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Platino report finally out


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I read it the same as BP, the autopilot Rams were hydraulic, but the steering system itself wasn't.

 

Markmt, apologies, I had misunderstood what you'd said in the earlier post. Although what the report says seems to me to make sense. The system failed (car managed to break through the stops and run off the end of the track), after several uncontrolled crash gybes. I'm no engineer, but I wouldn't have thought it was reasonable to expect it to hold up indefinitely. If you keep crash gybing a 700kg boom/sail setup in 40 knots eventually surely you'd expect to break it.

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Sure I agree with that raz88, though if I read correctly the failure occurred on just the second time the boom slammed to port, the same gybe that killed one of the crew (perhaps that's open to a different interpretation). On a boat the owners had just spent 4 million dollars on.

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The booms weight and swing radius were known, You can calculate the shock loads fairly well and repeated shocks are something engineers have to deal with every day in multiple fields so what will have happened is a compromise on either weight or cost of the system that could handle it. I wonder if they sized it for the operating loads and figured the safety factor would be enough in non-normal operation

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All good points. In terms of being sized for the loads vs cost/weight etc, the fact it slid off the end I guess means the main stuff had stood up to it and it was the relatively cheap simple stops and attachment bolts for those that failed. But it was the 3rd crash gybe with more to come, if the stops had held something else would have probably given out sooner or later.

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Incidentally the traveller separation thing is not an unheard of situation on a large boat. I happened to see this video just a week or so back describing (by an expert witness in an insurance case) something a bit similar happening on a 106ft boat in 5m seas 500 miles from Hawaii. Fortunately no one injured.

 

(Some parts of the video could perhaps be considered mildly NSFW - depending on the W. If you just want the sailing story, start at 7:13.)

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I've read the whole thing. Sad story. Lets see what we can learn from it to help prevent a repetition.

 

There were no SOPs discussed at any time before leaving, or while underway. No Log book, no daily mechanical & rig inspections, etc. Seemed a bit complacent to me.

 

IMO the main traveler arrangement was substandard.

 

The hydraulic steering was only the AP, but  shared a quadrant with the mechanical wheel system.

 

The AP had begun to wander, alarm, and make increasingly larger course changes to stay on course. No one (at least no survivors) noticed this. It was a warning all was not well with the AP.

 

Eventually this lead to a crash gybe, followed soon after by another. 

 

Seems likely in the panic following the accident,  the AP was never disengaged, therefore resistance in the steering from the remaining fluid and air. Simply turning it to standby would have made manual steering possible.

 

None of the crew knew how the MOB gear worked, and it was not used. It MAY have saved a life.

None of the crew had done a proper safety briefing before leaving, which would have (should have) included the requirement to hold the MOB button 3 secs to activate, how the EPIRB worked, and what was carried and how to use it for MOB. 

No plan was made to remove the danger from the boom - could the hydraulic kicker be released to allow it to touch the deck?/ - for many hours, until the rig was lost. No single person took control.

The gunnel dead eyes the preventers were attached to were undersized, and failed.

 

This story is, unfortunately, pretty typical of disasters. No single cause, and some bad luck. The boat had all the gear, but the crew did not know how to use it, nor did they act as a team, due to lack of leadership. The boat had some structural issues, IMO.

 

So, what can be done so none of us end up in a similar situation? I dont believe MNZ's idea of a written plan will help much, except perhaps to make the owners/skipper consider the issues a bit more, which is not a bad thing. However, a ship has a chain of command for a reason. Have a crew meeting, run thru the saftey gear on that boat and its operation. Plan ahead, know how the equipment works, have the rescue co-ordination centre ph number programmed into the sat ph with autodial 1! , assign primary taks to the crew before leaving , etc etc.

 

Did you all note that they left the forestay till last, and it worked as a sea anchor? - This is good practice! There is more to this, but the admiral is waiting to go out and I have to go!

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Is there anyone on this forum that actually thinks that their yacht can take repeated crash gybes in high winds without having a problem?

Other than the odd wharram or prout with a table cloth sized main maybe?

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Would I have gone to sea on that boat with that crew? Absolutely.

 

I see two errors, but individually very minor and we have all done very much worse but got away with it. Dumb luck.

 

Error 1 - Major work on an hydraulic system not followed with extensive testing and monitoring. 

 

Error 2 - hard to even call it an error but i would have had the main down much earlier.

 

Neither one alone would have constituted a crisis. With the main down no crash gybe, no autopilot failure nothing bad would have happened.

 

All the rest is ambulance at the bottom of the cliff stuff.

 

Have I ever cut corners before and got away with it? you bet. So this story is a good reminder not to become complacent.

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One other thought - cruising boats didn't used to be so big. When you go that big you become very, very reliant on mechanical , hydraulic, and electrical systems. And the loads become huge. If the topping lift breaks on a cav 32 you lift the boom up with one hand and tie it on with the other. On Platino if a topping lift (or similar) broke you have a major shitfight and potential damage.

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Great debate.

 

I know what it is like when the autopilot stops working in the middle of the pacific on a big boat.  All of the crew had experienced a very small amount of time on manual steering, that bit of experience was gold. We should have also practiced actually using the emergency tiller as well, It worked realy well but took a bit of getting used to.

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Would I have gone to sea on that boat with that captain? Absolutely not.

 

I interviewed quite a few captains before I crewed across the Pacific a few years ago. Most of them were crap.

 

I'd be enormously happy if MNZ insisted on better licensing for captains from powered dinghies up.

 

I'd be enormously happy if MNZ insisted on proper SOPs and briefing.

 

I insist my guests read my safety card and we go over it before setting sail (my life depends on it too).

https://kmccready.wordpress.com/2015/01/05/storm-fantasy-sailing-yacht-safety-card/

 

 

NZ safety culture is waaaaayyy behind the rest of the world.

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Must have been a massive amount of force on the rudder wwith the main up in 40 knots downwind,maybe thats why the ap failed.

Nope, the load would contribute only to the rate of fluid loss, the issue was already there.

IMO there are many boats with poorly attached, spec'd, or installed rams. I prefer NOT to attach them to the quadrant, but to a completely separate tiller arm, individually keyed to the rudder stock. Unfortunately some boats don't have the room for this, but IMO its a good safety feature . Also (as platino had) separate systems for the primary steering and autopilot. Like mechanical for primary and hydraulic for AP. This gives Max redundancy.

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One thing I've learned  from sailing experience, which is quite a while, is don't judge what should or shouldn't have been done unless you were there. You didn't experience the terror or horror ,cold,wind strength,sea state,sea sickness or the plethora of other events that may have taken place. Like BP says we've all had close calls that could have gone either way. And for once native is right in that we don't need inexperienced bureaucrats making us have more rules and sitting in warm stable classrooms learning how to "be safe !" Facts are that things happen.Driving to the boat is inherently as dangerous as a lot of what we do sailing . It's called life. Get used to it

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I have had a 1st hand description of what happened onboard,I think its time to shutup KM,

 

The way I see it, it was a series of compound errors, it certainly appears that the initial fault was with the AP, lets assume someone was at the helm station, would they have had enough time to disengage the AP and correct the sudden course change? Not sure but I doubt it. The undersized padeye was missed during the build, would the bigger one held? Biggest crew error was the collective decision to rig the preventer in that manner, from that point the cumulative breakdown was incredible.

Not sure I agree with that Native, as BP posted earlier, I don't think many preventers would survive a crash gybe in 40knots.

If the slowly increasing ap wandering off course was not noticed by anyone, or the ap alarms, then the first gybe was unavoidable. Things go wrong at sea sometimes, and a lot of seamanship is what happens next. IMO.

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Sitting here in an armchair but I've done enough sailing to know just how easy this can all go wrong. 

 

Sailing offshore or cruising it's very easy to get into the grove and after all 99% of the time everything is the same, it just takes one event and then it all goes down hill fast.  Out of the cabin quickly unprepared, someone tries some quick actions in order to rectify the situation and then sadly, it all goes wrong.  

 

I'd say the best procedures in the world or legislation won't change what happens in situations like this.  

 

Thanks IT for the report link. Very interesting read and the key points are in the memory bank for what not to do.  

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