lornajarrettblanchard

–10 UPI. “Lost ship could be Signaling.” The News, Port Arthur, TX, 7A.
–10 USCG. Marine Casualty Report. MV Holo Holo; Disappearance… 1978… Nov 18, 1981.
— 9 New York Times. “Research Ship Missing After Sailing to Hawaii.” 12-15-1978, p. A25.

Narrative Information

USCG Abstract: “On 9 December 1878 the M/V Holo Holo departed Honolulu, HI with ten persons on board for the purpose of collecting oceanographic data and deploying oceanographic equipment off the western coast of Hawaii. On 12 December the vessel was reported overdue and a ten day search effort commenced utilizing the facilities of the U.S. Coast Guard, Coast Guard Auxiliary, U.S. Navy,, the Civil Air Patrol, the University of Hawaii and the U.S. Air Force. The search failed to locate the Holo Holo.

“On 9 December 1979, the NOAA ship Cromwell detected a sonar signal in response to a triggering signal sent from the ship. On 10 December 1979, experts aboard the Cromwell identified these signals as coming from underwater acoustic devices known to have been on the Holo Holo. Based on this data, the Board concluded that the Holo Holo sank at 20⁰6’N, 156⁰28’N, the location of the acoustic devices….

“The Commandant has concurred with the Marine Board that the most probable cause of the casualty was that the Holo Holo encountered seas of sufficient height and frequency to flood the forecastle, for which drainage was grossly inadequate, to a point where the stability was lost, capsizing the vessel. A probable contributing cause was the vessel’s lack of watertight integrity which would have permitted progressive flooding to occur.” (USCG. Marine Casualty Report. MV Holo Holo; Disappearance in the Pacific Ocean on 11 December 1978 … Nov 18, 1981.)

USCG Marine Board of Investigation: “Findings of Fact:

“1. On the morning of 11 December 1978, the M/V HOLOHOLO did not appear as scheduled at the port of Kawaihae [Island of Hawaii], HI. She had sailed from Honolulu, HI at 1437 (all times HST +10 zone description) on 9 December 1978 with ten persons on board for the purpose of collecting oceanographic data and deploying oceanographic equipment off the western coast of the island of Hawaii. The vessel was last seen off Waikiki shortly after sailing. Neither the vessel nor any of the persons on board are known to have been seen or heard from since that time.

“2. Vessel

Description Obtained From Last Issued Document

Name: HOLOHOLO
….
Gross Tonnage: 134.24
Net Tonnage 91
Register Length: 77.4 feet
Register Breadth: 25.4 feet
Register Depth: 4.6 feet
Place and Year Built: Honolulu, HI in 1963
….
Register Service: Pleasure
Document: Consolidated Certificate of Enrollment and Yacht License issued 1
July 1977 [p. 1.]
“….
“Prior to the September 1978 sale, HOLOHOLO was used exclusively as a pleasure vessel. During October 1978, a contract was executed between…[blacked out ] and the Research Corporation of the University of Hawaii (RCUH) permitting the University of Hawaii to use HOLOHOLO for oceanographic research purposes. Before the December 1978 voyage, the vessel was used on one occasion for oceanographic work. There is no known record of the Coast Guard or the Secretary of Transportation being requested to find (designate) HOLOHOLO an Oceanographic Research Vessel in accordance with 46 USC 441…. [p. 3.]

“Structural Characteristics

“HOLOHOLO was a flat bottomed…steel vessel….No single deck was continuous for the length of the vessel. The forecastle deck was at the 9 moot 8 inch level (above the bottom plating), terminating at frame 14….

“The entire forecastle deck was enclosed by 3 foot solid bulwarks and a thwartship bulkhead at frame 14, 3 foot 8 inches high. There were seven openings in this well…. [p. 6.] Calculations indicate that the forecastle could hold 34.5 long tons of sea water instantaneously…. [p. 8.]

“Hull Structural Alterations

“Between 18 September and 9 December 1978 modifications and additions were made to HOLOHOLO which resulted in penetrations in weathertight and watertight bulkheads and decks as follows: [end of p. 8.]

a. A hatch and associated coaming were removed from the fantail by cutting flush with the main deck, leaving a 2’ by 4’ opening into the steering compartment.

b. A freezer box previously located on the fantail was relocated inside the galley/wet lab compartment….Removal of the associated refrigerant piping left two holes (1/2″ and 3/4″) in the deck of the fantail and through bulkhead 46 between the steering gear room and the after storeroom. Penetrations in the main deck at the new location were required to reactivate the freezer.

c. The entire upper half of bulkhead 46 separating the galley/wet lab compartment from the fantail was removed, leaving the compartment open to the weather.

d. A hydraulic winch was installed on the winch deck (13′ level) aft. The hydraulic pump was installed in the engine room. Penetrations were made in the winch deck at frame 45 ½, the main deck at frame 45 ½, and the after engine room bulkhead using a cutting torch. Two hydraulic lines were installed through these penetrations without stuffing tubes or other provisions for sealing them…. [p. 9.]

“Stability

“….Stability calculations were performed by a staff naval architect of the Ship Characteristics Branch…U.S. Coast Guard Headquarters…The stability calculations indicate that HOLOHOLO would either capsize or founder if both the after store room and steering compartments were flooded. They further indicate that the entrapment of 34.5 long tons of water in the forecastle area was possible. This amount of water in the forecastle, with the vessel on a 10 foot wave, crest amidship, would almost instantaneously reduce the HOLOHOLO’s righting moment to zero…The report concluded that, ‘Capsizing would be inevitable’, under these conditions. A twelve foot high wave with as little as 10 long tons of water in the forecastle well would produce the same result. The calculations were based on static conditions. [end p. 11.]

“3. Personnel Data [Pages 13-17 provide information on the ten people onboard, blacking out names.]

“4. Weather

“The National Weather Service broadcast four marine forecasts per day during December of 1978….At 1100 on Saturday, 9 December 1978 the forecast cancelled existing small craft advisories and indicated, ‘Winds over coastal waters East Northeast 15 knots seas 4 feet… All major channels East Northeast 20 knots seas 8 ft.’ These same conditions were predicted for Sunday. That afternoon, a charter oat operator estimated HOLOHOLO to be operating in two to three foot seas off Waikiki. She further estimated that there were 25 knot winds with four to five foot seas further offshore in the unprotected waters of the Kaiwi Channel, one of the major channels.

“The 1700, 9 December forecast stated, ‘Caution is advised due to marginal wind and sea conditions for all Hawaiian waters… Winds over coastal waters East Northeast 20 knots seas 8 feet… All major channels East Northeast 25 knots seas 10 feet. Other channels around Lanai variable 15 knots seas 4 feet.’ These conditions did not change for the two succeeding broadcasts, except the 0500, 10 December broadcast predicted ‘Channels around Lanai Easterly 20 knots seas 8 feet.’

“The 1100, 10 December forecasts stated, ‘Small craft advisories are effective at 1100 for all Hawaiian waters exposed to strong gusty trades… Winds over coastal waters East Northeast 25 knots seas 10 feet… All major channels East Northeast 30 knots seas 12 feet. Other channels around Lanai Easterly 25 knots seas 10 feet.’

“At 1310 on 10 December, the Army LCU-1573 reported 10-12 foot seas from the East-Northeast in the Alenuihaha Channel. The next day she reported similar seas…. [p. 18.]

“S/V JEANOYCE, crossing the Kaiwi Channel at 1845 on 10 December, estimated the wind at 35 knots from ENE with 20 foot seas. The wave period was described as ‘short and very sharp’.

“The marine weather forecasts remained the same until gale warnings were broadcast at 1700 on 11 December. This forecast stated, in part ‘Gale warnings are effective at 5 PM for all channels exposed to strong gusty trade winds. Small craft advisories remain in effect for other waters around the Hawaiian Islands exposed to the trades…Winds over coastal waters East Northeast 30 nots seas 12 feet…All major channels East Northeast 40 knots seas 20 feet…Other channels around Lanai Easterly 30 knots seas 12 feet.

“Gale warnings remained in effect thereafter until 0500 on 22 December 1978…. [p. 19.]

“The Last Voyage [p. 24.]

“HOLOHOLO was…to call at Kawaihae, Hawaii, 17 miles to the east of the benchmark, on the morning of 11 December 1978 to disembark the two NOAA persons and embark three other scientific personnel…. [p. 26.]

“At least four attempts were made by the scientists to call the HOLOHOLO through the marine operator on 11 December without success…. [p. 30.]

CONCLUSIONS

“1. The exact cause of the casualty is unknown. It is concluded that the most probable cause was that HOLOHOLO encountered seas of sufficient height and frequency to flood the forecastle, for which drainage was grossly inadequate, to a point where stability was lost, capsizing the vessel.
….
b. The acoustic devices which were located by CROMWELL are the ones which were carried by HOLOHOLO. Therefore, the casualty occurred at or near position 20⁰ 6′ N, 156⁰ 28′ W, where the devices were found, and where HOLOHOLO is now located on the bottom.

c. The casualty occurred on 10 December 1978 during the afternoon or evening. Calculating the elapsed time on a direct route between Diamond Head and the presumed location of the casualty, at the estimated speed when last seen, HOLOHOLO reached that point no sooner than 1600 [4 o’clock] on 10 December 1978.

d. Significant wave heights at the probable time and place of the casualty were 14 to 17.5 feet which were in excess of those predicted. It is therefore probable that the vessel encountered occasional wave heights of 22.4 to 28 feet….” [p. 36.]

USCG Commandant’s Action on The Marine Board of Investigation convened to investigate the circumstances surrounding the disappearance of the M/V HOLOHOLO in the Pacific Ocean near the Hawaiian Islands on or about 11 December 1978 with loss of life:

“….It is recognized that the circumstances surrounding the loss of the HOLOHOLO could not be determined with certainty, and that other scenarios are possible. Regardless, the investigation has established that HOLOHOLO departed on its final voyage with a number of serious deficiencies which could have adversely affected the vessel’s ability to survive the sea conditions encountered on 10 December 1978….” [p. ii.]

Newspaper

Dec 14, NYT: “Honolulu, Dec 14 (UPI) — Rescue planes searched the Pacific Ocean south of Hawaii today for a University of Hawaii research vessel with nine men aboard that disappeared in rough weather on a trip between two Hawaiian islands.

“Moderating weather raised hopes that the missing 90‐foot vessel, the Holo Holo, would be found. She vanished after leaving Oahu Saturday [Dec 9] for the island of Hawaii.

“Aboard the vessel, chartered by the University of Hawaii for an ocean study program, were John Laney, the owner; and James Resukas, a crewman; Robert Harvey, Gary Niemeyer and Michael Allen of the University of Hawaii; James Sandusky of El Cerrito, Calif., and Stephen Shannon of Berkeley, Calif., physicists at California’s Lawrence Berkeley Laboratory, and Robert Charnell and Norman Laird of the National Oceanographic and Atmospheric Administration, based in Seattle.” (New York Times. “Research Ship Missing After Sailing to Hawaii.” 12-15-1978, p. A25.)

Sources

New York Times. “Research Ship Missing After Sailing to Hawaii.” 12-15-1978, p. A25. Accessed 6-30-2021 at: https://www.nytimes.com/1978/12/15/archives/research-ship-missing-after-sailing-to-hawaii.html

UPI (United Press International). “Lost ship could be Signaling.” The News, Port Arthur, TX, 7A. Accessed 6-30-2021 at: https://newspaperarchive.com/port-arthur-news-dec-13-1979-p-7/

United States Coast Guard. Marine Casualty Report. MV Holo Holo; Disappearance in the Pacific Ocean on 11 December 1978 with Presumed Loss of Life (USCG 16732/01280). USCG, 11-18-1981.

Wikipedia. “MV Holoholo,” 7-14-2020 edit. Accessed 6-30-2021 at: https://en.wikipedia.org/wiki/MV_Holoholo

— 5 ASN. Accident descrip. USAF Lockheed C-130E, near Hopkinsville-Fort Campbell AAF.
— 5 Baugher, Joseph F. 1968 USAF Serial Numbers. 1-10-2012 revision.
— 5 Daily Herald, Chicago, IL. “Air Force plane crash kills 5.” 12-11-1978, p. 3.

Narrative Information

Baugher: “Lockheed C-130E-LM Hercules….10951 (c/n 382-4331) crashed at Ft. Campbell, KY Dec 10, 1978. All 5 onboard killed (ASN).” (Baugher. 1968 USAF Serial Numbers. 1-10-2012 rev.)

ASN: “….First flight: 1969
“Crew: Fatalities: 5 / Occupants: 5
“Passengers: Fatalities: 0 / Occupants: 0….
“Departure airport: Jacksonville-Little Rock AFB, AR,,,
“Destination airport: Hopkinsville-Fort Campbell AAF, KY…
“Narrative: Crashed on approach due to broken throttle linkage.”

(Aviation Safety Network. Accident Description. United States Air Force, Lockheed C-130E Hercules, 1978, Dec 10, near Hopkinsville-Fort Campbell AAF, KY.)

Newspaper

Dec 11, Daily Herald: “Hopkinsville, Ky. (AP) – A military cargo plane crashed early Sunday in a farm field short of a runway at Fort Campbell Army base in southwestern Kentucky, killing all five crew members aboard, a military spokesman said. Lt. Col. A.T. Brainerd, public information officer at the base, said the Air Force C-130 Hercules crashed while in a landing pattern. The plane was en route to the base from the Little Rock, Ark., Air Force Base, to participate in a training exercise with members of the 101st Airborne Division, Brainerd said.

“It was the seventh fatal crash of a C-130 from the Little Rock base since the planes were deployed there in 1970. The worst accident occurred in 1971 when 10 persons died in the crash of a plane shortly after takeoff.

“A spokesman for the Military Air Command division at Scott Air Force Base in Belleville, Ill., said all C-l30s built before 1973 have been grounded as a result of the crash.

“Brainerd said the plane crashed and burned near the intersection of State highway 1453 and county road 901, about five miles from I-24.

“Sgt. Gary Louden of the Little Rock base, identified four of the dead as Lt. Col. Larry 6. Hodge, 40, of Marion, Ky., the aircraft commander; Capt. Earl R. Gray Jr., 27, of Easton, Kan., navigator; Staff Sgt. Joseph N. Babicz, 28, of Chicago, flight engineer; and Sgt. Donald G. Estes, 26 of Melbourne, Ark. Louden said all four lived in Jacksonville, Ark. The fifth victim was. not immediately identified, pending notification of relatives.” (Daily Herald, Chicago, IL. “Air Force plane crash kills 5.” 12-11-1978, p. 3.)

Sources

Aviation Safety Network. Accident Description. United States Air Force, Lockheed C-130E Hercules, 1978, Dec 10, near Hopkinsville-Fort Campbell AAF, KY. Accessed 3-9-2012 at: http://aviation-safety.net/database/record.php?id=19781210-0

Baugher, Joseph F. 1968 USAF Serial Numbers. 1-10-2012 revision. Accessed 3-5-2012 at: http://www.joebaugher.com/usaf_serials/1968.html

Daily Herald, Chicago, IL. “Air Force plane crash kills 5.” 12-11-1978, 3. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=15808820

–15 Bell. “Fifteen Residents Die in Mental Hospital Fire.” Fire Journal, 73/4, July 1979, p. 68.
–15 Jones. “1978 Multiple-Death Fires: Smoking Materials Lead…” Fire Journal, 73/4, July 1969, p8.
–15 National Fire Protection Association. Key Dates in Fire History. 1996.
–15 National Fire Protection Association. The 1984 Fire Almanac. 1983, p. 137.
–15 National Fire Sprinkler Association. F.Y.I. 1999, p. 6.
–15 NYT. “15 Women Die in Dormitory Fire at School for Mentally Retarded.” 12-10-1978, p.26.
–15 Paris News, TX. “15 Women Die in Dormitory Blaze,” December 10, 1978.

Narrative Information

Bell: “On December 9, 1978, an early morning fire originating in a clothing storage room in a residential custodial-care dormitory at a state mental hospital outside Ellisville, Mississippi, killed 15 of the 63 residents and hospitalized 16 others. Smoke spreading from the storage room simultaneously filled two wards on the top floor of the two-story, fire-resistive building. Primary factors resulting in the fatalities were the lack of compartmentation and automatic sprinkler protection of the storage room, lack of subdivision of the facility by a smokestop partition, lack of an automatic detection and alarm system, and lack of automatic alarm transmission to the fire department. Additional factors contributing to the loss of life included the lack of illumination during the evacuation of residents, limited fire service resources, and the mental and physical handicaps of the residents.

“Magnolia Dormitory, the building in which the fire occurred, was one of approximately 20 residential buildings on the hundred-acre campus of the Ellisville State School, located outside Ellisville, Mississippi. The building, classified according to NFPA 101, the Life Safety Code, as a residential custodial facility, was constructed as a two-story structure in 1962 and operated as a single housing unit. An addition to the ground floor that was built in 1975 allowed each floor to operate as a separate dormitory unit….

“The physical and ambulatory capabilities of the residents varied. Wheelchairs and walkers indicated that a number of residents had difficulty in movement. These residents would have requited assistance in descending the fire escape stairs….

“On the evening before the fire, the residential custodial care facility housed 63 moderately to severely mentally retarded female residents on the first floor ranging in age from 40 to 68. The ground floor contained another housing unit designated as the ‘Swinging 60’s,’ which housed a similar number of both male and female, moderately to severely mentally retarded residents segregated in male and female sleeping wards….

“Magnolia Dormitory was one of three residential buildings on the Ellisville School campus that had been designated for upgrading to state standards for intermediate care and mentally retarded care facilities. In addition, it had recently been further identified for upgrading to skilled nursing facility standards using the requirements of NFPA 101 – 1973 (the Life Safety Code) for new health care occupancies…Funding had been appropriated by the State Legislature at its last session to cover the cost of these renovations. The preliminary plans had been prepared by an architect retained by the state….

“A structural survey completed by the Mississippi State Building Commission had identified the building’s fire protection deficiencies as part of its overall building survey…It the area of Safety Standards…the building received 0 (zero) out of a possible 8 points. The building had an overall rating of Satisfactory-Adequate, based on this rating system.

“The Fire

“On December 9, 1978, three of the six night attendants normally assigned to Magnolia Dormitory were on duty for the night shift. After taking a break, all three attendants were in the Ward 1 area, folding and sorting clothes in two separate clothing storage rooms. A resident of Ward 1 asked one of the attendants for permission to get a drink of water. The resident then walked out of the ward and went to the Day Room. At the same moment, an attendant in Ward 1 asked the other attendant if she smelled something. The resident immediately returned from the Day Room, saying, ‘There’s smoke in the Playroom (Day Room).’ The attendant called to the other two attendants, and told them about the reported smoke. All three attendants ran into the Day Room and found the far (north) end filling with smoke. The time was approximately 1:45 am.

“The first attendant went to the nearby office and telephoned security personnel. She informed the guard who answered that there was a fire in Magnolia Dormitory and that they needed help. The guard did not call the Fire Department; instead, he went to the Magnolia Dormitory, after going to the switchboard operator’s office to give the alarm. The attendant then returned to Ward 1, pulling the double corridor doors closed behind her. (The continued spread of smoke into Ward 1, however, indicated that they were not closed. During a later inspection, it was found that if the doors were not fully closed, with both leaves secured, one leaf had a tendency to swing back into the open position and come to rest parallel to the wall.)

“The attendant immediately went to an area in Ward 1 in which three residents confined to wheelchairs were sleeping, awakened them, and told them to get into their wheelchairs. She then continued down the right-hand row of beds, rousing the residents and telling them to get out of bed and follow her. As the passed the fifth set of beds, she reported later, the lights flickered and went out. (The lights referred to were lights in the storage closed adjoining the ward, not the main ward lights or lights on the emergency lighting circuit.) She then made her way to the rear of the ward to the exit door, opened it, and stayed at the door calling for the residents to come to her. She stayed at this location directing residents to come to her until additional on-duty staff, security personnel, and off-duty staff began to arrive to help her. With this assistance, they began to carry the wheelchair-confined residents down the fire escape stairs and guided the ambulatory residents into the ward on the ground-level floor below.

“Meanwhile, the two remaining attendants had entered the Day Room and found it filling with smoke at the far (north) end. They ran through the Day Room to the north end. They looked down the corridor leading toward Ward 2 and noted that smoke was coming from the clothes storage room that adjoined the corridor ‘as if blown by a fan.’

“Seeing that they could not make it down the corridor to Ward 2 past the door of the clothing storage room, the attendants ran down the open stairway into the women’s ward located in the ‘Swinging 60’s’ area on the ground floor. They went out the exit door to grade level and up the fire escape to the exit door leading to Ward 2. Pulling the door open, they were met by a rush of smoke. They called into Ward 2 for the residents to ‘come to Momma.’ Seeing that Ward 2 was both dark and smoky, both attendants ran back down the stairs. Reentering the ‘Swinging 60’s’ area, they met the female attendant in the female ward, told her that there was fire upstairs, and advised her to get the residents in her ward out of the building.

“One of the attendants then found a flashlight and returned to the exit door of Ward 2, shining it into the ward while calling for the residents to come to the light. The other attendant went to the office in the ‘Swinging 60’s’ area and called the night switchboard operator; she informed her of the fire in Magnolia Dormitory, and said that they could not see because the lights were out. The attendant asked that flashlights be brought. With the flashlights, she was able to evacuate eight to ten residents prior to the arrival of fire fighters.

As the night switchboard operator was taking this call, the security guard came in and told the assistant operator to go to the guard station at the main entrance of the hospital grounds and man it while he went to the Magnolia Dormitory.

“At approximately 1:50 am, about five minutes after discovery of the fire, the night switchboard operator called the Ellisville Fire Department to report the fire. She then called the School’s Director and other staff members on the call list, starting with local Ellisville numbers. Some of the administrative staff members lived in housing directly across Highway 11 from Magnolia Dormitory. This situation was a significant factor in the evacuation and/or rescue of a large number of the Dormitory’s residents.

“The two attendants on the ground floor awakened the residents of the two ground-floor wards, then started moving them to the lobby area to await further evacuation. The lights on the ground floor were turned on and remained on throughout the fire. Some of the ground-floor residents had to be physically carried out to the lobby area when they refused to leave the ward or proceeded to follow their normal pattern of activity when they first awakened in the morning (i.e., such as making their beds). The attendants also stated that they had difficulty preventing patients from returning to the ward unless an attendant was in view. They residents, they said, would follow the orders given by attendants they knew.

“…Efforts of the attendants to enter the ward [1] were prevented by heavy black smoke. There was no outside illumination, which made it difficult to move in the nearly total darkness.

“The first engine from the Ellisville Fire Department arrived at approximately 2:05 am. The Assistant Chief, who was driving, parked the apparatus on the north side of the building. After placing the pump in gear, he heard the attendant on the outside fire escape call, stating that she ‘needed help; there are people in there.’ As he climbed the exit stairs, the attendant again said that she had 28 people inside the building. He donned self-contained breathing apparatus and was joined by a fire fighter who was similarly equipped. He entered Ward 2, located five residents, whom he brought to the exit doorway, and then ran out of air.

“Off-duty administrative personnel and staff members who lived across the highway from the Magnolia Dormitory were arriving to help evacuate patients and care for those who had been evacuated. Additional night staff members from other residential buildings also arrived, either in response to a call from the School’s switchboard operator or because they were attracted by the fire noise and activity.

“At approximately 2:15 am, the telephone operator in the Security Building was requested to place a call to the Fire Department in Laurel, 5½ miles north of Ellisville. Two engines were dispatched at 2:15 am with two men each, and the Laurel Chief of the Department responded from his home. These fire units arrived between 2:25 and 2:30 am. Laurel fire fighters immediately donned breathing apparatus and began search-and-rescue operations in Ward 2 and then in Ward 1. These sweeps located the first reported fatalities at approximately 2:45 am. Search-and-rescue operations continued until 3:15 am, when the last victim was removed from Ward 2….

“The lack of sufficient refill air for breathing apparatus and the small number of breathing apparatus units available made it difficult for Fire Department personnel to perform both fire-fighting and search-and-rescue activities….

“Bodies of 14 victims were found at the scene. The fifteenth victim reportedly died after being transported to the Infirmary.

“Autopsies were performed on two of the 15 fatalities, one from each ward. The cause of death for each of these victims was listed as carbon monoxide inhalation…neither victim was burned. However, one other victim, a resident of Ward 2 whose bed was closest to the fire, was burned….

“The double-leaf doors in each ward corridor had no self-closing devices and required manual closing. Doors were installed that way on the assumption that when detection occurs, the alarm is given and appropriate action is taken to close the corridor doors. In this fire, the required actions outlived above did not occur.

“Neither an approved automatic smoke detection system nor a manually operated fire alarm system had been installed in Magnolia Dormitory. Since all three of the duty attendants were in the area of Ward 1, detection of the fire was delayed until the fire had reached an advanced stage. Further delays were encountered in notifying the Fire Department. Early detection could have provided time to confine the fire, give the alarm, and evacuate residents while ambient conditions were less hostile….

“Heat and flame issuing from the open doorway of the clothing storage room impinged directly on the emergency lighting conduit, causing the insulation to melt and a short circuit to occur. The short tripped the circuit breaker in the emergency circuit-breaker panel located in the mechanical room, leaving the north end of the building without emergency lighting.

“However, in this fire, the emergency lighting circuits on the first floor were not used. The dual-function lighting circuits were switch in the ‘off’ position in both wards. The attendant entering Ward 1 to evacuate the residents did not turn the lights on. In Ward 2, the switch could not be reached by the attendants, and the circuit shorted out soon after discovery of the fire….

“The School’s emergency procedures required that the switchboard operator be notified of a fire. The operator’s initial call was required to be placed to the Ellisville Fire Department. The notification procedures then provided that subsequent calls be placed according to the standing staff call list. In this fire, the initial call reporting the fire was made to the security guard’s office, rather than directly to the switchboard operator. This resulted in a delayed alarm, since the security guard then left his office to go to the switchboard operator’s office in a nearby building. By the time he had reached that office, the second call was being received. The operator then notified the Ellisville Fire Department at approximately 1:50 am, and then placed calls to school staff members.

“In terms of numbers alone, the three (first-floor) on-duty attendants could not be expected to perform an orderly and expedient evacuation of both dormitory areas in time to prevent casualties. The mentally handicapped condition of the residents required a constant face-to-face contact in order to obtain the proper movement. Prior training, established behavior patterns, and limited ability to perceive the danger and develop an appropriate response added to the evacuation problem.

“Although hampered by continued smoke and heat conditions and lack of lighting, on-duty and off-duty staff members and responding fire fighters were ale to evacuate 48 of the 63 residents of both wards; 16 of the 48 residents evacuated were injured. Key factors in the evacuation were the availability of staff in nearby homes and the fact that the exterior doors to both wards were unlocked and accessible.” (Bell. “Fifteen Residents Die in Mental Hospital Fire.” Fire Journal, Vol. 73, No. 4, July 1979, p. 68-76.)

Jones: “Institutional
“Institution for the Mentally Retarded, Ellisville, Mississippi…
“On December 9, 1978, a fire that originated in a clothing storage room of this residential custodial care dormitory killed 15 residents. The primary factors leading to the loss of life were reported to be: lack of compartmentation and lack of automatic sprinkler protection in the room of origin, lack of subdivision of the facility by smokestop partitions, lack of an automatic detection and alarm system, and the lack of automatic alarm transmission to the Fire Department.” (Jones. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, Vol. 73, No. 4, July 1969, p. 38.)

Newspapers

Dec 9, NYT: “Ellisville, Miss., Dec. 9 — Fifteen women patients died after they were overcome by smoke and heat early today in a dormitory at the Ellisville State School for the mentally retarded. Gov. Cliff Finch called the fire the ‘worst tragedy to ever hit our state.’ Calling for an investigation ‘from top to bottom,’ Governor Finch was critical of the institution’s staff for not alerting the patients in time for them to escape.

“The dead, who were in a second‐floor sleeping area for 69 middle‐aged and elderly female patients, were overcome by smoke from a fire in a clothes and linen closet at the end of the sleeping area, the authorities said. Sixteen other patients were taken to Jones County General Hospital, where three were reported to be in critical condition.

“Dr. Paul Cotten, director of the institution, defended the actions of his staff. He said three attendants were on duty on the dormitory floor and a total of six were in the building at the time of the fire. The first floor of the building is used for ceramics and therapy training and the upper floor is used as a sleeping area, which is divided into three wards.

“Fire officials, who arrived at the scene soon after receiving the alarm at about A.M., said most of the dead were found in their beds but that several were on the floor under their beds.

“ ‘There were no smoke detectors in the building as far as we know,’ said Capt. Donald Rogers of the Laurel Fire Department, which was called to assist the volunteer Ellisville Fire Department. ‘There was no problem bringing the fire under control,’ Capt. Rogers said. ‘The main problem was getting the patients out of the smoke‐filled and darkened dormitory.’

“Governor Finch had flown here this morning from the Democratic midterm convention in Memphis to inspect the site, and he later returned to Memphis. He charged that the staff was ‘not in close enough proximity’ at the time of the fire to properly assist the patients.

“The State Fire Marshall, James Crutcher, arrived at the scene this morning to conduct a preliminary investigation.” (New York Times. “15 Women Die in Dormitory Fire at School for Mentally Retarded.” 12-10-1978, p. 26.)

Dec 10, AP/Paris News, TX: “Ellisville, Miss. (AP) — A smoldering fire in a clothing room sent a blanket of smoke through a dormitory of a center for the mentally retarded early Saturday, killing 15 women patients and injuring 16 others, authorities said. The victims — all women 40 years and older and classified as moderately to severely retarded — died of smoke inhalation in the fire at the Ellisville State School in this town 75 miles southeast of Jackson. The center served as both a school and hospital for 129 patients. ‘Some of them were in their beds and others were on the floors,’ said Ellisville Fire Chief Frank Williams. ‘They were trying to get out but they just didn’t make it.’

“The fire broke out during the early morning in a room for storing clean clothing adjacent to two second-floor wards where 66 women patients were sleeping. The 63 men and women who occupied the ground floor escaped without injury. The state fire marshal’s office said it appeared the fire began in a closet in the room.

”Hospital staff, firefighters and police officers dashed into the dense smoke to evacuate the patients. ‘It was thick smoke from the floor to the ceiling and it was superheated,’ said Van Carter, a dormitory supervisor. ‘They kept going back in and helping people out. Nobody panicked.’ ‘The difficulty was we couldn’t get into parts of the building because of the smoke,’ said a nurse who helped pull coughing patients from the building. ‘It was so thick. I’d get in a few feet and get dizzy and fall to my knees.’

”Dr. Paul Cotten, the school’s director, said most of the damage was confined to the clothing room, but that there was ‘a tremendous amount of smoke.’ The room held the electrical panel for the upper floor. Cotten said that there were no fire detection devices in the center and that it appeared the fire was unnoticed until one of three cottage parents assigned to the second floor smelled smoke. He said patients in the upper level, women either moderately or severely mentally retarded, were helped down stairs to safety. ‘When it started, the power went off,’ said a hospital staff member who asked not to be identified. ‘They were fighting to get out (in the dark) .. It’s bad enough when we have fire drills in the day.’

”Officials said 14 of the women apparently died either before or during the evacuation, and another died later at the center’s infirmary.” (Paris News, TX. “15 Women Die in Dormitory Blaze,” December 10, 1978.)

Sources

Bell, James R.. “Fifteen Residents Die in Mental Hospital Fire.” Fire Journal, Vol. 73, No. 4, July 1979, pp. 68-76.

Jones. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, Vol. 73, No. 4, July 1969, pp. 33-40.

National Fire Protection Association. Key Dates in Fire History. 1996. Accessed 2010 at: http://www.nfpa.org/itemDetail.asp?categoryID=1352&itemID=30955&URL=Research%20&%20Reports/Fire%20statistics/Key%20dates%20in%20fire%20history&cookie%5Ftest=1

National Fire Protection Association. The 1984 Fire Almanac. Quincy, MA: NFPA, 1983.

National Fire Sprinkler Association, Inc. F.Y.I. – Fire Sprinkler Facts. Patterson, NY: NFSA, November 1999, 8 pages. Accessed at: http://www.firemarshals.org/data/File/docs/College%20Dorm/Administrators/F1%20-%20FIRE%20SPRINKLER%20FACTS.pdf

New York Times. “15 Women Die in Dormitory Fire at School for Mentally Retarded.” 12-10-1978, p. 26. Accessed 6-15-2021 at: https://www.nytimes.com/1978/12/10/archives/15-women-die-in-dormitory-fire-at-school-for-mentally-retarded-most.html

Paris News, TX. “15 Women Die in Dormitory Blaze.” 12-10-1978. Accessed at: http://www.newspaperarchive.com/PdfViewerTags.aspx?img=113060608&firstvisit=true&src=search&currentResult=0

— 12 Jones. “1978 Multiple-Death Fires…” Fire Journal, Vol. 73, No. 4, July 1969, p. 38.
— 12 National Fire Sprinkler Association. F.Y.I. 1999, 6.
— 12 Newark Fire Department. Newark Fire Department History…1797-2014. (Webpage)
— 12 Newark Public Library. “High Street Inferno Took 27 Lives [1910]…” 7-2-1998.
–11-12 NYT. “11 Killed in Newark Blaze; Firemen Searching for 12th.” 12-8-1978, p. A1.

Narrative Information

Jones: “Residential

Tenement, Newark, New Jersey. Twelve residents died in a fire in this 100-year-old, three-story, wood-frame tenement building. The cause of the December 7, 1978 fire is listed as undetermined. The fire reportedly began in the first-floor hallway and spread rapidly up an open stairway, trapping many of the occupants on the upper floors.

“The fire was discovered at approximately 12:15 am, but Fire Department records show that the first report was received at the fire alarm office at 12:44 am. First-arriving fire fighters found the building fully involved and were unable to attempt rescue. A second alarm was ordered at 12:53 am.

“The long delay between the discovery of the fire and the notification of the Fire Department plus the age and condition of the building all contributed to the large loss of life in this fire.”

Newark Fire Department. Newark Fire Department History…1797-2014:
“….Tragedy struck in the early morning hours of December 7, 1978 when a fire was reported at 569 South 12th Street, a three story frame. Arriving units found a condition of almost total involvement. Before the fire was subdued the building was completely destroyed and 12 people had lost their lives.”

Newark Public Library. “High Street Inferno Took 27 Lives [1910]…” 7-2-1998:
“Twelve Newark residents also were killed in a blaze on December 7, 1978, in a tenement. As in other cases, fire officials said the problems of fighting fires in Newark centered on the huge number of deteriorating houses built before 1940.”

Newspaper

Dec 8, NYT: “Newark, Dec. 7 — Eleven persons, including seven children, among them a 2‐year‐old girl, died early this morning when a fire raced through a three‐story tenement in the decaying Central Ward here.

“Late this evening, firemen poked through the smoldering rubble searching for a 12th resident of the century‐old frame building who is missing and presumed dead.

“Among the victims were a 37‐year‐old woman, Dorothy Jackson, and her five children, who ranged in age from 4 to 12. Her companion, Richard Brown, escaped death with them by jumping from a second‐story window, suffering only a broken wrist. Twelve other persons escaped.

“Francel Scott, 47, who led his wife and five children to safety through dense smoke and flames down the back stairs of the building, said six of his relatives —two sisters, a brother‐in‐law and three nieces — had died. Watching the firemen poking through the ruins, he said he had seen one sister at a window and had called to her to jump to safety, ‘but she didn’t.’ ‘I ran back up the stairs,’ he continued, ‘but when I got to about three feet from her door the flames were just too much. When I got back downstairs, I didn’t see her anymore. I guess she was overcome.’

“The Fire Department Arson Squad is investigating reports that a man was seen running from the building, at 569 South 12th Street, some time after midnight, just before flames erupted, trapping many of the victims who were asleep at the time.

“The fire marshals are also investigating allegations that the landlord had threatened to burn the building, as well as charges by relatives of those who perished that the first fire engine arrived at the scene more than a half an hour after calls were made to New Jersey Bell asking them to report the fire.

“The landlord of the building, Reuben Ritz of Springfield, was incredulous when told of the allegations. ‘Why should I want to burn the house down?’ he asked. ‘This building has been in my wife’s family for more than 40 years. We have the best tenant‐landlord relationships possible. It’s such a tragedy.’ He said that he had completely rewired the building a few years ago and recently had a new oil burner installed. ‘Everything was perfect,’ he said.

“Mr. Scott said that when he emerged neighbors told him that the Fire Department had already been notified, but that the first fire engine did not arrive until much later. ‘It took about 30 minutes before the fire truck came,’ he said as he surveyed the still‐smoldering hulk. ‘I told them that there were still three families trapped in the building, but they just took their time. Nobody tried to go in and get them out. They just waited for the other truck. They could have saved some of them if they had gone in when they first arrived.’

“Ethel Goethe, who lives across the street from the fire scene, said she had called the telephone operator at about 12:15 A.M. to say that there was a fire in the building where her cousin, Mrs. Jackson, lived. ‘When I called the operator she said that they had already been notified,’ she told a fire marshal. ‘I didn’t do it in the dark. I had turned on the light and I had looked at my clock. It said a quarter after 12. The trucks didn’t get here until about 20 to 1.’

“Rosie Lee Jackson, whose daughter and five grandchildren died in the blaze, said other neighbors had told her that they had also notified the telephone company about the same time. Newsmen noted that the kitchen clock in the Jackson home, where Mrs. Goethe lives, was about 10 minutes fast.

“However, Fire Director John P. Caufield said that the first report of the fire was received by the department from a woman caller and was recorded at 12:44 in the morning. He said that a second alarm, from firemen already on the scene, came in at 12:53, just nine minutes later, and that this meant the trucks had arrived within a ‘few minutes of the first call. ‘We didn’t get any calls from telephone company operators,’ Mr. Caufield said. ‘I checked on that. All our calls are taped.’

“Throughout the day, firemen, aided by a crane, went through the grim task of sifting through the rubble of the building looking for bodies of those who perished. As neighbors watched from across the street behind police lines, a crane lifted off a section of the collapsed roof at about 9 A.M. and the bodies of six victims were uncovered.

“There were only two other buildings on the rubble‐strewn block on the west side of South 12th Street, a two‐story garage and a three‐story frame residence immediately north of the tenement.

“Helen Prude, who lived on the first floor of the building with her husband and small child, said she had been asleep at the time of the fire. ‘I woke up because I heard a popping noise and I smelled smoke,’ she recalled as she waited on the porch of a house across the street. ‘I hollered, ‘Fire, fire,’ and then I got out.’

“In addition to the Jackson family, firemen listed the victims as Mr. and Mrs. James Thomas and their two daughters, Dewey, 3, and Starfu, 2; Marie Scott, about 90, and her 21‐year‐old daughter, Linda. Firemen were also checking reports that a friend of Miss Scott, who went to school with her, had been visiting and had not returned home. The girl’s mother, Beatrice Joyner, theorized that her daughter, Garlinda, may have slept at the Scott residence.”

Sources

Jones, Jon C. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, Vol. 73, No. 4, July 1969, pp. 33-40.

National Fire Sprinkler Association, Inc. F.Y.I. – Fire Sprinkler Facts. Patterson, NY: NFSA, November 1999, 8 pages. Accessed at: http://www.firemarshals.org/data/File/docs/College%20Dorm/Administrators/F1%20-%20FIRE%20SPRINKLER%20FACTS.pdf

New York Times. “11 Killed in Newark Blaze; Firemen Searching for 12th.” 12-8-1978, p. A1. Accessed 6-22-2021 at: https://www.nytimes.com/1978/12/08/archives/11-killed-in-newark-blaze-firemen-searching-for-12th-sister-failed.html

Newark Fire Department. Newark Fire Department History…1797-2014. (Webpage) Accessed 6-22-2021 at: https://nfd.newarkpublicsafety.org/history.php

Newark Public Library. “High Street Inferno Took 27 Lives [1910] but Helped Bring Reform.” 7-2-1998. Accessed 6-22-2021 at: https://knowingnewark.npl.org/high-street-inferno-took-27-lives-but-helped-bring-reform/

— 11 Blanchard total for the Piper and the C-130 crashes.

Piper Cherokee, Albany GA:
— 5 Pharos-Tribune, Logansport, Ind. “Air Crashes Claim Eight in South.” 12-1-1978, 10.
— 5 Times News, Twin Falls, ID. “Body of fourth victim found.” 12-2-1978, A14.

USAF C-130, Cottageville, SC:
— 6 ASN. Accident descrip. USAF Lockheed C-130E Hercules, 56 km…W of Charleston, SC.
— 6 Baugher, Joseph F. 1968 USAF Serial Numbers. 1-10-2012 revision.
— 6 The Robesonian, Lumberton, NC. “Dead Airmen Found.” 12-5-1978, 9.

Narrative Information

Piper Cherokee, Albany Airport, Georgia:

Dec 1: “UPI…. Five people died Thursday night when their private plane crashed just short of the runway at the Albany, Ga….Federal Aviation Administration spokesman Jack Barker said the Piper Cherokee Six aircraft, en route to Albany from Columbus, Ga., was attempting to make an instrument landing when it went down. Barker said the pilot and four passengers, whose identities were not immediately released, were killed. Officials said they believed there were two men, two women and a young girl on board. Barker said the pilot, who had filed flight plans to Orlando Fla. but changed them to stop in Albany, did not indicate that he was having trouble before the crash. He said the plane disappeared from air traffic controller’s radar about four miles southwest of the airport.” (Pharos-Tribune, Logansport, Ind. “Air Crashes Claim Eight in South.” 12-1-1978, p10.)

Dec 2: “….Dougherty County Coroner Chester Anderson Sr. said the victims were two men, two women and a young girl. The plane was registered to J. Sterling Carter of Indian Point, Ind., and based at Greentown, Ind. It was not known if Carter was aboard. The single engine Piper Cherokee was bound for Orlando, Fla., after a refueling stop at Columbus, Ga., when it went down Thursday night in fog which reduced visibility to about 200 feet.” (Times News, Twin Falls, ID. “Cargo Plane Crash. Body of fourth victim found.” 12-2-1978, A14.)

USAF C-130, Cottageville, South Carolina:

Baugher: “Lockheed C-130E-LM Hercules….10936 (c/n 382-4316) w/o Nov 30, 1978 when it crashed 36 mi W of Charleston, SC after being struck by lightning. 6 crew killed. (ASN).” (Baugher, Joseph F. 1968 USAF Serial Numbers. 1-10-2012 revision.)

Dec 1: “Cottageville (AP) — “It shook us good,” said Carrol Hathcock after an Air Force C-130 cargo plane crashed on this small Colleton County farm, killing at least three of the six crewmen. The others were listed as missing. Hathcock, an electronics technician who works the soybean and corn fields part-time, said he and his wife, Sybil, were in their mobile home when they first heard the plane. ‘I told her it was a plane, and about that time, it hit the ground, bursting into a giant ball of flame,’ he said. Mrs. Hathcock said she just had time to go to a window and watch the 97-foot plane go down.

“A spokesman at Charleston Air Force Base, about 25 miles away, said the cause of the crash was unknown. He declined to confirm a report that the plane was struck by lightning.

“A search for the missing crewmen, which had been hampered by low clouds and an almost constant rain, was called off Thursday night. It was expected to resume today.

“The crew was identified as

Capt. Samuel P. Eskew, 28, of Greenville, pilot;
Capt. Mark D. Greer, 27, of Kewadin, Mich., co-pilot;
1st Lt. Daniel K. Morris, 31, El Monte, Calif., navigator;
Staff Sgt. Bernie C. Finch, 28, Kingsville, Tex.;
Staff Sgt. Robert J. Cator, 26, Corona, Calif.; and
Airman 1st Class Robert Vanwinkle, 22, Denville, N.J.

“The Air Force said it had not identified the bodies of the three dead crewmen and did not know which men were dead and which were missing.

“The snub-nosed, four-engine aircraft was on a training mission from Pope Air Force Base, N.C., to Charleston. It was assigned to the 317th Tactical Airlift Wing at Pope. The C-130 is designed for transport duty in combat zones.

“The impact of the crash gouged a trench about 20 feet wide, 100 feet long and up to 12 feet deep in a small wooded area. Bits of the camouflaged green and brown fuselage were strewn over an area about the size of a football field.

“The Colleton County Sheriff’s Department said it had located part of the plane’s tail section at a school in Cottageville, a community of only a few hundred persons 35 miles from Charleston.” (Aiken Standard, SC. “3 Missing After Air Crash.” 12-1-1978, 3B.)

Dec 2: “UPI. The Air Force Friday recovered the body of a fourth victim of a C-130 cargo plane that crashed in a rainstorm, but military personnel trudging through muddy fields and hampered by continued foul weather could not locate the other two crewmembers.

“The discovery of a fourth body in the South Carolina crash Thursday raised to nine the number of known dead from two plane crashes in the South….” (Times News, Twin Falls, ID. “Cargo Plane Crash. Body of fourth victim found.” 12-2-1978, A14.)

Dec 5: “Charleston, S.C. (AP) — All six bodies of the crewmen aboard an Air Force cargo plane that crashed last week on a small farm have been recovered, the Air Force says. The C-130 Hercules went down Thursday afternoon near the Colleton County town of Cottageville, about 35 miles northwest of Charleston.

“Air Force and local law enforcement personnel had searched the woods and soybean fields near the crash site since then. Three bodies were recovered Friday. The Air Force announced Monday that the others had been found….

“Air Force officials are continuing their investigation into the crash at the site. Just before the crash, the pilot radioed that the aircraft had been hit by lightning and that he was having ‘control
Difficulties’.” (The Robesonian, Lumberton, NC. “Dead Airmen Found.” 12-5-1978, p. 9.)

Sources

Aviation Safety Network. Accident Description. United States Air Force, Lockheed C-130E Hercules, 1978, Nov 30, 56 km (35 mls) W of Charleston, SC. Accessed 9-25-2021 at:
http://aviation-safety.net/database/record.php?id=19781130-0

Baugher, Joseph F. 1968 USAF Serial Numbers. 1-10-2012 revision. Accessed 3-5-2012 at: http://www.joebaugher.com/usaf_serials/1968.html

Pharos-Tribune, Logansport, IN. “Air Crashes Claim Eight in South.” 12-1-1978, 10. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=109377451

The Robesonian, Lumberton, NC. “Dead Airmen Found.” 12-5-1978, 9. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=103850922

Times News, Twin Falls, ID. “Body of fourth victim found.” 12-2-1978, A14. Accessed at: http://newspaperarchive.com

–10 Craig & McDermott. “40 years after Greece Holiday Inn fatal fire…” Democrat, 2-4-2019.
–10 Demers, David P. “Ten Die in Greece, New York Hotel Fire.” Fire Journal, July 1979, p25.
–10 Democrat and Chronicle, Rochester, NY. “Greece Holiday Inn fatal fire…” 2-4-2019.
–10 Greenpeace. PVC Fires List. “Cambridge, Ohio.” June 1994.
–10 Jones, Jon C. A Brief Look At The Hotel Fire Record.” Fire Journal, May 1981, p. 41.
–10 UPI. “Rochester-area Fire Kills 10.” Post-Standard, Syracuse, NY, 11-27-1978, p. 1.

Narrative Information

Demers: “On Sunday, November 26, 1978, a fire that was most likely incendiary in origin occurred at the Holiday Inn – Northwest in Greece, New York, a suburb of Rochester with a population of 90,000. The fire resulted in the deaths of 10 occupants of the hotel and gained widespread media attention.

“The primary factors that led to the fatalities in this fire were the combination of the highly combustible interior finish in an exit stairway, unprotected openings in the stairway, and inadequate alerting of occupants. Extensive rescue efforts by fire fighters prevented a much larger loss of life….

“Openings into the three-story west wind were ‘protected’ by Class B labeled, 1½-hour fire doors with closers. Installed on these fire doors were kick-down type doorstops. The doors at the first and second stories (the top two stories) appeared to have been blocked open at the time of the fire…The openings into the two-story passageway from the stairway to the north wing were not protected in any way….

“The building had no emergency lighting….

“Investigating authorities determined that this fire was incendiary in origin. The area of fire origin was at the base of the central stairway, adjacent to the combustible storage closet. ….

“As the fire developed, the products of combustion would initially have traveled upward and through the unprotected openings in the stairway into the north wing by way of the passageway, and directly into the west wing because of the blocked-open fire doors. The plain glass windows in the stairway and passageway failed, providing oxygen to fan the already well-established fire….”

Democrat and Chronicle, Rochester NY. “Greece Holiday Inn fatal fire…” 2-4-2019:
“As the 40th anniversary of the deadly Holiday Inn fire in Greece approaches — a horrific inferno that claimed 10 lives — the investigation remains stalled because of unusual twists: authorities can’t say with certainty how the fire started, and, if even if it were, there have been multiple suspects for the crime.

“November 26, 2:38 AM:

“Off-duty Greece firefighter Harold “Bud” Phillips uses his two-way car radio to notify the Greece-Ridge Fire Department of a fire at the 91-room Holiday Inn Northwest at 1525 W. Ridge Road. Phillips spotted the flames as he was driving past on his way home from a moonlighting job as a security guard. Also among those first to the scene: Francis Neidert of Albion, former chief of the Albion Fire Department. He too spotted flames from the building on his way past, heading home from his job as a foreman at Eastman Kodak Co.

“….One hundred and twenty-five firefighters from six area fire companies responded. About 170 people were rescued from the building by firefighters and passers-by. Neidert was credited with helping at least 8 to 10 people escape from the motel’s second floor. ‘It was just totally unbelievable,’ he said at the time. ‘I’ve been a volunteer fireman for 27 years, and I’ve never seen fire move as fast as it did there. The flames were hissing, they moved so fast.’

“….Investigators said the fire broke windows in the hallways connecting the motel’s two wings. Flames shot up to the roofs of both wings and swept through an open area between the room’s ceilings and roofs. Firewalls in the buildings did not extend to the roof, allowing the fire to rip through the top floor of each wing. The burning roof had collapsed into the top floor rooms.

“….five bodies were found jammed against a doorway in a third-floor hallway, three other motel guests were found dead inside their rooms. One was charred beyond recognition and required dental records to identify. Guests had included 100 Canadians on a tour from Toronto and Hamilton. Eight of the dead were Canadian. The medical examiner said the cause of death for all killed that night was smoke inhalation.

“Injured firefighter Michael Zodarecky said at the time that ‘the smoke was just tremendous. You would look in windows for people, but you couldn’t see inside. Sometimes you couldn’t see people screaming from the upper floors.’

“November 27, 1978. Hard questions

“Questions arose about whether or not the fire alarms could be heard in the lobby of the Holiday Inn when firefighters arrived. While hotel officials said the alarms were functioning, firefighters first at the scene said they were unable to hear the bells. Although the building met existing fire codes, it lacked some fire prevention equipment:

• There were no smoke detectors
• There was no sprinkler system
• The alarm system wasn’t connected to the Greece-Ridge Fire Department of other security agency.
• There was only one vertical fire wall between the two wings
• The alarm system consisted only of one bell in the middle of each of the two wings’ five floors.
….
“November 30, 1978. Evidence points to arson:

“Greece Police Chief Gerald Phelan announces the fire was ruled an arson. However, he said, investigators were still looking into the manner in which the fire was set. And he said there were no suspects in the blaze….

“January 1979. Safety violations cited:

“Holiday Inns Inc. contests fines and fire safety violations cited by the federal Occupational Safety and Health Administration related to the Nov. 26 fire. The federal agency fined the company $4,480 for seven “serious fire safety violations” and said the violations aided the rapid spread of the fire and failed to provide “safe access” for the hotel’s guests at the time of the fire….

“April 1979. Faulty design?

“The designer of the Holiday Inn Northwest says the fire would have been contained to just one room if builders in 1963 had followed his plans and added room partitions that extended to the roof of the hotel….

“May 1979. Investigation report released:

“The National Fire Protection Association releases its report on the Nov. 26 fire. It cites numerous design problems with the building, saying they contributed to the quick spread of the blaze. ‘Primary factors leading to the fatalities’ included highly combustible interior finishes, unprotected openings in the stairway and inadequate alerting of occupants. The report says the hotel’s fire alarm was likely activated early on during the fire, but with just one bell per corridor, the alarm wasn’t heard or recognized as a fire alarm by the hotel guests….

“2011. Documentary identifies ‘person of interest’:

“Canadian television investigative newsmagazine 16:9 The Bigger Picture runs a segment on the fire, naming Harold Philips, now Chief of the Ridge Road Fire District, is a ‘person of interest’ in the case. Phillips releases a statement calling the insinuations bunk. ‘I had no involvement with this fire and have nothing to hide,’ he said.

“For the first time, police officials say they believe the accelerant used in the fire was the solvent methyl ethyl ketone, or MEK….

“October 31, 2013. Search warrant:

“In connection with the investigation, Greece police serve a search warrant at the Long Pond Road headquarters of the Ridge Road Fire District. They are there for hours, searching through offices. Officials say investigators are looking for documents, but will not specify the nature of the documents….”

Newspaper (at the time)

Nov 27 (UPI), Post-Standard, Syracuse, NY, “Rochester-area Fire Kills 10.” 11-27-1978, p1:
“Greece (UPI) – Fire early Sunday [Nov 26] tore through a suburban Holiday Inn jammed with Thanksgiving guests and celebrants attending a singles dance, leaving at least 10 persons dead and 25 others injured.

“By Sunday night, authorities were able to account for 13 persons they had previously listed as missing. Most of them had gone to the homes of relatives or friends when they were evacuated at the start of the fire, officials said.

“Fire officials said they were trying to determine whether a fire alarm inside the three-story hotel in the Rochester suburb sounded at the time of the blaze. ‘The hotel was equipped with a local alarm pull, somebody had to physically pull the alarm box,’ noted Fire Chief Kenneth Volkmar. ‘Some people said the alarm was ringing for some time. But we never did get a phone call.

“Guests who escaped the flames claimed they did not hear an alarm. ‘Somebody banged on our door at about 2:45 a.m. and yelled ‘There’s a fire,’ recalled Ann Hamelin, of Hamilton, Ont., who was part of a group of Canadians staying at the 15-year-old hotel during a 48-hour shopping spree. ‘It was terrible. Why didn’t we have a warning?’ she asked. ‘Why wasn’t there an alarm system?’

“Authorities were unable to obtain an exact count of guests, but hotel officials said up to 200 guests had been registered and scores of other persons had lingered after a singles dance that ended shortly before the fire broke out.

“Fire Lt. Bud Phillips, off duty and on his way to a moonlighting job as a guard, first discovered the flames shooting from the 91-room hotel shortly after 2:30 a.m. ‘There was nothing but screaming. A few people were yelling for help, but mostly it was just screams,’ he said. ‘I though probably several persons would be killed, but I never thought it would be this bad.’

“Chief Volkmar at first said some of the hotel’s frightened guests jumped to their deaths, but officials later said all 10 persons, eight women and two men, were apparently the victims of smoke inhalation….

“Town Supervisor Donald Riley said the death toll was the worst fire-related tragedy in the town’s history.

“The masonry motel, taken over by Holiday Inn from Schrafft’s in 1968, was fully booked for the Thanksgiving weekend.

“Volkmar said cause of the blaze was undetermined, but arson had not been ruled out.

“Lt. Phillips said the flames appeared to have started in a corner stairwell between the second and third floors of the ‘L’ shaped structure. By the time the first firemen arrived, the building was engulfed in flames.

“Firefighters, hampered by temperatures in the 20s and winds gusting up to 25 mph, battled the stubborn blaze for more than two hours.

“Volkmar said the department had trouble ‘simply because we had to deal with the rescue operations before we could even start fighting the fire.’….”

Nov 28, UPI, “Firemen, Guests Heard No Alarm.” Syracuse Post Standard, 11-28-1978, p.3:
“Rochester (UPI) – Holiday Inn and fire department officials Monday disputed whether an alarm system in a 15-year-old Holiday Inn was working when a blaze killed 10 guests and injured 34 persons. Firemen said the in-house bell alarm, not connected to any central alarm system in suburban Greece, was not ringing when they arrived early Sunday at the 91-room, three-story hotel. Holiday Inn officials said it rang. Some of the hotel’s 200 guests and others attending a holiday singles dance also claimed they did not hear the alarm.

“The hotel had passed a fire inspection Nov. 8, but it was wrapped in flames when firefighters arrived….

“Officials said five of the victims were discovered on the second floor, about 19 feet from an exit.”

Sources

Craig, Gary and Meaghan M. McDermott. “40 years after Greece Holiday Inn fatal fire. Investigation stymied by multiple suspects” Democrat & Chronicle, Rochester, NY. 2-4-2019, updated 2-4-2019. Accessed 6-13-2021 at: https://www.democratandchronicle.com/story/news/2018/11/20/holiday-inn-fire-greece-ny-1978-fatal-arson-bud-phillips/2064481002/

Demers, David P. “Ten Die in Greece, New York Hotel Fire.” Fire Journal, Vol. 73, No. 4, July 1979, pp. 25-29. Boston: National Fire Protection Association.

Democrat and Chronicle, Rochester, NY. “Greece Holiday Inn fatal fire: Timeline of a 1978 tragedy.” 11-20-2018, updated 2-4-2019. Accessed 6-13-2021 at: https://www.democratandchronicle.com/story/news/2018/11/20/greece-ny-holiday-inn-fatal-fire-timeline-tragedy-rochester/2069288002/

Greenpeace. PVC Fires List. June 1994. Accessed 7-20-2017 at: http://pvcinformation.org/assets/pdf/PVC_FiresList.pdf

Jones, Jon C. A Brief Look At The Hotel Fire Record.” Fire Journal, May 1981, pp. 38-41. Boston: National Fire Protection Association.

United Press International, “Firemen, Guests Heard No Alarm.” Syracuse Post Standard, 11-28-1978, p.3. Accessed 6-13-2021 at: https://newspaperarchive.com/syracuse-post-standard-nov-28-1978-p-3/

United Press International. “Rochester-area Fire Kills 10. 25 Injured in Holiday Inn Blaze.” The Post-Standard, Syracuse, NY, 11-27-1978, p. 1. Accessed 6-13-2021 at: https://newspaperarchive.com/syracuse-post-standard-nov-27-1978-p-1/

–918  Wikipedia. “Jonestown.” 8-21-2018 update.

–909  Jonestown. Ordered suicides and murder.

—    5  Port Kaituma. Murder of Congressman Leo Ryan and party at airport.

—    4  Georgetown. Murder-suicide at Jonestown Temple.

–915  Flexner and Flexner. A Pessimist’s Guide to History. 2008, pp. 335-336.

–910  Jonestown

—    5  Congressman Leo Ryan and four others while boarding two planes.

–913  CNN. “Inside the Jonestown massacre.” 11-13-2008 update.

–909  Jonestown compound

—    5  Airstrip murders

–CA Representative Leo Ryan

–NBC correspondent

–NBC cameraman

–Newspaper photographer

–Jonestown member attempting to leave with Representative Ryan

 

Narrative Information

 

CNN: “Thirty years ago, 909 Americans were led to their death by the Rev. Jim Jones in a mass murder-suicide pact in a South American jungle, shortly after Jones’ gunmen killed a visiting U.S. congressman and four others at a nearby airstrip.

 

“Of the nearly 1,000 church members who began the day in Jonestown, a cult commune, only 33 survived to see the next day.

 

“The following is a thumbnail history of the Jonestown tragedy on Nov. 18, 1978:

 

“What happened? More than 900 Americans died in a South American jungle upon the orders of Rev. Jim Jones, who had tried to create a socialist paradise that survivors called a slave camp.

 

“What led up to this? When California Rep. Leo Ryan arrived on a one-man investigative mission, bringing along a TV camera crew and various reporters, 15 church members asked to leave with him. Jones sent gunmen to a nearby airstrip, where they killed Ryan, an NBC correspondent and his cameraman, a newspaper photographer and one of the departing family members.

 

“Who was Jim Jones? He was a self-appointed minister from a small town in the Midwest, who first led his flock to California, where he hoped to avoid fallout from a possible nuclear war. He then moved his people to Guyana when he came under criticism for church beatings and financial abuses.

 

“Where did the money come from? Jones was a phony faith healer, and much of his money came in mail-order donations from the desperate. Elderly members handed over their Social Security checks, working adults gave 25 percent of their wages to the church and some signed over all their property. Government investigators would later find at least $10 million in Swiss banks, mainly in Panama. Another $1 million in cash was recovered in Jonestown.

 

“Did anyone survive? Thirty-three people who began that day in Jonestown escaped with their lives. There were two main groups of survivors. Eleven people, four of them small children, walked almost 30 miles through the jungle to another town. Fourteen departing church members lived through the airport ambush — five of them youngsters who were lost for three days when they ran into the jungle to hide….

 

“What happened to the killers? All but one of the airport gunmen died in the mass suicide. Larry Layton, who posed as a defector, was captured after badly wounding two people inside a plane trying to take off. He was not paroled from an American prison until 2002.

 

“How did Jones die? He did not drink the cyanide. He was shot in the head, probably by a trusted aide, at the very end. His body was among the first to be identified — through fingerprints that had been taken after a vice squad arrest five years earlier in the men’s room of a Los Angeles movie theater….” (CNN. “Inside the Jonestown massacre.” 11-13-2008 update.)

 

Sources

 

CNN. “Inside the Jonestown massacre.” 11-13-2008 update. Accessed 8-27-2018 at: http://www.cnn.com/2008/US/11/12/jonestown.factsheet/index.html?_s=PM:US

 

Flexner, Doris and Stuart Berg Flexner. A Pessimist’s Guide to History: An Irresistible Compendium of Catastrophes, Barbarities, Massacres, and Mayhem – From 14 Billion Years Ago to 2007. New York: Harper Collins, 2008. Partially digitized by Google at:  http://books.google.com/books?id=tpeK8WZby0gC&printsec=frontcover#v=onepage&q&f=false

 

Wikipedia. “Jonestown.” 8-21-2018 update. Accessed 8-27-2018 at: https://en.wikipedia.org/wiki/Jonestown

 

[1] Northeast South America, with Venezuela to the west, Brazil to the south and southwest and Suriname to the east.

–10 Greenpeace. PVC Fires List. June 1994.
–10 Jones. “1978 Multiple-Death Fires…” Fire Journal, Vol. 73, No. 4, July 1969, p. 38.
–10 NFPA. Investigative Report: Younkers Department Store Fire. Undated.
–10 National Fire Protection Association. 1984 Fire Almanac. 1983, p. 139.
–10 Wallace, D. In the Mouth of the Dragon: Toxic Fires in the Age of Plastics. 1990, p. 59.

Narrative Information

Greenpeace: “A fire in the Younkers Brothers department store produced a thick, black curtain of smoke that killed quickly. The toxic smoke was traced to the PVC wire insulation in the electrical system of the building.

“Twenty two people were present that Sunday morning; ten died, and at least four were injured. Two of the survivors died shortly afterwards, one of cancers and lung disease.

“The first sign of fire was a low energy explosion that occurred in the ceiling of the second floor, knocking down ceiling tiles. Immediately, a black curtain of smoke descended from the second floor ceiling in the southwest corner of the store, incapacitating all who came in contact with it almost instantaneously. Those who couldn’t flee the smoke died. The medical examiner and the forensic pathologist both concurred that the deaths occurred before the flames touched the bodies.

“The plaintiffs’ council found that the soot found in the lungs of the victims was from PVC.

“Later, it was discovered that the fire had actually started late the night before. An unspecified electrical malfunction occurred in the southeast quadrant of the second floor plenum. The wiring
involved in the malfunction overheated and decomposed. The other wiring in the area also overheated and decomposed directly from the heat radiated from the malfunction and indirectly from the hot gases generated. The overheating spread and continued for at least many hours and produced both corrosive and combustible gases.

“This occurred before workers arrived Sunday morning. One of the first to arrive went to the boiler/utility area of the store and turned on the air circulation fans. This caused the oxygen level in the effected quadrant to rise until the oxygen/fuel ratio reached the explosive level. Then the flaming stage of the fire began. The explosion knocked ceiling tiles and freed the soot and decomposition gases that had accumulated during those hours of overheating. The pressure wave and the expanding gases moved the smoke and fumes through the store. As the smoke and fumes moved through the store, they became diluted, and the acid reacted with the surrounding surfaces so that the smoke became less harmful. Those people present at the point where the smoke was first released were exposed to lethal concentrations of decomposition/combustion products almost immediately. Those farther away either became incapacitated and died later or were injured. Those farthest from the first release of the smoke were either injured or got away without permanent injury, depending on susceptibility and length of time exposed to the smoke.

“The heat from the fire traveled through the air ducts in the store and set secondary fires. At first the smoke was white and hazy, then it became black and thick. The smoke was so dense that arriving firefighters had to turn on the headlights of their rigs while they were still approaching the parking lot from the highway. In trying to get into the store, their handheld flashlamps proved useless against the pervasive darkness of the smoke.

“Of the survivors, two young people, a man and a woman, suffered frequent respiratory infections of prolonged duration. The woman also felt tired all the time, had upper respiratory membrane swelling and reddening that included sinus troubles, and was troubled by lower back pain. The young man was suddenly afflicted with high blood pressure and two types of heart problems, tachycardia and a systolic ejection murmur. An older man came down with chronic coughing, phlegm production and winter bronchitis. This man was taken to the hospital hours after the fire because of adult respiratory distress.

“The long decomposition period also explains the fire that was seen by the firefighters and attributed to natural gas. Natural gas does not burn with a green flame, such as the firefighters saw. Chlorine, however, imparts a green color to the flame. A mix of chlorinated and non-chlorinated hydrocarbons, which arise from pyrolyzing PVC, would behave like a natural gas fire and impart a green flame.

“A jury ruled that PVC caused the fire and the damage. All the plaintiffs then each settled out of court. No one went to trial to assess damages.” (Greenpeace. PVC Fires List. June 1994; cites Deborah Wallace, In the Mouth of the Dragon.)

Jones, Jon C. “1978 Multiple-Death Fires…” Fire Journal, Vol. 73, No. 4, July 1969, p. 38:
“Department Store, Des Moines, Iowa. On November 5, 1978, ten employees died in a fire in this large, two-story, unsprinklered department store. The fire occurred at approximately 9:30 am, before the store was scheduled to open for the day. Twenty-two employees were the only occupants of the building. Reports state that the fire originated in a ceiling space and was accidental. The fire spread rapidly, and the victims were trapped before they could reach exits.”

Wallace, D. In the Mouth of the Dragon: Toxic Fires in the Age of Plastics. 1990, p. 59:
“The danger of the fires discussed in this book is their speed – not necessarily the speed of the flames, but the speed at which the smoke becomes incapacitating. On November 5, 1978, a fire in the Younkers Brothers Department Store produced a thick, black curtain of smoke that killed quickly. The toxic smoke was traced to the polyvinyl chloride (PVC) wire insulation in the electrical system of the building.

“The store was located in a mall in West Des Moines, Iowa. Twenty-two people were present that Sunday morning; ten died, and at least four were injured. The first sign of fire was a low-energy explosion that occurred in the ceiling of the second floor, knocking down ceiling tiles. Immediately, a black curtain of smoke descended from the second floor ceiling in the southeast corner of the store, incapacitating all who came into contact with it almost instantaneously. The smoke rolled through the store, and those who could fled the dense blackness. Those who couldn’t died. Survivors later said that the smoke was so black and thick that it looked like rolling death.

“….The smoke was so dense that arriving firefighters had to turn on the headlights of their rigs while they were still approaching the parking lost from the highway. In trying to get into the store, their hand-held flashlamps proved useless against the pervasive darkness of the smoke. [p. 59-60]

“….The Investigation

“Shortly after the fire, the NFPA sent one of its investigators to West Des Moines to reconstruct the fire. The NFPA tries to issue a report for every fire of ten or more deaths. The report that resulted from this visit and from extensive cooperation with the Des Moines Fire Department described the store in great detail. It also included the occupancy of the store at the time of the fire, and a description of the event itself from the low-grade explosion in the plenum (the space between the ceiling of one story and the floor of the one above it) through the extensive damage that occurred after the merchandise and the furnishings were involved in the fire. The investigator who was a fire science expert, was confronted with an explosion in the plenum; with an account of greasy, extremely dense and black acidic smoke bursting from the ceiling; and with most fatality victims slowing evidence of nearly instantaneous incapacitation.

“No theory of origin or initial fuel came out of the NFPA report. The Des Moines Fire Department, with fewer resources available to it, and less pretension, turned up more evidence and tried harder than the NFPA, whose report was one of the lamest in the fire reconstruction literature. One of their main conclusions was that the store wasn’t sprinkled! Sprinklers in the habitable space would have had no effect on the events that occurred above the ceiling or on the generation of the killer smoke. The NFPA report was not only inadequate, but also unconvincing in its parroting of conventional platitudes meant to mislead….

“The Des Moines Fire Department and its consultant acted on the description of the dense, acidic smoke and on the placement of the explosion in the plenum. They generated a hypothesis that the freon in the air conditioning system interacted with the aluminum of the ducts and started a fire, and that this fire created hydrogen chloride….” [pp. 66-68]

Sources

Greenpeace. PVC Fires List. June 1994. Accessed 7-20-2017 at: http://pvcinformation.org/assets/pdf/PVC_FiresList.pdf

Jones, Jon C. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, Vol. 73, No. 4, July 1969, pp. 33-40.

National Fire Protection Association. Investigative Report: Younkers Department Store Fire. Boston, MA: NFPA, undated.

National Fire Protection Association. The 1984 Fire Almanac. Quincy, MA: NFPA, 1983.

Wallace, Deborah. Chapter 4. “The Younkers Brothers Department Store Fire.” In the Mouth of the Dragon: Toxic Fires in the Age of Plastics. Garden City Park, NJ: Avery Publishing Group, 1990.

–20 National Fire Sprinkler Association. F.Y.I. Fire Sprinkler Facts. 1999, 7.
–12 Best. “Suspected Arson Kills Twelve in 120-Year-Old Pennsylvania Inn.” Fire Journal, 24.
–12 Compton, T. “Remembering the Hotel Allen inferno.” WayneIndependent. 12-20-2010.
–12 Jones. “1978 Multiple-Death Fires…” Fire Journal, July 1979, p. 38.
–11 Cornell, James. The Great International Disaster Book (Third Edition). 1982, p

Narrative Information

Best: “Twelve hotel guests died November 5, 1978, when a fire attributed to arson raced through the 120-year-old Allen Motor Inn in which a large-loss-of-life fire could have been predicted. The three-story hotel, labeled a ‘fire-trap’ by a county official, had open wooden stairs, no fire protection features except for portable fire extinguishers, and no fire alarm system. Despite recent attempts by officials to enforce safety codes, the hotel owner had been granted three separate time extensions to make repairs, and the hotel had continued in use with major fire-safety violations until the November 5 fire took the lives of more than half of its occupants….

“The original 85-foot-square building, built in 1858, was believed to be the oldest concrete hotel in Pennsylvania….

“The hotel was occupied by about 20 elderly or transient guests on the date of the fire. One guest was a cerebral palsy victim. Another retired guest was handicapped and needed a walker to move around….

“Two previous firs had occurred…in 1978. A midsummer fire in the basement…was believed to have been accidental. Another fire on October 5, 1978, one month to the day prior to the November fire, was determined to have been incendiary in origin. The October fire had involved a pile of newspapers under the front stairway. On that occasion, the hotel guests had been successfully evacuated, and the fire had been extinguished without injuries to the occupants….

“The Pennsylvania Department of Labor and Industry had inspected the Allen Motor Inn in 1977 and had ordered that 16 violations of the Department of Labor and Industry regulations be corrected. The conditions cited included the lack of a fire alarm system, fire extinguishers, and emergency lighting in the building. An open stairway between the second and third floors of the hotel was included….the hotel was continuing to operate with major life safety violations at the time of the fire….” (Best, Richard, “Suspected Arson Kills Twelve in 120-Year-Old Pennsylvania Inn.” Fire Journal, NFPA, March 1979, pp. 24-27 & 96.)

Compton: “Honesdale, Pa…. It’s been 32 years since the Hotel Allen fire claimed so many innocent lives…. ‘There was a person in the second floor window,’ Texas #4 firefighter Paul Lautenschlager remembered. ‘We got the hand ladder off of the truck and by the time we got it over to the window and put the ladder up, the person was gone. And the fire was just burning that fast, whether the floor caved in and we lost them, we don’t know. We never saw or found the person after that.’ The Nov. 5, 1978 arson fire was one of the worst Wayne County had ever seen.

“Built in 1857, the three-story Hotel Allen, located at the corner of Church and 9th Streets in Honesdale, was credited with being the first concrete building in the state. But that’s not why it’s remembered. Twelve of the hotel’s occupants died the morning of the fire.

“The fact that it was arson was evident, said then-Wayne County Coroner Bob Jennings. ‘Huge balls of flame exploded in different areas. I knew there had to be some type of accelerant used for this type of a fire,’ he said. ‘Fire doesn’t spread that fast. And it doesn’t create a mushroom, high volume of flames, not unless there’s some type of accelerant used. I continued to photograph the scene — record it.’ Having received intensive training at the Medical Examiner’s office in both New York City and Philadelphia, Jennings knew what to look for. His recollection of that day is vivid. ‘It’s something that I’ll never forget. But there was an advantage to this particular fire, because there had been a fire there previously, a few weeks prior,’ he said. ‘It was thought to be a suspicious fire, set at that time.’

“A police probe found Frederick Blady — described in published reports as a ‘36-year-old drifter from New Jersey’ — arrested on both fires. A jury trial ended with Blady being charged with second degree arson in the Oct. 5 blaze, which caused more than $5,000 worth of damage to the hotel. However, a separate trial in the fatal fire found the jury returning a much different verdict: Not guilty.

“Not a year goes by that Atty. Steve Bresset, then a Wayne County Assistant District Attorney who helped prosecute the case, doesn’t think about the tragedy. ‘It was a tragic event across the board. The person who I felt was responsible for it was not convicted. Frederick Weiler Blady….’You ask any trial attorney and they can tell you every detail of every case they lost and not the details of the cases they won,’ Bresset said.

What stood out the most was the difference 15 minutes can make. ‘[Blady] had confessed to having started the (fatal) fire during the investigation. And then his council filed a motion to suppress on the basis of what was then called the Futch-Davenport rule which requires a person be arraigned within six hours of their arrest. He was arraigned, according to the court’s conclusion, six hours and 15 minutes after he was arrested,’ Bresset said. Though they appealed to the Pennsylvania Supreme Court, suppression of the confession was upheld. Based on that 15 minutes, Blady’s confession was thrown out. Still facing life in prison on murder and arson-related charges involving the death of the 12 fire victims, a jury trial found Blady not guilty on all 119 counts. It’s a verdict that still haunts Bresset. ‘It was an extremely empty feeling that stays with me ‘til today,’ he said.

“The morning of the fatal fire, Jennings reached out to the New York City Fire Marshal’s Office for assistance. ‘They arrived later that Sunday afternoon. In the meantime, I ordered that nothing be removed from the hotel… ‘Don’t touch any of the bodies.’ They wanted the scene as it was,’ he said….

“It would be days before all of the victims were accounted for. ‘I took off work for the next three days and had the aerial ladder down there every day. We were in the third floor, looking for bodies. The roof caved in, and then the ceiling caved in and you had to dig down through that char to get down to the floor,’ said Glen Gunuskey, then newly appointed foreman of Texas #4….” (Compton, Tammy. “Remembering the Hotel Allen inferno.” WayneIndependent. 12-20-2010.)

Jones/NFPA: “Hotel, Honesdale, Pennsylvania…On November 5, 1978, 12 guests died in a fire in this 120-year-old hotel. The origin of the fire has been ruled incendiary. Major fire safety violations had been noted prior to the fire by local officials, but the owner had been granted extensions to complete the necessary work and the hotel continued to be used. The fire took the lives of more than half of the building’s occupants.” (Jones, Jon C. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, July 1979, p. 38.)

Sources

Best, Richard, “Suspected Arson Kills Twelve in 120-Year-Old Pennsylvania Inn.” Fire Journal, NFPA, March 1979, pp. 24-27 & 96.

Compton, Tammy. “Remembering the Hotel Allen inferno.” WayneIndependent. 12-20-2010. Accessed 3-4-2013: http://www.wayneindependent.com/article/20101220/NEWS/312209994?refresh=true

Cornell, James. The Great International Disaster Book (Third Edition). New York: Charles Scribner’s Sons, 1982.

Jones, Jon C. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, July 1979, pp. 33-40.

National Fire Sprinkler Association, Inc. F.Y.I. – Fire Sprinkler Facts. Patterson, NY: NFSA, November 1999, 8 pages. Accessed at: http://www.firemarshals.org/data/File/docs/College%20Dorm/Administrators/F1%20-%20FIRE%20SPRINKLER%20FACTS.pdf

–11 Ferrara, Grace M. (editor). The Disaster File: The 1970s. 1979, p. 44.
–11 NTSB. Safety Recommendation (s) M-79-17 through -30. Washington, DC: 3-2-1979.
–11 New York Times. “Officer Guilty in Sinking of Cutter.” 11-4-1979, p. 40.
–11 Nova Tech (Northern Virginia Technical Diving Community). “Cuyahoga.”
–11 USCG. Cuyahoga, 1927 WIX / WMEC / WSC-157. 2008.
–11 USCG. Marine Casualty Report. USCGC Cuyahoga, M/V Santa Cruz II… Oct 1978. 1979.
–11 Washington Post (Frankel) “Cuyahoga Skipper Given Token Cut in Seniority…” 11-6-1979.
–11 Washington Post (S. Mansfield). “Cutter Captain Had Other Accidents.” 11-3-1978.

Narrative Information

NTSB Safety Recommendation(s) M-79-17 through -30:
“At 2107 e.d.t. on October 20, 1978, the Argentine freighter M/V SANTA CRUZ I1 and the U.S. Coast Guard Cutter CUYAHOGA collided in the Chesapeake Bay at the mouth of the Potomac River, Maryland. As a result of the collision, the CUYAHOGA sank. Eleven Coast Guardsmen were killed; 18 Coast Guardsmen were rescued by the SANTA CRUZ I1 which experienced minor damage.

“Although the Commanding Officer (CO) of the CUYAHOGA knew that the two vessels would pass close to each other for at least 20 minutes prior to the collision, the CO did not call the SANTA CRUZ I1 on the bridge-to-bridge radiotelephone to relate the navigational intentions of his vessel or to determine the intentions of the SANTA CRUZ 11. A call on the bridge-to-bridge radiotelephone would have alerted the CO to the course of the SANTA CRUZ I1 and may have averted the collision.

“The regulations concerning the use of bridge-to-bridge radiotelephone are not clear as to when vessels should exchange bridge-to-bridge navigational information in passing, meeting or crossing situations. There is a need for the Coast Guard to determine the minimum distance at which navigational information should be transmitted and promulgate regulations.

“The VHF radiotelephone installed on the CUYAHOGA was not capable of constantly monitoring channel 13 as required by the Vessel Bridge-to- Bridge Radiotelephone Act. If the CUYAHOGA had been broadcasting on some other channel, the CUYAHOGA’s radio could not receive navigational information from other vessels on channel 13. [p.1]

“The enlisted crew of the CUYAHOGA, who were assigned to bridge watches were suitably qualified for assignment to a vessel of this size. However, the experience and training level was less than adequate to provide safe operations of a training vessel operating in the congested water of the Chesapeake Bay. The CO and 12 crewmen, including 3 reservists assigned to active duty for training, of the CUYAHOGA were overtaxed with the requirement to provide training to 16 officer candidates in addition to conducting normal vessel operations. There were no personnel assigned to the CUYAHOGA for the sole purpose of conducting officer candidate training. The personnel assigned to the CUYAHOGA were not adequate to allow a three-watch system. Furthermore, the Coast Guard does not have any uniform servicewide standards to guide CO’s in determining personnel qualifications for assignment to such duties as officer-of-the-deck, helmsman, and lookout.

“The radar on the CUYAHOGA was located in a space other than the wheelhouse where there was a possibility of the loss of night vision. Because of its position and the possibility of losing night vision, the CO of the CUYAHOGA made minimal use of this important navigational instrument. The CO failed to determine the relative motion, course, speed, or closest point of approach of the SANTA CRUZ I1 prior to collision. There is a need to establish a policy concerning the use of radar equipment on Coast Guard cutters for plotting navigational data.

“The Coast Guard does not provide the CO’s of Coast Guard cutters with sufficient guidance on what effect medications may have on the ability of watchstanders to perform their duties. The CO cannot be expected to know the effects medication can have on himself or his crew. Standards should be set for the taking of medication by watchstanding officers. In addition, the Coast Guard should require that watchstanding officers who have visual impairments wear corrective lenses when on duty.

“The International Rules for Preventing Collisions at Sea, 1972 permits the stand-on vessel in a crossing situation to take action to avoid collision as soon as it becomes apparent that the vessel required to keep out of the way is not taking appropriate action. The Pilot Rules for Inland Waters require the stand-on vessel to hold course speed in a crossing situation until immediate danger of collision exists The Inland Rules and the Pilot Rules for Inland Waters should be amended to conform with the International Rules. This would avoid confusion between the Inland and International Rules and permit the stand-on vessel to take corrective action before immediate danger of collision exists.

“The stowage of all lifejackets on the 0-1 deck level of the CUYAHOGA prevented their use in time of emergency. Lifejackets should be distributed throughout the berthing and working areas on Coast Guard cutters convenient for each person on board. Additional lifejackets should be stowed where the crew normally musters for abandon-ship drill. [p.2]

“The only automatic emergency lighting provided on the CUYAHOGA was in the cutter’s engineroom. When the collision occurred, the CUYAHOGA’s mess and berthing areas were in complete darkness, making escape from these areas difficult. Coast Guard standards for new cutters require automatic emergency lighting in all manned spaces. Existing Coast Guard cutters should be examined and emergency lighting provided on all cutters.

“Although it is not known when the drawers in the inclined ladders broke loose, enough drawers had opened to make climbing both ladders hazardous, when the CUYAHOGA was raised. The drawers probably broke loose at time of collision and impeded escape from the berthing areas. All Coast Guard vessels should be examined and drawers removed from any inclined ladders.

“Therefore, the National Transportation Safety Board recommends that the U.S. Coast Guard:

Install VHF radiotelephones on Coast Guard cutters which will constantly monitor channel 13. (Class II, Priority Action) (M-79-17)

Determine in quantitative terms at what minimum distance navigational information should be transmitted by bridge-to-bridge radiotelephone in passing, crossing, or meeting situations, and promulgate regulations accordingly. (Class II, Priority Action) (M-79-18)

Review the personnel assignment policy of the Coast Guard to insure that the experience and training level of critical personnel is high, and that their time on board is adequate for familiarization with the vessel. (Class II, Priority Action) (M-79-19)

Review the manning level of Coast Guard vessels, particularly training vessels, to insure that an adequate number of experienced persons are assigned to stand watches, and that trainees are not required to stand critical watches. (Class 11, Priority Action) (M-79-20)

Establish requirements to insure that all training vessels have enough instructors aboard so that the safe navigation of the vessel is not adversely affected by the training program. (Class II, Priority Action) (M-79-21) [p.3]

Establish a servicewide policy to provide guidance to Commanding Officers of vessels concerning the necessary qualifications for personnel who are assigned the duties of OOD, lookout, helmsman, quartermaster, and other important positions. (Class II, Priority Action) (M-79-22)

Evaluate the installation of radar equipment on Coast Guard vessels and insure that indicators are so located that the equipment can be easily and properly used by personnel on watch in the wheelhouse. (Class II, Priority Action) (M-79-23)

Establish a policy concerning the use of radar equipment and the plotting of radar data. (Class II, Priority Action) (M-79-24)

Establish standards for the taking of medication by watchstanders on Coast Guard vessels to insure that the medication does not impede the individual’s ability to perform his duties. II, Priority Action) (M-79-25)

Require that watchstanders who have visual impairment wear their corrective lenses while on duty aboard Coast Guard vessels. (Class II, Priority Action) (M-79-26)

Take the action necessary to amend the Inland Rules and the Pilot Rules for Inland Waters to provide mariners the flexibility to initiate early action in crossing situations to prevent dangerously close situations as has been done in the International Rules for Preventing Collisions at Sea, 1972. (Class II, Priority Action) (M-79-27)

Locate lifejackets on Coast Guard cutters so that they are readily accessible to all crewmen. (Class II, Priority Action) (M-79-28)

Provide automatic emergency lighting for egress from all manned spaces on all Coast Guard cutters. (Class II, Priority Action) (M-79-29)

Examine all Coast Guard cutters and remove drawers from any inclined ladders. (Class II, Priority Action) (M-79-30)”

[Signed by NTSB Chairman James B. King. [p. 4]

United States Coast Guard. Cuyahoga: “The USCGC Cuyahoga, which was homeported at the Reserve Training Center at Yorktown, Virginia celebrated 50 years of commissioned service on 3 March 1977. She was the oldest operational commissioned ship in all of the United States sea services at that time. Cuyahoga (WIX-157) was built at the American Brown Boveri Corporation in 1926. She was launched 27 January 1927 and placed in commission 3 March 1927 at Camden, New Jersey. She was 125 feet long, had a beam of 23 feet 6 inches and a draft of 9 feet. Her total displacement was 276 tons. Her hull was steel and she had two diesel engines and twin screw propulsion which gave her a maximum speed of 13 knots and maximum cruising range of 4,900 miles….

“At about 2100 hours on 20 October 1978, in an area about 3½ miles northwest of Smith Point, which marks the mouth of the Potomac River as it empties in the Chesapeake Bay, catastrophe occurred.

“The Argentine coal freighter Santa Cruz II, a 521-foot bulk carrier, hit the Cuyahoga on her starboard side between amidships and the stern. A consensus of accounts indicated that the cutter was dragged backwards for a minute and then fell away from the tanker, rolled on her side, and sank within a couple of minutes. The Santa Cruz rescued 18 survivors from the water and stayed on the scene until help arrived. The remaining 11 men embarked on the Cuyahoga were lost. Four days after the accident, a Marine Board of Inquiry convened in Baltimore, Maryland, at the Marine Safety Office to investigate the accident.

“After some delay due to heavy seas and high winds, two massive floating cranes were used to raise the Cuyahoga, which was in 57 feet of water. After an initial inspection, the ship was placed on barges and towed 65 miles to Portsmouth for a full inspection.

“The Marine Casualty Report, number USCG 16732 / 92368 and dated 31 July 1979, concluded:
The Commandant has determined that the proximate cause of the casualty was that the commanding officer of the USCGC CUYAHOGA failed to properly identify the navigation lights displayed by the M/V SANTA CRUZ II. As a result he did not comprehend that the vessels were in a meeting situation, and altered the Cuyahoga’s course to port taking his vessel into the path of the SANTA CRUZ II. The Cuyahoga was later sunk off the coast of Virginia as an artificial reef.” (USCG. Cuyahoga, 1927 WIX / WMEC / WSC-157. 2008.)

U.S. Coast Guard Marine Casualty Report: USCGC Cuyahoga, M/B Santa Cruz II…:

PRELIMINARY STATEMENT

“The Marine Board of Investigation [MBI] was ordered to convene by the Commandant by letter of 24 October 1978. The Board convened in Baltimore, Maryland on 24 October 1978, and then in Yorktown and Norfolk, Va. The taking of testimony was completed on 14 November, the Board having heard from 47 witnesses, including all survivors of the Cuyahoga and all persons associated with the navigation of Santa Cruz II. The Board viewed salvage of Cuyahoga on 30 October, and boarded the vessel as it lay on a barge at Portsmouth, Va. On 31 October 1978.

“Empresa Lineas Maritimas Argentinas S.A., as owner of M/V Santa Cruz II, and Captain [blacked out] her master, were designated as parties in interest to the investigation and afforded their rights as set forth in 46 CFR part 4. CWO4 [blacked out, though identified on page 12 as Chief Warrant Officer Donald K. Robinson], commanding officer of USCGC Cuyahoga, was designated a party in interest to the investigation and afforded his rights as set forth in 46 CFR part 4 and paragraph 0304d, Coast Guard Supplement to the Manual for Courts-Martial.

“After giving limited background testimony, CWO4…[Robinson] exercised his right to remain silent and did not testify as to the circumstances of the collision, nor did he submit to cross-examination by parties with regard to his background testimony. The Board requested a grant of testimonial immunity from the Commandant. Testimonial immunity, as opposed to transactional immunity, was desired so that the possibility of future criminal action, if found appropriate, would not be impaired. This request was denied, and CWO4…[Robinson] maintained his silence. A prior statement, made by CWO4…[Robinson] on 22 October, was received into evidence. The Board has been hampered in its investigation as a result of the unavailability of his testimony. While the Board was able to determine how this casualty occurred, many questions as to why it occurred can only be answered by CWO4…[Robinson].

“The investigation was conducted jointly with representatives of the National Transportation Safety Board, pursuant to joint regulations, 46 CFR 4.40. Although the investigation phase was conducted jointly, the deliberations resulting in this report were conducted separately and independently of those of the National Transportation Safety Board.

Findings of Fact

“Summary

“1. On the evening of 20 October 1978, the U.S. Coast Guard, Cutter Cuyahoga (WIX-157), under command of CWO4…[Robinson], USCG, was underway on a training cruise in Chesapeake Bay, with 16 officer candidates, 9 crewmembers, and four augmenting crewmembers on board. The intended track was generally northerly, until off the mouth of the Potomac River, when the course was changed to the left so as to take the vessel into the river for a planned overnight anchorage.

“The Argentine Motor Vessel Santa Cruz II had departed the port of Baltimore, Md. On the afternoon of 20 October and proceeded southbound in Chesapeake Bay for sea, loaded with a cargo of coal.

“Cuyahoga and Santa Cruz II closed on nearly reciprocal courses in Chesapeake Bay, off the mouth of the Potomac River. Neither vessel used bridge-to-bridge radio to communicate with the other or sounded whistle signals as they closed. When about one mile from Santa Cruz II, Cuyahoga changed course 35⁰ to the left, putting her on a collision course with Santa Cruz II. Santa Cruz II sounded a single short blast signal. Cuyahoga heard and answered the signal, but it was not heard on Santa Cruz II. Santa Cruz II sounded a second single short blast, and then the danger signal twice. The engine was stopped and the rudder placed hard to port when the second danger signal was sounded. Cuyahoga backed engines and sounded a single short blast signal.

“At 2107 (all times eastern daylight savings time), 20 October 1978, the vessels collided. Cuyahoga was struck on the starboard side aft of the wheelhouse by the bow of Santa Cruz II. Cuyahoga heeled to part and sand in two minutes.

“Eighteen men escaped from the sinking Cuyahoga, and made their way to the utility boat which had surfaced, where they waited until Santa Cruz II returned and they were able to board that vessel.

“Eleven men perished. Nine bodies were recovered by Navy and Coast Guard divers and two were recovered on the surface before salvage of Cuyahoga, which occurred on 30 October 1978.
….
“3. Record of Dead:

Michael Andrews Atkinson
Seaman Apprentice, USCGR….[Blacked out are SSAN, DOB, address, and next of kin.]

Ernestino Acogido Balina
Subsistence Specialist First Class, USCG….

William McDonald Carter
Yeoman First Class, USCG….

James Wesley Clark
Officer Candidate, USCGR….

John Paul Heistand
Officer Candidate, USCGR….

James Lowell Hellyer
Fireman Apprentice, USCG….

David Bryan Makin
Senior Chief Machinery Technician….

David Scott McDowell
Seaman Apprentice, USCGR….

Wiyono Sumalyo
Captain, Indonesian Navy….

Edward Jerry Thomason
MK1/Officer Candidate, USCG

Bruce Earl Wood
RM 1/Officer Candidate, USCG…. [pp. 5-7]
….

“No VHF-FM radio call was initiated by Santa Cruz II on channel 13, the designated vessel bridge-to-bridge radio frequency, or on channel 16, the designated calling frequency. Pilot…[name blacked out] brought with him a portable VHF-FM radio, capable of broadcasting at a one watt, low power and five watt, high power level on channels 13, 16, 11, and 18A. The radio was in apparent good working order, and had been used on this voyage on channels 13 and 11. At all times material to this casualty, the portable radio was hanging by its strap from the motor of the starboard clear view screen, about 15 feet from the position kept by Pilot…in the minutes before the collision.

“Pilot…testified that before Cuyahoga changed course and showed its green sidelight he felt no need to communicate any navigation information by bridge-to-bridge radio because of the apparent routine nature of the anticipated port-to-port meeting. He said it was his practice to use the radio when there was some question about vessel intentions.

“Pilot…testified that after Cuyahoga changed course and showed its green sidelight that he did not attempt to retrieve his radio and make a call because he did not want to be distracted from watching, or lose the position and reference point he was using to establish bearing drift. He further testified that he could not have anyone bring the radio to him because people on the bridge did not know the location of his radio. He testified that he would not command or allow vessel personnel to make a bridge-to-bridge call because of language difficulty and possible confusion….” [p. 11-12]

“Voyage of Cuyahoga

“9. ….At about 2045, Cuyahoga was approximately 1.7 miles east of Smith Point Light (L.L. No. 2725)…when the lights of what were to be identified as Santa Cruz II were seen. The lights were first spotted by then OC-OOD…, who reported the sighting to CWO4 Robinson. Both men used binoculars to confirm that the lights were of a vessel; they could see a masthead light and a red sidelight. CWO4 Robinson went to the chartroom and by radar ascertained that the range was 15,700 yards. Based on the small size of the radar contact and his perception of a single white light, he formed the opinion that the lights were of a small vessel proceeding into the Potomac River.

“The planned track called for two course changes that would take Cuyahoga into the lower Potomac River. With Smith [end p.15] Point Light, L.L. No. 2725, bearing 270⁰T at a range of 3900 yards, course would be changed left to 338⁰T. With Smith Point Light bearing 199⁰T, at a range of 5400 yards, course would be changed left to 303⁰T. That course would take the vessel into the river. At about 2049 course was changed left to 338⁰T, the change being delayed to allow clear passage of a tug and tow. The engines remained at ahead full, turning for 11.8 knots…. [p.16]

“Collision occurred at 2107.0.

“12. The effect of the collision on Cuyahoga was to heel the vessel to port 40 to 50 degrees. The effect below decks of the severe impact was to cast adrift personal effects and equipment, and throw crewmembers about, leaving all spaces in disarray. The port side of the main deck was submerged. Cuyahoga ‘hung up’ on the bow of Santa Cruz II and was pushed through the water at nearly 13 knots for 30-45 seconds. Down-flooding was rapid through the two partially submerged portside watertight doors because of the speed. There was gross down-flooding of the forward accommodation spaces, engine room, galley, and after accommodation spaces.

“Electrical power was lost on Cuyahoga in impact, and all lights went out. After some 30 seconds, the four battle lanterns in the engine room equipped with solenoids automatically came on. There were no other relay lanterns or automatic emergency lighting units on the ship, and all other spaces remained dark.

“The port heel progressed until Cuyahoga was on her beam ends, and she came free. Cuyahoga then slid down the starboard side of Santa Cruz II. [end p. 18]

“Two minutes after collision, Cuyahoga sank.

“Rescue

“13. As Cuyahoga heeled to her beam ends, those men who were able to, crawled and climbed to the starboard side of the vessel, where they perched on the side of the deckhouse and the hull. The lifejacket bin was found to be already underwater; no lifejackets were obtained from it. The starboard inflatable liferaft was found to have been crushed in its container, and was not used; the port inflatable liferaft was already underwater. The men jumped or stepped into the water as Cuyahoga sank. No life rings or float lights were used. A number of men testified that they were aware of the suction effect that would result from the sinking of the ship; one man experienced it and was pulled underwater, but he was able to swim to the surface. The swimmers initially sought pieces of flotsam for support. In ice chest came to the surface and was used for flotation.

“The Cuyahoga’s utility boat, a 14 ft Boston Whaler came free and surfaced. The boat became the focal point of the survivors efforts….

“Eighteen men found themselves swimming in total darkness. CWO3…, one of the more experienced men with extensive sea service, emerged as a leader and kept the other men calm and together. When the Boston Whaler surfaced he gave instructions to the group to move to the boat, but not to attempt to board lest the boat be swamped…. [p19]

“Cuyahoga Command
….
“35. CWO4 Robinson was ordered to assume command of Cuyahoga by message orders from the Commandant dated 30 March 1977, and he did so on 17 June 1977. His orders provided:

Attention is called to COMDRINSR 1540.3 series, Formal School Training Standards for Major Cutters. Every effort should be made to obtain as much of the recommended training as possible prior to reporting for duty….

“Among the courses recommended for commanding officers were:

a. Emergency Shiphandling for Senior Officers, and
b. Rule of the Road and Shiphandling (Refresher).

“Among the courses recommended for those who stand deck OOD watches were:

a. Rules of the Nautical Road, and
b. Emergency Shiphandling.

“CWO4 Robinson never received any of the recommended training…. [p32]

“CWO4 Robinson testified that he had not undergone classroom courses or training in these matters. Rather, all his training was described as ‘practical.’…. [p33]

“There are no records attesting to SWO4 Robinson’s proficiency in seamanship, rules of the road, emergency Shiphandling, or local knowledge.

“36. CWO4 Robinson is myopic, with his most recent eye examinations showing 20/30 right eye, 20/100 left eye vision. His vision is correctable to 20/20 in each eye. He has sunglasses which were worn during daylight activity; these are corrective prescription eyeglasses. There is no record of his ever having obtained clear prescription eyeglasses for nighttime use. CWO4 Robinson was not wearing corrective prescription eyeglasses at any time material to this casualty.

“The statement of CWO4 Robinson was to the effect that on initial sighting, he perceived a single white light and single red light. However, Santa Cruz II was showing a white masthead light and white forward range light in addition to her red and green side lights. These lights were on and working properly.

“There are no objective standards of visual acuity within the Coast Guard which reflect the particular demands of vessel command or deck watch officer duty. There is no procedure for identifying those individuals who must be wearing corrective prescription eyeglasses to meet eyesight requirements while performing such duties…. [p. 34]

Conclusions

“1….Cuyahoga violated its duty to pass port to port…. [p38]

“3. ….The evidence adduce with regard to practices of mariners demonstrates a stubborn determination to resist full use of technological advances such as bridge-to-bridge radio. The result of such resistance is seen in casualties such as this…. [p40]

“7. Contributing to the loss of life in this casualty was the fact that the main deck watertight doors on the port side by way of frame station 30 and 40 w4re open for ventilation. When Cuyahoga was pushed over by Santa Cruz II, these doors were partially submerged. As the two vessels continued through the water by virtue of the momentum of Santa Cruz II, a tremendous volume of water entered Cuyahoga through the doors. As a result of this rapid down-flooding, personnel below decks were hampered in their efforts to escape against the rush of water. In addition, this condition resulted in Cuyahoga’s rapid sinking, reducing the time in which those below decks could escape.

“8. Contributing to the loss of life in this casualty was the failure to sound the general alarm or use the public address system, which could have warned the personnel located below decks in Cuyahoga of the impending collision.

“9. Contributing to the loss of life in this casualty was the absence of adequate automatic emergency lighting in the passageways, berthing, and accommodation spaces in Cuyahoga, which absence inhibited escape from below decks in those minutes before Cuyahoga sank. It is probable that this lack of lighting contributed to the deaths of:

SS1 Ernestino Acogido Balina,
OC James Wesley Clark,
OC John Paul Heistand,
MK1/OC Edward Jerry Thomason, and
Capt. Wiyono Sumalyo [p.43]
….

“13….The lack of an objective system of record for vessel commanding officers to demonstrate their competence and professional knowledge is considered a weakness in the assignment process…. [p.44]

Commandant’s Action on The Marine Board of Investigation….

Comments on Conclusions

1. The relevant facts indicate that the proximate cause of the casualty was that CWO4…
[Robinson] failed to properly identify the navigation lights displayed by the M/V Santa Cruz II. As a result he did not comprehend that the Cuyahoga and the M/V Santa Cruz II were in a meeting situation subject to 33 USC 203 (Article 18, Rule I, Inland Rules of the Road) and 33 USC 157 (33 CFR 80.4). Subsequent to his initial erroneous conclusion as to the heading of the M/V Santa Cruz II, CWO4…[Robinson] altered his course to port which eventually placed the Cuyahoga directly in the path of the oncoming M/V Santa Cruz II. The reason why SWO4…[Robinson] failed to properly identify the navigation lights of the M/V Santa Cruz II or comprehend that both vessels were in a meeting situation can not be positively determined…. [p.2]

Action Concerning The Recommendations

1. Recommendation 1: Violation of Article 110, Uniform Code of Military Justice, is a serious
offense. In the case of negligent hazarding of a vessel, punishment may include dishonorable discharge and confinement at hard labor for two years; a general court-martial is the only forum empowered to consider such punishments. Despite the gravity of this case, the Board is mindful of the contributing causes which have been identified and which may act in mitigation when consideration is given to the appropriate action to be taken with regard to the conduct of CWO4… [Robinson]

“A charge sheet has been prepared in accordance with Paragraph 0302 d(11) ©, Coast Guard Supplement to the Manual for Courts-Martial, and is forwarded herewith. The Board recommends referral to an appropriate court-martial convening authority for such further investigation and action under the Uniform Code of Military Justice as he many consider appropriate.

“Action: Court-martial process under the Uniform Code of Military Justice has been initiated.

“2. Recommendation 2: “It is recommended that the Commandant consider the need to amend existing regulations by defining specific and objective parameters for those situations where exchange of navigational information between vessels by bridge-to-bridge radio is necessary.

“Action: This recommendation is not concurred with. To develop a regulation accounting for all of the variable factors that must be considered in setting specific and objective parameters for the exchange of navigational information would result in a ponderous regulation that would be impractical in its application. However, it may be possible to amend the Vessel Bridge-to-Bridge Regulation (33 DFR 26) to more fully emphasize the need for compliance and to provide further guidance in its application.
….
“4. Recommendation 4: It is recommended that the Commandant consider the need to require appropriate Coast Guard personnel to demonstrate the professional knowledge required for vessel command and deck watch officer duty, and to record individual qualifications in that regard. An objective system such as the present merchant marine licensing program, including the concept of radar observer endorsement, would appear adaptable to this end. [end of p.3]

“Action: Selectees for command are currently required to demonstrate their professional knowledge and competence and be recommended for command during their afloat tours. Their performance is objectively reported in the existing fitness report system. A pilot project will be initiated utilizing an examination system similar to the mr4echant marine licensing program to evaluate the feasibility of enhancing this process.

“5. Recommendation 5: It is recommended that the Commandant consider the need for a policy which would insure that Coast Guard vessels with trainees embarked for underway training be manned sufficiently to insure that those persons tasked with the safe navigation of the vessel need not be simultaneously tasked with instructor duties.

“Action: Procedures are in the process of being modified to insure that Coast Guard vessels with trainees embarked for underway training be manned sufficiently to insure that those persons tasked with the safe navigation of the vessel need not be simultaneously faced with instructor duties….[end p. 4]
….
“9. Recommendation 9: It is recommended that the Commandant consider the need to establish standards for physical competence and fit-for-duty status appropriate to vessel command and deck watch officer duty.

“Action: Prior to relieving as commanding officer or officer in charge and prior to being assigned to deck watch officer duty, these personnel will be required to be certified as fit for duty within six months of the date of the orders. Further, these personnel will be required to obtain annual physical examinations while they are assigned duty afloat….” [Sighed by J.B. Hayes, Admiral, U.S. Coast Guard, Commandant. End of p. 5.]

Newspapers

Nov 3, Washington Post (Stephanie Mansfield). “Cutter Captain Had Other Accidents”:

“The captain of the Coast Guard cutter Cuyahoga – named as a ‘suspect’ in the official inquiry into the ship’s collision with an Argentine freighter in which 11 crewman died – was also the subject of two separate Coast Guard investigations earlier this year.

“Chief Warrant Officer Donald K. Robinson, 46, was reprimanded for “poor judgment” and “poor seamanship” after the Cuyahoga ran into a drawbridge near Baltimore Harbor on May 31, according to Coast Guard documents. The impact knocked the ship’s radar antenna off the mast, causing more than $5,000 in damages.

“A month earlier, the Cuyahoga struck a sea wall while mooring near the same harbor, dislodging a large piece of granite, according to the accident report.

“Robinson was held accountable for the bridge incident and received a letter of reprimand that his immediate superior yesterday called ‘a chewing out.’

“A 27-year veteran of the Coast Guard, Robinson was promoted between the first and second incidents to chief warrant officer 4th class.

“Documents also revealed that as a result of the bridge incident, a Coast Guard investigative board recommended that the 51-year-old Cuyahoga’s pilot house controls be updated. The modern equipment was not installed, a senior Coast Guard officer said yesterday.

“On May 31, the accident report states, the Cuyahoga left the Coast Guard Yard in Curtis bay near Baltimore enroute to Yorktown, Va., where the training vessel-described as a ‘floating classroom’ – was stationed. While attempting to pass under the Pennington Avenue drawbridge – which Robinson had been told four hours earlier would have only half of its span open – the Cuyahoga swung to the left and struck the bridge’s closed west span, the report said. Immediately before the collision, Robinson ordered the engines reversed. He heard no response from the engine room, the report states, and signaled full astern again to ensure the crewmen ‘understood the urgency of the order.’….

“The May 31 incident occurred as the Cuyahoga was navigating two bridges, the I-635 bridge and the Pennington Avenue bridge. The Cuyahoga with its mast height of 52 feet, passed under the first bridge at the center span. Then, according to the report, Robinson tried a ‘zig-zag’ maneuver, turning right, then left. ‘The intricacy, if not impossibility, of this maneuver, as planned, constitutes poor judgment on the part of CWO Robinson, said…the report. ‘A prudent seaman would navigate his vessel so as to pass through both spans on a constant course . . . several alternative means of doing this were available to CWO Robinson, citing excessive speed and too sharp a course change….

“Robinson, the father of six from Yorktown, Va., has been described as a deeply religious man who is a deacon in his Baptist church. ‘I’ve been praying daily . . . continuously,’ Robinson was quoted as saying in an interview yesterday. “God is my strength in this time to face each day.’”

Nov 3. New York Times. “Officer Guilty in Sinking of Cutter.” 11-4-1979, p. 40:

“Yorktown, Va., Nov. 3 (AP) — A jury of Coast Guard officers today found Chief Warrant Officer Donald K. Robinson guilty on a reduced charge of dereliction of duty in the collision that sank his cutter and killed 11 men. The jury returned its verdict after deliberating about 12 hours yesterday and today. It is to return Monday to hear arguments on what punishment should be imposed.

“Mr. Robinson’s defense was based on medical inability to function. He was originally charged with negligently hazarding his vessel, but that charge was reduced by the jury.

“Punishment for dereliction of duty could range from a finding of no punishment to a maximum of three months in custody, dismissal from the service and forfeiture of all benefits.

“Mr. Robinson, 47 years old, was silent as the court‐martial verdict was announced in the courtroom at the Yorktown Coast Guard Station.

“He had been accused of making a criminally negligent decision when he ordered a turn that resulted in the collision of the cutter Cuyahoga and an Argentine freighter the night of Oct. 20, 1978, in the Chesapeake Bay….

“At least five votes were needed to convict Mr. Robinson. Two captains, a commander and four chief warrant officers, all former ship commanders, made up the panel.

“Testimony throughout the trial showed the Cuyahoga’s skipper was weary from sleeplessness due to a pulmonary disorder that went undiagnosed by military doctors from March 1978 until December 1978— two months after the accident. Defense witnesses testified that Mr. Robinson did not know how sick he was and that he had made repeated trips to the medical staff at Yorktown. He had also gone to the Walter Reed Army Hospital for tests on several occasions, including twice in the two weeks before the collision.”

Nov 6. Washington Post. “Cuyahoga Skipper Given Token Cut in Seniority…” 11-6-1979.

“The Coast Guard officer whose actions were blamed for a collision that killed 11 servicemen was sentenced today to receive a letter of reprimand and a token reduction in seniority for his role in the accident. The verdict, issued by a military court, will have little practical effect on Chief Warrant Officer Donald K. Robinson, 48, skipper of the cutter Cuyahoga.

“Moments after he was sentenced, Robinson said he soon will retire from the service. Neither the formal letter of reprimand he will receive nor the loss of ranking among other warrant officers is sufficient to block him from receiving a full military pension, retirement benefits, and an honorable discharge.

“‘I’m very happy with it,’ said Robinson, a 27-year Coast Guard veteran who dashed into an anteroom with tears in his eyes to thank the jurors after the sentence was pronounced….

“The jury, which on Saturday had found Robinson guilty of dereliction of duty, could have sentenced him to as much as three months in jail at hard labor and dismissal from the service — a punishment equivalent to dishonorable discharge that, would have meant the loss of his pension. Instead, the jurors, who spent an addition two hours and forty minutes deliberating Robinson’s sentence today apparently heeded the plea of defense attorney Jerome V. Flanagan. He told them this morning that Robinson had already suffered enough for his role in the mishap, the worst Coast Guard disaster in more than 10 years.

“The sentence will be routinely reviewed by Coast Guard Commandant Adm. John B. Hayes and Transportation Secretary Neil Goldschmidt, who have the power to reduce it or throw out the verdict. Court officials said the review process could take up to a year, after which Flanagan said he plans to appeal the case to either a military or a federal court.

“Today’s sentencing ended the two week trial at the Coast Guard Reserve Training Center here, where the Cuyahoga was based before the tragedy….

“Robinson was originally charged with involuntary manslaughter, destruction of government property and negligence — charges that could have resulted in up to five years imprisonment. The first two charges were dropped last June when a military judge ruled that the Coast Guard would have to renew its investigation to justify the allegations.

“Chief prosecutor Cdr. James F. Meade, said after the sentencing that the Coast Guard did not plan to revive the other charges in the case. ‘As far as we’re concerned it’s over,’ he said….

“After 12 hours of deliberation ending Saturday, the jury rejected the negligence charge — which carried a maximum penalty of two years in jail and dismissal from the service — but found Robinson guilty of the lesser dereliction of duty charge….

“Asked what he would say to the families of the 11 dead crewmen, Robinson paused in the courtroom and replied: ‘I don’t think it would be an appropriate time to say anything.’”

Other

1984 US Court of Appeals for the Fourth Circuit ruling:
“….
“The United States appeals from an order denying its claim for limitation of liability under 46 U.S.C. § 183(a) (1958). We affirm the judgment of the district court.

“This suit arises out of a collision between the United States Coast Guard Cutter Cuyahoga and the Argentinian freighter, Santa Cruz II. How the collision occurred is undisputed. On a clear night in October 1978, the Cuyahoga, under the command of Chief Warrant Officer Donald K. Robinson, was northbound in the Chesapeake Bay on an officer candidate training cruise from its base at the Coast Guard Reserve Training Center (RTC) in Yorktown, Virginia. The Santa Cruz II, a freighter loaded with coal, was southbound in the Bay from Baltimore, Maryland.

“While standing watch on the Cuyahoga, Captain Robinson and several officer candidates noticed the lights of a vessel, which turned out to be the Santa Cruz II, off the port bow. Captain Robinson checked the radar and determined that the vessel was about eight miles away and had a left-bearing drift. From the configuration of the lights, Captain Robinson, despite many years of experience, guessed erroneously that the Santa Cruz II was a small vessel traveling in the same direction as the Cuyahoga. When the vessels were about a mile apart, Captain Robinson ordered a change of course, turning left to take the Cuyahoga into the mouth of the Potomac River to moor for the night. Having erroneously concluded that the Cuyahoga and the Santa Cruz were traveling in the same direction, Captain Robinson thought that by turning left the Cuyahoga would cross astern of the Santa Cruz. In fact, the left turn caused the Cuyahoga to cross the bow of the Santa Cruz II. When the Cuyahoga crossed its path, the Santa Cruz II sounded its warning signals. Captain Robinson did not realize that his vessel was in the path of the Santa Cruz until it was too late. The bow of the Santa Cruz struck the Cuyahoga. The Cuyahoga sank in two to three minutes. Eleven of her crew died. The Santa Cruz II sustained substantial injury to her bow.

“II

“Empresa Lineas Maritimas Argentinas, SA (ELMA), the owner of the Santa Cruz II, filed a complaint against the United States seeking recovery for damages to the Santa Cruz II and for indemnity and contribution for any claims arising out of the accident for which ELMA might be held liable to third parties. The United States denied liability but asserted that, in the event that it was found liable, its liability should be limited under 46 U.S.C. § 183(a) to the value of the Cuyahoga, which is nothing.

“In a memorandum opinion, Judge Blair found that the multiple errors of judgment and perception made by Captain Robinson were the sole cause of the collision. Consequently, the United States was 100% liable. The court also held that the government was entitled to limit its liability under Sec. 183(a) because the United States did not have privity or knowledge of the cause of the collision.

“Before judgment was entered, Judge Blair died. The case was reassigned to Judge Thomsen. Upon motion of ELMA, which the government opposed, Judge Thomsen reopened the case and held another trial at which additional evidence was received and new witnesses heard. Judge Thomsen agreed with Judge Blair’s conclusion that the Cuyahoga was solely responsible for the collision. Judge Thomsen, however, held that the United States could not limit its liability under Sec. 183(a) because “one or more persons in the chain of command over Robinson had knowledge or were charged with knowledge of the existence of Robinson’s physical problems and loss of sleep, which were responsible for his bad judgment, the cause of the collision.” It is from this judgment that the United States appeals.

“III

“Under 46 U.S.C. § 183(a) the liability of a shipowner for any loss, damage, or injury by collision may not exceed the amount or value of the interest of the owner in the vessel if the loss is occasioned without the privity or knowledge of the owner. Determining whether a shipowner may limit liability under this section is a two-step process. First, the court must consider what acts of negligence or conditions of unseaworthiness caused the accident. Here, the United States does not appeal the district court’s finding that Captain Robinson’s errors of judgment due to his physical condition caused the collision. Consequently, we must address only the second question, whether the shipowner had knowledge of the events which caused the loss.

“To preclude limitation under Sec. 183(a), the shipowner’s knowledge need not be actual. The shipowner is chargeable with knowledge of acts or events or conditions of unseaworthiness that could have been discovered through reasonable diligence. See Spencer Kellogg Co. v. Hicks, 285 U.S. 502, 511-12, 52 S. Ct. 450, 452-53, 76 L. Ed. 903 (1932). Thus, the inquiry here is whether the United States had sufficient knowledge of Robinson’s medical condition, which the district court found caused his errors in judgment, so that limitation of liability should be denied.

“The same standards are applicable to the United States when it seeks a limitation of liability because it lacked privity or knowledge of the cause of the loss as when a private corporation seeks the same benefit. United States v. Standard Oil of California, 495 F.2d 911, 917 (9th Cir. 1974). In both instances, liability may not be limited under Sec. 183(a), where the negligence is that of an executive officer, manager, or superintendent, whose scope of authority includes supervision over the phase of the business out of which the injury occurred. Coryell v. Phipps, 317 U.S. 406, 410-11, 63 S. Ct. 291, 293-94, 87 L. Ed. 363 (1943) (dicta). Here, the record shows that three officers were above Captain Robinson in the chain of command at Yorktown. The authority of the commanding officer of the Reserve Training Center in Yorktown included the operational control of the Cuyahoga. Below him in the chain of command was the executive officer. Finally, Captain Robinson’s reporting officer was the chief of the training division at Yorktown. As head of the training division, he had operational and administrative control of the Cuyahoga. Each of these officers had sufficient authority over the operation of the Cuyahoga to impute to the United States his knowledge of the events that caused the accident. See Spencer Kellogg Co., 285 U.S. at 511, 52 S. Ct. at 452.

“IV

“The United States argues that it cannot be charged with privity or knowledge of Robinson’s errors of navigation and seamanship when the vessel is underway. See La Bourgogne, 210, U.S. 95, 28 S. Ct. 664, 52 L. Ed. 973 (1908). Nonetheless, the United States may not absolve itself if through the use of reasonable diligence it could have taken action while the vessel was in port and under its authority and control that would have prevented Robinson’s negligent acts at sea. Spencer Kellogg Co., 285 U.S. at 511-12, 52 S. Ct. at 452-53; States Steamship Co. v. United States, 259 F.2d 458, 474 (9th Cir. 1957). We turn then to consider whether Robinson’s superiors exercised reasonable diligence to ascertain the effect Robinson’s medical condition might have on his performance as commanding officer of the Cuyahoga.

“Robinson first visited the medical clinic at the RTC in Yorktown in April 1978 complaining of wheezing, coughing, and shortness of breath. Initially, he was treated by corpsmen at the medical clinic who apparently diagnosed his condition as a sinus infection and prescribed antihistamines and a cough expectorant. Robinson returned to the medical clinic several times over the next few months because his symptoms persisted. Sometimes he was seen by a doctor, at others by a physician’s associate or corpsman. From July to September he visited the clinic frequently, going two to three times a week for treatment. During this period he was treated by a doctor who had diagnosed Robinson’s illness as bronchial asthma. Robinson repeatedly complained to the doctor that his coughing and difficulty in breathing were affecting his sleep. Some nights he said he slept only two to three hours. The doctor’s testimony conflicted with Robinson’s. The doctor admitted Robinson told him about difficulty in resting. He denied that he had any discussion about lack of sleep, and he asserted that he did not think Robinson was unfit for duty.

“Robinson’s condition did not improve materially, so in September the doctor sent him to the allergy clinic at Walter Reed Hospital. Robinson visited the allergy clinic at Walter Reed three times between September 14 and October 20, 1978. During this period he saw the doctor at the Yorktown clinic only on an informal basis, keeping him apprised of his progress and treatment at Walter Reed. His last visit to Walter Reed was the day before the collision, at which time he still complained of coughing, wheezing, chest congestion, and sleeplessness. Because Robinson’s condition had not improved, his physician at the allergy clinic arranged for him to go to the pulmonary clinic for further testing. Robinson’s illness was not correctly diagnosed as aspergillosis until after the accident, in December 1978.

“The medical clinic at Yorktown documented most visits on a daily medical report that was circulated to the commanding and executive officers. It listed patients seen at the clinic, their diagnosis, and a fitness-for-duty determination made by medical personnel. The district court found that although Robinson’s superiors knew his name was appearing frequently on this list, they took no reasonably adequate steps to determine whether his medical condition affected his ability to perform his duties as the commanding officer of the training vessel Cuyahoga.

“The government argues that Robinson’s superiors exercised due diligence and concluded that his condition would not impair the performance of his duties. The executive officer asked the doctor at Yorktown about Robinson and he also asked Robinson on at least one occasion how he was feeling. To require more, the United States argues, places an impossible burden on Robinson’s superiors.

“The executive officer testified that he noticed Robinson’s name on the daily medical report several days in a row in July 1978. He testified, however, that his conversation with the doctor, which the United States asserts constitutes sufficient diligence, was for a limited purpose. He questioned the doctor because he could not decipher the notation of Robinson’s diagnosis on the daily medical report. He did not ask medical personnel whether Robinson’s condition in any way affected his ability to perform as the commanding officer of the Cuyahoga. Moreover, although the executive officer notified the commanding officer that Robinson’s name was appearing frequently on the daily medical report, neither officer initiated any action or made any inquiry concerning the necessity of sick leave for Robinson or relief from his command. The chief of the training division made no attempt to determine the extent of Robinson’s illness, although, as Judge Thomsen found, he, too, had knowledge that Robinson had been ill for some time.

“The United States argues that to require Robinson’s superiors to conclude that he should not perform his duties as commanding officer when the doctors at Yorktown and Walter Reed had not recommended that he be removed from duty is to hold the United States to a standard of omniscience. The government relies on the doctor’s testimony that had he thought Robinson was too ill for duty he would have insisted that Robinson stay home in a not-fit-for-duty status.

“Conflicting evidence undermines the government’s reliance on the doctor’s testimony. Medical personnel at the RTC generally did not place senior officers like Robinson on limited or not-fit-for-duty status because senior officers could determine their own duty status. Consequently, a senior officer often would not be put on not-fit-for-duty status under circumstances where an enlisted man would be. Indeed, the doctor testified at Robinson’s court martial that he would have put Robinson on not-fit-for-duty status on several occasions had Robinson been an enlisted man on the Cuyahoga.

“Robinson, however, did not know that he could declare himself not-fit-for-duty for medical reasons, nor did he feel that he was incapable of performing his duties. He was confident that if he were unfit, the medical officers would tell him. Robinson believed that because his superiors received the daily medical report and thus were aware of his condition, they would relieve him of his duty if they thought it was necessary. Unfortunately, Robinson’s superiors considered senior officers listed on the daily medical report fit-for-duty unless medical personnel or the individual recommended otherwise. Consequently, they did not suggest independently that Robinson may not be fit-for-duty.

“That the policy was unclear for declaring senior officers not-fit-for-duty does not absolve the United States. Knowledge within the context of Sec. 183(a) includes both actual knowledge and the knowledge of conditions likely to produce or contribute to loss which the owner or superintendent could have discovered through reasonable diligence. “The measure in such cases is not what the owner knows, but what he is charged with finding out.” States Steamship Co., 259 F.2d at 466 (quoting Great A & P Tea Co. v. Brasileiro, 159 F.2d 661, 665 (2d Cir. 1947). The executive officer’s limited questioning of the doctor did not meet this standard. The Coast Guard officers whose authority included the operational command of the Cuyahoga had a duty to conduct a more probing inquiry to determine whether Robinson’s condition might affect his ability to perform as the commanding officer on training missions on the Cuyahoga. Failing in this duty, the United States may not limit its liability under Sec. 183(a). See Spencer Kellogg Co. 285 U.S. at 512, 52 S. Ct. at 453.

“V

“Other considerations support the district court’s finding that the United States had privity and knowledge. Robinson had been involved in two minor accidents in April and May of 1978. After investigating these accidents, the Coast Guard reprimanded Robinson for exercising poor judgment. The government argues that these accidents bore no relationship to Robinson’s competence. Nonetheless, we agree with the district court’s observation that, although these accidents do not compel the conclusion that Robinson was incompetent, they are factors that in conjunction with Robinson’s medical problems should have prompted Robinson’s superiors to investigate whether he was fit to perform full duty.

“ELMA also asserts that independent grounds support a denial of limitation of liability. First, ELMA argues that the Cuyahoga was not sufficiently manned with a competent crew. ELMA presented as evidence three Coast Guard district inspection reports, from 1973, 1975, and 1978, which concluded that the Cuyahoga was undermanned and recommended an increased personnel allowance. Additionally, ELMA introduced a letter written by Robinson to the Commandant of the Coast Guard requesting an electrician billet for the Cuyahoga. In his letter Robinson explained that the personnel allowance was “far below the level of the necessary manpower needed to maintain this class and size of vessel, provide the routine administration, watchstanders and furnish qualified instructors for the training of the officer candidates ….” The district court found, however, that Robinson’s errors of judgment, not undermanning or an incompetent crew, caused the damage to the Santa Cruz. We cannot say that this finding is clearly erroneous.

“ELMA also asserts that the Coast Guard had knowledge of material deficiencies on the Cuyahoga, including inadequate radar and emergency lighting, and poor watertight integrity, that were sufficient to deny limitation. The district court found that material deficiencies did not cause or contribute to the damage to the Santa Cruz but that they would be important with respect to 46 U.S.C. § 183(e), the loss of life provisions of the statute, if ELMA were held liable for damages in the Massachusetts cases. This finding also is not clearly erroneous, and we will not disturb it on review.

“We turn finally to ELMA’s claim for indemnity and contribution. Like the district court, we find this claim is premature because no judgment for damages has been rendered against ELMA in the wrongful death and personal injury suits filed in Massachusetts.

“We conclude that Judge Thomsen’s findings are not clearly erroneous and that he correctly applied the legal principles that govern this suit. Accordingly, we hold that the United States may not limit its liability under 46 U.S.C. § 183(a) because it had privity and knowledge of the conditions that caused the collision between the Cuyahoga and the Santa Cruz. The judgment of the district court is affirmed.”

Sources

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United States Coast Guard, Marine Board of Investigation. Marine Casualty Report. USCGC Cuyahoga, M/V Santa Cruz II (Argentine); Collision in Chesapeake Bay on 20 October 1978 with Loss of Life. Washington, DC: USCG (Report No. USCG 16732/92368) Commandant’s Action July 31, 1979, 66 pages. Accessed 6-23-2021 at: https://www.dco.uscg.mil/Portals/9/DCO%20Documents/5p/CG-5PC/INV/docs/boards/cuyogasantacruz.pdf

Washington Post (Glenn Frankel). “Cuyahoga Skipper Given Token Cut in Seniority; Cuyahoga Skipper Given a Reduction in Seniority.” 11-6-1979. Accessed 6-29-2021 at: https://www.washingtonpost.com/archive/local/1979/11/06/cuyahoga-skipper-given-token-cut-in-seniority-cuyahoga-skipper-given-a-reduction-in-seniority/7f1a91c4-e35d-4851-84f4-b139ebe17dd2/

Washington Post (Stephanie Mansfield). “Cutter Captain Had Other Accidents.” 11-3-1978. Accessed 6-29-2021 at: https://www.washingtonpost.com/archive/local/1978/11/03/cutter-captain-had-other-accidents/30afb6f6-16d4-4bca-8cc3-5a382a098b98/

Wikipedia, “USCGC Cuyahoga,” 6-12-2021 edit. Accessed 6-23-2021 at: https://en.wikipedia.org/wiki/USCGC_Cuyahoga