The report, which was published on April 4, detailed problems with equipment, training and communications that may have contributed to the accident. Capt. Kevin Murray died after falling into the Pacific from a ship’s ladder as he was attempting to transfer to a pilot boat on the night of Jan. 9 during bad weather. His body was found on Jan. 11 on the beach 70 miles north of the Columbia River.
Even though the strobe light had a hydrostatic switch, the light did not go on when Murray fell into water. In a subsequent test of the recovered light, it operated properly when switched on and exposed to water, the report said.
Murray was wearing an inflatable jacket with a manual switch. When he was found, the jacket, manufactured by Stormy Seas, had not inflated. Its CO2 cylinder had not been discharged. After the accident, when the inflation handle was pulled, the cylinder discharged into the jacket and it inflated correctly.
“These two failures were the result of human factors, and not caused by any failure of the equipment,” the report concluded. “The initial spatial disorientation, darkness and temperature of the water likely prevented Capt. Murray from having the judgment necessary to inflate his jacket. Fatigue does not appear to have been a factor on the part of anyone involved in this incident.”
The report recommended that all pilots have automatically inflating flotation devices, wear and display on their jacket some type of continuous illumination when making a transfer at night, and carry an automatic strobe light and a personal EPIRB.
The deck hand of the pilot boat Chinook and the third officer of the log carrier that Murray had piloted both told the investigators, “Murray jumped before the Chinook was completely lined up with the log carrier.”
Murray had limited experience disembarking from ships in bad weather. He had completed 262 transits since he became a bar pilot in November 2004; just over one quarter of those were by pilot boat. The remainder were via the bar pilots’ helicopter.
When Murray fell from the ladder, Chinook broadcast a “man overboard” alarm and began a search pattern. The boat operator went to the aft rescue steering station where he did not have access to the boat’s VHF radio. After three to five minutes, Murray was sighted in the 47Â° water on the starboard (lee) bow and appeared to be conscious. The boat’s crew lost sight of him under the starboard side and did not see him for five to 10 minutes. When they did spot Murray again, he was floating face down. They attempted to get him into the retrieval basket, which runs on tracks on the transom, but couldn’t get him aboard and did not sight him again.
” It is possible that he was overrun by the Chinook during the search,” the investigators said.
They recommended setting up periodic training for pilots and boat crews focusing on getting off vessels at night, water survival training, as well as man-overboard drills and training.
The report noted a serious problem with the way the man-overboard alarm was interpreted over the radio, which may have hampered the search and rescue efforts.
When Chinook’s operator reported a man overboard on the VHF, a crew member on a nearby vessel, Rainbow Wing, heard the report and relayed it to his captain and the bar pilot aboard. They both assumed that the man in the water was from their ship. They contacted the Coast Guard, telling them they had a man overboard. When the Coast Guard helicopter assumed command at the scene at 2200, it focused its efforts around that vessel.
At 2252, the crew of Chinook realized there was confusion about who was overboard and told the Coast Guard the man overboard was Murray, not a man from Rainbow Wing.
The report suggested that the protocols for communication and coordination between the Coast Guard and the bar pilots for a man overboard should be reviewed.
The bar pilots declined to comment on the report.