— 13 NTSB. MAR. Sinking of the Amphibious Passenger Vehicle Miss Majestic…May 1, 1999.

— 13 USCG. Investigation into…Sinking…Miss Majestic…Lake Hamilton…May 1, 1999.

Narrative Information

NTSB: “On May 1, 1999, the amphibious passenger vehicle Miss Majestic, with an operator and 20 passengers on board, entered Lake Hamilton near Hot Springs, Arkansas, on a regular excursion tour. About 7 minutes after entering the water, the vehicle listed to port and rapidly sank by the stern in 60 feet of water. One passenger escaped before the vehicle submerged but the remaining passengers and the operator were trapped by the vehicle’s canopy roof and drawn under water. During the vehicle’s descent to the bottom of the lake, 6 passengers and the operator were able to escape and, upon their reaching the water’s surface, were rescued by pleasure boaters in the area. The remaining 13 passengers, including 3 children, lost their lives. The vehicle damage was estimated at $100,000.

“The Safety Board’s investigation of this accident identified the following major safety issues:

. Vehicle maintenance,

. Coast Guard inspections of the Miss Majestic,

. Coast Guard inspection guidance,

. Reserve buoyancy, and

. Survivability.

“The National Transportation Safety Board determines that the probable cause of the uncontrolled flooding and sinking of the Miss Majestic was the failure of Land and Lakes Tours, Inc., to adequately repair and maintain the DUKW. Contributing to the sinking was a flaw in the design of DUKWs as converted for passenger service, that is, the lack of adequate reserve buoyancy that would have allowed the vehicle to remain afloat in a flooded condition. Contributing to the unsafe condition of the Miss Majestic was the lack of adequate oversight by the Coast Guard. Contributing to the high loss of life was a continuous canopy roof that entrapped passengers within the sinking vehicle.” (NTSB. Sinking of the Amphibious Passenger Vehicle Miss Majestic, Lake Hamilton, Near Hot Springs, Arkansas, May 1, 1999, p. v.)

USCG Summary: “On May 1, 1999, at about 1158 local time, the Coast Guard inspected small passenger vessel M/V MISS MAJESTIC rapidly sank in 60 feet of water about 250 yards west of St. John’s Island in Lake Hamilton, near Hot Springs, Arkansas. Flooding of the vessel was not known to those on board before down-flooding over the stern was imminent. The vessel sank in less than 30 seconds after the master recognized the vessel was in distress. The vessel’s master and seven of the twenty passengers escaped from the vessel after it sank and made it to the surface alive. Thirteen of the twenty passengers were found drowned in or near the vessel as it rested on the bottom. The vessel was salvaged, having sustained only minor damage from the sinking.” (p. 1)

USCG Findings of Fact:

“1. MISS MAJESTIC was built in 1944 as an amphibious truck (DUKW) for the government of

the United States. (p. 4) ….

“3. The MISS MAJESTIC had the following fundamental modifications for passenger service. These modifications are typical for DUKWs used in passenger service, although details vary.

Installation of 8 rows of school bus type seating, outboard of a centerline aisle for access.

Installation of a hinge mounted ladder on centerline at the stern, for boarding the vessel.

Raising and lengthening the canopy, making it high enough to allow persons to stand.

Installation of roll-up vinyl windows, to provide shelter from the weather.

Removal of the forward bilge pump and disabling of original bilge piping.

Installation of 3 electric bilge pumps, all operated with a single switch:

1100 gph pump to port of the Higgins bilge pump, discharging near the driver seat.

750 gph pump aft of the port rear wheel well, discharging next to the boarding ladder.

750 gph pump aft of starboard rear wheel well, discharging next to boarding ladder.

Removal of the drive train serving the after rear axle, including the differential.

Engine changed to V8 and transmission changed to automatic. (pp. 8-9)

“4. In early May 1999, there were about 63 DUKWs across the nation with Coast Guard certificates of inspection for passenger service. They were certificated by seven coastal MSOs and five inland MSOs. The allowed route was typically Rivers or Lakes, Bays and Sounds. Of the ten certificated by MSO Memphis, all operating in Hot Springs, six were owned/operated by Land & Lake Tours and four by National Park Duck Tours. Numerous other DUKWs operate in passenger service, beyond Coast Guard jurisdiction. As an example, there are about 40 Wisconsin Dell Ducks.

“5. In early May 1999, a review of the Coast Guard’s marine casualty data for the period 1992 to 1998 revealed only twelve reported casualty cases. Most of the cases involved collisions, allisions, steering failures, engine shutdowns and/or pollution. The three unintentional flooding cases involved a fracture caused by impact with the ground upon launching, a broken leaf spring penetrating the hull, and damage caused by an oscillating propeller shaft. No evidence was found to indicate any substantial casualty record for Coast Guard inspected DUKW small passenger vessels, specifically no deaths or sinkings.

“6. The owner of the MISS MAJESTIC, Mr. ……, first started to operate DUKWs in passenger service, in Hot Springs, in 1958. The vessels were first subjected to Coast Guard jurisdiction in the mid 1970’s. The owner does not clearly remember why, but believes it was a consequence of a casualty on another owner’s vessel. In 1982 Land & Lakes challenged and was granted exemption by the United States District Court (Western District of Arkansas) from Coast Guard Inspection based on lack of Admiralty jurisdiction. In 1984, the U.S. Court of Appeals for the Eighth Circuit overturned the ruling. The issue under appeal was the Ouachita River being subject to interstate navigation. The appeals court ruled that the waterway was navigable prior to being dammed and commerce laws therefore allowed the Coast Guard jurisdiction on Lake Hamilton, created by damming the Ouachita River.

“7. Mr. ….. has operated DUKWs inspected and certificated by the Coast Guard since the mid 1980s. Once owning 15 DUKWs, Land & Lake Tours owned 12 DUKWs on May 1, 1999, operating only 3 DUKWs at the time due to market conditions. One of these 3 was MISS MAJESTIC, originally named MISS VELDA ROSE when Mr. ….. acquired her in 1962.

Mr. ….. stated he never envisioned or witnessed rapid flooding of a DUKW in his 41 years of managing DUKW passenger vessels. He never heard of a case where passengers had to evacuate through the windows. He remembers one case where a broken metal band clamp on a boot seal caused flooding but the Higgins bilge pump prevented sinking. He never had a marine surveyor evaluate his DUKWs, including as a condition of insurance…. (p. 9)

“10. On May 1, 1999, MSO Memphis had approximately 20 certificated small passenger vessels for which it issued a Certificate of Inspection (COI). Ten of these vessels were DUKWs in Hot Springs. Neither the Officer in Charge, Marine Inspection (OCMI), nor the Chief of Merchant Vessel Safety Branch (the supervisor of marine inspectors) had ever personally inspected a DUKW. Both persons were unaware of any Coast Guard inspection policy documents specific to

DUKWs.

“11. Coast Guard regulations applicable to DUKWs in passenger service are found in Title 46 Code of Federal Regulations (CFR) Subchapter T, Small Passenger Vessels, Parts 175-185. Subchapter T underwent a substantial revision in 1996, including the addition of requirements for bilge high level alarms and operating procedures to improve passenger safety. Coast Guard wide inspection policy applicable to small passenger vessels is contained in the Marine Safety Manual, Navigation and Vessel Inspection Circulars (NVICs), and policy letters issued by the Commandant. In addition to Coast Guard inspection, the DUKWs in Hot Springs were inspected by the State of Arkansas and the City of Hot Springs for safety while operating on land.

“12. Coast Guard wide inspection policy specific to DUKWs is limited to one paragraph in the Marine Safety Manual, volume II, chapter 10. That policy deals with air-cooled engines. MSO Chicago and MSO St. Louis have promulgated multiple page local OCMI policy documents specific to the inspection and certification of DUKWs. Prior to May 1, 1999, MSO Memphis had no inspection policy documents specific to DUKW small passenger vessels.

“13. The 1991 to 1998 vessel inspection records for the MISS MAJESTIC indicate an absence of recorded deficiencies, with the exception of two items which were documented with a form CG-835 in 1995. The Coast Guard’s Marine Safety Information System (MSIS) product set Vessel File Marine Inspection Log (VFMI) for the MISS MAJESTIC shows no deficiencies were recorded in MSIS from 1985 to 1998.

“14. The latest COI for the MISS MAJESTIC was issued on March 11, 1997. The COI is valid for a period of three years, pending satisfactory completion of an annual Reinspection within 60 days of the anniversary of the issue date. The COI limited the vessel’s operation to 250 yards of St. John’s Island and 30 minutes of waterborne operation. The longstanding 30 minute limit was due to the absence of toilet facilities and distress signals on board. The reason behind the longstanding 250 yard limit is not evident from the vessel’s inspection file. The owner stated that the Coast Guard derived the 250 yard limit, for reasons not known to him. For the allowed route, Subchapter T and the COI require life preservers and one life ring buoy as lifesaving equipment.

“15. The last annual Reinspection for the MISS MAJESTIC was conducted by CWO3 ….. from MSO Memphis on February 23. 1999…. (pp. 10-11)

“30. Land & Lake Tours had no organized or formal training program for its DUKW masters, the only crew on the DUKWs during tours. The only training materials held by Land & Lake Tours was Coast Guard license preparation materials from Houston Marine and drug and alcohol program videotapes. Training was conducted on the job by going with more experienced persons and through informal discussions in the office. Discussions involving Ms. Helmbrecht and Mr. …. or Mr. ….. addressed contingencies. The mechanics would also informally train new drivers on using vessel controls. Applying her experience as a school bus driver, Ms. Helmbrecht developed an operational checklist with Mr. to allow her to do her duties well as a DUKW master. Over time, she became comfortable to the point of not using a written checklist. Her routine before operating a DUKW included checking brakes, lights and hull drain plugs.

“31. Land & Lake Tours had no written policy on emergency procedures. No evidence was found to indicate that the emergency instructions required by 46 CFR 185.510 to address fire, heavy weather, and man overboard conditions ever existed. Training consisted of informal discussions in the office. Ms. Helmbrecht had developed a good working relationship with the mechanics, who readily helped her with occasional operational difficulties. Policy amounted to designation of five places on St. John’s Island to exit the water in an emergency, an expectation to rapidly exit the water if the Higgins bilge pump discharged, and an expectation to have the electric bilge pumps turned on at all times while a DUKW was waterborne. Emergency drills were not formally held for the master, the only crew on the DUKWs during tours. However, some unrecorded emergency equipment familiarization was done. Mr. ….. stated that drills were not being recorded, per work list item 1, because corrective actions were focused elsewhere….” (p. 15)

“39. On May 1, 1999, Ms. Helmbrecht and 20 passengers arrived at the water’s edge on St. John’s Island, at about 1150 local time. Her passenger ticket count matched Mr. ….. having conversed using the radio. He did not include in his count one young passenger, because Land & Lake Tours did not charge for children deemed to be infants. Land & Lake Tours generally considered children 2 years of age or younger to be infants….

“42. Ms. Helmbrecht stated that she often offers parents to put life preservers on children. Arkansas state law requires children under the age of 13 to wear a life preserver at all times while aboard recreational boats. The Coast Guard leaves it up to the master to decide when people must put on life preservers on inspected small passenger vessels, per 46 CFR 185.508. No one donned a life preserver for this tour. Mr. …. never consciously thought about having children wear life preservers during DUKW tours.

“45. Approximately seven minutes after entering the water and while rounding Catalina Point, Ms. Helmbrecht felt the MISS MAJESTIC react sluggishly, not very responsive to throttle changes, and list to port. ….. was on a 26 foot long recreational pontoon boat about 60 yards from MISS MAJESTIC’s port quarter. Upon seeing MISS MAJESTIC, he noted her to be exceptionally low in the water. Passenger ….. familiar with recreational boats but not DUKWs, splashed his hand in water over the port side after noticing another passenger being able to touch the water. He looked behind him to see water washing on deck at the last row of seats, the eighth row. He heard passengers at the stern joking about water coming on deck.

“46. Ms. Helmbrecht turned around and made eye contact with Mr. ….. She told him to move to the other (starboard) side to compensate for the list. She attempted to turn the vessel slowly toward shore. Mr. ….. and ….. noticed water on the last foot of floorboards, at row 6. Mr. …..stood to move as asked and looked aft again. This time he noted water on deck under the last 2 rows of seats and felt water over his feet at the fifth row of seats. He knew something was terribly wrong and did not sit down on the starboard side. He remembers Ms. Helmbrecht attempting to increase the speed of the propeller. She noticed water on deck at the stern and over the floorboards near rows 5 and 6. Ms. Helmbrecht told the passengers to get off the vessel because it was going down. She opened a valve in the nearby fixed fire extinguishing system, believing the gas might displace water and add buoyancy. Mr. ….. managed to get a few life preservers down from the overhead stowage. He found the preservers hard to remove from the slide out storage containers against the canopy. He gave them to his wife and daughter. The passengers were generally calm, apparently not aware of the distress, or in shock.

“47. In less than 30 seconds from the recognition of distress, the vessel down-flooded over the stern and went down by the stern with all 21 persons on board. A notch in the raised coaming had been cut out to provide the aisle between the seats. Down-flooding occurred through the notch at first, although some water may have leaked through a deck hatch on the port side aft of the coaming, under the feet of passengers in that location. The bow paused at the surface for less than five seconds, with the bow nearly vertical. Ms. Helmbrecht had never seen water at passengers’ feet or seen it entering a DUKW before. She had never heard of such occurring to other masters.

“48. As the MISS MAJESTIC rapidly sank, passengers floated up under the canopy and forward to the closed windshield. The windshield and forward vinyl windows prevented people from floating free of the vessel, causing them to bump into each other.

“49. After the vessel sank, Ms. Helmbrecht and seven passengers managed to swim through open side windows and make it to the surface, despite disorientation in dark waters and being submerged more than a minute. Many of them were not able to get out of the vessel until it was well submerged. Many of the side windows had clear dimensions of about 24 inches in height and 33 inches in length.

“50. The MISS MAJESTIC landed in about two feet deep soft silt, on her wheels, about 250 yards from Catalina Point on St. John’s Island. The bow was slightly closer to shore, being uphill

from the stern. The vessel appeared to divers to have rolled backward several feet…..

“52. The divers recovered twelve bodies between 1258 and 1545 local time on May 1, 1999. Six deceased passengers were found floating near the driver’s seat inside MISS MAJESTIC. Another six deceased passengers were found scattered about the vessel on the bottom of Lake Hamilton, up to 105 feet from the vessel…. These passengers escaped the vessel alive or floated out of the vessel dead. Garland County Sheriffs lead diver indicated that due to the distance from MISS MAJESTIC that some of the deceased were found, it appears that some of them managed to escape the vessel and tried to swim. He noted that disorientation, darkness and reduced buoyancy with depth affect the ability of people to ascertain the direction to the surface….

“54. The divers recovered the body of a thirteenth passenger, that of James Leon Patton, at 0857 local time on May 2, 1999. All thirteen deaths were caused by drowning. Death certificates for James Leon Patton and Lana Jo Berry also indicate asphyxiation caused by drowning.

“55. The divers noted zero visibility at the 60 foot depth….

“59. MSO Memphis decided to have all DUKW operations in Hot Springs stopped until all DUKW vessels could be specifically examined. However, the owners of both companies in Hot Springs had terminated all tours on their own initiative. Subsequent actions in this matter are separate from this case.

“60. On May 6, 1999, Commandant issued a message to all Marine Safety Offices to call attention to inspection issues on DUKWs. Specifically mentioned for scrutiny were water intrusion points, such as shaft housing boot seals.

“61. On May 9, 1999, the MISS MAJESTIC was salvaged under the supervision of the U.S. Navy Supervisor of Salvage. As the vessel was lifted from the water, water drained out of the aft shaft housing where the aft boot seal was found disconnected from the shaft housing. The vessel was briefly examined on the barge and on shore then moved to temporary storage at the Arkansas Air National Guard facility at Hot Springs Airport.

“62. Examination of the MISS MAJESTIC revealed the following…:

Aft shaft housing dislocated, being pushed into the hull forward.

Aft shaft housing off and in front of the shaft housing support, with deformed housing.

Hinge assembly for positioning shaft housing removed, mounts ground off.(removal is a common practice with some DUKW owners)

Welded lap patch on shaft housing where drive shaft rubs when rear end is low. (common location for needing repairs)

Boot seal metal band clamp in place on boot seal with 42 notches past the screw head.

The boot seal, when put back on shaft housing with 42 notches past the screw head was

physically loose. (3 turns of the screw were possible and 2 1/4 turns made the clamp reasonably tight. Mr. Woodall felt an in-water test at a boat ramp would likely have indicated the seal loose. He also stated that there existed a good chance the boot seal would have slid off the shaft housing during operation in that tightened condition.)

No raised ring on aft end of shaft housing as on forward end, for keeping boot seals in place.

Path for water ingress through shaft housing annulus. (around 3 inch diameter drive shaft, inside a 5 inch diameter shaft housing)

Key missing from keyway in Higgins bilge pump shaft/chain drive sprocket, gouged shaft.

Leading edge of 1 of 3 vanes on Higgins impeller broken off and missing, scored housing.

Higgins strainer housing off of pump housing and in bilge. (strainer housing cracked at set screw intended to hold it on pump housing)

Higgins strainer screen missing over part of strainer housing.

Upper edge of Higgins inlet pipe fitting located 5 inches above vessel’s bottom plating….

Elbow in Higgins discharge piping not held by flexible hose with metal band clamp.

U-bolt for securing Higgins bilge pump discharge piping elbow missing.

Variety of steel repairs to hull above rear axles. (steel doublers and inserts)

Dime size hole in hull above rear axles. (due to wastage of hull plate)

Electric bilge pumps actual capacity less than rated for no head.

Electric bilge pump switch in the on position.

Ring life buoy attached to vessel with bicycle chain and lock, lock open, no lifeline. (chain bought by Bridges, applied by Helmbrecht, in reaction to theft in town. Helmbrecht unlocked the lock before each tour.)

Hull drain plugs in place, shaft housing drain plugs in place.

Boot seals stretch about 1.5 inches total when aft axle falls due to lack of wheel contact. (driveshaft is splined to allow axial mechanical motion). (pp. 16-21) ….

“Conclusions:

“1. The apparent root cause of this casualty was the unchecked flooding of the MISS MAJESTIC

resulting from the aft shaft boot seal dislodging from the shaft housing at the start of waterborne

operation.

“2. The contributing causes of this casualty are as follows:

Boot Seal Installation: The aft shaft housing boot seal came off of the aft shaft housing

when the MISS MAJESTIC entered the water. The drop of the axle accentuated the

elongated geometry along the shaft housing and resulted in greater tension on the boot

seals. The aft shaft housing boot seal may not have come off of the shaft housing if

(1) that end of the shaft housing had a raised ring like the one on the front end, and/or

(2) the aft shaft housing boot seal metal band clamp was tighter, and/or

(3) the aft shaft housing hinge assembly was in place, and/or

(4) the rear differential had been in place not allowing the forward axle to drop; and/or

(5) the aft seal had been operationally tested in water prior to allowing the vessel to return

to commercial service.

Operator Experience: Ms. Helmbrecht did not notice the discharge from the forward

electric bilge pump due to the position of its discharge point being hidden from her view

and her focus on being a tour guide. She could not have noticed any discharge from the

aft electric bilge pumps due to the locations of their discharge points at the stern. She

would have noticed any substantial discharge from the Higgins bilge pump discharge

point. The presence of a crew member not engaged as a tour guide would likely have led

to earlier recognition of the unintentional flooding and resulted in fewer lives being lost.

Higgins Bilge Pump: The Higgins bilge pump did not work because of the missing key

from the shaft keyway. The cause of the key being missing can not be determined. It

likely sheared or fell out upon the pump ingesting a solid object that broke an impeller

vane. An object could have been ingested through the missing section of the strainer

screen. This may have happened during the short operation of the Higgins bilge pump on

April 29, 1999, or soon after flooding started on May 1, 1999. The assorted damages to

the Higgins pump and its attachments indicate it suffered a dramatic shock. If it was

operational, the Higgins bilge pump would likely have been able to keep up with

flooding, or at least allowed time to beach the MISS MAJESTIC. When the Higgins

bilge pump would have begun to discharge, the increase in draft would have been only a

couple of inches. The water in the bilge would not have reduced vessel maneuverability

appreciably, as it did not a few days before when the pump briefly discharged.

High Level Bilge Alarm: The bilge high level alarms were not installed before the

casualty. Land & Lake Tours failed to understand the recent regulation and failed to install the alarms before the due date and before the casualty….

Compartmentation: Had the MISS MAJESTIC been fitted with watertight compartmentation or flotation materials, the vessel would have not sunk or sank so slowly that passengers would have had ample time to escape the vessel.

Passenger Entrapment: Had the windshield and forward vinyl windows been open, most or all of the passengers would have escaped as the vessel sank. External button snaps could not be quickly undone from behind the windshield. The snaps are of a style that often require a concerted effort to release, even from the button side…. (pp. 25-26.)

USCG Commandant: “I concur that the cause of the sinking of the MISS MAJESTIC was flooding through the aft drive shaft housing after the boot seal had dislodged from the shaft housing. Contributing factors were: the removal of the aft shaft housing hinge assembly; the inoperability of the Higgins bilge pump; the absence of a bilge high level alarm; the lack of operational testing of recent repairs to the aft shaft boot seal; the lack of adequate written maintenance manuals or procedures; the ineffective oversight of the vessel’s operation by the management of Land & Lakes Tours, Inc.; the vessel operator’s failure to recognize the flooding in a timely manner; the poor communications between the vessel mechanic and the Coast Guard inspector; and, the lack of comprehension regarding the Coast Guard inspection program by Land & Lakes Tours, Inc.” (Commandant Comments)

USCG Commandant Response to Recommendations:

“….Recommendation 2: It is recommended that the Commandant of the Coast Guard ensure that every owner of certificated DUKW passenger vessels has a copy of the War Department’s

Technical Manual.

“Recommendation 3: It is recommended that the Commandant of the Coast Guard ensure that

every OCMI certificating DUKW passenger vessels has a copy of the War Department’s

Technical Manual.

“Action on recommendations 2 and 3: I concur with these recommendations. Title 46, Code of Federal Regulations, Subchapter T, Subpart B lists the plans and information required to be submitted by an owner for vessel certification. The War Department’s Technical Manual could be substituted for some of the required plans, but due to the modification of many aspects of present-day DUKW vessels, the manual is not always applicable. However, because I consider the War Department’s Technical Manual to be a valuable resource for the owners of these vessels and for Coast Guard vessel inspection personnel, all known DUKW vessel owners shall be notified on how they can obtain a copy of the manual and each Coast Guard Officer-in-Charge, Marine Inspection (OCMI) shall be provided a copy of the manual.

“Recommendation 4: It is recommended that the Commandant of the Coast Guard encourage or

require crews to be present at annual inspections of small passenger vessels.

“Action: I concur with this recommendation….

“Recommendation 5: It is recommended that the Commandant of the Coast Guard encourage or

require in-water testing of vessel integrity after repairs to the watertight hull and its appendages,

especially for DUKWs and other vessels which do not normally reside in the water.

“Action: I partially concur with this recommendation. All repairs conducted in drydock should be tested in drydock and then re-examined after the vessel is afloat. However, repairs to an amphibious craft’s watertight hull or appendages that cannot be adequately tested out of the water should be tested in water. The Coast Guard will consider this recommendation further

under recommendation 7.

“Recommendation 6: It is recommended that the Commandant of the Coast Guard encourage or require the testing of bilge pumps with water at every Coast Guard triennial inspection and annual reinspection.

“Action: I concur with this recommendation.

“Recommendation 7: It is recommended that the Commandant of the Coast Guard establish a working group of industry experts and DUKW operating companies to develop a compilation of best practices with DUKWs, with emphasis on drive trains and hull integrity. The compilation of best practices should be made readily available to the public.

“Recommendation 8: It is recommended that the Commandant of the Coast Guard publish policy on DUKWs to allow OCMIs to reassess vessel survivability in the face of risk of flooding from drive train breaches and obtain an equivalent level of safety to that is intended in 46 CFR Subchapter T. The policy should be made readily available to the public, including state agencies

that regulate DUKWs operating as passenger vessels on state waters.

“Recommendation 9: It is recommended that the Commandant of the Coast Guard publish policy on inspecting unique features of DUKWs, with emphasis on shaft housings and boot seals. The policy should be made readily available to the public, including state agencies that regulate DUKWs operating as passenger vessels on state waters.

“Recommendation 10: It is recommended that the Commandant of the Coast Guard develop policy on the use of canopies and similar structures on small passenger vessels, with specific consideration of the escape provisions of 46 CFR 177.500.

“Recommendation 13: It is recommended that the Commandant of the Coast Guard encourage OCMIs to re-evaluate the need for requiring more than one person in the crew of inspected vessels where a member of the crew is engaged in service as a tour guide. This is especially true on vessels where the operating station is forward of the passengers.

“Action on recommendations 7 through 10 and 13: I concur with these recommendations insofar as they relate to DUKW vessels. Commandant (G-MOC) shall convene a group of industry and government experts, including DUKW owners and operators and appropriate Coast Guard personnel, to develop comprehensive guidelines relating to the design, maintenance, operation, and inspection of DUKW vessels. When completed, the guidelines will be distributed to all known DUKW owners and operators, to all known state agencies involved with DUKW oversight, and to all appropriate Coast Guard units. In addition, the guidelines will be available on the Coast Guard’s Internet site.

“Recommendation 11: It is recommended that the Commandant of the Coast Guard re-emphasize the need for MSOs to have complete inspection files, including worklists and a MSIS Marine Safety Deficiency Summary containing all deficiencies found.

“Action: I concur with is recommendation….

“Recommendation 12: It is recommended that the Commandant of the Coast Guard consider engaging the Quality Assurance Staff, G-MO-1, to evaluate consistency among MSOs in DUKW

inspection and provide training when needed.

“Action: I concur with this recommendation….

“Recommendation 14: It is recommended that a copy of this report be provided to all states with state regulated DUKWs used in commercial passenger service and all state boating law administrators.

“Recommendation 15: It is recommended that each OCMI be provided with a copy of this report.

“Recommendation 16: It is recommended that the National Transportation Safety Board be provided a copy of this report.

“Action on recommendations 14 through 16: I concur with these recommendations. Commandant (G-MOA) will provide copies of this report as recommended….” (pp. 6-9)

USCG Listing of Deceased (Sep 29, 1999, p. 2):

James Leon Patton
Floye Christine Patton
Jennifer Diane Patton
Ronald Gene Todd
Thomas Cornelius Todd
Emily Anne Todd
Andrea Marie Beasley
Logan Reed Beasley
Melanie Lynn McGuirk
Danna Lynne Morse-Powers
Mary Elaine McGee
Vernon Lee Johnson
Lana Jo Berry

Sources

National Transportation Safety Board. Marine Accident Report. Sinking of the Amphibious Passenger Vehicle Miss Majestic, Lake Hamilton, Near Hot Springs, Arkansas, May 1, 1999 (NTSB/MAR-02/01). Washington, DC: NTSB, adopted 4-2-2002, 73 pages. Accessed 12-11-2015 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/MAR0201.pdf

United States Coast Guard. Marine Board of Investigation. Investigation into the Circumstances Surrounding the Sinking of the M/V Miss Majestic on Lake Hamilton, Hot Springs, Arkansas on May 1, 1999 with Multiple Loss of Life (16732/MC99005211). Washington, DC: Commandant, USCG, Dec 7, 1999, 41 pages. Accessed 12-11-2015: http://www.uscg.mil/hq/cg5/cg545/docs/boards/dukw.pdf

1999, May 1, Miss Majestic DUKW tour boat sinks off St. John’s Isl., Lake Hamilton, AR-13