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Marine Safety Investigation Unit
MARINE SAFETY INVESTIGATION REPORT
Safety investigation into the loss of life from the tender boat to the
Belgian registered pleasure yacht
EL PIRATA
off the coast of Gozo, Malta
on 06 May 2013
201305/012
MARINE SAFETY INVESTIGATION REPORT NO. 13/2014
FINAL
ii
The MSIU gratefully acknowledges the assistance of the Spanish
Comisión Permanente de Investigación de Accidentes e Incidentes Marítimos, during the
safety investigation of this accident.
Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.
This safety investigation report is not written, in terms of content and style, with litigation in
mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident
Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings
whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,
under prescribed conditions, a Court determines otherwise.
The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 06 May 2013. Its sole purpose is
confined to the promulgation of safety lessons and therefore may be misleading if used for
other purposes.
The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.
© Copyright TM, 2014.
This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.
The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.
MARINE SAFETY INVESTIGATION UNIT
Malta Transport Centre
Marsa MRS 1917
Malta
iii
CONTENTS
LIST OF REFERENCES AND SOURCES OF INFORMATION .......................................... iv
GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v
SUMMARY ............................................................................................................................. vi
1 FACTUAL INFORMATION .............................................................................................1 1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1 1.2 Description of the Pleasure Yacht and the Tender Boat .............................................2 1.3 Sites of Direct Relevance to the Accident ..................................................................3
1.3.1 Dwejra Bay .............................................................................................................3 1.3.2 Xlendi Bay ..............................................................................................................4
1.4 Navigation and Weather Monitoring ..........................................................................5 1.5 Narrative .....................................................................................................................6
1.5.1 Departure from Monastir ........................................................................................6 1.5.2 Arrival at Dwejra Bay.............................................................................................6 1.5.3 Deterioration of weather conditions during the evening ........................................7 1.5.4 Actions at day break ...............................................................................................8 1.5.5 SAR operation ......................................................................................................10
2 ANALYSIS .......................................................................................................................11 2.1 Purpose .....................................................................................................................11 2.2 Responsibility and Command ...................................................................................11 2.3 The Damage to the Tender Boat and the Propeller ...................................................12
2.3.1 Material damages to the tender boat .....................................................................12 2.3.2 Design and overloading of the tender boat ...........................................................15 2.3.3 The condition of the propeller blades after the accident .......................................15
2.4 Donning of Lifejackets .............................................................................................18 2.5 The Weather Forecast and Actual Weather Conditions ...........................................20 2.6 Night trip from Xlendi Bay to El Pirata ...................................................................24 2.7 Local Knowledge of the Coastline ...........................................................................24 2.8 Risk ...........................................................................................................................27
2.8.1 Acceptance of risk ................................................................................................27 2.8.2 Decision-making processes ..................................................................................28
3 CONCLUSIONS ...............................................................................................................31 3.1 Immediate Safety Factor ...........................................................................................31 3.2 Latent Conditions and other Safety Factors .............................................................31
4 RECOMMENDATIONS ..................................................................................................32
iv
LIST OF REFERENCES AND SOURCES OF INFORMATION
Armed Forces of Malta.
Blance, G. (2007). Norie’s nautical tables. St. Ives: Imray Laurie Norie and Wilson
Ltd.
Crew member of El Pirata.
Glendon, I. (1998). Management of risks by individuals and organisations. Safety
Science Monitor, 3 (Special Edition), 1-11.
Her Majesty's Stationery Office[HMSO]. (1978). Meteorology for Mariners
(Met. O 895) (3rd ed.). London: Meteorological Office.
HMSO. (2013). The Nautical Almanac. NP314. London: Her Majesty's Nautical
Almanac Office.
Hillson, D., & Murray-Webster, R. (2007). Understanding and managing risk attitude
(2nd ed.). Hants: Gower Publishing Ltd.
Hofmann, D. A., & Morgeson, F. P. (2003). Climate as a moderator of the
relationship between leader-member exchange and content specific citizenship:
safety climate as an exemplar. Journal of Applied Psychology, 88(1), 170-178.
Local fishermen and boatmen.
Malta Police Force.
Sjöberg, L., Bjørg-Elin, M., & Tobjørn, R. (2004). Explaining risk perception. An
evaluation of the psychometric paradigm in risk perception research, Rotunde no.
84. Trondheim: Norwegian University of Science and Technology.
The Meteorological Office, Malta International Airport.
The United Kingdom Hydrographic Office [UKHO]. (1994). IALA Maritime buoyage
system. Combined cardinal and lateral system. NP 735 (Edition 5-1994).
Somerset: UKHO.
UKHO. (2012). Admiralty list of radio signals - maritime safety information services.
Europe, Africa and Asia (excluding the Far East). NP 283(1) (Vol. 3. 2012/13).
London: UKHO.
Trimpop, R., & Zimolong, B. (n.d.). Risk acceptance. Retrieved 27 November, 2006,
from http://www.ilo.org/encyclopedia/?d&nd=857100080&prevDoc=857100076.
Trimpop, R., & Zimolong, B. (n.d.). Risk perception. Retrieved 27 November, 2006,
from http://www.ilo.org/encyclopedia/?d&nd=857100076&prevDoc=857000106.
Wilson, R. (1984). Commentary: risks and their acceptability. Science, Technology, &
Human Values, 9(2), 11-22.
v
GLOSSARY OF TERMS AND ABBREVIATIONS
BA British Admiralty
Cm Centimetres
E East
ENE East Northeast
EPIRB Emergency Position Indicating Radio Beacon
ESE East Southeast
GPS Global Positioning System
GRP Glass-reinforced plastic
HP Horse power
IMO International Maritime Organization
ISO International Organization for Standardization
Kmhr-1
Kilometres per hour
Kg Kilogrammes
kW Kilowatt
m metres
Met Office Meteorological Office, Malta International Airport, Luqa
mm Millimetres
MSIU Marine Safety Investigation Unit
N North
NE Northeast
NM Nautical mile
NW Northwest
NW by N Northwest by North
RPM Revolutions per minute
SAR Search and Rescue
SE Southeast
TOO Time of origin (weather forecast)
UTC Coordinated Universal Time
VHF Very high frequency
W West
vi
SUMMARY
In the evening of Sunday 05 May 2013, four adults (two males and two females) and
one male teenager boarded the small tender boat to the pleasure motor yacht
El Pirata, which was anchored inside Dwejra Bay, on the Western coast of Gozo.
The tender boat motored to the Southeast, to Xlendi Bay, some two nautical miles off,
in relatively good weather conditions, for an evening meal in a restaurant. One of the
passengers on the tender boat was the owner of El Pirata. It was the owner’s first
time in Gozo by sea. An experienced yachtsman remained behind to tend El Pirata.
By late evening, and by the time the five persons had finished their meal and were
ready to motor back to their yacht, the weather conditions had deteriorated
substantially. The five persons boarded the tender boat and headed out of Xlendi Bay,
in pitch darkness and into rough head seas. The tender boat did not arrive at Dwejra
Bay.
At first light, on Monday 06 May 2013, El Pirata sailed through the South entrance of
Dwejra Bay and headed out to sea, steamed Southeast towards Xlendi Bay and then
continued onwards to Mġarr Harbour, where eventually, the missing five persons
were reported to the local authorities.
On 07 May, the bodies of two adult females and the battered, capsized hull of the
tender boat, with its outboard engine and other flotsam, were spotted at Fomm ir-Riħ,
Malta. The two bodies were recovered on the same day. However, due to its close
proximity to the rocks, the tender boat was recovered during the following morning.
The body of an adult male was spotted and recovered in the South Comino Channel
on 08 May. One adult and one teenager remain missing.
The safety investigation by the Marine Safety Investigation Unit (MSIU) concluded
that in all probability, the primary cause of the accident was the swamping of the
tender boat in adverse weather conditions. Other factors, which may have influenced
the dynamics of the events included lack of experience and appreciation of risk. One
recommendation has been made to Transport Malta, aimed to enhance safety
awareness within the yachting industry.
1
1 FACTUAL INFORMATION
1.1 Vessel, Voyage and Marine Casualty Particulars
Name El Pirata
Flag Belgium
Type Pleasure yacht
Construction GRP
Registered Length 17.18 m
Beam 5.18 m
Depth 2.90 m
Port of Departure Monastir, Tunisia
Port of Arrival Mġarr, Gozo
Type of Voyage International
Date and Time 06 May 2013 at 0030
Type of Marine Casualty or Incident Very Serious Marine Casualty
Location of Occurrence 36° 01.95’N 14° 11.21’E
Place on Board Not Applicable
Injuries/Fatalities Three fatalities and two missing
Damage/Environmental Impact None
Ship Operation Normal service – In passage
Voyage Segment Mid-water
External & Internal Environment Dark, Northwesterly wind force 4 to force 5, and
moderate seas (1.0 m to 2.0 m). Sea temperature was
about 18oC.
Persons on Board 5
2
1.2 Description of the Pleasure Yacht and the Tender Boat
El Pirata is a Gallart 17.50 MA pleasure yacht built by Astilleros Gallart in 1985.
Her hull is of glass-reinforced plastic (GRP). She has a registered length of 17.18 m
and a beam of 5.18 m. Her moulded depth is 2.90 m. Propulsive power is provided
by two inboard GM Detroit 12V71TI diesel engines, each rated at 478 kW at
2300 rpm.
The tender boat in use at the time of the accident was a Boston Whaler-type dinghy.
It had an approximate length of 4.1 m and a beam of about 1.65 m. Her depth was
0.5 m. The hull of the tender boat was constructed of GRP, sandwiched in such a way
that rendered it practically unsinkable.
This tender boat, which is of a conventional type, is considered within the industry as
a strong and seaworthy boat. Depending on the means of propulsion and the load on
board, it is also generally considered a fast boat; when light and in calm sea
conditions, the tender boat could reach speeds in excess of 30 knots1. The tender boat
was fitted with an Evinrude 50 HP outboard engine (purchased in 2012), an
aluminium propeller and an external fuel tank. It was estimated that with the engine,
fuel, equipment and five persons of average weight on board, the freeboard2 of the
tender boat on that day would have been as low as 0.33 m.
The tender boat had a seating capacity of six; two passengers sitting aft, two
amidships and two at the bow. The tender boat was provided with:
one anchor and a 5 m chain;
two paddles; and
50 m of synthetic rope with a diameter of 14 mm.
El Pirata was well equipped with life saving equipment, including an EPIRB, two six-
person liferafts, rocket flares and 31 lifejackets3.
1 One knot is equal to 1.852 kmhr
-1.
2 For the purpose of this safety investigation, the freeboard is defined as the distance measured
vertically downwards amidships from the upper edge of the tender boat to the waterline.
3 The lifejackets on El Pirata were manufactured in accordance with the relevant requirements
adopted by the International Maritime Organization (IMO) and the International Organization for
Standardization (ISO) Standard 12402-4:2006 Personal flotation devices – Part 4: Lifejackets,
performance level 100 – Safety requirements.
3
1.3 Sites of Direct Relevance to the Accident
1.3.1 Dwejra Bay
Dwejra Bay is secluded on the Western coast of the island of Gozo. It is
approximately 300 m long and 300 m wide. It is flanked by a sheer cliff face to the
South, which gradually slops down towards the North. At the entrance to the Bay lies
Il-Ġebla tal-Ġeneral (Fungus Rock) (Figure 1).
Figure 1: Dwejra Bay and Fungus Rock (arrow)
The Bay is accessible from a Westerly direction from seaward either via the Northern
channel (about 33 m wide) or via the Southern channel, which is approximately 60 m
wide (Figure 2). The Bay provides excellent shelter from the Northeast through to
Southerly winds. However, it is exposed to Northerly and all Westerly winds.
Dwejra Bay offers ample depth of water for all boats, which are capable of safely
navigating the two entrances. The depth rapidly drops off further Westwards beyond
the channels.
There are no known dangerous, submerged rocks in the area. The immediate area
around the Bay is uninhabited, but is frequently visited during the day by locals and
tourists due to its natural beauty.
4
© Crown Copyright and/or database rights. Reproduced by permission of the Controller
of Her Majesty’s Stationery Office and the UK Hydrographic Office (www.ukho.gov.uk)
Not to be used for Navigation
Figure 2: Access points to Dwejra Bay
1.3.2 Xlendi Bay
Xlendi Bay lies on Gozo’s Southwest coast. The Bay is approximately 300 m long
and 70 m wide. The depth of water in the Bay is sufficient, relative to the size of
boats, which can safely navigate the Bay. However, at the entrance to the Bay, is a
submerged reef just below the surface of the water. The reef is well known to local
boatmen.
The village of Xlendi (Figure 3) lies at the bottom of the Bay and is inhabited all year
round. It also holds a small community of fishermen and boatmen, who are provided
with a small jetty and a slipway for their boats. The village is a very popular
destination for tourists and its population soars during the summer months. During
this period, the village also supports a local pleasure boating industry.
Figure 3: The village of Xlendi
5
Seaward access to Xlendi Bay is from a Westerly direction (Figure 4).
Figure 4: Seaward access as seen from Xlendi Bay
1.4 Navigation and Weather Monitoring
El Pirata was provided with one small scale (1:674,000) paper navigational chart,
covering the Malta – Sicily Channel (BA Chart 2537). However, BA Chart 2537 was
only used for general reference purposes because due to its scale, it was inadequate
for safe coastal navigation.
Navigation was actually conducted by referral to electronic maps displayed on a
portable conventional tablet computer (Navionics Gold software was installed), which
was owned and used by the owner of El Pirata. The computer tablet was also used to
monitor the weather via a number of internet sites. As an additional navigational aid,
the pleasure yacht was also fitted with one GPS plotter.
6
1.5 Narrative4
1.5.1 Departure from Monastir
El Pirata sailed from Monastir, Tunisia at around 0500 on 04 May 2013. The weather
at the time was Northeast force 3 to force 4 with moderate seas. The owner’s plan
was to sail to the island of Linosa for diving and then proceed onwards to the island of
Gozo. The original plan was to spend a couple of days exploring the area and then
proceed to Valletta Harbour in Malta to enjoy some sightseeing.
Accompanying the owner on board El Pirata were his partner, his teenage son and
another couple. All five persons were French nationals. Additionally, there was also
an experienced yachtsman who, up to the previous year, had been the owner of
El Pirata. The yachtsman was a Spanish national. The new owner of El Pirata had
invited the yachtsman to join his family and friends in order to help out with the
manoeuvring of the yacht and to be of general assistance.
As the voyage towards Linosa progressed, the wind and sea conditions deteriorated.
To this effect, the owner decided not to stop at Linosa but to proceed directly towards
Gozo. However, it was noticed that the aft lifting bracket of the tender boat was
damaged and therefore, as originally planned, El Pirata stopped over at Linosa in
order to repair the tender boat’s lifting bracket. Meanwhile, a fender was placed
under the tender boat to avoid damages to her hull. The damage to the lifting bracket
did not affect the structural integrity of the tender boat in any way.
1.5.2 Arrival at Dwejra Bay
El Pirata departed Linosa at around 0500 on 05 May 2013 with the tender boat towed
astern by an 18 mm diameter towing rope. The length of the tow was between 30 m
to 40 m. El Pirata proceeded at approximately 15 knots, although her speed had to be
adjusted to ensure a safe tow. The weather during the crossing from Linosa towards
Gozo was Northeasterly force 2 to force 3.
El Pirata arrived at Dwejra Bay in very good weather conditions at around 1200 on
05 May 2013 and dropped her anchor, using about 40 m of cable. She did not report
her arrival to the local authorities.
4 Unless otherwise stated, all times in the safety investigation report are local (UTC+1).
7
It so happened that on 05 May, the owner was celebrating his birthday. Evidence
suggested that on the same day, (late afternoon / early evening), he booked a table at a
local restaurant in Xlendi Bay5. The weather that afternoon was between force 1 to
force 2, initially from the Northeast, backing to the North and Northwest later during
the afternoon and early evening.
The yachtsman recalled that he had been invited by the owner to join his family and
friends for dinner at the restaurant in Xlendi Bay. However, the yachtsman declined
the offer as he would rather remain behind to tend El Pirata, as she laid anchored in
the Bay.
1.5.3 Deterioration of weather conditions during the evening
The owner, his partner and son, and their two friends, departed El Pirata by the tender
boat at around 2000 on 05 May 2013 and proceeded Southwards to Xlendi Bay6. The
owner was in control of the outboard’s engine and steered the tender boat.
Meanwhile, the weather during the preceding hour had been increasing from a
Northwesterly force 3 to force 4.
The five sat at the table at the restaurant in Xlendi Bay shortly after 2100 and had a
full meal. During the course of the evening, the four adults shared one bottle of
champagne and one bottle of wine. They may have also consumed a complimentary
short drink at the end of their meal.
During the evening, the weather conditions deteriorated substantially. The wind had
by then been blowing consistently from a Northwesterly direction for several hours
and had increased to force 5. Indeed, up to around 2000, the sea in Xlendi Bay had
been calm, to the extent that parents and children were still playing on the small
beach. However, as the evening progressed, the sea conditions deteriorated.
5 Information which reached the MSIU at a late stage during the safety investigation process
suggested that the owner did not purposively go to Xlendi Bay in the afternoon to book the table. It
was also stated that the owner had booked the table directly from his Paris office. Although this
detail did not have a bearing on the events’ dynamics, the MSIU followed the matter. Whilst the
MSIU was unable to confirm that the owner and his son had earlier gone to Xlendi Bay by the
tender boat (the yachtsman stated that he had retired to his cabin and had fallen asleep between
1530 and 1800), the restaurant management confirmed that no overseas booking had been received
and the booking had been made by the owner and his son at Xlendi Bay.
6 Evidence suggested that initially, it was considered to proceed directly to Xlendi Bay with
El Pirata. However, it was concluded that the area was narrow, with limited depth and many small
buoys, making the manoeuvring very complicated and difficult to enter and exit the Bay.
8
Further to the North, El Pirata, which remained anchored in Dwejra Bay, also started
experiencing the deteriorating weather conditions. At some time between 2300 and
midnight, the yachtsman, alone on board, started to feel increased movement and in
the light of a portable searchlight, he could see algae floating on the surface of the sea.
Past midnight, the sound of waves hitting the rocky shore inside the Bay was
becoming even more conspicuous.
Concerned about the deteriorating weather and the safety of the yacht, the yachtsman
decided to start both engines in order to reduce the strain on the anchor cable and to
maintain a safe distance from the rocks. However, at about 0030 (06 May 2013), he
decided to weigh anchor and steam up and down inside the confined space of Dwejra
Bay; due to the sea state and the darkness of the nearly moonless night, the yachtsman
thought that it would be too dangerous to attempt to sail out of the Bay (Figures 1 and
2).
Meanwhile, the owner and the rest of the group were seen leaving the restaurant in
Xlendi Bay between 0005 and 0030. The owner was observed carrying a torch light.
By now, there was a high tide and waves were coming into Xlendi Bay and hitting the
small jetty where the tender boat was moored. The sound of waves hitting the jetty
and rocks inside the Bay could be heard clearly. With difficulty, the five boarded the
tender boat and, in the darkness of the night, proceeded out of the Bay to the open sea.
1.5.4 Actions at day break
At the first signs of daybreak, and after carefully observing and timing the waves’
pattern, El Pirata sailed under full power out of the South entrance of Dwejra Bay at
around 0530, after long hours of continuous steaming up and down inside the Bay.
On her way out, she took on beam seas and rolled very heavily. On board, her sole
crew member was unaware of the actions or predicament of the owner and the rest of
the group. Instead, he assumed that they would not have attempted to return to
El Pirata in such harsh weather conditions. Actually, he thought that they were safe
somewhere ashore. Indeed, this had been his assumption throughout the long and
difficult night and thus there were no attempts to contact the group on the mobile
phone.
9
Not to be used for Navigation
© Crown Copyright and/or database rights. Reproduced by permission of the Controller
of Her Majesty’s Stationery Office and the UK Hydrographic Office (www.ukho.gov.uk)
Once safe in open waters and between 200 m and 300 m off the coast, El Pirata sailed
in a Southwesterly direction, altered course to port and rounded Il-Pinnur tal-Wardija,
before altering course again to the East, towards Xlendi Bay (Figure 5). The
Northwesterly sea was rough, with waves occasionally exceeding two metres in
height. As El Pirata approached Xlendi Bay, the yachtsman started calling the owner
on the mobile phone and continued trying at about 30-minute intervals.
Notwithstanding his numerous calls, he did not manage to establish contact.
Figure 5: El Pirata’s approximate course (red arrow), towards Xlendi Bay at daybreak
Contrary to his expectations, the yachtsman found no shelter off the cliffs, West of
Xlendi Bay. He therefore decided to proceed to Mġarr Harbour, where he arrived and
anchored off the Harbour at around 0700. Meanwhile, he remained convinced that the
owner, his family and friends were safe and that they would soon turn up. However,
as time progressed, he started to feel very anxious and at around 1500, he weighed
anchor and proceeded inside Mġarr Harbour where, with the help of some locals, he
berthed El Pirata.
Shortly after berthing, he proceeded to report the matter to the local Police at Mġarr.
At around 1600, he took a taxi to Xlendi Bay in the hope that he would spot the tender
boat and meet up with the owner and the rest of the group. After an unsuccessful
search in some restaurants, he went to the local Police station to report. He was then
10
accompanied by a Police Officer and called again at all restaurants in Xlendi Bay,
following which, he was driven by the Police to Gozo’s main Police Station in
Victoria for further formalities.
1.5.5 SAR operation
At 1650, Victoria Police informed the Operations Centre of the Armed Forces of
Malta about the missing five persons and within minutes, an intense sea, air and land
search and rescue (SAR) operation was launched involving Maltese, Italian, American
and French assets.
On 07 May, late in the afternoon, following reported sightings by a local fisherman,
the bodies of the two adult females and the swamped tender boat were located at
Fomm ir-Riħ on the West coast of Malta, approximately 9.5 nautical miles (nm) from
Xlendi Bay. The bodies were recovered by helicopter some time during the evening,
although it was not possible to recover the tender boat due to its close proximity to the
rocks. Two lifejackets and other flotsam were also recovered. The tender boat was
eventually recovered on the following morning.
Meanwhile, on the same morning of 08 May 2013, a fisherman reported sighting a
body in the sea, close to the South Comino Channel, about 6 nm off Xlendi Bay. The
body of an adult male was recovered by a SAR boat shortly afterwards. Extensive
SAR operations continued. The last air search was conducted on 12 May 2013, with
the helicopter leaving the search area at 1148. The last search by the patrol boat was
conducted on 20 May 2013 and ended at 14027.
7 At the time of writing, one adult male and one male teenager remain missing.
11
2 ANALYSIS
2.1 Purpose
The purpose of a marine safety investigation is to determine the circumstances and
safety factors of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.
2.2 Responsibility and Command
As indicated elsewhere, the owner had bought El Pirata in 2012 from the yachtsman
who, on the night of the accident, had remained on board at Dwejra Bay. The owner
had asked the yachtsman to accompany him on El Pirata for the trip from Monastir to
assist him with the handling of the pleasure yacht.
Whilst the previous owner was an experienced yachtsman and had regularly
manoeuvred El Pirata, the presence of the new owner on board, together with his
family and friends, may have created ambiguity as to who was actually responsible
for the safety of El Pirata and the persons on board.
This point may have had a bearing on how the events evolved, even prior to the
decision to leave the relative safety of El Pirata and head to Xlendi Bay. Subject that
(at least) the yachtsman and the owner were aware of the weather forecast, evidence
did not indicate that the two held a detailed discussion on whether or not the trip to
Xlendi village for dinner should be carried out. Then, once the decision was taken to
do the trip in the tender boat, evidence did not indicate that there was a discussion on
the appropriate clothing and use of life saving equipment8.
Role ambiguity (which is not necessarily a conflict) has been the topic of a number of
academic studies. In this particular case, the yachtsman may have taken the role of an
experienced skipper, responsible for the safe navigation and manoeuvring of
El Pirata. However, it seemed that the formality of this role was limited to this level,
i.e. the safe navigation and manoeuvring of the pleasure yacht.
8 The matter will be further discussed in the following sections.
12
The fact that, notwithstanding the weather forecasts which were being transmitted, a
decision was made to proceed to sea in a small tender boat, seemed to suggest that the
‘overall’ safety role was not integrated within the role of the yachtsman as one would
expect in the case of the role of a skipper.
One may compare the context on board El Pirata with a very small organisation
where the yachtsman was only assuming the role which, in reality, was expected of
him by the owner. It may be stated that the relationship established between the
yachtsman and the owner was such that a leader and sub-ordinate role was created.
This does not mean that a leader / sub-ordinate relationship does not allow the
engagement of problem-solving techniques. However, such a relationship would
depend on the quality of the relationship between the two.
The working context on board is not considered to have supported a safety climate
that would have crystallised and / or influenced a defined role beyond the safe
navigation and manoeuvring of El Pirata.
2.3 The Damage to the Tender Boat and the Propeller
2.3.1 Material damages to the tender boat
The tender boat was spotted capsized during the course of the SAR operation in the
late afternoon / early evening of 07 May 2013.
An inspection of the tender boat revealed that her bow had suffered some damage but
was generally still sound, indicating that she had not received any initial direct impact.
The entire length and breadth of her bottom (Figure 6) was practically intact, which
suggested that the tender boat had not run aground while making way (such as on the
reef just outside Xlendi Bay – Figure 7). Her port side (Figure 8) had not suffered any
serious damage, other than relatively minor scratches in her gelcoat.
Her starboard side, however, was severely damaged, with entire sections missing
(Figure 9). The nature of the damage indicated severe side impact against rocks. This
damage could have happened immediately prior to the tender boat capsizing (and
therefore whilst the five persons where still on board), but also during that period
13
when the tender boat was adrift and subsequently battered against the rocky coastline
off Fomm ir-Riħ, until it was salvaged.
Figure 6: Relatively intact underside of the tender boat
Figure 7: Reef just outside Xlendi Bay
14
Figure 8: Port bow and bottom view of the tender boat
Figure 9: Starboard bow and bottom view
15
2.3.2 Design and overloading of the tender boat
As already stated, the tender boat was a Boston Whaler – type dinghy of approximate
dimensions of 4.1 m, 1.65 m and 0.5 m (approximate length, breadth and depth,
respectively).
Estimates and comparisons with boats of similar design and dimensions indicated that
the displacement of the tender boat, including the outboard engine, fuel tank and (an
estimated) 10 litres of fuel, would have been approximately 445 kg. Bearing in mind
the design of the boat, and particularly her underwater form, her average freeboard
would have been approximately 0.41 m. This would have corresponded to a draft of
about 9 cm (0.09 m).
It was further estimated that the additional weight of the four adults, one teenager,
personal effects, and boat equipment, would have added approximately a further
360 kg of weight. This would have brought the final displacement of the tender boat
to approximately 805 kg. Estimates with this new displacement (0.805 tonnes)
indicated that the average freeboard of the fully loaded tender boat at the time she
departed Xlendi Bay, may have been approximately 33 cm, with a probable higher
value forward and a smaller value aft due to a trim by the stern (this would have
corresponded to a mean draft of 17 cm (0.17 m)).
The relatively flat bottom would have provided limited wave-piercing properties.
Furthermore, the tender boat was fitted with a 50 HP outboard engine. An analysis of
boats with similar design and dimensions showed a tendency towards substantially
smaller engines; thus indicating that the tender boat may have been over-powered.
Therefore, there can be little doubt that, bearing in mind the prevailing weather
conditions and in particular the indicated wave heights, the tender boat was
overloaded. The hypothesis that excess propulsive power may have been applied
(even erroneously) with a catastrophic effect was also considered. However, the
MSIU had no evidence that could confirm this possibility.
2.3.3 The condition of the propeller blades after the accident
Taking into consideration that the MSIU did not have available a history of this
particular propeller, its condition, and previous repairs (if any), the conclusion was
reached that the manifested deformation was typical of an Aluminium propeller
16
Blade face
hitting a hard object. Aluminium, further to being the cheapest option, is soft and can
absorb significant impact shocks, possibly preventing the transmission of energy to
other components of the engine.
The presence of some chipping on the blade edges also suggested a hard surface
impact (Figure 10). It was likely, however, that the impact did not last for an
extended period of time; otherwise, the rotating blades would have work hardened and
started to shatter. The propeller is a right-handed propeller as its direction of rotation,
when thrusting ahead and viewed from astern, is clockwise. All three propeller blades
were present albeit badly damaged (Figures 10 and 11).
Figure 10: Damaged propeller blades (Blade face showing)
17
Blade back
Figure 11: Damaged propeller blades (Blade back showing)
The nature of the damage did not suggest that the propeller had come into contact
with a hard object whilst it was rotating in the ahead direction. Figure 10 reveals that
the propeller blade tips and trailing edges were bent over the blade faces. This
suggested that at the time of damage, the propeller was not rotating in the ahead
direction; otherwise, the blade tips would have been bent over the blade back.
Therefore, considering the nature of the damage sustained by the propeller, the
possibility that the propeller came in contact with a hard surface whilst operating in
the astern direction cannot be completely excluded. The safety investigation was
unable to accurately identify the reasons why and when the outboard engine could
have been engaged in the astern direction. Whilst it is not excluded that there could
have been propeller contact with the reef just outside Xlendi Bay, a plausible time
and place would have possibly been either upon arrival at Xlendi Bay or during the
(rather difficult) boarding and departure after the dinner. The propeller hub was also
bearing impact damage (Figure 10). It was therefore not excluded that the lower part
of the outboard engine made contact with a submerged object, even in close proximity
of the jetty.
The outboard engine had other visible damages, including missing parts of the skeg
and paint scratches. However, for the reasons explained in Section 2.7, the damages
18
sustained by the outboard engine, if present at the jetty, would not have prevented the
group from leaving Xlendi Bay.
Therefore, whilst it is not determined beyond any reasonable doubt, the MSIU is of
the view that, considering the condition of the underwater portion of the hull and the
nature of the damage sustained by the propeller of the outboard engine, it is
considered to be likely that the tender boat actually sustained damages to the propeller
at the jetty.
2.4 Donning of Lifejackets
It was established that when the five persons boarded the tender boat and left
El Pirata, they were wearing light, smart, casual clothes. In addition to small bags
with personal effects, the group carried a portable tablet computer, at least one mobile
phone, and a two-cell diving torch. Moreover, two lifejackets were taken from
El Pirata and transferred to the tender boat9. Documentary evidence suggested that
upon departure, none of the five passengers on the tender boat was wearing a
lifejacket (Figure 12).
Figure 12: The tender boat just before the group’s departure to Xlendi Bay. One of the
lifejackets is seen on the tender boat’s port side
9 The MSIU was informed that in addition to the two lifejackets taken on the tender boat, there were
also three inflatable lifejackets on the tender boat, stored in the forward compartment.
19
Due to the circumstances surrounding the events after the group left the restaurant in
Xlendi Bay, the safety investigation was unable to determine neither who of the
persons was wearing a lifejacket, if any, nor who was in control of the outboard
engine. However, the MSIU is aware that none of the bodies found during the SAR
operation had a lifejacket on. The two lifejackets (Figure 13) were found close to the
first two bodies. This meant that either the lifejackets were not donned, were not
secured well and consequently slipped off, or else were taken off at some point after
the group left Xlendi Bay. The latter option did not seem realistic.
Figure 13: The two lifejackets which were recovered during the SAR operation
In view of the prevailing weather conditions, it is very improbable that the lifejackets
had been taken off after the tender boat left Xlendi Bay. In fact, it would be more
plausible to hypothesise that the lifejackets would have been donned somewhere
during the trip but not secured well in the dark and prevailing seas.
Irrespective of what happened, the fact that the group left El Pirata without any one
wearing the available lifejackets, provided some indications on the group’s risk
perception. This point is further discussed in Section 2.8.
20
2.5 The Weather Forecast and Actual Weather Conditions
El Pirata made the approximate 66 nm crossing from Linosa Island to Gozo in a
Northeasterly force 2 to force 3 winds. She anchored inside Dwejra Bay in good
weather conditions.
On the day, the Meteorological (Met) Office issued a number of forecasts, valid for
Malta and up to a 50 nm radius. These forecasts are mainly intended for mariners and
are also continuously available on the internet. Weather forecasts are also transmitted
on marine VHF radio four times daily. Evidence suggested that once at anchor, the
VHF radio on the bridge had been switched off and therefore weather forecasts were
not received by El Pirata. The only available source was the tablet computer.
Early in the morning of 05 May, the wind was forecast to back and increase from the
East to Northeast force 3 to force 4 and locally force 4 to force 5, becoming
Northwest force 5 locally force 5 to force 6, by the evening of the same day.
Subsequent forecasts confirmed the expected wind shift and very substantial increase
in force (Table 1).
Table 1: Summary of the weather forecasts promulgated by the Met Office
TOO Validity Wind Sea Swell
0515 0600 - 1800
E to NE force 3 to force 4 locally
force 4 to force 5, becoming NW
force 5 locally force 5 to force 6
later.
Moderate to rough.
Low SE
becoming
low ESE.
0930 1000 - 2200
ENE force 3 to force 4 locally
force 4 to force 5 backing NW
force 4 to force 5 locally force 5
to force 6 by the evening.
Moderate becoming
moderate to rough. Low SE.
1530 1600 – 0400
(06 May)
NW force 3 becoming force 4 to
force 5 and increasing to force 5
to force 6 by end of period.
Moderate gradually
becoming rough.
Low SE
becoming W.
2100 2100 – 0900
(06 May)
NW force 4 becoming force 5 to
force 6.
Moderate to rough
becoming rough.
Low SE
becoming W.
Analysis of real-time weather data (Table 2) recorded at the Met Office’s remote
weather observation station in Xewkija, the station closest to the Dwejra – Xlendi
21
coast10
, for the period starting at 1600 on 05 May to 0400 on 06 May, confirmed the
accuracy of the weather forecasts issued by the Met Office.
It is also pertinent to note that due to friction, the wind speed over land tends to be
lower than that blowing over the sea. Therefore, the wind experienced at sea may
have been even stronger than that actually recorded at the Xewkija remote weather
observation station.
Although the forecasts on the deteriorating weather conditions, which prevailed from
the afternoon of 05 May to the early morning hours of 06 May had been transmitted,
evidence suggested that these were either missed (with the VHF radio switched off
and possibly due to weak mobile network coverage at Dwejra Bay), or not appreciated
enough by any of the persons on board El Pirata.
As indicated elsewhere, a table was booked at a restaurant for the evening some time
late in the afternoon or early evening on 05 May. Evidence that someone went by
tender boat to Xlendi Bay remained uncorroborated. However, hypothesising that
they did, the wind during this period would have been force 1 to force 2, initially
blowing from the Northeast and backing to the Northwest during the late afternoon
and early evening. During this period, the trip from Dwejra Bay to Xlendi Bay would
have been uneventful, either in following light wind or in sheltered waters. Likewise,
the return trip from Xlendi Bay to El Pirata (in Dwejra Bay) would have been in
slight head sea but in sheltered waters up to Il-Pinnur tal-Wardija (Figure 14).
Later that day, the group left El Pirata at about 2000. At this time, it would have been
just after sunset and the wind direction would have had already changed to the
Northwest and picked up to force 4. Since the wind shift and increase in force had
only just taken place, Dwejra Bay would have either still not felt its effect or had just
started to feel some increased movement. It was evident that the five occupants of the
tender boat were not particularly concerned at that time as the waves would not have
yet built up. Moreover, the tender boat would have encountered following seas all the
way to Xlendi Bay, thus possibly resulting in a false perception on the weather
conditions.
10
Xewkija is approximately 3.5 nm inland and Eastwards from the Xlendi – Dwejra coast.
22
Table 2: Average real-time weather data (Xewkija weather observation station)11
Time
from
Time
to
Average
wind
speed
(knots)12
Highest
recorded
wind speed
(knots)
Average wind
direction
(quadrantal
notation)13
Force
(Beaufort
wind
scale)
Wave
height
(m)14
1600 1630 3 5 NE 1 - 2 0.1
1630 1700 4 6 NE backing N 2 0.2
1700 1730 4 5 N - N by W 2 0.2
1730 1800 3 6 N - N by W 1 - 2 0.1
1800 1830 6 10 NW (occ NW by N) 2 - 3 0.2 – 0.6
1830 1900 7 11 NW (occ NW by N) 3 0.6
1900 1930 11 14 NW (occ NW by N) 4 1.0
1930 2000 15 23 NW (occ NW by N) 4 1.0
2000 2030 18 24 NW 5 2.0
2030 2100 15 21 NW 4 - 5 1.0 – 2.0
2100 2130 16 22 NW (occ NW by N) 4 - 5 1.0 – 2.0
2130 2200 16 22 NW 4 - 5 1.0 – 3.0
2200 2230 17 22 NW 5 2.0
2230 2300 17 22 NW 5 2.0
2300 2330 15 21 NW 4 - 5 1.0 – 2.0
2330 2400 16 22 NW 5 2.0
0000 0030 15 21 NW 4 - 5 1.0 – 2.0
0030 0100 15 19 NW 4 - 5 1.0 – 2.0
0100 0130 16 21 NW (occ NW by N) 5 2.0
0130 0200 16 23 NW (occ NW by N) 5 2.0
0200 0230 16 22 NW 5 2.0
0230 0300 17 24 NW (occ NW by N) 5 - 6 2.0 – 3.0
0300 0330 19 25 NW 5 - 6 2.0 – 3.0
0330 0400 17 24 NW 5 - 6 2.0 – 3.0
11
The shaded columns containing the relative Beaufort wind force and the average wave heights were
added for reference purposes.
12 Rounded to the nearest number.
13 Actual wind direction was recorded in degrees true. Here, it is converted in a quadrantal notation
for ease of reference.
14 These average wave heights may be observed in open waters and not along the shore. However,
they are indicative of what can be expected relative to the prevailing wind force.
23
© 2
01
3 G
oog
le
Imag
e ©
20
13
Ter
raM
etri
cs
Dat
a ©
SIO
, N
OA
A,
US
Nav
y,
NG
A,
GE
BC
O
Figure 14: Aerial view of the coastline between Xlendi Bay, Dwejra Bay and Il-Pinnur tal-
Wardija
24
2.6 Night trip from Xlendi Bay to El Pirata
After having dinner in a local restaurant in Xlendi Bay, the group boarded the tender
boat at around 0015 (06 May). Witnesses claimed that this was done with difficulty
due to the movement of the tender boat whilst alongside the jetty under the effects of
the increasing weather conditions. Up to around 2000, the sea condition inside Xlendi
Bay was calm and the sea level was low. However, by around midnight, the sea level
had risen and waves could be heard and seen hitting the rocks and the small jetty
inside the Bay. The real-time wind data records from Xewkija remote weather
observation station showed that by 2000, the wind had backed to Northwest and had
reached a force 4, increasing to force 5 through the evening (Table 2). Sea
temperature at the time of the year around the Maltese Islands is about 18°C.
Notwithstanding the weather conditions, the tender boat, with her five occupants,
motored out of Xlendi Bay in pitch darkness but never arrived at their destination in
Dwejra Bay15
. The safety investigation did not exclude that the deteriorating weather
conditions were a concern to the group; but rather than staying at Xlendi Bay, they
had eventually decided to leave the restaurant at that particular time.
2.7 Local Knowledge of the Coastline
Both Dwejra Bay and Xlendi Bay are very popular with tourists, especially because
the coastline between the two Bays is a stretch of sheer cliff faces, which rise
perpendicularly out of the sea to a height of about 150 m.
This stretch of coast is also well known to local fishermen and boatmen as a
potentially very dangerous coast. The approximate two nautical mile stretch is
completely exposed to all winds blowing from the Westerly direction and it offers
absolutely no place of shelter whatsoever to anyone who may be caught out in a small
boat anywhere between the two Bays (i.e. Dwejra Bay and Xlendi Bay).
In particular, the point known as Il-Pinnur tal-Wardija (Figure 14) is dangerous,
especially in strong Northwesterly winds. In a Northwesterly wind, which is the
15
The safety investigation was not in a position to establish with certainty that the tender boat headed
to Il-Pinnur tal-Wardija after it had left Xlendi Bay. However, this would have been a plausible
route that would have been taken in order to navigate back to El Pirata, anchored at Dwejra Bay.
25
predominant wind in the Maltese archipelago, an outbound boat from Xlendi Bay
heading to Dwejra Bay, may initially experience a certain degree of shelter in the lee
of the cliffs running in an East to West direction (Figure 15). However, when one
approaches Il-Pinnur tal-Wardija, the sheltering effect of the cliffs will diminish until
eventually, one becomes entirely exposed to the full force of the wind and waves.
Locals describe the point as notorious, where the sudden exposure to wind, combined
with the depth of water, may give rise to unusually large and steep waves, which crash
ferociously at the foot of the cliffs.
Figure 15: Cliffs, looking Westwards from Xlendi (bottom right), in the direction of
Il-Pinnur tal-Wardija
Locals claimed that in such weather conditions, one must keep a minimum distance of
100 m from Il-Pinnur tal-Wardija. Whilst it is doubtful as to whether or not the
person at the wheel of the tender boat was aware of the dangers of this part of the
coastline, additionally and significantly, in this area and close to the cliffs, both VHF
and mobile telephone reception are known to be either poor or erratic at best. This
would have significantly reduced the possibility for the persons on board to call for
help.
Bearing in mind the prevailing weather conditions (albeit still sheltered in the lee of
the cliffs), the MSIU is also of the view that the swamping is more likely to have
26
occurred closer to Dwejra Bay than Xlendi Bay; the closer it would have happened to
Xlendi Bay, the higher the probability for the tender boat to drift back inside the Bay
(Figure 16).
Figure 16: Chart extract showing the entrance to Xlendi Bay (note location of reef with the South
Cardinal mark16
)
It is the conclusion of the safety investigation that in all probability, the tender boat
was swamped somewhere along the stretch of water between Dwejra Bay and Xlendi
Bay, possibly in the vicinity of Il-Pinnur tal-Wardija, after gradually becoming more
exposed to the Northwesterly weather conditions. Following the swamping, the
tender boat and its occupants would have then drifted downwind and away from
Xlendi Bay entrance to Fomm ir-Riħ. The time when the swamping happened
remained an unknown factor.
Moreover, it was not excluded that the tender boat’s outboard engine could have
failed first, resulting in the tender boat and its occupants drifting Southeasterly and
eventually getting swamped. This hypothesis would still be suggestive of the tender
16
Cardinal marks are used in conjunction with the compass to indicate where the mariner may find
the best navigable water.
© Crown Copyright and/or database rights. Reproduced by permission of the Controller of
Her Majesty’s Stationery Office and the UK Hydrographic Office (www.ukho.gov.uk)
Not to be used for Navigation
27
boat being close to Il-Pinnur tal-Wardija; otherwise, rather than ending on the rocks of
Fomm ir-Riħ, the tender boat would have ended on the shores of Gozo.
2.8 Risk
Risk acceptance raises a philosophical question as to whether or not risk is actually
acceptable. Risk acceptance may be determined by the application of mathematical
models or any other criteria. This accident, however, has indicated otherwise.
Nonetheless, rather than concluding that unreasonable decisions were taken, the safety
investigation’s main focus was to give a meaning to these decisions and identify the
conditions, which influenced the group to accept these risks.
Risk (which implies the existence of uncertainty, i.e. a distinction between reality and
possibility) is only accepted if the alternative is unacceptable. There are therefore
risk-benefit trade-offs, which are made before a decision is made on whether risk is
accepted or not.
2.8.1 Acceptance of risk
At least on two occasions, a certain degree of risk was accepted by all the members of
the group, who boarded the tender boat, i.e.
the departure from El Pirata without donning the lifejackets; and
the departure from Xlendi Bay after dinner, in dark and adverse weather
conditions.
Knowledge and experience are important considerations in the assessment of risk. If
knowledge is complete and experience is rich, than uncertainty would not exist (given
that uncertainty is only a psychological concept).
Risk acceptance may be considered to be the result of a (subjective) assessment of the
probabilities and consequences. This subjectivity is linked to the appreciation of risk
indicators. Whereas some risk indicators do not need to be interpreted, most hazards
are not immediately perceptible and may require a series of interpretations.
Interpretation may be a complex exercise and this is where knowledge and experience
play a vital role. For instance, the group had neither any knowledge nor experience of
28
the local characteristics of the coastline and the wind and wave interaction, thereby
compromising their perceptions of the risk involved.
Moreover, the MSIU did not exclude the possibility that a degree of risk was tolerated
because of a prevailing sense of controllability. For instance,
a well designed and built boat, which is renowned world-wide to be sturdy;
significant propulsion power (50 HP on a 4.1 m tender boat); and
the presence of a group of people,
could have well altered the attitude taken vis-à-vis risk tolerance. One particular
research study suggested that people who are in control17
, tend to perceive risk to be
smaller than it actually is. This phenomenon is known as the ‘illusion of control.’
Research on the concept of risk also suggests that ‘illusion of control’ and unrealistic
optimism are correlated. One scholar defines this as ‘a sense of subjective immunity.’
It has to be stated that the group (collectively) may have also become concerned that
the yachtsman was alone on El Pirata in deteriorating weather conditions.
The perception of risk may be also temporarily impaired by alcohol. However, the
MSIU did not have any evidence which would have suggested that cognitive and
physiological impairment were an issue due to excessive consumption of alcohol at
any stage. This factor was therefore not pursued in detail.
2.8.2 Decision-making processes
Decision-making processes in risk-settings are very important. It may be stated that
the most appropriate decision is taken when an accurate diagnosis of the prevailing
situation would have been made. The assessment of risk, which as indicated above,
may be influenced by a number of factors, plays a central role in the decision-making
process. In fact, risk perception may be considered to be the process upon which risk
acceptance depends.
Decision errors made prior to the accident had occurred because the situation and the
prevailing weather conditions were either not fully understood, or completely
misunderstood, even under the influence of ‘illusion of control’ referred to above.
17
This may have been the case with the person at the wheel of the tender boat.
29
The arising inaccurate situation awareness was therefore a manifestation of an
incorrect mental picture which had formed. Moreover, especially with respect to the
decision to leave Xlendi Bay in adverse weather conditions (and possibly a damaged
propeller), one may also propose that the situation assessment was not updated. The
environment was dynamic – the weather conditions had worsened – but the situation
assessment remained static. The increasing sea, as a risk indicator, was not
appreciated18
. Moreover, the group had no clear clue of the weather conditions
outside Xlendi Bay and, most especially, at Il-Pinnur tal-Wardija, about 1.3 nm
Northwest of their position.
This meant that the probability that the tender boat would not have made it safely to
El Pirata at Dwejra Bay was higher.
At that particular stage, the group had at least two options and a choice had to be
made. The group could have left the tender boat at Xlendi Bay and taken a taxi to
Dwejra Bay (or stayed at Xlendi Bay in a nearby hotel). The other option (which was
the selected option) was to return to El Pirata on the tender boat. Whilst the taxi ride
would have increased the probability of arriving safely at Dwejra Bay, it would have
still created a very serious and dangerous situation when it would have eventually
came to the boarding of El Pirata; there are no berthing facilities at Dwejra Bay
where the pleasure yacht had anchored.
It may be stated, therefore, that the chosen option was seen by the group as one which
best addressed the needs of the prevailing situation. Ideally, the selection of any
option is made only after all features would have been taken into consideration in an
unbiased and objective manner. In the absence of these two important conditions, it is
very probable that an exhaustive evaluation of the prevailing context would have been
lacking19
.
18
There is a difference in a signal which was not detected and a signal which was not appreciated.
Given that the group were experiencing difficulties to board the tender boat is suggestive that the
risk signal was detected (but not appreciated).
19 Scientifically, this is described as the concept of ‘bounded local rationality’, i.e. the group was not
knowledgeable of all the relevant information and clear indicators of possible outcomes were not
available.
30
THE FOLLOWING CONCLUSIONS AND
RECOMMENDATIONS SHALL IN NO CASE CREATE
A PRESUMPTION OF BLAME OR LIABILITY.
NEITHER ARE THEY BINDING NOR LISTED IN ANY
ORDER OF PRIORITY.
31
3 CONCLUSIONS
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factor
.1 The tender boat was swamped after becoming completely exposed to the
Northwesterly weather conditions.
3.2 Latent Conditions and other Safety Factors
.1 In all probability, the yachtsman’s role on board El Pirata was limited to the
safe navigation and manoeuvring of the pleasure yacht whilst the ‘overall’
safety role was not formalised as one would expect in the case of the role of a
skipper as a result of the working context on board;
.2 Although the local weather forecast was accurate and reliable, it was either not
monitored carefully, misunderstood and underestimated, or not monitored at
all;
.3 Before the departure from Dwejra Bay, the five occupants of the tender boat
were not particularly concerned at that time as the waves would not have yet
built up;
.4 The deteriorating weather conditions did not deter the group to board the
tender boat and leave the relative safety of Xlendi Bay;
.5 The group lacked crucial local knowledge of the coast and its potential
dangers;
.6 Several influential factors may have altered the risk perception of the group,
leading to a higher degree of risk tolerance;
.7 Decision errors made prior to the accident had occurred because the situation
and the prevailing weather conditions were either not fully understood, or
completely misunderstood, potentially under the influence of a series of
influential factors;
.8 A number of influential factors may have compromised the objective and
exhaustive evaluation of available options prior to departure from Xlendi Bay.
32
4 RECOMMENDATIONS
In view of the conclusions reached following the analysis of all the available
evidence,
Transport Malta’s Ports and Yachting Directorate is recommended to:
13/2014_R1 Disseminate safety notices to the local and foreign yachtsmen who
engage in coastal activities on the:
general characteristics of the coastline of the Maltese Islands and potential
hazardous areas;
quality of VHF and mobile network reception around the coast;
importance of life-saving equipment;
basic navigational principles and seamanship practices.
