Discover more from The Emergency Management Network
Fatal Expectations: Lessons from the George Prince Ferry Disaster
This October 20th will mark the 47th anniversary of the M/V George Prince Ferry Disaster (1976), in which at least 77 perished, and became the worst disaster of its kind in the nation’s history.
The early morning of October 20, 1976 on the Mississippi River near Luling, Louisiana was clear, crisp, without haze or fog and visibility measuring around 8 miles (USCG, 1978). The George Prince Ferry, which had been moving people, their vehicles and other cargo across the river from Luling to Destrehan since the 1920s was no stranger to these waters or its passengers, many of whom relied upon the vessel to get to work every day. This trip in particular left just before daylight at around 6:10 am and was loaded with 20 cars, 8 trucks, 6 motorcycles and an unknown number of pedestrians (USCG, 1978). Being that the route normally took under 4 minutes, many passengers elected to stay in their vehicles for the short endeavor to escape the early morning cold.
The SS Frosta, with whom the ferry would eventually collide, was a 666-foot Norwegian tanker that had been traveling upstream from Baton Rouge, Louisiana where she had recently completed the delivery of her cargo. The George Prince was much smaller in comparison, measuring approximately 128 feet long and 58 feet wide. In order to keep this river crossing transportation route available 24 hours a day, both the M/V George Prince and M/V Ollie K. Wilds worked in tandem; the latter serving as the split shift boat augmenting the ferry service during the hours of 0530-1000 and 1400-1900 daily – when the traffic flow was highest.
M/V George Prince will load and go with M/V Ollie K. Wilds following behind into the just vacated landing. Because of her smaller capacity, M/V Ollie K. Wilds will discharge and load faster than M/V George prince and will time her departure for the opposite bank when M/V George Prince is about 3 quarters loaded, arriving just in time to take its place (USCG, 1978).
With this dance happening dozens of times a day, communication between ferry pilots rarely ever occurred; each coming to understand and predict what their peer would do. The morning of October 20, 1976 had been no different. In order to make efficient ferry landings, the boats would let the current carry them slightly downriver before accessing the landing zone. This, in turn, created a figure-8 pattern (as seen below).
As the captain of the Ollie K. Wilds was getting ready to depart the West landing (Luling) and head to its Eastern counterpart (Destrehan), he noticed the oncoming SS Frosta on a steady heading. Calculating that his ferry would be able to make it across before the Frosta’s arrival to the “operational area,” he pushed the vessel forward. By the half way mark, the Ollie K. Wilds had around 2500 feet of clearance to spare; and soon made it completely across without incident or communication with either ship.
It should be noted that the Western ferry landing was located directly beside a large grain elevator and dock, which on this day, was being used by the M/V Polyviking, a vessel with a width of 130 feet. Together, they jutted out more than 400 feet into the river and created a significant blind spot for any vessels approaching from upstream until they were about 700 feet away. As the George Prince departed (which allowed the Ollie K. Wilds to make a landing), no communication occurred between the two ferry captains - as per the norm - despite the latter’s knowledge of the approaching ship.
Now with both vessels (George Prince & SS Frosta) traveling towards each other’s path at about 10 mph, collision would be inevitable unless they took drastic and immediate action. With the SS Frosta requiring an estimated 5000 feet to stop at this speed, her captain sounded multiple warning blasts and continued on course – assuming that the ferry would take appropriate actions instead. It did not. They collided at 0615 am.
After striking her, the ferry was moved for several feet before being pushed under the bow and capsized upside down, dumping all its vehicle cargo (many of which still contained their occupants). Some survivors found themselves stuck under the ship after it capsized while others attempted to grab on to any floating debris they could find. Few passengers were able to grab life jackets in time and none were able to put them on – indicating just how rapidly events progressed from their point of view. With their vision being obstructed by the grain elevator and ship, they had not the slightest sight of danger until the SS Frosta was less than 800 feet away.
Of the 18 that survived, 14 (~78%) were thrown clear of the vessel, 3 (~17%) were trapped under the overturned ferry and were able to swim down and away, and 1 (~5%) was trapped in their vehicle until they were able to kick out the windshield once it had sunk to the bottom of the river.
Lessons for Routine Normalcy
Although it is not specifically cited as a major contributing factor to the accident in the Coast Guard report, it is incredibly difficult to imagine this disaster happening to any degree – under almost any circumstances (i.e., impairment) – had the captain of the Ollie K. Wilds communicated with his colleague on the George Prince about the approaching ship he just cut in front of. Since the ferry service operated 24 hours a day, the very nature of its repetitiveness could be a significant and overlooked factor. Psychologically speaking, environmental comfort and route familiarity, if not provided proper corrective attention, reduce participant risk perception and hazard avoidance capabilities (Harms et al., 2021; Intini et al., 2016; Chen et al., 2022).
Routine, in due time, cultivates the growth of mental shortcuts to safety procedures and precautions (Harms et al., 2021). It is not all bad though. Repetitive behaviors also have a multitude of benefits when it comes to functions like productivity and stress reduction (Schneider & Harknett, 2019), but it is important to remember that unintended consequences know no bounds.
Newton’s Third Law said it best:
Every action has an equal and opposite reaction.
Following routine and repetitive task normalcy, comes increased comfort – whether the hazards are active or passive – often resulting in an autopiloted subconscious (Harms et al., 2021).
Yanko and Spalek (2013) explain:
“One task that most of us engage in daily that illustrates this practice effect is the task of driving a car. When we first started driving, we had to devote a lot of attention to checking our mirrors, having our hands in the 10 and 2 positions, watching the speedometer, etc. Over time, however, the task of driving that car becomes easier. In addition to learning the general aspects associated with driving a vehicle, similar learning also occurs with respect to learning the route between two locations. Initially we have to pay a lot of attention to road signs, etc., but as we become familiar with the route, these aspects, as well as more subtle things like the curves in the road and intersection locations, no longer have to be sought out, but rather are provided to us through our memories. That is, we shift from a more controlled, effortful, processing of the route, to a more automatic one.”
It therefore does not appear to be a coincidence that most serious traffic accidents occur close to home (Haas et al., 2015; Abdalla et al., 1997). A driver that routinely travels a certain route will develop expectations that in turn guide their scanning of hazards (Martens & Fox, 2007). Whether these expectations are accurate or not is a different story; and needless to say, it only takes the “non-conforming” actions of a single other person to bring it all crashing down.
Expect the unexpected.
When faced with a new hazard along a routine traffic route, it can take as little as a single previous encounter for drivers to mentally incorporate this addition into their future route expectations. Once subconsciously established as the norm, the collective perception of risk can drastically fade over the course of just a few days (Intini et al., 2016).
The pilot of the SS Frosta also fell victim to procedural routine normalcy when he failed to take appropriate evasive action (NTSB, 1979) as he was expecting the George Prince to move out of the way – which was a custom. But customs to not trump rules on the books – which at the time would have given the ferry the right of way (USCG, 1978; NTSB, 1979).
Eventually, comfort evolves into the antithesis of caution.
In order to combat some of these routine procedural-hazard issues, some organizations have sought to develop customized standard operating procedures. While there is nothing inherently wrong about this, studies regularly show that active participatory worker involvement in its design and implementation from the ground-level up, is a critical factor in obtaining program success and longevity. Compliance adherence is directly related to worker buy-in and participation; which if ignored may lead to pitfalls such as:
Written by management, procedures can be used as a means of control instead of to support work performance (Carim et al., 2016).
Little thought is put in to ensuring that new rules do not conflict with already existing ones (Lawton, 1998).
Perception discrepancies of the work being performed (Lawrence, 2005)
Failure to make it user-friendly (Dahl, 2013)
Lack of training and safety culture (Petitta et al., 2017;)
Feelings of resentment and “decoupling” from important decision making by outsiders (Almklov et al., 2013)
See What They Saw
By the time both the SS Frosta and George Prince Ferry first saw each other, they were separated by only about 700 feet. In order to properly understand this sequence, it is important to view it how they would have that day. Although somewhat crude, here is my attempt (based off of the Coast Guard Report (1978).
Crew: Egidio Auletta, Nelson Eugene Sr., Douglas Ford, Jery Randle & Ronald Wolfe
Passengers: Mark Abadie, Hurest Anderson, Glen Barreca, John Basso, Thomas Beasley, Anthony Breaux, Jerry Brown Jr., Martin Campbell, Jim Carter Sr., Harry Clement, Richard Cobb, Oscar Dermody, Dwight Dobson, Melvin Dright Jr., Herman Eugene Jr., Lenwood Fenroy, Al Fleming, Charles Frank Jr., Benny Fuller, Jimmy Gast, Ervin Gehegan, John Goldston Jr., Oscar Green, Ronnie Hall, Joseph Harris, Paul Harris, Willie Harris, Joseph Hastings Jr., Henry Hills Jr., Larry Hills, Hollis Hodges, Edgar ‘Joe’ Holmes, James Hughes, Timothy Hymel, Robert Jones Jr.., Lindsey LeBlanc, Mary Lightsey, Lonie Marts, Charles McKeithen, Joseph Michelli, Hubert Minor Jr., Roosevelt Mixon, Anthony Monistere, Barry Moore, Willian Moore, Robert Newton Sr., Joseph Nicolosi Sr., Terry Norton, Benjamin Pape Jr., Eddie Plaisance Jr., Larry Pontiff, Kevin Pritchett, Jeffrey Quarles, Darrel Rodriguez, Elmore Schexnayder, Ronald Schexnyder, Adolph Smith Sr., Ivory Smith, Arthur Snyder, Richard Songy Sr., Michael Stewart, Anita PooleStadler, Rafael Tolentino, Anestasia Wanko, Michael Webre, Jessie Wheat Jr., Leon Williams, Steven Williamson, Eastman G. Willie & All Those Lost and Unknown.
The Official Memorial is located at 13244 River Road, Destrehan, LA 70047 (29° 56.856′ N, 90° 22.232′ W.). Additional information about the memorial and its markers can be found here.
Abdalla, I. M., Raeside, R., Barker, D., & McGuigan, D. R. D. (1997). An investigation into the relationships between area social characteristics and road accident casualties. Accident Analysis & Prevention, 29(5), 583–593. https://doi.org/10.1016/S0001-4575(97)00011-0
Almklov, P. G., Rosness, R., & Størkersen, K. (2014). When safety science meets the practitioners: Does safety science contribute to marginalization of practical knowledge? Safety Science, 67, 25–36. https://doi.org/10.1016/j.ssci.2013.08.025
Carim, G. C., Saurin, T. A., Havinga, J., Rae, A., Dekker, S. W. A., & Henriqson, É. (2016). Using a procedure doesn’t mean following it: A cognitive systems approach to how a cockpit manages emergencies. Safety Science, 89, 147–157. https://doi.org/10.1016/j.ssci.2016.06.008
Chen, Y., Liu, X., Xu, J., & Liu, H. (2022). Underestimated risk perception characteristics of drivers based on extended theory of planned behavior. International Journal of Environmental Research and Public Health, 19(5), 2744. https://doi.org/10.3390/ijerph19052744
Dahl, Ø. (2013). Safety compliance in a highly regulated environment: A case study of workers’ knowledge of rules and procedures within the petroleum industry. Safety Science, 60, 185–195. https://doi.org/10.1016/j.ssci.2013.07.020
Haas, B., Doumouras, A. G., Gomez, D., de Mestral, C., Boyes, D. M., Morrison, L., & Nathens, A. B. (2015). Close to home: An analysis of the relationship between location of residence and location of injury. The Journal of Trauma and Acute Care Surgery, 78(4), 860–865. https://doi.org/10.1097/TA.0000000000000595
Harms, I. M., Burdett, B. R. D., & Charlton, S. G. (2021). The role of route familiarity in traffic participants’ behaviour and transport psychology research: A systematic review. Transportation Research Interdisciplinary Perspectives, 9, 100331. https://doi.org/10.1016/j.trip.2021.100331
Intini, P., Colonna, P., Berloco, N., & Ranieri, V. (2016). The impact of route familiarity on drivers’ speeds, trajectories and risk perception. https://www.semanticscholar.org/paper/The-impact-of-route-familiarity-on-drivers’-speeds%2C-Intini-Colonna/67e56056d331e86aa7fa87c59f022840251974c9
Lawton, R. (1998). Not working to rule: Understanding procedural violations at work. Safety Science, 28(2), 77–95. https://doi.org/10.1016/S0925-7535(97)00073-8
Martens, M. H., & Fox, M. R. J. (2007). Do familiarity and expectations change perception? Drivers’ glances and response to changes. Transportation Research Part F: Traffic Psychology and Behaviour, 10(6), 476–492. https://doi.org/10.1016/j.trf.2007.05.003
NTSB. (1979). Ferry M/V George Prince Collision with the Tanker SS Frosta (Norwegian) on the Mississippi River: Luling/Destrehan, Louisiana October 20, 1976 (Marine Accident Report NTSB-Mar-79-4). National Transportation Safety Board. https://books.google.com/books?id=jAxUAAAAMAAJ&pg=RA3-PA1#v=onepage&q&f=false
Petitta, L., Probst, T. M., Barbaranelli, C., & Ghezzi, V. (2017). Disentangling the roles of safety climate and safety culture: Multi-level effects on the relationship between supervisor enforcement and safety compliance. Accident Analysis & Prevention, 99, 77–89. https://doi.org/10.1016/j.aap.2016.11.012
Schneider, D., & Harknett, K. (2019). Consequences of routine work-schedule instability for worker health and well-being. American Sociological Review, 84(1), 82–114. https://doi.org/10.1177/0003122418823184
USCG. (1978). SS Frosta (Norwegian), M/V George Prince; Collision in the Mississippi River on October 1976 With Loss of Life (Marine Casualty Report: US Coast Guard Marine Board of Investigation Report and Commandant’s Action USCG 16732/73429). United States Coast Guard. https://www.dco.uscg.mil/Portals/9/DCO%20Documents/5p/CG-5PC/INV/docs/boards/frosta.pdf
Yanko, M. R., & Spalek, T. M. (2013). Route familiarity breeds inattention: A driving simulator study. Accident; Analysis and Prevention, 57, 80–86. https://doi.org/10.1016/j.aap.2013.04.003