Clipper Ventures Yacht Ichor Coal: MAIB report now out

[lw395]

It's not the real answer and you cant design out the risks except by not going to sea. The fact is that both the risks were known and understood, both put themselves into the danger zone and set themselves up so that when the boom gybed / yacht healed heavily they experience the consequences, no 'lucky' escape, unfortunately. It is so sad and tragic but the the controls / design / whatever was already in place, they chose not use the controls.

The risks can be altered by the spec of the yachts, the choice of people on them, operating rules etc etc.

 

[co256]

Would a boom brake be any more effective at arresting the force of a gybe rather than a restraining device like the preventer used?

 

[co256]

For many years I have been of the opinion that a preventer should be sacrificial, in the case of CV21, were it not, the prevented mainsail would have pinned the boat flat once it had gone aback until someone eased/released the preventer.

A sacrificial preventer merely buys you enough time to get out of harms way...

 

[Fr J Hackett]

Looking at the size of the boom and mainsail I am surprised that any preventer would withstand a big accidental gybe without ripping out the deck fittings.

 

[mainsail1]

If the preventer is strong enough to stop the gybe before it starts then surely the forces would be no more than the mainsheet encounters holding the boom in the same wind?
To do this I think the preventer must rigid, possibly hydraulic. Rope always gives a bit thus starting the gybe and increasing the load when the boom is stopped.

 

[ShinyShoe]

When you heave to the sails don't flog. They certainly flog when you try and drop them.

In a F9? With massive waves. And heaving to isn't actually getting you back to the casualty it is "stopping you" going forward.

A yacht that is worried about going backwards as it may damage the rudders is not fit for purpose.

Coz reversing in a F9 is something we've all tried? And when we tried it we didn't worry about being in the middle of the pacific with no rudder.
My car is fine driving backwards, I try not to reverse on the mo

Obviously no-one wants to jump into a liferaft in a storm but it would have been in the lee, if the boat was hove to.

If you can't manouvre a hard hull to line up I'm far from convinced a squidgy raft can be either. Not to mention getting them lifted etc. There were mistakes in the MOB recovery procedure. It should have been practiced more to make it more automatic. But practice is never going to be real life with one of your mates life in the balance. So they could do with a MOB action card/check list. Like a plane pilot uses. They can initiate the steps for MOB automatically but while making way back it becomes someones job to shout the actions on the card and ensure they have been done...

- Swimmer **change to Manual LJ** - Done
- Scramble nets erected - Done

The real answer is to design out the risks and I still think this could largely be done. People make mistakes, you need to design out the chance/result of those mistakes where possible. For example, it would appear to me, a daft, experienced sailor, that Sarah would be around today if the guard wires had been laced with netting. The trouble is I cannot see how this could have been done effectively with the toerail design in use.

But they are adding netting...

 

[co256]

Clipper 70 Mainsail area 123m2

The biggest Walder Boom Brake is for mainsail areas upto 110m2

 

[co256]

If the preventer is strong enough to stop the gybe before it starts then surely the forces would be no more than the mainsheet encounters holding the boom in the same wind?
To do this I think the preventer must rigid, possibly hydraulic. Rope always gives a bit thus starting the gybe and increasing the load when the boom is stopped.

In heavy airs the head of the mainsail invariably gybes over before the boom has even begun to move, that's its most lethal potential... the boom is like the crack of a whip! That same force most likely exceeded the break load of the partially spliced strop attached to the bow.

So you see, that the preventer... doesn't.

Personally I only use a preventer in light airs to stop the boom from being a nuisance.

 

[Uricanejack]

One of those "punters" was a friend. The clipper training stresses time and time and time again about not going into the area Andy was in (called "Milton Keynes") , the first time IIRC in the first hour of the first day of training.

The other thing stressed constantly was clip on.

Several posters have expressed how slow.it was to turn the boat. I doubt you have ever been out in such conditions, on such a boat. Indeed one poster thinks it should be done in 5 mins - not really achievable on all but the smallest ocean going yacht.

30 hours out of Cape Town we got hit with a weather bomb, with wind changing from 15knts to 45knts+ in 2 minutes. Getting the main reefed, the staysail dropped and secured, and the yankee 1 changed for the 3 took several hours. Across the southern ocean we got hit with many big squalls, always at night, with wind speeds rarely encountered in the Solent, and again it took a while to reduce sail, even with the off watch called up for extra man power.

Another poster goes on about it being the first time Andy would have had to lead the reef in bad weather in the dark. I can assure you it wasn't.

Both deaths were a terrible accident.

I was just quoting the MAIB. Here are the actual quotes from the report. As you can see. All the crew would have taken part in reefing while training. Clearly this was the first time Andrew was in charge of reefing the vessel. Under real conditions.


"It is possible that Andrew intended to place a more experienced helmsman on the wheel prior to the actual reefing evolution, and was planning to provide detailed roles to his team once they had assembled. However, this was the first reefing evolution that the starboard watch had completed during the Race, so Andrew’s intentions and expectations cannot be known."

"The skipper had appointed Andrew as watch leader having spent two of the four pre-Race training courses working with him; he clearly trusted Andrew and had faith in his abilities. Although reefing had been conducted by all crew during training, this was the first reefing evolution by the starboard watch during the Race, but the skipper was content that Andrew was capable of leading the evolution unsupervised. Consequently, he decided to remain below"

They were both terrible accidents.
The immediate causes of those Accidents. "Andy" Steeping over the traveller and standing in the danger zone.
Followed by "Sarah" not clipping here tether on when coming out of the hatch into the cockpit.

The MAIB are reporting on why, This could have happened,
The report specifically mentions it was the starboard watches first time reefing since the race started.

Clipper had a policy and training specifically to not step over the traveller or stand in the danger zone. It was not followed. The MAIB are asking and reporting. Why the Clipper policy was not followed.

The Clipper Policy was not an effective barrier because it was not followed.
The Training was not an Effective Barrier. It was not Followed.

The actions of stepping over the traveller to stand in the danger zone was not challenged.

The Procedure was not supervised, An Opportunity to point out or correct the error was not in place.

Clipper did not effectively monitor the Clipper vessels to ensure Clipper Policy was Followed.

The Helm lost control, The vessel Gybed, The preventer Broke, In The very short time 'Andy" was standing in the danger zone.
This accident did not just happen. The accident did not just because "Andy" stood in the danger zone.

I agree completely with you about comments regarding MOB.
The conditions described, Severe Gale with storm Force Gusts. In the Middle of the N Pacific 1000 miles from land.
I don't think I've ever seen Sustained Strom Force, Going to sustained Hurricane Force with gusts to 90 knots. Few sailors ever have.
It took them an hour and 20 minutes to get back to her. In those conditions. I'm surprised they ever got back,

Again Clippers policy was an ineffective barrier. Clipper did not ensure the policy was consistently followed on all of its boats.
The Training was not an effective barrier.

Quoted from the report.

" While some crew members clipped on to varying degrees in accordance with the above instructions, others clipped on only when they deemed necessary because, in doing so, they considered their movement was hampered significantly. Crew members sometimes reminded each other to clip on."

" While the skipper always wore a lifejacket when on deck, he did not always clip on when other crew considered it appropriate to do so."

Says it all really. "Sarah" started out as an inexperienced sailor when she joined clipper for her training prior to the race.
She was presumably trained to clip on as per the Clipper policy. By the time of the incident she had thousands of miles of Ocean racing sailing experience.
All of it on this boat where Clipper Policy was not consistently followed. Particularly it was not consistently followed by the Skipper, She probably learned a lot by experience, Much of what she learned would be from the skipper.
She would have been one of the most experienced and confident crew on board.

Why didn't she clip on. Nobody knows. Including the MAIB.
They do suggest she had learned from experience she did not need to.

I am sorry you lost your friend. It should not have happened, It was not just your friends mistake.

 

[co256]

Extract from
The United Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) 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 investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

NOTE
This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame.

© Crown copyright, 2017
You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identi ed any third party copyright material you will need to obtain permission from the copyright holders concerned.

 

[savageseadog]

Last time I did a heavy weather "gybe" I tacked round and that was during an offshore race. Mine was in an F8 with moderate seas, perhaps 3m, I'm not sure if that was a practical proposition for the Clippers in the circumstances.

 

[lw395]

I was just quoting the MAIB. Here are the actual quotes from the report. As you can see. All the crew would have taken part in reefing while training. Clearly this was the first time Andrew was in charge of reefing the vessel. Under real conditions.


"It is possible that Andrew intended to place a more experienced helmsman on the wheel prior to the actual reefing evolution, and was planning to provide detailed roles to his team once they had assembled. However, this was the first reefing evolution that the starboard watch had completed during the Race, so Andrew’s intentions and expectations cannot be known."

"The skipper had appointed Andrew as watch leader having spent two of the four pre-Race training courses working with him; he clearly trusted Andrew and had faith in his abilities. Although reefing had been conducted by all crew during training, this was the first reefing evolution by the starboard watch during the Race, but the skipper was content that Andrew was capable of leading the evolution unsupervised. Consequently, he decided to remain below"

They were both terrible accidents.
The immediate causes of those Accidents. "Andy" Steeping over the traveller and standing in the danger zone.
Followed by "Sarah" not clipping here tether on when coming out of the hatch into the cockpit.

The MAIB are reporting on why, This could have happened,
The report specifically mentions it was the starboard watches first time reefing since the race started.

Clipper had a policy and training specifically to not step over the traveller or stand in the danger zone. It was not followed. The MAIB are asking and reporting. Why the Clipper policy was not followed.

The Clipper Policy was not an effective barrier because it was not followed.
The Training was not an Effective Barrier. It was not Followed.

The actions of stepping over the traveller to stand in the danger zone was not challenged.

The Procedure was not supervised, An Opportunity to point out or correct the error was not in place.

Clipper did not effectively monitor the Clipper vessels to ensure Clipper Policy was Followed.

The Helm lost control, The vessel Gybed, The preventer Broke, In The very short time 'Andy" was standing in the danger zone. .......

The cause is not that the poor chap was in the danger zone, but that the vessel gybed.
You have to pass the mainsheet area to get from the wheel area forwards.

The helmsman may have done 1000's of miles of Clipper experience, but he was not able to keep the boat from gybing.
Teaching people to sail downwind is a difficult thing to do.
The bigger the boat, the harder it is to get the understanding across it seems?
20 minutes in a Laser will tell you very clearly about sailing downhill.
I've seen RYA cruising instructors fail utterly at getting the message across.
People over the age of 14 can be harder to teach too.

Any trained crewperson on a boat should be able to steer through a routine reefing operation?

 

[bitbaltic]

The cause is not that the poor chap was in the danger zone, but that the vessel gybed.

Absolutely.

The helmsman may have done 1000's of miles of Clipper experience, but he was not able to keep the boat from gybing.

Being only on the first leg of the race it is unlikely that the helm had anything like that, although his experience is not discussed. The report is pretty unequivocal that the helmsman was not (yet) skilled enough for the job he was being asked to do. The responsibility for realising and acting on that was placed, by the skipper and the Clipper system, on the shoulders of the chap who ultimately died. Hence the call for more professional supervision. The report's suggestion seems to me that at that early point in their Clipper career, everyone fell short in the experience needed to make the right calls at the moment of that reefing 'evolution', and it's hard to disagree.

 

[lw395]

.....

Being only on the first leg of the race it is unlikely that the helm had anything like that, although his experience is not discussed. ......

The helm should have had some weeks of pre-race training?
Equivalent to several RYA courses in hours and miles?
Once the race is on, there is only one pro on the boat, so not much training or mentoring.
Crossing oceans is mostly hours/days on end of pointing the same way.
And if you are racing, there is pressure to always use the best helms when it matters.

I think there is a much bigger problem of the quality of teaching/coaching/mentoring etc in sailing, but the ethos of the Clipper outfit seems to cause a particular concern. It may just be a few loud individuals associated with it colouring views of the whole thing of course.
Beyond Clipper, I have seen too many people who've just done a dazed kipper course, but can't helm a boat reasonably downwind.
Too many instructors who are well qualified in seamanship, but know SFA about teaching or man-management?

 

[Resolution]

I suspect that most of us have learnt our sailing skills by trial and error in smallish boats, working our way up gradually to present size. Probably lots of procedural errors become habits, which we get away with because most of our sailing is inshore and in relatively benign conditions. The big difference here of course is that Clipper Ventures is a business and the crews on these yachts are paying customers. This puts an enormous stress on getting procedures right for all the conditions in which they may be sailing. Can this be done, in this litigious and compensation-driven age? I would hate to try to run a profitable business in this activity sector these days. And I bet the directors of Clipper Ventures are looking long and hard at whether to carry on now.

 

[Deleted member 36384]

The cause is not that the poor chap was in the danger zone, but that the vessel gybed......

That's quite wrong. The hazard is an 'uncontrolled gybe' of which there are a number of realistic 'outcomes', one being 'crew member struck by traveller'. There are a number of causes for the 'uncontrolled gybe', mis steering, over steering, rudder failure, quartering seas. Each of these causes has a control e.g. maintenance, instruments and helm competence, as you suggest.

But the hazard happened, now there are a number of controls to prevent 'crew member struck by traveller', such as staying out of the traveller zone, gybe preventer, the duck/down command. The consequence was immediately caused by him being in the danger zone. As always in these matters, many causes lined up, each removing a barrier,/control, such that an outcome was realised, this time fatally so. The root cause is far more difficult to determine, especially if you have a skipper that condones risk taking by not clipping on. That sends a powerful subconscious signal to the team that risk taking is acceptable. Standing anywhere near the traveller / danger zone is risk taking in heavy conditions.

 

[mainsail1]

In a F9? With massive waves. And heaving to isn't actually getting you back to the casualty it is "stopping you" going forward.

*** Give it a try with a fender (bucket attached) as the casualty next time you are out in a F9. I have.
They knew immediately that the poor lady had gone overboard. They should have started the engine and heaved to, without delay, using the engine to help push through the tack and the waves. They could then fore reach the relatively short distance to a position upwind of the casualty, using the engine as required. They would then need to go astern to stop the boat and drift down towards the casualty. Launch the liferaft on the lee side, secured to the boat and the casualty in this case would have been able to get herself into the raft as she was very fit and would have only been in the water five or ten minutes.


Coz reversing in a F9 is something we've all tried? And when we tried it we didn't worry about being in the middle of the pacific with no rudder.

*** A rudder system should be designed to take everything that an around the world trip can throw at it when there are passengers onboard. AlexThompson and the like can take whatever risks they like.

If you can't manouvre a hard hull to line up I'm far from convinced a squidgy raft can be either. Not to mention getting them lifted etc.

*** My point here is that a liferaft is often easier to get into from the water than trying to hoist the casualty onto the deck in one go. The lifraft would be tied to leeward and should not be squidgy.

There were mistakes in the MOB recovery procedure. It should have been practiced more to make it more automatic. But practice is never going to be real life with one of your mates life in the balance. So they could do with a MOB action card/check list. Like a plane pilot uses. They can initiate the steps for MOB automatically but while making way back it becomes someones job to shout the actions on the card and ensure they have been done...

**** Checklists in a F9 on deck. yea right!



But they are adding netting....

*** I think you will find it has been recommended but I suspect it will prove quite tricky with the limited toerail these boats seem to have (based on the photos, never seen one of these new boats up close)

Now, I realise that these new boats are probably tippy and flighty which always makes things more difficult. Maybe they are the wrong design for a race with paying passengers?

 

[duncan99210]

Minor point I know but according to the report (Section 5.2), Clipper laced up the guard rails over the length of the vessels. So whatever technical difficulties might have existed, they sorted them and the boats now have an additional measure of protection from the crew going overboard.

 

[ShinyShoe]

A rudder system should be designed to take everything that an around the world trip can throw at it when there are passengers onboard. AlexThompson and the like can take whatever risks they like.

So I think the debate in some of the forumites minds is about these people being passengers. I don't think any of them consider themselves passengers. I realise the law may do. But they don't. They are there to take part in a race. They are paying to be there, but they aren't there to be taken care of - they are there to try and win a race.

My point here is that a liferaft is often easier to get into from the water than trying to hoist the casualty onto the deck in one go.

If they can get the halyard on they shouldn't have a problem winching in.

Checklists in a F9 on deck. yea right!

That is exactly when they are needed. Check lists are used in all sorts of high pressure situations. You have a crew of > 20 people. One needs to lift a laminated card and read from it (loudly) and the person responsible confirms they've done it. The crew of the plane that parked on the Hudson used them. If you have time to use the emergency cards to park a plane on the hudson you have time on a yacht. In fact someone posted about water in the bilge on another thread and remembering to taste it. These are all the things you may need to be reminded - why not have an emergency checklist for water in bilge, for MOB etc. Even fire which quite frankly for me says "get off the boat ASAP" but depending on the boat should say "Close engine compartments, activate self fighting fire extinguishing system, press red mayday button, switch off gas at cylinder if accessible etc..."

But they are adding netting....

I think you will find it has been recommended but I suspect it will prove quite tricky with the limited toerail these boats seem to have (based on the photos, never seen one of these new boats up close)

So I may have mis-understood the meaning of this "After Seattle, Clipper took the following actions: Laced up guard rails over the length of the vessel." (Page 63). Is lacing up different from netting?

Now, I realise that these new boats are probably tippy and flighty which always makes things more difficult. Maybe they are the wrong design for a race with paying passengers?

If you could get a place for free rather than paying for it would it make any difference?
If you were being paid to be on it would it make any difference?

 

[mainsail1]

Correct me if I am wrong but I think you will find they only laced up the gap between the two guard wires. That would leave a gap at deck level for someone to be washed overboard.
I think the fact these people were fare paying crew is very important as Clipper Ventures has a duty of care to them whether they are happy to take the risks or not.