Clerk misread one character in entering the beacon ID code for a scalloper that sank, with the loss of six
A clerical error in the registration of an EPIRB was a factor in an 87-minute delay in the Coast Guard’s search for the scalloper Lady Mary, which sank off New Jersey in the predawn hours of March 24 with the loss of six of her seven crewmembers.
The unique 15-character identification code embedded in Lady Mary’s EPIRB signal differed by one character from the EPIRB code assigned to the 71-footer in the National Oceanic and Atmospheric Administration’s database, according to testimony at a May 7 Coast Guard inquiry in Cape May, N.J.
The character in question was a “C,” which a clerk working for a NOAA contractor erroneously transcribed from the mailed-in registration form as an “O” in NOAA’s database during the beacon’s initial registration in January 2007, according to the testimony of Dan Karlson, a NOAA program analyst.
Because of that discrepancy, when the EPIRB activated and sent its alert signal to a NOAA computer via satellite, the computer couldn’t find the EPIRB’s identifier code in the database, so it classified the beacon as “unregistered.” The EPIRB, a Satellite 2 406 MHz beacon manufactured by ACR Electronics, was not equipped with GPS, so it couldn’t transmit its own position. It had to rely on satellites to figure out where it was.
In an interview after the hearing, Karlson said a Geosar (geostationary) satellite picked up Lady Mary’s emergency alert at 5:40 a.m., but these satellites can’t calculate an EPIRB’s location.
“The computer couldn’t find the registration information, and it had no location,” says Karlson. “The system had no actionable information [from the EPIRB] to work with.” So it held on to that information until a Leosar (low-earth orbiting) satellite passed over Lady Mary and fixed the EPIRB’s position using Doppler effect technology.
Leosars pass over most points around the globe once every hour-and-a-half. A Leosar had passed over Lady Mary 15 to 20 minutes before it sank, Karlson says, so it was a long wait for the next pass. The Coast Guard received its first alert from Lady Mary’s EPIRB — along with its location, courtesy of the Leosar — at 7:07 a.m., 87 minutes after the beacon first activated.
Had Lady Mary’s EPIRB been properly registered, the response could have been quicker. The computer would have found the identifier code in the database and passed the emergency alert on to rescue coordinators immediately. They would have used the identifier code to pull up the EPIRB’s registration information — the owner’s name and emergency phone numbers — contacted him, found out where the Lady Mary had been fishing, and sent a helicopter right away. Then, they could have contacted the National Marine Fisheries Service for the last position report from the transmitter on Lady Mary that NMFS uses to track commercial fishing boats, and used that to help pinpoint its position.
All of this could have taken place before the Leosar nailed Lady Mary’s position.
Lady Mary’s owner, Royal “Fuzzy” Smith Sr., told the five-person Marine Board of Investigation that he had registered the EPIRB as the law requires and had the paperwork to prove it. Yet there was a problem with that initial registration paperwork.
“The handwriting wasn’t legible, and that’s probably what caused confusion for the database entry clerk,” says Karlson. The EPIRB manufacturer, ACR Electronics, puts a registration form in the box with any new EPIRB and fixes a decal to that form with the EPIRB’s identifier on it. That decal had the correct identifying number on it. Yet registrants also are asked to check the ID number on their EPIRB and write that number on the registration form, as well.
Karlson says data entry clerks had been trained to get the EPIRB’s ID from the owner’s handwritten entry because not all manufacturers place a preprinted decal on the form. Karlson says that protocol has changed. Clerks now are instructed to look at both the handwritten entry and the decal, if there is one, and consult a supervisor if there is a discrepancy. The EPIRB owner will be contacted if the discrepancy isn’t resolved.
There were at least three other opportunities to correct the error, Karlson says. Once the EPIRB was registered, NOAA sent a letter back to Lady Mary’s owner confirming the registration. That letter included a proof-of-registration decal with the erroneous EPIRB identifier code printed on it. In retrospect, the owner should have checked that decal against the identifier code on Lady Mary’s EPIRB to make sure it was correct, Karlson says. NOAA did include in its confirmation letter instructions to double-check the registration information. Now that letter advises EPIRB owners to be especially vigilant about checking the ID code.
NOAA sent a letter last fall to Lady Mary’s owner advising that it was time to reregister the EPIRB. That letter would have included the information NOAA carries in its database about that EPIRB. Lady Mary’s owner reregistered the beacon Nov. 10, 2008, but the reregistration form was sent in without correcting the erroneous identifier code on it, according to Karlson. Again, after reregistering, NOAA sent a letter confirming the reregistration, along with a proof-of-registration decal with the identifier code printed on it. Again, that number was wrong.
Geosar with GPS
Karlson says NOAA is embarking on a letter and e-mail campaign to contact its 235,000 registered beacon owners and advise them to check the information it has in its database about their EPIRBs — including the identifier code — to make sure it is correct. In early May, the agency started sending e-mails to its 110,000 beacon owners who registered online, and plans to contact others later by mail. “We’re trying to get beacon owners to heed this call to verify their information and provide us with updates,” he says. “We’re asking them to do the check, look at their beacon ID, and check it against the information we have on file.”
NOAA is looking ahead to the day when it will have GPS on its constellation of Geosar satellites so it can fix an EPIRB’s position from the skies almost instantaneously, even if the EPIRB doesn’t have its own GPS, Karlson says. GPS on Geosars would work like the GPS we know “in reverse,” he says — the satellites triangulating an EPIRB’s position from the alert signal they receive from three different locations. However, Karlson says, this is at least nine years away. NOAA is testing the concept. The Defense Department must give its OK to implement it. The feature would be engineered into satellites at least two generations removed from today’s.
“We’re always looking at ways to optimize the system,” Karlson says.
One crewmember aboard the Lady Mary, Jose Luis Arias, survived the sinking. The water that morning was about 40 F, the air temperature 30 degrees — cold enough to bring on hypothermia in a matter of minutes. Rescuers found an empty life raft about 75 miles off Cape May, then rescued Arias — in his survival suit — and found two bodies, also in survival suits. Divers recovered a third body May 13 from inside the sunken vessel. The other three remain missing.
The investigation continues, as does NOAA’s campaign to verify beacon ID numbers. “Nothing, I guess, is ever foolproof,” Karlson says.
Se related story: "Steps for proper EPIRB registration."
This article originally appeared in the July 2009 issue.