regarding "all traffic a vessel may encounter both visually and by radar while transiting the VTSA." VTS watchstanders are instructed to "anticipate changing conditions to include weather, vessel speeds, locations, operations, and the embarking/disembarking of pilots at the pilot station. Traffic advisories shall be passed to enhance safety and vessel navigation. They shall be passed when applicable and between reporting points, if needed." On 23 December 2009, no traffic advisory was provided to the PATHFINDER because there was no other traffic operating in the PWS VTSA throughout the PATHFINDER's transit. hh. Unless requesting navigational assistance from the VTS or operating in the shipping lanes and endangering TSS traffic, tug boats, fishing boats, charter boats and other smaller craft do not normally receive traffic advisories from the VTS and are responsible for their own safe navigation throughout Prince William Sound. The PATHFINDER did not request navigational assistance at any time during their operations leading up to the grounding. ii. All VTS Prince William Sound da and night watchstanders on 23 December were fully qualified. The personnel on watch. and accounted for a total of 21 years total combined years of VTS experience and both had previously attended the National VTS Operator Course at the Maritime Institute of Technology and Graduate Studies (MITAGS). jj. Previous meetings were held prior to the 2009 Ice Season with port partners (MSU Valdez, SERVS and the PWSRCAC) to discuss ice routing procedures. Based on these meetings and stakeholder input, the VTS made minor revisions to the Ice Routing Section of the ISOP manual. At that time, neither the VERP nor the ISOP specifically identified the operational duties and responsibilities, including area of operation, for an ISV. kk. All Aids to Navigation (ATON) throughout the PWS VTSA were fully operational and watching properly at the time of the grounding. 4. Opinions. a. As a learning organization, the Coast Guard always seeks ways to improve performance. This investigation was intended to assess whether improvements could be made to the vessel traffic service provided to Prince William Sound. This investigation was not initiated under 6

Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 5800 any presumption that any action or inaction by the VTS watchstanders contributed in any way to the grounding of the PATHFINDER. b. In reviewing the watch routine and practices of the personnel on watch and comparing this to the ISOP, the NSOP, and the Code of Federal Regulations, the actions of the VTS watchstanders were fully in compliance with those policies, rules and regulations. I have determined that the actions of the VTS watchstanders did not contribute, either directly or indirectly, to the PATHFINDER grounding on Bligh Reef. With respect to other potential causal factors, specifically the actions of the PATHFINDER's master and crew which may have contributed to the grounding, the Coast Guard conducted a separate Marine Casualty Investigation which specifically addressed these separate factors. c. Pursuant to 33 CFR 161.11 (VTS Measures), "conditions of vessel congestion, restricted visibility, adverse weather, or other hazardous circumstances, a VTS may control, supervise, or otherwise manage traffic, by specifying times of entry, movement, or depat1ure to, from, or within a VTSA." The most recent weather report provided by the PATHFINDER (85 minutes prior to grounding) indicated weather conditions of four-foot swells, a southeast "breeze" of 15 knots, and visibility of about four nautical miles. Recognizing that PATHFINDER's operations were observed to be consistent with typical ISV operations and the absence of any additional reports indicating a change of weather conditions, VTS watchstanders did not suspect that the PATHFINDER was in danger of creating a hazardous situation, posing a danger to other vessels, or engaging in any activity which would require the watchstanders to initiate any of the affirmative control measures provided under 33 CFR 161.11. Given the non-standard nature of the operations of ISV's, it is not reasonable to expect that VTS watchstanders would or should have performed in a maimer any different than what occurred leading up to the PATHFINDER grounding. The unique facts surrounding this incident do not indicate a need to modify VTS Prince William Sound procedures for monitoring the much higher risk tanker traffic transits into and out of the Port of Valdez operating inside the TSS. d. Further, 33 CFR 161.10 (Services) provides that "a VTS may issue advisories or respond to vessel requests for information, on... hazardous conditions or circumstances" within the VTSA. The above referenced federal regulations are consistent with the Coast Guard position that, absent a specific request from the vessel, these measures and services are discretionary in function and are issued based on the judgment of the VTS watchstander. In reviewing the radio transmissions from 23 December, such a request was never made by the PATHFINDER. Based on the experience of the watchstanders in observing vessels operating in the vicinity of Bligh Reef, there was no reason to transmit an unsolicited advisory. e. Since both watchstanders were at their assigned stations at the time of the grounding, the requirement for a VTCWS to perform minor housekeeping or security tasks while on watch was not a contributing factor to the PATHFINDER grounding. The requirement for the 7

Subj: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 5800 VTCWS to perform these infrequent tasks is not considered an impediment to the watchstanders ability to monitor the safe transit of vessels throughout the PWS VTSA. f. The inoperative PIRP was not a factor to the grounding of the PATHFINDER since the visual ice report was required in accordance with the VERP. When it was operational, the PIRP feed into the VTS was considered beneficial to help determine the amount of ice in the TSS, but was never used as a substitute to the visual ice report to initiate closure of the traffic lanes. The Coast Guard made proper notifications and outreach with respect to notifying PWSRCAC and SERVS regarding the Terma radar upgrade of 2009 on Reef Island and the impact it would have on the PIRP operability. g. VTS Prince William Sound is a critical component for ensuring the safe movement of vessel traffic in the TSS and through the PWS VTSA. As indicated above, current authorities satisfactorily ensure the safe movement of crude oil tanker traffic inside the TSS and through Prince William Sound. Although PATHFINDER ultimately grounded on a known navigational hazard, it appeared to VTC watchstanders to be operating in conformity with typical ISV operations. This incident does not serve as an indication that the VTS was not working properly. In this instance the entire VTS system, both human and equipment, operated in conformity with applicable requirements and regulations and was not a contributing factor to this mishap. h. The purpose of the VTS is to help mariners safely navigate through a VTSA where there is typically a high volume of vessel traffic. It is not intended, nor should it be expected that the presence of a VTS in a port should relieve professional mariners from the responsibility to adhere to prudent and vigilant navigation practices. In the maritime industry, it has always been customary to bestow full responsibility for the safe navigation and operation of a vessel to the captain. This basic principle is also supported under federal law, which provides under 33 C.F.R 161.1 that "the master is responsible for the safe navigation of the vessel." The captain of a vessel is ultimately responsible for the safe navigation of their vessel. VTS Prince William Sound has adequate authorities to ensure the safe, non-obstructed transit of crude oil tankers inside the traffic separation scheme and through Prince William Sound. i. The PATHFINDER ran aground while conducting normal duties operating outside the TSS. While the PATHFINDER was associated with SERVS, this situation could have just as easily involved a fishing boat, chm1er boat, recreational vessel or another vessel not associated with SERVS. 5. Additional Comments a. Although not specifically addressed in the investigation, there was speculation among some Prince William Sound stakeholders that the Coast Guard either had or should be given authority to actively direct all vessels all the time inside the PWS VTSA (the expansive area of Prince Williams Sound as differentiated from the more narrowly defined TSS) in order to prevent all marine casualties. The proposition was offered that the Coast Guard should adopt 8

Subj: FINAL ACTION ON ADMINISTRATIVE 5800 INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 a vessel traffic control scheme similar in operation to the air traffic control scheme administered by the Federal Aviation Administration (FAA). I do not agree with this suggested modification of the VTS function for several reasons, including the following: 1) As discussed above, the authorities provided to the Coast Guard for the operation of VTS do not mirror authorities those authorities employed by the FAA in regulating movement in restricted airspace; the former relying on the captain of a vessel to safely navigate their vessel as compared to the specific courses, speeds, and altitudes provided to aircraft by the latter. Should the Coast Guard be given additional authority and the requirement to actively track and direct all vessels and ensure they navigate safely inside a VTSA, the Coast Guard would need significant additional resources. 2) There are significant differences between air traffic and vessel traffic control systems. Unlike controlled airspace for aircraft, vessel traffic systems rarely, if ever, provide actual courses and speeds to steer. They provide navigational assistance only when requested. Due to the high degree of responsibility given to masters of vessels; vessel traffic systems, with limited exceptions, are generally advisory in nature. Unlike aircraft, vessels can be stopped or even anchored. b. Since full radar coverage of Prince William Sound was completed post-exxon VALDEZ, VTS Prince William Sound has helped facilitate the safe movement of 9.4 billion barrels of oil. 6. Actions. The following actions are ordered for CG MSU Valdez: a. Conduct an Internal Review Board (IRB) at VTS Prince William Sound in compliance with the NSOP. b. Review VTS Watchstanders assigned duties to ensure they do not have the potential to interfere with watchstander duties or could be better accomplished by another crewmember of the unit. c. Work with local stakeholders in developing an SOP for the PIRP, if it becomes operational. d. Review the duties of an ISV with Prince William Sound stakeholders to determine whether ISV duties should be more specified or whether it is better to leave the duties of an ISV as flexible as possible similar to current operations. e. Review the VERP with Prince Williams Sound stakeholders to determine whether the VERP needs to be amended. 9

Subj: FINAL ACTION ON ADMINISTRATIVE 5800 INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE PATHFINDER ON 23 DEC 09 f. Conduct training and take action to ensure drug testing of watchstanders is properly completed in a timely manner in accordance with U.S. Coast Guard policy as appropriate for any future marine casualty. # 10

United States Coast Guard Report of Investigation into the Circumstances Surrounding the Incident Involving M/V PATHFINDER grounding On 12/23/2009 MISLE Activity Number: 3655472 Originating Unit: Marine Safety Unit Valdez MISLE Activity Owner: Commandant (CG-5453) MISLE Activity Controller: Commandant (CG-5453) MISLE Case Number: 485689

I. INCIDENT BRIEF On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef. The vessel re-floated itself without assistance and transited under its own power to Busby Island where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact amount discharged could not be determined. A Marine Casualty Investigator from MSU Valdez was deployed to the scene. The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully towed back to Valdez where the removal of the remaining fuel commenced. Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA where it will undergo permanent repairs. The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost during the incident was 6,410 gallons of diesel fuel. 2

II. EXECUTIVE SUMMARY Incident Summary On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef. The vessel re-floated itself without assistance and transited under its own power to Busby Island where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact amount discharged could not be determined. A Marine Casualty Investigator from MSU Valdez was deployed to the scene. The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully towed back to Valdez where the removal of the remaining fuel commenced. Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA where it will undergo permanent repairs. The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost during the incident was 6,410 gallons of diesel fuel. Incident Involved: Marine Casualty, Reportable Discharge of Oil USCG Credentialed Mariner, Misconduct USCG Credentialed Mariner, Negligence Civil Offense(s) This incident resulted in a discharge or substantial threat of discharge of oil. This report does not limit the discretion of the Director, NPFC, to determine facts, rights and liabilities with respect to any claims, submitted to or by the NPFC, for removal costs and damages under the Oil Pollution Act of 1990. (b)(6) & (b)(7)(c) Level of Investigation: IMO Classification: Routine USCG Classification: Major Marine Casualty Was this a Serious Marine Incident? Yes Was a Marine Board Convened by Commandant? Personnel Casualty Summary Total Missing = 0 Total Dead = 0 Total Injured = 0 Total at Risk, t Injured = 0 Total People at Risk = 6 Other Personnel (t at Risk) = 0 3

Vessel(s) Status Summary Actual Total Loss(es) = 0 Total Constructive Loss, Salvaged = 0 Total Constructive Loss, Unsalvaged = 0 Damaged = 1 Undamaged = 0 Property Damage Summary/Total Damage Vessel(s) = $500000* Cargo = $ Facility(s) = $ Other = $ * Includes estimates Waterway Mobility Summary Vessel Delays (including speed restrictions): ne 4

Actions on Recommendations III. ACTIONS IN RESPONSE TO THIS REPORT Safety Recommendation #7135: Crowley Marine Services Policy Review During the course of the investigation into the grounding of the PATHFINDER, numerous company policies and procedures pertaining to the vessel's mission, crew performance and training were reviewed. Crowley Marine Services published numerous policies regarding all aspects of marine operations. However, events leading up to the grounding, including subsequent crew interviews, revealed that the PATHFINDER's bridge team had largely chosen to disregard policy and procedure regarding proper watch reliefs, charting, and the maintenance of vigilance on the bridge. It is recommended that Crowley Marine Services develop a system that ensures company policies and procedures are being followed in the field. This should include, but is not limited to, a thorough review of vessel logs that are turned in to the company to certify that they are being completed in accordance with company policy, focusing on watch reliefs and fix intervals. It is further recommended that the company deploy a team of personnel to conduct an operational review of vessel missions at least bi-annually. This would enable the company to evaluate the effectiveness of its policies and procedures. Adopting these recommendations would provide Crowley Marine Services a system that evaluates the level of adherence to company policy, potentially increasing employee support. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:16:11 PM Priority: rmal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:09 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Adherance to company policy and accountability for such actions may have prevented the incident. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:00 >STATUS: Forward--->Forward 5

>NEW OWNER: COMDT 545 Concur. Crowley management is responsible for the corporate culture where complacency is discouraged and robust bridge resource practices are encouraged. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:15 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:15: The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. ----------------- > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:16: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction Required Actions: Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7138: Chemical Testing Review 6

Following the grounding of the PATHFINDER, chemical testing was completed onboard the vessel by the Master and Chief Mate. Crowley Marine Services maintains an adequate program and ensures their personnel are trained by a third party in specimen collection procedures following a Serious Marine Incident. However, several mistakes were made on the chain of custody form as well as during the collection process. Fortunately, the mistakes were not so egregious as to prevent them from being useable. However, it is imperative that post-casualty drug testing be completed in accordance with applicable regulations. It is recommended that Crowley Marine Services review its policies regarding chemical testing following a Serious Marine Incident, specifically, who is authorized to test, documentation, and chain of custody. Crowley Marine Services should make the necessary changes to prevent future oversight of the requirements. It is also recommended that Crowley Marine Services review its determination policy on when it is appropriate to send a third party collector to the site of an incident. A letter from the District Seventeen Drug and Alcohol Program Inspector has been submitted to Crowley Marine Services addressing this recommendation. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:16:51 PM Priority: rmal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:14 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Following proper procedures may have alleviated any fatal flaws. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:03 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, District Seventeen DAPI letter to Crowley Marine Services dtd 26Jan10. ----------------- 7

Report of Investigation >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:16 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:16: We note this recommendation was forwarded to Crowley Marine Services on January 26, 2010 by U.S. Coast Guard Seventeenth District. D. S. Fish By direction Required Actions: Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7139: Computer Useage It is recommended that Crowley Marine Services provide additional guidance on the use of computers, electronic media, cell phones, etc., while standing the navigational watch. Company policy states in general terms that the computer should only be used for company business. Recommend company policy be expanded upon to include times for use that are appropriate (outside of a bridge watch), and the content that is allowable, specifically, prohibited use of computer games on the bridge. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:17:31 PM Priority: rmal 8

Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:19 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. The Master may not have been distracted from his navigational responsiblities had he adhered to company policy regarding use of the computer on the bridge. Additionally, revising company policy to provide specific examples of inappropriate computer use would provide more clarity to vessel crews. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:07 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. The use of computers, cell phones and other handheld devices is expanding into nearly every facet of daily life. Recently, social media devices and computers took center stage in horrific accidents (commuter train wreck in California caused when the train conductor missed a signal while texting ) or frightening near misses ( the northwest pilots who overflew their destination because they were trying to decipher their work schedule on their laptops). Games, music, phone calls to far away family are a strong temptation and could easily distract a ship's officer from maintaining a proper lookout. Like aviation and rail transportation, the marine transportation system is equally vulnerable to accidents with significant loss of human life. Recommend CG545 promulgate a Safety Alert cautioning the maritime community about the distracting affects of using such devices on the bridge of vessels. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:17 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:17: 9

We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. Regarding District's additional recommendation to issue a safety alert, Commandant issued a marine safety advisory on distracted operations on October 29, 2010, in response to an earlier National Transportation Safety Board (NTSB) recommendation. D. S. Fish By direction Required Actions: Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7140: Training Evaluation During the course of the investigation, it was discovered that the Second Mate was involved in two marine casualties within the last year, which may have indicated a problem with his ability to make sound decisions during critical situations. While interviewing the Master and Chief Mate, both individuals discussed incidents where the Second Mate mistakenly wrapped a line in the screw of a line boat after making an improper judgment call during a training evolution, and again when the Second Mate failed to respond to a steering pump alarm and failure on the PATHFINDER. The Chief Mate and the Master failed to counsel the Second Mate on the proper actions he should have taken in the given situations, nor did they relay their concerns to the company. The Second Mate was never given any remedial training on bridge management and therefore was not aware of his shortcomings. It is recommended that Crowley Marine Services develop a system that requires progress reports of new personnel and trainees be submitted to the company. This would enable the company to identify shortcomings and devise remedial action plans. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:18:28 PM Priority: rmal Endorsement(s): 10

>USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:26 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Immediate counselling to discuss shortcoming and remedial actions would provide timely feedback to the individuals involved in casualties. Addtionally, tracking a member's performance and periodic counselling by the supervisor would help identify any trends of performance issues. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:09 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:17 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:18: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction Required Actions: Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: 11

Action Commentary: Safety Recommendation #7141: Night Vision Maintenance At the time of the grounding, the Master was using the computer located on the bridge, which may have affected the Second Mate's or Master's night vision. It is recommended that Crowley Marine Services provide screens for computer monitors or laptops located on the bridge to darken white light being emitted from the computer while in use. Although neither the Second Mate nor the Master identified the computer screen as a latent unsafe condition, the maintenance of night vision in a bridge environment cannot be overstated. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:19:21 PM Priority: rmal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:30 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Use of adequate tools would improve night vision on the bridge. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:10 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:18 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: 12

Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:19: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction Required Actions: Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7143: Navigational Chart Plotting Standardization It is recommended that Crowley Marine Services establish policy for taking navigational fixes, to include chart markings and proper fix identification (i.e. dead reckoning, global positioning system, estimated position, etc.). At the time of the grounding, there were several marks on the PATHFINDER's chart that were all dissimilar. When questioned about the markings on the chart, the Second Mate stated that each conning officer had his own symbol for a fix, and pointed out his fix signature. The current method of charting or plotting a fix is not standardized and can provide confusion as to who took the fix, when the fix was taken, or what means was used to acquire the fix. Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:19:59 PM Priority: rmal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:31 >STATUS: --->Forward >NEW OWNER: D17 dp 13

Concur with safety recommendation. Use of standardized chart symbology is good marine practice. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:11 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:19 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:19: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction Required Actions: Proposed Start Date: 01/20/2010 Actual Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Actual Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7190: Increased Navigational Fix Frequency Current Crowley Marine Services policy states that the vessel's position will be charted every two hours at a minimum. Any increase in the fix interval is left up to the mariner. 14

It is recommended that Crowley Marine Services establish a minimum fix interval while vessels transit near shoal waters, known hazards, or in decreased visibility environments. Although in this incident the Master and Second Mate failed to comply with company policy on numerous occasions, a policy mandating an increase in fix intervals when operating in or near known hazards, shoal waters or in decreased visibility can positively impact the safe navigation of Crowley Marine Services' vessels. Date Created: 02/25/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:20:41 PM Priority: rmal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:37 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Increasing the fix intervals while transiting in hazardous situations would provide the mariner with better awarenss of the vessel's location in relation to such hazards. ----------------- >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:13 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:20 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:20: 15

We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction Required Actions: Proposed Start Date: 02/25/2010 Actual Start Date: 02/25/2010 Proposed Completion Date: 02/25/2010 Actual Completion Date: 02/25/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7191: Equipment Failure Tracking It is recommended that Crowley Marine Services review their equipment repair procedures to ensure prioritization of essential navigational equipment. The Electronic Bearing Line (EBL) on the starboard radar had not been operational since October 2009, despite a repair order that had been filed with the maintenance department. According to statements from the crew of the PATHFINDER, this was the second time that this piece of equipment was inoperable. The company's current repair process fails to identify equipment needing immediate repairs, such as an EBL on a radar system. It also fails to recognize essential equipment that has a history of defects. Without changes to the way Crowley Marine Services prioritizes vessel equipment failures and repair times, these failures may directly impact the safe navigation of their vessels. Date Created: 02/25/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:21:19 PM Priority: rmal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:39 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Maintenance tracking and prioritization are essential to identifying critical equipment failures and repairing such in a timely fashion. ----------------- 16

Report of Investigation >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:14 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ----------------- >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:21 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant. Final Agency Action: Concur- Alternate Acceptable Action > (b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:21: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction Required Actions: Proposed Start Date: 02/25/2010 Actual Start Date: 02/25/2010 Proposed Completion Date: 02/25/2010 Actual Completion Date: 02/25/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7194: Refloat Policy It is recommended that Crowley Marine Services develop a system that requires its Masters to complete a risk assessment prior to refloating a vessel after it has grounded. It is also recommended, when the situation permits, that the Master contacts the company and Coast Guard to discuss threats and option for refloating the vessel. Immediately following the grounding of the PATHFINDER, the Master deemed it appropriate to refloat the vessel. There was no discussion or request for guidance between the Master, 17