Marine Disaster: Thirteen People Died When Boat Sunk Due To Small Deficiencies

TASA ID: 674

TYPICAL CASE IN WHICH LACK OF ATTENTION TO SMALL DEFICIENCIES RESULTED IN A MAJOR DISASTER

The location:

Hot Springs, Arkansas.

The circumstances:

A beautiful day for 21 tourists to take a sightseeing tour in the calm waters of Lake Hamilton, one of the scenic lakes of the Hot Springs National Park.

The vessel:

A World War II-Vintage amphibious vehicle known as a "duck," named "Miss Majestic." The "duck" has wheels and a propeller; hence, it can be used on land or water, and although it is an open boat, it is covered with a canopy, which is supported by closely- spaced stanchions.  The canopy is built with a rack to hold life preservers.

The disaster:

After 7 minutes in the water, the "Miss Majestic" sunk in less than half a minute in 51 feet of water, resulting in 13 deaths.

The main problem:

The "duck" has one engine that drives both sets of wheels and the propeller shaft.  Two days before the accident, the driver noticed water in the bilges and took the "duck" to the shop.  After the accident, it was found that the rubber seal of one of the shafts was improperly installed, allowing it to leak water into the bilges, but the "duck" was not tested after it left the shop, prior to the accident.

Early indications of trouble:

Within a few minutes of entering the water, the driver noticed that "the duck" was taking a small list and directed some passengers to move to seats on the other side of the "duck." The bilge pumps were discharging water overboard.  These two observations should have alerted the driver that something was not right.

Contributory causes for the large number of deaths:

a) The "duck" did not have a bilge alarm.

b) As water started collecting in the bilges, the "duck" was trimming by the stern.  The driver could not see the loss of freeboard at the stern until it was too late, just 15 seconds before the "duck" went underwater.

The driver's seat was located too low, and this position allowed the driver only a limited forward vision.  The driver could see only a small side portion of the stern through a rear view mirror.  Because of the low freeboard, the small trim aft (created by the water entering the bilges) was not noticed until the transom was submerged.  Once the transom was submerged, it took a few seconds for the "duck" to sink by the stern.

c) The life preservers were stored in an overhead rack under the canopy.  The rack was too small.  Therefore, the life preservers were jammed in the rack, requiring a major muscular effort to pull the life preservers out of the rack.

d) The canopy over the boat was improperly designed.  It was almost impossible for most people to get out of the "duck" through the front or the sides, except in a couple of positions close to the stern.

Conclusion:

The failure to do proper repairs to a leaking rubber seal of a shaft and to test the "duck" after repairs were the main causes of this disaster.  The deficient design of the canopy and life preserver rack was a large contributory cause of multiple deaths because people could not remove the life preservers fast enough from the rack and could not get out of the "duck" through the sides. 

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