"How Lack of Attention to Small Deficiencies Can Lead to A Major Disaster"
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It was a beautiful day for the 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, Arkansas. They were on board the "Miss Majestic", a World War II-Vintage amphibious vehicle known as a "duck". The vessel had wheels and a propeller, and although it was an open boat, it was covered with a canopy, which was supported by close spaced stanchions. The canopy was built with a rack to hold life preservers.
Within a few minutes of entering the water, the driver noticed that the vessel was taking a small list and directed some passengers to move to seats on the other side of the boat. The bilge pumps were also discharging water overboard. These two observations should have alerted the driver that something was not right.
After just seven minutes in the water, the "Miss Majestic" sunk in less than 30 seconds in 51 feet of water, resulting in 13 deaths.
I became involved as an Expert Witness in the case by being retained by a law firm that represented several of the victims.
My subsequent investigation found the following: 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 repair 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.
It was also found that there were a number of other 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 only see a small side portion of the stern thru 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" thru the front or the sides, except in a couple of positions close to the stern.
The failure to do proper repairs to a leaking rubber seal of a shaft and to test the "duck" after repairs, was the main cause of this disaster. The deficient design of the canopy and life preservers rack were 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" thru the sides.
Eventually, the case was settled out of court.
About the Author:
Hector V. Pazos is a Naval Architect, Marine Engineer and a Registered Mechanical Engineer and has been engaged in Accident Investigation/Reconstruction for more than 30 years. He has been retained as an Expert Witness in over 1,000 Maritime cases, related to both commercial vessels and pleasure crafts, for both defense and plaintiff.
He has offices in St. Petersburg, FL and New Orleans, LA. He can be reached by phone at (727) 347-2556 or (504) 367-4072 or by email at: Hectorpazos75597@aol.com and Oceanoilpazos@cs.com
For more information, please visit his website at: http://www.siterrific.com/pazos
© Hector V Pazos, 2006
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