The findings

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Six NTSB investigators spent 19 months on the probe, interviewing 60 people, says public affairs officer Peter C. Knudson. Findings in the synopsis include:• The Coast Guard boat was on plane at a minimum of 19 knots at the time of the collision, faster than a safe speed of 8 knots or less under the conditions.

• The patrol boat’s coxswain and crew were aware of the high vessel density in the area and the prevailing conditions of darkness, background lighting.
• Traveling at a slow speed would have compensated for the conditions that limited the Coast Guard crew’s visibility.
• The patrol boat, a 33-foot special purpose craft, has obstructions to forward visibility from the helm and the forward port positions.
• At the time of the accident, the absence of Station San Diego speed restrictions for routine patrols at night allowed coxswains too much latitude in boat speed.
• Station San Diego oversight of small-boat operations was ineffective in ensuring compliance with established policies for safe operations.

Recommendations
The synopsis also recommends that the Coast Guard:
• Develop and implement procedures for operators and crew of the 33-foot special purpose craft that allow them to compensate for the vessel’s visibility obstructions.
• Examine oversight of small-boat operations to determine where local procedures are inadequate, and implement procedures at Station San Diego and nationally to ensure crewmembers are operating their vessels safely in all conditions and circumstances.
• Require each small-boat station, including San Diego, to establish specific operating procedures governing boat speeds that account for prevailing conditions and circumstances.

See related article:

- NTSB cites speed in fatal Coast Guard crash

This article originally appeared in the September 2011 issue.