"Bayesian" s/y sinks in Palermo

[MisterBaxter]

While it was knocked down, the mini tornado would no doubt have been pushing surface water around pretty wildly - it wasn't just lying on its side in a flat calm. And potentially the boat itself was being driven through the water as it lay there too, forcing more water towards the open hatches etc.

 

[Sandy]

I think I do. Its quite clearly defined: The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting andInvestigation) Regulations 2012 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an such investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame. [my bold]

What I am saying is that actually they seem to wander off looking for things to criticise which were not the causes of the accident. Sometimes they comment on rescue service response and sometimes they don't. Of course that is never a cause but it might mitigate the outcome.

One of the problems is the MAIB essentially define "best practice" by default - its hard for an industry or an individual operator to question or not follow their recommendations without being criticised. But its easy to define good practice sitting behind a desk in an ideal world.

And that is exactly what they are doing.

It is up to others to take the findings and look at what they can do to prevent future accidents.

You don't wander off and criticise things you look at best practice, or regulation, and see if it has been followed. Lets take this:

Army Cadet capsize - made an issue about paperwork for the LJ maintenance, but in fact all the LJs were in working order (had they not the fatality may not have happened), many did not remember to pull the toggle but no question about how easy that is to do on surprise immersion or how well training focussing on ensuring the toggle is accessible etc.

At some point in the past an incident will have happened where on inspection the LJs on a vessel had not been inspected or tested for some considerable time resulting in a death. As a result 'best practice/regulation/its a bloody good idea' if we check LJs on a regular basis and can evidence that to an accident investigation team, Coroner or judge becomes the norm. Rather than the skipper thinks that the LJs were checked last month, but actually they weren't as the skipper was on leave and the relief skipper was dealing with blocked head,

From time to time I sail as sea staff on a sail training vessel and while checking and testing 50 life jackets AND filling in the paperwork each month is a time consuming task every time we go to sea the staff know it has been done and can prove who checked every LJ. The audit is available should the MCA ask to see it. We also check that there are two green bars on any jacket being work are showing each day. We spend a lot of time at the start of each voyage demonstrating the use of a LJ, but when in extremism will the wearer remember where the red toggle is should the automatic system does not work.

On my boat I wear a totally different LJ one with a grab handle not a toggle and need to stop and say every time I am onboard 'here is the toggle' and place my hand on it. So much so that it has become part of the ritual of going on watch I am trying to build in that muscle memory for something that is different to normal.

As a side note I wrote to Spinlock after inflating one of their LJs at the London Boat Show, that will age me, and finding that I would need arms that almost reached to floor given the length of string between the toggle and the firing mechanism - it might have been that one jacket it might of been a design fault, but I had alerted somebody that there was an issue when I inflated one of their jackets. Hopefully, somebody at SpinLock would have checked. I've never bought one of their LJs since.

Best practice is the only thing that an investigation board can publicly do, we won't know what is done privately and I am not willing to disclose the conversations I've had with organisations. Others look at the report some say how do we sort that while others, usually in the legal domain, rush to legislation or regulation and some sadly ignore it.

Given the two high profile deaths due to food allergy reactions recently ordering a simple meal has become quite a long process. That is the hospitality industry adopting best practice. Our daughter, who works in hospitality, visited us this week and we went out for a meal. Mrs Sandy has a few food intolerances and was faced with a barrage of questions and double checks of ingredients on an iPad. After all that was able to choose what she wanted and passed the comment 'well, that was a faff', daughter replied 'we do the same intolerances are treated just the same as being allergic. There is huge reputational risk to us killing a customer!'

 

[fatsdoodah]

This is very dreadful incident but interesting from safety perspective.

I am wondering if the diameter of tornado compared to length of vessal may have been reason why she didn't bear up, was knocked down, and couldnt recover.

 

[ylop]

At some point in the past an incident will have happened where on inspection the LJs on a vessel had not been inspected or tested for some considerable time resulting in a death. As a result 'best practice/regulation/its a bloody good idea' if we check LJs on a regular basis and can evidence that to an accident investigation team, Coroner or judge becomes the norm. Rather than the skipper thinks that the LJs were checked last month, but actually they weren't as the skipper was on leave and the relief skipper was dealing with blocked head,

Of course but in THAT incident it clearly was not an issue with lack of inspection of the LJ that caused fatality as it was the fact it was inflated which caused the entrapment. Thats my point - it may be indicative of safety culture or even merit a conversation outside the report but better paperwork about lifejacket checks would not stop THAT accident happening again. Meanwhile:

We spend a lot of time at the start of each voyage demonstrating the use of a LJ, but when in extremism will the wearer remember where the red toggle is should the automatic system does not work.

A number of the survivors on that incident didn't pull the toggle themselves (at least some of them were manual). That got a cursory comment in the discussion. Of course its easy to not do that or not find it in the panic - but thats surely a lesson to be learned - making sure its actually visible during boarding, making sure the briefing involved people actually looking for it on their jacket. Your briefings sound like exactly the sort of thing they should be - the MAIB seemed to gloss over that. Part of the delay in "rescuing" the entrapped person was a poor headcount, but nothing mentioned on how that could be better - lots of recommendations about systems of work and supervision - but those really only apply to that organisation in that setting; what about all the other organisations that could learn from not flipping a boat, and responding better if you do.

They've got a few lifejacket examples where the outcomes don't really match with their commentary. Another one I mentioned above 2 people thrown out a RIB in the Solent. One wearing a proper LJ, one wearing a bouyancy aid. The bouyancy aid wearer survived the LJ wearer did not. Not only did the report not explore why - they specifically "criticised" the choice of bouyancy aid in those conditions. In reality it appears to have saved his life! In another incident after a dinghy sailing event (which was atrociously planned and executed from a safety perspective) they berated the use of bouyancy aids for transferring people by rib at night. I can see the point, but a lot of people ended up in the water, all came back out the water alive. There were several ribs around. That didn't contribute to the accident and looking at the two previous incidents with people wearing lifejackets and perhaps assuming teenagers in a panic hitting the water will be better with LJs than bouyancy aids is a bit less certain. My interpretation from this is that they are professional mariners judging watersports. In some ways that may be helpful but it shows a disconnect for me.

 

[NormanS]

And that is exactly what they are doing.

It is up to others to take the findings and look at what they can do to prevent future accidents.

You don't wander off and criticise things you look at best practice, or regulation, and see if it has been followed. Lets take this:

At some point in the past an incident will have happened where on inspection the LJs on a vessel had not been inspected or tested for some considerable time resulting in a death. As a result 'best practice/regulation/its a bloody good idea' if we check LJs on a regular basis and can evidence that to an accident investigation team, Coroner or judge becomes the norm. Rather than the skipper thinks that the LJs were checked last month, but actually they weren't as the skipper was on leave and the relief skipper was dealing with blocked head,

From time to time I sail as sea staff on a sail training vessel and while checking and testing 50 life jackets AND filling in the paperwork each month is a time consuming task every time we go to sea the staff know it has been done and can prove who checked every LJ. The audit is available should the MCA ask to see it. We also check that there are two green bars on any jacket being work are showing each day. We spend a lot of time at the start of each voyage demonstrating the use of a LJ, but when in extremism will the wearer remember where the red toggle is should the automatic system does not work.

On my boat I wear a totally different LJ one with a grab handle not a toggle and need to stop and say every time I am onboard 'here is the toggle' and place my hand on it. So much so that it has become part of the ritual of going on watch I am trying to build in that muscle memory for something that is different to normal.

As a side note I wrote to Spinlock after inflating one of their LJs at the London Boat Show, that will age me, and finding that I would need arms that almost reached to floor given the length of string between the toggle and the firing mechanism - it might have been that one jacket it might of been a design fault, but I had alerted somebody that there was an issue when I inflated one of their jackets. Hopefully, somebody at SpinLock would have checked. I've never bought one of their LJs since.

Best practice is the only thing that an investigation board can publicly do, we won't know what is done privately and I am not willing to disclose the conversations I've had with organisations. Others look at the report some say how do we sort that while others, usually in the legal domain, rush to legislation or regulation and some sadly ignore it.

Given the two high profile deaths due to food allergy reactions recently ordering a simple meal has become quite a long process. That is the hospitality industry adopting best practice. Our daughter, who works in hospitality, visited us this week and we went out for a meal. Mrs Sandy has a few food intolerances and was faced with a barrage of questions and double checks of ingredients on an iPad. After all that was able to choose what she wanted and passed the comment 'well, that was a faff', daughter replied 'we do the same intolerances are treated just the same as being allergic. There is huge reputational risk to us killing a customer!'

Unfortunately, the cadet died because her lifejacket DID work. She might have been saved if the gung-ho OIC had bothered to count numbers aboard.

 

[Sandy]

Unfortunately, the cadet died because her lifejacket DID work. She might have been saved if the gung-ho OIC had bothered to count numbers aboard.

Of course but in THAT incident it clearly was not an issue with lack of inspection of the LJ that caused fatality as it was the fact it was inflated which caused the entrapment. Thats my point - it may be indicative of safety culture or even merit a conversation outside the report but better paperwork about lifejacket checks would not stop THAT accident happening again. Meanwhile:

A number of the survivors on that incident didn't pull the toggle themselves (at least some of them were manual). That got a cursory comment in the discussion. Of course its easy to not do that or not find it in the panic - but thats surely a lesson to be learned - making sure its actually visible during boarding, making sure the briefing involved people actually looking for it on their jacket. Your briefings sound like exactly the sort of thing they should be - the MAIB seemed to gloss over that. Part of the delay in "rescuing" the entrapped person was a poor headcount, but nothing mentioned on how that could be better - lots of recommendations about systems of work and supervision - but those really only apply to that organisation in that setting; what about all the other organisations that could learn from not flipping a boat, and responding better if you do.

They've got a few lifejacket examples where the outcomes don't really match with their commentary. Another one I mentioned above 2 people thrown out a RIB in the Solent. One wearing a proper LJ, one wearing a bouyancy aid. The bouyancy aid wearer survived the LJ wearer did not. Not only did the report not explore why - they specifically "criticised" the choice of bouyancy aid in those conditions. In reality it appears to have saved his life! In another incident after a dinghy sailing event (which was atrociously planned and executed from a safety perspective) they berated the use of bouyancy aids for transferring people by rib at night. I can see the point, but a lot of people ended up in the water, all came back out the water alive. There were several ribs around. That didn't contribute to the accident and looking at the two previous incidents with people wearing lifejackets and perhaps assuming teenagers in a panic hitting the water will be better with LJs than bouyancy aids is a bit less certain. My interpretation from this is that they are professional mariners judging watersports. In some ways that may be helpful but it shows a disconnect for me.

Can you point me at the report. I have a vagile recollection of that incident.

 

[doug748]

Of course, the C32 will sink at 78 degrees unless you’re sailing with the washboards in and the hatch closed, I’ve been on board one at less heel than that, and watched in horror as the green stuff rushed down the hatch. The Bavaria, perhaps not.

I have no idea what the down flooding angle is for the Contessa but 100deg or more is the norm.

Have you got link showing 78 degrees ?

.

 

[zoidberg]

'Back in the day' military aircrew were trained intensively in Sea Survival, which included multiple practice wearing LifeSavingJackets. It was then the norm for such LSJs to be 'manual inflate' only, for no-one wants an LSJ to auto-inflate in the confines of a cockpit while airborne - and even less so if in a ditched aircraft, when swift, effective exit through whatever hatch might be available was vital. That's 'entrapment' of a high order.

For that specific hazard, military aircrew were issued with a special knife, strapped to one's thigh. Of course, other uses for it were found.

 

[Frogmogman]

I have no idea what the down flooding angle is for the Contessa but 100deg or more is the norm.

Have you got link showing 78 degrees ?

.

Chiara does qualify that with that being the down flooding angle if the washboards are not in place. Seems about right to me.

 

[Fr J Hackett]

I wonder if they had a watch in operation?

 

[Chiara’s slave]

I have no idea what the down flooding angle is for the Contessa but 100deg or more is the norm.

Have you got link showing 78 degrees ?

.

It might be 100 deg if it’s glassy calm. Ask yourself, will a C32 get knocked to 78 degrees in calm water. We had a huge kite miscalculation and got laid over about 60-65 degrees, in a 1.5m chop. Huge amounts of water went inside, knives were used to cut the sheets, order was gradually restored. Without cutting the sheets, I have little doubt she’d have sunk. A very unpleasant situation.

 

[Fr J Hackett]

If you listen to the PBO sinking test in the Swede 55 thread they shipped 2 tonnes of water in 7 minutes through a hole that was not big enough to put your fist in and for much of that time they were trying to close the hole by various means. A largish open companion way will take in tonnes of water in seconds and with each tonne its stability is compromised and decreased as is its righting moment.

 

[Daedelus]

I recall reading somewhere that other vessels of this class are ketch rigged but because Bayesian is a sloop the size of the mast was increased to allow for the loss of the mizzen. Whether this would have had any adverse effect or had been allowed for already in ballast or other actions I don't know

 

[steveeasy]

Not if the lifting part of the keel is unballasted - in that case the ballast is in the hull or non-retractable part of the keel. AIUI most, if not all, of these mega-deep mega-yachts are really centreboarders, presumably so that they can safely transition to shallower draft to allow them to get to interesting places. In that case speculation about whether the 'keel' was up or down is pretty much irrelevant.

Not sure if agree. The keel even if not weighted would have provided some additional stability. It’s almost unbelievable the boat had such a high COG that it would not right itself. The boat in the first film that was blown over righted itself straight away when the force on the mast Was lost.

Steveeasy

 

[CDT]

Looking at the manufacturer's brochure a couple of design characteristics stand out. One is the steps that lead down from the rear quarters to a guest salon:



Secondly, I believe you can see the port staircase to the left of this picture. Looking at the layout it seems behind the sofa on the other side of the patio doors is the staircase down to the guest accommodation:




Manufacturer's brochure:

https://www.perininavi.it/wp-content/uploads/2018/05/bayesian-formerly-salute_brochure.pdf

 

[Mark L]

Not sure if agree. The keel even if not weighted would have provided some additional stability. It’s almost unbelievable the boat had such a high COG that it would not right itself. The boat in the first film that was blown over righted itself straight away when the force on the mast Was lost.

Steveeasy

A centreboard (all else being equal) will act to increase the heeling moment as it increases (and lowers) the lateral resistance underwater. This is why you slightly raise the centreboard in a dinghy if you are getting overpowered.

 

[Barnacle Bill]

Two extracts from the FT:

Karsten Borner, the skipper of a nearby boat, was quoted by Reuters as saying he was using his motor to maintain control of his own vessel and to avoid a collision with Bayesian when the weather hit. Bayesian “went flat [with the mast] on the water, and then went down”, he said.

According to Perini Navi, Bayesian had a so-called lifting keel, a system for reducing the depth of the keel — otherwise nearly 10m — for easier entrance to shallow harbours. If the keel were for some reason in the raised position rather than fully extended, that would compromise the boat’s stability in a strong wind.

Hence my earlier post. (#70)

 

[MikeBz]

A lot of the quotes in the press (some from anonymous supposed experts) are just wrong.

 

[Chiara’s slave]

A lot of the quotes in the press (some from anonymous supposed experts) are just wrong.

If there’s anything in the news that either of us happens to know much about, we always find it’s woefully inaccurate. Which leads to the conclusion that most news is very poorly reported.

 

[NormanS]

Can you point me at the report. I have a vagile recollection of that incident.

Sorry, I can't give an actual link to the incident. It took place near Loch Carnan, in South Uist. I was in the area at the time. If you find the report, you'll see why I said that the guy in charge was gung-ho.