707.300.110429.USCGPathfndrFAMrpt.

pdf Received 5/5/2011

u.s. Department o~ Homeland Security
United States Coast Guard

Commander Seventeenth Coast Guard District

PO Box 25517 Juneau, Alaska 99802-5517 Staff Symbol: (d) Phone: (907) 463-2025 Fax (907) 463-2037 Email: Christopher.C.Colvin@uscg.mil

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From: To: Thru: Subj:

CH LV CGD SEVENTEEN (d) D. P. VERFAILLIE, CDR CG MSU VALDEZ CG SECTOR ANCHORAGE (s)

DM

FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO COAST GUARD ACTIONS AND RESPONSE ACTIVITIES CONCERNING THE GROUNDING OF THE TUG PATHFINDER ON 23 DEC 09 (a) Administrative Investigations Manual, COMDTINST M5830.lA (b) Memorandum, Administrative Investigation into Coast Guard actions and response activities concerning the grounding of the tug PATHFINDER on 23 DEC 09 dated 22 JAN 10 (c) USCG Regulations, COMDTINST M5000.3 (series) (d) Vessel Traffic Services National Standard Operating Procedures Manual (VTS NSOP), COMDTINST M16630.3 (e) VTS Prince William Sound Standard Operating Procedures, MSUVALDEZINST 16630A (f) Prince William Sound - Vessel Escort and Response Plan (VERP) - Published January 2007 (g) U.S. Coast Guard Vessel Traffic Service Prince William Sound - User's Manual (Eighth Edition - September 2008)

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1. Having considered reference (a) and other applicable references, appropriate actions are hereby ordered, and this administrative investigation is closed. A summary of the pertinent facts and my opinions based on those facts are herein provided. All times provided are in Alaska Standard Time. Progress with respect to the ordered actions shall be reported on a monthly basis to CGD SEVENTEEN (dcs) until all ordered actions have been implemented. 2. This investigation was directed for the purpose of ascertaining the facts and circumstances associated with the mishap and to provide recommendations for the implementation of improved procedures which, ultimately, reduce the risk of similar incidents occurring in the future. The actions of the master and crew of the Tug PATHFINDER ("PATHFINDER") have been investigated under a separate Coast Guard Marine Casualty Investigation. This informal administrative investigation was not intended to determine the cause of the PATHFINDER grounding. This investigation must be viewed in conjunction with the Marine Casualty Investigation to fully understand the cause of this casualty. 3. Factual Summary. a. On 23 December 2009, the Ship Escort/Response Vessel System (SERVS) directed the PATHFINDER to serve as an Ice Scout Vessel (ISV) to conduct ice scouting operations and

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provide an ice report in accordance with the Vessel Escort and Response Plan (VERP). b. Ice reports are required pursuant to the VERP to provide periodic situational updates regarding the presence of icebergs which can create navigational hazards in the vicinity of Bligh Reef. Icebergs are produced throughout the year due to calving of the nearby Columbia Glacier, some of which occasionally drift into the nearby Traffic Separation Scheme (TSS). c. The VERP is designed as a port specific guide to further aid and enhance the safety of tanker navigation and the protection of the marine environment within the waters of the Prince William Sound. The Prince William Sound Regional Citizens Advisory Council (PWSRCAC), the SERVS, and the Coast Guard Captain of the Port Valdez are all signatories to the VERP. d. The VERP requires an "ice scout" to visually check for ice in the vicinity of Bligh Reef no longer than six hours prior to a tanker transiting Prince William Sound. An ice report was required due to the scheduled departure of the tanker KODIAK which was scheduled to depart outbound from the Port of Valdez later that evening. Although the PATHFINDER was designated as an ISV for 23 December 2009, an ice scout is not specifically required to be a tug. Virtually any vessel or even an aircraft can serve as an ice scout. The primary objective is to visually identify any floating ice that may endanger a tanker transit through the TSS. e. An ISV is defined as "any suitably sized vessel equipped with an operational radar and searchlight." Due to size and power limitations, the PATHFINDER does not provide tanker escort services and was regularly chosen by SERVS to perfolm ice scouting duties. f. At approximately 1402, the PATHFINDER checked into the Prince William Sound Vessel Traffic Service Area (PWS VTSA) and indicated they were enroute to Bligh Reef to provide the ice report. As a Vessel Movement Reporting System (VMRS) user, the PATHFINDER was required to check-in with the Vessel Traffic Service (VTS) to provide an initial sail plan, report any deviations from the initial sail plan, or check-out of the VMRS when transit or operations were complete. g. The PATHFINDER was not required to check-in at any of the designated VTS RepOlting Points in the PWS VTSA because the Ports and Waterways Safety System (PAWSS) at Vessel Traffic Center (VTC) Prince William Sound received Automatic Identification System (AIS) information from the PATHFINDER. VTS Prince William Sound was also able to track vessels operating in the PWS VTSA, including the PATHFINDER, based on information provided from the USCG radar site on Reef Island. h. The PATHFINDER did not encounter any opposing or overtaking traffic during its outbound transit.

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i. At approximately 1649, the PATHFINDER provided an ice report reporting no ice in the area while abeam Bligh Reef, in the outbound traffic lane. j. At 1650, the PATHFINDER reported on-scene weather in the vicinity of Bligh Reef as follows: four-foot swells from the south, southeast winds at 15 knots and visibility of approximately four nautical miles. At this time, the PATHFINDER also stated that they would remain in the vicinity of Bligh Reef until 1800 in order to provide an 1800 ice report. This was in anticipation of an outbound transit by the Tanker KODIAK from the Port of Valdez later that evening. k. Earlier in the day, at 0520, Cape Hinchinbrook Entrance was closed to all outbound laden tanker vessels due to weather. The 1800 ice report would extend the window of opportunity for the Tanker KODIAK to depart Valdez to midnight if the Cape Hinchenbrook entrance was opened later in the day.

l. At approximately 1654, the PATHFINDER began to cross the TSS toward the inbound lane.
m. At 1657 relieved of the VTC Watch Supervisor (VTCWS) duties. In addition to normal watchstanding responsibilities, the VTCWS in Valdez is responsible for performing a variety of routine maintenance and unit security duties while on watch. These duties include security rounds, colors, unlocking access doors, and removing snow from the front-door sidewalk in extreme snow-fall situations. VTC watchstanders are permitted regular breaks (at least 15 minutes every 3 hours) n. The VTS Prince William Sound Internal Standard Operating Procedures (ISOP) provides for minimum manning requirements that ensure 24-hour coverage of the VTS. Section 4.B.I.a provides that "[alt least one of the two personnel assigned to the watch must be in the VTC at all times" and that "during inbound and outbound tanker transits of the Valdez Narrows, when hazardous circumstances exist or are anticipated anywhere within the PWS VTSA both rwatchstanders I shall be present to monitor the transit." Both the VTS National Standard Operating Procedures (NSOP) and ISOP also provide for mandatory minimum rest periods of at least 15 minutes for every 3-hour period for all watchstanders. o. At approximately 1724, the PATHFINDER crossed and departed the TSS and continued ice scout duties in vicinity of Bligh Reef. ISV's typically travel at various courses and speeds and close to reefs and shoal water when transiting outside the TSS. Since ISV's routinely operate in close proximity to Bligh Reef, neither watchstander detected any anomalous activity associated with the PATHFINDER's operations. p. At 1725, relieved LT of the VTC Specialist (VTCS) duties. LT duties include her primary responsibility as VTS Chief, and she remained on scene at the VTC following her relief.

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q. At approximately 1800, the PATHFINDER provided an ice report reporting "no visible ice" to the VTS.
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At approximately 1802, the PATHFINDER, while on a south-southeast heading at an approximate speed of 3.5 knots, reported to the VTS that they had been released of ice . the duty VTCS, scouting duties by SERVS and were headed back to Valdez. acknowledged receipt of the PATHFINDER's radio communication.

s. At approximately 1803, the PATHFINDER turned on a northerly heading and increased speed to approximately 11-13 knots. At this time, the PATHFINDER was approximately 1 Y2 miles due south of Bligh Reef.
t. Since the PATHFINDER's activity was consistent with both watchstanders experience with respect to ISV operations, neither watchstander magnified the location of the PATHFINDER on their radar screen. Both watchstanders maintained the radar scale at a smaller scale setting in order to provide maximum visual coverage of the PWS VTSA and the entire Vessel Traffic Lanes. At this scale setting, the PATHFINDER's location could not be differentiated from Bligh Reef.

u. At 1814, the PATHFINDER reported to VTS via channel 13 that the vessel was aground on Bligh Reef. The location of the PATHFINDER was within the PWS VTSA but was operating well outside of the TSS. v. Both VTS watchstanders stated that at the time of the grounding, they were both actively watching their consoles and focused on monitoring the entire TSS. Immediately following the PATHFINDER's report of grounding, the VTS watchstanders replied via radio to the PATHFINDER and followed standard procedures as they had been trained. They used the Quick Response Cards (QRC) for both search and rescue (SAR) and marine pollution and conducted notifications up the chain of command. w. At the time of the grounding, the weather and tidal information was as follows: I) Tides: were estimated to be +8.74 foot tide ebbing to a low tide of +2.48 foot at approximately 2330. 2) Currents in the vicinity of Bligh Reef were estimated to be weak and variable. 3) Weather: The NOAA West Orca Bay weather buoy, located 15 NM south of Bligh Reef, recorded 7-8 foot seas with east-southeast winds at 23 knots. x. At 1826, VTCWS delivered notice of the grounding to , Executive Officer (XO), Marine Safety Unit (MSU) Valdez, who at the time was also serving as the Acting Commanding Officer (CO) of MSU Valdez since CDR Darryl Verfaillie, CO, was on leave.
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y. At 1827, notified CDR Verfaillie of the situation. CDR Verfaillie immediately checked off of leave and resumed command. At approximately 1900, CDR Verfaillie arrived at VTS Prince William Sound. z. Shortly after the report of the grounding, the CGC LONG ISLAND was dispatched from Valdez to provide on-scene information regarding the PATHFINDER's status. aa. The USCG Sector Anchorage Command Center (CC) was monitoring marine radio frequencies and began to communicate with the PATHFINDER to assess the need for potential SAR assistance. bb. At 1845, the PATHFINDER notified the CC that the tug was no longer aground and was heading to the northeast where it anchored just northeast of Bligh Reef. cc. CDR Verfaillie suspected the damage to the PATHFINDER may not be in excess of $100,000 and was uncertain on the amount of fuel discharged; consequently, post-accident drug testing for the VTS watchstanders was considered but not conducted shOitly after the grounding. In accordance with the NSOP, Commandant (CG-1312) was notified on 28 December 2009 that a required post-accident test for illegal drug use was not conducted within four hours of the accident. Drug testing of the watchstanders was conducted at 1000 on 28 December 2009 following direction by District Seventeen. Drug test results were negative for all personnel tested. dd. The Processed Ice Radar Picture (PIRP), designed to feed into the VTS system and provide watchstanders with current information on the amount of ice in the TSS, was installed in the VTS in February 2009. However, on 23 December 2009, the PIRP was not available to the VTS because the ice processor had not been upgraded to be compatible with the Terma radar upgrade completed in 2 October 2009. VTS watchstanders considered the PIRP to be a good situational awareness tool for the VTC; however, use of the PIRP did not circumvent the VERP requirement for on-scene ice reports delivered by vessel or aircraft. ee. Although physically located in the VTC, the PIRP is neither owned nor maintained by the Coast Guard. Under standard Coast Guard policy, Coast Guard technicians are not authorized to repair or upgrade non-standard, non-Coast Guard property. However, anticipating the potential need, the Coast Guard specifically left a port open on the Terma radar for a technician to access and upgrade the system and notified the PWSRCAC and SERVS in July 2009 that the system was inoperable absent an upgrade.
ff. The VTS program was established by the Ports and Waterways Safety Act, 33 U.S.c. 1221 et seq, to employ navigation safety systems and practices to reduce risk and to facilitate maritime commerce in U.S. ports and waterways. The primary function of a VTS is to facilitate good order and predictability on a waterway by providing a variety of services to mariners operating in and around the ports where VTS systems have been implemented.

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These services include: providing infonnation to mariners such as positions, intentions, and destinations of other vessels operating within a VTSA; traffic organization information which includes providing advance planning of movements, mandatory position reporting, or speed restrictions through certain areas; and, upon request, providing navigation assistance to vessels which includes positions relative to waypoints, ATON, and navigational infonnation such as course or speed made good. gg. VTS watchstanders are required to provide traffic advisories to vessels equipped with operational Automatic Identification Systems (AIS), including the PATHFINDER, that elect to make automated reports. A vessel traffic advisory includes infonnation regarding "all traffic a vessel may encounter both visually and by radar while transiting the VTSA." VTS watchstanders are instructed to "anticipate changing conditions to include weather, vessel speeds, locations, operations, and the embarking/disembarking of pilots at the pilot station. Traffic advisories shall be passed to enhance safety and vessel navigation. They shall be passed when applicable and between reporting points, if needed." On 23 December 2009, no traffic advisory was provided to the PATHFINDER because there was no other traffic operating in the PWS VTSA throughout the PATHFINDER's transit. hh. Unless requesting navigational assistance from the VTS or operating in the shipping lanes and endangering TSS traffic, tug boats, fishing boats, charter boats and other smaller craft do not normally receive traffic advisories from the VTS and are responsible for their own safe navigation throughout Prince William Sound. The PATHFINDER did not request navigational assistance at any time during their operations leading up to the grounding. ii. All VTS Prince William Sound da and night watchstanders on 23 December were fully qualified. The personnel on watch. and accounted for a total of 21 years total combined years of VTS experience and both had previously attended the National VTS Operator Course at the Maritime Institute of Technology and Graduate Studies (MITAGS). jj. Previous meetings were held prior to the 2009 Ice Season with port partners (MSU Valdez, SERVS and the PWSRCAC) to discuss ice routing procedures. Based on these meetings and stakeholder input, the VTS made minor revisions to the Ice Routing Section of the ISOP manual. At that time, neither the VERP nor the ISOP specifically identified the operational duties and responsibilities, including area of operation, for an ISV. kk. All Aids to Navigation (ATON) throughout the PWS VTSA were fully operational and watching properly at the time of the grounding. 4. Opinions. a. As a learning organization, the Coast Guard always seeks ways to improve performance. This investigation was intended to assess whether improvements could be made to the vessel traffic service provided to Prince William Sound. This investigation was not initiated under

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any presumption that any action or inaction by the VTS watchstanders contributed in any way to the grounding of the PATHFINDER. b. In reviewing the watch routine and practices of the personnel on watch and comparing this to the ISOP, the NSOP, and the Code of Federal Regulations, the actions of the VTS watchstanders were fully in compliance with those policies, rules and regulations. I have determined that the actions of the VTS watchstanders did not contribute, either directly or indirectly, to the PATHFINDER grounding on Bligh Reef. With respect to other potential causal factors, specifically the actions of the PATHFINDER's master and crew which may have contributed to the grounding, the Coast Guard conducted a separate Marine Casualty Investigation which specifically addressed these separate factors. c. Pursuant to 33 CFR § 161.11 (VTS Measures), "conditions of vessel congestion, restricted visibility, adverse weather, or other hazardous circumstances, a VTS may control, supervise, or otherwise manage traffic, by specifying times of entry, movement, or depat1ure to, from, or within a VTSA." The most recent weather report provided by the PATHFINDER (85 minutes prior to grounding) indicated weather conditions of four-foot swells, a southeast "breeze" of 15 knots, and visibility of about four nautical miles. Recognizing that PATHFINDER's operations were observed to be consistent with typical ISV operations and the absence of any additional reports indicating a change of weather conditions, VTS watchstanders did not suspect that the PATHFINDER was in danger of creating a hazardous situation, posing a danger to other vessels, or engaging in any activity which would require the watchstanders to initiate any of the affirmative control measures provided under 33 CFR § 161.11. Given the non-standard nature of the operations of ISV's, it is not reasonable to expect that VTS watchstanders would or should have performed in a maimer any different than what occurred leading up to the PATHFINDER grounding. The unique facts surrounding this incident do not indicate a need to modify VTS Prince William Sound procedures for monitoring the much higher risk tanker traffic transits into and out of the Port of Valdez operating inside the TSS. d. Further, 33 CFR § 161.10 (Services) provides that "a VTS may issue advisories or respond to vessel requests for information, on... hazardous conditions or circumstances" within the VTSA. The above referenced federal regulations are consistent with the Coast Guard position that, absent a specific request from the vessel, these measures and services are discretionary in function and are issued based on the judgment of the VTS watchstander. In reviewing the radio transmissions from 23 December, such a request was never made by the PATHFINDER. Based on the experience of the watchstanders in observing vessels operating in the vicinity of Bligh Reef, there was no reason to transmit an unsolicited advisory. e. Since both watchstanders were at their assigned stations at the time of the grounding, the requirement for a VTCWS to perform minor housekeeping or security tasks while on watch was not a contributing factor to the PATHFINDER grounding. The requirement for the

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VTCWS to perform these infrequent tasks is not considered an impediment to the watchstanders ability to monitor the safe transit of vessels throughout the PWS VTSA. f. The inoperative PIRP was not a factor to the grounding of the PATHFINDER since the visual ice report was required in accordance with the VERP. When it was operational, the PIRP feed into the VTS was considered beneficial to help determine the amount of ice in the TSS, but was never used as a substitute to the visual ice report to initiate closure of the traffic lanes. The Coast Guard made proper notifications and outreach with respect to notifying PWSRCAC and SERVS regarding the Terma radar upgrade of 2009 on Reef Island and the impact it would have on the PIRP operability. g. VTS Prince William Sound is a critical component for ensuring the safe movement of vessel traffic in the TSS and through the PWS VTSA. As indicated above, current authorities satisfactorily ensure the safe movement of crude oil tanker traffic inside the TSS and through Prince William Sound. Although PATHFINDER ultimately grounded on a known navigational hazard, it appeared to VTC watchstanders to be operating in conformity with typical ISV operations. This incident does not serve as an indication that the VTS was not working properly. In this instance the entire VTS system, both human and equipment, operated in conformity with applicable requirements and regulations and was not a contributing factor to this mishap. h. The purpose of the VTS is to help mariners safely navigate through a VTSA where there is typically a high volume of vessel traffic. It is not intended, nor should it be expected that the presence of a VTS in a port should relieve professional mariners from the responsibility to adhere to prudent and vigilant navigation practices. In the maritime industry, it has always been customary to bestow full responsibility for the safe navigation and operation of a vessel to the captain. This basic principle is also supported under federal law, which provides under 33 C.F.R § 161.1 that "the master is responsible for the safe navigation of the vessel." The captain of a vessel is ultimately responsible for the safe navigation of their vessel. VTS Prince William Sound has adequate authorities to ensure the safe, non-obstructed transit of crude oil tankers inside the traffic separation scheme and through Prince William Sound. i. The PATHFINDER ran aground while conducting normal duties operating outside the TSS. While the PATHFINDER was associated with SERVS, this situation could have just as easily involved a fishing boat, chm1er boat, recreational vessel or another vessel not associated with SERVS. 5. Additional Comments a. Although not specifically addressed in the investigation, there was speculation among some Prince William Sound stakeholders that the Coast Guard either had or should be given authority to actively direct all vessels all the time inside the PWS VTSA (the expansive area of Prince Williams Sound as differentiated from the more narrowly defined TSS) in order to prevent all marine casualties. The proposition was offered that the Coast Guard should adopt

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a vessel traffic control scheme similar in operation to the air traffic control scheme administered by the Federal Aviation Administration (FAA). I do not agree with this suggested modification of the VTS function for several reasons, including the following: 1) As discussed above, the authorities provided to the Coast Guard for the operation of VTS do not mirror authorities those authorities employed by the FAA in regulating movement in restricted airspace; the former relying on the captain of a vessel to safely navigate their vessel as compared to the specific courses, speeds, and altitudes provided to aircraft by the latter. Should the Coast Guard be given additional authority and the requirement to actively track and direct all vessels and ensure they navigate safely inside a VTSA, the Coast Guard would need significant additional resources. 2) There are significant differences between air traffic and vessel traffic control systems. Unlike controlled airspace for aircraft, vessel traffic systems rarely, if ever, provide actual courses and speeds to steer. They provide navigational assistance only when requested. Due to the high degree of responsibility given to masters of vessels; vessel traffic systems, with limited exceptions, are generally advisory in nature. Unlike aircraft, vessels can be stopped or even anchored. b. Since full radar coverage of Prince William Sound was completed post-EXXON VALDEZ, VTS Prince William Sound has helped facilitate the safe movement of 9.4 billion barrels of oil. 6. Actions. The following actions are ordered for CG MSU Valdez: a. Conduct an Internal Review Board (IRB) at VTS Prince William Sound in compliance with the NSOP. b. Review VTS Watchstanders assigned duties to ensure they do not have the potential to interfere with watchstander duties or could be better accomplished by another crewmember of the unit. c. Work with local stakeholders in developing an SOP for the PIRP, if it becomes operational. d. Review the duties of an ISV with Prince William Sound stakeholders to determine whether ISV duties should be more specified or whether it is better to leave the duties of an ISV as flexible as possible similar to current operations. e. Review the VERP with Prince Williams Sound stakeholders to determine whether the VERP needs to be amended.

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f. Conduct training and take action to ensure drug testing of watchstanders is properly completed in a timely manner in accordance with U.S. Coast Guard policy as appropriate for any future marine casualty.
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United States Coast Guard

Report of Investigation into the Circumstances Surrounding the Incident Involving M/V PATHFINDER grounding On 12/23/2009

MISLE Activity Number: 3655472 Originating Unit: Marine Safety Unit Valdez MISLE Activity Owner: Commandant (CG-5453) MISLE Activity Controller: Commandant (CG-5453) MISLE Case Number: 485689

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation I. INCIDENT BRIEF On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef. The vessel re-floated itself without assistance and transited under its own power to Busby Island where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact amount discharged could not be determined. A Marine Casualty Investigator from MSU Valdez was deployed to the scene. The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully towed back to Valdez where the removal of the remaining fuel commenced. Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA where it will undergo permanent repairs. The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost during the incident was 6,410 gallons of diesel fuel.

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Report of Investigation II. EXECUTIVE SUMMARY Incident Summary On December 23, 2009 at approximately 1815, the towing vessel PATHFINDER was underway in Prince William Sound, Alaska with 6 crewmembers when the vessel grounded on Bligh Reef. The vessel re-floated itself without assistance and transited under its own power to Busby Island where it set anchor. Consequently, the PATHFINDER sustained extensive damage along its keel and two center fuel tanks (#2 and #3). Initial report indicated some pollution but an exact amount discharged could not be determined. A Marine Casualty Investigator from MSU Valdez was deployed to the scene. The vessel was lightered at while anchored in Busby Bay. The vessel was then successfully towed back to Valdez where the removal of the remaining fuel commenced. Temporary repairs were completed and the vessel was allowed to transit, via tow, to Seattle, WA where it will undergo permanent repairs. The tug PATHFINDER released a Post Incident Sounding Log indicating the amount of fuel lost during the incident was 6,410 gallons of diesel fuel. Incident Involved: Marine Casualty, Reportable Discharge of Oil USCG Credentialed Mariner, Misconduct USCG Credentialed Mariner, Negligence Civil Offense(s)

This incident resulted in a discharge or substantial threat of discharge of oil. This report does not limit the discretion of the Director, NPFC, to determine facts, rights and liabilities with respect to any claims, submitted to or by the NPFC, for removal costs and damages under the Oil Pollution Act of 1990. Level of Investigation: IMO Classification: Routine USCG Classification: Major Marine Casualty Was this a Serious Marine Incident? Yes Was a Marine Board Convened by Commandant? No Personnel Casualty Summary Total Missing = 0 Total Dead = 0 Total Injured = 0 Total at Risk, Not Injured = 0 Total People at Risk = 6 Other Personnel (Not at Risk) = 0
(b)(6) & (b)(7)(c)

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Report of Investigation Vessel(s) Status Summary Actual Total Loss(es) = 0 Total Constructive Loss, Salvaged = 0 Total Constructive Loss, Unsalvaged = 0 Damaged = 1 Undamaged = 0 Property Damage Summary/Total Damage Vessel(s) = $500000* Cargo = $ Facility(s) = $ Other = $
* Includes estimates

Waterway Mobility Summary Vessel Delays (including speed restrictions): None

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Report of Investigation III. ACTIONS IN RESPONSE TO THIS REPORT Actions on Recommendations Safety Recommendation #7135: Crowley Marine Services Policy Review During the course of the investigation into the grounding of the PATHFINDER, numerous company policies and procedures pertaining to the vessel's mission, crew performance and training were reviewed. Crowley Marine Services published numerous policies regarding all aspects of marine operations. However, events leading up to the grounding, including subsequent crew interviews, revealed that the PATHFINDER's bridge team had largely chosen to disregard policy and procedure regarding proper watch reliefs, charting, and the maintenance of vigilance on the bridge. It is recommended that Crowley Marine Services develop a system that ensures company policies and procedures are being followed in the field. This should include, but is not limited to, a thorough review of vessel logs that are turned in to the company to certify that they are being completed in accordance with company policy, focusing on watch reliefs and fix intervals. It is further recommended that the company deploy a team of personnel to conduct an operational review of vessel missions at least bi-annually. This would enable the company to evaluate the effectiveness of its policies and procedures. Adopting these recommendations would provide Crowley Marine Services a system that evaluates the level of adherence to company policy, potentially increasing employee support.

Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:16:11 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:09 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Adherance to company policy and accountability for such actions may have prevented the incident. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:00 >STATUS: Forward--->Forward

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Report of Investigation >NEW OWNER: COMDT 545 Concur. Crowley management is responsible for the corporate culture where complacency is discouraged and robust bridge resource practices are encouraged. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:15 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:15: The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

---------------->(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:16: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions: Proposed Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7138: Chemical Testing Review Actual Start Date: 01/20/2010 Actual Completion Date: 01/20/2010

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Following the grounding of the PATHFINDER, chemical testing was completed onboard the vessel by the Master and Chief Mate. Crowley Marine Services maintains an adequate program and ensures their personnel are trained by a third party in specimen collection procedures following a Serious Marine Incident. However, several mistakes were made on the chain of custody form as well as during the collection process. Fortunately, the mistakes were not so egregious as to prevent them from being useable. However, it is imperative that post-casualty drug testing be completed in accordance with applicable regulations. It is recommended that Crowley Marine Services review its policies regarding chemical testing following a Serious Marine Incident, specifically, who is authorized to test, documentation, and chain of custody. Crowley Marine Services should make the necessary changes to prevent future oversight of the requirements. It is also recommended that Crowley Marine Services review its determination policy on when it is appropriate to send a third party collector to the site of an incident. A letter from the District Seventeen Drug and Alcohol Program Inspector has been submitted to Crowley Marine Services addressing this recommendation.

Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:16:51 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:14 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Following proper procedures may have alleviated any fatal flaws.

---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:03 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, District Seventeen DAPI letter to Crowley Marine Services dtd 26Jan10.

-----------------

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation >USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:16 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:16: We note this recommendation was forwarded to Crowley Marine Services on January 26, 2010 by U.S. Coast Guard Seventeenth District. D. S. Fish By direction

Required Actions: Proposed Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7139: Computer Useage It is recommended that Crowley Marine Services provide additional guidance on the use of computers, electronic media, cell phones, etc., while standing the navigational watch. Company policy states in general terms that the computer should only be used for company business. Recommend company policy be expanded upon to include times for use that are appropriate (outside of a bridge watch), and the content that is allowable, specifically, prohibited use of computer games on the bridge. Actual Start Date: 01/20/2010 Actual Completion Date: 01/20/2010

Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:17:31 PM Priority: Normal

8

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:19 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. The Master may not have been distracted from his navigational responsiblities had he adhered to company policy regarding use of the computer on the bridge. Additionally, revising company policy to provide specific examples of inappropriate computer use would provide more clarity to vessel crews. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:07 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. The use of computers, cell phones and other handheld devices is expanding into nearly every facet of daily life. Recently, social media devices and computers took center stage in horrific accidents (commuter train wreck in California caused when the train conductor missed a signal while texting ) or frightening near misses ( the northwest pilots who overflew their destination because they were trying to decipher their work schedule on their laptops). Games, music, phone calls to far away family are a strong temptation and could easily distract a ship's officer from maintaining a proper lookout. Like aviation and rail transportation, the marine transportation system is equally vulnerable to accidents with significant loss of human life. Recommend CG545 promulgate a Safety Alert cautioning the maritime community about the distracting affects of using such devices on the bridge of vessels.

---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:17 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:17:

9

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. Regarding District's additional recommendation to issue a safety alert, Commandant issued a marine safety advisory on distracted operations on October 29, 2010, in response to an earlier National Transportation Safety Board (NTSB) recommendation. D. S. Fish By direction

Required Actions: Proposed Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7140: Training Evaluation During the course of the investigation, it was discovered that the Second Mate was involved in two marine casualties within the last year, which may have indicated a problem with his ability to make sound decisions during critical situations. While interviewing the Master and Chief Mate, both individuals discussed incidents where the Second Mate mistakenly wrapped a line in the screw of a line boat after making an improper judgment call during a training evolution, and again when the Second Mate failed to respond to a steering pump alarm and failure on the PATHFINDER. The Chief Mate and the Master failed to counsel the Second Mate on the proper actions he should have taken in the given situations, nor did they relay their concerns to the company. The Second Mate was never given any remedial training on bridge management and therefore was not aware of his shortcomings. It is recommended that Crowley Marine Services develop a system that requires progress reports of new personnel and trainees be submitted to the company. This would enable the company to identify shortcomings and devise remedial action plans. Actual Start Date: 01/20/2010 Actual Completion Date: 01/20/2010

Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:18:28 PM Priority: Normal Endorsement(s):

10

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:26 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Immediate counselling to discuss shortcoming and remedial actions would provide timely feedback to the individuals involved in casualties. Addtionally, tracking a member's performance and periodic counselling by the supervisor would help identify any trends of performance issues. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:09 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010.

---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:17 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:18: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions: Proposed Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Actual Start Date: 01/20/2010 Actual Completion Date: 01/20/2010

11

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Action Commentary: Safety Recommendation #7141: Night Vision Maintenance At the time of the grounding, the Master was using the computer located on the bridge, which may have affected the Second Mate's or Master's night vision. It is recommended that Crowley Marine Services provide screens for computer monitors or laptops located on the bridge to darken white light being emitted from the computer while in use. Although neither the Second Mate nor the Master identified the computer screen as a latent unsafe condition, the maintenance of night vision in a bridge environment cannot be overstated.

Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:19:21 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:30 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Use of adequate tools would improve night vision on the bridge. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:10 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:18 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action:

12

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:19: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions: Proposed Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7143: Navigational Chart Plotting Standardization It is recommended that Crowley Marine Services establish policy for taking navigational fixes, to include chart markings and proper fix identification (i.e. dead reckoning, global positioning system, estimated position, etc.). At the time of the grounding, there were several marks on the PATHFINDER's chart that were all dissimilar. When questioned about the markings on the chart, the Second Mate stated that each conning officer had his own symbol for a fix, and pointed out his fix signature. The current method of charting or plotting a fix is not standardized and can provide confusion as to who took the fix, when the fix was taken, or what means was used to acquire the fix. Actual Start Date: 01/20/2010 Actual Completion Date: 01/20/2010

Date Created: 01/20/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:19:59 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:31 >STATUS: --->Forward >NEW OWNER: D17 dp

13

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Concur with safety recommendation. Use of standardized chart symbology is good marine practice. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:11 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010. ---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:19 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:19: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions: Proposed Start Date: 01/20/2010 Proposed Completion Date: 01/20/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7190: Increased Navigational Fix Frequency Current Crowley Marine Services policy states that the vessel's position will be charted “every two hours at a minimum”. Any increase in the fix interval is left up to the mariner. Actual Start Date: 01/20/2010 Actual Completion Date: 01/20/2010

14

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation It is recommended that Crowley Marine Services establish a minimum fix interval while vessels transit near shoal waters, known hazards, or in decreased visibility environments. Although in this incident the Master and Second Mate failed to comply with company policy on numerous occasions, a policy mandating an increase in fix intervals when operating in or near known hazards, shoal waters or in decreased visibility can positively impact the safe navigation of Crowley Marine Services' vessels.

Date Created: 02/25/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:20:41 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:37 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Increasing the fix intervals while transiting in hazardous situations would provide the mariner with better awarenss of the vessel's location in relation to such hazards. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:13 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010.

---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:20 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:20:

15

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions: Proposed Start Date: 02/25/2010 Proposed Completion Date: 02/25/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7191: Equipment Failure Tracking It is recommended that Crowley Marine Services review their equipment repair procedures to ensure prioritization of essential navigational equipment. The Electronic Bearing Line (EBL) on the starboard radar had not been operational since October 2009, despite a repair order that had been filed with the maintenance department. According to statements from the crew of the PATHFINDER, this was the second time that this piece of equipment was inoperable. The company's current repair process fails to identify equipment needing immediate repairs, such as an EBL on a radar system. It also fails to recognize essential equipment that has a history of defects. Without changes to the way Crowley Marine Services prioritizes vessel equipment failures and repair times, these failures may directly impact the safe navigation of their vessels. Actual Start Date: 02/25/2010 Actual Completion Date: 02/25/2010

Date Created: 02/25/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:21:19 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:39 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. Maintenance tracking and prioritization are essential to identifying critical equipment failures and repairing such in a timely fashion. -----------------

16

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation >USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:14 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010.

---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:21 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:21: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez. D. S. Fish By direction

Required Actions: Proposed Start Date: 02/25/2010 Proposed Completion Date: 02/25/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Recommendation #7194: Refloat Policy It is recommended that Crowley Marine Services develop a system that requires its Masters to complete a risk assessment prior to refloating a vessel after it has grounded. It is also recommended, when the situation permits, that the Master contacts the company and Coast Guard to discuss threats and option for refloating the vessel. Immediately following the grounding of the PATHFINDER, the Master deemed it appropriate to refloat the vessel. There was no discussion or request for guidance between the Master, Actual Start Date: 02/25/2010 Actual Completion Date: 02/25/2010

17

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Crowley Marine Services or the Coast Guard about whether or not the vessel should be refloated and the manner in which the refloat should be completed.

Date Created: 03/03/2010 Current Owner Unit: Commandant (CG-545) Date Last Modified: 03/31/2011 1:22:03 PM Priority: Normal Endorsement(s): >USER: (b)(6) & (b)(7)(c) MSU Valdez >TIME: 03/04/2010 11:48 >STATUS: --->Forward >NEW OWNER: D17 dp Concur with safety recommendation. A thorough assessment of a grounding situation should be conducted prior to moving any grounded vessel. Fortunately the breaches to the hull were such that refloating the vessel did not negatively impact it's stability. However, refloating the vessel may have caused additional damage to the hull's integrity. ---------------->USER: (b)(6) & (b)(7)(c) D17 dp >TIME: 04/07/2010 15:14 >STATUS: Forward--->Forward >NEW OWNER: COMDT 545 Concur. See attached correspondence, MSU Valdez letter to Crowley Marine Services dtd March 22, 2010.

---------------->USER: (b)(6) & (b)(7)(c) COMDT 545 >TIME: 03/31/2011 13:21 >STATUS: Forward--->Final Agency Action >NEW OWNER: COMDT 545 The final agency action has been determined and approved by CAPT D. S. Fish by direction of the Commandant.

Final Agency Action: Concur- Alternate Acceptable Action >(b)(6) & (b)(7)(c) COMDT 545 >03/31/2011 13:22: We note this recommendation was forwarded to Crowley Marine Services on March 22, 2010 by U.S. Coast Guard Marine Safety Unit Valdez.

18

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation D. S. Fish By direction

Required Actions: Proposed Start Date: 03/03/2010 Proposed Completion Date: 03/03/2010 Estimated Effort to Complete: 0 Staff Days Action Status: Action Commentary: Safety Alerts Actual Start Date: 03/03/2010 Actual Completion Date: 03/03/2010

19

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation IV. FINDINGS OF FACT Subjects of the Investigation Vessels. The following vessels were subjects of this investigation. Particulars for each vessel follow. Vessel Name: Flag: Vessel Identification Number: Call Sign: Status: Role: Vessel Class, Type, Sub-Type: Gross Tonnage(GRT): Net Tonnage(NRT): Deadweight Tons: Length: Home/Hailing Port: Keel Laid Date: Delivery Date: Place of Construction: Builder Name: Propulsion: Horsepower: Master: Classification Society: Owner: PATHFINDER UNITED STATES 524616 WBN8467 Damaged Involved in a Marine Casualty

136.2

AMELIA, MH, UNITED STATES MCDERMOTT SHIPYARD Diesel Reduction 7000 American Bureau of Shipping CROWLEY MARINE SERVICES INC 1102 SW MASSACHUSETTS ST SEATTLE,, WA, 98134 US PUGET SOUND TUG & BARGE CO 14020 SE JOHNSON ROAD SUITE 201 MILWAUKIE, OR, 97267 US

Operator: Inspection Subchapter: Most Recent Vessel Inspection Activity:

Facilities. The following facilities were subjects of this investigation. Particulars for each facility follow.

20

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Parties and Organizations. The following people and organizations were subjects of this investigation.

(b)(6) & (b)(7)(c)
Status: Role: Gender: Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence): Not at Risk Subject of Investigation M

(b)(6) & (

(b)(6) & (b)(7)(c)
(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c) .

(b)(6) & (b)(7)(c)
US Comments:

(b)(6) & (b)(7)(c)
Status: Role: Gender: Age: SSN: Birth Date: Email Address: Phone Number(Daytime Phone): Address(Primary): Not at Risk Medical Review Officer M

215-637-6800 University Services MRO 10551 Decatur Rd Suite 200 Philadelphia, PA 19154 US

Comments:

(b)(6) & (b)(7)(c)
Status: Role: Gender: Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence): Not at Risk Witness M

(b)(6) & (

(b)(6) & (b)(7)(c)
(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c) (b)(6) & (b)(7)(c)
US

Comments:

(b)(6) & (b)(7)(c)

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Status: Role: Gender: Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

(b)(6) & (

Not at Risk Witness M

(b)(6) & (b)(7)(c)
(b)(6) & (b)(7)(c)

(b)(6) & (b)(7)(c) (b)(6) & (b)(7)(c)
US

Comments: MONSEN, RONALD EUGENE Status: Role: Gender: Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

Not at Risk Subject of Investigation M

US Comments:

Status: Role: Gender: Age: SSN: Birth Date: Email Address: Phone Number(): Address(Home/Primary Residence):

Not at Risk Subject of Investigation M

UNITED STATES US Comments:

Status: Role: Gender: Age: SSN: Birth Date:

Not at Risk Witness M

22

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Email Address: Phone Number(): Address(Home/Primary Residence): US Comments: COAST GUARD VALDEZ VTC Status: Role: Email Address: Phone Number(): Address(): Comments: CROWLEY MARINE SERVICES INC Status: Role: Email Address: Phone Number(Work): Address(Primary):

Not at Risk Witness

Not at Risk Subject of Investigation (206) 332-8037 1102 SW MASSACHUSETTS ST SEATTLE,, WA 98134 US

Comments: Drug and Alcohol Testing. The following people have been determined by the Coast Guard, Law Enforcement Personnel, and/or the Marine Employer to have been directly involved in a Serious Marine Incident as defined in 46 CFR 4.03-2: Subject of Investigation MONSEN, RONALD EUGENE; Subject of Investigation Subject of Investigation (b)(6) & (b)(7)(c) Witness (b)(6) & (b)(7)(c) Witness Witness (b)(6) & (b)(7)(c) Response Resources. The following incident response resources were subjects of this investigation. Resource Name: Resource ID: Kind: Sub-Kind: Type: Resource Name: Resource ID: HC130H - 1700 1700 Aircraft (Fixed Wing)

MH60J - 6007 6007

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Kind: Sub-Kind: Type: Resource Name: Resource ID: Kind: Sub-Kind: Type:

Aircraft (Helicopter)

WPB - 1342 1342 Vessels

Other Subjects. The following were subjects of this investigation. Waterway Segment(s). The following waterway segment(s) were subjects of this investigation. PRINCE WILLIAM SOUND Role: Location Local Name: Description: TATITLEK, AK VALDEZ HARBOR Role: Location Local Name: Description: VALDEZ HARBOR, AK

Incident Information Location(s). Description Bligh Reef, Prince William Sound, Alaska PRINCE WILLIAM SOUND Sequence of Events. 10/05/2009 12:00:00 to 12/23/2009 18:15:00 (Estimated): Electronic Bearing Line on the starboard radar was not operational at the time of the incident. There was a work order submitted to the company on October 5th, 2009. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Vessel Material/Equipment Condition Subject Type: Navigation Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Latitude 61 06.5 N 60 51.8664 N Longitude 148 03.5 W 146 40.902 W

24

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Material/Equipment Condition
System: Sub-System: Component: Details: Cite: Navigation Electronic Positioning Radio Direction Finding Device EBL was not operating properly on starboard radar.

12/20/2009 18:15:00 to 12/23/2009 18:15:00 (Estimated): Attached evidence is 96 hour work rest history for subject. Condition Class: Person Condition Type: 96-Hour Work/Rest History Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/20/2009 18:15:00 to 12/23/2009 18:15:00 (Estimated): Attached evidence is the 96 work/rest history for the subject. The subject was unable to give a full work/rest history due to the fact that he did not have the vessel's logs. Condition Class: Person Condition Type: 96-Hour Work/Rest History Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 0:00:00 to 12/23/2009 0:00:00 (Known): The VTS National Standard Operating Procedures Manual states that the VTS may provide navigation assistance service to vessels who request it. It goes on to state that navigation assistance service may include specific warnings to individual vessels.

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name COAST GUARD Party Not at Risk VALDEZ VTC Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Law/Regulation: No Name: VTS NSOP COMDINST M16630.3 Effective Date: 08/18/2009 ISM Policy: No ISO 9001 Policy: No Issued By: Commandant, USCG Policy Nature: General management Reason Inadequate: Instruction clearly articulates the role of the VTS watchstander as an additional navigational tool that a mariner may use. It does not replace mandatory safe practices on the part of the mariner. Latent Unsafe Condition: No

Role Witness

No No

No No

No No

12/23/2009 0:00:00 to 12/23/2009 0:00:00 (Estimated): Alaska Chadux is the Oil Spill Response Organization for the PATHFINDER. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Non-Vessel Material/Equipment Condition

26

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Subject Type: Pollution Prevention/Response Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER Details Filed: None 12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Crowley Marine Services does not have established ice scouting areas, or transit areas for its assigned Ice Scout vessels. Policy only exists regarding instruction on what to look for and how to work with tank vessels proceeding in and out of the port. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name CROWLEY MARINE Party Not at Risk SERVICES INC Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented:

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Role Subject of Investigation
No No

No No

No No

Policies/Procedures that Do Not Exist Explanation of Nonexistence: There is no policy for vessel routing or transit areas for ice scouting missions. Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate

27

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Latent Unsafe Condition: No

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Capt. Monsen admittedly suffered from constant stress caused by his wife being disabled/handicapped at home in Anchorage. Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Type Name MONSEN, RONALD Party EUGENE Details Filed: Personnel Condition
Human Factors: Human Factor: Factor Type: Factor Sub-Type: Description: Anchorage. Latent Unsafe Condition:

Status Not at Risk

Role Subject of Investigation

Psychosocial Factors Family Captain's wife is disabled and at home by herself in No

Merchant Mariner: Yes Personnel Credentials: Credential Number: 1121418 Issue Date: 04/28/2006 Expiration Date: 04/28/2011 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON COASTAL WATERS; ALSO RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Master

33 Years Months Time in Position 15 Years, 0 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): The Master had 33 years in the industry, had worked on the PATHFINDER for more than 10 years and was planning on retiring within the next 8 months.

28

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Type Name MONSEN, RONALD Party EUGENE Details Filed: Personnel Condition

Status Not at Risk

Role Subject of Investigation

Human Factors: Human Factor: Overall experience Factor Type: Psychological Factors Factor Sub-Type: Experience and Recency Description: The Master had become complacent when it came to following company policies. He had worked with the company for a number of years and had transited through the area frequently. Latent Unsafe Condition: No Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 04/28/2006 Expiration Date: 04/28/2011 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON COASTAL WATERS; ALSO RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Master

33 Years Months Time in Position 15 Years, 0 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to Crowley Marine Services' policy, the Master was required to keep an accurate deck log, ensure that a proper lookout was maintained, ensure vigilance was maintained on the bridge, ensure that the voyage plan is laid out and checked in advance, and on transfer of watch plot the vessel's position, intended track, course and speed, obtaining confirmation of the same. Condition Class: Policy, Procedures, or Regulations

29

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name MONSEN, RONALD Party Not at Risk EUGENE Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes

Role Subject of Investigation
No No

No No

No No

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to Crowley Marine Services' policy regarding watchstanding and change of watch, the watch shall not be relieved until both the off-going and on-coming watch personnel are satisfied in the exchange and understanding of pertinent watch standing information, such as, but not limited to: orders, position, course, speed, navigational hazards, traffic, and prevailing conditions. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details:

30

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Name MONSEN, RONALD EUGENE Details Filed: None (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation Subject of Investigation

Party

Not at Risk

Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes No No

No No

No No

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Crowley Marine Services' Directive VDZ 09-008 states that any time a watch change occurs, log entries are to be signed by both the off-going and oncoming watchstanders and, when underway, include an entry of the vessel's position. Anyone must be able to accurately reconstruct the voyage if necessary. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name CROWLEY MARINE Party Not at Risk SERVICES INC Details Filed: Policy/Regs/Procedures Condition

Role Subject of Investigation

31

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes No No

No No

No No

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Regarding General Navigation and Navigation Safety, Crowley Marine Services' policy states: "The watch will not allow himself to be distracted when accurate and timely navigation is critical." Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name MONSEN, RONALD Party Not at Risk EUGENE Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented:

Role Subject of Investigation
No No

No No

No No

32

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): According to the Master and Chief Mate, an electronic charting system called Nobletech was removed from the PATHFINDER after it failed, never to be replaced. The Master felt that this equipment was very useful as a navigational tool. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Vessel Material/Equipment Condition Subject Type: Navigation Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Material/Equipment Condition
System: Navigation Sub-System: Piloting/Steering Component: Marine Charts Details: Electronic charting system called NOBLETECH removed from vessel. According to company, system was to be used primarily for tanker assist tugs. Cite:

12/23/2009 7:00:00 to 12/23/2009 18:15:00 (Estimated): Over the past year the Second Mate had been involved in two separate incidents that should have led to concern in his judgment and abilities but failed to be addressed by the company. See MISLE Activity Numbers 3674494 and 3674499 for incident details. Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W

33

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Subject(s) and Details: Name

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Personnel Condition
Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Information Processing Description: The Chief Mate voiced concern over the ability of the Second Mate during his interview, and was witness to the Second Mate wrapping a line in the lineboat's propeller. The Chief Mate failed to inform Crowley Marine Services of this concern. Latent Unsafe Condition: Yes Merchant Mariner: Yes Personnel Credentials: Credential Number: 000017988 Issue Date: 07/23/2009 Expiration Date: 03/23/2014 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS UPON OCEANS; MASTER OF STEAM OR MOTOR VESSEL OF NOT MORE THAN 1600 GROSS REGISTERED TONS (DOMESTIC VOYAGE), 3000 GROSS TONS (ITC TONNAGE) UPON OCEANS. Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

Years Months Time in Position

MONSEN, RONALD Party EUGENE Details Filed: Personnel Condition

Not at Risk

Subject of Investigation

Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Perceptions Description: While the Second Mate was standing a bridge watch a steering pump failure occurred. The Second Mate failed to act accordingly resulting in the master having to take over. Latent Unsafe Condition: Yes Merchant Mariner: Personnel Credentials: Credential Number: Issue Date: Expiration Date: Issuing Authority: Yes 1121418 04/28/2006 04/28/2011 United States

34

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED) EXPIRES APRIL 2011. Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Master

33 Years Months Time in Position 15 Years, 0 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

(b)(6) & (b)(7)(c)

Party

Not at Risk

Subject of Investigation

Details Filed: Personnel Condition
Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Information Processing Description: The Second Mate was involved in two separate incidents within the last year that should have brought into question his ability to make sound decisions when on the bridge by himself or when faced with a difficult situation. Latent Unsafe Condition: Yes Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 08/05/2009 Expiration Date: 10/08/2013 Issuing Authority: United States Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSEL OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Trainee Second Mate

1 Years 6 Months Time in Position 0 Years, 6 Months, 0 Days 0 Years, 6 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

35

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation 12/23/2009 13:45:00 to 12/24/2009 1:00:00 (Estimated): PATHFINDER U/W from SERVS mooring Buoy 1 for Ice Scouting tasking Action Type: Bridge Operations - Shiphandling Action Class: Maneuver vessel in accordance with conning orders Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 14:02:00 to 12/23/2009 14:05:00 (Estimated): PATHFINDER calls VTC on VHF to inform of being underway from SERVS buoy #1 for ice report. Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Communications Details
Communications Description: Communications Type: Sent or Received: Means of Communication: Communication Acknowledged: Communication Protocols: Communications Effectiveness: Effectiveness Description: Interference Difficulties: Interference Description: Vessel informs traffic that they are underway Ship to Shore Sent Verbal Yes Transmitted via Channel 13 Communication Effective

12/23/2009 16:49:00 to 12/23/2009 16:55:00 (Estimated): PATHFINDER reports to VTC via VHF that they are off of Bligh Reef and have "no ice." Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W

36

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Subject(s) and Details: Name

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Communications Details
Communications Description: Communications Type: Sent or Received: Means of Communication: Communication Acknowledged: Communication Protocols: Communications Effectiveness: Effectiveness Description: Interference Difficulties: Interference Description: Ice reports passed to VTC Ship to Shore Sent Verbal Yes Transmitted via Channel 13 Communication Effective

12/23/2009 16:50:36 to 12/23/2009 16:55:00 (Estimated): PATHFINDER receives word from SERVS duty officer that they are to remain in the vicinity of Bligh Reef and provide another ice report at 1800. Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Communications Details
Communications Description: on scene until 1800. Communications Type: Sent or Received: Means of Communication: Communication Acknowledged: Communication Protocols: Communications Effectiveness: Effectiveness Description: Interference Difficulties: Interference Description: SERVS base informed vessel that they would need to remain Ship to Shore Received Verbal Yes Communication Effective

12/23/2009 16:59:30 to 12/23/2009 17:05:00 (Estimated): It is Crowley Marine Services' policy that all reliefs will be logged, and that prior to relief the oncoming watch (Conn) will have ascertained the location or current position of the vessel. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition

37

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty
No No

Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Vessel: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Vessel: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Vessel: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Law/Regulation: No Name: Vessel Operations: Voyage Management Effective Date: 02/10/2009 ISM Policy: No ISO 9001 Policy: No Issued By: Crowley Maritime Corporation Policy Nature: Division of tasks and responsibilities Reason Inadequate: Policy clearly outlines the responsibilities of watchstanders in regards to watch relief. Latent Unsafe Condition: Yes

No No

No No

12/23/2009 17:00:00 to 12/23/2009 17:22:00 (Estimated): In order to skip waypoints in the GPS, the Master, Chief Mate and Second Mate admittedly had to go into the GPS operator's manual for directions. The GPS is described as being difficult to use with this function. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Vessel Material/Equipment Condition Subject Type: Navigation Location: Known; US Waters

38

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Material/Equipment Condition
System: Navigation Sub-System: Electronic Positioning Component: GPS/DGPS Receiver Details: The feature which allows the operator to "skip" waypoints requires a review of the operator's manual. Cite:

12/23/2009 17:00:00 to 12/23/2009 17:30:00 (Estimated): Master came up to the bridge and relieved the Chief Mate for dinner, assuming the Conn. Master admittedly did not take a fix, check the radars, or log a relief. Action Type: Bridge Operations - Changing Watch Action Class: Ensure that watch is relieved Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name

Type Party

Status Not at Risk

Role Subject of Investigation Subject of Investigation

Details Filed: None MONSEN, RONALD EUGENE Details Filed: None

Party

Not at Risk

12/23/2009 17:14:00 to 12/23/2009 18:30:00 (Estimated): The vessel was in auto pilot. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Maneuverability Condition Subject Type: Vessel Maneuverability Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Maneuverability Details
Handling Characteristics

39

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Angle of Turn: Rudder Angle: Advance: Transfer: Length Between Perpendiculars: Tactical Diameter: Maneuverability Rating: Control Configuration Critical System Alarm Vessel Control Status Location of Navigation Controls: Location of Officer with the Conn: Diving (Ballast) Vertical Maneuvering Capabilities: Ballast Control Power Adequacy Evaluation: Hydrodynamics Bank Cushion: Bank Suction: Current Effect: Squat: Other Effects: Pilots/Tugs Pilot Aboard: AIS Onboard/Operating: Escort Tugs Required: Present: Assist Tugs Present: Navigation Type of Navigation Equipment: Required/Additional: Operational/Malfunctioning: Location: Approved Equipment: Unapproved Items Used: Equipment Tested: Equipment Serviced: Required Equipment Missing: Equipment Used Properly: Applicable Charts On Board: Chart Number: Mapping Agency: Used Corrected Errors Degrees Degrees Meters Meters

No No No No No

No No No No No Auto pilot Additional Equipment Operational No No No No No Yes Yes

No No No

40

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation 12/23/2009 17:15:00 to 12/23/2009 18:01:00 (Estimated): Master brought the throttles back to one throttle ahead slow, making four to five knots, steering a 140 course, abeam Bligh Reef. Action Type: Bridge Operations - Shiphandling Action Class: Maneuver vessel in accordance with conning orders Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 17:20:00 to 12/23/2009 18:30:00 (Estimated): Second Mate arrives on the Bridge after eating dinner. Action Type: Bridge Operations - Changing Watch Action Class: Ensure that watch is relieved Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 17:21:59 to 12/23/2009 17:45:00 (Estimated): There was no relief or watch change brief conducted, no fix taken and no log entry made to indicate the Second Mate relieved the Conn. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Procedure Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Policy/Regs/Procedures Condition
ISM Code Data

41

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Does the ISM Code apply to the Vessel: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Vessel: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Vessel: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes No No

No No

No No

12/23/2009 17:22:00 to 12/23/2009 17:25:00 (Estimated): Second Mate laid down a fix on the chart at 1722 that he describes as "for his information only". Action Type: Bridge Operations - Grounding Avoidance and Navigation Action Class: Determine vessel position by use of available systems Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Detail Description
The Second Mate was on the bridge to relieve the watch from the Captain so the Captain could lay below. The Second Mate laid down a fix but claims it was for his information purposes only. Crowley Marine Services' policy requires that the positioning of the vessel is ascertained prior to relief. Proper reliefs per company policy were not conducted.

12/23/2009 17:22:30 to 12/23/2009 18:15:00 (Estimated): Second Mate reports that at the time he arrived on the bridge and checked the GPS for his fix, the route was on inbound with the next waypoint being Rocky Point. The "dogleg" and Bligh Reef waypoints had been manually "skipped". Condition Class: Person Condition Type: Personnel Condition

42

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Personnel Condition
Human Factors: Human Factor: Factor Type: Factor Sub-Type: Description: switched to inbound. Latent Unsafe Condition: Psychological Factors Knowledge The Second Mate noticed that the GPS had been Yes

Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 08/05/2009 Expiration Date: 10/08/2013 Issuing Authority: United States Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSELS OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED) Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Trainee Second Mate

1 Years 6 Months Time in Position 0 Years, 6 Months, 0 Days 0 Years, 6 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

12/23/2009 17:30:00 to 12/23/2009 17:44:00 (Estimated): Master laid below for dinner, leaving the Second Mate on the Bridge. Action Type: Bridge Operations - Changing Watch Action Class: Ensure that watch is relieved Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details:

43

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Type Name MONSEN, RONALD Party EUGENE Details Filed: Detail Description

Status Not at Risk

Role Subject of Investigation

Master departed the bridge without ensuring the Second Mate knew the position of the vessel, discussing the course and speed of the vessel or ensuring a log entry was made. All are violations of company policy.

12/23/2009 17:44:00 to 12/23/2009 18:15:00 (Estimated): Master returns to the bridge from dinner. Action Type: Bridge Operations - Changing Watch Action Class: Ensure that watch is relieved Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 17:45:00 to 12/23/2009 17:50:00 (Estimated): The Chief Mate reports having "poked" his head back on the bridge before going to bed and observed the Master working on the GPS. Action Type: Bridge Operations - Bridge Communications Action Class: Communicate and coordinate effectively among the vessel’s crew (Bridge, Engine, and Deck) Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 17:47:00 to 12/23/2009 18:00:00 (Estimated): Master was reportedly on the bridge computer shortly after leaving the GPS, and admittedly, checked weather, looked at company email and resumed playing hearts/solitaire. Action Type: Bridge Operations - Bridge Communications Action Class: Communicate and coordinate effectively among the vessel’s crew (Bridge, Engine, and Deck) Location: Known; US Waters

44

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 17:47:10 to 12/23/2009 18:00:00 (Estimated): The computer on the bridge is located on the port after shelf requiring its operator to be facing aft. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Non-Vessel Material/Equipment Condition Subject Type: Communications Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER Details Filed: None 12/23/2009 17:47:20 to 12/23/2009 18:15:00 (Estimated): The computer screen on the bridge was not protected from emitting high glare or white light into a visually sensitive area. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Vessel Material/Equipment Condition Subject Type: Communications Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Material/Equipment Condition
System: Sub-System: Component: Details: Cite: Operations/Management Vessel Safety Management Company Verification/Review/Evaluation Computer screen was not protected.

12/23/2009 17:50:00 to 12/23/2009 18:14:00 (Estimated): On scene weather

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Condition Class: Marine Environment Condition Type: Marine Environment Subject Type: Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Status Type Name PRINCE WILLIAM Waterway SOUND Details Filed: Marine Environment Details
Weather Conditions: Weather Forecast Conditions Wind Speed: Wind Direction: Wind Gusts: Ceiling: Sky Conditions: Air Temperature: Weather/Precipitation: Visibility/Precipitation: Visibility: Precipitation (24 hr period): Sea Level Pressure: Weather a Forecast Obtained: Date/Time Obtained: Source of Forecast: How were Conditions Predicted: Weather Forecast Error: Water Conditions: Water Forecast Water Temperature: Water Depth/River Stage: Tide: Tidal Current Speed: Tidal Current Direction: River Current Speed: River Current Direction: Ice Coverage: Character of Ice: Wave Height: Wave Direction: Wave Period: Swell Height: Swell Direction: Swell Period: Warnings in Effect: Was a Water Forecast Obtained: Date/Time Obtained: Source of Forecast: Actual Water Conditions °F (Feet above MLLW) Knots Knots % feet seconds feet seconds Actual Weather 25 Knots 130 30 Knots Feet Sky obscured 39° F Rain 0.5 nm 29.63 Millibars

Role Location

No

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Water Forecast Error: Latent Unsafe Condition: No

12/23/2009 17:50:30 to 12/23/2009 17:52:00 (Estimated): Second Mate reports seeing the Bligh Reef racon on radar off the vessel's port side, while on a course of 140. Action Type: Bridge Operations - Visual Monitoring and Lookout Action Class: Maintain lookout to detect objects, traffic, or navigational aids and assess visibility Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 17:55:00 to 12/23/2009 18:00:00 (Estimated): Master believed he was in the "dogleg" portion of the track which would have allowed the vessel to transit clear of Bligh Reef. The "dogleg" portion of the track is northwest of Bligh Reef. Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Type Name MONSEN, RONALD Party EUGENE Details Filed: Personnel Condition

Status Not at Risk

Role Subject of Investigation

Human Factors: Human Factor: Other attention information Factor Type: Psychological Factors Factor Sub-Type: Attention Description: Master believed he was in a position other than where the vessel was actually positioned because he had not ascertained the vessels' position prior to changing course and speed. Latent Unsafe Condition: Yes Merchant Mariner: Personnel Credentials: Credential Number: Issue Date: Expiration Date: Issuing Authority: Yes 1121418 04/18/2006 04/28/2011 United States

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED) EXPIRES APRIL 2011 Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Master

33 Years Months Time in Position 15 Years, 0 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

12/23/2009 18:00:00 to 12/23/2009 18:00:30 (Known): Second Mate communicated ice report to SERVS base and received "release from ice scout" orders from SERVS base and was to return to Valdez. Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Communications Details
Communications Description: Communications Type: Sent or Received: Means of Communication: Communication Acknowledged: Communication Protocols: Communications Effectiveness: Effectiveness Description: Interference Difficulties: Interference Description: Telephone call to SERVS base Ship to Shore Sent Verbal Yes Communication Effective

12/23/2009 18:01:00 to 12/23/2009 18:02:00 (Estimated): Second Mate made radio call to VTC to inform of the release from ice scout and that they would be returning to Valdez. Action Type: Bridge Operations - Bridge Communications Action Class: Establish and maintain VHF radio communications with other vessels and appropriate shore authorities

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Communications Details
Communications Description: Communications Type: Sent or Received: Means of Communication: Frequency/Channel Power Setting: Communication Acknowledged: Communication Protocols: Communications Effectiveness: Effectiveness Description: Interference Difficulties: Interference Description: VHF radio call to VTC Ship to Shore Sent Communications Equipment Channel 13 Yes Communication Effective

12/23/2009 18:01:12 to 12/23/2009 18:01:45 (Estimated): Second Mate returns to the "operating station/chair" after calling and receiving release from ice scouting. Action Type: Bridge Operations - Shiphandling Action Class: Maneuver vessel in accordance with conning orders Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 18:01:13 to 12/23/2009 18:10:00 (Estimated): Master reached over the Second Mate and altered speed to all ahead full, and altered course to approximately 025 after getting the word that the PATHFINDER was cleared to transit back to Valdez. Action Type: Bridge Operations - Shiphandling Action Class: Maneuver vessel in accordance with conning orders Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details:

49

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 18:01:14 to 12/23/2009 18:15:00 (Estimated): Master did not know the actual position of the vessel prior to changing course. Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Type Name MONSEN, RONALD Party EUGENE Details Filed: Personnel Condition
Human Factors: Human Factor: Factor Type: Factor Sub-Type: Description: Latent Unsafe Condition:

Status Not at Risk

Role Subject of Investigation

Psychological Factors Knowledge Master believed the vessel was in another position. Yes

Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 04/28/2006 Expiration Date: 04/28/2011 Issuing Authority: United States Ratings/Endorsements: MASTER OF TOWING VESSELS OF NOT MORE THAN 200 GROSS REGISTERED TONS (DOMESTIC TONNAGE), 500 GROSS TONS (ITC TONNAGE) UPON NEAR COASTAL WATERS; ALSO, RADAR OBSERVER (UNLIMITED) EXPIRES APRIL 2011. Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Master

33 Years Months Time in Position 15 Years, 0 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation 12/23/2009 18:01:15 to 12/23/2009 18:07:00 (Estimated): Second Mate turned to the chart table to log position and weather. Action Type: Bridge Operations - Grounding Avoidance and Navigation Action Class: Check and update navigation charts and publications Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Detail Description
The Second mate felt uncomfortable with the Master reaching across his lap to increase the vessel's speed. The Second Mate decided to leave the conning chair and begin to complete his required log book entries. The 1800 log book entry included the vessel's position, on-scene weather and the statement that the vessel was released from ice scout.

12/23/2009 18:01:20 to 12/23/2009 18:01:30 (Estimated): Master made the comment to the Second mate, after changing course and speed to "take us home". Action Type: Bridge Operations - Bridge Communications Action Class: Communicate and coordinate effectively among the vessel’s crew (Bridge, Engine, and Deck) Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name MONSEN, RONALD Party Not at Risk EUGENE Details Filed: Communications Details
Communications Description: Master. Communications Type: Sent or Received: Means of Communication: Communication Acknowledged: Communication Protocols: Communications Effectiveness: Effectiveness Description: Master. Interference Difficulties: Interference Description:

Role Subject of Investigation

Verbal communication between the Second Mate and the Internal Sent Verbal No No log entries were made confirming who had the watch. Problems Interpreting Communication The Second Mate never admits to hearing this from the

12/23/2009 18:01:21 to 12/23/2009 18:06:00 (Estimated): Second Mate believed that the Master's actions in changing the course and speed to return home indicated the Master had the

51

707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Conn. The Second Mate stated he asked the Master if he had the Conn, with the Master indicating he did because he was still on the bridge. Condition Class: Person Condition Type: Personnel Condition Subject Type: Person Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Personnel Condition
Human Factors: Human Factor: Factor Type: Psychological Factors Factor Sub-Type: Information Processing Description: Second Mate believed the Master had the Conn of the vessel. The Second Mate reportedly questioned the Master, and the Master replied that he did. Latent Unsafe Condition: Yes Merchant Mariner: Yes Personnel Credentials: Credential Number: Issue Date: 08/05/2009 Expiration Date: 10/08/2013 Issuing Authority: United States Ratings/Endorsements: THIRD MATE OF STEAM OR MOTOR VESSELS OF ANY GROSS TONS UPON OCEANS. RADAR OBSERVER (UNLIMITED). Upgrade Date: Personnel Training: Personnel Experience: Total Time in Industry: Positions Held: Position Trainee Second Mate

1 Years 6 Months Time in Position 0 Years, 6 Months, 0 Days 0 Years, 6 Months, 0 Days

Experience in Current Type of Position: Other Experience (Shipboard): Other Experience (Shoreside):

12/23/2009 18:01:45 to 12/23/2009 18:15:00 (Estimated): Master returned to the computer after altering course and speed. Action Type: Bridge Operations - Bridge Communications

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Action Class: Communicate and coordinate effectively among the vessel’s crew (Bridge, Engine, and Deck) Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 18:07:00 to 12/23/2009 18:10:00 (Estimated): Second Mate returned to the starboard radar and attempted to locate the Bligh Reef racon using the 3-6 mile scales. After several attempts, the Second Mate was unable to locate the racon on the radar and began scanning for the Bligh Reef Light through the starboard side windows of the bridge, never looking ahead. Action Type: Bridge Operations - Grounding Avoidance and Navigation Action Class: Determine vessel position by use of available systems Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 18:08:00 to 12/23/2009 18:15:00 (Estimated): The Second Mate was required by Crowley Policy to notify the Master when he was unsure of the vessel's position. He failed to do this when he was unable to locate the Bligh Reef Light. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Policy Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: Policy/Regs/Procedures Condition
ISM Code Data

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: Yes No No

No No

No No

12/23/2009 18:10:00 to 12/23/2009 18:15:00 (Estimated): Second Mate returned to the chart table to lay down a fix after not being able to locate Bligh Reef on radar or visually out of the starboard side windows. Second Mate noticed that the speed at this time was 13.2 kts. Action Type: Bridge Operations - Grounding Avoidance and Navigation Action Class: Determine vessel position by use of available systems Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name (b)(6) & (b)(7)(c)

Type Party

Status Not at Risk

Role Subject of Investigation

Details Filed: None 12/23/2009 18:12:00 to 12/23/2009 18:45:00 (Estimated): PATHFINDER grounded on Bligh Reef. The vessel was outside of the traffic separation scheme and returning from ice scouting operations. Event Type: Grounding Event Class: Outside marked channel Event Subclass: Full Control Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Latitude: 61 06.5 N Subject(s) and Details: Name PATHFINDER

Longitude: 148 03.5 W

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Grounding Details
Type of Grounding: Type of Bottom: Depth of Water: Charted: Actual: Recorded: Part of Vessel Aground: Vessel Course: Vessel Speed: Steering Functional: Propulsion Functional: Hazard to Navigation: ATON Survey Required: Fuel On Board: Cargo On Board: Cargo Name Additional Information: Hard Rock 16 Feet Feet Feet Centerline Midships 25 True 13.2 Knots Fully Fully No Yes diesel Quantity

12/23/2009 18:13:00 to 12/23/2009 18:15:00 (Estimated): Master called Valdez Traffic to report that the PATHFINDER had run aground on Bligh Reef. Action Type: Other Actions - Reporting/Notifications Action Class: Report/Notification of Casualty or Incident Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name MONSEN, RONALD EUGENE Details Filed: None

Type Party

Status Not at Risk

Role Subject of Investigation

12/23/2009 18:15:00 to 12/27/2009 18:15:00 (Estimated): ACOE CODE 4816 includes Bligh Reef where the incident occurred Condition Class: Marine Environment Condition Type: Waterway Condition Subject Type: Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation Subject(s) and Details: Status Type Name VALDEZ HARBOR Waterway Details Filed: Environmental Damage Details Details Filed: Waterway Condition
Waterway Characteristics Waterway Description: Approach Constriction: Waterway Constriction: Constriction Description: Narrow Channel: Anchorage: Fleeting Area: Visibility Obstructions: Shoreline Congestion: Channel Crossing: Bridges: Number of Turns: Blind Turns: Ferry Crossings: Junctions: Aids to Navigation (ATON) Was ATON involved in any way: Latent Unsafe Condition: No

Role Location

Open Open No No No No No No No No No No

No

12/23/2009 18:20:00 to 01/20/2010 18:45:00 (Estimated): Failure of the forward side of approximately frame 8 of the hull structure and keel both port and starboard to approximately frame 42 in way of the #3 centerline fuel/oil tank. The damage to the hull was primarily centered near the keel with opening from 2" to approximately 18" along the keel structure. There is further damage in way of the props and rudders. Event Type: Material Failure (Vessels) Event Class: Construction/Loadline Event Subclass: Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Material/Equipment Failure
System: Construction/Loadline Sub-System: Hull Component: Keel Plate Failure: Yes Category: Non-Catastrophic Failure Requiring Repair/Replacement Details: Failure of the keel and associated plating from approximately frame 8 to frame 42, sustained from grounding and removal from Bligh Reef. Cite:

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Equipment Approval Information Q-Number: Manufacturer: Serial No: Year Built: Description:

12/23/2009 18:20:01 to 01/05/2010 13:00:00 (Estimated): Vessel schematics from a sister ship to the PATHFINDER was used in determining the potential amount spilled. It was later determined that the tank sizes were not the same and there was no record of the actual tank size on the PATHFINDER. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Cargo Condition Subject Type: Bunker/Fuel/Lube Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER Details Filed: None 12/23/2009 18:21:00 to 12/28/2009 23:59:08 (Known): PATHFINDER discharged approximately 6410 gallons of diesel into Prince William Sound. The initial spill was caused when the vessel struck Bligh Reef. A secondary spill occurred when the vessel was being lightered on 25-Dec-09. Event Type: Damage to the Environment Event Class: Oil Discharge Event Subclass: Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Name PATHFINDER

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

Details Filed: Discharge Details
Substance Name: Oil: Diesel Potential Volume/Amount: 36000 Gallon (known) Potential Only: No Discharge/Released Amount: Situation: Impacted Medium and Amount: 6000 Gallon (estimated) Point-source discharge over a period of time

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Water 6000 (estimated) Circumstances/Means Halted: The upward pressure of the water inside the breached fuel tank kept the diesel fuel from completely discharging. Not Discharged/Released Amount: 30000 Gallon (estimated) Method Contained/Accounted For: Substance Name: Oil: Diesel Potential Volume/Amount: Potential Only:

36000 Gallon (estimated) No

Discharge/Released Amount: 410 Gallon (estimated) Situation: Point-source one-time discharge Impacted Medium and Amount: Water 410 (estimated) Circumstances/Means Halted: During lightering operations, the back pressure in the tank was disrupted causing diesel to discharge from the tank. Lightering operations were immediately halted. Not Discharged/Released Amount: 35590 Gallon (estimated) Method Contained/Accounted For:

12/23/2009 18:25:00 to 12/23/2009 18:45:00 (Estimated): Master made a decision to navigate off of the reef and find a safe anchorage area. The vessel was free of the reef at approximately 1845. Action Type: Bridge Operations - Shiphandling Action Class: Maneuver in accordance with sea/river/weather conditions Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Type Status Role Name MONSEN, RONALD Party EUGENE Details Filed: None

Not at Risk

Subject of Investigation

12/23/2009 21:00:00 to 12/23/2009 21:40:00 (Known): Chemical testing/Post Casualty Action Type: Other Actions - Drug and Alcohol Use and Testing Action Class: Take Alcohol Test - Post-casualty Location: Known; US Waters Description: Bligh Reef, Prince William Sound, Alaska Latitude: 61 06.5 N Longitude: 148 03.5 W Subject(s) and Details: Type Status Role Name Party

Not at Risk

Subject of Investigation

Details Filed: Drug and Alcohol Test Details
Sample Collection

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Reason for Sample: Post-casualty Date/Time Directed: 12/23/2009 9:00:00 PM Means of Direction: Directed By: Organization: Marine Employer Description: Crowley Marine Directed to get DOT Test: Yes Chemical Test Sample Provided: Yes Chemical Test Type: Alcohol Sample Type: Breath Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Chemical Test Type: Dangerous Drugs Sample Type: Urine Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: No Field Sobriety Test Field Sobriety Test Performed: No Alcohol Analysis Method of Analysis: Breath Test Instrument Used: Lifeloc Technologies Date/Time Results Obtained: 12/23/2009 9:00:00 PM Results: Agency Conducting Analysis: Crowley Marine Description of Analysis: Irregularities in Analysis: No Drug Analysis Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED, Norristown, PA 19403 DOT Protocols Used: Yes Test Results: Medical Review Officer: (b)(6) & (b)(7)(c) MRO Conclusions: Sample Transferred and Chain of Custody Complete: Yes Drug Re-Analysis

Party

Not at Risk

Subject of Investigation

Details Filed: Drug and Alcohol Test Details
Sample Collection Reason for Sample: Date/Time Directed: Means of Direction: Post-casualty 12/23/2009 9:00:00 PM Marine Employer

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Directed By: Organization: Marine Employer Description: Crowley Marine Directed to get DOT Test: Yes Chemical Test Sample Provided: Yes Chemical Test Type: Alcohol Sample Type: Breath Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Chemical Test Type: Dangerous Drugs Sample Type: Urine Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Field Sobriety Test Field Sobriety Test Performed: No Alcohol Analysis Method of Analysis: Breath Test Instrument Used: Lifeloc Technologies Date/Time Results Obtained: 12/23/2009 9:00:00 PM Results: Agency Conducting Analysis: Crowley Marine Description of Analysis: Irregularities in Analysis: No Drug Analysis Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED, Norristown, PA 19403 DOT Protocols Used: Yes Test Results: Medical Review Officer: (b)(6) & (b)(7)(c) MRO Conclusions: Sample Transferred and Chain of Custody Complete: Yes Drug Re-Analysis

(b)(6) & (b)(7)(c)

Party

Not at Risk

Subject of Investigation

Details Filed: Drug and Alcohol Test Details
Sample Collection Reason for Sample: Date/Time Directed: Means of Direction: Directed By: Organization: Post-casualty 12/23/2009 9:00:00 PM Vessel Master Marine Employer

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Description: Post Cas. Directed to get DOT Test: Yes Chemical Test Sample Provided: Yes Chemical Test Type: Alcohol Sample Type: Breath Date/Time Sample Taken: 01/23/2010 9:30:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Chemical Test Type: Dangerous Drugs Sample Type: Urine Date/Time Sample Taken: 12/23/2009 9:40:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Field Sobriety Test Field Sobriety Test Performed: No Alcohol Analysis Method of Analysis: Breath Test Instrument Used: Lifeloc Technologies Date/Time Results Obtained: 12/23/2009 9:30:00 PM Results: Agency Conducting Analysis: Crowley Marine Description of Analysis: Irregularities in Analysis: No Drug Analysis Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED, Norristown, PA 19403 DOT Protocols Used: Yes Test Results: Medical Review Officer: (b)(6) & (b)(7)(c) MRO Conclusions: Sample Transferred and Chain of Custody Complete: Yes Drug Re-Analysis

Party

Not at Risk

Witness

Details Filed: Drug and Alcohol Test Details
Sample Collection Reason for Sample: Date/Time Directed: Means of Direction: Directed By: Organization: Description: Directed to get DOT Test: Chemical Test Sample Provided: Post-casualty 12/23/2009 9:00:00 PM

Marine Employer Crowley Marine Yes Yes

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation
Chemical Test Type: Alcohol Sample Type: Breath Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Chemical Test Type: Dangerous Drugs Sample Type: Urine Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Field Sobriety Test Field Sobriety Test Performed: No Alcohol Analysis Method of Analysis: Breath Test Instrument Used: Lifeloc Technologies Date/Time Results Obtained: 12/23/2009 9:00:00 PM Results: Agency Conducting Analysis: Crowley Marine Description of Analysis: Irregularities in Analysis: No Drug Analysis Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED, Norristown, PA 19403 DOT Protocols Used: Yes Test Results: Medical Review Officer: (b)(6) & (b)(7)(c) MRO Conclusions: Sample Transferred and Chain of Custody Complete: Yes Drug Re-Analysis

(b)(6) & (b)(7)(c)

Party Not at Risk Details Filed: Drug and Alcohol Test Details

Witness

Sample Collection Reason for Sample: Post-casualty Date/Time Directed: 12/23/2009 9:00:00 PM Means of Direction: Master Directed By: Organization: Marine Employer Description: Crowley Marine Directed to get DOT Test: Yes Chemical Test Sample Provided: Yes Chemical Test Type: Alcohol Sample Type: Breath Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel

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Report of Investigation
DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Chemical Test Type: Dangerous Drugs Sample Type: Breath Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Field Sobriety Test Field Sobriety Test Performed: No Alcohol Analysis Method of Analysis: Breath Test Instrument Used: Lifeloc Technologies Date/Time Results Obtained: 12/23/2009 9:00:00 PM Results: Agency Conducting Analysis: Crowley Marine Description of Analysis: Irregularities in Analysis: No Drug Analysis Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED, Norristown, PA 19403 DOT Protocols Used: Yes Test Results: Medical Review Officer: (b)(6) & (b)(7)(c) MRO Conclusions: Sample Transferred and Chain of Custody Complete: Yes Drug Re-Analysis

(b)(6) & (b)(7)(c)

Party

Not at Risk

Witness

Details Filed: Drug and Alcohol Test Details
Sample Collection Reason for Sample: Post-casualty Date/Time Directed: 12/23/2009 9:00:00 PM Means of Direction: Vessel Master Directed By: Organization: Marine Employer Description: Crowley Marine Directed to get DOT Test: Yes Chemical Test Sample Provided: Yes Chemical Test Type: Alcohol Sample Type: Breath Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine

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Report of Investigation
Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: No Chemical Test Type: Dangerous Drugs Sample Type: Urine Date/Time Sample Taken: 12/23/2009 9:00:00 PM Sampling Location: Aboard Vessel DOT Protocols Used: Yes Collection Agent Name: Collection Agent's Organization: Crowley Marine Donor Certified: Yes Irregularities Noted: No Transferred/Chain of Custody Complete: Yes Field Sobriety Test Field Sobriety Test Performed: No Alcohol Analysis Method of Analysis: Breath Test Instrument Used: Lifeloc Technologies Date/Time Results Obtained: 12/23/2009 9:00:00 PM Results: d Agency Conducting Analysis: Crowley Marine Description of Analysis: Irregularities in Analysis: No Drug Analysis Analyzing Laboratory: QUEST DIAGNOSTICS INCORPORATED, Norristown, PA 19403 DOT Protocols Used: Yes Test Results: Medical Review Officer: (b)(6) & (b)(7)(c) MRO Conclusions: Sample Transferred and Chain of Custody Complete: Yes Drug Re-Analysis

12/23/2009 23:15:00 to 12/25/2009 0:00:00 (Estimated): Pollution response gear was deployed. Condition Class: Vessel, Facility, Equipment, Gear, or Cargo Condition Type: Non-Vessel Material/Equipment Condition Subject Type: Pollution Prevention/Response Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Name PATHFINDER Details Filed: None 01/05/2010 9:00:00 to 01/05/2010 11:00:00 (Estimated): The Coast Guard District Seventeen Drug and Alcohol Program Inspector audited Crowley Marine Services at the request of MSU Valdez. Several mistakes during the post casualty drug testing were identified and

Type Vessel

Status Damaged

Role Involved in a Marine Casualty

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Report of Investigation recommendations were given to the company to assist in ensuring this does not happen in the future. See Correspondence # 133810. Condition Class: Policy, Procedures, or Regulations Condition Type: Policy, Regs, and Procedures Condition Subject Type: Procedure Location: Known; US Waters Description: PRINCE WILLIAM SOUND Latitude: 60 51.8664 N Longitude: 146 40.902 W Subject(s) and Details: Status Type Name CROWLEY MARINE Party Not at Risk SERVICES INC Details Filed: Policy/Regs/Procedures Condition
ISM Code Data Does the ISM Code apply to the Party: Safety Management System (SMS) implemented: ISO 9000 Data Does ISO 9000 apply to the Party: Quality Management System (QMS) implemented: ISO 14000 Data Does ISO 14000 apply to the Party: Environmental Management System (EMS) implemented: Policies/Procedures that Do Not Exist Explanation of Nonexistence: Major Nonconformity: No Policies/Procedures that Are Not Aboard Explanation why Not Aboard: Major Nonconformity: No Policies/Procedures/Law/Regulation that is Present but Inadequate Law/Regulation: No Name: Vessel Operations Manual Effective Date: ISM Policy: No ISO 9001 Policy: No Issued By: Crowley Marine Policy Nature: Assignment of duties Reason Inadequate: Although the Master and Chief Mate were trained in how to conduct post casualty testing, they failed to complete it properly. The company does not conduct refresher training for their collectors which led to improper collections. Policies/Procedures/Law/Regulation that is Present and Adequate Latent Unsafe Condition: No

Role Subject of Investigation
No No

No No

No No

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Report of Investigation V. CAUSAL ANALYSIS The Initiating Event of the Incident Initiating Event: Grounding (12/23/2009 6:12:00 PM) Production Factors Active Human Failures - Execution Errors - Attention Failures - Inattention errors Description Error; The Master made a decision to make a course change and bring the speed to all ahead full, which in itself was use of a good rule. The fact that he didn't have enough information to determine the vessel's position and failed to chart his intended course made this decision an unsafe act that resulted in the grounding of the vessel. Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Active Human Failures - Planning Errors - Mistakes - Rule-based Mistakes - Use of a bad rule Inadvisable Rule; The Master decided to skip the vessel's normal waypoints for their inbound route. His assumption of where the vessel was located made him believe that by skipping the waypoints the voyage home would be faster. Bridge Operations - Bridge Communications: 12/23/2009 5:45:00 PM, Bligh Reef, Prince William Sound, Alaska, Active Human Failures - Planning Errors - Mistakes - Knowledge-based Mistakes Heuristic "As If" Heuristics; The Master acted on what he perceived to be "good information" on what the position of the vessel was. The only information that he used in determining the vessel's location was experience and the course and speed that they were on. A chart was never consulted or a fix taken to verify this conclusion prior to changing course and speed. Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Active Human Failures - Planning Errors - Violations - Routine adaptation Routine Adaptation; The Master was at the computer playing "hearts" after changing course. This was against company policy on several different levels. First, there needs to be someone actively engaged in pilotage of the vessel or maintaining a plot. Second, there needs to be a "lookout" at all times. Bridge Operations - Bridge Communications: 12/23/2009 6:01:45 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Active Human Failures - Planning Errors - Violations - Willful violation Routine Adaptation; The Master took actions, changed course and speed, without determining the position of the vessel. He failed to pass any information to the Second Mate, who he claims "had the Conn." Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE

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Report of Investigation Routine Adaptation; Due to the bridge configuration, the conning officer is supposed to act as the lookout. In this case, no conning officer was identified, therefore no one was acting as a lookout. Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009 6:01:15 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Routine Adaptation; The Master admittedly did not ascertain the position of the vessel when arriving on the bridge to relieve the Chief Mate for dinner. The Master did not log his relief in the logbook. Crowley Marine Services' policy requires both of these actions to take place prior to relief. Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh Reef, Prince William Sound, Alaska, Routine Adaptation; Master did not follow company policy to lay down a fix or ascertain the position of the vessel prior to watch relief. No watch reliefs were logged as required by company policy. Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Routine Adaptation; The Second Mate arrived on the bridge and failed to follow policy and ascertain the position of the vessel prior to watch relief. The Second Mate failed to log an entry as to the change of watch. The Second Mate failed to ascertain what role he would be playing in the upcoming transit into the port of Valdez after being relieved from ice scouting duties. Bridge Operations - Changing Watch: 12/23/2009 5:20:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Routine Adaptation; The Second Mate failed to follow company policy when he did not notify the Master that he was unable to ascertain the ship's position by radar ranging the racon on Bligh Reef or find the reef visually out of the starboard window. Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009 6:07:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Other Violation Error; The Master returned from dinner but no fix was taken and there was no discussion of the vessel's intentions. The only discussion was about the need to make a call for the 1800 position. There was no relief logged to assign positions on the bridge (i.e. Conning Officer). Bridge Operations - Changing Watch: 12/23/2009 5:44:00 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Master deliberately violated company policy and used the vessel's computer to play hearts or other games, directly after changing course and speed. The Master's actions left the vessel's position unknown, other than an assumption made by the Master on the vessel's previous course. Bridge Operations - Bridge Communications: 12/23/2009 6:01:45 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Second Mate failed to follow company policy and log relief, leaving question as to who had the Conn.

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Report of Investigation Second Mate failed to ascertain the position of the vessel when coming on watch. Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009 6:10:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Preconditions LUCs in People - Limitations of the person - Psychological conditions The Second Mate has a history of failing to act quickly in adverse situations. Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,

(b)(6) & (b)(7)(c)
The Master was planning on retiring in 8 months and had done 33 years with the company. This could indicate a lack of concern, focus, or affect his decision making abilities. Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE LUCs in People - Limitations of the person - Psychosocial conditions According to Captain Monsen, his wife is disabled and in poor health, causing him continual stress and concern over her condition. Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE LUCs in People - Person Mismatches - Mismatches between the person and software, guidance or procedures As part of its management activities, a Vessel Traffic Service (VTS) uses its communications resources to highlight particular information or recommend particular actions to vessel operators, shoreside facilities and other organizations. Recommendations usually are given to resolve miscommunication or otherwise call attention to particular circumstances, hazards, or conflicts when there is doubt that appropriate action is being taken. The PATHFINDER frequently operates in the vicinity of Bligh Reef and did not request navigation assistance from the Prince William Sound VTS. The VTS watch stander did not believe that the PATHFINDER had entered into a hazardous situation due to the fact that ice scout vessels commonly operate in close proximity to known hazards, such as Bligh Reef which is well marked with both a RACON and a light. Additional safeguards have been implemented to address future such operations. Policy, Procedures, or Regulations: 12/23/2009, PRINCE WILLIAM SOUND, COAST GUARD VALDEZ VTC LUCs in People - Person Mismatches - Mismatches between the person and the equipment Crowley reps described the GPS as easy to use. The crew considered it difficult and cumbersome when attempting to skip waypoints. Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 5:00:00 PM, Bligh Reef, Prince William Sound, Alaska, PATHFINDER LUCs in People - Person Mismatches - Mismatches between the person and another person

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Report of Investigation The Second Mate was intimidated by the master's presence on the bridge. The senior/subordinate relationship between the Master and Second Mate led to confusion as to who was conning the vessel. Person: 12/23/2009 6:01:21 PM, Bligh Reef, Prince William Sound, Alaska, (b)(6) & (b)(7)(c) LUCs in Equipment - Improper condition (i.e., wear, etc.) The EBL on the starboard radar was inoperable since October of 2009. Vessel, Facility, Equipment, Gear, or Cargo: 10/05/2009 12:00:00 PM, PRINCE WILLIAM SOUND, PATHFINDER LUCs in Equipment - Mismatch between design use and production activity The computer screen on the laptop computer on the bridge was not protected from emitting white light on the bridge which can affect night vision. Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 5:47:20 PM, PRINCE WILLIAM SOUND, PATHFINDER Workplace Factors LUCs in Supervision - Inadequate guidance The Second Mate was never given a course and speed to steer, or directed to ascertain the position of the vessel prior to or immediately following the course change by the Master. The only command given was "take us home". The Second Mate assumed that the Master still had the Conn even though the Master had his back to the window and was on the computer at the time of the grounding. Person: 12/23/2009 6:01:21 PM, Bligh Reef, Prince William Sound, Alaska, (b)(6) & (b)(7)(c) LUCs in Operations - Operations not in accordance with rules and regulations Both the Master and Second Mate failed to follow policy on keeping logs, watch reliefs, and lookouts. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE LUCs in Known Problem Correction - Corrective actions deferred/ignored The Master and Chief Mate failed to adequately address the known deficiencies of the Second Mate (line in prop and steering failure). Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,

Organization Factors LUCs in Equipment/Facility Resources - Poor design The GPS unit on the vessel was complex, requiring its users to refer to the manual whenever they needed to adjust/change waypoints. Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 5:00:00 PM, Bligh Reef, Prince William Sound, Alaska, PATHFINDER LUCs in Structure - Missing or inadequate accountability for actions On two occasions, the company was made aware of deficiencies in the judgment of the Second Mate, however these deficiencies were not addressed. Person: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND,

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Report of Investigation LUCs in Policies - Inadequate or improper drug and alcohol policies Company's drug and alcohol policy is inadequate. It fails to provide refresher training for their crews to ensure proper drug and alcohol testing is completed. Policy, Procedures, or Regulations: 01/05/2010 9:00:00 AM, PRINCE WILLIAM SOUND, CROWLEY MARINE SERVICES INC LUCs in Operational Culture - Inadequate or absent organizational justice Although the company published numerous policies regarding watchstanding and navigation, there is no procedure in place to ensure the vessel crews are following that policy. Policy, Procedures, or Regulations: 12/23/2009 4:59:30 PM, PRINCE WILLIAM SOUND, PATHFINDER LUCs in Government - Inadequate or absent policies Company's ice scout policy is inadequate. It fails to address the inherent dangers that could be encountered during an ice scout mission. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, CROWLEY MARINE SERVICES INC Defense Factors Defenses that were in place but failed due to inadequacy - Inadequate engineered defenses The electronic bearing line on the vessel's radar had been inoperable for a number of months. The company's maintenance policy is inadequate. Vessel, Facility, Equipment, Gear, or Cargo: 10/05/2009 12:00:00 PM, PRINCE WILLIAM SOUND, PATHFINDER Defenses that were in place but failed due to inadequacy - Inadequate briefings Master made a comment to the Second Mate after changing course and speed to "take us home." The Master did not give the Second Mate information on the vessel's course, speed or anything other than telling the Second Mate to "take us home". The Second Mate did not question the Master, he assumed the Master "knew what he was doing". Bridge Operations - Bridge Communications: 12/23/2009 6:01:20 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE No information was passed regarding vessel's intended course, speed, or intentions, other than doing an 1800 ice report. More importantly, it was not communicated as to who had the Conn of the vessel. Bridge Operations - Changing Watch: 12/23/2009 5:20:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) No information was passed as to who had the Conn, position of the vessel, intended course and speed, and future plans. No log entry was completed. Bridge Operations - Changing Watch: 12/23/2009 5:44:00 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Improper reliefs. No information was passed as to the vessel's position, fix and intended course. Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh Reef, Prince William Sound, Alaska, Defenses that were in place but failed due to inadequacy - Inadequate/incorrect information about hazards

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Report of Investigation Master made the decision to alter course and speed without ascertaining the vessel's position, failing to follow company policies regarding course changes. Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Defenses that could reasonably have been expected but were never put in place - Absence of supervision There is no company policy on appropriate computer use. Bridge Operations - Bridge Communications: 12/23/2009 5:47:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Active Human Failures - Execution Errors - Attention Failures - Inattention Errors Description Error; The Master believed that he was in a different location at the time of the action. His action would have been correct if the vessel was actually in the "dogleg", as he incorrectly assumed. The error is a result of the Master assuming the vessel's position. If there would have been good communication and company policy followed, a fix would have been laid down to ascertain the position of the vessel and a course would have been plotted on the chart prior to the course change. Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Active Human Failures - Planning Errors - Violations - Willful violation Routine Adaptation; Watch reliefs were not properly conducted and a fix of the position of the vessel was not done. Reliefs were not logged. Bridge Operations - Changing Watch: 12/23/2009 5:00:00 PM, Bligh Reef, Prince William Sound, Alaska, Routine Adaptation; The Master failed to pass his intentions to the Second Mate. The Second Mate never logged the relief or took a fix. Bridge Operations - Changing Watch: 12/23/2009 5:30:00 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; The Second Mate never made the Master aware of his concern for the positioning of the vessel or the fact that he could not "find" Bligh Reef Light, visually or via radar. When unsure of the vessel's position, company policy requires the watchstander to inform the Master. Bridge Operations - Grounding Avoidance and Navigation: 12/23/2009 6:07:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Routine Adaptation; After changing course, a fix or the Master's intentions for the transit were never passed to the Second Mate, other than "take us home". Company policy requires the vessel's course, speed and intended track be passed to the oncoming watchstander. Bridge Operations - Shiphandling: 12/23/2009 6:01:13 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Routine Adaptation; The Second Mate "believed" the Master had the Conn after the Master made a course change. Policy requires a watch relief be logged and communicated, which it was not. Adherence to company policy would have answered the question as to who had the Conn prior to the incident. Person: 12/23/2009 6:01:21 PM, Bligh Reef, Prince William Sound, Alaska, (b)(6) & (b)(7)(c)

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Report of Investigation Routine Adaptation; Instead of assuming the vessel's position, the Master was required to ascertain the position of the vessel prior to relief. Company policy requires the vessel's position to be logged upon watch relief. Person: 12/23/2009 5:55:00 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Routine Adaptation; Failure to follow company policy and the Rule of Good Seamanship. Person: 12/23/2009 6:01:14 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Log entries for relief or required fixes were not made after the Chief Mate left the bridge. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, CROWLEY MARINE SERVICES INC Routine Adaptation; Reliefs were not logged. Policy, Procedures, or Regulations: 12/23/2009 4:59:30 PM, PRINCE WILLIAM SOUND, PATHFINDER Routine Adaptation; The Master was not notified when the Second Mate was unsure of intentions for the voyage or positioning of the vessel. Policy, Procedures, or Regulations: 12/23/2009 6:08:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Routine Adaptation; Watch reliefs were not conducted. Policy, Procedures, or Regulations: 12/23/2009 5:21:59 PM, PRINCE WILLIAM SOUND, PATHFINDER Routine Adaptation; Reliefs were not conducted or logged. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Routine Adaptation; Reliefs were not logged and information regarding intentions or the position of the vessel was never ascertained. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Accurate logs per policy were not maintained. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Company policy requires the full attention of the bridge crew while navigating. The Master was playing hearts and the Second Mate was looking at the chart, both with their backs to the forward bridge window, as the vessel grounded. Policy, Procedures, or Regulations: 12/23/2009 7:00:00 AM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; The Master was aware of company policy, but never ascertained the position of the vessel the entire time he was on the bridge. He admittedly didn't have an idea as to where they were prior to the course change. The fact that he went to the computer to play video games after a course change further aggravates the situation and amplifies the lack of attention on the bridge between the Master and Second Mate. Bridge Operations - Bridge Communications: 12/23/2009 6:01:45 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE

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Report of Investigation Routine Adaptation; The Master made the comment "take us home" to the Second Mate and assumed that this was his relief of the Conn. If policy were followed they both would have been comfortable with the vessel's position prior to relief, and a log entry would have been made as to who had control, or the Conn. Bridge Operations - Bridge Communications: 12/23/2009 6:01:20 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Reliefs were not conducted as required. Important information was not passed and log entries were not made. Bridge Operations - Changing Watch: 12/23/2009 5:44:00 PM, PRINCE WILLIAM SOUND, MONSEN, RONALD EUGENE Routine Adaptation; Reliefs were not conducted as required by policy. The position of the vessel and intentions were left unknown. Log entries were not made. Bridge Operations - Changing Watch: 12/23/2009 5:20:00 PM, PRINCE WILLIAM SOUND, (b)(6) & (b)(7)(c) Failures of Defense Against Subsequent Events in the Incident Subsequent Event #1: Material Failure (Vessels) (12/23/2009 6:20:00 PM) Defense Factors Active Human Failures - Planning Errors - Mistakes - Knowledge-based Mistakes - Bias Framing Bias; The master believed that if he stayed on the reef, the vessel would not have been able to be refloated. The actions to remove the vessel caused additional damage to the hull. Bridge Operations - Shiphandling: 12/23/2009 6:25:00 PM, Bligh Reef, Prince William Sound, Alaska, MONSEN, RONALD EUGENE Active Equipment/Material Failures - Active failures of material The vessel grounded on Bligh Reef causing substantial damage to C/L tanks 2 and 3, and several other areas. Material Failure (Vessels): 12/23/2009 6:20:00 PM, Bligh Reef, Prince William Sound, Alaska, PATHFINDER Subsequent Event #2: Damage to the Environment (12/23/2009 6:21:00 PM) Defense Factors Defenses that were in place but failed due to inadequacy - Inadequate supervision The lack of on-scene leadership may have directly affected the amount of fuel recovered. At the incident command post, there was confusion as to who the responsible party was. The vessel was contracted by SERVS and therefore it was believed that they should take part in the response.

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Report of Investigation Vessel, Facility, Equipment, Gear, or Cargo: 12/23/2009 11:15:00 PM, PRINCE WILLIAM SOUND, PATHFINDER Active Human Failures - Planning Errors - Mistakes - Rule-based Mistakes - Misuse of a good rule General Rule; The oil spill response personnel applied good marine practice and stopped the pump when they heard unusual noises. The stopping and restarting of the pump led to the release of additional fuel from the ruptured tank. Damage to the Environment: 12/23/2009 6:21:00 PM, Bligh Reef, Prince William Sound, Alaska, PATHFINDER Active Equipment/Material Failures - Active failures of equipment The vessel grounded removing most of the bottom plating of tanks 2 and 3 centerline. Material Failure (Vessels): 12/23/2009 6:20:00 PM, Bligh Reef, Prince William Sound, Alaska, PATHFINDER

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Report of Investigation VI. REFERRAL FOR ENFORCEMENT ACTION The following referrals for enforcement action have been made as a result of this investigation and represent those instances where the Coast Guard has gathered evidence that indicates one or more alleged violations or offenses may have occurred. Any determinations as to whether or not one or more actual violations or offenses have occurred are documented in the appropriate Coast Guard enforcement activities. Referral #1: USCG v (b)(6) & (b)(7)(c) Party: (b)(6) & (b)(7)(c) Enforcement Action: Suspension and Revocation - Status: Open - In Progress Alleged Violations Cite Date/Time 46CFR5.27 12/23/2009 7:00:00

Event/Action/Condition Location Policy, Procedures, or PRINCE Regulations WILLIAM SOUND

Subject(s) MONSEN, RONALD EUGENE;
(b)(6) & (b)(7)(c)

Evidence 3655472-01- Bridge Log; ; Date/Time Collected: 12/24/2009 3:30:00 PM 3655472-05- Master Statement; ; Date/Time Collected: 12/24/2009 3:41:00 PM 3655472-07- Bridge Log Page from the day of the Grounding; ; Date/Time Collected: 12/24/2009 3:44:00 PM 3655472-09- 2692 and form B; ; Date/Time Collected: 12/24/2009 3:47:00 PM 3655472-10- Chief Mate Statement; ; Date/Time Collected: 12/26/2009 3:49:00 PM 3655472-32- VOM Part D, Vessel Operations; ; Date/Time Collected: 01/04/2010 9:39:00 AM 3655472-31- VOM Part K, Port Transits; ; Date/Time Collected: 01/04/2010 10:05:00 AM 3655472-30- VOM Part G, General Navigation and Navigation Safety; ; Date/Time Collected: 01/04/2010 10:08:00 AM 3655472-29- VOM Part C2, Supervisors/Mates; ; Date/Time Collected: 01/04/2010 10:22:00 AM 3655472-19- Crowley Directive VDZ-09-008; ; Date/Time Collected: 01/04/2010 11:27:00 AM 3655472-18- VOM Part Q, Voyage Routing; ; Date/Time Collected: 01/05/2010 11:29:00 AM 3655472-17- VOM Part R, Watchstanding and Change of Watch; ; Date/Time Collected: 01/05/2010 11:31:00 AM 3655472-16- VOM Part C1, Master; ; Date/Time Collected: 01/05/2010 11:33:00 AM

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Report of Investigation 3655472-15- VOM, Part I, Notifying the Master; ; Date/Time Collected: 01/05/2010 11:35:00 AM 3655472 VR 1Voice Recording of interview with Master; ; Date/Time Collected: 01/05/2010 11:38:00 AM Referral #41: PATHFINDER Damage to the Envirnoment 23DEC09 Party: CROWLEY MARINE Enforcement Action: Administrative Civil Penalty (Class I) - Status: Closed - Payment Received Alleged Violations Cite Date/Time 33USC§ 12/23/2009 1321(b)(3) 18:21:00

Event/Action/Condition Location Damage to the Bligh Environment Reef, Prince William Sound, Alaska

Subject(s) PATHFIN DER

Evidence 3655472-37 ; Photographs of PATHFINDER spill; ; Date/Time Collected: 01/14/2010 8:20:00 AM 3655472-38 ; Pollution Investigator's Statement; ; Date/Time Collected: 01/14/2010 8:24:00 AM Referral #35: USCG v RONALD MONSEN Party: MONSEN, RONALD EUGENE Enforcement Action: Suspension and Revocation - Status: Closed - Administrative Action Alleged Violations Cite Date/Time 46CFR5.27 12/23/2009 7:00:00 46CFR5.29 12/23/2009 18:12:00

Event/Action/Condition Location Policy, Procedures, or PRINCE Regulations WILLIAM SOUND Grounding Bligh Reef, Prince William Sound, Alaska

Subject(s) MONSEN, RONALD EUGENE PATHFIN DER

Evidence 3655472-01- Bridge Log; ; Date/Time Collected: 12/24/2009 3:30:00 PM 3655472-06- 2nd Mate Statement; ; Date/Time Collected: 12/24/2009 3:42:00 PM 3655472-07- Bridge Log Page from the day of the Grounding; ; Date/Time Collected: 12/24/2009 3:44:00 PM 3655472-09- 2692 and form B; ; Date/Time Collected: 12/24/2009 3:47:00 PM

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Report of Investigation 3655472-10- Chief Mate Statement; ; Date/Time Collected: 12/26/2009 3:49:00 PM 3655472-34- LPS Directive 009-001; ; Date/Time Collected: 01/04/2010 3:28:00 PM 3655472-36- Chief Eng. Statement; ; Date/Time Collected: 01/06/2010 3:30:00 PM 3655472-32- VOM Part D, Vessel Operations; ; Date/Time Collected: 01/04/2010 9:39:00 AM 3655472-31- VOM Part K, Port Transits; ; Date/Time Collected: 01/04/2010 10:05:00 AM 3655472-30- VOM Part G, General Navigation and Navigation Safety; ; Date/Time Collected: 01/04/2010 10:08:00 AM 3655472-29- VOM Part C2, Supervisors/Mates; ; Date/Time Collected: 01/04/2010 10:22:00 AM 3655472-19- Crowley Directive VDZ-09-008; ; Date/Time Collected: 01/04/2010 11:27:00 AM 3655472-18- VOM Part Q, Voyage Routing; ; Date/Time Collected: 01/05/2010 11:29:00 AM 3655472-17- VOM Part R, Watchstanding and Change of Watch; ; Date/Time Collected: 01/05/2010 11:31:00 AM 3655472-16- VOM Part C1, Master; ; Date/Time Collected: 01/05/2010 11:33:00 AM 3655472-15- VOM, Part I, Notifying the Master; ; Date/Time Collected: 01/05/2010 11:35:00 AM Referral #34: USCG v CROWLEY MARINE SERVICES, INC. Party: CROWLEY MARINE SERVICES INC Enforcement Action: Administrative Civil Penalty (Class I) - Status: Closed - Agency Action Complete Alleged Violations Cite Date/Time 46CFR4.05-1 12/23/2009 7:00:00

Event/Action/Condition Location Subject(s) Person PRINCE WILLIAM SOUND MONSEN, RONALD EUGENE;
(b)(6) & (b)(7)(c)

Evidence 3655472-043CG-2692 from ROGER G incident; ; Date/Time Collected: 01/28/2010 3:27:00 PM 3655472-044Log from the ROGER G, line boat; ; Date/Time Collected: 01/28/2010 3:27:00 PM

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Report of Investigation

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Report of Investigation APPENDIX 1 - EVIDENCE 3655472 VR 1Voice Recording of interview with Master Collection Information: Date/Time: 01/05/2010 11:38:00 AM Location: MSU Valdez conference room Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; MSU Valdez Tracking: Attachments: - WS210005.WMA; Marine Safety Unit Valdez; 01/07/2010; 3655472 VR2Voice recording of the 2nd Mate Interview Collection Information: Date/Time: 01/05/2010 11:45:00 AM Location: MSU Valdez conference room Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; MSU Valdez Tracking: Attachments: - WS210006.WMA; Marine Safety Unit Valdez; 01/07/2010; 3655472-01Bridge Log Collection Information: Date/Time: 12/24/2009 3:30:00 PM Location: Aboard Vessel Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-01- pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-02Lightering Plan Collection Information: Date/Time: 12/25/2009 3:32:00 PM Location: Crowley Marine Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-02- pdf; Marine Safety Unit Valdez; 02/18/2010;

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Report of Investigation 3655472-03Eninge Room Log Collection Information: Date/Time: 12/24/2009 3:37:00 PM Location: Aboard Vessel Pathfinder Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Engine Room Log.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-04Sounding Sheet Collection Information: Date/Time: 12/25/2009 3:39:00 PM Location: Aboard Vessel Pathfinder Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Sounding Record.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-040CG-2692 rcvd frm company Collection Information: Date/Time: 01/28/2010 10:21:00 AM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-040pdf; Marine Safety Unit Valdez; 01/29/2010; 3655472-041Vessel Logs book Collection Information: Date/Time: 01/28/2010 10:21:00 AM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-041pdf; Marine Safety Unit Valdez; 01/29/2010;

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Report of Investigation 3655472-042Engine room log dtd 07-16-2009 Collection Information: Date/Time: 01/28/2010 10:21:00 AM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-042pdf; Marine Safety Unit Valdez; 01/29/2010; 3655472-043CG-2692 from ROGER G incident Collection Information: Date/Time: 01/28/2010 3:27:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-043pdf; Marine Safety Unit Valdez; 01/29/2010; 3655472-044Log from the ROGER G, line boat Collection Information: Date/Time: 01/28/2010 3:27:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-044pdf; Marine Safety Unit Valdez; 01/29/2010; 3655472-047Vessel Traffic Center Valdez schematic Collection Information: Date/Time: 02/11/2010 9:11:00 AM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-047pdf; Marine Safety Unit Valdez; 02/11/2010;

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Report of Investigation 3655472-048E-VRP for the PATHFINDER Collection Information: Date/Time: 02/10/2010 1:00:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-048pdf; Marine Safety Unit Valdez; 02/11/2010; 3655472-049IO statement Collection Information: Date/Time: 02/05/2010 10:00:00 AM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-049pdf; Marine Safety Unit Valdez; 02/11/2010; 3655472-05Master Statement Collection Information: Date/Time: 12/24/2009 3:41:00 PM Location: Aboard Vessel Pathfinder Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Master Statement.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-050Chapter 2 from the Vessel Traffic Services National Standard Operating Procedures Manual (VTS NSOP) , Commandant Instruction Manual 16630.3 Collection Information: Date/Time: 02/11/2010 11:04:00 AM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments:

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Report of Investigation - 3655472-050pdf; Marine Safety Unit Valdez; 02/11/2010; 3655472-052Alcohol test results for entire crew Collection Information: Date/Time: 02/18/2010 3:44:00 PM Location: MSU Valdez Collected By: USCG Gathered; CWO2, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-052- pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-053Summary of interview with LT conducted by LCDR Collection Information: Date/Time: 01/24/2011 3:46:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; LCDR, USCG, D17 Tracking: Attachments: - VTC Statement.pdf; Marine Safety Unit Valdez; 01/31/2011; 3655472-054Summary of interviews conducted with Mr. conducted by LCDR Collection Information: Date/Time: 01/24/2011 3:46:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; LCDR, USCG, D17 Tracking: Attachments: - VTC Statement.pdf; Marine Safety Unit Valdez; 01/31/2011; 3655472-055Summary of interview with Mr. conducted by LCDR Collection Information: Date/Time: 01/24/2011 3:45:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; LCDR, USCG, D17 Tracking: Attachments:

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Report of Investigation - VTC Statement.pdf; Marine Safety Unit Valdez; 01/31/2011; 3655472-056Summary of interview with OSC conducted by LCDR Collection Information: Date/Time: 01/24/2011 3:26:00 PM Location: MSU Valdez Collected By: USCG Gathered; LT, USCG, MSU Valdez Witnessed By: USCG Witness; LCDR, USCG, D17 Tracking: Attachments: - VTC Statement.pdf; Marine Safety Unit Valdez; 01/31/2011; 3655472-062nd Mate Statement Collection Information: Date/Time: 12/24/2009 3:42:00 PM Location: Aboard Vessel Pathfinder Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 2nd Mate Statement.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-07Bridge Log Page from the day of the Grounding Collection Information: Date/Time: 12/24/2009 3:44:00 PM Location: Aboard Vessel Pathfinder Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Bridge Log short.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-08Vessel Schematic Collection Information: Date/Time: 12/24/2009 3:46:00 PM Location: Aboard Vessel Pathfinder Collected By: USCG Gathered; Witnessed By: USCG Witness; , Tracking: Attachments:

MSU Valdez

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Report of Investigation - Vessel schematic.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-092692 and form B Collection Information: Date/Time: 12/24/2009 3:47:00 PM Location: Aboard Vessel Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-09- pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-10Chief Mate Statement Collection Information: Date/Time: 12/26/2009 3:49:00 PM Location: Crowley Marine Services Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Chief Mate Statement.pdf; Marine Safety Unit Valdez; 12/27/2009; 3655472-11Approved Tow Plan Collection Information: Date/Time: 12/26/2009 10:10:00 AM Location: Crowley Unified Command Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-11- pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-12 Notice Of Federal Interest (NOFI) issued to CROWLEY Collection Information: Date/Time: 12/28/2009 2:22:00 PM Location: VALDEZ Collected By: USCG Gathered; PO , MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-12 .pdf; Marine Safety Unit Valdez;

02/18/2010;

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Report of Investigation 3655472-13SERVS Duty Log Collection Information: Date/Time: 12/29/2009 7:24:00 AM Location: Via Email Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-13- pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-14PPT of various pics on PATHFINDER Collection Information: Date/Time: 12/23/2009 10:22:00 AM Location: Aboard Vessel Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - PATHFINDER Grounding.pps; ; Marine Safety Unit Valdez; 12/31/2009; 3655472-15VOM, Part I, Notifying the Master Collection Information: Date/Time: 01/05/2010 11:35:00 AM Location: Crowley Marine Services, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Voyage Mgmt-Notifying the Master.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-16VOM Part C1, Master Collection Information: Date/Time: 01/05/2010 11:33:00 AM Location: Crowley Marine Services Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Master Masters Authority.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-17-

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Report of Investigation VOM Part R, Watchstanding and Change of Watch Collection Information: Date/Time: 01/05/2010 11:31:00 AM Location: Crowley Marine Services Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Watchstanding and Change of Watch.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-18VOM Part Q, Voyage Routing Collection Information: Date/Time: 01/05/2010 11:29:00 AM Location: Crowley Marine Services, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Voyage Routing.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-19Crowley Directive VDZ-09-008 Collection Information: Date/Time: 01/04/2010 11:27:00 AM Location: Crowley Marine Services, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Crowley Directive VDZ 09-008.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-20Urinalysis Results, (b)(6) & (b)(7)(c) Collection Information: Date/Time: 01/05/2010 11:26:00 AM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - (b)(6) & (b)(7)(c) Results.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-21-

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Report of Investigation Urinalysis Results, Collection Information: Date/Time: 01/05/2010 11:23:00 AM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: Results.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-22Urinalysis Results, (b)(6) & (b)(7)(c) Collection Information: Date/Time: 01/05/2010 11:20:00 AM Location: MSU Valdez Collected By: USCG Gathered; Witnessed By: USCG Witness; , Tracking: Attachments: Results.pdf; Marine Safety Unit Valdez; 01/07/2010;

MSU Valdez

3655472-23Urinalysis Results, (b)(6) & (b)(7)(c) Collection Information: Date/Time: 01/05/2010 11:19:00 AM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: Results.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-24Urinalysis Results for Ronald Monsen Collection Information: Date/Time: 01/05/2010 11:17:00 AM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Monsen Results.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-25-

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Report of Investigation Urinalysis Results for Collection Information: Date/Time: 01/05/2010 11:12:00 AM Location: MSU Valdez Collected By: USCG Gathered; Witnessed By: USCG Witness; , Tracking: Attachments: Results.pdf; Marine Safety Unit Valdez; 01/07/2010;

MSU Valdez

3655472-26Ice Scout Vessel Procedures SERVS Collection Information: Date/Time: 01/04/2010 10:58:00 AM Location: Crowley Marine Services, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - SERVS Ice Scout Vessel Procedures S550108.pdf; Marine Safety Unit Valdez; 01/07/2010; - SERVS Ice Scout Vessel Procedures PG 2.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-27SERVS shift briefing log Collection Information: Date/Time: 01/05/2010 10:51:00 AM Location: Crowley Marine Services Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - SERVS Duty Log.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-28Ice Navigation Procedures Collection Information: Date/Time: 01/04/2010 10:28:00 AM Location: Crowley Marine Services Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VERP Ice Navigation Procedures.pdf; Marine Safety Unit Valdez; 01/07/2010;

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Report of Investigation 3655472-29VOM Part C2, Supervisors/Mates Collection Information: Date/Time: 01/04/2010 10:22:00 AM Location: Crowley Marine Services, Valdez, Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Mate Responsibilities.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-30VOM Part G, General Navigation and Navigation Safety Collection Information: Date/Time: 01/04/2010 10:08:00 AM Location: Crowley Marine Services, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Gen Nav and Nav Safety.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-31VOM Part K, Port Transits Collection Information: Date/Time: 01/04/2010 10:05:00 AM Location: Crowley Marine Services, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Port Transits.pdf; Marine Safety Unit Valdez; 01/07/2010; 3655472-32VOM Part D, Vessel Operations Collection Information: Date/Time: 01/04/2010 9:39:00 AM Location: Crowley Marine, Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - VOM Vessel Operations.pdf; Marine Safety Unit Valdez; 01/07/2010;

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Report of Investigation 3655472-33-

(b)(6) & (b)(7)(c) 96 hr work/rest history
Collection Information: Date/Time: 02/18/2010 3:05:00 PM Location: MSU Valdez Collected By: USCG Gathered; CWO2, USCG, MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 3655472-33- pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-34LPS Directive 009-001 Collection Information: Date/Time: 01/04/2010 3:28:00 PM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Crowley Directive LPS 009-001.pdf; Marine Safety Unit Valdez; 01/06/2010; 3655472-35Work Rest History Collection Information: Date/Time: 01/05/2010 3:27:00 PM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: Work Rest.pdf; Marine Safety Unit Valdez; 01/06/2010; 3655472-36Chief Eng. Statement Collection Information: Date/Time: 01/06/2010 3:30:00 PM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Chief Eng Statement.pdf; Marine Safety Unit Valdez; 01/06/2010;

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Report of Investigation - Chief Engineer Statement Pg 2.pdf; Marine Safety Unit Valdez; 01/06/2010; 3655472-37 Photographs of PATHFINDER spill Collection Information: Date/Time: 01/14/2010 8:20:00 AM Location: MSU VALDEZ Collected By: USCG Gathered; MST3 MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - DSCN0443.JPG; Marine Safety Unit Valdez; 01/14/2010; - DSCN0441.JPG; Marine Safety Unit Valdez; 01/14/2010; - IMG_1394.JPG; Marine Safety Unit Valdez; 01/14/2010; - IMG_1396.JPG; Marine Safety Unit Valdez; 01/14/2010; - 105.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 106.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 107.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 108.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 109.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 110.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 111.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 112.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; - 113.JPG; Red Diesel discharged by PATHFINDER; Marine Safety Unit Valdez; 02/02/2010; 3655472-38Pollution Investigator's Statement Collection Information: Date/Time: 01/14/2010 8:24:00 AM Location: MSU VALDEZ Collected By: USCG Gathered; MST3 Witnessed By: USCG Witness; , Tracking: Attachments: - PI Statement.pdf; Marine Safety Unit Valdez; 3655472-39Starboard radar EBL work order

MSU Valdez

03/29/2010;

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Report of Investigation Collection Information: Date/Time: 01/05/2010 10:07:00 AM Location: Crowley Marine Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - Radar EBL WO.pdf; Marine Safety Unit Valdez; 01/15/2010; - Starboard Radar WO 1.pdf; Marine Safety Unit Valdez; 01/15/2010; 3655472-45 Tank soundings from a third party source of before and after amounts of fuel on board showing 6410 gallons missing. Collection Information: Date/Time: 02/02/2010 2:48:00 PM Location: MSU VALDEZ Collected By: USCG Gathered; MST3 MSU Valdez Witnessed By: USCG Witness; MST2 MSU Valdez Tracking: Attachments: - 3655472-45 .pdf; Marine Safety Unit Valdez; 02/18/2010; 3655472-46 VTC GIS displays of PATHFINDER's track at Bligh Reef Collection Information: Date/Time: 02/02/2010 3:13:00 PM Location: MSU Valdez Collected By: USCG Gathered; MST3 MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 1630-1700.JPG; Marine Safety Unit Valdez; - 1700-1730.JPG; Marine Safety Unit Valdez; - 1730-1800.JPG; Marine Safety Unit Valdez; - 1800-1812.JPG; Marine Safety Unit Valdez; - 1812-1830.JPG; Marine Safety Unit Valdez; 3655472-51Capt. Ronald Monsen 96 hour work rest history Collection Information: Date/Time: 02/18/2010 3:24:00 PM Location: MSU Valdez Collected By: USCG Gathered; Witnessed By: USCG Witness; , Tracking: Attachments:

02/02/2010; 02/02/2010; 02/02/2010; 02/02/2010; 02/02/2010;

CWO2, USCG, MSU Valdez

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Report of Investigation - 3655472-51-

pdf; Marine Safety Unit Valdez;

02/18/2010;

3655472-VTC LogVTC Log for 23 Dec 10 Collection Information: Date/Time: 02/01/2010 3:27:00 PM Location: MSU Valdez Collected By: USCG Gathered; MSU Valdez Witnessed By: USCG Witness; , Tracking: Attachments: - 23DEC09 VTC Log.doc; Marine Safety Unit Valdez; 02/01/2010; 3655472-VTC VoiceVoice Log for VTC Collection Information: Date/Time: 02/01/2010 3:30:00 PM Location: MSU Valdez Collected By: USCG Gathered; Witnessed By: USCG Witness; , Tracking: Attachments: - 01 Track 1.wma; Marine Safety Unit Valdez; 02/01/2010; - 02 Track 2.wma; Marine Safety Unit Valdez; 02/01/2010; - 04 Track 4.wma; Marine Safety Unit Valdez; 02/01/2010; - 03 Track 3.wma; Marine Safety Unit Valdez; 02/01/2010; - 05 Track 5.wma; Marine Safety Unit Valdez; 02/01/2010; - 06 Track 6.wma; Marine Safety Unit Valdez; 02/01/2010; - 07 Track 7.wma; Marine Safety Unit Valdez; 02/01/2010; - 08 Track 8.wma; Marine Safety Unit Valdez; 02/01/2010; - 09 Track 9.wma; Marine Safety Unit Valdez; 02/01/2010; - 10 Track 10.wma; Marine Safety Unit Valdez; 02/01/2010; - 11 Track 11.wma; Marine Safety Unit Valdez; 02/01/2010; - 12 Track 12.wma; Marine Safety Unit Valdez; 02/01/2010;

MSU Valdez

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Report of Investigation - 13 Track 13.wma; Marine Safety Unit Valdez; 02/01/2010; - 14 Track 14.wma; Marine Safety Unit Valdez; 02/01/2010; - 15 Track 15.wma; Marine Safety Unit Valdez; 02/01/2010; - 16 Track 16.wma; Marine Safety Unit Valdez; 02/01/2010; - 17 Track 17.wma; Marine Safety Unit Valdez; 02/01/2010; - 18 Track 18.wma; Marine Safety Unit Valdez; 02/01/2010; - 19 Track 19.wma; Marine Safety Unit Valdez; 02/01/2010; - 20 Track 20.wma; Marine Safety Unit Valdez; 02/01/2010; - 21 Track 21.wma; Marine Safety Unit Valdez; 02/01/2010; - 22 Track 22.wma; Marine Safety Unit Valdez; 02/01/2010; - 23 Track 23.wma; Marine Safety Unit Valdez; 02/01/2010; - 24 Track 24.wma; Marine Safety Unit Valdez; 02/01/2010; - 25 Track 25.wma; Marine Safety Unit Valdez; 02/01/2010; - 26 Track 26.wma; Marine Safety Unit Valdez; 02/01/2010; - 27 Track 27.wma; Marine Safety Unit Valdez; 02/02/2010; - 28 Track 28.wma; Marine Safety Unit Valdez; 02/02/2010; - 29 Track 29.wma; Marine Safety Unit Valdez; 02/02/2010; - 30 Track 30.wma; Marine Safety Unit Valdez; 02/02/2010; - 31 Track 31.wma; Marine Safety Unit Valdez; 02/02/2010; - 32 Track 32.wma; Marine Safety Unit Valdez; 02/02/2010; - 33 Track 33.wma; Marine Safety Unit Valdez; 02/02/2010; - 34 Track 34.wma; Marine Safety Unit Valdez; 02/02/2010; - 35 Track 35.wma; Marine Safety Unit Valdez; 02/02/2010; - 36 Track 36.wma; Marine Safety Unit Valdez; 02/02/2010;

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Report of Investigation - 37 Track 37.wma; Marine Safety Unit Valdez; 02/02/2010; - 38 Track 38.wma; Marine Safety Unit Valdez; 02/02/2010; - 39 Track 39.wma; Marine Safety Unit Valdez; 02/02/2010; - 40 Track 40.wma; Marine Safety Unit Valdez; 02/02/2010; - 41 Track 41.wma; Marine Safety Unit Valdez; 02/02/2010; - 42 Track 42.wma; Marine Safety Unit Valdez; 02/02/2010; - 43 Track 43.wma; Marine Safety Unit Valdez; 02/02/2010; - 44 Track 44.wma; Marine Safety Unit Valdez; 02/02/2010; - 45 Track 45.wma; Marine Safety Unit Valdez; 02/02/2010; - 46 Track 46.wma; Marine Safety Unit Valdez; 02/02/2010; - 47 Track 47.wma; Marine Safety Unit Valdez; 02/02/2010; - 48 Track 48.wma; Marine Safety Unit Valdez; 02/02/2010; - 49 Track 49.wma; Marine Safety Unit Valdez; 02/02/2010; - 50 Track 50.wma; Marine Safety Unit Valdez; 02/02/2010; - 51 Track 51.wma; Marine Safety Unit Valdez; 02/02/2010; - 52 Track 52.wma; Marine Safety Unit Valdez; 02/02/2010; - 53 Track 53.wma; Marine Safety Unit Valdez; 02/02/2010; - 54 Track 54.wma; Marine Safety Unit Valdez; 02/02/2010; - 55 Track 55.wma; Marine Safety Unit Valdez; 02/02/2010; - 56 Track 56.wma; Marine Safety Unit Valdez; 02/02/2010; - 57 Track 57.wma; Marine Safety Unit Valdez; 02/02/2010; - 59 Track 59.wma; Marine Safety Unit Valdez; 02/02/2010; - 60 Track 60.wma; Marine Safety Unit Valdez; 02/02/2010; - 61 Track 61.wma; Marine Safety Unit Valdez; 02/02/2010;

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Report of Investigation - 62 Track 62.wma; Marine Safety Unit Valdez; 02/02/2010; - 65 Track 65.wma; Marine Safety Unit Valdez; 02/02/2010; - 66 Track 66.wma; Marine Safety Unit Valdez; 02/02/2010; - 67 Track 67.wma; Marine Safety Unit Valdez; 02/02/2010; - 68 Track 68.wma; Marine Safety Unit Valdez; 02/02/2010; - 69 Track 69.wma; Marine Safety Unit Valdez; 02/02/2010; - 70 Track 70.wma; Marine Safety Unit Valdez; 02/02/2010; - 71 Track 71.wma; Marine Safety Unit Valdez; 02/02/2010; - 72 Track 72.wma; Marine Safety Unit Valdez; 02/02/2010; - 73 Track 73.wma; Marine Safety Unit Valdez; 02/02/2010; - 74 Track 74.wma; Marine Safety Unit Valdez; 02/02/2010; - 75 Track 75.wma; Marine Safety Unit Valdez; 02/02/2010; - 76 Track 76.wma; Marine Safety Unit Valdez; 02/02/2010; - 77 Track 77.wma; Marine Safety Unit Valdez; 02/02/2010; - 78 Track 78.wma; Marine Safety Unit Valdez; 02/02/2010; - 79 Track 79.wma; Marine Safety Unit Valdez; 02/02/2010; - 80 Track 80.wma; Marine Safety Unit Valdez; 02/02/2010; - 81 Track 81.wma; Marine Safety Unit Valdez; 02/02/2010; - 82 Track 82.wma; Marine Safety Unit Valdez; 02/02/2010; - 83 Track 83.wma; Marine Safety Unit Valdez; 02/02/2010; - 84 Track 84.wma; Marine Safety Unit Valdez; 02/02/2010; - 85 Track 85.wma; Marine Safety Unit Valdez; 02/02/2010; - 86 Track 86.wma; Marine Safety Unit Valdez; 02/02/2010; - 87 Track 87.wma; Marine Safety Unit Valdez; 02/02/2010;

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Report of Investigation - 88 Track 88.wma; Marine Safety Unit Valdez; 02/02/2010; - 58 Track 58.wma; Marine Safety Unit Valdez; 02/02/2010; - 63 Track 63.wma; Marine Safety Unit Valdez; 02/02/2010; - 64 Track 64.wma; Marine Safety Unit Valdez; 02/02/2010;

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation APPENDIX 2 - CORRESPONDENCE 133802 - Letter of concern to Crowley from MSU Valdez Source: USCG Type: Outgoing Sent: To Crowley Maritime, Valdez on 02/04/2010 9:46:00 AM Attachments: - Crowley Letter.pdf; Marine Safety Unit Valdez; 02/04/2010; 133803 - Letter of Prediciation to CGIS Source: USCG Type: Outgoing Sent: To Sec Anchorage on 02/04/2010 9:48:00 AM Attachments: - Letter of Predication.pdf; Marine Safety Unit Valdez; 02/19/2010; 133810 - Drug and Alcohol Inspector Recommendations letter Source: USCG Type: Outgoing Sent: To Crowley Marine, FL on 02/04/2010 10:19:00 AM Attachments: - DAPI letter.pdf; Marine Safety Unit Valdez; 02/04/2010; 134717 - Interested Party Letter from attorney representing (b)(6) & (b)(7)(c) Source: 3rd Party Type: Incoming Received: At MSU Valdez on 01/08/2009 9:12:00 AM Attachments: - (b)(6) & (b)(7)(c) lawyer.pdf; Marine Safety Unit Valdez; 02/18/2010; 134790 - Monsen Lawyer Change Source: USCG Type: Incoming Received: At MSU Valdez on 02/19/2010 12:53:00 PM Attachments: - Monsen Lawyer change.pdf; Marine Safety Unit Valdez; 02/19/2010; 136853 - Safety Recommendations Letter Source: USCG Type: Outgoing Sent: To hand delivered to 11:00:00 AM Attachments:

Crowley Marine on 03/23/2010

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707.300.110429.USCGPathfndrFAMrpt.pdf Received 5/5/2011

Report of Investigation - Safety Recommendations Letter.pdf; Marine Safety Unit Valdez; 03/23/2010;

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