The sea is an inherently dangerous place to make a living for America’s fishing fleets. When an American life is lost at sea it is the job of the Coast Guard marine investigator to determine what happened and how it can be avoided in the future. One recent case that exemplifies the role of the Coast Guard marine investigator was the investigation into the loss of seven lives aboard the fishing vessel Katmai in 2008.
The lead investigator for the Katmai case was Cmdr. Malcolm McLellan. He and his team were responsible for reconstructing and investigating the events that led to the loss of both the vessel and its crew members and to make potentially lifesaving recommendations based on their findings.
The sinking of the Katmai resulted in a Marine Board of Investigation – reserved for the most severe and nationally significant marine casualties where there is multiple loss of life or loss of a vessel. The Katmai case was the first Commandant Marine Board of Investigation since 2001.
“The key purpose of Marine Board of Investigations is to identify causal factors and develop preventative safety recommendations which promote and improve safety of life and property at sea,” said McLellan.
In the end, McLellan and his team found that the Katmai sank because it was overloaded with more than 47,000 pounds of cargo, exposed to heavy seas and high winds and the vessel’s watertight doors were not properly secured. These findings ultimately resulted in 32 safety recommendations.
Perhaps more significant, however, was a fundamental flaw McLellan uncovered in the investigation process itself.
McLellan and his team noticed inconsistencies in the investigation process when it came to communicating with next of kin and the Coast Guard’s duty to make the report available to the public. Seeing this need, McLellan developed a communication action plan and effectively changed the way the Coast Guard handles formal investigations. His plan incorporated the same messages for the families involved, congressional updates and media releases which ensured the accuracy of information being published.
“Commander McLellan’s ability to professionally yet compassionately engage with the grieving survivors during an incredibly trying time while at the same time ensuring they understood factual elements of the accident as well as our safety recommendations was impressive,” said Capt. David Fish, chief of the Office of Investigations and Casualty Analysis. “His actions set the benchmark for future Marine Board’s use of the communication action plan. Additionally, his analysis and detailed lessons learned and safety recommendations stemming from this tragic event will assist fisherman in plying the dangerous waters off Alaska for years to come.”
When major marine casualties occur, there is an expectation from the public to know why and how a casualty happened. McLellan realized that the only way to effectively get the message out was to release it in a timely manner. McLellan and his team stuck to their proposed timeline and submitted their report in six months; a feat not accomplished previously.
“Most, if not all, marine casualty investigations can and should be completed in a year or less to ensure the lessons learned from the investigation can be promptly addressed through well developed preventative safety recommendations,” said McLellan.
The Katmai investigation, led by McLellan, laid the foundation for future investigations further ensuring all Coast Guard marine investigators make the maritime community safer and more secure.