The Tragic Sinking of Gloucester's Patriot

PREFACE

This book investigates the 2009 sinking of Patriot, a fishing boat out of Gloucester, Massachusetts, in which Captain Matteo Russo and his crewman and father-in-law, John Orlando, perished under mysterious circumstances. The book also explores normalcy bias—a psychological state that can lead rescuers to downplay a known or perceived threat and mire them in analysis paralysis: where a watch stander over-deliberates and ends up doing nothing or delaying a response when every moment counts.

For Russo and Orlando, the fatal outcome was already decided—in every imagined scenario, they perished before the Coast Guard had been initially alerted to potential danger, so their deaths were not the direct result of normalcy bias. Still, normalcy bias indirectly factored into the case, affecting fishermen and would-be rescuers alike.

Here’s what happened: Matteo Russo’s wife, Josie, who co-owned the Patriot, alerted the Coast Guard that Matteo wasn’t responsive to her mobile calls. She also reported that a fire alarm signal emanating from the boat had sounded. She knew her husband well and, as she too was from a fishing family, knew something was amiss. She was clear: things were not what they should be on that boat. Coast Guard rescue watch standers discussed for two hours and twenty-three minutes how to proceed once notified that the Patriot was in trouble. Without knowing that the crew was already dead, why did my former service deny and over-deliberate information that clearly showed a well-defined last known position, a searchable area and a harsh, unforgiving environment where minutes mattered? All within fifteen miles of Station Gloucester? This meant that critical information such as the boat’s last known position became obsolete in some rescuer’s minds.

Regrettably, two silos of normalcy bias were at play the night the Patriot sank. Professional responders had denied a case existed and over-deliberated and waited for more than two hours to send planes, boats and cutters to the vicinity of where the Patriot had been tracked by a government fisheries law enforcement system—close to a nearby rescue station. The boat’s captain took prescription drugs that might have altered his abilities, and he and his crewmember followed old risk equations by getting underway after dark and being short one crewman. It is important to note that normalcy bias resides in all humans in varying degrees and in different ways. Men customarily deny their inability to handle a situation more often than women, and women traditionally call for help earlier. In truth, members of the fishing fleet are vulnerable to normalcy bias. I’ve seen cases unrelated to the Patriot tragedy where boat captains, numbed by repeatedly accepting risk in a dangerous industry, waited too long to radio the Coast Guard for help.

Still, questions remain, with few clues for resolution. There were no traditional distress signals from a sinking vessel, no initial satellite alerts, no VHF-FM Digital Select Calling boat-to-boat-to-shore relayed distress calls, no flares and no radio transmissions, despite a well-equipped Patriot and more than forty years’ experience between the two lost mariners. There was a much later satellite Emergency Position-Indicating Radio Beacon (EPIRB) alert from the vessel. The EPIRB likely had been hung up on the sinking vessel for some time before coming free and surfacing. Or its batteries were too weak to have its signal reach the orbiting satellites.

My deep passion for investigating episodes in contemporary Coast Guard history where normalcy bias has led to unnecessary deaths or delayed rescues stems from my background in two areas. The first is my time as a former rescue field commander with experience in more than ten thousand cases both ashore and afloat. Second is my experience as a contributor to investigations in areas of watch standers’ fatigue, post-trauma stress and evaluating search and rescue boat crew risk.

I retired in January 2021, following a forty-five-year career across three federal agencies—twenty-six years in the Coast Guard and the rest with the Transportation Security Administration (TSA) and the Federal Emergency Management Agency (FEMA). My post-federal schedule allowed for the space and time to finally and thoroughly untangle the mysteries of normalcy bias as they relate to Coast Guard rescues. The sinking of the Patriot had long been on my radar.

As I reflect on my tenure at FEMA and the Coast Guard, I was able to draw parallels between different parties’ experiences as a result of normalcy bias: delays experienced by potential disaster victims and survivors, and on the other hand, the delays and thought processes experienced by rescue watch standers.

FEMA data confirmed that age and experience do not make people less vulnerable to normalcy bias. Older Americans tend to evaluate new threats during impending storms through the lens of their past capabilities and brushes with disaster. Why else would the lion’s share of victims after the 2011 Hurricane Irene be senior citizens who drowned? They erroneously explained away their risk based on past capabilities and circumstances rather than listening to public safety officials.

During my Coast Guard career, I spent more than nine and a half years undergoing U.S. Navy and Canadian Gunnery, Anti-Submarine Warfare, Tactical Action Officer and Electronic Warfare training and participating in Department of Defense (DOD) exercises during the ascent of wartime programs within the Coast Guard. This training and operational experience on two high-endurance Coast Guard cutters with wartime capabilities, as well as the Atlantic Area staff, helped me frame the analysis of underwater sounds from the Patriot sinking that were picked up by hydrophones designed to track critically endangered northern right whales near the Stellwagen Bank National Sanctuary.

The acoustical analysis was critical to the Coast Guard’s marine casualty report and enabled the guard to exclude a scenario where a tug and tow had rammed or overtopped the much smaller fishing vessel Patriot. Overtopping is when a vessel crosses between a tug and its tow and is overturned by the tug’s heavy towing hawser. My time with the U.S. Navy enabled me to interpret the Patriot’s engine noises to re-create the boat and its crew’s final hours, minutes and seconds before the vessel hit the bottom.

This is my third book about Coast Guard watch standers and normalcy bias. In 2014, I wrote about the fishing vessel Sol e Mar’s sinking off the coast of Martha’s Vineyard in 1990. The circumstances proved a case study in normalcy bias. The Coast Guard failed to respond to a radio call for help, linking the real call with the hoax transmission. But a senior watch stander didn’t go far enough to investigate whether the garbled Mayday was an actual hoax or the real thing. There was enough information to know immediately that the two calls were transmitted from two different locations and received by different Coast Guard units, but the easy solution of denying the real case was accepted, initially.

In 2018, I wrote about the sailing vessel Morning Dew allision—when a moving object collides with a stationary structure—in Charleston Harbor in 1997 in which a father, his two sons and a nephew died. It was another instance of normalcy bias: their Mayday went unanswered because the initial call was explained away as a nuisance call, a radio check. Later, survivors’ cries for help from the Charleston channel area were imagined to have come from a beach party in late December. And the senior decision maker also denied the very possibility that the survivors’ shouts could be heard from a passing ship. During a 2019 presentation of the new book’s findings, the present-day Charleston senior civilian search and rescue controller, when presented with the theory of normalcy bias as the why behind complacency, noted, Yeah, it’s another word for complacency. I challenge that it is not. Knowing about the phenomenon and understanding your own risk profile, whether mariner or rescuer, can positively affect the outcome of future cases and save lives.

Shortly after the January 2009 Patriot tragedy, I was invited to participate in a hot wash, or after-action review, at Sector Boston. Station Gloucester, which would have been responsible for a rescue mission of the Patriot, fell under Sector Boston’s jurisdiction. Secondly, at that time I happened to be researching the parallel mistakes from the 1990 Sol e Mar tragedy and the 1997 Morning Dew disaster, so the Patriot case drew me in.

At the hot wash, a 1998 report from the Morning Dew titled Top Ten Search and Rescue Lessons Learned was discussed. A colleague and friend who was involved in the case had coauthored the document, so I paid special attention to it. It was my sense that others at the hot wash were aware of the report. Some senior decision makers, however, were touting the rescue lessons as novel and ripe for adoption. It was as if they could not believe conditions of the Morning Dew case could happen again.

Perhaps they were reading it over as they thought about the Patriot case. I left that hot wash session wondering what other lessons had been lost to time. When I evaluated the lessons learned from the Patriot investigative materials that I had gathered from Coast Guard and public sources, including precious audio tapes, I knew I had to write about this case.

It is my hope that every Coast Guard watch stander, whether in the Coast Guard or civilian, officer or enlisted, and every mariner might read this book to understand and recognize normalcy bias and insist on changes to existing frameworks that allow these tragedies to occur time and time again. That said, any and all errors in this book are mine alone.

INTRODUCTION

This work attempts to answer two questions: Why did the Patriot sink? And why did the Coast Guard hesitate to send response assets after being notified that the Patriot was in trouble, even though it was later revealed that Russo and Orlando had perished before the Coast Guard was notified that the boat might be in trouble? The second question takes a reader through phases of normalcy bias as the phenomenon relates to Coast Guard rescues.

In granular detail, internal processes used in Coast Guard search and rescue missions are revealed to a civilian audience in three sections. Part I introduces the reader to Matteo Russo and John Orlando and follows events on the day of their death. Part II focuses on the Coast Guard’s investigations and explores what others think may have happened that led to their deaths. In Part III, a reader will learn of tensions between the Gloucester fishing community and elements of the maritime industry. Separate chapters on Coast Guard search and rescue operations and the perspectives of several retired flag officers about the Patriot case—their analyses are profound—round out the book.

Those retired flag officers—a trio of admirals—contributed to the larger context that the case occupied in 2009, a vital inflection point. That’s when the Coast Guard was managing multiple problems with the experience and capability of service members who were being assigned to operational units, including Sector Boston. Several preventable line-of-duty deaths of guardsmen were the catalyst for the twenty-fourth commandant, Admiral Bob Papp, the same individual who sponsored the Patriot administrative search and rescue investigation, to institute a new Steady the Service platform focusing on proficiency. He comments on his experience with the Patriot in this broader service-wide perspective. This section also provides a perspective of the law that protects the Coast Guard from being routinely sued.

Americans expect the Coast Guard to know and understand the dangerous seascapes they protect and to have the experience necessary to dynamically