Where was the investigation?

This is in response to your latest issue of Professional Mariner and your article about the death of CAPT Robert G. Cordes.  I have the unique position of being the person who last issued CAPT Cordes his Coast Guard license and worked with him as the Executive Director of the Boston Harbor Pilot Association for a few months before his untimely death.   I have read both the Coast Guard’s report and the article in PM with interest and of course there is always “the rest of the storyâ€.
First of all, no one from the Investigations Branch at Sector Boston came and interviewed me or any of the other nine pilots regarding the status of CAPT Cordes or to discuss any issues regarding the accident that killed him.   If for no other reason than to attempt to determine if anything was going on that MAY have contributed to this casualty or to discuss the issues regarding how a Pilot normally boards a vessel at this facility.  I found this very curious.  The CG report mentions quickly that CAPT Cordes had asked for a gangway, which was refused by the facility and the ship.  
Let’s review the “factsâ€:
• The medical examiner found no evidence of a medical “event†(heart attack etc.) that incapacitated him before he fell;
• The pilot ladder was in excess of 9 meters, which by IMO standards, should have had a gangway combination rigged with it (whether this applied at the pier or not);
• The pilot ladder was rigged OVER the deck rail, which added a few more feet to the climb and should have been placed in an opening in the rail;
• This sister ship to the BALDOCK was moored at the same facility this fall and the ladder was rigged in the exact same manner.  The Pilot refused to board the ship and had to use the gangway on the outboard side                  of the ship from a tug.  This is obviously a dangerous rigging condition and should not be used to board the ship at this facility.
• Prior to this accident CAPT Cordes had boarded thousands of ships over his 30 year career under extreme weather conditions including the last five years without incident or evidence of any physical competency issues.
• CAPT Cordes renewed his CG License in 2001 and 2006, while I was the Chief of the Regional Examination Center in Boston.  In 2001 he provided additional medical documentation from a licensed physician that he was “competent†to renew the license.  In addition, 46 CFR 10.209 states that a mariner can provide “certification by a licensed physician or physician assistant that he or she is in good health and has no physical impairment or medical condition which would render him or her incompetent to perform the ordinary duties of that license. This certification must address visual acuity and hearing in addition to general physical condition and must have been completed within 12 months of the date of application.† In 2006, CAPT Cordes met this requirement and provided no additional medical information to warrant any additional 
• Witnesses on the BALDOCK claim to have seen CAPT Cordes clutch his chest as he was falling.  This cannot be used as conclusive evidence that he had some medical event.  This could have easily been the result of him flailing and grasping for the ladder or the rail.  The medical examiner’s report again confirmed that he did NOT have a heart attack.   
The ultimate goal of the Coast Guard’s Investigative Branch is (or used to be) to determine the causes of a marine casualty for the purposes of:
1. Learning how to prevent such a casualty event from happening again; and 
2. Drafting or recommend regulations or policies to prevent future casualties of a similar nature.
In this particular casualty, the focus of the investigation seemed to be on the “system†that reviewed CAPT Cordes’ physical competency.   Historically and today, NMC “denies†about 1-2% of the thousands of applications that go before the medical review board.  Based on those numbers, CAPT Cordes would have easily been granted a waiver in 2001 and 2006 from NMC.  The “exercise†of sending paper to NMC for review would not have prevented CAPT Cordes from renewing his license.  Any conditions that may have been noted on his physical exam were being treated professionally and met ALL of the standards according to CG published guidelines.  I can say conclusively that CAPT Cordes would have held his license in October of 2006 regardless of the process or system that renewed it.   
CAPT Cordes was killed because he chose to attempt to board a ship with an unsafe ladder configuration.  If they had rigged a gangway, he would be alive today.  Why he chose to attempt to climb this rig we will never know, but I can tell you that he was not happy to board the ship in that manner.  Especially since he had requested a gangway and was denied.   If the CG is serious about preventing a casualty of this nature from occurring again, it should look more closely at the conditions of the facility and how mariners have to board a ship.   I am at a loss as to why no one from the Coast Guard interviewed me or any of the other pilots.  
If you have any questions, I’d be glad to discuss.
Best Regards,
Andy Hammond
Executive Director
Boston Harbor Pilot Association, LLC
By Professional Mariner Staff