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VERY SERIOUS MARINE CASUALTY REPORT NO 4/2012 March 2012

Report on the investigation of

a fatal man overboard from the Reflex 38 yacht

Lion14.5 miles south of Selsey Bill, West Sussex

18 June 2011

Extract from The United Kingdom Merchant Shipping (Accident Reporting and Investigation)

Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 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 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame.

© Crown copyright, 2012

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 identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

Front cover photograph (Lion) courtesy of Yachting Monthly.

All MAIB publications can be found on our website: www.maib.gov.uk

For all enquiries:Marine Accident Investigation BranchMountbatten HouseGrosvenor SquareSouthampton Email: maib@dft.gsi.gov.ukUnited Kingdom Telephone: +44 (0) 23 8039 5500SO15 2JU Fax: +44 (0) 23 8023 2459

CONTENTS

Page

GLOSSARY OF ABBREVIATIONS

SYNOPSIS 1

SECTION 1 - FACTUAL INFORMATION 2

1.1 Particulars of Lion and accident 21.2 Background 4

1.2.1 Preparation for participation in the 2011 Fastnet Race 41.2.2 Morgan Cup Race 41.2.3 Identificationofcrewmembers 4

1.3 Narrative 51.3.1 Events leading up to the race start 51.3.2 EventsfromthestartofracetotheNo.1genoagoingoverboard 71.3.3 No.1genoarecoverytothemanoverboard 101.3.4 Manoverboardrecovery 111.3.5 Post-recovery actions 14

1.4 Environmentalconditions 151.5 Yacht Lion’s Track 151.6 Ownershipandusage 15

1.6.1 Ownership 151.6.2 Usage 151.6.3 Fundingarrangementsforcompetinginthe2011FastnetRace 15

1.7 The International Sailing Federation 151.8 RoyalOceanRacingClub 161.9 Regulations 16

1.9.1 TheSmallCommercialVesselandPilotBoatCodeofPractice 161.9.2 ISAF Offshore Special Regulations 161.9.3 RORCNoticeofRace2011 17

1.10 Reflex38yachtLion - description 171.10.1 General 171.10.2 Decklayout 171.10.3 Stanchions,guardwiresandlacing 181.10.4 Sailwardrobe 19

1.11 Skipper’s clothing 191.12 Lifejackets 19

1.12.1 Skipper’s lifejacket 191.12.2 ISAF’sOSR-lifejacketharnesscrotch/thighstraprequirementsand

recommendations 221.12.3 ISAF’s Crotch Strap Working Party 23

1.13 Tethers 231.13.1 General 231.13.2 ISAF’sOSRtetherrequirements 231.13.3 RYA guidance 24

1.14 Re-enactmenttrial-jacklinesandtethers 241.15 Guidanceonsafetybriefings 27

1.16 Crewexperience 271.16.1 Skipper 271.16.2 Crew 271.16.3 Training 27

1.17 Manoverboardissues 281.17.1 RYA MOB recovery procedure guidance 281.17.2 ISAFMOBguidance 281.17.3 Lion’sSafetyTrainingManual 291.17.4 MOBrecoveryequipment 29

1.18 Similaraccidents 291.18.1 UKregisteredsmallcommercialsailingvessel-November2003 291.18.2 UKregisteredsmallcommercialsailingvessel-November2007 301.18.3 Pleasurecraft-non-commercialyacht-February2011 301.18.4 Pleasurecraft-non-commercialyacht-May2011 30

SECTION 2 - ANALYSIS 31

2.1 Aim 312.2 Accidentoverview 31

2.2.1 General 312.2.2 Delegation 312.2.3 Crewobservationsandalarm 312.2.4 Footwear 312.2.5 Evidenceofthepathtakenbytheskipper 322.2.6 Conclusion 32

2.3 Securing the No.1 genoa on deck 322.4 Crew’sactions 33

2.4.1 Post-recovery actions 332.5 Recovery options 332.6 Tethered MOB procedures 34

2.6.1 Trainingbyprofessionalbodies 342.6.2 OnboardMOBtraining 35

2.7 Guidance for use of short tethers 362.8 Incidentmanagement 36

2.8.1 Manoverboardmanagement 362.8.2 Publicationsguidance 37

2.9 Decisiontocompete 372.10 Lifejacketfittings 37

2.10.1 Purposeandadjustment 372.10.2 Skipper’slifejacketdisplacement 382.10.3 Lifting using the lifejacket integrated safety harness 382.10.4 ISAF’sworktodeterminelifejacketharnesscrotch/thighstrap

specifications 382.11 Fatigue 39

SECTION 3 - CONCLUSIONS 40

3.1 Safetyissuesdirectlycontributingtotheaccidentwhichhaveresultedin recommendations 403.2 Othersafetyissuesidentifiedduringtheinvestigationwhichhavebeen actioned 403.3 Other safety issues 40

SECTION 4 - ACTIONS TAKEN 42

4.1 TheRoyalOceanRacingClub 424.2 Mecal Ltd 424.3 HMCoronerforWestSussex 424.4 The International Sailing Federation 424.5 The Royal Yachting Association 42

SECTION 5 - RECOMMENDATIONS 43

FIGURES

Figure 1 ChartletshowingMorganCupRacecourseandkeyevents

Figure 2 ChartletshowingAIS/GPStracksforLion and Lickety Split

Figure 3 Position of the lashed No.1 genoa

Figure 4 Genoatackconnectedtotheforwardpadeye

Figure 5 Positionoftheforwardcentrelinecleat

Figure 6 DetailedAIStrackshowingkeyevents

Figure 7 Approximate pathbelievedtohavebeentakenbytheskipperwhenfallingoverboard

Figure 8 Pictorial interpretation of the spinnaker halyard connected to the skipper’s tether

Figure 9 Deck layout

Figure 10 Stanchion,guardwireandlacingarrangements

Figure 11 GapbetweenthefootoftheNo.3genoaandthedeck

Figure 12 Skipper’s Spinlock Deckvest 150 Pro Sensor lifejacket, harness and thigh straps

Figure 13 Spinlock Deckvest 150 Pro Sensor lifejacket thigh strap side release buckles

Figure 14 Two-hooktether

Figure 15 Three-hook tether

Figure 16 Three-hook tether connected to the port jackline

Figure 17 Three-hooktetherconnectedtothestarboardjacklineandpassingunderthespinnaker pole

Figure 18 Three-hooktetherconnectedtothestarboardjacklineandpassingoverthespinnaker pole

ANNEXES

Annex A RoyalOceanRacingClubNoticeofRace2011-MorganCupRacedetails

Annex B InternationalSailingFederationCategoryofEventsdefinitions

Annex C MorganCupRacecoursereleasedon17June2011

Annex D RoyalOceanRacingClubISAFOffshoreSpecialRegulations Checklist2011-SubmissionforLion dated 19 May 2011

Annex E Lion’sSafetyTrainingManualextract-topicsfortheSafetyBrief

Annex F ExtractfromRYA’sDaySkipperPracticalNotes-ManOverboardProcedures

Annex G ExtractfromRYA’sAutumnEditionoftheinstructors’magazine “Wavelength” - “What’s the Point of MOB Drills?”

Annex H ExtractfromRYA’sSeaSurvivalHandbook-ManOverboardProcedures

Annex I AppendixDtoISAF’sOffshoreSpecialRegulations2010-2011-ManOverboard-QuickStopandtheLifeSling

Annex J AppendixGtoOSR2010-2011-Session6-ManOverboardPreventionandRecovery of ISAF’s Model Training Course - Offshore Personal Survival

Annex K AppendixB3toLion’sSafetyTrainingManual-ManOverboard

Annex L ISAF’sOSR-amendementstosub-sections5.01.1b,5.02.5b,5.02.6,and1.02.1

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS

AIS - AutomaticIdentificationSystem

C - Centigrade

CG - Her Majesty’s Coastguard

cm - centimetre

CoC - CertificateofCompetence

COG - course over ground

CPR - cardio-pulmonaryresuscitation

CSWP - Crotch Strap Working Party

GD - general duties

GPS - GlobalPositioningSystem

EN - EuropeanNorm

ISAF - International Sailing Federation

ISO - InternationalOrganizationforStandardization

kg - kilogram

kgf - kilogram-force

kW - kilowatt

m - metre

MCA - MaritimeandCoastguardAgency

mm - millimetre

MNA - MemberNationalAuthority

MOB - manoverboard

OSR - Offshore Special Regulations

oz - ounce

RNLI - RoyalNationalLifeboatInstitution

RORC - RoyalOceanRacingClub

RYA - Royal Yachting Association

SCVCode - TheSmallCommercialVesselandPilotBoatCodeofPractice

SOG - speed over ground

SSR - SmallShipsRegister

T - True

BungyStrap - Alengthofelasticatedlinewithfasteningsateitherend.

Jackline - Alengthofstainlesssteelwireorwebbingextendingforeandafttowhichasafetytethercanbeattached.

Parbuckle - Adevice,usuallyofropesorfabric,thatismadefastatoneend.Theoppositeendispassedundertheobjecttobemovedandthenpassedbackforthepurposesofhaulingorlowering.

Spreader - Astrutthatholdstheshroudsawayfromthemast.

Times:AlltimesusedinthisreportareUTC+1unlessotherwisestated

1

SYNOPSIS

At0036on18June2011theskipperoftheyachtLion fell overboardanddrownedwhilestillattachedtotheyachtbymeansofatetherconnectedtohislifejacketharness.

LionsailedfromSouthamptonon17June2011tocompeteintheRoyalOceanRacingClub’s(RORC)95-mileMorganCupRacetoCherbourg.Theweatherconditionswerechallengingfortheyacht’screw,withwindsgusting25-30knotsandroughseas.

At0027on18June,thehelmsmannoticedtheNo.1genoa,whichhadbeensecuredondeckfollowingasailchange,had

slippedintothewater.Thesailwasrecoveredonboardandwasbeingpassedbyhandintothecockpitwhenitwasnoticedthattheskipperhadfallenovertheportsidenearthebow.Theskipperwasstillconnectedtothestarboardjacklinebyhis1.8m-longtether.Themainsheetwasimmediatelyslackenedandtheforesailwasreleasedashorttimelater,whichslowedtheyacht’sspeedto1.5knotsthroughthewater.

Ittookthecrew16minutestorecovertheskippertothedeck,wherehewaspronounceddeadbyaconsultantcardiologistwhowasoneofthecrew.Theinvestigationfoundthatthefollowingfactorsinfluencedtherescue:

• Theprevailingconditionsmadetherecoveryoftheskipperphysicallychallenging.

• Noonehadbeennominatedtoreplacetheskipperifhewasincapacitated;initiallyitwasunclearwhowasinchargewhichhinderedcommunications.

• Recoveryofatetheredmanoverboard(MOB)isnotroutinelycoveredduringRoyalYachtingAssociation’s(RYA)trainingcoursesandnotallthecrewhadparticipatedintheMOBdrill,conducted6weeksbeforetherace.

Actionshavebeentakenby:

TheRoyalYachtingAssociation(RYA)to:

• EncouragetheuseofasuitabledummyduringMOBtrainingexercises.• Promulgatethroughvariousyachtingrelatedpublicationsthepurposeanduse

of short tethers, including recovery of a tethered MOB, the need to anticipate andhowtodealwithavarietyofMOBsituations,andtheneedtonominateareplacementfortheskippershouldhe/shebecomeincapacitated.

TheInternationalSailingFederation(ISAF)to:

• AmenditsOffshoreSpecialRegulations(OSR)includingtheintroductionofarequirementforapersontobenominatedtotakeoverfromtheskipperintheevent of his/her incapacitation.

ArecommendationhasbeenmadetoRORCto:

• Promulgatethesafetyissuesidentifiedinthisinvestigationreport,inparticular;theneedtoformallynominateaskipper’sreplacement,guidanceontheappropriateuseoftethersandthedifficultiesthatmaybeexperiencedwhenrecovering a tethered MOB.

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ImagecourtesyofYachtingMonthly

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SECTION 1 - FACTUAL INFORMATION

1.1 PARTICULARS OF LION AND ACCIDENT

SHIP PARTICULARSFlag UnitedKingdomClassificationsociety NotapplicableSSRnumber 903775Type Reflex38,9/10fractionalsloopRegisteredOwner LionYachtCharterLimitedManager(s) NotapplicableConstruction glass-reinforced plasticLength overall 11.61mRegistered length NotapplicableDisplacement 6.16 tonnesMinimumsafemanning NotapplicableAuthorised cargo Notapplicable

VOYAGE PARTICULARSPort of departure SouthamptonPort of arrival Cherbourg(intended)Type of voyage Yacht raceCargoinformation Notapplicable

Manning 8(maximumpermissible10)

MARINE CASUALTY INFORMATIONDateandtime 18June2011at0036Typeofmarinecasualtyorincident VerySeriousMarineCasualtyLocation of incident 50º29.012’N000º46.447’W-14.5miles

southofSelseyBill,WestSussexPlaceonboard Over sideInjuries/fatalities 1 fatalityDamage/environmentalimpact NotapplicableShip operation RacingVoyagesegment Mid-waterExternal&internalenvironment Westerlywindforce7.Waveheight3.5m.

Tidalstreameasterly0.8.Seatemperature15ºC.

Personsonboard 8

4

1.2 BACKGROUND

1.2.1 Preparation for participation in the 2011 Fastnet Race

ChristopherReddish,theownerandskipperoftheracingyachtLion, intended to usehertocompeteintheAugust2011FastnetRace.TheorganisingauthorityfortheracewastheRoyalOceanRacingClub(RORC)inassociationwiththeRoyalWesternYachtClub,Plymouth,andtheRoyalYachtSquadron.

AstheFastnetRacecanbeahighlydemandingevent,RORChaddevelopedanumberofrequirementstomaintainandimprovesafety,includingacrew“ExperienceQualification”.Oneoftheoptionstosatisfythisrequirementwasthat:

“The Person in Charge, with at least half the crew, must have completed in the yacht in which they will race the Rolex Fastnet Race, in the 12 months preceding the start, 300 miles of RORC offshore racing”.

Detailsofthe12offshoreracesorganisedunderRORC’sauthoritywerepublishedinRORC’sNoticeofRace2011.CompletingboththeMythofMalhamandtheMorganCupRaceswouldhavesatisfiedLion’sentryrequirementsfortheFastnetRaceprovidedmorethanhalftheintendedFastnetRacecrewhadparticipatedinbothraces.

TheskipperandfourofthesevenothercrewwhowereonboardLionatthetimeoftheaccidenthadcompetedinandfinishedRORC’s230-mileMythofMalhamRaceduring27-28May2011.Also,atrainingweekendhadbeencarriedouton6-8May,whichincludedamanoverboard(MOB)exercise,where50%ofthecrewonboardatthetimeoftheaccidentwereinvolved.

1.2.2 Morgan Cup Race

TheMorganCupRaceon17June2011wasdesignatedbyRORCasanInternationalSailingFederation(ISAF)Category3racewiththeadditionalrequirementthataCategory2raceliferaftwastobecarried.AcopyoftheMorganCup Race details is at Annex A.TheISAFOffshoreSpecialRegulations(OSR)CategoryofEventsdefinitionsareatAnnex B.

Theracewasprovisionallyplannedtolastbetween24and36hoursandinitiallyhad110entrants.TheracestartwasatCowes,IsleofWight,withthefinishdesignatedasCherbourg,France.

1.2.3 Identificationofcrewmembers

Forthepurposeofthisreport,thecrewmembersareidentifiedasfollows:

• skipper • helmsman • navigator • bowman1

• mastman2 • trimmer1 • trimmer2 • generaldutiesman

1 Thebowmanwastheskipper’sson2 Themastmanwasaconsultantcardiologist

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1.3 NARRATIVE

1.3.1 Events leading up to the race start

FollowingtheMythofMalhamRace,twoofLion’sexperiencedcrewinformedtheskipperthattheywouldnotbeavailablefortheMorganCupRace.Astheracewasofrelativelyshortduration,theskipperdecidedtocompetewithacrewofeightinsteadoftheusualten.Hehadracedwitheightcrewpreviouslyandhadconsidered it safe.

Duringtheweekprecedingtherace,thenavigatorcloselymonitoredthesteadilydeterioratingweatherconditions.On14June,hesentane-mailtotheskipperraisingconcernsthatthepredictedweatherfortheperiodoftheracemightdamagetheyachtandjeopardisesafety.Theskipperconsideredthatthecrew’sexperienceandtheyacht’sperformancerenderedtheyachtsafetorace,andadvisedthenavigatoraccordingly.Nofurtherconcernswereraised.

On16June,anotherofLion’sMythofMalhamRacecrewbecameunavailable.Thenavigatorsuggestedthathisbusinesspartner,whohadconsiderableracingexperience,predominantlyasahelmsman,wouldbeabletojoinLion’screw.Theskipper agreed to the proposal.

At2004on16June,thenavigatorsentane-mailtotheskipperandcrewadvisingthemofthelatestweatherforecast,whichwasbroadlythesameashadbeenpromulgated2daysearlier.

At1130thefollowingday,theMeteorologicalOfficeissuedtheshippingforecastfortheperiod1200UTCon17June,to1200UTCon18June.Theforecast,whichwasobtainedbythenavigator,advisedofgalewarningsinanumberofseaareas.TheforecastweatherforseaareasThames,DoverandWightwas:

“South-east 5 to 7 veering south-west 7 to severe gale 9. Moderate, becoming rough or very rough. Rain then showers. Moderate to poor”.

At1320on17June,RORC’sRaceCommitteesentdetailsoftheMorganCupRacecoursetothecompetitorsbye-mail(Annex C).Thecourse,at95mileslong,wasrelativelyshorttotakeaccountofthedifficultconditionsexpected.AchartletshowingthecourseisatFigure 1.

By1500,thefullcrewhadarrivedatLion’sberthatShamrockQuay,Southampton,andatabout1630theskipperspokeingeneraltermstothemabouttheraceandthepredictedpoorweatherconditionswhichremainedexactlythesameastheearlierforecast.Healsoallocatedthecrewtotheirroles.Inviewoftheshortracedurationnowatcheswerespecified.Therewasnospecificbriefinggivenregardingnominationofapersontotakeoverfromtheskipperifhebecameincapacitated,manoverboardproceduresoranyothersafetyconsiderations.

At1720,LiondepartedShamrockQuay.ThebowmanwasonthehelmasLion motoreddownSouthamptonWaterandontowardsCowes.Aboutanhourlater,thehelmsmantookthehelmandthestormjibwasraised3.

3 ThiswasaRORCpre-racerequirementtoprovethattheequipmentwascarriedonboardallcompetingyachts.

6

Atapproximately1850,LionpassedclosetoRORC’scommitteeboatoffCowes.About5minuteslater,thestormjibwasloweredandthemainsailhoisted.However,thecrewfoundthatthereefinglineshadnotbeenriggedinthemainsail,soitwasloweredsothattheycouldrectifytheomission.TheNo.3genoawasthenhoisted,butthiswasdelayedbecauseofdifficultiesinkeepingthesail’sluffintheforestayluffgroove,whichwasverystiff.Duringthisoperation,oneofthespinnakerhalyardswasaccidentlyallowedtoflyupthemast,whereitremainedsnaggedaroundthespreaders.OncetheNo.3genoawasfinallyhoisted,thehelmsmannoticedatearinthe luff and advised the skipper.

Lioncrossedthestartlineat1920.Atthattime,thewindwas15knots(force4)froma direction of 134º.

1.3.2 EventsfromthestartofracetotheNo.1genoagoingoverboard

The early stages of Lion’sracewereuneventfulastheyachtprogressedeastalongTheSolentclose-hauledatspeedsovertheground(SOG)ofbetween6.4and8knots (Figure 2).Atabout2025,thehelmsmanfeltthatwiththeNo.3genoatheboatwasunder-powered.Theskipperagreed,andthesailwasreplacedwiththeNo.2genoa;theNo.3genoawasthentakenintothecabinforrepairstotheluff.

Atabout2100,LionwasoffBembridgeLedge.Theseastatehaddeterioratedslightlybutthewindforcehadreduced.TheskipperinstructedthattheNo.1genoabehoisted,andafterwardstheNo.2genoawasstowedinitssailbagandtakenbelowdeck.Sometimelater,withthewindveering,considerationwasgiventoriggingthespinnaker;inviewofthecrew’searlierproblemswiththesails,theskipper decided against doing so.

Figure 1:ChartletshowingMorganCupRacecourseandkeyevents

Tidalstream0.8kt

Finish-Cherbourg:courselength95nm

30-35 kts

Start-Cowes1820UTC

Owerslightbuoy

Accident

ReproducedfromAdmiraltyChartBA2045bypermissionoftheControllerofHMSOandtheUKHydrographicOffice

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Asthewindstrengthenedagain,theskipperandhelmsmanagreedthattheNo.3genoawouldberequiredonceLionroundedtheOwersLightBuoy.Becauseoftheearliersail-riggingproblems,bothfeltitprudenttochangethesailbeforetheyachtreachedthebuoyastheyexpectedthatconditionsweregoingtoworsenduringtheupwindlegacrosstheEnglishChanneltoCherbourg.At2210,withthewindhavingveeredfurther,thehelmsmangybedtoport.Atthattime,Lion’sGlobalPositioningSystem(GPS)recordedtheyacht’sSOGas8.8knots.TheNo.1genoawasthenloweredandthehelmsmangybedtostarboard.ImmediatelyafterwardstheNo.3genoawashoisted.

Lick

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MSOandtheUKHydrographicOffice

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ThehelmsmanthenheardtheskipperinstructthebowandmastmentolashtheNo.1genoaonthedeck.Thesailwassecuredtotheportguardwiresandsupportingstanchionsusinglight“bungy”strapsandtwosailties(Figure 3)whilethetackremainedclippedtotheforwardpadeye(Figure 4).Soonafterwardsthehelmsmaninstructedthatthefirstreefinthemainsailshouldbetakenin.Oncethemainsailhadbeenreefed,theskippertoldthehelmsmanthathewascontentwiththenewsailconfiguration.

At 2240, LionpassedtheOwersLightBuoyleavingittostarboardandturnedtocommencehercrossingoftheEnglishChannel.AstheyachtmadeherwayacrosstheEnglishChannelshewasclosehauledonastarboardtackandheelingabout20ºtoport.Thewindstrengthwasabout25knots,veeringandincreasing,andthewaveheightwas2.5mandbuilding.Theskipper,helmsmanandnavigatorwereaft,andtheremainingcrewwereonthehigh,starboardsideoftheyachtwiththeirtethersclippedtothestarboardjackline.Thehelmsmanfelttheyachtwasnowwell-balancedand,atupto9knotsSOG,wasovertakingotheryachts.

Atabout2315,theskippersuggestedthatsomeofthecrewshouldgotothecabintorest.Thebowandmastmenwentbelowand,at2330,theskipperfollowed,havingtoldthehelmsmanhewouldtakeabout30minutesrest.

Inthemeantime,thewindhadveeredto260ºandincreasedinstrengthtoabout30knots(force7-neargale),andthewaveheighthadbuilttoabout3-3.5m.Lion’s porttoeraildippedintothewaterassprayandoccasionalgreenseaswereshippedacrossthebowarea.

Astheweatherdeteriorated,trimmer2noticedthattheNo.1genoawasslippingfromitslashings.Heclippedhistethertothestarboardjackline,wentforwardupthestarboardsideandusedtwoadditionalsailtiestore-secureit.

Asthewindgustedabove30knots,thehelmsmanconsideredthatthesecondreefshouldbeputinthemainsail.Hecheckedhiswatch,whichshowed0016on18June2011,andcalledtheskippertothedeck,beforethesecondreefcouldbetakenin.

At0027,thehelmsmanfelttheyacht’shandlingcharacteristicschange.Atthesametime,henoticedthattheNo.1genoahadslippedfromitslashingsandwasstreamingdowntheportsideoftheyacht.However,thetackremainedsecuredtotheforwardpadeye,whichpreventedthesailfromfloatingaway.Theskippercalledthebowandmastmentothedecktohelprecoverthesailifrequired.Meanwhilethehelmsmanconcentratedonmaintainingasteadycoursetoassisttherecoveryoperation.Asthemastmanenteredthecockpithenotedthewindspeedindicatorwasreading38knots.Theyachtwasheelingtoportwithhertoeraildippingintothewater.

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No.1 genoa

Figure 3: Position of the lashed No.1 genoa

Figure 4: Genoatackconnectedtotheforwardpadeye

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1.3.3 No.1genoarecoverytothemanoverboard

Theskipperandtrimmer1clippedtheirtetherstothestarboardjacklineandmadetheirwayforwardtorecoverthesail.Onceinthepulpitareatheskippertransferredhistethertotheportjacklineastrimmer1wasjoinedbytrimmer2.

Astheskipperrecoveredthesailfromthewateritwaspassedalongthestarboardsidebytrimmers1and2,andthenavigatorguideditdownthecompanionwayandintothecabin.Whenallofthesailwasrecoveredonboard,theskipperdisconnectedthetackfromtheforwardpadeye.Hethentransferredhistetherfromtheporttothestarboardjacklineinpreparationtoreturntothecockpitalongthehigh,starboardside,aswashisusualpractice.Almostimmediately,thesailsnaggedandtheskippercalled“stop”.Trimmer1thensawhimlieonthedeck,onhisstomach,facingforwardandtostarboardofthecentreline.Itislikelythatthesailhadsnaggedontheforwardcentrelinecleat(Figure 5) and the skipper wasattemptingtofreeit.Afterashorttime,theskippercalled“OK”andthesailcontinuedtobepassedalongthestarboardside,partlyoverthecoachroofanddownthecompanionwayintothecabin.

Atabout0036,trimmer2sawawhitestrobelightthroughtheNo.3genoaandcalledouttotrimmer1,whorecogniseditasalifejacketstrobelight.Trimmer1shouted“manoverboard”,whichwasthenrepeatedbythenavigator.

Figure 5:Positionoftheforwardcentrelinecleat

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1.3.4 Manoverboardrecovery

Thehelmsman’simmediatereactionwastopreparetothrowoneoftheyacht’shorseshoelifebeltsoverboardinaccordancewiththestandardMOBprocedure.However,thenavigatorconfirmedthattheskipperwasstillattachedtotheyachtbyhistether;thehelmsmanrealisedthatthelifebeltwasunnecessaryandwasrelievedthattheskipperwasstillattachedtotheyachtwhichhehopedwouldmakehisrecovery easier.

Toassistintherecovery,thehelmsmaninstructedthegeneraldutiesmantoreleasethemainsheet,whichhadtheeffectofimmediatelyslowingLiondownfrom4.5knotsto1.5knotsthroughthewater,withacourseoverground(COG)ofapproximately135ºTrue(T) (Figure 6).

At0038,thenavigatortransmitteda“Mayday”distressmessage.ThiswasreceivedbySolentCoastguard(CG),whothenactivatedcoastguardrescuehelicopterR104,basedatLee-on-the-Solent,toprovideassistance.Inthemeantime,trimmers1and2andthebowandmastmenwentforward,withtheirtethersclippedtothestarboardjackline,totrytorecovertheskipper.TheNo.3genoa sheet wasreleasedsoonafterwardsontheinstructionofthehelmsman.Thenoisegeneratedbytheflappingsails,windandseamadeverbalcommunicationsbetweenthoseinthecockpitandtherecoveryteamforwarddifficult.

Theskipperwasfoundinthewaterontheportsidewithhislifejacketinflatedandthelifejacketbladderoverhishead,obscuringpartofhisface.Histetherwasstillconnectedtothestarboardjacklineandhadpassedoverthespinnakerpoleandunderthelowerguardwirebetweenthepulpitandthefirstverticalstanchion(Figure 7).Themastandbowmenwenttotheportsideandattemptedtopulltheskipperoutofthewater.Trimmers1and2remainedonthestarboardside;theyleantacrossthespinnakerpoleandhauledontheskipper’stether.Theteammanagedtoraisetheskipper’sheadabovewater,buttherewasnoreactionfromhim.Attemptsbythemastmantocleartheskipper’sairwaysandcheckforsignsoflifeprovedverydifficultbecauseoftheobstructinglifejacketbladder.

Asthehelmsmanconcentratedonkeepingtheyachtasuprightandsteadyaspossible,therecoveryteamfoughthardtokeeptheskipper’sheadabovewater.However,astheytired,herepeatedlyslippedunderthesurface.Afterabout8-9minutesoffrustratedeffort,themastmansuggestedusingoneofthespinnakerhalyardstolifttheskipper.Theyattemptedtolocatetheskipper’slifejacketharnesstetherattachmentloop(seeSection1.12.1)butwereunsuccessfulbecauseoftheyacht’smotionandbecausetheskipperwaspartiallyhiddenbytheflareofthebow.Themastman,whowasnowmanagingtherecovery,decidedtoclipthehalyarddirectly to the skipper’s tether (Figure 8).Theskipperwasliftedpartiallyclearofthewaterandwasgrabbedbytherecoveryteamashislifejacketstartedtoslipuphisbody.Theteammanagedtokeeptheskipper’storsoonthedeckandholdontohislegsbut,despitetheirbestefforts,theycouldnotpasshimunderthelowerguardwire.

ThebowmanshoutedtothehelmsmantoturnLion onto a port tack so that the skipperwouldthenbeonthehighsideoftheyachtandsoaidhisrecovery.At0050,thehelmsmantackedtheyachtand,atthesametime,hestartedtheengine.

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Figure 8: Pictorial interpretation of the spinnaker halyard connected to the skipper’s tether

Skipper’s tether

Spinnaker halyard

Figure 7:Approximatepathbelievedtohavebeentakenbytheskipperwhenfallingoverboard

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Atabout0052,theskipperwasrecoveredtothedeck.Thefinaleffortandloadonthehalyardpulledthelifejacketupandoverhishead.However,therecoveryteammanagedtoholdontotheskipper’sclothingtopreventhimfromfallingoverboardagain.

1.3.4 Post-recovery actions

Themastman(theconsultantcardiologist)immediatelyexaminedtheskipper,buthedetectednosignsoflifeanddeterminedthattheskipperhaddied.Toavoidthetraumaassociatedwithtakingtheskipperintothecockpitorcabin,itwasdecidedtosecurehimtotheportguardrailsandstanchions.Afterdoingso,therecoveryteammadetheirwaybacktothecabinwherethebowman(theskipper’sson)wascomforted.Themastmanremainedwiththeskipperforashorttimetocheckonhissecuritybeforereturningtothecabintocheckonthewell-beingoftheskipper’sson.

Thehelmsmanhadbynowassumedoverallchargeoftheyacht,andthecrewrecognisedandacceptedthis.At0108,thehelmsmaninstructedthenavigatortoconfirmtoSolentCGthattheskipperhadbeenrecoveredbutwasnotbreathing.AtthesametimethemainsailandNo.3genoawerelowered.At0021,Lion wassetonanorth-westerlyheadingtowardsTheSolent.At0127,rescuehelicopterR104arrivedonscene,andvariousoptionstorecovertheskipperwereconsidered.Inviewofthepoorweatherconditions,andconfirmationbythemastman(consultantcardiologist)thattheskipperhadpassedaway,itwasdecidednottoattempttorecovertheskipper’sbodyfromtheyachtand,at0145,SolentCGreleasedthehelicopterfromthescene.

LionmotoredtowardsPortsmouthfollowingagreementwithSolentCGandtheQueen’sHarbourMasterthatshecouldproceedtoasecureberthinPortsmouthNaval Base.

At0238,BembridgeRNLIlifeboatmetLion. At 0436, Lion’sfuellevelwaslow,and she wastakenundertow.Atthesametimeacrewmanwastransferredtotheyachttoprovidesupportandtotakeoverthehelm.At0530,thetowwasreleasedand Lion wasmanoeuvredintoPortsmouthNavalBase.At0550,shewassecuredalongside.OfficersfromHampshireConstabularyattendedtheyachtandtheskipper’sbodywasremoved.

MarineAccidentInvestigationBranch(MAIB)inspectorsattendedLion at 0900 on 18June2011.

Thesubsequentpostmortemdeterminedthattheskipperhaddrowned.

1.4 ENVIRONMENTAL CONDITIONS

Atthetimeoftheaccident,thetidalstreamwassettingeasterlyat0.8knotandtheseatemperaturewas15ºC.Therewasafullmoonbuttheskywasveryovercast.

TheenvironmentalconditionsdeterioratedasLion proceeded through The Solent andbeganracing(describedindetailatSection1.3).Lickety Split, a Grand Soleil 40yacht,wasequippedwithacomprehensiveweatherdatacollectionsuite.Atthetimeoftheaccident,Lickety Splitwaswithin1mileofLion andrecordedthewinddirectionas264ºandwindspeedas34.5knots.Anothernearbyyacht,Keronimo, reportedsteep3-4mhighseasinthevicinityoftheaccident.

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1.5 YACHT LION’S TRACK

Lion’scombinedAutomaticIdentificationSystem(AIS)andGPStracksuptotheaccidentandthereturnlegtoPortsmouthareatFigure 2.ThefigurealsoshowstheAIS track for Lickety Split.

AmoredetailedAIStrackforLion, showingthespecificstagesoftheaccidentandactions taken, is at Figure 6.

1.6 OWNERSHIP AND USAGE

1.6.1 Ownership

Lion wasbuiltin2000forcommercialuse,andwaspurchasedsecond-handon5January2007bytheskipperandtwobusinesspartners.OwnershipwaslaterpassedtotheskipperwhenLionYachtCharterLimitedwasestablished.

1.6.2 Usage

Theskipper/ownerusedtheyachtforprivatesailingandasaskipperedcharteryachtoperatingundertheLionYachtCharterLimitedbanner.Healsooffered Lion forbareboatcharter,withoutaskipper.

1.6.3 Fundingarrangementsforcompetinginthe2011FastnetRace

Theskipperandcrewagreedtosharethecostsoftheirentryinthe2011FastnetRace,whichwasincommonwithanumberofotherorganisations.Thecrewhadbeenassembledby“wordofmouth”andbyadvertisingontheRORCwebsiteforaprogrammethatincludedatrainingweekend,competinginthreeofRORC’sFastnetRace qualifying offshore races, and the Fastnet Race itself.

1.7 THE INTERNATIONAL SAILING FEDERATION

TheInternationalSailingFederation(ISAF)istheworldgoverningbodyforthesportofsailing.Assuch,ISAFisresponsibleforpromotionofthesportinternationally,developingtheRacingRulesofSailingforallsailingcompetitions,andthetrainingofraceofficials.

ISAF currently consists of 137membernations,whoareitsprincipalmembersandresponsibleforthedecision-makingthatgovernsyachtracingactivityworld-wide.

1.8 ROYAL OCEAN RACING CLUB

TheOceanRacingClubwasestablishedin1925immediatelyfollowingthefirstFastnetRace.TheClubreceiveditsroyalcharterin1931andbecametheRoyalOceanRacingClub.TheClubcomprisesapproximately3,300membersfrom54different countries.

RORCorganizesandpromotesoffshoreracingactivities,includingracemanagementandthedevelopmentandadministrationofratingrulesforracingyachtsaroundtheworld.Italsocontributesinadvancingrelatedstandards,particularlywithregardtosafetyissues.

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1.9 REGULATIONS

1.9.1 TheSmallCommercialVesselandPilotBoatCodeofPractice

Whenundertakingcommercialactivities,Lion wasrequiredtocomplywiththeMaritimeandCoastguardAgency’s(MCA)SmallCommercialVesselandPilotBoatCodeofPractice(SCVCode).Plymouth-basedMecalLtd(Mecal)actedastheMCA’s Certifying Authority and a Mecal surveyor carried out the related surveys on Lion.

LionwascertifiedasanMCACategory2vessel,whichpermittedhertooperateupto60milesfromasafehaven,carryingupto10persons,orupto12iftheywereonboardforlessthan24hours.

Section28.1oftheSCVCodeprovidesforvesselsoperatingunderracerulestobeexemptfromcomplyingwiththecode.Thereferencestates:

“A coded vessel chartered or operated commercially, for the purpose of racing need not comply with the provisions of the Code whilst racing, or whilst in passage directly to or from a race, provided that the vessel complies with the following:

1. It complies with the racing rule provisions of either the International Sailing Federation (ISAF) or the Union Internationale Motonautique (UIM)…” [sic]

Mecal carried out a post-accident Occasional Survey of Lionon6July2011.Anumberofdeficiencieswerenoted,someofwhichwerecausedbytheaccidentandothersthatwerepre-existing.Noneofthedeficienciescontributedtotheaccident,nor did they affect the recovery of the skipper.

1.9.2 ISAF Offshore Special Regulations

Whilecompetinginoffshoreraces,Lion wasrequiredtocomplywithISAF’sOSRfor2010-2011asinvokedbytheorganisingauthority.TheOSRcoversbothmonohullsandmultihullsracinginCategory0-trans-oceanicraces,throughtoCategory6-inshore racing.

TheOSRspecifiedmandatoryandpermissiverequirementscoveringstructure,stability,fixedandportableequipment,personalequipmentandtraining.TheappendicesincludedguidanceondealingwithamanoverboardsituationandamodelforanOffshorePersonalSurvivalTrainingCourse.

ProposalsforchangestotheOSRaremadeprimarilybytheISAFMemberNationalAuthorities(MNA);inthecaseoftheUK,theMNAistheRoyalYachtingAssociation(RYA).However,intheUK,RORCisrecognisedasthemostknowledgeablebodywithregardstotheOSRmatters,andisinfluentialinthedeliveryofchangeproposalsbytheRYA.

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1.9.3 RORC Notice of Race 2011

AllyachtscompetinginRORC’s2011raceeventshadtocomplywiththerequirementslaidoutintheRORCNoticeofRace2011.TheserequirementsgenerallymirroredthoseintheISAF’sOSRbutRORCalsoimposedadditionalprescriptions,someofwhichwereracespecific.

TodemonstratecompliancewithbothISAF’sOSRandRORC’sadditionalprescriptions,ownerswererequiredtosubmittoRORCacompleted“RoyalOceanRacingClubISAFOSRChecklist2011”.

ThesubmittedchecklistforLion, dated 19 May 2011 (Annex D),hadnodeficienciesnotedandremainedvalidfortheentire2011season.

BothISAF’sOSRandtheRORCNoticeofRace2011emphasised:

“The responsibility for a boat’s decision to participate in a race or to continue racing is hers alone”.

Thereferencesgoontostatethat:

“The safety of a yacht and her crew is the sole and inescapable responsibility of the Person in Charge…”

1.10 REFLEX 38 YACHT LION - DESCRIPTION

1.10.1 General

TheReflex38yachtwasdesignedbyChristianStimpsonandbuiltbyHarleyRaceboats.BothcompanieswerebasedatCowes,IsleofWight.

In 2011, LionwasfittedwithaType“B”AIStransponderasrecommendedforISAFCategory 3 races and as required for Category 0, 1 and 2 races.

1.10.2 Deck layout

Lion wasa9/10fractionalriggedsloopfittedwithakeelsteppedmastanddiscontinuousrodrigging.Atwingroovefoilfacilitatedconcurrenthoistingandloweringofthegenoasduringsailchanges.

Whennotinuse,theinboardendofthespinnakerpolewassecuredtothemastandtheoutboardendwaslooselystowedbypassingitbetweenthepulpitstanchionsonthestarboardside.Itwasnotusualpracticetosecuretheforwardendofthepole.Thelargestgapbetweenthebottomofthespinnakerpoleandthecoachroofandforedeckwas290mm.

Theportandstarboardwebbingjacklineswereindividuallysecuredtothetransomaftandtoaforwardcommondeckfittingpositionedjustaftofthecleatontheforedeck.Oninspection,followingtheaccident,thejacklinesandfasteningswerefoundtobeingoodcondition.

ThedecklayoutisshownatFigure 9.

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1.10.3Stanchions,guardwiresandlacing

Lion’sstainlesssteelverticalguardwirestanchionswere635mmhighandequi-spacedat2.14mintervals.Thespacingbetweenthelowerendoftheangledpulpitstanchiontothefirstverticalguardwirestanchionwas1.58m.Twostainlesssteelguardwireswerefitted.Thespacingfromthedecktothelowerguardwirewas320mm4,andfromthelowertotheupperguardwire,was290mm.

4 ThestanchionandguardwiredimensionscompliedwiththeISAFOSRsandSCVCode.

Figure 9: Deck layout

Forwardcentreline

cleat

Guardwirelacing

Portandstarboardjacklines

Spinnaker pole

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Acriss-crosscombinationoflight“bungy”lineandbraidedcordagelacingwasusedtohelppreventsailsfromfallingoverboard.Thelacingwasfittedoneachsidefromthedecktotheupperguardwirebetweenthepulpitafterstanchionandthefirstverticalguardwirestanchion,andfromthedecktothelowerguardwirebetweenthefirstandsecondverticalguardwirestanchions.

Thestanchion,guardwireandlacingarrangementsareshownatFigure 10.

1.10.4Sailwardrobe

Yacht Lion’ssailwardrobecomprisedthemainsail,Nos1,2and3genoas,astormjib,0.6ozand1.5ozspinnakersandatri-sail.

ThegapbetweenthefootoftheNo.3genoa,thesailinuseatthetimeoftheaccident,andthedeckwas295mm(Figure 11).

1.11 SKIPPER’S CLOTHING

Overhisunderclothing,theskipperworehighqualityMustoMPXracesalopettesandjacket.ThesalopettesincorporatedaVelcro-fastenedknifepouchwithlanyard.Followingtheaccident,theknifewasfoundtobestillinthepouch.

TheskipperalsoworeMustoHPXraceboots.Thesoleswere“razorcut”,thegroovesofwhichopenedupwhenthefootflexedtoprovidefirmtraction.Alltheclothingwasfoundtobeingoodcondition.

1.12 LIFEJACKETS

Therewere14RemployCommodore,150newton,manually-inflatedlifejacketsonboard,whichcompliedwiththeRORCNoticeofRace2011requirements.

1.12.1 Skipper’s lifejacket

TheskipperworehisownSpinlockDeckvest150ProSensorlifejacket.Thelifejacketwasoftheauto5andmanualinflationtypewithanintegralsafetyharness.ItwasmanufacturedinMay2008;thelifejacket’sintegralsafetyharnesscompliedwithEuropeanNorm(EN)1095/InternationalOrganizationforStandardization (ISO)12401,andthelifejacketcompliedwithEN396/ISO12402-3.

Thelifejacketharnesswasfittedwithindividuallyadjustable,contouredthighstrapswithside-releasebucklefasteners.Thestrapsweredesignedtohelppreventthelifejacket,wheninflated,from“ridingup”thetorsoofapersoninthewater.

Followingtheaccidentitwasnotedthatthethighstrapsidereleasebuckleswereeasily unclipped under straight load tension, and especially so under rotational load. Straightpullloadtestsshowedthattheleftandrightthighstrapbucklesreleasedwhenaloadof20kilogram-force(kgf)and40kgfwasappliedrespectively.Itisunderstoodfromthelifejacketmanufacturerthatthebucklesshouldwithstanda50kgfloadbeforeunfastening.

5 Thelifejacketwasdesignedtoauto-inflatewhentheinflationsensorcameincontactwithwater.

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“Bungy”lacing

1.58m290mm

320mm

Figure 10: Stanchion,guardwireandlacingarrangements

295mm

No.3 genoa

Figure 11: GapbetweenthefootofNo.3genoaandthedeck

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A25cmfibreliftingloopwasattachedtotheright-handsideofthelifejackettoassistwiththemanualrecoveryofapersonfromthewater.TheloopcompliedwiththerequirementsofISO12402-9andwasload-testedto3200N(326kg)inaccordancewithSection5.5-StrengthofENISO12402-3.Theloopwascontainedwithinthelifejacketvaliseandwasonlyexposedoncethelifejacketwasinflatedorthevalisewasmanuallyunzipped.Aseparatehigh-tensilefibreloopwithahigh-visibilitybarwasattachedtothefrontoftheharnessfortether/safetylineattachment.

Oninspectionfollowingtheaccident,thelifejacket,harnessandthighstrapswerefoundtobeingoodconditionwithnoobviousdamagetotheircomponents.ThearrangementisshownatFigures 12 and 13.

Lifting loop

Hightensilefibre tether connection point

Figure 12: Skipper’s Spinlock Deckvest 150 Pro Sensor lifejacket, harness and thigh straps

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1.12.2ISAF’sOSR-lifejacketharnesscrotch/thighstraprequirementsandrecommendations

Section5.01oftheOSRdealswithlifejacketrequirementsandrecommendations.

Sub-section5.01.1.bstates:

“Each crew member shall have a lifejacket as follows:

...Crotch straps or thigh straps together with related fittings and fixtures should6 be strong enough to lift the wearer from the water”.

Section5.02.5reiteratesthecommentmadeatSub-section5.01.1.baboveregardingcrotchstrapsetc,butadds:

“It is strongly recommended that:-

A harness should be fitted with a crotch strap or thigh straps. Crotch straps or thigh straps together with related fittings and fixtures should be strong enough to lift the wearer from the water”.

Inrecognitionthatsafetyharnessesarenotdesignedtowithstandthedynamicloadsassociatedwithtowingapersoninthewater,Section5.02.6oftheRegulationsprovidesthefollowingwarning:

6 TheRegulationsdefinetheterm“shall”asmandatoryand“should”aspermissive.

Figure 13:SpinlockDeckvest150ProSensorlifejacketthighstrapsidereleasebuckles

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“Warning - a safety harness is not designed to tow a person in the water and it is important that a harness is used to minimise or eliminate the risk of a person’s torso becoming immersed in water outside the boat. The diligent use of a properly adjusted safety harness is regarded as by far the most effective way of preventing man overboard incidents”.

Sub-section5.02.5.ehighlightsthatcrewmembersshouldadjusttheirharnessesbeforearace,andretainthatharnessforthedurationoftherace.

1.12.3 ISAF’s Crotch Strap Working Party

In2008,theISAFSpecialRegulationsSub-CommitteeestablishedtheCrotchStrapWorkingParty(CSWP).TheinitialpurposeoftheCSWPwastoreviewanydeficienciesinthelifejacketharnesscrotchandthighstrapsexperiencedduringthe1998SydneytoHobartRace7andtodeterminerequirementsforinclusionintheOSRs.ThoserequirementsarepromulgatedatOSRSub-sections5.01.1.bandSection 5.02.5.

1.13 TETHERS

1.13.1 General

Webbingtethersarecommonlyfittedwithspringsnaphooksatbothends,oneofwhichisclippedtoanindividual’ssafetyharness.Theotherspringhookcanbeconnectedtoajacklineorothersuitablestrongpointonavessel.Thepurposeoftheharnessandassociatedtetheristopreventapersongoingoverboard,orintheeventofapersongoingoverboardtoensuretheyremainattachedtothevessel.Thetetherisofparticularimportancewhencrewmembersaremovingaboutthevesselorwhenworkinginavulnerable,exposedpositionsuchastheforedeck.

Therearetwomaintypesoftether:thetwo-hookandthethree-hookversions.Thethree-hooktetherhasanadditional,shorttether,completewithhook,stitchedtothemaintetheratapproximatelythemid-point.TheconfigurationsareatFigures 14 and 15 respectively.

1.13.2 ISAF’sOSRtetherrequirements

Section5.02.1ofISAF’sOSRrequiredallcrewmemberstobeprovidedwithatetherofnotmorethan2minlength.TethersweretocomplywithISO1401orEN1095 standards.

Section5.02.2alsorequiredthat:

“At least 30% of the crew shall each, in addition to the above (Regulation 5.02.1) be provided with:-

a safety line not more than 1m long, or

a mid-point snaphook on a 2m safety line”.

Lion compliedwiththeaboverequirements8.

7 Alifejacketwaspulledfromacrewmemberduringhisrecoveryafterhefelloverboardfromacompetingyacht.8 Threeofthelongsafetytethers(1.8mlong)werefittedwithmid-pointsnaphooks.

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1.13.3 RYA guidance

RYA’sSeaSurvivalHandbookdiscussestheuseoftethersatChapter6-MOBPrevention.Thepublicationhighlightsthebenefitofusingathree-hooktetherasbeingabletofitaclipbeforeremovingoneofthem.Itdoesnotidentifythepurposeof the short tether option.

1.14 RE-ENACTMENT TRIAL - JACKLINES AND TETHERS

Are-enactmenttrialwascarriedouttodeterminewhethertheskippercouldhavefallenoverboardontheportsideofLion ifhewasusingeitheralongorshorttetherwhenclippedto:

• theportjackline;or

• thestarboardjacklinewiththetetherpassingunderoroverthespinnakerpole.

ThetrialwascarriedoutatShamrockQuayinSouthampton.Theyachtwasuprightandthefreeboardwas1.3m.

Bothjacklinesweresubjectedtodeflectionteststoreplicatetheirdisplacementunderload.Aloadof100kgwasinitiallyappliedtorepresenttheskipper’sbodymass.Theportjacklinewasdisplacedby360mmandthestarboardby345mm.

Figure 14: Two-hooktether

Figure 15: Three-hook tether

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Anadditionalloadof20kgwasthenappliedtorepresentthemassoftheskipper’swater-loggedclothingandthedynamiceffectoftheyacht’sspeedthroughthewater.Theportjacklinedisplacedby380mmandthestarboardoneby360mm.

Whenathree-hooktetherwasconnectedtothedeflectedportjackline,thelongandshorttethersextended1.2mand500mmovertheportdeckedgerespectively(Figure 16).

Whenthesamethree-hooktetherwasconnectedtothestarboardjacklineandpassedunderthespinnakerpole,thelongtetherextended450mmovertheportdeckedge.Whenpassedoverthespinnakerpoleitextended250mmovertheportdeck edge (Figure 17 and 18).Inbothcasestheshorttetherhookremainedwellclear of the port deck edge.

Port jacklines

Short length tetherhook(800mm)

Full length tetherhook(1.8m)

Figure 16: Three-hook tether connected to the port jackline

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Starboardjacklines

Short length tetherhook(800mm)

Full length tetherhook(1.8m)

Figure 17: Three-hooktetherconnectedtothestarboardjacklineandpassingunderthespinnaker pole

Spinnaker pole

Short length tetherhook(800mm)

Full length tetherhook(1.8m)

Jacklinedisplacedby380mm

Figure 18: Three-hooktetherconnectedtothestarboardjacklineandpassingoverthespinnaker pole

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1.15 GUIDANCE ON SAFETY BRIEFINGS

On16July2007,theskippercompletedtheRYA/ISAFOffshoreSafetyCourseasrequiredbyISAFOSR6.019.Session1ofthecourseemphasisedtheimportanceofa“safetyethos”.Italsocoveredtheimportanceofthecrewbriefingwhichshouldincludesafetyequipment,stowagedetails,emergencyproceduresandotherresponsibilitiesincasetheskipperandkeycrewmembersareincapacitated.

Annex7-SkipperedCharter-SafetyBriefing,oftheSCVCodediscussesthesafetyitemswhichshouldbecoveredduringthebriefing.Theseincludetheprocedurestobefollowedinanemergencyandthelocationofsafetyequipment.Annex7alsorequiredtheskippertobriefatleastoneotherpersonwhowouldbesailingonthevoyageonawiderangeofsafetyissues,including:

“Procedures for the recovery of a person from the sea”.

Lion’sSafetyTrainingManual,whichwasheldonboard,providedalistoftopicsthatshouldbecoveredduringthe“SafetyBrief”(Annex E).Thisincluded:locationofharnesses,whentheyweretobeworn,andclippingonpoints.Thebriefingrequirementalsoincluded“ActioninCaseofaManOverboard”.

1.16 CREW EXPERIENCE

1.16.1 Skipper

ChristopherReddishwas47yearsofageandthroughoutmostofhisadultlifehadbeeninvolvedwithleisuresailingandoffshoreracing.HehadregularlycompetedintheFastnetRace,initiallyin2003and2005ascrew,in2007asmate,andfinallyin2009 as the skipper of Lion.

Amongothersailingqualifications,theskipperwasawardedaCertificateofCompetence(CoC),RYA/MCAYachtmasterOffshorein2005.

1.16.2Crew

ThehelmsmanheldaCoC,RYA/MCAYachtmasterOceanqualificationandhad23,000milessailingexperience.Therestofthecrewhadconsiderableyachtingexperience,andvariouslyheldDayandCoastalSkipper,FirstAidandSeaSurvivalcoursequalifications.

1.16.3 Training

Theskipperarrangedatrainingweekendatseaduring6-8May2011whichformedpartoftheFastnetRacepackage.Withtheexceptionofthehelmsman,allofthecrewattended,butnotallatthesametime.Thetrainingcentredonsailmanagement,boat-handingandincludedonemanoverboarddrill.

9 Thereferencerequiresthattwocrewmembers,includingtheskipper,aretohavecompletedtheOffshoreSafetyCoursewithinthepast5years.

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1.17 MAN OVERBOARD ISSUES

1.17.1 RYA MOB recovery procedure guidance

TheRYA’scoursesandassociateddocumentationcoverproceduresfortherecoveryofanMOB.TheCompetentCrewcoursefocusesonthecrews’actions,sotheybecomefamiliarwithdeployingequipmentandknowwhattoexpectshouldtheemergencyoccur.Optionsforrecoveryfromthewaterarediscussed,includinguseof stern ladders and halyards.

DaySkipperPracticalCoursestudentsbecomemoreinvolvedinthedecision-makingprocess,whichincludespractisingreturningtoandfindinganMOB.Thereismoreemphasisontheskipperhavingarecoveryplanandensuringthecrewunderstandtheplan.Pages54and55oftheDaySkipperPracticalCoursenotesdescribetheMOBprocedures(Annex F).

TheYachtmasterexaminationsyllabusalsorequirescandidatestobeproficientatrecovering an MOB.

TheAutumn2011editionoftheRYAInstructors’magazine“Wavelength”carriedanarticle entitled “What’s the Point of MOB Drills?” (Annex G). The article highlighted the need for realistic training and preparation.

AdditionalinformationiscontainedintheRYA’sSeaSurvivalHandbook(Annex H), whichincludesrecoveryoptionsandsupportstheRYASeaSurvivalandRYA/ISAFOffshore Safety Courses.

1.17.2 ISAF MOB guidance

ISAF’sproceduralMOBguidanceiscontainedinAppendixD of the OSR 2010-2011 (Annex I).Thereferenceincludesoptionsforrecoveringthepersononboardthevessel.

AppendixG(Annex J) of the OSR 2010-2011, Session 6 of the Model Training CourseOffshorePersonalSurvival,dealswithMOBpreventionandrecovery.

TheOSRalsorecognisetheimportanceofroutinetrainingonboard.Section6.04.1states:

“It is recommended that crews should practice safety routines at reasonable intervals including the drill for man-overboard recovery”.

NoneofISAF’sMOBprocedures/guidanceexplainshowtodealwithaconscious/unconsciousMOBwhoisstillconnectedtothevessel.

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1.17.3 Lion’sSafetyTrainingManual

AppendixB3ofLion’s Safety Training Manual (Annex K) detailed procedures for dealingwithanMOBsituation.TheguidanceincludedthefollowingshortparagraphtodealwithanMOBwhoisstillconnectedtothevessel:

“If someone goes overboard, follow this standard procedure:

• If the person is still attached to vessel, stop engines and recover them using lifeline/harness or other recovery device;

• Throw lifebuoy immediately;

• Raise the alarm by shouting “MAN OVERBOARD”. 

1.17.4 MOBrecoveryequipment

Section22.8oftheSCVCode-RecoveryofPersonsfromtheWater-requires:

“An overside boarding ladder or scrambling net which extends from the weather deck to at least 600mm below the operational waterline, or other means to aid the recovery of an unconscious person from the water ...”.

AlthoughAppendixDoftheOSRdiscussesequipmentandmethodstorecovera MOB (Annex I); it does not specify the need for any dedicated MOB recovery equipmenttobecarried.However,RORChasaddedthefollowingprescriptiontoRegulation4.24-HeavingLine:

“The RORC recommends that yachts should carry a lifting strop to clip to a halyard, to aid MOB recovery from the water back onto the deck. The lifting strop or “helicopter strop” should fit under the arms and have a toggle to help keep the casualty from slipping out when lifted…”

Lionwasequippedwithavalise-contained“Sowester”manoverboardrecoveryladder. The vessel also carried a single helicopter recovery strop.

1.18 SIMILAR ACCIDENTS

TheMAIB’saccidentdatabaserecordsmanyinstancesofpersonsfallingoverboardfromyachtswhiletetheredanduntethered.Fortunately,mostresultedinthepersonbeingsafelyrecoveredbecausetherewereothercrewonboard,andthepersonwasconscious,sowereabletoassistintheirownrecovery.Thefollowingaccidentsare relevant to this investigation.

1.18.1 UKregisteredsmallcommercialsailingvessel-November2003

An11.3myacht,beingusedforanintensive13-weekYachtmastertrainingcourse,wasonpassagewhentheforecastedforce4windsincreasedtogaleforce.Thedesignatedskipperwasincapacitatedthroughsea-sickness,andthemostseniorstudenttookover.Theactingskipperwasonthehelmandconnectedbyhistetherwhenhewaswashedoverboardastheyachtwasnearingaportofrefuge.The

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crewwereunabletorecovertheMOBandsubsequentwavessurfedtheyachtontothebeach,whereshebrokeup.Theactingskippersufferedcrackedribs;othercrewmemberswereunharmed.

1.18.2UKregisteredsmallcommercialsailingvessel-November2007

Fourcrewmemberswentforwardtocarryoutasailchange.Theywereconnectedtotheyachtbylongtethersandwereallwearinglifejackets.Astheheadsailwasbeingsecured,itfellintothewater.Duringitsrecovery,alargewavecarriedoneofthecrewoverthesideandlefthimdanglingwaistdeepinthewater.TheyachtwashovetobuttheremainingcrewwereunabletoheavetheMOBbackonboard.Ashorttimelater,theMOBslippedfromhislifejacketandfellintothewater.Fortunately,hewasrecoveredunharmed.Thelifejacketwaiststrapandcrotchstrapwerefoundtohavereleasedduringtherecoveryattempt.

1.18.3Pleasurecraft-non-commercialyacht-February2011

A10myachtwasonadeliveryvoyageandwasapproachingitsplanneddestinationportusingitsenginebecauseofverylightwinds.Thetwocrewmenwerewearinglifejacketsandweretetheredtotheyacht,buttheskipperwaswearingneitheralifejacketnoratether.Duringtheentryintoharbour,theyachtadoptedaconsiderableheelduetotheeffectsofaverylargeswellontheportquarter.Theskipperandcrewwerewashedoverboard.Thecrewwereunabletogetthemselvesbackonboardandtheskipperdriftedawayfromtheyacht.Theyachtbrokeupontherocksand,althoughtheskippersurvived,thetwocrewmendied.Hadtheskipperandcrewwornshortertethers,itisprobabletheywouldallhaveremainedonboard.

1.18.4 Pleasurecraft-non-commercialyacht-May2011

Theskipperofa32footContessayachtwaswearingalifejacketandtetherashewasfurlingthemainsailinpreparationforenteringharbour.Waveswerebreakingagainstthemarinabreakwaterinthegaleforceconditionsduringwhichtheskipperwaswashedoverboard.Thecrewwereunabletobringtheskipperinboard,andbroadcasta“Mayday”.Theattendinglifeboatcrewrecoveredtheskipper,whowastakentohospitalforobservation.

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SECTION 1

SECTION 2 - ANALYSIS

2.1 AIM

Thepurposeoftheanalysisistodeterminethecontributorycausesandcircumstancesoftheaccidentasabasisformakingrecommendationstopreventsimilaraccidentsoccurringinthefuture.

2.2 ACCIDENT OVERVIEW

2.2.1 General

Becausetherewerenoeyewitnessestotheskippergoingoverboard,theactualcauseforhimdoingsoisamatterofspeculation.However,theinvestigationidentifiedthemostprobablecauseandanumberofimportantcontributoryfactors.

As Lion approachedtheOwersbuoy,andwiththewindstrengtheningandveering,thechangeofsailfromtheNo.1genoatotheNo.3genoainanticipationoftheincreasedapparentwindafterroundingthebuoywasappropriate.However,thesubsequentsecuringoftheNo.1genoatotheportstanchionsandguardwiresstartedachainofeventsthatledtotheskippergoingoverboard.

Althoughthecrewreactedimmediatelytotheemergency,theywereunabletorecovertheskipperbackonboarduntilafterhehaddrowned.

2.2.2 Delegation

Lion’s skipper wasreportedtobeahighlycompetitiveperson,wholedbyexample.AlthoughhehadoptionstodelegatetheNo.1genoarecoverytoothercrewmembers,itwastypicalthatinthedifficultweatherconditionsheoptedtoleadtherecoveryhimself.

2.2.3 Crewobservationsandalarm

Theskipperwasseentohaveused,andwasrecoveredwearinga1.8m-longtether.Duringthesailrecovery,hefollowedbestpracticebyclippingontothejacklines.ThelasttimetheskipperwasseenonboardwaswhenhelaidonthedecktoreleasethetackoftheNo.1genoafromwhateverwaspreventingitfrombeingfedaftintothecockpit.Noneofthesailrecoveryteambelievedthathewasindifficultyatanytime.

Whilethesailwasbeingdraggedalongthedecktherecoveryteamwerefacingaftandhadnovisibilityoftheskipper,whowasbehindthem.Itisthereforeunknowniftheskipperwasstanding,crouchingorcrawlingaft.Bythetimethesailrecoveryteamnoticedtheskipper’slifejacketstrobelightwasflashing,hehadprobablybeeninthewaterfornolongerthan1minute.Itispossiblethattheskippershoutedanalarmashewentoverboard.However,therewasconsiderablewindandseanoise,whichcouldhaveeasilypreventedanyonefromhearingashout.

2.2.4 Footwear

Thesolesoftheskipper’sbootswereingoodconditionandwerespecificallydesignedformaximumtractiononwetyachtdecks.However,thetractionwouldhavebeenreducedbecausetheforwarddeckwasintermittentlyawashfromoccasionalseas,andthismighthavecontributedtohispossiblylosinghisfooting.

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2.2.5 Evidenceofthepathtakenbytheskipper

Thereisnodoubtthattheskipperwentoverboardontheportside.However,noneofthecrewcouldrecallifhistetherfromthestarboardjacklinehadpassedoverorunderthespinnakerpole.Aperson,undermomentum,couldhavepassedthroughthe290mmgapunderthepole,whichcouldhavealsoliftedasitwashingedtothemast.However,membersoftherecoveryteamdorecallleaningoverthespinnakerpoletopullontheskipper’stether.Hadthetetherpassedunderthepole,theweightoftheskipperwouldhaveforcedthetethertothedeckandthecrewwouldhavesuffereddamagetotheirhandsastheytriedtogaingriponthetetherwithitpressedagainstthedeck.Inaddition,hadtheskipperpassedunderthepole,itwouldhaveliftedashewashauledinboardbythespinnakerhalyard,whichwasconnectedtohis tether. There is no evidence of this.

Alltheevidenceconfirmsthattheskipper’stetherpassedoverthespinnakerpole.Toachievethis,theskippermusthavebeeneitherstanding,oratleastbeeninasemi-crouchedposition,otherwisehewouldhavepassedunderthespinnakerpole,ashemovedtoport.

2.2.6 Conclusion

Thepost-accidentre-enactmenttrialprovedthatwhenconnectedtothestarboardjackline,theskipper’s1.8mtetherlengthallowedhimtopassoverthespinnakerpole,andthroughthe295mmgapbetweenthefootoftheNo.3genoaandthedeck.Hethenpassedthroughthe320mmgapbetweenthedeckandthelowerguardwireandbetweenthepulpitandfirstverticalstanchion.Thelight“bungy”lineandbraidedcordagefittedbetweenthedeckandguardwirewerenotstrongenoughtopreventhimfromgoingoverboard.

Intheabsenceofanymedicalconditionthatmighthavecausedtheskippertofalloverboard,itisconcludedthatheprobablyeitherlosthisfootingorwassweptawaybyacombinationoftheyacht’sheeltoport,theyacht’smotion,andseasbeingshipped over the foredeck.

2.3 SECURING THE NO.1 GENOA ON DECK

Followingasailchange,itisgoodpracticetoimmediatelystowthereplacedsailbelowdeckunlessitislikelytoberequiredagainverysoonafterthechange.Giventhatthewindstrengthwhenthesailswerechangedwasabove30knots,itwasmostunlikelythattheNo.1genoawouldhavebeenusedagainduringtherace.

Stowingsailsthatarenotinusebelowdeckkeepstheworkingdeckfreeofclutterandeliminatestheriskofhighvaluesailsbeinglostoverboard.Italsoreducestheneedforcrewmemberstospendtimeintheforward,high-riskareaduringhostileweatherandroughseaconditions.However,theskippermayhaveperceivedthatitwassafertohavesecuredtheNo.1genoaondeckintheprevailingcircumstances,given that LionwasabouttoroundOwerslightbuoyandsailupwind.Thiswouldhave increased pitching and angle of heel.

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2.4 CREW’S ACTIONS

Ithasbeencalculatedthat,oncethesailshadbeenreleased,theyachtwouldhavebeentravellingatabout1.5knotsthroughthewater,thisbeingacombinationofforwardmotionandleeway.Evenatthisspeed,thedragontheskipper’sbodywouldhavebeensignificant,causinghistethertopulltightandleadaftfromtheguardwirestanchion.Withtheskipper’stetherconnectedtothestarboardjacklinetheportionofitpassedoutboardwasquiteshort,whicheffectivelypinnedhimclosebytheyacht’ssidesothatasLionheeledhewasrepeatedlythrustunderwater.Withtheskippertrappedinthisway,itwasextremelydifficultforthecrewtopullhimforwardtoapositionwherehecouldberecoveredbackunderthelowerguardwire.Some12minutespassedwhilethecrewtriedvariousmethodsofrecoveringtheskipper,andafurther4minuteselapsedoncehisupperbodywasonboardbeforehewasfinallypulledclearofthewater.Duringthistime,therewasnoobservedreactionfromtheskipper,anditispossiblethathedrownedverysoonafterfallingoverboard.

2.4.1 Post-recovery actions

Oncetheskipperhadbeenfullyrecoveredonboard,themastman(consultantcardiologist)wasunabletodetectanysignsoflife.Heconcluded,duetothelengthoftimetheskipperhadbeeninthewater,muchofitsubmerged,andashehadshownnosignsoflifesincefallingoverboard,thattherewasnoprospectofcardio-pulmonaryresuscitation(CPR)orotherpossibleonboardmedicalinterventionsucceeding.Indeed,heconsideredthatanyattemptatCPRwouldhavecompromisedthesafetyofthecrewbecauseoftheskipper’sexposedpositionandthehostileweatherandseaconditions.

2.5 RECOVERY OPTIONS

AvarietyofproprietyMOBrecoveryequipmentisavailableonthemarket.Theseincludevariationsofabuoyanthelicopterstrop(ascarriedonboardLion)thatisattachedtothevessel;aninflatableraftonwhichacrewmanisplacedtohelprecovertheMOB,firstlyontotheraftandthenontothevessel;andaslingsupportedonaframewhichispassedundertheMOB.Otherequipmentincludesaparbuckledeviceanditsderivatives.TheseitemsofequipmentwouldhavebeendifficulttousebecauseoftheseaconditionsandbecausemostofthemrequiretheassistanceofaconsciousMOB.Also,alltheseitemsofrecoveryequipmenthavethepurposeofreconnectingapersoninthewatertothevessel:noneofthemcompletelyaddresstheproblemofthenrecoveringthatpersonbackonboard.

Inanidealsituation,ifamanoverboardisstillconnectedtothevesselbyatether,thenpullingonthetetherwillbesufficienttoretrievethemonboard.However,unlesstheMOBisconsciousandabletoassist,thiswilltakeconsiderablestrength,thatthecrewmightnothave.OtheroptionstorecoveranunconsciousorincapacitatedMOBarerequired.Theseinclude,usingasparehalyard(usuallyaspinnakerhalyard)whichisclippedtotheliftingloopoftheMOB’slifejacket.Inthiscase,theleadofthetetherundertheguardwirepreventedthecrewfromsimplyliftingtheskipperbackonboard,andanothermeansofrecoverywasrequired.Ultimately,unlesstheskipperwastoberecoveredbackthroughthegapbetweenthedeckandthelowerguardwire,hisweightneededtobetakenbyanothermeans,and his tether released.

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Themastman’sdecisiontoconnectthehalyarddirectlytotheskipper’stetherwasbornoutofnecessitytokeeptheskipper’sheadoutofthewater.Thisprovedtobesuccessful.However,oncethelifejacketliftingloopwasaccessible(Figure 12), a halyardcouldhavebeentakenoutboardoftheguardwires,andconnectedtotheloop.Theskippercouldthenhavebeencarefullymanoeuvredbackoverboardandthenhoistedovertheupperguardrail,whichwouldhaveprovidedamoredirectlift.Alternatively,anadditionallinecouldhavebeenconnectedtotheloopandhecouldthenhavebeentakentothestern,wherethevessel’sfreeboardwasless.Eitheroptionwouldhaveimprovedthecrew’sabilitytorecovertheskipperonboardafterreleasingtheinboardclipofthetether.

2.6 TETHERED MOB PROCEDURES

The survival of a MOB is largely dependent on a rapid recovery, especially in cold,roughweather.Toachievethis,itisimportantthatMOBdrillsareconductedregularlysothatactionsareinstinctiveandthecrewknowwhattherecoveryplanis.Thisaccidentstarklyillustratestheextremedifficultyinrecoveringaheavy,unconsciousMOB,evenwhenfourfitandstrongcrewareinvolved.

2.6.1 Trainingbyprofessionalbodies

MOBprocedurestaughtonseasurvival,boatingandyachtingtrainingcourses,andreferredtoinrelevantdocumentation,relatealmostentirelytoaconsciouspersondriftingawayfromavessel.

WhenpractisingMOBrecoveries,mostRYAtrainingcentresusealifebuoyorfendertosimulatetheMOB.WhilethisisadequateforpractisingmanoeuvringbackalongsidetheMOB,itdoeslittletopreparecrewsformanagingthebulkandweightofarealpersoninaMOBsituation.Thereisconsiderableadvantageinusingdummiestoreplicateascloselyaspossibletheweightandcharacteristicsofanunconsciouscasualtysothat,intherealevent,successismorelikely.

Chapter7ofRYA’sSeaSurvivalHandbook10liststhefollowingstandardactions:

1. Shout‘manoverboard’toalertthecrew.

2. PresstheMOBbuttonontheGPS.

3. Throwalife-buoyanddanbuoytotheMOB.MarktheMOBwithabuoyantsmokeflare.

4. AllocateacrewmembertopointattheMOBinthewater.

5. Send a DSC distress alert and a voice Mayday.

6. Keep pointing. Don’t lose sight of the MOB.

7. Onasailingboat,theskipperwillaskforthejibtobeloweredorfurledandthe engine started.

8. IfpossiblereassuretheMOBbytalkingtothem.

10 2008 edition, reprinted in 2010.

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9. Prepareathrowingline.

10. TheskipperwillbringtheboatalongsidetheMOB,withtheboatpointingintothewindandthepropellerstopped.

11. GetalinearoundtheMOBandgetthemaboard.

However,themosteffectiveactionstakeninaspecificcasewillvarydependingonthecircumstancesprevailingatthetime.Theseinclude:windandseastate,whethertheMOBistetheredoruntetheredandconsciousorunconscious,whetheranengineisavailable,andtheproximityofthevesseltootherassistance.Itisthereforenotpossibletobestrictlyprescriptive.

Inthisparticularcase,theskipperwasattachedtotheyachtandthehelmsmanwasrelieved,becauseheanticipatedthiswouldeasehisrecovery.Hisdecisiontoreducespeedandkeeptheyachtasuprightandsteadyaspossibletoassistwiththerecoverywasunderstandableandreasonableinthecircumstances.

Theenginewasnotstarteduntilabout14minutesaftertheMOBwascalledbecausethehelmsmanwasunsureiftherewereanylinesoverthesidewhichmightfoul the propeller. Checking over the side, starting the engine earlier and leaving the propelleroutofgearwouldhavegiventhehelmsmanimmediateaccesstomotivepower.However,inthiscaseitisunlikelytohavechangedtheoutcomeofthisaccident.

DuringtheRYAInstructor’sCourse,theissueofdealingwithaMOBwhilethepersonisstillattachedtothevesselisbroadlydiscussed.However,itisthenlefttotheindividualinstructor’sdiscretionastohowtoteachthesubjectduringaparticularcourse.

Thepromulgationofthedifficultiesrelatedtothismattermeritwidedistributiontotheleisureyachtingcommunityandthoseinvolvedinhigherriskoffshoreracing.

2.6.2 OnboardMOBtraining

InaccordancewithISAF’sMOBguidance,Lion’screwshouldhaveroutinelypractisedamanoverboardrecoverydrill.

ThecrewonboardLion last practised a MOB drill during the 6-8 May training weekend.However,only50%ofthecrewonboardatthetimeoftheaccidentwereinvolved.Asaresult,thecurrentcrewhadnotworkedasateamforMOBrecoverypurposes,andtherewasnoopportunityotherthanduringthepassagetotheCowesstartlinetodoso.AstheskipperhadnotplannedtoconductaMOBexercisebeforetherace,itwasallthemoreimportantthattheprocedureswerecoveredduringtheskipper’spre-sailingbriefing,buttheywerenot.

ThisaccidentdemonstrateshowdifficultitcanbetorecoveratetheredMOBespeciallyinpoorweatherconditions.Asdiscussedatsection2.6.1thereiscurrently very little professional training covering this scenario. Skippers are encouragedtoconsiderthetetheredMOBsituationwhenbriefingcrewsandhighlighttheimportanceofeffectivecommunicationsbetweenallthoseinvolvedinthe MOB recovery process.

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2.7 GUIDANCE FOR USE OF SHORT TETHERS

Itisusualandgoodpracticetoconnectashorttethertoastrongpointwhenworkinginanexposedpositionwheretheuseofalongtetherwouldallowapersontofalloverboard.

Thereisaneedtobalancetheneedformobilityagainsttheriskoffallingoverboard.Section6.1ofAppendixG(modelOffshorePersonalSurvivalTrainingCourse)toISAF’sOSRprovidesdetailsfor“Manoverboardpreventionandrecovery”.Thereferencerequiresinstructorsto:

“encourage the use of shorter safety line and in particular lines with mid-line clips11 as being most adaptable (highlighting issues with being towed in the water at speed while in a harness and how a shorter line (less than 1m) both aids recovery and reduces the potential risk particularly on high performance boats)”.

Someyachtsmenfeelthattheuseofathree-hooktethererodessafetyinthattheunusedhookpresentsasnagginghazard.Whilethisisrecognised,theavailabilityofbothalongandashorttetherprovidesthewearerwithachoiceofoptionstobestsuitthesituation,andthesparehookcanbetuckedawaytoreducethesnaggingrisk.

Thisaccidentshowsthebenefitsofusingashorttetherwhentherisksoffallingoverboardarehigh.WhiletheRYAPersonalSurvivalTrainingCourseattendeesareadvisedofthis,itwouldbebeneficialtofurtherpromulgatesuchadvicetothewideryachtingcommunity.

Hadtheskipperusedoneoftheshort800mmtetherswhichwereonboard,andhaditbeenclippedtothestarboardjackline,hewouldnothavegoneoverboard.

2.8 INCIDENT MANAGEMENT

Inanemergency,whetheritisafire,floodoramanoverboardsituation,effectiveandco-ordinatedincidentmanagementisoftheutmostimportance.Strongleadership,goodcommunicationsandanunequivocalunderstandingbythecrewofwhoisinchargearekeyfactorstoensuringasuccessfulandsafeoutcome.

2.8.1 Manoverboardmanagement

Lion’sskipperwasaforthright,confidentyachtsmanandthecrewhadnodoubtaboutwhowasincharge.However,oncetheskipperwaslostoverboard,therewasinitiallyalossofdirectionbecauseno-onehadbeennominatedtoreplacehimintheeventofhisincapacitation.Themastman,bydefault,assumedcontroloftherecoveryatthebowwhilethehelmsmanconcentratedoncontrollingtheyacht.Therecoveryteamwerefullyengagedinretrievingtheskipperonboard.Communicationsbetweenthoseinthecockpitandtherecoveryteamatthebowwereverydifficultbecauseofthenoisyenvironment,anditwassometimebeforethehelmsmanandnavigatorhadaproperunderstandingofthesituationforward.ThewhollyunderstandablerequestsfromtheCGforqualityinformationledtofrustrationonboardbecauseneitherthehelmsmannorthenavigatorhadthenecessaryinformation.

11 Thisisanothertermforthethree-hooktetherreferredtoinSection1.13.1

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Oncetheskipperwasrecoveredonboard,thecrewacknowledgedthatthehelmsman,asthemostexperiencedpersononboard,hadassumedtheroleofthepersoninchargei.e.thereplacementskipper.Assuch,thehelmsmanprovidedthedirectionthecrewwerelookingforfollowingthetraumaofrecoveringtheskipper.

2.8.2 Publicationsguidance

Annex7oftheSCVCode-SkipperedCharter-SafetyBriefing,impliesthatapersonisnominatedtotaketheplaceoftheskipperintheeventofhis/herincapacitation.

However,neithertheISAF’sOSRnortheRORC’sNoticeofRace2011requirethenominationofanappropriatepersontotakecontrolofthevesselintheeventoftheskipper’sincapacitation.Thisisanimportantomission,andonewhichshouldbeaddressedfortheoffshoreracingcommunityandbroughttotheattentionofrecreationalyachtsmen/women.

2.9 DECISION TO COMPETE

Offshoreyachtracingisanextreme,challengingsportandcarrieswithitfarhigherrisks than those of leisure sailing.

Oftheinitial110raceentrantsfortheMorganCupRace,38withdrewbeforethestartoftheracebecauseofthepredictedconditions.Therewere72starters,37ofwhichretiredduringtherace;35yachtsfinishedthecourse.

On14Junethenavigatorraisedconcernswiththeskipperaboutthepredictedweatherandthepotentialrisksofcompeting.ISAF’sOSRandtheRORCNoticeofRace2011madeitclearthatthedecisiontoparticipate,ortocontinueintherace,andthesafetyoftheyachtandhercrew,weresolelytheskipper’sresponsibility.Theskipperconsideredthatthecrew’sexperienceandtheyacht’sperformancerendered the yacht safe to race and advised the navigator accordingly.

Despitetheearlyproblemsinmanagingthesails,thecrewcarriedouttheirdutiessatisfactorily.Withtheexceptionofthegeneraldutiescrewman,thecrewhadwide-rangingsailingexperience.Theyachtwascapableoffunctioningsafelyintheconditions,sotheskipper’sdecisiontocompeteintheracewasreasonable.

2.10 LIFEJACKET FITTINGS

2.10.1Purposeandadjustment

Theattachmentlooponthefrontoftheintegratedlifejacketsafetyharnesswaiststrapisdesignedtoattachatether/safetyline.Thewaistcrotchand/orthighstrapsaredesignedtopreventthelifejacketridingupthetorsoofapersoninthewatersothattheoptimumtorsoandheadelevationisachieved.

Theeffectivenessofthelifejacketand,inparticularitsliftingloopformanualrecovery,islargelydependentuponitscorrectadjustment.Acorrectlyadjustedintegratedlifejacketsafetyharnessshouldbecapableofliftingapersonfromthe

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waterusingtheliftingloopwithoutbeingsignificantlydisplaced.Manypublications,includingthoseoftheRYA,RNLI,MCAandlifejacketmanufacturers12 highlight the importanceofcorrectlyadjustingthelifejacketharness,includingcrotch/thighstraps.

ToavoidhavingtorepeatedlyadjustthesecuringstrapstheISAFOSRrecommendthat,onceadjusted,crewmembersshouldkeepthesameharnessforthedurationof the race.

2.10.2Skipper’slifejacketdisplacement

Theskipperhadremovedhislifejacketharnesswhilehewasinthecabin.Whenhearrivedondecktorecoverthesail,thereisnodoubtthathiswaiststrapwasfastened,butno-onewasabletoconfirmifthethighstrapswerefastenedorwhethertheyhadbeentuckedbehindhiswaiststrap.

Whatisknownisthattheskipper’slifejacketbladderwasoverthefrontofhisfacewhenhewasdiscovered.Itisalsoknownthatthecrewdidnotusetheliftinglooptorecovertheskipper,butinsteadoptedtoconnectthehoistinghalyarddirectlytohistether.Whenthelifejacketwasfinallypulledfromhim,thewaiststrapwasstillfastened.Thissuggeststhatthelifejacketmighthavebeendisplacedbytheeffectoftheyacht’sspeedthroughthewaterand/orthatthewaiststraphadnotbeencorrectlyadjusted.Thismayhavebeencompoundedbythehalyardbeingconnectedtothetetherwhichwouldhaveresultedinadifferentangleofpullthanhaditbeenconnectedtotheliftingloop.Thethighstraps,hadtheybeeninitiallyfastened,arelikelytohavebeenreleased(seesection1.12.1)orslackenedwhileinthewaterorwhilebeingrecovered.

2.10.3 Lifting using the lifejacket integrated safety harness

Thereisacommonmisconceptionthatthetether/safetylineattachmentloopofanintegratedlifejacketsafetyharnessisdesignedtoliftapersonfromthewater.Thisisnot the case. The lifejacket lifting loop (Figure 12)istheonlycomponentdesignedandtestedtoliftapersonfromthewater.Thecrewwerefortunatethatthelifejacketwasnotpulledfromtheskipperuntilhehadbeenrecoveredonboard.Ifthishadhappenedduringtheearlystagesoftherecovery,theskippermightwellhavebeenlost.

Thelifejacketmanualprovidedanillustrationtohighlightthattheharnesswasnotdesignedtosupportaperson’sweight.TheSafetyNoticesectionofthemanualstated:

“A deck harness and safety line are intended to prevent the user falling overboard: they do not provide protection against falls from height”.

2.10.4ISAF’sworktodeterminelifejacketharnesscrotch/thighstrapspecifications

ISAF’sOSRSub-section5.01.1.bandSection5.02.5(seeSection1.12.2)containedarequirementandrecommendationrespectively,thatthecrotchandthighstrapsandassociatedfittingsofalifejacketharnessshouldbecapableofliftingapersonfromthewater.However,therearenorelatedISOorENstandardstoguideamanufacturerseekingtocomplywiththisrequirement.

12 TheSpinlockwebsite(www.spinlock.co.uk)alsoprovidedvideoguidanceonadjusting,fittingthighstraps,inflation,inspectingandrepackingthelifejacket.

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In2008,theCSWPwasformedtoresolvethisissue.TheCSWP’sprincipalaimwastopromulgaterecommendedminimumbreakingstrainsforcrotchandthighstraps,includingfastenings,bytheendofMarch2010.However,thedeadline,andarevisedtargetdateofMarch2011,werebothmissedandthestudyhasfallenintoabeyance.

ISAF’sSpecialRegulationsSub-committeemeton8November2010.ItrecognisedthecontinuingdifficultyfacedbytheCSWPandappointedanewchairman.ThisinvestigationidentifiedthatnonewtargetdatehasbeensetfortheCSWPtoreport,althoughISAFhadrecommendedtotheCSWPthataprogrammeoftrialsbeestablishedwiththeultimateaimofdevelopinganISOstandardtosatisfytherequirementfortheharnesscrotchandthighstrapstoliftapersonfromthewater.

TheworkoftheCSWPshouldbeexpeditedtoclarifythattherequirementsofISAFOSRSub-section5.01.1bandSection5.02.5aremeaningfulandachievable,andamendthereferencesasappropriate.

2.11 FATIGUE

Theskipperandcrewhadbeenawakeforsome18hourswhentheaccidentoccurred.Themastandbowmenwentbelowtorestatabout2315andtheskipperfollowedashorttimelater,buttherestperiodwasverybrief.Thehelmsmanwasduetotakerestataboutmidnight,aftertheskipperhadplannedtoreturntothedeck,butasthesituationdevelopedthiswasnotpossible.Althoughhavingspentover5hoursonthehelmthehelmsmanconsideredhimselffullyalertatthetimeofthe accident.

Thereisnodoubtthattheyacht’smotionandtheassociateddifficultyinmovingaboutwouldhavecontributedtothecrew’sgrowingfatigue.Thismighthavehadadetrimentaleffectontheskipperashewasmakinghiswayaftjustbeforegoingoverboard.Thephysicalexertionexperiencedbytherecoveryteamwasconsiderableastheystruggledtobringtheskipperonboard.Thiswasexacerbatedbytheskipperbeingunabletoprovideanyassistance.TheimpactofthisshouldbeconsideredbythosemanaginganMOBrecoverysituation,especiallyiftheMOBisunconscious.

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SECTION 3 - CONCLUSIONS

3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT WHICH HAVE RESULTED IN RECOMMENDATIONS

1. Had Lion’sskipperusedoneoftheavailable800mmtetherswhileclippedontothestarboardjacklinehewouldnothavegoneoverboard.[2.2.6,2.7]

2.  Lion’screwhadextremedifficultyinrecoveringtheskipperonboard.Theirexperienceofmanoverboardsituationsgainedduringtrainingdidnotcovertherecovery of a tethered unconscious person. [2.4, 2.6]

3. When Lion’sskipperwentoverboard,nooneinitiallytookchargeoftheoverallsituation,becauseareplacementhadnotbeennominatedintheeventoftheskipper’sincapacitation.Thishinderedonboardcommunications.NeitherISAF’sOSRnorRORC’sNoticeofRace2011requiressuchnomination.[2.8.1,2.8.2]

3.2 OTHER SAFETY ISSUES IDENTIFIED DURING THE INVESTIGATION WHICH HAVE BEEN ACTIONED

1. Therecoveryofanunconscioustetheredmanoverboardisnotroutinelycarriedoutduringprofessionalyachting-relatedtraining,anddummiesarenotcommonlyusedtosimulatethedifficultiesofdealingwithanunconsciouscasualty.[2.6.1]

2. ISAF’sOSRSub-section5.01.1.bandSection5.02.5respectivelyrequireandrecommendsthatthecrotchandthighstrapsandassociatedfittingsofalifejacketharnessbecapableofliftingapersonfromthewater.However,therearenorelatedISOorENstandardsforamanufacturertocomplywith.[2.10.4]

3. ISAF’sCrotchStrapWorkingParty’sstudyhasfallenlargelyintoabeyance.Ithasmisseddeadlinesindeterminingspecificationsforlifejacketcrotchandthighstraps.TheworkoftheCSWPshouldbeexpeditedtoensuretherequirementsofISAFOSRSubsection5.01.1.band5.02.5aremeaningfulandachievable.[2.10.4]

3.3 OTHER SAFETY ISSUES

1. Theskipper’sdecisiontolashtheNo.1genoaondeckwascontrarytogoodpracticeandrequiredcrewtoaccesstheforwardhighriskareawhenitbrokefree.However,hisdecisionwasprobablybasedonrisk,inthatheperceiveditwassafertosecurethesailondeckratherthantrytotakeitbelowinthesevereconditions.[2.3]

2. Theskipper’slifejacketwaspulledfromhisbodyandoverhisheadduringtherecoveryprocess.Theintegratedlifejacketsafetyharnessmightnothavebeencorrectlyadjustedandtheuseofthetetherloopinsteadoftheliftingloopmayhavecaused the lifejacket harness to “ride up” the skipper’s torso. [2.10.2]

3. Contrary to ISAF’s MOB guidance, Lion’screwatthetimeoftheaccidenthadnotpractisedaMOBdrillasateam.[2.6.2]

4. ContrarytoISAF’sOSRthepre-sailingsafetybriefingonboardLion did not include theactionstobetakeninanemergency(i.e.manoverboard).[2.6.2]

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5.  Lion’senginewasnotstarteduntil14minutesafterthemanoverboardcallduetoaperceivedriskoffoulingthepropellerbylooserunningrigging.Startingitearlierwouldhaveprovidedforgreatermanoeuvringoptions.[2.6.1]

6. Communicationsbetweenthoseinthecockpitandtherecoveryteamatthebowweredifficultbecauseofthenoisyenvironment,anditwassometimebeforethehelmsmanandnavigatorhadaproperunderstandingofthesituationforward.[2.8.1] 

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SECTION 4 - ACTIONS TAKEN

4.1 THE ROYAL OCEAN RACING CLUB

TheRoyalOceanRacingClubproducedapost-accidentreportdated5July2011.Thereportdidnotdrawanyconclusions,ormakeanyrecommendations.

4.2 MECAL LTD

MecalLtdcarriedoutapost-accidentOccasionalSurveyonboardLion on6July2011.

4.3 HM CORONER FOR WEST SUSSEX

HMCoronerforWestSussexheldaninquestintothedeathoftheskipperon24August2011andconcludedthathisdeathwasaccidental.

4.4 THE INTERNATIONAL SAILING FEDERATION

TheInternationalSailingFederationhasamendedsub-sections1.02.1,5.0.1.band5.02.5.boftheOffshoreSpecialRegulations(Annex L).

4.5 THE ROYAL YACHTING ASSOCIATION

TheRoyalYachtingAssociationhas:-

• Incorporatedinformationonthepurposeanduseofashorttetherinthe2012editionoftheRYA’sSeaSurvivalHandbook.

• IncludedMOBasakeytopicattheendofJanuary2012YachtmasterInstructorConferencewithspecificemphasison:

o MOB actions when the casualty is still attached to the vessel

o Use of realistic methods for the teaching of MOB recovery from the water, including the use of realistic MOB dummies.

• HighlightedtheneedformorerepresentativeMOBrecoverytrainingbyRYAinstructors,including,wherepossible,theuseofweightedMOBdummies,intheSeptember2011issueoftheRYAinstructormagazine“Wavelength”.

• IncludedintheJanuary2012issueof“Wavelength”,anarticleontheneedforinstructors on training courses to ensure that MOB recovery is not treated as a “roboticsetpiece”exercise.[sic]

• WrittenanarticlefortheDecember2011editionof“SailingToday”discussingtheneedforskipperstoensurethatoneoftheircrewwasadequatelytrainedtotakecontrolofthevesselintheeventoftheskipperbeingincapacitatedandtoensurethattherestofthecrewwasawareofwhotheresponsiblepersonwouldbe.

• WrittenanarticlefortheSpring2012“RYAMembersMagazine”discussingthe need for sailors to consider unusual MOB situations, such as an MOB remainingclippedon,andhowtodealwiththem.

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SECTION 5  -RECOMMENDATIONS

RoyalOceanRacingClubisrecommendedto:

2012/104 Promulgatethefollowingsafetyissuestotheirrespectivemembershipsandtotheoffshoreracingcommunity:

• Theimportanceofnominatingapersontotakeoverfromtheskipperintheevent of his/her incapacitation.

• The use of long and short tethers/safety lines, as appropriate, to prevent a manoverboardsituation.

• Proceduresindealingwith,andthedifficultiesassociatedwithrecoveringaconsciousandunconsciousmanoverboardwhiletetheredtothevessel.

Marine Accident Investigation BranchMarch 2012

Safetyrecommendationsshallinnocasecreateapresumptionofblameorliability

Marin

e Accid

ent R

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