MAIB Report Liquid Vortex

[dt4134]

The hardest decision I ever have sailing is telling the family/friends 'We are not going,'.

But this crew had paid to do the Fastnet. Entry in the Myth of Malham race may have been advertised as training, but lets face it, it was to meet the pre-qualification mileage requirements for the Fastnet. The requirements that had been put in place originally by RORC to stop inexperienced crews doing the Fastnet.

1) The Fastnet is long enough that you have no real idea what weather you will ultimately face when you start (which if people remember is why there was the need for pre-qual requirements anyway).

2) It would've been a harder decision for this skipper than just the disappointment of telling the crew they weren't going. If they didn't go, they couldn't do the Fastnet, so they'd be wanting their money back and it would've been goodbye to the skipper's livelihood.

I really am not saying at all that sailing school boats shouldn't enter RORC races. Some of the crews might want to brag in City of London bars, but some will go on to regularly race. Inexperienced crews have to start somewhere and all experienced racers were originally inexperienced.

There are quite a few boats like this going out and it is down to the skippers that they get away with it. If they want to make it safer, there should be more training sessions and the boats should be seeded with more experienced crew, but that would likely prove fatal to the commercial model of the sailing schools.

 

[mcframe]

The skipper failed to manage the boat, failed to ensure crew instruction was understood, failed to manage the collision risk.

"Crew safety is the first priority."

Allow me to quote in full - do your own substitutions:
"Spaceflight will never tolerate carelessness, incapacity, and neglect. Somewhere, somehow, we screwed up. It could have been in design, build, or test. Whatever it was, we should have caught it.
We were too gung ho about the schedule and we locked out all of the problems we saw each day in our work. Every element of the program was in trouble and so were we. The simulators were not working, Mission Control was behind in virtually every area, and the flight and test procedures changed daily. Nothing we did had any shelf life. Not one of us stood up and said, "Dammit, stop!"
I don't know what Thompson's committee will find as the cause, but I know what I find. We are the cause! We were not ready! We did not do our job. We were rolling the dice, hoping that things would come together by launch day, when in our hearts we knew it would take a miracle. We were pushing the schedule and betting that the Cape would slip before we did.

From this day forward, Flight Control will be known by two words: "Tough and Competent." Tough means we are forever accountable for what we do or what we fail to do. We will never again compromise our responsibilities. Every time we walk into Mission Control we will know what we stand for.
Competent means we will never take anything for granted. We will never be found short in our knowledge and in our skills. Mission Control will be perfect.
When you leave this meeting today you will go to your office and the first thing you will do there is to write "Tough and Competent" on your blackboards. It will never be erased. Each day when you enter the room these words will remind you of the price paid by Grissom, White, and Chaffee. These words are the price of admission to the ranks of Mission Control."

http://en.wikipedia.org/wiki/Gene_Kranz

 

[mcframe]

I genuinely don't think that would have worked on the day Alan. The seas were too large, we watched other 40.7s try that tactic and get repeatedly into a knock down, and they were boats with the owners experienced and successful crews onboard.

Fair point; I wasn't out that day, but that was my 'takeway' - the spirit of the MAIB's "If you haven't found at least *five* Root Causes, then you're not looking hard enough" - that was just the one i picked up on.

dt4134: Great summary up-thread about under-manning & roles.

 

[rotrax]

The whole incident is a perfect illustration of how a company is incapable of managing risk to their clients. The skipper failed to manage the boat, failed to ensure crew instruction was understood, failed to manage the collision risk. One big classic failure of a skipper if you ask me - he got involved in the spinnaker untwisting operation on the foredeck, when he should have called the crew back and re-planned the untwisting operation. He failed to manage changing circumstances.

He was also a stupid person. Having determined that the communication between him in the cockpit and the mate unwrapping the spinnaker was impossible, he then proceeded to the foredeck with a developing collision risk where he attempted to communicate from the fore deck with an inexperienced helms woman in the cockpit.

However, is it his fault? The owner of the company failed to have a proper standards of management for this activity and thus exposed his clients to unacceptable risk by having a poor skipper and less qualified first mate on board. This is where the incident commenced, at the hiring stage. The owner or manager of the Company should be penalised in some manner, instead they have been requested to implement what should have been in place.

Sadly this is typical of many incidents where those directly responsible tend to be blamed but the instigators get told to improve some aspect. Still it doesn't surprise me. In the UK today a Company can kill 165 people as a direct result through the lack of a legally required management system and no one within management is held accountable.

Hi, There is a little confusion in my mind when you say it is a illustration of how a company is incapable of managing risk to its clients. Once the shore lines are slipped the skipper is in charge and must alone take responsibility for the safety of the boat and crew. The company may well have rules and policies to guide its skippers but can do little to enforce them once the boat is under way. The company could concievably fail in not providing or maintaining boat and equipment to the required standard. It also must take on the chin any findings or successful prosecutions for negligence,should this happen. I have had a wry chuckle about this. Unless the company Hot Liquid Sailing has changed hands, the owner trained a motorsports collegue and I for our day Skipper when he was working for the On Deck sailing school. I hope it wasnt him who got on the sandbank! As a by the way, he seemed to know his stuff then.

 

[awol]

Hi, There is a little confusion in my mind when you say it is a illustration of how a company is incapable of managing risk to its clients. Once the shore lines are slipped the skipper is in charge and must alone take responsibility for the safety of the boat and crew.

Have you read the report? One of the findings was that the company "had not properly considered how the training of her crew in the ‘Fastnet Campaign’ was to be conducted."; the action already taken - "Hot Liquid Sailing Ltd has begun to develop operational procedures to cover the conduct of the training of its yachts’ crews involved in racing."; and the recommendations made - "Hot Liquid Sailing Ltd is recommended to establish a robust safety management system to ensure:
• The risks to its vessels and crews engaged in commercial operations are identified and thoroughly assessed
• Comprehensive operational procedures and guidance are developed to mitigate such risks
• Management oversight to ensure compliance with its procedures, once these are established."

I agree that on the water the skipper is responsible but there surely has to be guidance in the planned training objectives and methods, the expectation of competitiveness (or not) in the qualifying races, and support provided to match the skills (or lack of) of the paying punters. My sympathies lie with the injured lass and the skipper and none with the company. The suspicion is raised of a business model that maximises profit while minimising staff and material costs without the support of risk analyses or even simple HR procedures like checking qualifications .

 

[Deleted member 36384]

Hi, There is a little confusion in my mind when you say it is a illustration of how a company is incapable of managing risk to its clients. Once the shore lines are slipped the skipper is in charge and must alone take responsibility for the safety of the boat and crew. The company may well have rules and policies to guide its skippers but can do little to enforce them once the boat is under way. The company could concievably fail in not providing or maintaining boat and equipment to the required standard. It also must take on the chin any findings or successful prosecutions for negligence,should this happen. I have had a wry chuckle about this. Unless the company Hot Liquid Sailing has changed hands, the owner trained a motorsports collegue and I for our day Skipper when he was working for the On Deck sailing school. I hope it wasnt him who got on the sandbank! As a by the way, he seemed to know his stuff then.

Good companies have a high degree of control over their activities to prevent loss. On this occasion, from the report, I think they did not exercise any meaningful control over the skipper so that they could allow him to cast off the lines and have confidence that their interests were best protected.

They are now in a situation where they may be subject to a claim by the injured party and because of the commercial endorsement situation the may not be insured: poor governance, evidence of either negligence or incompetency to manage this business risk. I assume that the owner is not complicit in allowing an unlicensed skipper to manage commercial activities on his behalf.

 

[FlipFlop]

it has happened again, another MAIB report to follow??

From Echo Newspaper:

COASTGAURDS have been scrambled to rescue a stricken Southampton yacht caught in gale force winds and five metre swells.

Three of the seven crew on the forty foot yacht Liquid Vortex were suffering from sea sickness and another has a possible injury to his jaw and ribs after a fall onboard.

The skipper of the yacht, which is sailing from Southampton to London, made an urgency call to coastguards at 5.11am.

The yacht was caught in winds of around 60mph.

Dover Coastguard called out rescue teams from Margate.

RNLI lifeboats from Dungeness and Dover have been launched and an RAF rescue helicopter sent out to airlift the sick crew.

 

[alant]

Is that not obvious? Why would a RYA Training Insurance policy cover anything other than RYA Training?

Yachtmaster Prep, is a course usually run by an RYA accredited Sea School, in order to gain a RYA Certificate after the end of that week, with candidates examined by an examiner selected from the RYA stable of examiners.

Easy for anyone to assume that something to do with the RYA might validate the Sea School Instructor Insurance Cover or even the RYA Instructor Insurance.

Insurance within this 'industry', has been a very foggy issue for as long as I can remember. Broaching the issue, seems previously to get you kicked into the long grass.

On a mass weekend Solent Charter for 'Building Industry' Clients a few years ago, I was advised by the organiser that the 'charter' was an RYA course (even though it was a race organised informally with about 45 yachts - including some hired from Sunsail). When I asked about insurance, I was told that the RYA Instructor insurance would suffice, even though it was not a recognised RYA training course, so in my opinion this was a falsehood. I 'lost' the job, thankfully IMO, since the financial repercussions if an accident occurred could be horrendous without adequate cover.

Insurance Companies in almost every area of our lives, seem to want to wiggle out of paying out, so why does the sailing industry think they would be treated differently.

How many clients check if they can claim against an insurance, rather than sue the Skipper, who may have insufficient funds/capital?

How many clients would want to pay more, to ensure that they are adequately covered?

I have mentioned it in the past, but the situation when sailing with friends could also result in a claim against the 'skipper', but who thinks of it when inviting/invited?

Are you as a leisure sailor, sure, that you are protected financially should a friend/relative be badly injured onboard?

 

[alant]

Hi, There is a little confusion in my mind when you say it is a illustration of how a company is incapable of managing risk to its clients. Once the shore lines are slipped the skipper is in charge and must alone take responsibility for the safety of the boat and crew. The company may well have rules and policies to guide its skippers but can do little to enforce them once the boat is under way. The company could concievably fail in not providing or maintaining boat and equipment to the required standard. It also must take on the chin any findings or successful prosecutions for negligence,should this happen. I have had a wry chuckle about this. Unless the company Hot Liquid Sailing has changed hands, the owner trained a motorsports collegue and I for our day Skipper when he was working for the On Deck sailing school. I hope it wasnt him who got on the sandbank! As a by the way, he seemed to know his stuff then.

Yes, the Skipper is in charge when lines are slipped, but a passage plan should perhaps have been approved by the Principals before leaving.

On another thread, one of their yachts was rescued from near Dover, in the recent storm, which the Skipper knew was going to hit. Was that passage sanctioned by the company?

"I assume that the owner is not complicit in allowing an unlicensed skipper to manage commercial activities on his behalf."

Why did the owner not check beforehand?
Complicit by default surely, if they didn't.

 

[Deleted member 36384]

Yes, the Skipper is in charge when lines are slipped, but a passage plan should perhaps have been approved by the Principals before leaving.

On another thread, one of their yachts was rescued from near Dover, in the recent storm, which the Skipper knew was going to hit. Was that passage sanctioned by the company?

"I assume that the owner is not complicit in allowing an unlicensed skipper to manage commercial activities on his behalf."

Why did the owner not check beforehand?
Complicit by default surely, if they didn't.

The point I am making is not that a skipper is not responsible, or that Hot Liquid's management should sanction decisions by the skipper, but that Hot Liquids management should ensure that the skippers they hire are competent and comply with any obligations e.g. Commercial Endorsement.

Yes, complicit by default, but perhaps not a deliberate act e.g. believing a skipper who says he has a commercial endorsement (also first aid, VHF licence) but not verifying by checking the paper work.

I think a charge of grandstanding was being directed at me earlier in this thread. In my opinion more management should be held accountable for situations where incompetency and negligence by employees or hired hands exist - of course it all depends on the situation.

 

[alant]

The point I am making is not that a skipper is not responsible, or that Hot Liquid's management should sanction decisions by the skipper, but that Hot Liquids management should ensure that the skippers they hire are competent and comply with any obligations e.g. Commercial Endorsement.

Yes, complicit by default, but perhaps not a deliberate act e.g. believing a skipper who says he has a commercial endorsement (also first aid, VHF licence) but not verifying by checking the paper work.

I think a charge of grandstanding was being directed at me earlier in this thread. In my opinion more management should be held accountable for situations where incompetency and negligence by employees or hired hands exist - of course it all depends on the situation.

I agree with you.

I've had my tickets checked in detail, when working on 'commercial' workboat type vessels, but only occasionally, when working for 'commercial' yacht companies.

One company, one of the more responsible schools, wanted to see the originals, took copies & advised when they needed renewing. The person running their admin, was an ex female police person & bloody good at her job. Blokes running companies, seem to concentrate on the sailing/personality/trust bit & ignore paperwork. It shouldn't be difficult, since the RYA advise when they are running out, so have a data base which is checkable.

 

[prv]

In my opinion more management should be held accountable for situations where incompetency and negligence by employees or hired hands exist - of course it all depends on the situation.

As I understand the dimly-remembered law course that was tucked into my Computer Science degree, provided he was doing what he was employed to do (which he was) then the company are vicariously liable more or less automatically.

Pete

 

[rotrax]

Could be summed up by saying that sailing in heavier weather can have risks.

Preventers are OK in lighter conditions but in heavier weather should be avoided in my opinion.

I respect your opinion but why are you giving it on this post? I have just read the MAIB report and can find no reference to a preventer being used. On the other hand, a correctly used preventer may have been an advantage in this case.

 

[dt4134]

... On the other hand, a correctly used preventer may have been an advantage in this case.

Imagine what would happen sailing downwind under spinnaker and Chinese gybing with a preventer on the main in strong winds.

 

[rib]

i cant be bothered to read report again,but am i right in beliving that thay did,nt practise mob,and then had the two most experianced guys on the bow,if so good job nobody went over !