The water taxi Lady D, whose 2004 capsizing in a squall killed five passengers, was operating outside of its certified waters and should not have sailed in the face of the storm, U.S. Coast Guard investigators said.
The master of Lady D should have attempted to return to the dock when the weather turned severe instead of continuing across Baltimoreâ€™s Patapsco River, according to the final investigative report.
Lady D never should have been assigned a route that took it out of the Inner Harbor to Fort McHenry, the Coast Guard said. As one of the smallest vessels in Baltimore-based Seaport Taxi LLCâ€™s fleet, Lady D had a certificate of inspection that restricted it to the Inner Harbor. An unspecified potential defendant â€œmay have committed misconductâ€ in running the 36-footer out to Fort McHenry, the investigative report said.
The 36-foot pontoon vessel departed Fort McHenry on March 6, 2004, with 23 tourists and one other crewmember for a 15-minute voyage to Fells Point on the north shore of the river. Clouds were already darkening, winds were picking up and passengers noticed lightning, according to the Coast Guard report.
Minutes later, the winds gusted to 43 mph. Seas increased from 1 foot to 4 feet. Intense rain was blowing horizontally. The masterâ€™s senior port captain radioed an order to â€œhit the bulkheadâ€ for shelter. The 2-gross-ton Lady D was already in trouble, with the master reporting that the vessel was â€œpretty much in the middle of the riverâ€ â€” not near any dock.
The Coast Guardâ€™s final report, released in August 2009, said Lady D should have returned to the slip at Fort McHenry. Instead, the captain persisted in his northwest voyage against the gusts, hoping to reach Baltimore Marine Center.
Heavy seas were covering windows on Lady Dâ€™s port side, so the master attempted to steer the bow into the waves. The investigators said the captain was unable to heave to, and he couldnâ€™t control the pontoon boat. The vessel went into a circular motion, and winds pushed it backwards toward the east.
Lady D heeled to starboard, witnesses reported. A crewman ordered passengers to move over to the port-side seats, and the vessel leveled out. Less than one minute later, the water taxi heeled to starboard severely â€” possibly when the captain attempted another turn to port â€” and capsized. Passengers were flung to the starboard side and suffered blunt force trauma.
â€œIt looked like he was trying to turn back up into the Inner Harbor or at least make a left-hand turn,â€ said a Navy chief petty officer, an eyewitness. â€œThe pontoon was raised up due to the water or wind, or a combination of both.â€
While the vessel was upside down, passengers smashed through windows to escape. An assault landing craft from the nearby Naval Reserve Center arrived in less than eight minutes and rescued most of Lady Dâ€™s occupants. However, five passengers were killed in the accident. Four others were seriously injured.
The Coast Guard report said the master never should have sailed.
The captain â€œmay have been negligent in his assessment of the Lady Dâ€™s ability to operate in severe weather conditions and therefore in his decision to depart the dock in the face of an approaching squall and to continue the voyage even though he had to back into the wind in order to maintain control of the vessel,â€ the investigators wrote.
When the weather worsened while the vessel was underway, Lady D should have ridden out the winds, an action that would have helped the master to return to Fort McHenry, the report said.
Later in 2004, Seaport Taxi ceased operations. Baltimoreâ€™s nonprofit Living Classrooms Foundation, which was Seaport Taxiâ€™s parent, didnâ€™t respond to phone messages and an e-mail from Professional Mariner requesting comment on the Coast Guardâ€™s findings.
The incident changed the way pontoon passenger vessels are regulated in the United States. In a 2005 report, the National Transportation Safety Board (NTSB) faulted the Coast Guardâ€™s stability standards. The NTSB and Passenger Vessel Association concluded that the industry needed to increase assumptions for average passenger weight. The Coast Guard ordered all of the nationâ€™s pontoon passenger vessels to undergo a Pontoon Simplified Stability Test (PSST) under a stricter engineering protocol.
â€œAfter a thorough review of the entire fleet of certified pontoon vessels, we found that stability tests for many pontoon vessels contained errors which could have eroded the conservative nature of the PSST,â€ the Coast Guard wrote in its recent report. â€œMany of these (new) tests have resulted in a significant reduction in the vesselâ€™s authorized vessel capacity.â€
Lady D was approved for 25 or fewer occupants when it was built in 1995. An average passenger weight assumption of 140 pounds was used. The boat never underwent a stability test, because it inherited data from older sister ships. Lady D differed from those vessels, however, in that it had a fully enclosed cabin weighing hundreds of pounds. Assuming the actual average passenger weight of 168 pounds, Lady D would have been approved to carry 21 occupants.
The Coast Guard said Lady Dâ€™s canopy contributed to the loss of life because doors and windows â€œwere difficult to open.â€ The Coast Guard said future vessel designs should accommodate easier escape in an emergency.
â€œCanopy supports should be positioned to allow a majority of passengers unobstructed egress,â€ the report states. â€œSide windows or curtains, if installed, should be able to be opened with minimal force by one person.â€
Vessels that operate only within 1,000 feet of the shore should carry a National Oceanic and Atmospheric Administration weather radio, the report said. A VHF radio currently is not required. Lady Dâ€™s master wasnâ€™t aware that the National Weather Service had issued a small craft advisory that day.
â€œThe Lady D mishap clearly demonstrates how critical early warning of impending severe weather can be in certain cases for small passenger vessels,â€ Coast Guard Fifth District Commander Rear Adm. Fred M. Rosa wrote.
The Coast Guard urges vessel operators to consider how local environmental factors may impact vessel stability.
â€œI continue to have significant reservations that the effects of dynamic environmental conditions are poorly understood by mariners, in particular mariners holding lower-level licenses commonly employed on small passenger vessels,â€ wrote Capt. Brian D. Kelley, commander at Coast Guard Sector Baltimore.
The Lady D master had been licensed only since 2002 and had little experience in extreme weather. He held a master of steam or motor vessel of not more than 50 gross tons. He declined to renew his credentials in 2007, the Coast Guard said.