NATIONAL TRANSPORTATION SAFETY BOARD

Public Meeting of April 2, 2002

Synopsis of Final Report

(Subject to Editing)

Marine Accident Sinking of Amphibious Passenger Vehicle Miss Majestic Hot Springs, Arkansas May 1, 1999

NTSB-MAR-02/01 This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

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

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

Vehicle maintenance

Coast Guard inspections of the Miss Majestic

Coast Guard inspection guidance

Reserve Buoyancy

Survivability

As a result of this investigation, the Safety Board makes recommendations to the U.S. Coast Guard and the Governors of the States of New York and Wisconsin.

CONCLUSIONS:

1. Water initially entered the Miss Majestic through the gap between the driveshaft and its housing because the securing clamp for the watertight rubber boot had not been adequately secured by the maintenance mechanic.

2. The Miss Majestic sank because the DUKW had no watertight bulkheads and no reserve buoyancy and because its Higgins pump, which had been designed for significant dewatering capacity, did not operate.

3. The canopy on the Miss Majestic was a major impediment to the survival of the passengers.

4. Land and Lakes Tours, Inc.'s long-term vessel maintenance was inadequate and directly compromised the safety of the Miss Majestic and its passengers.

5. The Coast Guard's inspection program for the Miss Majestic was inadequate and cursory.

6. The lack of Coast Guard guidance and training for the inspection of DUKW's contributed to the inadequate inspections of the Miss Majestic.

7. Industry and Coast Guard inspectors need to become familiar with the general background and unique safety issues of all types of amphibious vehicles to improve the maintenance, inspection, and operation of specialized amphibious vehicles.

8. Flooding from failed boots, open hull plugs, hull damage, collisions, groundings, mechanical failures, improperly performed maintenance, and other scenarios continue to present serious risks of rapid flooding and sinking in amphibious vehicles lacking reserve buoyancy.

9. On amphibious passenger vehicles that cannot remain afloat when flooded, canopies can represent an unacceptable risk to passenger safety.

10. Wearing lifejackets before the vehicle enters the water would enhance the safety of passengers on board DUKW's without adequate reserve buoyancy where canopies have been removed.

11. Weather, drug and alcohol use, and operator fatigue were not factors in the sinking of the Miss Majestic.

12. Given the circumstances of this accident, the operator could not have taken any action to avert or mitigate its fatal outcome.

PROBABLE CAUSE:

 The National Transportation Safety Board determines that the probable cause of the uncontrolled flooding and sinking of the Miss Majestic was the failure of Land and Lakes Tours, Inc., to adequately repair and maintain the DUKW. Contributing to the sinking was the design of DUKWs as converted for passenger use, that is, the lack of adequate reserve buoyancy that would have allowed the vehicle to remain afloat in a flooded condition. Contributing to the unsafe condition of the Miss Majestic was the lack of adequate oversight by the Coast Guard. Contributing to the high loss of life was a continuous canopy roof that entrapped passengers within the sinking vehicle.

SAFETY RECOMMENDATIONS:

To the U.S. Coast Guard and the Governors of the States of New York and Wisconsin:

1. Require that amphibious passenger vehicle operators provide reserve buoyancy through passive means, such as watertight compartmentalization, built-in flotation, or equivalent measures, so that the vehicles will remain afloat and upright in the event of flooding, even when carrying a full complement of passengers and crew.

2. Until such time that owners provide sufficient reserve buoyancy in their amphibious passenger vehicles so that they will remain upright and afloat in a fully flooded condition (by recommendation I ), require the following:

(1) removal of canopies for waterborne operations or installation of a Coast Guard-approved canopy that does not restrict either horizontal or vertical escape by passengers in the event of sinking for vehicles in which there is no reserve buoyancy,

(2) reengineering of each amphibious vehicle to permanently close all unnecessary access plugs and to reduce all necessary through-hull penetrations to the minimum size necessary for operation,

(3) installation of independently powered electrical bilge pumps that are capable of dewatering the craft at the volume of the largest remaining penetration to supplement an operable Higgins pump or a dewatering pump of equivalent or greater capacity,

(4) installation of four independently powered bilge alarms,

(5) inspection of the vehicle in water after each time a through-hull penetration has been removed or uncovered,

( 6) verification of a vehicle's watertight condition in the water before the outset of each waterborne departure, and

(7) compliance with all remaining provisions of Navigation and Vessel Inspection Circular l-Ol.

3. Where canopies have been removed on amphibious passenger vehicles, for which there is not adequate reserve buoyancy as recommended in M-00-5, require that all passengers don lifejackets before beginning waterborne operations.

To the U.S. Coast Guard:

Develop and promulgate guidance for all amphibious passenger vehicles similar in purpose to the Navigation and Vessel Inspection Circular 1-01. Previously Issued Recommendation Classified in this Report:

The following Safety Recommendation was issued to 30 operators and refurbisher's of amphibious passenger vehicles in the United States: M-00-5.  Without delay, alter your amphibious passenger vessels to provide reserve buoyancy through passive means, such as watertight compartmentalization, built-in flotation, or equivalent measures, so that they will remain afloat and upright in the event of flooding, even when carrying a full complement of passengers and crew.

Based on information received, the Safety Board classifies, in this report, Safety Recommendation M-00-5 (previously classified "Open-Acceptable Response") "Closed-Acceptable Action" for the following company: Cool Stuff Tours C.A.M.I LLC.

Based on the lack of response to its February 18, 2000, initial letter and its August 17, 2000, follow-up letter, the Safety Board classifies Safety Recommendation M-00-5 "Open-Unacceptable Response" to the following companies: Aqua Traks, Inc; Austin Ducks; Buffalo Point; Chattanooga Ducks, Chicago Duck Tours; Ducks Amphibious Renovation/Sales; Land and Sea Tours; Maui Duck Tours; Naples Land and Sea Tours; National Park Duck Tours; Outfitter Kauai; Ozark Mountain Ducks; Sterling Equipment; and South Padre Water Sports/Breakaway.