What a clusterfuk:

http://www.sanluisobispo.com/mld/san...l/10875157.htm

Just over a month after Audrey Gail Richards died in the stormy ocean
waters north of San Simeon, investigators are beginning to understand
what went wrong in rescuers' attempt to save her.

Coast Guard officials who have reviewed the incident say they don't
believe Richards, 42, was wearing a life vest. Other decisions she and
her companion, Donald Upton, made before and during the rescue attempt
helped doom it to failure, officials say.

But questions remain about rescuers' actions, as well.

Other agencies are wondering aloud whether the Coast Guard should have
asked sooner for their assistance on shore. It was about three and a
half hours after the incident began before that call went out, Coast
Guard officials have acknowledged.

The agency's Los Angeles office is investigating the incident and will
file its report to superiors in Washington, D.C., in coming weeks.

Mistakes aboard the sloop

First among the factors leading to the disaster was the decision by
Upton, 39, and Richards to set sail from Ventura to the Bay Area.

For days, storm warnings had been posted. But Lt. j.g. Tony Migliorini,
spokesman for the Coast Guard in Los Angeles, said he did not know
exactly when they set sail.

Then, the couple reportedly planned to dock in Morro Bay before the
storm arrived Friday morning, Jan. 7. But they overshot.

Upton, the lone survivor and owner of the vessel named 42, spoke with
Coast Guard investigators, but declined requests to speak to a reporter
about the incident.

Perhaps the pivotal moment in the attempted rescue occurred shortly
after 10 a.m., after a Coast Guard vessel had finally found the
distressed sailboat.

The 42 was near the surf line and heading toward the rocky shore. Winds
of 40 to 50 mph whipped up the sea and blew rain sideways.

The sailboat's small engine was strong enough to reposition the boat
while docking but not large enough to battle big waves.

The rescuers signaled to the couple that they would try to bring the
rescue boat alongside the sailboat and "kiss bumpers" and the couple
should jump onto the rescue boat, said Mike Saindon, chief of the Morro
Bay Coast Guard unit.

But as Coast Guard pilot John Rose wrestled his vessel toward the
sailboat, Richards sat on the edge of the sailboat and dangled her legs
down toward the raging sea.

Afraid of crushing Richards' legs, Rose had to back the Coast Guard
craft away from the sailboat and the opportunity was lost.

The next waves swamped the smaller vessel, swept Upton and Richards
into the sea and dashed their craft onto the rocks.

The Coast Guard crew tossed life rings to the couple and prepared to
retrieve them from the water.

But another big wave sent the rescue craft on its side and, briefly,
onto the rocks, so the crew had to save their own lives and boat. The
Coast Guard team couldn't reach the pair.

Upton wore a life vest, but "none of my crew ever saw a life vest on
(Richards)," Saindon said.

A vest assumed to belong to Richards was later retrieved from debris
along the shore.

A delayed call for help

The emergency crews at the San Luis Obispo Coast District of state
parks and Cambria Fire Department believe the Coast Guard should have
called sooner for on-shore assistance.

It was 6:41 a.m. when Richards dialed 911 on her cell phone.

The operator, after losing the connection several times, patched her
through to the Coast Guard in Morro Bay by about 6:55 a.m.

A 47-foot rescue craft was under way within minutes with coordinates
for the sailboat's location.

Lack of cell phone contact

Unbeknownst to them, shifting winds had pushed the boat farther north
and closer to shore. Cell phone contact had been lost by that time, and
radio contact with the boat hadn't been functioning all day.

It took about three hours in slanting sheets of rain and high waves for
the Coast Guard boat to reach San Simeon and find the tiny sailboat --
which was heading toward the rocky shore.

Not until then did the Coast Guard call other agencies for help.

Terese Zilke, a state official in charge of security at Hearst Castle
and nearby state parks, wondered if earlier notification of North Coast
public safety officials would have given Richards a better chance of
surviving.

Zilke and Ranger Kyle Brady heard radio transmissions from the Coast
Guard boat and went out on their own to San Simeon Pier to look for the
sailboat in its reported location.

If they'd been called out earlier, "We could have told them, 'No, it's
not at San Simeon Cove,' and saved them some time," she said.

A Coast Guard official in Morro Bay called Cambria Fire Department
about 7 a.m. to see if ocean conditions would allow its shore unit to
launch a rescue boat, but the official didn't formally request
assistance because the crew of its rescue craft still didn't know the
sailboat's situation or location.

Coast Guard officials said they were aware that rescue crews on the
North Coast had been inundated by calls triggered by the storm. And
relying on their earlier information, they assumed the sailboat was too
far out to sea for land crews to help.

In hindsight, Saindon, the Coast Guard chief, said it's impossible to
know whether shore crews could have made a difference if they had been
called out sooner.

"It's a very big ocean," he said. "The sailboat might have been too far
offshore to see."

On their own, several rescuers, including ambulance crews, headed to
the shore about 2.5 miles north of San Simeon Cove after hearing Coast
Guard radio traffic about the unfolding emergency.

Although intermittent rain limited visibility, the boat was clearly
visible from Highway 1.

The investigation is continuing. The Coast Guard in Los Angeles will
forward its findings to the Guard's Office of Investigations and
Analysis in Washington, D.C., for final review.

"Of course, there were a lot of what ifs," Saindon said. "But there
were also a lot of things we all did (well). Everybody worked hard and
we brought one person home alive. Our crew came home alive."