The Investigation

The sky was black as the Munro entered Iliuliuk Bay. The ship steamed for the cluster of lights that marked the village of Unalaska, then swerved to starboard, toward the Coast Guard pier. The Munro’s crew had searched for fish master Satoshi Konno for twenty-six hours. There’d been lots of debris—fishing net and buoys, a couple of life rings—and a half-mile-wide oil slick. The rescue swimmer on the new Jayhawk crew from St. Paul had been lowered on the hoist line to puncture and deflate the empty life rafts so they wouldn’t offer false hope to the next group of searchers. Like the seamen posted on deck as the Munro zigzagged up and down the ocean, the helo crew had seen no trace of the Japanese fisherman.

Erin Lopez was back on duty in Combat, studying the radar for any traffic in the channel and supervising the more junior operations specialists as they plotted the ship’s approach into Dutch Harbor. Lopez had taken charge of developing the Munro’s search patterns for Konno, working with District Command in Juneau to be sure the ship’s plans and those of the Coast Guard aircraft complemented one another. As the ship neared the pier, she went up to the deck so she could watch the fishermen go ashore.

In the hours after the last men were lowered to the ship, Lopez had talked to some of the survivors. The room she shared with a handful of other female crew members was right across from the rec deck where the men were resting. She’d poked her head in there and introduced herself, offering the guys popcorn and PowerBars from her private stash. A few of the survivors said they remembered her voice. They’d heard it coming over the radio in the Ranger’s wheelhouse before they abandoned ship.

Now most of the fishermen were on the mess deck, waiting to get off the boat. Out the portholes, they could see that there were a handful of vehicles next to the pier, including an ambulance to transport the body of David Silveira.

As the Munro’s deckhands raised the aluminum gangway up to the side of the ship, Lopez moved to the rail. It was after midnight, but Captain Lloyd was there, along with Luke Cutburth and Jimmy Terrell. As the rescued crewmen stepped off the boat, Lopez shook each of their hands. A couple of the guys leaned down to give her a hug. Then she watched them file quietly off the ship and disappear into the cold night.

WITHIN A DAY OF THE SINKING, the Coast Guard and the National Transportation Safety Board (NTSB) convened a joint Marine Board of Investigation into the loss of the Alaska Ranger. The Marine Board is the Coast Guard’s most formal type of accident analysis, most often reserved for incidents that result in multiple deaths, as well as the total loss of a vessel. It had been seven years since the Coast Guard’s last Marine Board, which investigated the disappearance of the Arctic Rose, the head-and-gut boat that sank in the Bering Sea in April 2001 and cost the lives of fifteen men.

The Alaska Ranger’s Marine Board began questioning witnesses on the morning of Friday, March 28, in a conference room at the Grand Aleutian hotel. The board was headed by Coast Guard Captain Mike Rand, then finishing out his career at Coast Guard headquarters in Washington, D.C. Assisting him were three other Coast Guard officers, one from Anchorage, the other two from the East Coast. The four-man NTSB team was led by a young maritime accident investigator named Liam LaRue. Though the fact-finding phase of the investigation would be a joint effort between the Coast Guard and NTSB, each agency would ultimately prepare its own independent report on the disaster.

Marine accidents represent the smallest slice of the pie of all transportation casualties investigated each year by the NTSB, the federal agency charged with examining the causal factors of airline crashes, train derailments, and highway disasters. LaRue was in a good position to lead the investigation. A 2000 graduate of the Coast Guard Academy, he’d spent two years as a deck watch officer on a cutter that had patrolled in the Bering. He then served for three years as a Coast Guard marine inspector before joining the NTSB. In his time with the agency, LaRue had worked on a number of high-profile incidents, including the capsizing of the passenger vessel Ethan Allen in Lake George, New York, in 2005, which resulted in the deaths of twenty-one elderly vacationers, and the collision of the freighter Cosco Busan with San Francisco’s Bay Bridge in 2007.

“This investigation is intended to determine the cause of the casualty to the extent possible,” Captain Rand explained in his opening statement, “and…to obtain information for the purpose of preventing or reducing the effects of similar casualties in the future.”

The board would look for evidence of any “incompetence, misconduct, unskillfulness, or willful violation of the law” that may have contributed to the accident, Rand said. Though the board would examine the decisions and actions of Coast Guard marine inspectors and rescuers, he identified a single “party of interest” to the investigation: the Fishing Company of Alaska. Before calling the first witness, the Coast Guard captain asked everyone in the conference room to stand and observe a moment of silence for the five men who had lost their lives just days before.

Julio Morales testified on the third day. Along with the other rescued men on the Munro, he’d been brought by van back to the Grand Aleutian hotel after arriving in Dutch Harbor. The guys who’d been picked up by the Warrior were already partying. There’d been another open tab. But this time, the company’s rule against alcohol had been lifted. The men could drink as much as they wanted and they’d each been given a wad of spending cash, courtesy of FCA. Some of the guys said the company was trying to butter them up. Julio had more than a few drinks. He kept seeing Byron’s face at night—but with enough beer, he could fall asleep.

Julio had been told he had to stay for the investigation. He missed the funeral. The family was Catholic, so the service was held right away. The day after they got off the Coast Guard ship, Julio had gotten a call from the cops in Dutch Harbor. They wanted him to come to the airport and identify his cousin’s body. Julio didn’t want to do it and asked Marco to go instead. The police came and picked Marco up, and brought him to the airport, where Byron’s body was waiting to be flown to the medical examiner in Anchorage. Julio waited at the hotel.

On the witness stand, Julio told the Marine Board about the holes in his suit, the rip at the seam that had allowed water to leak in. The investigators asked Julio about his training. Had he ever put on the survival suit before the night of the sinking? Yes, Julio said. He’d practiced getting into the suit soon after he’d first boarded the ship. His cousin Byron had done the same when he joined the crew a few weeks later. Other than that, though, there’d been no training. No one told them how to abandon ship, how to board the life rafts from the boat, or what to do once they were in the water.

The next day, the board called fisheries observer Gwen Rains. They questioned her about the safety checklist she’d filled out when she first boarded the Ranger. “Did you find any discrepancies during your inspection?” Gwen was asked. There were several things she felt that the ship needed to address, she responded, but the boat did have the current Coast Guard safety decal required to sail with an observer, and none of the boat’s problem areas were on her no-go list.

She gave some examples: “Like, the watertight doors, do they seal properly? No, they don’t,” Gwen said. “Are there fire extinguishers in every corridor that are in good and serviceable condition? No, they’re not. There were several things like that.”

Gwen recalled the safety drill carried out less than a week before the sinking. Unlike in other drills she’d witnessed as an observer, the men on the Ranger didn’t actually put on their survival suits or fire suits, or act out emergency scenarios with the full crew. Instead, they mustered in the wheelhouse, and the emergency squad members reported to the officers where they would be in different emergency situations. There was no discussion about what to do in an abandon ship scenario.

“What else is there that we need to know?” Rand asked at the end of Gwen’s testimony.

“I feel very strongly that a bad situation was made worse by people not knowing what to do. By people not being trained,” she answered.

The Marine Board took seven days of testimony in Dutch Harbor and, two days later, reconvened at the Hilton hotel in downtown Anchorage. Jayhawk pilot Brian McLaughlin and his wife, Amy, had flown from Kodiak, along with three crew members of the 65 Dolphin: pilot TJ Schmitz, rescue swimmer Abe Heller, and flight mechanic Al Musgrave. The primary goal of the investigation was to determine why the Ranger sank and why so many people failed to abandon ship safely into life rafts. But the board would also look at the Coast Guard’s response: What went well; what went wrong; and how could it have gone better.

It wasn’t the first time the Coast Guard rescuers had told their stories. When the Munro arrived in Dutch Harbor with the Ranger fishermen, the crew of the 65 Dolphin packed their things and left the ship. The next day they were flown to the Coast Guard outpost in Cold Bay, where they were met by a team of experienced Alaskan aviators who would conduct an internal fact-finding mission into how one of the shipwrecked men had fallen from the rescue basket. Each 65 crew member was questioned about Byron Carrillo independently, and then they talked together about how things might have gone differently. Back on the Munro, each Coastie had been given drug and alcohol tests, which is standard Coast Guard practice after any major mishap. All the men’s tests were negative.

Not long after the men were back home in Kodiak, the air station commander announced a safety stand-down—a meeting where all the rescuers involved in the Alaska Ranger case would recount what happened and discuss how and why they made the decisions they did. The gathering was held at the movie theater on base and was open to the entire air station—and to any family members who wanted to attend.

It was crowded as Amy McLaughlin walked into the warm theater. Framed film posters hung on the walls alongside signs for the weekday, kid-friendly screenings where she sometimes saw new releases with her young daughter in tow. Amy was curious to hear more about what had happened on the case. But mostly she just wanted to support Brian. She saw a few of the other wives there, too.

Brian had called Amy from St. Paul that Easter night. They’d had a pretty big case, he told her. He sounded exhausted, too tired to tell the whole story. It wasn’t until she saw the news the next day that Amy realized just how huge the rescue had been. She noticed that most of the headlines focused on the five who died. Of course, it was heartbreaking for those families, but the endless spotlight on those who hadn’t survived made Amy feel bad for the pilots, and for all the guys on those aircrews. She wished the media would concentrate on the ones who’d been saved. It was hard for Brian, Amy knew, to accept the fact that they’d left people behind. He’d never had to leave anybody before. He seemed concerned that she know his crew had done everything they could out there—and she did.

One by one, the Coast Guard rescuers stood before the familiar faces in the crowded movie house and told their stories. They presented the rescue on a timeline: the 60 guys went first, followed by the 65 guys, then back to the 60 crew. They talked for more than an hour, and then took questions. Amy was interested in hearing what the other pilots asked about the decision making. It was by far the most intense rescue Brian had ever experienced. Hearing her husband describe all the lights in the water, the high seas and winds, and the disorienting snow squalls made her feel uneasy. But mostly she felt proud.

The Munro was back on routine patrol in the Bering Sea at the time of the safety stand-down in Kodiak. But the ship’s crucial role in the rescue was duly recounted by the aviators, including Brian McLaughlin. He had already offered his appreciation personally. On the morning of Monday, March 24, as the Munro was still tracing search patterns across the Bering Sea, Ops Boss Jimmy Terrell had received an e-mail message from the aircraft commander:


I wanted to drop you a line to try to express our sincere appreciation for your crew’s efforts yesterday during the main portion of the Alaskan [sic] Ranger case. As we left, we asked your Control watch stander to relay that to your CO, but it’s kind of hard to get the point across on a working freq….

It is vividly apparent to me and my crew that your crew was rolling as continuously as we were from the 3 o’clock hour, and continued to do so even after we left scene.

This case covered literally just about every aspect of CG SAR training that they beat into us as pilots: navigating and operating in poor weather, high seas, hoisting survivors in the water and in rafts, hoisting to a pitching fishing vessel, then to a pitching cutter, HIFR ops, search planning, etc. It was by far the most large-scale CG operation that I have ever been involved with, employing 5 aircraft, 7 crews, good sams, etc., all of which centered about the Cutter Munro. If you hadn’t been there, I can’t imagine what the final outcome would have been.

As you continue on your patrol and on this case, as I’m sure you are, please know that outside of the obvious numerous survivors that you are bringing back home, your fellow Coasties are well aware of what you put forth to make it happen, and are damn thankful that you were there to do it. Please pass our gratitude and sincere respect to your crew.

Semper Paratus.


WITHIN A COUPLE OF WEEKS, the cutter was on patrol back up near the ice edge. It was a sunny day with no wind, and the water was dead calm near the retreating ice floe. Captain Lloyd piped an instruction for the crew to report to the flight deck. It was time for a swim call. The ship’s bagged survival suits were sorted by size. The crew pulled them on and leaped off the stern deck into the ocean. They bobbed up and down in the water, practicing swimming and linking arms in the flat seas. The officers paid $3 each for the privilege, a collection for the ship’s morale fund. For the junior crew, the exercise was free. Chuck Weiss observed from the deck. He was impressed by how well the suits worked, and it made him feel good to see everyone out there for so long.

Weiss had seen a few of the rescued Ranger crew members again, in the UniSea Bar in Dutch Harbor. He was accustomed to getting some nasty looks from fishermen at the bars in Dutch. The Coasties didn’t always feel welcome in there; they were the cops on the water, after all. But after the rescue, when Weiss walked in with a group from the ship, several fishermen came right up to them.

“Hey, we want to get you guys some beers!”

More people approached the Coasties: “You guys off the Munro?”

“Yeah,” one of the seamen answered.

“Right on!”

Weiss was slapped on the back. Someone ordered him a drink. Soon, there was a round of shots in front of them.

“These guys right here, they’re lifesavers,” one fisherman announced to the crowded bar.

IN MID-APRIL, THE COAST GUARD and NTSB Marine Board of Investigation convened in a third location, in a conference room at the Red Lion Hotel in downtown Seattle, just a few blocks from the famous fishmongers at Pike Place Market and less than two miles from the Fishing Company of Alaska’s corporate office. One by one, the Ranger fishermen described what they thought had contributed to the sinking. The engineers often didn’t keep consistent watch, some said. Several more testified that there was regular drinking on the boat, often among the ship’s officers. A number of men said that in recent months the Ranger had been traveling through ice more forcefully than they had experienced before, on this or other vessels.

“The ice is just like being…on a frozen lake,” Ryan Shuck explained several days into the Seattle hearings. “You see a few little cracks in it…. You couldn’t really see a lot of water between one piece and the other. It was pretty dense.”

Shuck recounted for the board the arguments he’d witnessed between the fish master and the previous captain, Steve Slotvig, including the fight about the boat’s speed traveling through ice. And he was questioned about who he’d seen drinking on the ship.

“Quite honestly,” Ryan answered, “I’d say probably 80 percent of the crew, at one point or another.”

“Did you use alcohol on board?” Shuck was asked.

“I have.”

“Was alcohol allowed on board?” one of the Coast Guard investigators pressed.


“What was the company’s policy?”

“The company’s policy is no drugs or alcohol on the vessel.”

“But you’d estimate 80 percent of the crew was drinking even though that was the policy?”

“Yeah,” Ryan said. “I’d say that’s probably a conservative estimate.”

Ryan was asked if he’d seen any of the engineers drinking. He testified that the assistant engineer, Rodney Lundy, was frequently intoxicated.

“Did you ever see him actually drinking alcohol or beer?” the Coastie pushed.

“Not on the boat.”

“So how did you know that he was frequently intoxicated?”

“I guess just the same way that, if you went down to the bar right now and had a six-pack of beer and came back up, I’d probably know,” Ryan said to a few grim smiles. “You can just tell.”

Many of the Ranger crew, including Ryan, answered the Marine Board’s questions with counsel by their side. Even before they arrived back in Dutch Harbor, some of the men had been talking about lawsuits, and soon after Ryan Shuck’s girlfriend read his e-mail from the Coast Guard ship, she Googled “maritime lawyer.” When the rescued men checked into the Grand Aleutian, they were greeted by messages from lawyers wanting to represent them. By the time the board convened in Seattle three weeks later, the crew had split fairly evenly into two groups: those who wanted to keep fishing for the FCA, and those who were ready to lawyer up.

The company had made settlement offers to the fishermen early on: $25,000 to those who got into a life raft pretty much right away, $35,000 to the men who struggled in the water for a time before finding their way to a raft, and $75,000 for those who were airlifted by the Coast Guard. Larger offers were made to some of the more senior crew members who’d played a key role in evacuating the ship. Factory manager Evan Holmes was one of them.

Like many of the Ranger fishermen, Evan had lawyers calling him in the days and weeks after the disaster. He was told that he was hurting some of the more junior guys by settling, that because he was a more experienced crew member, his lawsuit would help theirs. The pressure pissed Evan off—and so did some of the things he’d heard the guys saying. Like that they’d called the ship “Ranger Danger,” as a few crew members had told reporters. It wasn’t the boat that people were talking about when they used that phrase, as Evan remembered it. It was the crew.

Evan took the FCA’s money. He just wanted it over with. People died, and no lawsuit was going to change that. Evan wasn’t planning to go back to fishing—at least not right away. He wouldn’t rule it out for the future, though. He still had buddies up in Dutch. It was decent money, after all, and he’d been good at the job.

SEVERAL DAYS INTO THE MARINE BOARD testimony in Seattle, Coast Guard Commander Chris Woodley was called to the witness stand. The Ranger had been one of about sixty head-and-gut boats enrolled in the Alternative Compliance and Safety Agreement (ACSA) and Woodley had been the original mastermind behind that program.

The goal of ACSA had been to take a fleet with proven safety problems—driven home by the loss of the Arctic Rose and the Galaxy, just a year apart—and increase its safety standards. The fact that most of the boats in the fleet had been making and selling fish products that legally only classed and load-lined vessels were permitted to sell gave the Coast Guard the leverage needed to get the program off the ground. Most ships in the fleet were too old to be touched by the class and load line societies, Woodley explained to the Marine Board, and new fisheries management regulations focused on conservation banned companies from replacing old boats with new ones. The companies’ hard-fought fishing quotas were “tied to the steel.” Even if a company were willing to scrap an aging vessel and spend $10 million or $15 million on a new ship, they’d just end up with a beautiful new boat they couldn’t fish.

“We had several options in front of us,” Woodley testified. “Our first option is we could tell them, you guys can’t make these products anymore…. They could simply operate as fishing vessels, engage in simple head-and-gut processing operations, and there would be no increased safety standard for about fifteen hundred to sixteen hundred people that work on board those boats. That didn’t really seem to be a viable option. We’re about improving safety, not the status quo.”

Instead, Woodley explained, they came up with a new program that would bring the boats up to an “equivalent” level of safety as to what the class and load line societies require. Going into the program, the major concerns were about vessel stability, watertight integrity, and the degree to which crew could safely get off the boat in an emergency (an issue that is not addressed by class and load line societies).

“Did [the ship owners] ever express their concern over the workload that it was going to take for them to come into compliance with the program?” a Marine Board member asked.

“Absolutely,” Woodley answered. “This is a heavy lift for this fleet. We’ve estimated—this is a rough estimate—about forty million dollars going into these boats. I think, quite frankly, a lot of owners were very surprised at the condition of their vessels once they started dry-docking them and you had a marine inspector—a Coast Guard marine inspector—climbing the tanks and finding a lot of damage.”

The board had already questioned FCA Operations Manager Bill McGill about the FCA’s experience with ACSA. The tall, gray-haired captain had sailed as master of the Alaska Ranger for more than a decade before advancing to a desk job, and he acted as the spokesperson for the FCA throughout the Marine Board process. (Company owner Karena Adler was never called to the witness stand.) McGill told the Marine Board that it would have made more financial sense for the FCA to stop making the ancillary products that would be banned if they didn’t comply with ACSA, than to comply and invest in the significant upgrades the safety program required. Still, the FCA had enrolled their seven vessels and had spent several million dollars on the program to date.

“We are fishermen, but we are not dummies,” McGill told the board. “The North Pacific is a rough place to make a living, and anything that enhances safety and seaworthiness of a vessel is an admirable goal.”

In late 2007, Coast Guard marine inspectors traveled to the shipyard in Japan where the FCA had most of its dry dock work done. There was more work than could be finished in the scheduled time, and the Ranger left the yard with a number of work items unaccomplished. All the boats enrolled in ACSA were originally supposed to have met the program’s safety requirements by January 1, 2008. By the time the Alaska Ranger sank three months later, the FCA ship still hadn’t met many of the ACSA goals. Then again, neither had significantly more than half of the other head-and-gut boats.

It appeared that the Coast Guard’s effort had fallen short. The Marine Board heard testimony that ACSA was underfunded and undermanned. The Coast Guard’s Chief of Inspections for the state of Alaska revealed under questioning in Anchorage that he’d never even heard of ACSA until late in 2007, almost a year and a half after the program got off the ground. Clearly, there were communication problems between the two districts involved in bringing the boats up to the new standards. Inspectors were behind on their paperwork, and the Coast Guard’s computer data system wasn’t updated to effectively keep track of the ACSA work lists. But the Marine Board’s fact-finding revealed that the underlying problem was that this fleet of boats was in much worse shape than the Coast Guard examiners knew when they started out. The ships’ work lists were long, and the extensive dry dock time required to complete the repairs was hard to come by. It was true that most of the enrolled head-and-gut boats still hadn’t met the ACSA standards. But almost all of them were in much better shape than they had been a few years before—or than they ever would have been if the local fishing vessel examiners hadn’t pushed for the program in the first place.

WHILE THE COAST GUARD WAS FOCUSING on what had gone wrong with its alternative safety program, the National Institute for Occupational Safety and Health (NIOSH) in Anchorage was studying what had gone right. Fishing vessel safety expert Jennifer Lincoln had witnessed the ACSA program from its inception. She remembered the day when she’d driven to downtown Anchorage to meet her friend Chris Woodley for lunch. On his desk were the data from the National Marine Fisheries Service that proved the head-and-gut boats were illegally processing ancillary products. Woodley told Lincoln about his plan for an alternative safety program that would improve the seaworthiness of the Bering Sea head-and-gut fleet and showed her a list of additional safety requirements he and Charlie Medlicott had come up with based on the Arctic Rose and Galaxy casualty investigations. Woodley asked Lincoln what she thought.

She was thrilled. Woodley’s program would require the head-and-gut boats to install life rafts on the rail of the ship that could be launched by a single person. There would be stronger requirements for training: at least five drill instructors on each boat that sailed with thirty-six or more crew. Study of earlier disasters had found that reflective tape and standard flashlights were sometimes not enough to allow rescuers to find survivors in the water—especially at night. As part of ACSA, all the survival suits on the Bering Sea head-and-gut fleet would be equipped with strobe lights.

On Sunday, March 23, 2008, Lincoln got a text message from Charlie Medlicott, the Coast Guard’s fishing vessel examiner in Dutch Harbor. “Alaska Ranger sank. Forty-seven people on board,” it read.

Lincoln called him. It wasn’t just about his job, and the devastating fact that one of the ACSA boats sank just as the program they’d pushed so hard for was getting off the ground. Charlie knew the guys on that boat.

On Monday morning, Lincoln was on a plane to Dutch. She’d guessed that the Alaska Ranger sinking would warrant a Marine Board, and she’d read enough Coast Guard accident reports to know the board would focus on a wide array of topics. She wanted to be sure that data on training and survival equipment were well captured. It would be valuable for evaluating the changes that had been implemented as a result of ACSA. Lincoln knew that it was essential to gather the information immediately, while the survivors’ memories were fresh and before they left town. Together with the NTSB investigators, Lincoln interviewed each of the fishermen before the formal questioning began. “What’s your first language?” she asked each of the survivors. “Tell me about your immersion suit.” “Did you have a strobe light?”

Lincoln quickly reached some first conclusions. It was apparent that the newly required strobe lights had saved lives. Until the very end of the rescue, there had been little “search” in this search and rescue case. The flashing lights on the fishermen’s survival suits had directed the Coasties right to their targets. And though the abandon ship procedures had been anything but smooth, the life rafts were each successfully launched by one or two people. When the rafts bolted away from the boat, a number of individuals entered the water by climbing down the ship’s Jacob’s Ladders, survival equipment that was mandated through ACSA.

Lincoln found that 30 percent of the people on board—fourteen in all—had had recent safety training. The number wasn’t ideal, but chances are it would have been lower without ACSA. Most significant, she discovered that 80 percent of the people who were recently trained got into a raft, while only 38 percent made it into a life raft without training. All of those who made it to a raft survived.

ON SEPTEMBER 30, 2009, A YEAR and a half after the Alaska Ranger was lost in the Bering Sea, NTSB investigator Liam LaRue presented his group’s findings to President Barack Obama’s recently appointed head of the National Transportation Safety Board, Deborah Hersman. As LaRue and his coinvestigators gathered their papers and settled in front of microphones, Captain Mike Rand and two of the other Coast Guard Marine Board members found seats together in the spacious auditorium. Their own report was still working its way up the Coast Guard chain of command, and the Coasties had yet to see the NTSB’s findings. Most of the seats in the large room were empty, but a handful of people sat in the front row. Among them was Karen Jacobsen, Captain Pete Jacobsen’s daughter.

“We are here today to make sure an accident like this does not happen again. That’s the purpose of our work,” began Hersman.

She turned to LaRue, who described the ship, its fishing practices, and its crew, then gave the board a condensed timeline of its last hours: The flooding was discovered in the Alaska Ranger’s rudder room around 2:30 A.M. There was no evidence of any collision or breach in the skin of the ship. LaRue’s team had concluded that, as originally reported, the flooding had most likely resulted from the physical loss of one of the ship’s two rudders. The board members had found that the Ranger’s conversion to a factory fishing trawler years before the accident had left the boat sitting more than two feet lower in the water than as originally designed. The difference was enough to bring the waterline to the top of the ship’s rudder shaft and to allow a constant flow of seawater into the ship. Rough seas most likely made the situation worse.

Losing a rudder is a bad—and unusual—scenario. But it should not have caused the boat to sink. The NTSB’s marine engineer explained to Hersman and her colleagues that if the Ranger’s watertight integrity had been intact, even complete flooding of the rudder room would not have led to the loss of the vessel. But the ship’s watertight integrity was not, in fact, intact. Testimony had revealed that there was a permanent breach in the rudder room bulkhead, and that at least one of the ship’s watertight doors had begun leaking not long after it was closed.

The final blow to the Ranger came when its controllable pitch propeller (CPP) system kicked into reverse soon after the vessel lost power. The CPP system was a remnant of the Ranger’s earlier life as an oil-rig supply boat. For a time, many ships were designed to automatically shift into reverse at an unexpected loss of power, the idea being that it would be far better to suddenly back away from an oil rig than ram right into it.

The NTSB concluded that the Ranger’s movement astern both accelerated the sinking and prevented the fishermen from entering life rafts directly from the boat. The officers on board the ship did have the ability to shut down the ship’s engines and stop the vessel’s backward movement. There was no testimony or evidence, however, that any member of the crew attempted to do so.

In July 2008, three months after the accident, the Coast Guard had issued an industry-wide safety warning titled “Controllable Pitch Propeller Systems and Situational Awareness.” There had been other recent incidents of CPP systems surprising crews with a shift into reverse. For instance, just a few months before the loss of the Ranger, a cruise ship carrying adventure tourists sank off the coast of Antarctica (all 154 passengers safely evacuated the ship before it shifted astern). The Coast Guard’s warning encouraged owners and operators of boats with CPP propulsion to be sure they understood their system and knew how to react in the case of a sudden casualty. LaRue explained to Hersman that it was unclear if the officers on the Ranger actually understood the ship’s CPP system. What was clear was that the ship and its crew would have fared better if the boat was dead in the water during abandon ship procedures, rather than moving full-speed astern.

Still, LaRue resisted judging the actions of men who weren’t there to explain themselves. All of the Ranger’s top officers, after all, had died in the sinking: “We don’t know what they knew and when they knew it, so it’s hard to make a judgment on what they should have done,” he told Hersman.

In the end, the NTSB’s investigation resulted in five recommendations to four different groups. The Fishing Company of Alaska was advised to “review and modify as necessary the procedures for enforcing your drug and alcohol policy to ensure full crew compliance.” Though there was significant evidence of substance use on the vessel, LaRue stated that the NTSB had been unable to determine whether alcohol or drugs had played a role in the incident since no drug or alcohol testing was conducted on the survivors.

“They definitely talked the talk but didn’t follow through,” LaRue responded to Hersman, after she quoted from the FCA’s strongly worded no-tolerance drug and alcohol policy. “It appears that the policy was not enforced.”

Though the NTSB had investigated the role of the fish master on board the vessel, LaRue said, they’d concluded that there was no compelling evidence that the fish master’s power exceeded that of the captain, and had taken no action on the issue. Under questioning, former Captain Steve Slotvig had maintained that he left the Ranger of his own accord, and that he was, in fact, in control of the vessel.

The board’s second and third recommendations were to the National Marine Fisheries Service and the North Pacific Fishery Management Council. Both organizations were told to amend their regulations to allow ships like the Alaska Ranger to be replaced in situations other than vessel loss without a company sacrificing its quotas.

The final two recommendations were directed at the Coast Guard. The Marine Board’s investigations had revealed that the engineers on board the Ranger were not properly licensed. Chief Engineer Dan Cook held a Coast Guard license for vessels up to 6,000 horsepower. The Ranger’s horsepower was 7,000. Only one of the ship’s two assistant engineers was licensed, and his license was for up to 4,000 horsepower. There was no reason to think, the investigators said, that the licensing of the engineers contributed to the casualty, but nevertheless their lack of qualifications was a notable oversight on the part of the FCA—and the Coast Guard.

The most significant of the NTSB’s recommendations was one that the safety agency had made four times in the past twenty years, with no results. LaRue’s group concluded that the Coast Guard should go to Congress and seek the legislative authority required to regulate commercial fishing boats to an appropriate level of safety. It was clear that the Ranger’s demise was the result of a series of preventable malfunctions. Had the ship been required to adhere to higher standards of seaworthiness, the Ranger and her entire crew would very likely have made it safely back to Dutch Harbor.

The NTSB recognized that the problems the Coast Guard faced in improving safety in the commercial fishing fleet went far beyond the lack of dedicated resources for Woodley’s ACSA program. The Coast Guard needed Congressional authority to regulate the entire industry to a common standard. Like every other type of boat, commercial fishing vessels should be inspected.

“There are a lot more regulations for the fish than there are for the fishermen’s safety,” Hersman noted in her concluding statements. “That needs to get rectified…. The Deadliest Catch is not called that for no reason. The statistics bear it out. This is the deadliest industry…. Whether you’re on the Cornelia Marie or the Alaska Ranger, you should be assured of one level of safety.

“Issuing these recommendations is not the end. It’s just the beginning of the process,” she promised. “We’re hoping the fourth time will be the charm.”

Meanwhile, in Alaska and throughout the United States, fishing boats leave port every day, many of them headed to some of the most violent and unforgiving waters on Earth. As always, many of the vessels are crewed by greenhorns, with little or no experience in using the safety equipment that the owners of their boats are finally required to provide. When disaster strikes, they may be able to make their way into a survival suit or a life raft. As for the actual seaworthiness of their ship? As long as commercial fishing vessels retain their uninspected status, all the fishermen can do is pray.

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